Tracheostomy

Overview of Treatment

Tracheostomy is a surgical procedure that involves creating a permanent or temporary artificial airway through an incision in the neck and opening the trachea. The primary goal 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 rescue scenarios, 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 caused by neuromuscular diseases, or patients requiring long-term intubation after head and neck surgeries. The surgical methods are divided into traditional open and endoscopic-assisted types, which should be selected based on the patient's specific condition.

Types and Mechanisms of Treatment

Tracheostomy mainly falls into three types:

• Emergency Tracheostomy: suitable for critical cases with immediate airway obstruction, to be completed within 15-30 minutes
• Elective Tracheostomy: for patients expected to require ventilation support for more than 2 weeks
• Endoscopically Guided: utilizes endoscopy for precise localization, reducing tissue damage with minimally invasive techniques

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 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 surgeries often incorporate imaging navigation technology to improve positioning accuracy.

Indications

Main indications include:

• Upper airway obstruction (such as neck trauma, severe pharyngeal swelling)
• Long-term mechanical ventilation needs (over 2 weeks)
• Respiratory muscle weakness caused by neuromuscular diseases
• Post-head and neck surgery to prevent glottic compression

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

Other applicable conditions include:

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

However, contraindications include uncorrected coagulation disorders or uncontrolled local infections.

Usage and Dosage

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

1. Disinfecting the neck and making a curved incision
2. Separating subcutaneous tissue to expose the trachea
3. Incising the anterior wall of the trachea and inserting the cannula
4. Suturing and fixing 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:

• Clearing secretions every 4 hours
• Replacing the cannula weekly
• Maintaining airway humidity with a humidifier

Long-term users should be evaluated every 3 months to determine if the incision needs to be enlarged or converted to a permanent tracheostomy.

Benefits and Advantages

Main advantages include:

• Reducing the risk of laryngeal edema 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
• Lower risk of airway injury

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 (incidence 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 a backup tracheal intubation set should be prepared.

Precautions and Contraindications

Absolute contraindications include:

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

Relative contraindications are severe neck deformities or aortic aneurysms.

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-adjusting the cannula position or removing 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 adjust medication doses, typically keeping warfarin INR below 1.2. When used with high-flow oxygen therapy, monitor for airway mucosal dryness.

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 a weaning success rate increased to 78% after use.

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

Alternative Options

For short-term ventilation needs, nasal intubation can be considered, but switching to tracheostomy is recommended if ventilation exceeds 2 weeks. Acute airway obstruction can be initially managed with bronchoscopy foreign body removal or laryngeal mask ventilation.

Non-invasive alternatives include:

• High-flow nasal cannula oxygen therapy
• Extracorporeal membrane oxygenation (ECMO)
• Tracheal dilation under bronchoscopy

However, these methods have limited effectiveness in severe obstruction.

 

Frequently Asked Questions

What preparations are needed before surgery?

Preoperative assessments include a full physical examination to evaluate cardiac and pulmonary function, and confirming the necessity of the procedure with the medical team. Patients should stop taking anticoagulants (such as aspirin) to reduce bleeding risk, and receive airway clearance training. Psychological preparation is also important; discussing postoperative adaptation and care plans with the physician is recommended.

How can I prevent infection during daily postoperative care?

Daily cleaning of the skin around the tracheostomy, using sterile saline to rinse the tracheostomy tube, and regularly changing the cannula and dressings are essential. Maintaining environmental humidity at 50-60% and using humidifiers can reduce mucus viscosity. If secretions change color or have an odor, seek medical attention promptly to rule out infection.

Will long-term tracheostomy affect speech permanently?

Initially, speech may be affected due to the tracheostomy tube blocking the vocal cords, but most patients can gradually regain normal speech after tube removal. For long-term use, speech can be facilitated with special tracheal valves or communication aids. The expertise of speech therapists is crucial in restoring communication abilities.

Are there special dietary considerations after surgery?

Initially, avoid liquid foods to prevent aspiration; pureed or solid foods are recommended. Maintain an upright position at a 45-degree angle during meals, and enhance airway suction afterward. If swallowing difficulties occur, nasogastric feeding or swallowing assessments may be necessary, with personalized dietary plans developed by a nutritionist.

Does long-term cannula placement cause tracheal stenosis?

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