Dictionary:

tracheostomy

  (trā'kē-ŏs'tə-mē)

Also from Answers.com... Human Papilloma Virus HPV How to know if you have HPV.

1. Surgical construction of an opening in the trachea for the insertion of a catheter or tube to facilitate breathing.
2. The opening so made.

Key Terms: Cricothyrotomy, Larynx, Trachea.

A tracheostomy is an artificial airway, which is surgically inserted through the windpipe to allow normal respiration.

The key purpose of a tracheostomy is to provide a patient with an open, functional airway. Normal respiration can become hindered or blocked by an obstruction to the upper respiratory tract; the area between the nose and mouth down through the larynx. When a serious obstruction occurs, normal respiratory techniques, such as oral or nasal intubation, may be inadequate or completely ineffective. Obstructions can come from several sources, including foreign bodies, swollen soft tissue, and injury to the larynx and/or trachea. Furthermore, proper respiration can also be obstructed by the growth of malignant tumors in the mouth, larynx, trachea, nasopharynx (the space above and behind the soft palate), and the nasal cavity and paranasal sinuses.

Proper oxygenation of the lungs may also require the use of a tracheostomy. Malignant pulmonary cancers, such as bronchioloalveolar carcinoma and mesothelioma, can cause serious respiratory problems, including hypoxia (an insufficient oxygen level in the blood and tissues) or hypercapnia (excess levels of carbon dioxide in the blood due to hypoventilation). A tracheostomy can provide the required oxygen levels via the tracheobronchial tree, also known as the bronchia.

A tracheostomy may also be used to clean and remove secretions that build up in the bronchia and throat due to injury, disease, and tumors. This excess fluid can cause obstructions and/or restrict proper oxygenation. Blood and secretions can be suctioned out through the trachea to relieve breathing problems.

There are no known contraindications for the use of a tracheostomy. However, some surgical modalities, such as removal of malignancies, may be required prior to the tracheotomy procedure.

At the simplest level, a tracheostomy is an artificial airway that is inserted into the trachea (windpipe) to bypass the upper airway. The surgical procedure to create this secondary airway is known as a tracheotomy. Tracheostomies provide physicians with one of the most effective methods to relieving breathing problems due to obstruction. Indeed, historical evidence reveals that tracheostomies may have been used as far back as 2000B.C. Since Antonio Brasavola performed the first documented tracheotomy in the 16^th century, surgeons and doctors have been developing and refining this effective medical procedure.

The most common form of tracheostomy is a hollow tube of plastic, silicon, or metal, also known as a tracheostomy tube or trach. During a tracheotomy, this tube is surgically inserted into the patient's neck just beneath the larynx to provide access to the trachea, thus acting as a secondary airway. The surgical opening through which the tracheostomy is inserted is also known as the stoma. Depending on the underlying cause of obstruction and/or respiratory distress, a tracheostomy may be temporary or permanent in nature. Tracheostomies are far more effective for suctioning purposes and maintaining respiratory function than other artificial airways. There are three key types of tracheotomies: Elective, Awake, and Emergent.

• Elective—The majority of tracheotomy procedures are elective in nature. Most patients will have already been intubated by this point in time and may require more prolonged and/or more effective form of intubation. These procedures are conducted under controlled conditions, usually performed in a hospital's operating room under the supervision of a surgeon and anesthesiologist.
• Awake—Acute respiratory distress may require an "awake" tracheotomy. These procedures are typically conducted under controlled conditions and using local anesthesia. However, the patient remains conscious throughout the procedure, which can be extremely disconcerting for the patient. The operating surgeon must be prepared for difficulties caused the heightened levels of anxiety the patient will undoubtedly exhibit.
• Emergent—Emergent tracheotomies, sometimes crudely referred to as "slash" tracheostomies, generally should not be considered unless the patient is in extremis and intubation is inadvisable. Even in these extreme cases, a cricothyrotomy is more advisable to relieve respiratory distress that a tracheotomy.

There are several variations of the tracheotomy, but follow a basic guideline. Once the patient is anesthetized, either generally or locally, the neck is cleaned and positioned. Surgical incisions expose the tough cartilage rings that form the trachea's outer wall. An incision is made through two of these rings and a tracheostomy tube inserted into the windpipe.

