What is a Trach?

The word “trach” (pr. trake) is a shortened term for either a tracheotomy, a tracheostomy or a tracheostomy tube. Tracheotomy (TRA-ke-AW-tow-me) is the surgical procedure that creates a tracheostomy. A tracheostomy (TRA-ke-OS-tow-me) is a surgically created opening at the front base of the neck that creates a pathway directly into the trachea (TRA-kee-ah), or windpipe.

A tracheostomy tube is usually placed into this opening to provide an open path for air exchange, airway protection, and to serve as a means for invasive suctioning for removal of secretions from the lungs. Breathing is done through the tracheostomy tube rather than through the nose and mouth, bypassing the humidification and immune functions of the upper airway (nose, mouth and nasopharyngeal airway). The term “tracheotomy” refers to the procedure of the incision into the trachea (windpipe) that forms a temporary or permanent opening, which is called a “tracheostomy.” The term “trach” is often used interchangeably with these slightly varied terms.

A tracheostomy is a common medical procedure, but it is not commonly needed. In a large study from 2015 of over 8,000 patients admitted to a cardiothoracic intensive care unit whom were also mechanically ventilated, less than 3% of these patients needed a tracheostomy. (3)

In a study, complications of tracheotomy were judged to be more severe than those of endotracheal intubation. Adverse effects of both endotracheal intubation and tracheotomy are common. (5)

How is a tracheostomy is performed?

A tracheostomy may be performed during either a planned or emergency procedure.

Planned tracheostomy

Many tracheostomy procedures are performed in intensive care departments, where there is time to prepare for the procedure and explain to the patient and family what will happen during the procedure.

A planned tracheostomy can be carried out in one of two ways:

1. Percutaneous dilational tracheostomy (PDT)

Percutaneous dilational tracheostomy (PDT), also referred to as bedside tracheostomy, is the placement of a tracheostomy tube without direct surgical visualization of the trachea.  This is considered a minimally invasive, bedside procedure that may be easily performed in the intensive care unit or at the patient’s bedside – with continuous monitoring of the patient’s vital signs.

A percutaneous dilational tracheostomy is usually performed under local anaesthetic (patient’s neck is made numb) in an intensive care unit. A doctor will make a small cut (incision) in the throat, or will insert a thin needle through the throat and into the windpipe (trachea).

A wire is then passed into the windpipe through the needle or incision and is used to guide a specially shaped instrument called a dilator into the opening.

The dilator helps open up the hole in the throat and windpipe so a tracheostomy tube can be inserted.

In some cases, an endoscope is passed down the throat during the procedure so the doctor can make sure everything is in the correct position.

Patients should not be considered for this procedure if they are:

One study has shown that PDT was performed with informed consent obtained in only 60% of cases (1). Informed consent is a process for getting permission before proceeding with a healthcare intervention on a patient. Patients should always be informed of all possible dangers, complications, and recovery schedules for any medical procedure.

Comparing hospital patients receiving a trach to those without, one study has shown patients receiving a tracheostomy had significantly longer durations of mechanical ventilation (19 days vs. 4 days) and hospitalization (30 days vs. 13 days) compared with patients not receiving a tracheostomy. Also, the average length of stay of intensive care was significantly longer among the hospital nonsurvivors receiving a tracheostomy compared with the hospital nonsurvivors without a tracheostomy (30 days vs. 7 days). (2)

Open tracheostomy

An open tracheostomy is usually performed in an operating room under a general anaesthetic (patient is asleep). The surgeon will make a cut in the lower part of the patient’s neck and part the tissues covering the trachea. They will then make an incision in the wall of the trachea so the trach (tracheostomy) tube can be inserted through the opening.

Whether an open surgical trach or a PDT, the opening in the neck where the tube is inserted into the trachea is called the trach stoma or just the stoma. This type of tracheostomy is performed when it is not safe or possible to perform a percutaneous tracheostomy.

It may be recommended:

  • For pediatric patients younger than 12 years old
  • When the structure of the neck has been compromised, such as with the presence of a tumor
  • If a patient is obese and has a large amount of fat in his or her neck area

After the procedure

After both procedures, an X-ray may be taken to check the tube is in the correct position. Antibiotics may be prescribed to reduce the risk of an infection at the site of the incision.

If the patient cannot breathe without assistance, the tracheostomy tube can be attached to a positive pressure ventilator (a machine that supplies oxygen and assist with breathing).

When the tracheostomy tube is in position, a wound dressing is placed around the stoma, and tape or stitches will be used to hold the tube in place.

