Tracheostomies: The Complete Guide

Table of Contents

Click on the link for a description of each chapter.

This chapter reviews normal anatomy & physiology of the airway: including the trachea, glottis, epiglottis, vocal cords, and esophagus. This chapter also discusses the mechanism of airway protection and review the normal processes of swallow, cough, and speech, highlighting the functional relevance of each airway structure.

Key Points:

  • The upper airway provides a natural conduit for gas exchange, it humidifies and protects the lower airway and participates in the functions of deglutition and phonation.

  • Alteration of pharyngeal anatomy may lead to the development of obstructive sleep apnea (OSA) and upper airway obstruction.

  • The larynx is the organ of phonation.  Disruption of its highly innervated structure immediately interferes with upper airway patency and, thus, impedes respiration.

  • Deglutition and phonation are highly coordinated processes between several structures of the upper airway and gastrointestinal tracts, and are dependent on intact sensory and motor innervation.

  • Pediatric airway anatomy varies from that of adult anatomy in the size of the head, the position of the larynx, the shape of the epiglottis, the angle of the mainstem bronchi, and, most importantly, the diameter of the upper airway.

This chapter reviews the placement of a tracheostomy, including a standard surgical approach, percutaneous approach, and discusses the anesthetic management for the procedure. Illustrations and bronchoscopic photos illustrate the procedure.

Key Points:

  • Open surgical tracheotomy can be performed in the operating room or the ICU, with bedside tracheotomies having the advantage of decreased patient transport risk, operating room cost, and schedule burden.

  • Percutaneous dilatational tracheotomy has become an important alternative approach and is best performed under bronchoscopic guidance to identify immediate complications and confirm tube placement.

  • After the procedure, patients require continuous monitoring of vital signs and are usually placed in an ICU.

This chapter discusses the different types of tracheostomy tubes available, discussing tube structure, unique features, and use. Included are dual-cannula, cuffed, dual-cannula uncuffed, single cannula, cuffed, and single-cannula, uncuffed tubes, as well as special use tubes such as metal, extra-length, and fenestrated tubes. Numerous photos highlight differences between the different types of tracheostomy tubes.

Key Points:

  • Tracheostomy tubes can be classified into four categories: dual-cannula, cuffed tubes; single-cannula, cuffed tubes; dual-cannula, cuffless tubes; and single-cannula, cuffless tubes.

  • Tracheostomy tubes are constructed of a variety of materials, including polyvinyl chloride, silicone, nylon, stainless steel, and silver.

  • Tracheostomy tubes with inner cannulas should be used in patients who have large amounts of secretions.

  • Laryngectomy tubes are always cuffless and are usually shorter than a standard tube.

  • Cuffless tracheostomy tubes can be used in patients who can protect their airway.

This chapter discusses the proper procedure for changing a tracheostomy tube and the numerous decisions to be made in order to fit the appropriate tube for the specific individual patient. These decisions include when to use cuffed vs. uncuffed tube, when to use dual cannula vs. single cannula trach, and when to use extended length tubes. This chapter features tables that include inner diameter, outer diameter, and length of adult, pediatric, and neonatal tubes.

Key Points:

  • The first decision when fitting a tracheostomy tube is if the patient requires a cuffed tube.

  • A dual-cannula tube should be chosen for a patient who has a large amount of thick secretions.

  • A larger tube size is optimal for a patient who is breathing through the tube; whereas, a smaller tube size is more appropriate for a patient who is breathing around the tube.

  • The tracheostomy tube can be changed by using either the classic method or the tube exchanger method; the latter is used when the patient is hemodynamically unstable or there is concern about loss of the airway.

  • Fenestrated tracheostomy tubes must be fitted carefully to prevent granulation growth in the aperture

This chapter discusses numerous conditions that can be encountered with the tracheostomy patient, such as management of the critical ill patient on mechanical ventilation, management of cuff leaks, altitude, anesthesia, complex wounds, and tracheostomy as a lived experience.

Key Points:

  • For the patient on mechanical ventilation, high peak pressure in the presence of normal plateau pressure indicates an airway problem, including and obstruction due to secretions or a tracheostomy tube that is too small.

  • Cuff leaks can occur within the cuff, around the cuff, or within the tube itself.  A systematic approach should be used to determine the cause of a cuff leak.

  • Stomal erosion commonly occurs from traction caused by the ventilator circuit against the tracheostomy tube.

  • Cuff pressures dramatically increase at altitude and with administration of nitrous oxide anesthesia.  Close attention to cuff pressure is warranted in these situations.

  • To minimize apprehension and fear, patients need continued guidance and information about how to manage specific functions such as tube care, feeding, and phonation.

This chapter discusses the numerous considerations involved in providing phonation for a patient with a tracheostomy. Methods to restore voice are discussed for patients on continuous or intermittent mechanical ventilation, and those who do not require mechanical ventilation. This chapter highlights an algorithm on phonation.

Key Points:

  • Speaking valves are ideally used with a cuffless tracheostomy tube but may be used with a completely deflated cuff as long as the patient’s ability to breathe comfortably has been thoroughly assessed.

