Key Facts

A tracheostomy is an artificial opening created in the anterior wall of the trachea to provide a secure airway. It may be temporary or permanent. Safe tracheostomy care is a core competency for healthcare professionals in acute and community settings.

Epidemiology

• Approximately 15,000 temporary tracheostomies performed annually in the UK
• Approximately 5,000 patients with permanent tracheostomies (post-laryngectomy)
• ICU: 10-24% of ventilated patients require tracheostomy

Aetiology/Indications

• Prolonged mechanical ventilation: failed weaning from endotracheal tube (most common ICU indication)
• Upper airway obstruction: tumour, angioedema, bilateral vocal cord palsy, facial trauma, burns
• Airway protection: aspiration risk (bulbar palsy, severe neurological injury)
• Secretion management: inability to clear secretions (neuromuscular disease, spinal cord injury)
• Post-surgical: total laryngectomy (permanent), major head and neck surgery

Types

• Surgical tracheostomy: open procedure, horizontal incision between 2nd-4th tracheal rings, performed in theatre
• Percutaneous dilatational tracheostomy (PDT): Seldinger technique (Ciaglia), performed at bedside in ICU under bronchoscopic guidance
• Temporary: cuffed or uncuffed tube; plan for decannulation
• Permanent: total laryngectomy (no connection between trachea and pharynx - cannot be ventilated via mouth/nose)

Normal Tracheostomy

• Patent, well-positioned tube
• Clean stoma site without erythema, swelling, or discharge
• Effective cough and secretion clearance
• Inner cannula clean
• Appropriate cuff management

Complications

• Early (<7 days): haemorrhage, tube displacement (DANGEROUS before tract matures), subcutaneous emphysema, pneumothorax, tube occlusion
• Late (>7 days): tube occlusion (secretions), granulation tissue, tracheal stenosis (most common long-term complication), tracheo-innominate fistula (life-threatening haemorrhage), tracheo-oesophageal fistula, stomal infection

Red Flags - Tracheostomy Emergency

• Unable to ventilate through tracheostomy tube
• Tube displacement or dislodgement
• Massive haemorrhage from stoma (tracheo-innominate fistula)
• Increasing respiratory distress, desaturation
• Subcutaneous emphysema
• Inability to pass suction catheter (tube obstruction)

Bedside

• Observations: SpO2, RR, work of breathing
• Suction catheter passage: if passes easily, tube patent; if resistance, possible obstruction or displacement
• Cuff pressure check (20-25 cmH2O)
• Capnography: confirm ventilation through tube
• Check bed-head sign: tube type, size, date of insertion

Bloods

• ABG: if respiratory compromise
• FBC, CRP: if stomal infection suspected

Imaging

• CXR: post-insertion (confirm position, exclude pneumothorax)
• CT neck/airway: for suspected tracheal stenosis, granulation, tube malposition
• Bronchoscopy/nasendoscopy: for tracheal assessment, granulation, stenosis

Special Tests

• Cuff leak test: assess readiness for decannulation
• Swallow assessment (SALT): before cuff deflation and oral intake
• Fibreoptic assessment through tracheostomy tube: for tracheal pathology

Routine Tracheostomy Care

• Inner cannula: remove, clean, and replace at least 4-6 hourly and as needed
• Suctioning: use aseptic technique; pre-oxygenate; suction catheter should not exceed half the internal diameter of the tracheostomy tube
• Humidification: essential to prevent secretion crusting; heat-moisture exchanger (HME/'Swedish nose') or heated humidification
• Stoma care: clean around stoma BD with saline; change tapes/ties; assess skin integrity
• Cuff management: maintain cuff pressure 20-25 cmH2O; deflate when no longer needed for ventilation or aspiration protection
• Communication: speaking valve (Passy-Muir) for patients with cuff deflated and able to breathe around tube

Tube Changes

• First tube change: at 5-7 days (allows tract maturation); performed by experienced clinician
• Subsequent changes: every 7-30 days depending on tube type and clinical need
• Always have replacement tube (same size and one size smaller) available
• Stay sutures or tracheal dilators at bedside for first 7 days

Emergency Management (NTSP Algorithm)

1. Call for help: 2222 (emergency), ENT/anaesthetics
2. Assess patency: remove inner cannula, attempt suction
3. If unable to ventilate through tracheostomy: deflate cuff, remove tube
4. Attempt oral/nasal ventilation: cover stoma, head-tilt-chin-lift, bag-valve-mask
5. If laryngectomy (permanent stoma): can ONLY ventilate via stoma - do NOT attempt oral ventilation
6. Advanced airway: re-insert tracheostomy tube or intubate (oral or via stoma)

Decannulation

• Multidisciplinary assessment (medical, SALT, physiotherapy, nursing)
• Criteria: underlying indication resolved, able to protect airway, effective cough, cuff deflation tolerated, passed swallow assessment
• Downsize tube, then cap/occlude for 24-48 hours; decannulate if tolerated
• Monitor for 24-48 hours post-decannulation

Referral Criteria

• ENT/airway team: for difficult tube changes, granulation tissue, suspected tracheal stenosis
• SALT: for swallow assessment before oral intake and speaking valve use
• Physiotherapy: for chest physiotherapy and secretion management

• Most temporary tracheostomies are successfully decannulated
• Tracheal stenosis: most common long-term complication; occurs in 1-2% of tracheostomies; may require surgical intervention (tracheal resection and anastomosis)
• Tracheo-innominate fistula: rare but life-threatening; mortality >50% despite intervention
• NCEPOD 2014: identified significant avoidable deaths from tracheostomy complications, leading to national safety initiatives
• Decannulation: successful in >80% of patients who no longer require the tracheostomy
• Stomal wound typically closes within 5-7 days after decannulation
• Permanent tracheostomies (post-laryngectomy): lifelong management required

National Tracheostomy Safety Project (NTSP) Bed-Head Signs

Tracheostomy Emergency Algorithm Summary

Tracheostomy vs Laryngectomy - Critical Difference