Source: Tracheostomy teaching.pptx (12 slides) Date: September 2023 Learning Level: 🟢 Foundation through 🔴 Advanced
1. What Is a Tracheostomy?
🟢 Foundation
“The surgical formation of an opening into the trachea through the neck especially to allow the passage of air.”
Breathing is conducted through the artificial airway in place of the patient’s own upper airway.
2. Indications for a Tracheostomy
🟢 Foundation
Tracheostomies are indicated across several clinical categories:
2.1 Airway Patency
| Indication | Notes |
|---|---|
| Tumours | Obstructing upper airway |
| Tracheomalacia | Weakness/collapse of tracheal walls |
| Foreign body obstruction | When other methods of removal have failed or airway cannot be maintained |
| Subglottic stenosis | Narrowing below the vocal cords |
| Epiglottitis / croup (infection) | Severe upper airway infection causing obstruction |
| Vocal cord paralysis | Bilateral paralysis causing airway compromise |
| Obstructive sleep apnoea (OSA) | Severe cases unresponsive to other treatments |
| Treacher Collins or Pierre Robin Syndromes | Congenital craniofacial abnormalities causing airway compromise |
| Burns to upper airway | Thermal or chemical injury |
| Congenital abnormalities to upper airway | Structural abnormalities present from birth |
| Neck or mouth injuries | Traumatic injury compromising the airway |
| Anaphylaxis | Severe allergic reaction with airway compromise |
2.2 Dependency on Long-Term Ventilation (LTV)
| Indication | Notes |
|---|---|
| Spinal cord injury | High-level injury affecting respiratory muscles |
| Neuromuscular disease | Progressive weakness of respiratory muscles |
| Long-term unconsciousness | Prolonged need for ventilatory support |
| Disorders affecting respiratory control | e.g. Congenital Central Hypoventilation Syndrome (CCHS) |
2.3 Lung Conditions
| Indication | Notes |
|---|---|
| Bronchopulmonary dysplasia (BPD) | Chronic lung disease of prematurity |
| Chronic pulmonary disease | Ongoing respiratory insufficiency |
2.4 Secretion Management
| Indication | Notes |
|---|---|
| High secretion load | Inability to manage secretions with non-invasive methods |
| Frequent aspirations | Recurrent aspiration events |
| Poor clearance | Ineffective cough/secretion clearance despite intervention |
3. Types of Tracheostomy Insertion
🟡 Intermediate
3.1 Surgical Tracheostomy
A formal surgical procedure:
- An incision is made in the skin just above the sternal notch
- Just below the thyroid, the membrane covering the trachea is divided
- The trachea itself is cut
- A cross incision is made to enlarge the opening
- A tracheostomy tube is put in place
3.2 Percutaneous Tracheostomy
A minimally invasive approach:
- Often completed in ITU
- Small cut made to visualise the trachea
- Cannula inserted into the trachea
- Guide wire passed into the trachea
- Opening into the trachea is dilated
- Tracheostomy tube is inserted
4. Types of Tracheostomy Tubes
🟡 Intermediate
4.1 Cuffed vs Uncuffed
| Feature | Uncuffed | Cuffed |
|---|---|---|
| Use in paediatrics | Most common type in paediatric population | Used when specific indications require |
| Airway trauma | Minimises airway trauma and granulation | Overinflation can cause trauma to airway mucosa |
| Lower airway protection | Does NOT provide protection to lower airway — need to manage oral secretions well | Provides protection to lower airways |
| Tube stability | Standard fixation | Helps to hold tube in place |
| Ventilation | May have air leak around tube | Allows for optimal delivery of positive pressure |
| Cuff pressure monitoring | N/A | Pressures should be checked twice daily |
4.2 Single Lumen vs Dual Lumen
| Feature | Single Lumen | Dual Lumen |
|---|---|---|
| Use in paediatrics | Most common type in paediatric population | Often used in adult population |
| Airway diameter | Allows for maximal airway diameter to reduce airway resistance | Reduced internal diameter due to inner cannula |
| Blockage management | If blockage occurs, requires tracheostomy change | Inner cannula is regularly changed throughout the day to prevent obstruction and blockage |
4.3 Paediatric-Specific Tube Types
| Tube | Material | Key Features |
|---|---|---|
| Bivona Flextend | Silicone | Most common type in paediatric population; changed once monthly; allows for flexible movement at extended flange |
| Shiley | PVC (rigid) | Should always be one present in the emergency tracheostomy box |
Clinical Pearl: A Shiley tube (rigid PVC) should ALWAYS be available in the emergency tracheostomy box, even if the child routinely uses a Bivona. This is because in an emergency, the rigid tube is easier to insert.
5. New Tracheostomy Management
🟢 Foundation / 🟡 Intermediate
Critical clinical information for post-insertion care:
| Parameter | Guideline |
|---|---|
| Suction frequency | Every half an hour initially — higher secretion load due to body adapting to foreign body in airway |
| Bloodstained secretions | Can be typical in first few hours post insertion. If there is excessive bleeding or this persists, ENT should be notified |
| Humidification | Patients should be left on a humidified system |
| First tracheostomy change | Usually completed after 5-7 days post insertion |
6. Tracheostomy Weaning Considerations
🔴 Advanced
Weaning from a tracheostomy requires an MDT approach and careful assessment:
6.1 Pre-Weaning Assessment
- Consider initial reasoning for tracheostomy — has this been resolved?
- MDT approach involving:
- Respiratory medicine
- ENT (Ear, Nose and Throat)
- SLT (Speech and Language Therapy)
- Physiotherapy
6.2 Weaning Steps
| Step | Details |
|---|---|
| Optimisation of ventilation | In accordance with sleep studies |
| Speaking valve trials | Assessing ability to tolerate airflow through upper airway |
| Circuit transition | Monitoring time on set circuit vs dry circuit |
Key Principle: Tracheostomy weaning is a multidisciplinary decision. The physiotherapist’s role includes assessment of secretion management capacity, respiratory muscle strength and exercise tolerance.
7. Cross-References to Other Modules
- Deep suction (see 01-deep-suction.md): Tracheostomy patients require regular suctioning, including inline suction with sterile technique. Understanding suctioning principles is essential for tracheostomy care.
- Nebulisers and saline instillation (see 03-nebulisers-and-saline-instillation.md): Ventilated tracheostomy patients may require nebulised therapies and saline instillation for secretion management. Humidification via the tracheostomy circuit is a key consideration.