What is a tracheostomy?

Your humble question:  What is a tracheotomy and why is it needed?

My humble question:  A tracheostomy is a small hole or stoma in your neck -- your windpipe -- that the person can breathe through.  It's usually temporary, yet in some cases it can be permanent.

Your question:  Who inserts a trach and where and how is it inserted?

My humble answer:  The procedure is usually done in a sterile environment such as in an operating room by a surgeon, however an emergency trach can be inserted just about anywhere.  Any hollow tube can be used in emergency procedures.  An incision is made through the crichoid cartilage between the 2nd and 4th tracheal rings.  

Your humble question:  What are the indications for tracheostomies?

My humble answer:  There are a variety of indications:  

• To create an easy passage for the person to breathe when there is an obstruction of the upper airways caused by disease (epiglotitis, cancer, foreign object, paralysis of vocal cords, and trauma).
• Long term ventilation is required.  This makes it easier to manage the airway and is more convenient to the patient than having an ETT in her throat.  It's also improves infection control.  It also makes it easier to wean some patients off a ventilator.  
• It shortens the airway and makes breathing easier by reducing airway resistance.  This is essential for diseases such as chronic bronchitis, empysema, severe pneumonia or chest injury.
• Respiratory muscle paralysis.  This may be permanent as a result of a disease such as a neuromuscluar disorder such polio or ALS.   It can also be temporary as with head trauma.
• Diseases with thick secretions such as cystic fibrosis or chronic bronchitis associated with pneumonia. This makes it easier to clear secretions.
• Inability to cough and remove secretions, as with a stroke or neuromuscular disorder

Your humble question:  What are the advantages of a tracheostomy?

My humble answer:  There are a variety of advantages:

• More comfortable than an ETT
• Makes it easier to wean a patient off a ventilator
• Reduces need for sedation because it's not as uncomfortable as an ETT
• Reduces risk of trauma to airway as might be causes by an ETT
• Reduces airway resistance to make breathing easier for patients
• Allows patient to breathe when upper airway is swollen or collapses (such as with paralysis caused by neuromuscular disorders or epiglotitis)
• Makes it easier to suction the patient with thick, or copious secretions
• A patient can talk with special trachs

Your question: What does a trach consist of?  What does it come with?

My humble answer:  Most trachs come with three parts:  Outer cannula, Inner cannula, and obturator.  The outer cannula holds the stoma open and it has neck plates that extend on both sides so it can be secured by a velcro trach collar or trach ties.  The inner cannula has a lock to keep it from being coughed out.  It is easily removed so it can be cleaned.  Essentially, the inner cannula makes cleaning easier.  The obturator is used to insert the trach.  It slips into the tube and helps the doctor guide the trach into place.

Your question:  What is a fenestrated trach?  What are the benefits and disadvantages of it?

My humble answer:  It's a trach with holes or fenestrations in the outer cannula that allow air to pass into the upper airway so the patient can cough to remove secretions and talk.  Basically, it allows normal breathing and the ability to speak. It allows a trial of normal breathing and normal talking before a trach is removed, and may also necessary for long term trachs.  To take advantage of the fenestrations the inner cannula must be removed and the cuff (if there is one) deflated.

Your question:  What are the different types of trachs?  

My humble answer:  What trach to use depends on the patient, and trach should be 3/4 the diameter of the patient's trachea.  The following are the types of tracheotomy tubes according to John Hopkins:

• Cuffed with inner cannula:  The inner cannula may be either disposable or reusable.  Cuff should be inflated only for positive pressure breaths.  It must be deflated to use a speaking valve.  
• Cuffless tube with inner cannula:  T'he inner cannula may be either disposable or reusable.  Good trach for people who don't need to be on a ventilator.
• Fenstrated cuffed tracheostomy tube:  This increases the risk for aspiration due to the fenestrations.  The fenestrations also make it difficult to ventilate these patients.  However, good for weaning off trachs and for some patients who want to use a speaking valve. This type of tube is good for long term ventilator patients.
• Fenestrated cuffless tracheostomy tube:  Only used for patients who have difficulty using a speaking valve with the other trach tubes. There are risks associated with using fenestrations, such as aspiration and glanulation formation around the site of the fenestrations
• Metal tracheostomy tubes:  Rarely used.  Cannot use during MRI, and will cause alarm during airport security checks.  

Your question:  What is an inner cannula?

My humble answer: An inner cannula is a cannula inserted into the trach.  It allows for easy maintenance of the trach especially if there are thick secretions.  It also has a universal adaptor on it so the patient can be connected to a Ambubag or ventilator circuit to receive positive pressure ventilation.  

Your question:  How can a person with a trach speak?  

My humble answer:   The patient can speak either if the tube has a speaking valve or if the patient simply covers the opening with a finger.  For this to occur, the outer cuff must be fenestrated.  

Your question:  When should the trach cuff be inflated?  Deflated?

My humble answer:  The cuff, if there is one, should only be inflated during positive pressure ventilation, such as with a ventilator, bagging, or BiPAP.  The only reason a cuffed tracheotomy tube is necessary is when positive pressure breaths is indicated.  A cuff will irritate the trachea, and therefore should not be used unless needed for positive pressure breaths.  It also traps secretions (even when deflated) and can increase rates of infection.  If a patient requires continuous positive pressure ventilation, the cuff should be deflated four times a day to prevent tracheal necrosis and the lowest possible pressure should be used to inflate the cuff.

Your humble question:  What is a stoma?

My humble answer:  Any opening between an internal body part and the external environment.  A colostomy is a form of stoma because it allows feces to bypass the rectum and anis so it can be removed from the body into a clostomy bag.  A tracheotomy is another form of stoma because air can bypass the upper airway.  Stoma is Greek for mouth, in when we refer to a stoma we are generally referring to providing a "mouth" to some internal part.  Generally speaking, when an RT refers to a stoma he's referring to a tracheostomy of any form, either when their is a trach present or when there is simply a hole in the neck.  A tracheostomy is the opening or stoma made by the incision in the neck.

Your question:  So what is a tracheotomy?

My humble answer:    A tracheotomy is the opening or stoma made by the incision in the neck.

Your humble question:  When a tracheotomy is removed, what happens to the hole?

My humble answer:  The hole will seal and seal fast.  It's for this reason if a trach slips out it must be reinserted as rapidly as possible.  A person will continue to have a scar where the incision was.