A tracheostomy is a surgical procedure to create an opening in the neck at the front of the windpipe (trachea). A tube is inserted into the opening and connected to an oxygen supply and ventilator to assist with breathing.
Fluid that has built up in the throat and windpipe can also be removed through the opening.
A tracheostomy may be performed as:
- a planned procedure – to help someone who can't breathe as part of treatment in intensive care or because of a long-term condition, such as multiple sclerosis
- an emergency procedure – for example, if someone is unable to breathe following an injury or accident
Read more about why a tracheostomy is necessary.
Planned tracheostomies are usually carried out in an operating theatre using general anaesthetic.
If it’s an emergency, the tracheostomy will be carried out at the site of the accident or in the nearest hospital’s accident and emergency department. Local anaesthetic may be used if there is not enough time to use general anaesthetic.
Read about how a tracheostomy is performed.
Is a tracheostomy permanent?
A tracheostomy can be temporary or permanent. When it's possible for a person to breathe, protect their airway and clear fluids unaided, then the tracheostomy tube may be able to be removed. The opening will usually close on its own within a couple of weeks, leaving a small scar. If it doesn’t close on its own, it can be closed using stitches.
The tube may need to stay in permanently if a person has a long-term condition.
A tracheostomy is a safe and effective procedure. However, as with all medical procedures, there is a small risk of complications, such as bleeding and infection.
Read more about any complications of a tracheostomy that could arise.
Living with a tracheostomy
It's possible to enjoy a good lifestyle with a permanent tracheostomy tube. However, adapting to life with a tracheostomy tube can take some time and most people will initially have difficulty with talking, eating, exercise and keeping the tracheostomy tube clean and free of blockages.
If you or your child needs to have a tracheostomy, a specially trained nurse will be available to give you advice and answer any questions that you have.
Great Ormond Street Hospital for Children also has a comprehensive guide about living with a tracheostomy.
Why it is necessary
A tracheostomy is often required when a person is unable to breathe normally, due to an underlying health condition or a blockage in one of their airways.
For example, a tracheostomy may be used:
- to deliver oxygen to the lungs when a person is unable to breathe normally – the loss of normal lung function is called respiratory failure
- to bypass an airway that has become blocked
- to remove fluid that has built up in the upper airway, particularly in the throat and windpipe (trachea)
These are discussed in more detail below.
There are many conditions that can lead to respiratory failure and the need for a tracheostomy. Examples are:
- being unconscious or in a coma as a result of a severe head injury or stroke
- paralysis (an inability to move one or more muscles) after a serious neck and spinal cord injury
- a condition that causes extensive damage to the lungs, such as pneumonia or cystic fibrosis
- a condition that causes progressive damage to the nervous system, such as motor neurone disease or Guillain-Barré syndrome (both conditions can lead to paralysis and breathing difficulties)
The airways can become blocked due to:
- accidentally swallowing something that gets stuck in the windpipe, such as a piece of bone
- an injury, infection, burns or a severe allergic reaction (anaphylaxis) that causes the throat to become swollen and narrowed
- a cancerous tumour that blocks one or more airways – this can sometimes happen with mouth cancer, laryngeal canceror thyroid gland cancer
In addition, some children are born with birth defects that cause one or more of their airways to be abnormally narrow.
There are several factors that can cause fluid to build up inside the airways and lungs, resulting in breathing difficulties. There is also a danger that the fluid could become infected.
In some circumstances, it may be necessary to carry out a tracheostomy so the fluid can be sucked out through the tracheostomy tube. This may be necessary when the person:
- is unable to cough properly due to chronic pain, muscle weakness or paralysis
- has a serious lung infection, such as pneumonia, that has caused their lungs to become clogged with fluid
- has an injury that has resulted in their airways or lungs becoming filled with blood
It's possible to enjoy a good lifestyle with a permanent tracheostomy tube. However, some people may find it takes some time to adapt to breathing and communication.
You should be able to resume everyday activities, but you should avoid vigorous activities for about six weeks after the procedure.
When you're outside, it's very important that your tracheostomy opening is kept clean and dry. The opening will usually be covered with a dressing, but a loose piece of clothing, such as a scarf, can also be worn over the top. This will stop substances such as water, sand or dust from entering the opening and causing breathing problems.
It is usually difficult to speak after having a tracheostomy. Normally, speech is generated when air passes over the vocal cords at the back of the throat. After a tracheostomy, most of the air that you breathe out will pass through your tracheostomy tube rather than over your vocal cords, which means you will be unable to speak normally.
One solution is to use a speaking valve, which is a plastic attachment that sits at the end of the tube and is designed to temporarily close over every time you breathe out. This prevents the air leaking out of the tube and allows you to speak. However, it can take a while to get used to speaking with the valve.
After having a tracheostomy, you may be referred to a speech and language therapist. They will be able to give you further advice and training in speaking while the tracheostomy tube is in place so that you can improve your ability to communicate.
