The question of whether a tracheostomy is “better” than a ventilator presents a misunderstanding of how these two medical interventions relate. A mechanical ventilator is a machine that performs the work of breathing, while a tracheostomy is a surgical opening that serves as an alternate access point for delivering that ventilation. They are not competing treatments; rather, a tracheostomy is often the preferred, long-term method for connecting a patient to the ventilator. The decision to perform a tracheostomy is a choice about how to deliver life-sustaining breathing support.
Mechanical Ventilation: What the Machine Does
Mechanical ventilation is a supportive treatment used when a patient’s spontaneous breathing is inadequate to sustain life, typically due to respiratory failure or neurological impairment. The machine’s primary purpose is to deliver sufficient oxygen to the blood and remove excess carbon dioxide from the body. This intervention is often necessary in cases of severe pneumonia, acute respiratory distress syndrome (ARDS), coma, or conditions that cause respiratory muscle fatigue.
The most common form used in hospitals is positive pressure ventilation, where the machine gently pushes air into the patient’s lungs. Modern ventilators manage the volume and pressure of each breath delivered, ensuring the delicate air sacs in the lungs, called alveoli, remain open and functional.
Specific settings, such as Positive End-Expiratory Pressure (PEEP), are applied to maintain a small amount of pressure in the lungs even at the end of exhalation. This pressure prevents the alveoli from collapsing, which is important in lung injury. The machine takes over the work of breathing, allowing the body to focus its energy on healing the underlying medical condition.
Endotracheal Tube Versus Tracheostomy: Choosing the Airway Access
The initial method of securing an airway in a crisis is almost always the insertion of an endotracheal tube (ETT) through the mouth and into the trachea. This method, known as intubation, is rapid and effective for managing acute, short-term respiratory emergencies. The ETT passes between the vocal cords, temporarily securing the airway and connecting the patient to the mechanical ventilator.
If mechanical ventilation is required for an extended period, generally longer than 7 to 10 days, the ETT becomes problematic. The tube’s presence through the mouth and larynx carries a high risk of laryngeal injury, including vocal cord damage, edema, and potential long-term narrowing of the trachea (tracheal stenosis). The ETT is also uncomfortable, requiring high doses of sedation to prevent accidental extubation.
The tracheostomy procedure creates a small surgical opening, or stoma, directly in the neck below the vocal cords, into which a shorter tube is placed. This bypasses the larynx and vocal cords, significantly reducing the risk of damage. The shorter, wider tracheostomy tube also lowers resistance to airflow, which can reduce the patient’s work of breathing and help facilitate weaning from the ventilator.
Patients with a tracheostomy often require less sedative medication because the tube is more comfortable and stable than an ETT. This reduction in sedation allows for better patient awareness, increased participation in physical therapy, and earlier mobilization. Switching from prolonged ETT to a tracheostomy is associated with a shorter duration of mechanical ventilation and a decreased length of stay in the Intensive Care Unit. The tracheostomy also allows for more effective suctioning and clearance of airway secretions, lowering the risk of ventilator-associated pneumonia (VAP).
Practical Considerations for Tracheostomy Care
The shift to a tracheostomy offers several practical advantages for recovery and quality of life. Communication, which is impossible with a standard ETT, can often be restored using a one-way speaking valve, such as a Passy-Muir valve. This valve attaches to the tracheostomy tube and directs inhaled air into the lungs but forces exhaled air up around the tube and through the vocal cords, allowing the patient to speak.
Swallowing function, which is often impaired in ventilated patients, can also be assessed and managed more easily with a tracheostomy. The speech-language pathology team conducts swallow studies to check for safe consumption. For a speaking valve to be used, the cuff around the tracheostomy tube must be deflated. This deflation allows air to pass over the vocal cords, which is a necessary step for:
- Restoring a sense of smell.
- Restoring a sense of taste.
- Allowing the patient to speak.
- Facilitating the assessment of swallowing function.
For patients transitioning to home care, managing the tracheostomy involves routine cleaning of the stoma and the inner cannula of the tube to prevent infection and blockages. The ultimate goal for most patients is decannulation, the removal of the tube entirely. This process, known as weaning, is gradual and involves trials where the tube is temporarily capped or downsized. The patient must prove they can breathe adequately and manage their own secretions before the surgical opening is allowed to close naturally.