Tracheostomy

Overview of Treatment

Tracheostomy is a surgical procedure that involves creating a permanent or temporary artificial airway through an incision in the neck into the trachea. The primary purpose is to provide stable respiratory function for patients with upper airway obstruction, long-term ventilation needs, or inadequate airway protection. This procedure is commonly performed in intensive care units or emergency settings, allowing direct removal of secretions and reducing laryngeal injury caused by intubation.

The core value lies in restoring airway patency, applicable to cases of acute airway obstruction, respiratory failure due to neuromuscular diseases, or patients requiring long-term intubation after head and neck surgery. The surgical methods are divided into traditional open and endoscopic-assisted techniques, which should be selected based on the patient's specific condition.

Types and Mechanisms of Treatment

Tracheostomy mainly falls into three categories:

• Emergency Tracheostomy: suitable for immediate airway obstruction cases, to be completed within 15-30 minutes
• Elective Tracheostomy: for patients expected to require ventilation support for more than 2 weeks
• Endoscopic-guided: using endoscopy for precise localization, minimally invasive to reduce tissue damage

The surgical mechanism involves incising between the second and third tracheal cartilage rings, inserting a specialized cannula to form a permanent airway, allowing gases to pass directly through the artificial channel for gas exchange.

The mechanism includes:

• Eliminating resistance in the upper airway
• Expanding the airway diameter
• Reducing the risk of laryngeal paralysis

The cannula diameter is usually 6-8mm and should be adjusted according to the patient's age and airway size. Modern techniques often incorporate image-guided navigation to improve placement accuracy.

Indications

Main indications include:

• Upper airway obstruction (e.g., neck trauma, severe pharyngeal swelling)
• Long-term mechanical ventilation (over 2 weeks)
• Respiratory muscle weakness caused by neuromuscular diseases
• Post-head and neck surgery requiring avoidance of glottic compression

For patients with traumatic brain injury combined with secretion clearance difficulties, this procedure can significantly reduce the risk of pneumonia.

Other applicable situations:

• Recurrent aspiration leading to lower respiratory tract infections
• Severe burns causing craniofacial nerve damage
• Congenital airway abnormalities in children

However, contraindications include coagulation disorders or uncontrolled local infections.

Usage and Dosage

The procedure is usually performed under general anesthesia, with steps including:

1. Disinfection of the neck followed by a curved incision
2. Dissection of subcutaneous tissue to expose the trachea
3. Incision of the anterior wall of the trachea and insertion of the cannula
4. Suturing to fix the cannula to the trachea

The choice of cannula should be adjusted based on the patient's age; adults typically use 6-8mm internal diameter, while infants use specially designed 4-6mm cannulas.

Postoperative management includes:

• Clearance of secretions every 4 hours
• Weekly replacement of the cannula
• Use of humidifiers to maintain airway moisture

Long-term users should be evaluated every 3 months for possible enlargement of the incision or conversion to a permanent tracheostomy.

Benefits and Advantages

Main advantages include:

• Reducing laryngeal edema risk by up to 60%
• Decreasing the incidence of ventilator-associated pneumonia by 40%
• Improving patients' ability to eat and speak

For long-term ventilated patients, it can reduce the risk of facial and neck pressure ulcers and vocal cord damage.

Compared to nasal intubation, its advantages are:

• Longer retention time (up to several months)
• Better secretion management
• Less airway trauma

Suitable for patients requiring mechanical ventilation for more than 2 weeks, it can reduce complications related to respiratory muscle atrophy.

Risks and Side Effects

Main risks include:

• Bleeding (3-5%)
• Subcutaneous emphysema (10-15%)
• Tracheoesophageal fistula (0.5-1%)

Severe complications may lead to pneumothorax or vocal cord paralysis, requiring immediate surgical repair.