Cleaning the tracheostomy tube
A tracheostomy tube needs to be cleaned whenever it gets blocked with mucus or fluid. The tube may need to be cleaned several times a day.
If the tube is permanent, or if you are allowed to return home with the tube still in place, a specialist tracheostomy nurse will teach you how to take care of the tube. They will show you how to suction fluid from your windpipe (trachea) and how to clean and change your tracheostomy tube.
Removing the tracheostomy tube
If you have a temporary tracheostomy, the tube should be able to be removed when you are able to breathe, protect your airway and clear fluids unaided.
After the tracheostomy tube has been removed, the opening in your neck will be covered with a dressing. The opening will usually take one to two weeks to heal and afterwards you may have a small scar where the opening was. If the opening does not close on its own, stitches may be needed to close it.
Over time, a tracheostomy opening tends to narrow, so if you have a long-term or permanent tracheostomy tube, you may need to have further surgery to widen it.
How it is performed
A tracheostomy may be carried out as either an emergency or planned procedure.
Many tracheostomies are performed on people in intensive care, but where there is time to prepare for the procedure and explain what is happening.
A planned tracheostomy can be carried out in one of two ways:
- a percutaneous tracheostomy
- an open tracheostomy
Both procedures are described below.
A percutaneous tracheostomy is usually carried out under general anaesthetic on an intensive care unit.
The intensive care specialist will make a small cut in the throat (about 1.5cm to 2cm long) and use a surgical instrument called a dilator to open a hole in the tissues and trachea. The tracheostomy tube is inserted through the incision and guided into place using a guidewire.
An open tracheostomy is usually carried out in an operating theatre, under a general anaesthetic. This means you are asleep during the procedure and will not feel any pain.
The surgeon will make a cut in the lower part of your neck, in between your Adam’s apple and the top of your breastbone. The muscles are parted and the thyroid gland is cut or moved so that the surgeon has a clear view of your windpipe. They will then make an incision in the wall of your windpipe so that the tracheostomy tube can be inserted through the opening.
After both procedures
After both procedures, an X-ray may be taken to check that the tube is in the right position. Antibiotics may be prescribed to reduce the risk of an infection at the site of the incision.
If you are unable to breathe unaided, the tracheostomy tube can be attached to a ventilator to increase the flow of oxygen to your lungs.
After the tracheostomy tube is in position, a dressing is placed around the opening in your neck and tape or stitches will be used to hold the tube in place.
Percutaneous versus open tracheostomy
An open tracheostomy will be carried out when it is not safe or feasible to perform a percutaneous tracheostomy.
It may be recommended:
- for children younger than 12 years old
- when the normal structure of the neck has been affected by something, such as a tumour or a collection of blood
- when the person is very overweight and has a large amount of fat in and around their neck
- if there is an infection inside the neck or surrounding tissue
An emergency tracheostomy may be needed if a person’s airway suddenly or unexpectedly becomes blocked following an accident or injury.
It may also be required if someone has 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 and should feel severe pain.
Trained healthcare professionals, such as paramedics, are able to perform an emergency tracheostomy very quickly. The person will be placed on their back and a rolled-up towel, or something similar, will be positioned under their shoulders. This stretches out 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 connected to a ventilator (a machine that supplies oxygen to assist with breathing).
Having a tracheostomy is considered to be a safe and straightforward procedure, but as with many medical procedures it does carry a risk of complications.
The likelihood of complications occurring will depend on:
- your age and general health
- the reason why you need the tracheostomy
Generally, a planned tracheostomy carries a lower risk of complications than an emergency tracheostomy.
Complications that can occur during or shortly after a tracheostomy are outlined below.
Any surgical procedure can be complicated by bleeding which can be minor or major. If there is significant blood loss a blood transfusion may be necessary.
Sometimes, air will collect around the lungs and cause the lungs to collapse inwards. This is known as a pneumothorax. In mild cases this often corrects itself without the need for treatment. In more serious cases, a tube will need to be surgically implanted into the chest to drain the air away from the lungs.
The nerves near the windpipe can be accidentally damaged, such as those controlling the voicebox (larynx) or the oesophagus (tube that runs from the back of the throat to the stomach). This may cause problems with speaking and swallowing.
The windpipe or nearby tissues can become infected with bacteria. These usually need to be treated with antibiotics.
Complications that can occur days, weeks or even months after a tracheostomy are described below.
Failure to heal
Sometimes, the tracheostomy wound will not heal properly and starts to bleed. If this happens, the tracheostomy tube may need to be temporarily removed so that surgery can be carried out to stem the bleeding.
Sometimes, the windpipe collapses in on itself because the walls of the windpipe are not strong enough to support it. This usually occurs when the tracheostomy tube has not been fitted properly, and it requires further surgery.
Any form of accidental damage to the throat can result in the airways becoming narrowed, which can cause breathing difficulties. Surgery may be needed to widen the airways. This may involve implanting a small tube, called a stent, to keep the airways open.