  • For patients who do not require continuous mechanical ventilation, a cuffless tube  with capping trials allows phonation for the majority of patients.

  • For patients who require intermittent mechanical ventilation, a TTS or CTS tube with capping trials allows the flexibility of a cuff and offers minimal resistance to airflow when deflated.

  • Ventilator-dependent patients who can tolerate cuff deflation can be managed with leak speech, but those who are on continuous mechanical ventilation and who require cuff inflation usually provide the greatest challenge.

This chapter provides extensive discussion of all of the care issues involved with a tracheostomy. These include care of the stoma, inner cannula, securing and cleaning the tube, managment of secretions, nutrition, mobility, activities , and patient teaching. Care of other appliances such as the T-tube and tracheal cannula are also discussed.

Key Points:

  • During the first postoperative week, the security of the tracheostomy tube is a priority.

  • The inner cannula, when present, should be cleaned regularly to prevent tube obstruction.

  • Cuff pressures should be maintained at 20-25 cm H2O to prevent overinflation or underinflation of the cuff.

  • Routine tube changes should take place every 1-2 months.

  • The mainstay of secretion management includes adequate hydration and humidity, suctioning, and physical mobility.

Children with tracheostomy tubes pose certain considerations. In this chapter, pediatric issues are discussed, including tube selection, tube care, medication delivery, home monitoring, safety, and school and activity issues. Also growth and development issues are described in relation to the child with a tracheostomy.

Key Points:

  • Contrary to adults, prolonged endotracheal intubation is common in children.

  • Because of the narrow inner diameter of pediatric tracheostomy tubes, inner cannulas are never used, and cuffed tubes are rarely used.

  • The sizing of tracheostomy tubes must keep up with the child’s normal growth and development.

  • Tracheostomy placement early in life negatively affects the development of expressive language skills, including phonation, vocal quality, and articulation.

  • The decannulation process takes longer in children than adults and generally includes at least 7 days of continuous capping.

Patients with a laryngectomy pose additional problems because they are also coping with a diagnosis of cancer. The partial laryngectomy, hemilaryngectomy, and the total laryngectomy are discussed, with implications for care and therapy. Psychosocial issues are discussed because these patients are also facing partial or complete loss of their vocal cords.

Key Points:

  • Patients who undergo supraglottic and hemilaryngectomy may require speech therapy, but they reestablish functional swallowing and retain the ability to use their natural voice; however, the patient with a total laryngectomy must learn new methods of phonation.

  • Patients may have difficulty swallowing after laryngectomy, particularly with an inflated cuff on the tracheostomy tube.

  • TEP, used only with total laryngectomy patients, creates a passageway between the trachea and esophagus and uses airflow to vibrate the tissue of the pharyngoesophagus.

  • The quality of life following total laryngectomy can be characterized by changes in self-image perception as well as social factors and may encompass affective disorders.

This chapter discusses complications of the tracheostomy and how to manage emergencies during the intraoperative and early postoperative periods, as well as late postoperative complications. This chapter features an algorithm on how to manage tube obstruction.

Key Points:

  • Complications of tracheotomy can be encountered in the intraoperative as well as the early and late postoperative periods.  Adherence to preventive measures may avoid these complications.

  • Tube displacement and loss of airway can occur before the stoma has matured (prior to the fifth postoperative day.)

  • Signs of tube displacement include resistance with the use of the manual resuscitation bag, the inability to pass a suction catheter, subcutaneous emphysema, and the inability to obtain an end-tidal CO2 measurement.

  • Mucus plugs are very common and can be prevented by adequate hydration and effective mobilization of secretions.

  • There is a high incidence of tracheal stenosis that can be lessened by maintaining optimal cuff pressures.

Downsizing is the gradual process of gradually decreasing the size of the tracheostomy tube with the goal of complete decannulation. This chapter discusses the procedure of downsizing and decannulation, tube choices and resulting confounding issues, such as increased airway pressures. This chapter features an algorithm on downsizing.

Key Points:

  • The issues that led to the placement of the tracheostomy must be resolved before decannulation is considered.

  • As a tracheostomy tube gets smaller, it is more difficult to breathe through it and easier to breathe around it.

  • A planned and systematic approach to downsizing and decannulation usually prevents decannulation failure.

  • Deconditioned patients often require a vigorous program of physical exercise prior to decannulation to improve cough strength and ensure airway protection.

This chapter discusses the more long-term issues involved in managing a patient with a tracheostomy. Other issues with recovery and rehabilitation are also discussed, including discharge planning, home care, and psychosocial issues such as quality of life and caregiver burden.

Key Points:

  • When progressing tracheostomy tubes, the clinician must always consider the need for mechanical ventilation, suctioning, airway obstruction, and airway protection.

  • Patients with a history of stroke or TBI have a high frequency of soft tissue upper airway obstruction.

  • Patients and their caregivers must be given predischarge instructions to become comfortable managing their care at home.

  • Patients should be provided with clinical follow-up to manage tracheostomy-related issues.