Tracheostomy tubes come in a variety of shape, sizes, and compositions. Tubes are generally designed to meet specific medical requirements, and can be either disposable or reusable in nature. The Universal is most commonly used tracheostomy tube. Also known as the "double-luman" or "double-cannula" tube, the Universal consists of three parts: the outer cannula (with cuff and pilot tube), the inner cannula, and the obturator. Other commonly used tracheostomy tubes include:

• Single cannula (used for patients with long and/or thin necks)
• Fenestrated (allow speech and improve swallow function)
• Tracheostomy Button (used to wean patients before final removal of tracheostomy tubes or in the treatment of sleep apnea)
• Cuffed tube (used commonly when mechanical ventilation is required and prevents aspiration of secretions)
• Cuffless tube (used in long-term management)

If possible, the patient should fully discuss the procedure and other viable opinions with their physician at length before undergoing a tracheostomy. Additionally, cancers of the upper airway and throat may require the use of other surgical procedures beforehand. In these cases, an effective treatment plan incorporating the tracheostomy should be established. Stabilization of precipitating factors may also be required beforehand.

Successful tracheostomies require effective and thorough postoperative care. Patients may require one to three days to breathe normally following the insertion of a tracheostomy tube. The tube may prevent verbal communication for a prolonged period, and other methods of communication should be utilized. All patients with tracheostomy tubes require humidification to prevent further complications associated with inspired gases. Aftercare modalities should strive to accomplish four key goals:

• Maintain the patient's airway
• Maintain tracheal integrity
• Avoid infections
• Avoid tube displacement

Patients and family members should be educated in aftercare modalities and information as soon as possible. Home nursing service may be required for patients. Otherwise, a return to regular home life is encouraged. However, while outdoors, a scarf or similar covering around the throat is indicated.

Directly following the procedure, the trachea will produce excessive secretions due to trauma. In addition to monitoring of these secretions, continual saline irrigation and suctioning will be required. Mucolytic (antimucus) agents can be utilized to prevent dangerous obstructions. Assessment of the patient's vital signs should also be maintained, in addition to monitoring for other complications associated with surgery.

Further complications can be encountered at all stages of recovery following a tracheotomy: immediate, early, and late.

Immediate complications can occur directly following the tracheotomy and include:

• Apnea
• Bleeding
• Pneumothorax (accumulation of air or gas in the pleural cavity)
• Pneumomediastinum (escape of air into the pleural tissues)
• Injury to adjacent structures
• Postobstructive pulmonary edema (accumulation of fluid in the lungs)

Early complications typically occur within seven days of the tracheotomy and include:

• Bleeding
• Mucus obstructions
• Inflammation of the trachea
• Inflammation of subcutaneous or connective tissue around the incision
• Tube displacement
• Subcutaneous emphysema (air or gas in subcutaneous tissues)
• Total or partial collapse of the lung

Late complications can occur at any time seven days following the tracheotomy and can include:

• Bleeding
• Tracheomalacia (degeneration of the elastic and connective tissue of the trachea)
• Tracheoesophageal fistula (an abnormal connection between the trachea and the esophagus)
• Tracheocutaneous fistula (an abnormal connection between the trachea and the surface of the neck)
• Granulation and scarring
• Failure to remove the tracheostomy tube

The normal tracheostomy can be used for days, weeks, and even or years with proper treatment. However, tracheostomy tubes should be downsized and removed as quickly as medically viable. Once the tracheostomy is removed, the stoma is sealed and allowed to heal over a period of five to seven days. Typically, a full recovery can be expected within two weeks with little to no scarring.

Several abnormal results of varying seriousness areassociated with tracheostomies. However, patients should contact localemergency services if their tracheostomy tube is dislodged and cannot bereplaced. Additional concerns include:

• Infection
• Fever
• Chills
• Incision sites problems, such asswelling, increased pain, and excessive bleeding
• Nausea and/orvomiting
• Shortness of breath and/or cough despite suctioning
• Persistent speech difficulties after tracheostomy removal

Resources

Books

Russell C, and B Matta. Cambridge, UK: Cambridge University Press, 2003.