Long-term complications include:

• Tracheal stenosis (5-10%)
• Granulation tissue proliferation around the cannula
• Chronic airway dryness causing mucosal damage

Important Warning: Cannula dislodgement may cause immediate suffocation, so backup tracheal intubation equipment should be prepared.

Precautions and Contraindications

Absolute contraindications include:

• Uncontrolled coagulation disorders (INR >1.5)
• Congenital tracheal stenosis
• Uncontrolled local infection

Relative contraindications include severe neck deformities or aortic aneurysm.

Postoperative care should focus on:

• Daily cleaning of the tracheostomy tube
• Maintaining environmental humidity at 40-60%
• Turning every 2 hours to prevent pressure ulcers

Strictly prohibit self-adjustment of the cannula position or removal of the fixation dressing.

Interactions with Other Treatments

Compared to endotracheal intubation, tracheostomy can reduce vocal cord injury but may affect speech function. Compared to bronchoscopy treatments, its advantage lies in maintaining a patent airway 24 hours a day, but regular cleaning by a respiratory therapist is necessary.

Patients on anticoagulants should have their medication doses adjusted, typically keeping warfarin INR below 1.2. When used with high-flow oxygen therapy, monitoring for airway mucosal dryness is essential.

Treatment Outcomes and Evidence

According to a 2020 Cochrane review, tracheostomy can reduce the incidence of ventilator-associated pneumonia by 37% and shorten ICU stay by an average of 4.2 days. Long-term ventilated patients have an increased success rate of decannulation to 78% after use.

However, follow-up studies show that 12-15% of long-term tracheostomy patients may develop tracheal stenosis, requiring periodic bronchoscopy follow-up. Pediatric patients need specially designed cannulas to accommodate growth and development.

Alternatives

Short-term ventilation needs can consider nasal intubation, but switching to tracheostomy is recommended after 2 weeks. For acute airway obstruction, initial management may include bronchoscopy for foreign body removal or using a laryngeal mask airway for ventilation.

Non-invasive alternatives include:

• High-flow nasal cannula oxygen therapy
• Extracorporeal membrane oxygenation (ECMO)
• Endoscopic dilation procedures

However, these methods have limited effectiveness in severe obstruction.

 

Frequently Asked Questions

What preparations are needed before surgery?

Preoperative assessment should include a full physical examination to evaluate cardiac and pulmonary function, and confirmation of the necessity of the procedure with the medical team. Patients should stop anticoagulant medications (such as aspirin) to reduce bleeding risk and undergo airway clearance training. Psychological preparation is also important; discussing the expected adaptation period and care arrangements with the physician is recommended.

How can infection risk be avoided in daily postoperative care?

Daily cleaning of the skin around the tracheostomy site, using sterile saline to rinse the tube, and regular replacement of the tracheostomy tube and dressings are essential. Maintaining environmental humidity at 50%-60% with humidifiers can reduce mucus viscosity. If secretions become discolored or foul-smelling, medical attention should be sought promptly to rule out infection.

Will tracheostomy permanently affect speech ability?

Short-term effects may include voice impairment due to the tracheostomy tube blocking the vocal cords, but most patients can gradually regain normal speech after tube removal. Long-term use may involve speech aids such as specialized tracheal valves or communication devices. Speech therapy is crucial for rebuilding communication skills.

What dietary adjustments are necessary after surgery?

Initially, liquid foods should be avoided to prevent aspiration; pureed or solid foods are recommended. Patients should sit upright at a 45-degree angle during eating and perform airway suctioning afterward. If swallowing difficulties persist, nasogastric feeding or swallowing assessments may be necessary, with a dietitian developing a personalized plan.

Does long-term tracheostomy increase the risk of tracheal stenosis?

Prolonged cannula placement can lead to granulation tissue proliferation or soft tissue atrophy, increasing the risk of stenosis. Regular bronchoscopic follow-up every 3-6 months is recommended to assess cannula fit. If stenosis develops, balloon dilation or stent placement can be performed, with close follow-up by an ENT specialist.