Tracheostomy Overview

geekymedics.com/tracheostomy-overview

Jimmy Ng August 27, 2019

Introduction
Tracheostomy is a procedure where an artificial airway is established in the cervical
trachea. The first clearly documented tracheostomy (or tracheotomy) dates back to the 15th
century, although it is believed that the procedure might have been performed as early as
2000 BC. In modern medicine, this procedure is performed on a daily basis. However, the
term ‘tracheostomy’ has evolved to refer to both the procedure and the clinical condition of
having a tracheostomy tube.

The National Tracheostomy Safety Project estimates that in England each year, around 10 –
15000 percutaneous tracheostomies are performed in the intensive care unit, and 5000
surgical tracheostomies within head and neck surgical practice.¹ The implications are wide-
reaching, as safe caring for tracheostomy patients requires knowledge and competencies in
dealing with everyday care, weaning and decannulation as well as emergencies arising from
tracheostomy tubes.

Caring for a patient with tracheostomy can be challenging and is often a source of anxiety for
junior doctors, especially when they do not work within specialist units that handle these
patients routinely. In this article, we will talk about the basic principles of routine and
emergency tracheostomy management.

You might also be interested in our surgical flashcard collection which contains over 500
flashcards that cover key surgical topics.

1/9
 Figure 1: Tracheostomy. Note that the native upper
airway is bypassed

Why, when, how and what?

The most common indication for a tracheostomy is to facilitate weaning off ventilation in
intensive care patients.

Other reasons for tracheostomy include:

upper airway obstruction;

to secure and maintain a safe airway in cases where the upper airway is unsafe (e.g.
injuries to the face, head and neck);
bronchial toilet and secretion removal;
airway protection (e.g. neuromuscular disorders)

In non-emergency settings, there is no convincing data to guide the timing of tracheostomy in

patients who are ventilated via endotracheal tube on an intensive care unit, but ten days is
often widely accepted as the time when tracheostomy should be considered. Nevertheless,
the benefits and potential risks of tracheostomy need to be considered, and in all cases
discussed with patients and family members.

Tracheostomy can be performed with open dissection through the anterior neck or
percutaneously. The percutaneous tracheostomy technique has gained popularity since its
introduction in the 1980s, as it is seen to be an effective alternative to surgical tracheostomy,
whilst avoiding the need for transfer to the operating theatre with comparable outcomes.2,3
Seldinger technique is the most widely practiced and described percutaneous tracheostomy
technique.

The basic descriptions of tracheostomy tubes are shown in Table 1.

2/9
Table 1 Basic descriptions of tracheostomy tubes

Description Variation Remarks

Size The inner diameter of the tube is taken as the size. For
example, the commonly used size for an average female
adult is 7.0mm.

Cuff Cuffed A soft balloon around the distal end of the tube to seal the
airway. Cuffed tubes are necessary when airway protection
or positive ventilation is required. Assuming tube and cuff
are correctly placed and inflated, the patient will not be able
to breathe through an occluded lumen.

Uncuffed Rarely used in acute care. Generally used in patients who

have an effective cough and gag reflex, for longer-term
management of secretions.

Fenestration Fenestrated Opening(s) in the outer cannula that allows air to pass
through the patient’s oral/nasal pharynx, as well as the
tracheal opening. Allows speech but increases the risk of
aspiration. A non-fenestrated inner cannula can be placed if
needed (e.g. emergency ventilation).

Non- No opening(s)
fenestrated

Cannula Single Rarely used due to concerns surrounding blockage and

difficulty in cleaning.

Double Commonly used. Inner cannula serves as a removable line

to facilitate cleaning. In cases of blockage, the inner cannula
can be removed and the airway re-established (assuming
the tube is correctly placed).

Some tubes may have subglottic suction, which is thought to reduce the incidence of
ventilator-associated pneumonia. In patients with an abnormally large distance from skin to
the trachea, adjustable flange tracheostomy tubes may be used.

Figure 2: A tracheostomy tube 5

3/9
 Figure 3: (a) an example of
decannulation cap | (b) speaking
valves | (c) heat-moist-exchanger 6

There are many different manufacturers and devices. Common brand names in the U.K. are
Shiley, Kapitex, Tracoe Twist, and Portex. The silver Negus is a common permanent
tracheostomy tube. The specifications of the tubes by different manufacturers guide their use
and purpose.