Periodicals

Lewis C, J Carron, J Perkins, K Sie, and C Feudtner. Tracheotomy in Pediatric Patients: A National Perspective. 129 (May 2003): 523-529.

Hsu CL, KY Chen, CH Chang, JS Jerng, CJ Yu, and PC Yang. Timing of Tracheostomy as a determinant of Weaning Success in Critically Ill Patients: A Retrospective Study. 9 (#1, 2005): R46-R52.

Other

Morgan C, and S. Dixon. Tracheostomy. .

Dixon S. Tracheostomy: Postoperative Recovery. .

Tracheostomy Home.

—Jason Fryer

An opening in the trachea (stoma: Greek for ‘mouth’). The operation which creates the opening is tracheotomy (tome: Greek for ‘incision’) ; it involves slitting open the trachea (windpipe), to enable the patient to breathe when the upper respiratory tract is obstructed either by a foreign body or as a result of disease or injury.

It is an operation with an ancient history, reportedly first thought of by Asculaepius in 100 bc when he was, according to Galen, trying to devise a way of relieving patients suffering from ‘those species of quinsies in which there is great danger of suffocation’. There is evidence that the operation was used occasionally in antiquity, and with increasing frequency from the Renaissance. In this simple form, however, it afforded the patient only brief relief, since the artificial opening rapidly closed itself. It was only with the invention of the cannula — a hollow tube which permits the draining of fluids — around 1600, that more extended opening could be practised. The invention of the double cannula in the late eighteenth century was an important improvement: it allowed for the tube to be cleared and cleaned without inconveniencing the patient.

Despite these improvements, tracheostomy was only rarely performed before the mid nineteenth century, most notably in attempts to revive the hanged. It then achieved greater — and increasing — prominence as more virulent strains of diphtheria emerged in Western Europe in the 1850s. Diphtheria is an acute infectious disease characterized by the development of a membrane across the back of the throat, which may threaten suffocation, although death is usually due to the effects of the toxin released into the patient's system by the infecting organism. Diphtheria was first identified as a specific disease by Pierre Bretonneau in 1824, and it was his pupil, Armand Trousseau, who established tracheostomy as a treatment option through his work at the Paris Childrens' Hospital in the 1830s and 1840s.

With the spread of the virulent form of diphtheria after 1855, doctors across Europe became increasingly familiar with the operation, and its technique was gradually refined. It was the only operation which, it was said, every practising doctor had to be prepared to perform. By the turn of the century, however, American hospital practitioners had begun to use intubation (passing a tube into the trachea via the mouth) in preference to tracheostomy, and this development gradually influenced European practice. Despite the introduction of anti-toxin therapy in the 1890s, diphtheria remained a public health problem in the twentieth century until the development and application of active immunization in the interwar period, and for as long as the disease was present, tracheostomy remained a treatment option, notably in Britain, where it continued to be the intervention of choice for threatened obstruction. By 1950, however, diphtheria had all but vanished as a public health problem in the West.

Meanwhile tracheostomy was beginning to be applied not to relieve obstruction to the airway, but to assist the use of artificial ventilation, for example in cases of paralytic poliomyelitis, head injuries, chest injuries, and barbiturate poisoning.

Tracheostomy remains a routine procedure in intensive therapy units when prolonged connection to an artificial ventilator is required. In other instances, permanent tracheostomy allows a person to breathe for himself after operation for cancer of the larynx.

— Anne Hardy

1. the formation of an opening into the trachea and the suturing of the edges of the opening to an opening in the skin of the neck. 2. surgical formation of an opening into the trachea, usually through the tracheal rings below the cricoid cartilage, to give the patient an airway.

Creation of an opening into the trachea through the neck, with insertion of an indwelling tube to facilitate passage of air or evacuation of secretions. The procedure may be an emergency measure or an elective one.

• t. tube — two identical down-curving, semicircular tubes are fitted one inside the other. They both have wide flanges which fit against the skin when the tubes are inserted in and down through the tracheostomy incision. When the tubes are snugly in position the inner tube is rotated through 180° making the tube self-retaining.