In this article Dr Alexia Paolineli, Speciality Registrar, and Dr Ed Burdett, Consultant Anaesthetist at University College London Hospitals, present the nomenclature of altered airways, the indications for insertion and some important characteristics.
The care of patients with tracheostomies and laryngectomies is high-risk and often causes anxiety. “Neck breathing” patients may look similar but it is important to recognise that their airways can be altered in different ways.
A tracheotomy (derived from two Greek words meaning trachea + cut) is the surgical procedure which forms the tracheostomy.
A tracheostomy (derived from two Greek words meaning trachea + mouth or opening) is a hole in the trachea created to protect the airway and/or facilitate ventilation or weaning. In principle, in a patient who has had a tracheostomy, the airway is still accessible via the mouth and nose (upper airways).
A tracheostomy tube is the piece of equipment, or device which is inserted into the trachea through the hole in the neck (stoma). There are different types of tracheostomy tubes, they may have specialised functions.
A laryngectomy is a procedure to remove the larynx and bring the trachea forward to an opening in the neck. This leads to complete isolation of the lower airways from the upper airways. It is often impossible to differentiate a tracheostomy from a laryngectomy stoma simply by looking at it.
Patients who have had a total laryngectomy, do not have a connection between the mouth and/or the nose and the lower airways. They can only be oxygenated through the stoma in their neck.
Globally, over 100,000 tracheostomies are performed each year. Many are only required for a short period of time, whereas some may remain long-term. Laryngectomies are irreversible and far less common. Their incidence is declining as other less invasive treatments develop. In this table we summarise a list of indications for each type of procedure:
|To bypass an upper airway problem or obstruction – for example tumour, trauma or major surgery||Tumours, benign or malignant|
|Protection against airway soiling in patients with impaired swallowing||Laryngeal stenosis, often after trauma|
|Management of airway secretions for patient who cannot cough adequately||Bypassing a non-functional larynx, to avoid recurrent aspiration|
|Prolonged mechanical ventilation for respiratory failure.|
|Failed airway management, Can’t Intubate, Can’t Oxygenate, requiring emergency FONA|
Types of tracheostomy tubes
A variety of tubes are available for paediatric and adult patients. Names and characteristics differ between manufacturers.
Standardising tubes within institutions reduces the risk of confusion and we advise to become familiar with the types and makes of tracheostomies available in your workplace.
Answering the following questions, may help in creating a simple classification system:
1.Is there a cuff? When the cuff is inflated, it creates a seal which allows positive pressure ventilation and prevents secretions from the upper airways soiling the lungs.
Cuffed tracheostomy tube
2.Is there an inner tube? An inner tube provides a safety mechanism: if the tracheostomy tube is blocked by secretions or blood, the inner tube can easily be removed. Note: paediatric tubes rarely have an inner tube.
Tracheostomy tube with inner tube, non-fenestrated and fenestrated
3.Is there a fenestration? A fenestration allows air to flow from the lower airways to the upper airways, helping with the production of voice. A non-fenestrated inner tube can be used with a fenestrated tube to allow positive pressure ventilation.
Some tracheostomy tubes have an adjustable flange so the length can be altered to fit very large or small necks. They may have speaking valves and caps and catheters to provide subglottic suction; there are even double-lumen tracheostomies which allow lung isolation techniques.
Tracheostomy with subglottic suction catheter
Although connections are standardised, some tracheostomies, such as older silver Negus tubes, or some models without their inner cannula, cannot be connected to a standard 15mm ventilation circuit. These need to be changed if positive pressure ventilation is required.
Tracheostomies and laryngectomies bypass the upper airways, leading to several anatomical and physiological changes. The filtration and humidification of gases by the nose is lost, and the shortened respiratory tract results in a reduced dead space and resistance to breathing. Swallow and speech are impaired as the vocal cords are bypassed, fenestrated or uncuffed tubes and speaking valves allow phonation to occur and form part of weaning.
Removing a person’s voice has important consequences; patients may feel very vulnerable as they can’t communicate verbally and they can’t attract attention easily when they need it. Laryngectomy patients may use an electrolarynx or tracheo-oesophageal prosthesis (TEP), a small valve inserted between the trachea and oesophagus, often visible in the posterior wall of the stoma. This allows air to travel through the trachea and the upper airways when the stoma is occluded. Taste and smell are reduced if the pharynx is bypassed.
Medium to long-term complications of tracheostomies include the development of scarring, strictures and psychological effects. Patients suffering from these changes require holistic support from the multidisciplinary team, and this will be discussed later this week.
You may want to read the articles below for a more in depth overview of tracheostomies. You may also want to have a look at the Anatomy activity in Week 1 to remind yourself of the main structures of the front of the neck. In the Download section you will find an infographic summary on altered airways
In the next step we will learn how tracheostomies are formed.