It is far more important to understand the basic descriptions and the types of tubes
commonly used in their hospital settings than remembering a list of manufacturer brands!

‘Routine’ care and weaning

Multidisciplinary, ward-based tracheostomy care is internationally recognised to minimise
tracheostomy-related complications and to improve outcomes.4 Ideally, weekly tracheostomy
ward rounds should be performed, with the team comprising of a physician (commonly
intensive care or ENT specialist), physiotherapist, airway clinical nurse specialist, speech
and language therapist and nurse.

The team aims to ensure that routine care of tracheostomy is achieved and provides a
strategy for eventual weaning or decannulation. In addition, the team is able to identify
issues surrounding staff competencies, logistics and shortfalls in care, whilst providing
support and setting standards.

The cornerstone in caring for patients with tracheostomy remains the prevention of tube
blockage. A useful tip to remember in managing tracheostomy is to imagine that all the
native functions of the upper airway need to be replicated i.e. humidification, clearing of
secretions, stoma care, speech, airway protection and swallowing (Figure 1). The
commonest measures undertaken in the day-to-day care of a tracheostomy tube are outlined
in Table 2.

Table 2 Common measures taken in the daily management of a tracheostomy

Care Actions

4/9
 Daily checks Items that must be checked include bedhead sign with correct
information, type and size of the tube, availability of spare and emergency
equipment, cough effort, swallowing, sputum characteristics, inner
cannula, tracheostomy tube and stoma, observations.

Each patient should have an emergency tracheostomy box that contains

all the necessary equipment.

Humidification A method of artificial humidification must be employed to avoid drying up

of secretions, which may form a crust around tracheostomy or cause a
fatal blockage. Examples of humidification are heated humidification
circuit, heat-moist-exchanger, saline nebuliser, mucolytics and hydration.

Clearing of In addition to cough, suctioning with flexible suction catheters through the
secretions tracheostomy tube must be performed with varying intervals and depth
depending on the patient’s condition.

Stoma care The wound should be checked regularly to ensure it is clean and healthy.
Granulation, skin sore and wound breakdown may occur.

Inner cannula The inner cannula should be removed and inspected at least once per 8-
care hour shift. Again, intervals may be shorter for better management of
secretions. At Charing Cross Hospital, it is recommended that inner
cannula be checked every four hours.

Oral care and Oral care is important to prevent colonisation by microorganisms and
swallowing superimposed infection. If unable to self-care, daily assessment of the
oral cavity and clearing of oral secretions should be carried out.

Cuff Capillary pressure of the trachea wall is normally between 20 – 30 mmHg

management and blood flow may be impaired by obstruction pressure between 22 – 37
mmHg, causing tissue necrosis and subsequent fistula, stenosis,
tracheomalacia etc. The recommended cuff pressure, which should be
checked once every 8-hour shift, is between 10 – 18 mmHg (15 – 25 cm
H2O).

Weaning is a process towards complete independence from ventilatory or respiratory

support, which eventually leads to decannulation (except for cases where the tube is
permanent).

In order to achieve safe decannulation, various protocols exist to ascertain and establish the
ability of the native airway to function without the artificially inserted tracheostomy tube.
Speaking valves and caps are commonly used to cause an increase in resistance to airflow
through the trachea and to encourage airflow through the normal passage. If patients are
able to tolerate these systems that are applied over a period of time, often 24 hours, without
extra respiratory support, they are deemed suitable for decannulation. It is important to note
that neither of these processes should be trialled with an inflated cuff!

5/9
Weaning is a dynamic process that involves an assessment of the patient at each step.
Some patients may achieve decannulation with very little problem; some may not achieve
safe decannulation at all.

In principle, when the decision is made for weaning and decannulation, patients go through
(I) cuff deflation, (II) use of one-way valve, (III) capping off tracheostomy tube, and (IV)
decannulation in a step-wise manner.

Where there are difficulties, troubleshooting potential causes requires experience and
guidance from the multidisciplinary tracheostomy team. For example, stridor may occur when
a cap is used. In this instance, the cap should be removed and ENT advice should be sought
(endoscopic assessment of the upper airway may be warranted to identify obstruction in the
supraglottic, glottic or subglottic region).

Decannulation is considered when there is MDT agreement that the patient is able to tolerate
capping off for a set period of time, there is sufficient swallowing function, cough strength is
sufficient to expel secretions from the trachea and there is no planned intervention requiring
an artificial airway.

