A tracheostomy is a surgical procedure that creates a new pathway for air, allowing a person to breathe directly through the neck instead of the nose and mouth. This common medical intervention is performed when the natural airway is compromised. This article explains what a tracheostomy is, why it is needed, and what it means for daily life and recovery.
Defining the Tracheostomy
A tracheostomy is established by a surgeon making an opening, called a stoma, through the front of the neck and into the trachea (windpipe). This stoma allows air to move directly into the lungs, bypassing the upper airway structures. To keep this new passage open and stable, a curved, hollow device known as a tracheostomy tube, or “trach tube,” is inserted.
The trach tube has several specialized components. The main structure remaining in the trachea is the outer cannula, secured against the neck by a flange or neck plate. Many tubes also contain a removable inner cannula that locks into the outer tube and can be taken out for regular cleaning. This dual-cannula design is helpful for maintenance, as it prevents mucus buildup from blocking the airway.
Trach Tube Components
Some tracheostomy tubes feature an inflatable balloon, called a cuff, located at the end of the outer cannula. When inflated, this cuff seals the space between the tube and the tracheal wall. This seal ensures all delivered air goes into the lungs, such as when connected to a ventilator, and helps protect the lower airway from secretions or inhaled food. Tubes without a cuff are often used for patients who are breathing independently and are not at high risk for aspiration.
Medical Reasons for Placement
The need for a tracheostomy arises when the natural airway is blocked, requires long-term support, or needs protection from foreign material.
Airway Obstruction
One primary reason for placement is a blockage of the upper airway that prevents normal breathing. Causes include swelling from a severe allergic reaction or injury, a tumor in the throat or larynx, or conditions that narrow the windpipe, such as subglottic stenosis. In these situations, the tracheostomy immediately provides a route for oxygen to reach the lungs.
Prolonged Ventilation
Another frequent indication is the requirement for prolonged mechanical ventilation, often after a patient has been on a breathing machine for one to two weeks. Placing a tracheostomy tube instead of an endotracheal tube (which goes through the mouth or nose) is safer and more comfortable for long-term use. This alternative pathway reduces potential damage to the vocal cords and simplifies the management of respiratory secretions.
Airway Protection
Airway protection is necessary for individuals who have difficulty managing their own secretions or swallowing due to neurological conditions or paralysis. The tube helps prevent the accidental inhalation of food or saliva, known as aspiration, which can lead to severe lung infections. The procedure can be performed as an emergent intervention or as a planned, elective surgery.
Daily Care and Communication
Maintaining the tracheostomy is central to daily life to ensure the airway remains open and free from infection.
Tracheostomy Care
A routine aspect of care involves suctioning, which is the gentle removal of mucus and secretions from the trachea using a specialized catheter. Because the tube bypasses the natural filtration and humidification of the nose, the body often produces thicker secretions that must be cleared regularly to prevent a plug from forming.
For tubes with an inner cannula, this component must be removed and cleaned multiple times daily or replaced with a new disposable one. This practice is important for maintaining the diameter of the airway and preventing the buildup of dried mucus. Care of the stoma site involves gently cleaning the skin around the opening with saline to remove drainage and prevent irritation or infection.
Communication
A significant concern for new patients is the ability to speak, as the air used to create sound bypasses the vocal cords through the tube. Devices known as speaking valves can restore a person’s voice. A speaking valve attaches to the end of the tracheostomy tube, opening to allow air in, but closing upon exhalation. This directs the exhaled air upward around the tube and through the vocal cords, enabling speech.
The use of a speaking valve requires the cuff to be completely deflated or the use of a cuffless tube to allow air to pass freely up to the larynx. When a speaking valve is not in use, patients communicate using writing, communication boards, or briefly covering the end of the tube with a finger to divert air upward. Speech-language pathologists help patients adjust to new speaking methods.
Long-Term Outlook and Decannulation
For many patients, a tracheostomy is a temporary measure, only needed until the underlying medical issue is resolved. The process of removing the tube is known as decannulation, which is gradual and carefully monitored. Decannulation can begin once a patient no longer requires mechanical ventilation, their upper airway is stable, and they can manage their own secretions.
The first step in decannulation often involves a trial of capping, where the tube is temporarily closed off with a cap or plug. This forces the individual to breathe through their natural upper airway, proving the passage is clear and functional. If the patient tolerates capping for a prescribed period, the tube can then be removed completely.
Once the tube is taken out, the stoma in the neck is typically covered with a sterile dressing. The opening is not sutured closed; the body’s natural healing process allows the stoma to close on its own, usually within a few days to a couple of weeks. In rare instances, a small surgical procedure may be required if the opening is slow to close. Many patients who undergo decannulation experience a full return to breathing through their nose and mouth.