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Tracheotomy (Tracheostomy)

A tracheotomy is a surgically created passage through the midline of the lower part of the neck into the trachea. That surgical opening is held open by a tracheotomy tube.

The tracheotomy provides a “back door” into the airway, allowing air directly into the trachea and down into the lungs. It may be performed because of a blockage of the upper airway by tumor or other swelling. Or it may be installed in patients who require long-term mechanical ventilation.

If the tracheotomy is no longer needed, the passage / opening usually closes completely after removal of the tracheotomy tube, leaving a scar where it entered the skin.

Tracheotomy vs. Tracheostomy

A similar term—tracheostomy—is used interchangeably with tracheotomy, though technically a tracheostomy should refer to a surgical opening created in a way that makes the opening permanent, and often not requiring a tube to keep the passageway open.

Tracheotomy Care: Mucus Plugs

Why do they occur?

Usually because of:

Insufficient fluid intake/ Dehydration, causing thick or crusted mucus
Insufficient use of saline “squirts.”
Insufficient cleaning of the inner cannula often enough.
Very low humidity, such as in Winter, in desert climes, or during long airline flights.

How do we respond in general if mucus plugs are tending to occur?

Hydrate copiously (at least 8 glasses of liquid per day).
Use the saline squirts regularly and frequently. I usually say “not more than 50 times a day” to make the point that one can use many of these.
Use a bedside humidifier in the Winter, when it is very cold outside, IF the saline squirts are not worlking well enough.
Remove and clean the inner cannula more frequently to “stay ahead” of the mucus.

How do we respond if there is a sudden (unexpected) mucus plug that is partial-just causing noisy breathing but no anxiety?

Cough a series of times.
Squirt some saline, and cough again (20 seconds or so).
Squirt again, and cough again (20 seconds or so).
Repeat 2 and 3 as many times as desired.
If you don ‘t produce the mucus and the noisy breathing continues, remove the inner cannula, run tap water through it and if that dislodged the plug, then replace the inner cannula.
If you can’t simply dislodge with running water, proceed to hydrogen peroxide and brush, rinse, and replace.

What if there is a sudden, nearly complete blockage of the trach tube?

Remove the inner cannula.
If that resolves the problem, run tap water through it and if that dislodged the plug, replace the inner cannula.
If you can’t simply dislodge with running water, proceed to hydrogen peroxide and brush, rinse, and replace.

Hands-Free Tracheoesophageal Voice

After laryngectomy, most people prefer to glue a small voice button over the stoma that they push when they wish to speak. When not pushed, the button springs up and allows air into the trachea.

This person is instead using a hands-free valve. He can initiate voice by beginning each sentence with a little “kick” of exhaled air that closes a flexible diaphragm and diverts pulmonary air through the TEP device and into the pharyngoesophageal segment.

Hands-Free TEP when breathing

Here is the hands-free device during quiet breathing. It is attached with a biological glue to the skin that surrounds the stoma. When this man breathes in, the path of air follows the arrows into the “open white crescent” on either side of the tan flutter valve. When he breathes out normally, the air travels though the same space in the opposite direction.

Hands free TEP during voicing

If he “kicks” the air out slightly, the curled diaphragm unfurls in an outward direction and plugs the passage, so that air is diverted through the tracheoesophageal prosthesis (not seen here). The result: hands-free tracheoesophageal voice.

Tracheal Deformity After Tracheotomy

This man had a grave and life-threatening illness that required mechanical ventilation in an ICU for about 3 months. The initial weeks were through an oro-tracheal tube (a tube placed through the mouth, between the vocal cords, and into the trachea); the remaining 2 ½ months were via a tracheotomy (breathing tube inserted through the base of the neck directly into the trachea).

Now out of hospital for many months, he has a barking cough, and occasionally mild harsh inspiratory noise.

No breathing tube damage on the vocal cords (1 of 5)

First of all, we see that the initial oro-tracheal breathing tube did not do visible damage at the level of the vocal cords. And this correlates with his essentially normal voice.

Airway is narrowed below vocal cords (2 of 5)

Viewing from immediately below the vocal cords, it appears that the airway is exceedingly narrowed. That is because we are looking “in line” but the trachea takes a sharp bend. Air of course does not mind traveling in curves, and this explains why the patient is breathing better than this “in-line” photo might suggest.