After decannulation, patients are actively monitored for signs of respiratory distress for 48
hours with emergency equipment available by the bedside during this period of time. Safe
decannulation should be achievable if the patient progresses through the weaning process
satisfactorily.

Emergency care
Remember, tracheostomy emergencies should be managed with the same ABCDE
principles as any other emergency situation!

An algorithm developed by the National Tracheostomy Safety Project is extremely useful in

an emergency.

A bedhead sign developed following consultation with key national bodies, (Figure 4) also
contains useful information that summarises key details regarding the tracheostomy, method
of formation of the stoma and presence of ‘stay sutures’; whereas the algorithm (Figure 5)
provides stepwise guidance in dealing with an emergency in a tracheostomy or
laryngectomy. 7

There are separate bedhead signs and algorithms for laryngectomy (‘red algorithm’) and
these should also be clearly displayed.

6/9
 Figure 4: Bedhead sign for tracheostomy 7

Figure 5: Patent airway algorithm – for tracheostomy

– ‘Green algorithm’ 7

Tips for junior doctors

Junior doctors are often the first to be called or be present in an emergency. It is recognised
that competency of the staff, including junior doctors, looking after tracheostomy patients
should be achieved and maintained. In the United Kingdom, hospital trusts have local
policies in place to ensure that this is the case. There are also various resources available
online, such as interactive algorithms and videos, for learning by healthcare staff. A helpful
resource is the National Tracheostomy Safety Project.

A few tips for junior doctors:

Remember ABCDE: the first clinical steps should always involve opening the airway
and looking for evidence of breathing (if cardiac arrest is identified, commence CPR).
The priorities are oxygenation and getting help!
Learn and acquire competency to detect airway problems, assess tracheostomy and
airway patency and to provide basic emergency oxygenation.
Tracheostomy patients have potentially two airways, so the face and tracheostomy
tube should be assessed following basic airway opening manoeuvres.

7/9
 Oxygen should be provided via the face as well as the tracheostomy tube if the patient
is breathing.
Tube blockage by mucous plugging or thick secretions is one of the commonest causes
for an emergency, therefore primary responders should remove the inner cannula and
pass a suction catheter as part of the assessment of tube patency or treatment of tube
blockage. Difficulty in passing the suction catheter suggests that the tube may be
displaced or partially obstructed, so the next reasonable step is to assess for air
movement via the tracheostomy tube. If help was sought early, it should arrive by this
point. Further manoeuvres often require specialised skills by anaesthetics or ENT
specialists. Removing the tracheostomy tube and attempting to replace should be done
only once anaesthetic or ENT help has arrived. Sometimes the insertion of an
endotracheal tube through the tracheostomy wound can provide an airway in an
emergency.

Conclusion
It is becoming increasingly common that junior doctors look after patients with tracheostomy.
Basic understanding of the management of tracheostomy on a day-to-day basis and during
emergencies is paramount in delivering safe care. A multidisciplinary approach to
tracheostomy care is internationally recognised to be effective and to improve outcomes.
Junior doctors should develop a good grasp of the basic principles of tracheostomy
management, and where appropriate they should know to seek help or advice.

References
1. MC Grath BA. Comprehensive Tracheostomy Care: The national tracheostomy safety
project manual. McGrath B, editor. Wiley; 2014. 52-61 p.
2. Higgins KM, Punthakee X. Meta-Analysis Comparison of Open Versus Percutaneous
Tracheostomy. Laryngoscope. 2007;
3. Johnson-Obaseki S, Veljkovic A, Javidnia H. Complication rates of open surgical
versus percutaneous tracheostomy in critically ill patients. Laryngoscope. 2016;
4. Speed L, Harding KE. Tracheostomy teams reduce total tracheostomy time and
increase speaking valve use: A systematic review and meta-analysis. J Crit Care.
2013;
5. Tenbergen. Tracheostomy tubes. Licence: [CC BY-SA 4.0].
6. Photo courtesy of National Tracheostomy Safety Project Comprehensive Tracheostomy
Care Manual.
7. McGrath BA, Bates L, Atkinson D, Moore JA. Multidisciplinary guidelines for the
management of tracheostomy and laryngectomy airway emergencies. Anaesthesia.
Published in 2012.

8/9
Copyright © Geeky Medics

9/9