What is a tracheostomy?

Tracheostomies are performed in head and neck surgical practice, with over 5000 procedures performed yearly in England. We estimate around 10 000–15 000 percutaneous tracheostomies are performed each year in England’s critical care units, although the actual figure is currently unknown. Tracheostomies are also becoming more commonplace on the general wards of the hospital. This is partly due to pressures on intensive care beds and the increasing drive to de-escalate care quickly, along with increasing numbers of patients benefiting from temporary tracheostomies. These groups include those with chronic respiratory or neurological problems. Increasing numbers of patients with tracheostomies are being cared for on wards outside the specialist ward [typically ENT or maxillofacial wards, or sometimes neurosurgical or neurology wards] or critical care infrastructure.

This has implications for the safety of patients who may be cared for on wards without the necessary competencies and experience to manage this challenging cohort and local measures need to be in place to ensure that safe routine and emergency care can be provided. This manual has evolved to provide information to those caring for patients with temporary or permanent tracheostomies, either regularly or occasionally. It aims to provide basic background information and the rationale for tracheostomy care (Figure 2.1).

Figure 2.1 A sagittal section through the upper airway anatomy showing a tracheostomy in situ.

Reproduced with permission of HEE eLfH.

What problems can occur with tracheostomies?

While tracheostomies are increasingly commonplace, patient safety incidents associated with their use are unfortunately increasing. Over 1700 incidents were reported to the NPSA between 1 January 2005 and 31 December 2008, including over 30 deaths. We know from research with the NPSA that when a clinical incident occurs relating to a tracheostomy, the chance of some harm occurring is between 60% and 70%, depending on the location in which that the patient is being cared for [see links to these abstracts for NPSA papers in Thomas and McGrath (2009) and McGrath and Thomas (2010)].

Incidents may be classified as

incidents at the time of performing the tracheostomy (e.g. airway loss; damage to adjacent structures; bleeding);
blockage or displacement of the tracheostomy tube after placement;
equipment incidents (usually lack of equipment or inappropriate use);
competency (skills and knowledge) incidents;
infrastructure (staffing and location) incidents;
late complications (e.g. tracheomalacia, stenosis, infection of stoma).

The majority of these incidents are due to the same recurring themes and the resources we have developed as part of this project are specifically aimed at addressing these.

There is more detail on tracheostomy and laryngectomy problems in the complication, red flags and emergency management section.

What is a laryngectomy?

The larynx (voice box) can be involved in oral, pharyngeal or laryngeal carcinomas. These are usually squamous cell carcinomas and can be treated by radiotherapy and surgery, depending on the site and the general condition of the patient. Surgical resection of the tongue base or epiglottis may not necessarily involve removal of the larynx and is sometimes referred to as a supraglottic laryngectomy. It is sometimes possible to resect only one half of the larynx for localised disease with a hemilaryngectomy. However, if a total laryngectomy is required, this involves complete surgical removal of the larynx, which disconnects the upper airway (nose and mouth) from the lungs. This is a permanent and irreversible procedure (although partial laryngectomies are possible). The trachea is transected (cut) and then the open end is stitched onto the front of the neck. Once this has been performed, the patient will never be able to breathe or be oxygenated or ventilated through the upper airway again. An animation showing the difference between a tracheostomy and a laryngectomy ¹ can be found in the link provided in the footnote.

As shown in Figure 2.2, a tracheostomy still provides a potentially patent upper airway. Remember though that tracheostomies are often performed because of actual or anticipated difficulty with the upper airway, so upper airway patency cannot be guaranteed.

Figure 2.2 The differing anatomy of a tracheostomy (a) and laryngectomy (b).

Reproduced with permission of HEE eLfH.