What are the parts of a tracheostomy tube?

In 1543, Andreas Vesalius (1514-1564) described how he breathed for a animals by blowing into a reed inserted into their necks through a tracheal opening. This was one of the first descriptions of a tracheostomy tube.  By the 19th century the operation of tracheotomy was perfected, and tracheostomies resembled those used today.

Since we have already discussed the procedure of tracheotomy and the basic indications for them, this post will cover the basics of the tracheostomy tubes themsevles.

1.  What is a tracheostomy tube?  This is a small, hollow tube inserted into a stoma created by a tracheotomy.

2.  What does a tracheostomy tube 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.

3.  What is a fenestrated tracheostomy?  What are the benefits and disadvantages of it?  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.

4.  What are the different types of tracheostomies?  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.  

5.  What is an inner cannula?  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.  

6.  How can a person with a trach speak?  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.  

7.   What is a tracheostomy cuff? When is it needed and when should it be inflated?  When should it be deflated?   A cuff will irritate the trachea, and therefore should not be used unless needed for positive pressure breaths. It also allows a place for secretions to pool, and therefore increases the risk of micro-aspiration of secretions, increasing the risk for lung infections.  The only reason a cuffed tracheostomy is necessary is when positive pressure breaths are indicated. When a person is receiving positive pressure breaths, whether by AMBU-bag, BiPAP, or mechanical ventilator, it is necessary to inflate the cuff. This is necessary to prevent air from leaking around the tube in order so the patient receives an adequate breath or tidal volume.  If a patient is not receiving positive pressure breaths the cuff, if there is one, should be deflated.  For patients who require positive pressure ventilation, the lowest possible cuff pressure should be used to inflate the cuff, and it should be deflated four times a day to prevent tracheal necrosis

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Why are tracheostomies better than endotracheal intubation?

The general recommendation for the management of patients who require endotracheal intubation and mechanical ventilation is to extubate as soon as possible.  However, in the event a ventilator is required long term, the experts recommend the patient be trached after seven days.  

Why is this?  What are some advantages of tracheostomy over intubation? 

What follows are the essential advantages of tracheostomy over intubation:

• 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

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What is a tracheotomy? What are the indications?

Tracheotomy is one of the oldest surgeries performed by mankind.  There is written evidence the procedure was performed on a person suffocating from an upper airway obstruction as early as 4,000 B.C. The operation was a last ditch effort to save a life.

Today the procedure is safer and more common than ever before.  The following are some of the basic terms to describe the procedure.

What is a tracheotomy:  An opening or stoma made by the incision in the neck.

What is a stoma:  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.

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

What is a tracheostomy tube:  This is a small, hollow tube inserted into a stoma created by a tracheotomy.

Who performs the operation of tracheotomy and tracheostomy insertion? The procedure of tracheotomy is usually performed in a sterile environment such as in an operating room by a surgeon, however an emergency trach can be inserted just about anywhere by any trained professional.  Any hollow tube can be used as a tracheostomy in emergency procedures.  An incision is made through the crichoid cartilage between the 2nd and 4th tracheal rings.

What are the indications for tracheostomies? There are a variety of indications:

• To reduce resistance to breathing: Anything that may cause the upper airway to become obstructed increases airway resistance, making it hard to inhale or exhale.  Diseases that may obstruct the upper airway include epiglotitis, cancer, foreign object, paralysis of vocal cords, and trauma. By making the airway shorter resistance is reduced.  By creating a shorter airway and thereby reducing resistance, the procedure may be beneficial to patients with end stage emphysema, chronic bronchitis, severe pneumonia or chest injury
• 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 the throat.  It's also improves infection control and facilitates weaning from a ventilator. 
• Respiratory muscle paralysis. Various neuromuscular disorders such as polio myelitis, amyotrophic lateral sclerosis,  stroke, muscular dystrophy may inhibit the ability to breathe and closed head injury. 
• Enhance secretion clearance:  Some diseases, such as chronic bronchitis, cystic fibrosis and pneumonia may cause thick secretions that are difficult to expectorate.  A tracheotomy creates an easy access route for expectorating and suctioning the airway.  It may also enhance a cough, making it easier to clear the airway

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4000-2000 B.C: The birth of tracheotomy

Perhaps as back as 4,000 years before the birth of Christ some mother grappled for something to do as she watched her child struggle for breath and stop breathing.  She had already chanted incantations, and even called the medicine man, so she placed her mouth over the boy's mouth, and exhaled.  She watched as his chest expanded.  This would have been the first attempts at mouth to mouth breathing.

This first effort probably failed, although it would have at least given the child a chance, albeit a small a small chance.  The medicine man watching this was touched by the mother's efforts, and he used it on a child a year later, only this time it worked.  Yet it never worked again.  Still, he shared this information with his son, who passed it along to his children.

The above story is fictional, although it shows how such wisdom may have been obtained and shared through the annals of time. Such stories, and such medical knowledge, would have been recorded as soon as a written language was invented, first in ancient Mesopotamia and later in Egypt.  Now, for the first time ever, such wisdom could be taught in schools, and later expounded upon.

There is some written evidence that tracheotomies were performed as early as 4,000 B.C. (1, page 222) This is a procedure where a small opening was cut into the trachea of a person who was suffocating, usually due to an upper airway obstruction.  The procedure was usually a last ditch effort to help someone breathe better.

In 2000 B.C. Ancient Hindu medicine mentioned "throat incision," and about 1500 B.C. the ancient Egyptiann architect, scribe and physician Imhotep became the first mention the procedure in writing. While his original works are lost to history, we learn about his thoughts by later writers who would have had access to his original works.  (1, page 222)

This operation would have been among the first ever performed, although chances are there was a low success rate.  Patients who survived the operation probably died later on due to the unintentional introduction of pathogens into the blood stream.  Still, if nothing was done the patient would have died anyway, so this at least gave the patient a fighting chance, albeit a small one.

References: 

1. Szmuk, Peter, eet al, "A brief history of tracheostomy and tracheal intubation, from the Bronze Age to the Space Age," Intensive Care Medicine, 2008, 34, pages 222-228
2. Price, J.L., "The Evolution of Breathing Machines," Medical History, 1962, January, 6(1), pages 67-72; Price references The Bible, Kings, 4: 34 
3. Fourgeaud, V.J, "Medicine Among the Arabs," (Historical Sketches), Pacific medical and surgical journal, Vol. VII, ed. V.J. Fourgeaud and J.F. Morse, 1864, San Fransisco, Thompson & Company,  pages 193-203  (referenced to page 198-9)
4. "Biographical Dictionary of the society for the diffusion of useful knowledge," Longman, Brown, Green and Longmans, volume III, 1843, A. Spottingwood, London, page 124-5
5. Garrison, Fielding Hudson, "An introduction to the history of medicine," 1922, Philadelphia, W.B. Saunders Company
6. Lee, W.L., A.S. Stutsky, "Ventilator-induced lung injury and recommendations for mechanical ventilation of patients with ARDS," Semin. Respit. Critical Care Medicine, 2001, June, 22, 3, pages 269-280
7. Tan, S.Y, et al, "Medicine in Stamps:  Paracelsus (1493-1541): The man who dared," Singapore Medical Journal,  2003, vol. 44 (1), pages 5-7
8. Ball, James B, "Intubation of the Larynx," 1891, London, H.K. Lewis
9. Hill, Leonard, Benjamin Moore, Arthur Phillip Beddard, John James Rickard, etc., editors, "Recent Advances in Physiology and bio-chemistry," 1908, London, Edward Arnold

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