The area between the skin and the tracheal channel may take approximately 2 weeks (10-14 days) to mature. The first trach tube change for cleanliness is typically performed around 10-14 postoperatively.

Emergency tracheostomy

An emergency tracheostomy may be needed if a person’s airway suddenly or unexpectedly becomes blocked after an accident or injury, or if they have respiratory failure (a serious and life-threatening condition where the lungs cannot provide enough oxygen for the rest of the body).

An emergency tracheostomy is sometimes carried out using local anaesthetic if there is not enough time to use a general anaesthetic, or if the procedure is not being carried out in a hospital. If local anaesthetic is used, the person will be awake throughout the procedure but shouldn’t feel severe pain.

The patient will be placed on their back, extending their neck, making it easier to see the structure of the throat.

A cut will be made in the skin of the neck and underlying tissue. The tracheostomy tube will be inserted into the airway and may be connected to a ventilator.

What To Expect After a Tracheostomy

Depending on a patient’s overall health, a hospital stay may be required for 3–10 days or more after getting a tracheostomy. It can take up to 2 weeks for a tracheostomy to fully form, or mature.

Having a tracheostomy can lead to a much longer intensive care stay, according to one study, with a trach patient averaging a 40 day stay compared to a 4 day stay with mechanical ventilation non-trach.(3)

A patient may be sedated during the recovery process. This means that medicine will be given to help a patient relax or become sleepy.

Eating

Until the tracheostomy is mature, a patient will not be able to eat normally. Rather than chewing and swallowing food, a patient may receive nutrition through an intravenous (IV) line inserted into a vein, or a patient may get food through a feeding tube placed through the nose or mouth and guided to the stomach. If the patient is expected to be on a ventilator for a long time, the tube might be placed directly into the stomach or small intestine through a surgically-created hole in the abdomen.

After the tracheostomy has matured, a patient will likely work with a speech therapist to regain the ability to swallow normally. A patient may have swallowing tests to show whether they can swallow safely. If possible, normal eating may be reintroduced.

Communicating

Speaking will not be possible right after the procedure. Even after the tracheostomy has matured, speaking may still be very difficult. The trach tube interferes with the normal voice process, preventing air from the lungs from passing over the vocal folds or voice box.

Once the tracheostomy has matured, a speech therapist can inform a patient on ways in which they can use their voice to speak clearly.

One option is a speaking valve that attaches to the trach tube. The valve lets air enter the tracheostomy, pass into the windpipe and up over the voice box, and then exit the mouth or nose. Speaking valves may be used with the ventilator until it can be discontinued and may be required after until the patient can tolerate having the trach capped.

Ongoing

A tracheostomy may still be required after a patient leaves the hospital.

Proper care and handling of the tracheostomy and the related supplies can help reduce the risk of complications, such as infection.

It is essential to learn how to clean the tracheostomy site, change the trach tube, suction the airways using the trach tube, and work with a home care service.

Home care services allow patients with special needs to receive care in their homes. Home care services may offer medical equipment, check-ups from health care professionals, and help provide medicines.

Practices vary. Some trach tubes have a removable inner cannula that is changed daily allowing possibly longer intervals between tube change outs. Some physicians will prescribe trach changes monthly or even less frequently once out of the hospital. environment.

Secretions from the lungs cover the inside of the trach tube, requiring the tube to be changed once a week, although some different types of tubes can be left in longer. Practices vary. Some trach tubes have a removable inner cannula that is changed daily allowing possibly longer intervals between tube change outs. Some physicians will prescribe trach changes monthly or even less frequently once out of the hospital.The tube may have to be changed more often if secretions become very dry or if the patient has a chest infection and is producing more and thicker secretions. The trach tube change or should be before a feeding or wait for at least two hours after a feeding to minimize chances of vomiting and possible aspiration resulting spillage of vomitus into the trachea.

In an ENT (Ear Nose Throat) hospital department, newly trached patients remain in the hospital until the first tracheostomy change. This can happen anywhere from 3 – 5 days, when the suctioning machine and supplies arrive, and when the patient and/or caregiver perform competent suctioning skills.

However, in an ICU setting, the first tracheostomy change may be done only after 7 days, and keeping the patient in the hospital is necessary to try to correct the critical illness that brought them to the intensive care unit. The required time in solving this condition usually determines how long the patient will stay in the hospital.

Suggested alternative: Considering the dangers and complications of placing a tracheostomy, why use a trach without trying other non-invasive options that offer a chance for avoiding the trach first?