Airway lumen is bigger and deformed — Deformed airway (3 of 5)

Viewing a little closer, one can see that the airway lumen is bigger than it appears, but just deformed and deviated.

distinctly narrowed but not marginal airway (4 of 5)

Even closer, showing a distinctly narrowed but not marginal airway, explaining why this man chose not to undergo tracheal resection and repair.

Carina is normal (5 of 5)

The distal-chip scope is passed through the area of stenosis. This man is aware that airway is further narrowed by this sharing with the scope, but he is not “panicked” as he would be momentarily if his airway were truly marginal. In a case like this, it is crucial to make sure that there isn’t a second area of narrowing; here there is not as distal trachea to the carina (C) is normal.

Nuances of Endotracheal Tube Injury

This woman with high-risk comorbidities of diabetes and obesity, was in ventilated in ICU more than a month for pulmonary complications of Covid-19 infection. She had an orotracheal tube in place for 3.5 weeks, and then a tracheotomy tube was placed.

Now at her first visit a year later, she remains tracheotomy-dependent, and is told she has bilateral vocal cord paralysis (disproven in the following photo series).

Maximum glottic opening (1 of 8)

Is it paralysis, as diagnosed elsewhere? At a fairly distant view, the maximum opening between the vocal cords at any phase of breathing appears to be approximately a 4mm glottic opening.

Undersurface mucosa indraws (2 of 8)

When the patient inspires rapidly with tracheotomy tube plugged, the vocal cord undersurface mucosa indraws (grey bands at dotted lines), further narrowing the glottic chink. One sees a faint suggestion of breathing tube injury (divot) at the arrow. Notably, there is a very low pitched rumbling sound heard that does not come from the glottis.

vocal cords approximate fully — Phonation (3 of 8)

During phonation, the cords approximate fully, and in fact the voice is remarkably normal-sounding and she even has an excellent upper range.

Posterior commissure divot (4 of 8)

At close range while breathing with trach plugged, the posterior commissure divot subtly visible in Photo 2 is confirmed. A divot in the right posterior cord “always” indicates that the tube was taped to the left corner of the mouth. The patient’s mother confirmed that this was so.

Further evidence of scarring (5 of 8)

Angling farther posteriorly, additional evidence of inter-arytenoid and possible joint capsule injury is seen. Faint dotted lines outline this area. The problem is not bilateral vocal cord paralysis but posterior commissure scarring, tethering the arytenoids together.

membranous trachea moves in and out with respiratory phase — View into trachea (6 of 8)

Looking now into the subglottis and trachea, there is narrowing only at trach entry site, accentuated functionally because the membranous trachea (MT) moves in and out with respiratory phase.

Vibration of trachea (7 of 8)

When the patient plugs the trach tube and inspires rapidly, the deep rumbling sound is again heard, and comes from vibration of the membranous trachea indrawing (arrows) and vibrating (zigzag line).

Open trachea beyond the tube (8 of 8)

A view past the tip of the trach tube shows no secondary area of tracheal stenosis.

The plan here is posterior commissuroplasty, followed by placement of a smaller trach tube and a trial of plugging. If plugging is tolerated during the day, she will need a sleep study with it plugged at night, given the tracheomalacia and her obesity.

A Fenestrated Tracheotomy Tube allows Voicing when there Is Stenosis

View below vocal cords (2 of 4)

The tip of the scope has been taken below the vocal cords. Note the fenestrated tracheotomy tube within the high trachea.

Fenestra (3 of 4)

When the patient plugs her trach tube with a finger, air comes into the distal tip of the tube (dark circle within the tube), passes up and out of the fenestra (window) and can power the vocal cords which are above our view. The trachea surrounds the tube as a whole without any “blow-by”. If there were no fenestra, the patient would be unable to speak.

circular scar in esophagus — Patient post-trach (4 of 4)

After tracheal resection and re-anastomosis, the tracheotomy is no longer needed. The circular scar is at the dotted line. The M denotes overlying mucus. The patient now breathes normally.

Trach Front Profile

In a tracheotomy, breathing is achieved through the stoma and not the mouth or nose.

How to Change a Tracheotomy Tube

Ideally, the person wearing a tracheotomy tube will do his or her own changes and cleaning...

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Tracheotomy (Tracheostomy)

Tracheotomy vs. Tracheostomy