Abstract
A tracheostomy is a surgical procedure that entails making a surgical incision in the anterior aspect of the neck to open a direct airway by making an incision into the trachea (Durbin et al., 2005). It provides an alternative pathway for breathing when the normal airway is blocked, obstructed or reduced. A tracheostomy tube is a curved line inserted into the hole after a tracheostomy has been conducted. There are various types of tracheostomy tubes. Many companies manufacture these tubes. However, a specific tube type will have the same effect and structure despite the company that manufactures it. The most common tracheostomy tubes are fenestrated cuffless tracheostomy tubes, cuffed tubes with a reusable inner cannula, cuffless tubes with a disposable inner cannula, cuffed tubes with a disposable inner cannula, metal tracheostomy tubes and special tracheostomy tubes. Tracheostomies are a standard procedure in medical practice globally. According to data collected on the number of tracheostomies performed in a hospital setting in the United States by PMC, there were around 80,000 tracheostomies performed in the year 2000 alone. 2008 had the highest number of tracheostomies performed, falling to under 90,000 procedures. In the last decade, 2018 had the lowest number of tracheostomies performed, averaging about 58 000 tracheostomies (Galli et al., 2019).
Most tracheostomies are carried out in hospitals or other patient care facilities. However, in emergencies such as accidents with acute respiratory blockage, an emergency tracheostomy may be necessary at the accident scene to save the patient’s life. Emergency tracheostomies require additional care due to the different settings in which they are performed. They must be done by a qualified physician or emergency health respondent expert. There is an increased risk of complications in emergency tracheostomies; hence most emergency respondents prefer to use alternative procedures such as cricothyrotomy.
Indications for tracheostomy
Some of the indications for tracheostomy are discussed herein. If a patient is scheduled for a significant head or neck operation, a tracheostomy may be done to assist in breathing during the procedure. In traumatic brain injury, where important respiratory centres are affected, impairing the ability to remove secretions from the respiratory tract, it is also prudent to do a tracheostomy. When there is a blockage in the respiratory tract, and it is above the level of the trachea, or if a physician anticipates such a blockage, a tracheostomy is done to avoid respiratory failure. Physicians may prefer tracheostomy due to its perks over intubation for more than a fortnight in routine patient care where long-term intubation is necessary. Patients have attested to being more comfortable with tracheostomies than intubation, not to mention the reduced risk of injury in tracheostomy compared to intubation.
Moreover, tracheostomy uses a shorter tube; hence there is improved management of respiratory tract secretions with a higher safety of airway control. Another significant advantage over intubation is decreased occurrence of sinusitis. Other indications for a tracheostomy include the inability to intubate a patient with general anaesthesia during operative procedures, penetrating trauma of the larynx and post-cricothyrotomy. Once a cricothyrotomy has been performed, and the patient is stable, it is recommended that a tracheostomy is done.
Contraindications for tracheostomy include active cellulitis, inability to extend the neck, obesity when the brachiocephalic (innominate) artery is high-riding, high ventilatory demand and infection of a wound following a surgical procedure. However, it must be noted that no absolute contraindications for tracheostomy have been put in place. The above conditions may be present, but a physician may decide to override them and perform a tracheostomy if it is necessary to maintain life or good health.
Parts of a tracheostomy tube
A standard tracheostomy tube has three parts: the outer cannula, the obturator and the inner cannula (Hess et al., 2005). These parts may, however, not be usable with a different tube of the same type. Not all trach tubes have an inner cannula, and a few exceptions exist. The outer cannula refers to the part that fits into the incision made. It may have a cuff at its distal end. When the cuff is inflated, it acts as a seal, preventing air leakage between the tube and the trachea. Proximally it has a flange, which may be structured differently to accommodate different designs of the inner cannula or to secure the trach tube in place. The tube may have holes/ fenestrations along the greater curvature to allow speech production.
The obturator is usually pulled onto the outer cannula to allow insertion into the trachea. Once the outer cannula is in place properly inside the trachea, the outer cannula is usually removed to open the lumen of the trach tube, hence opening the patient’s airway. If the trach tube is displaced at any time during the procedure, the obturator is usually reinserted, and the tube is put in place again. For this reason, the trach tube must always be on standby for use during tracheostomy. The inner cannula is usually inserted into the outer cannula. It must be locked into position for use with ventilatory equipment. Some inner cannulas are only used once, then they are disposed of, while others are reusable and only require to be removed for cleaning.
Differences, advantages, and disadvantages
Shiley flex tracheostomy tubes have been in use for over four decades and have a proven history in the medical field. New generation Shiley tubes have better and improved features, which make them different and more effective compared to legendary Shiley tubes. The new Shiley tubes have larger inner diameters compared to the legendary ones. This feature provides for increased airflow. It has been documented that this feature increases airflow by a whopping 242%. The new tubes have an improved TaperGuard cuff, unlike the legendary old generation Shiley flex tubes, which have a cylindrical cuff. The cuff protects the lungs and trachea. Besides improving the clinician’s ability to give mechanical ventilation, fluid leakage is significantly reduced, and less pressure is exerted on the tracheal wall with the new Shiley tubes. According to Medtronic, fluid leakage is reduced by 99%, pressure on the tracheal wall by 19% and the clinic has a 65% greater ability to provide ventilation (Bourke et al., 2018). The new Shiley tubes have a design which allows ventilation without the inner cannula, another significant variation from the legendary tubes. The new tubes come in a wider variety of sizes, are made of soft material and have a clear flange, unlike old Shiley tubes. Furthermore, new Shiley tubes incorporated colour coding by size for easier choice by clinicians, unlike in legendary tubes where colours had no definitive meanings.
New generation Shiley flex tubes have lower cuff pressure. They are easily identifiable by size and given colour coding, allowing for better visualization of the incision and ventilation without the inner cannula. These new tracheostomy tubes also have a few demerits. Most of these tubes are more expensive, putting additional financial strain on patients and their kin. The softer material means they can be damaged more quickly than the traditional tubes necessitating replacement prematurely. The new tubes fail to solve the problem that tracheostomies are often painful and scary for patients. The colour codes may significantly induce additional fear in patients. New generation Shiley tubes with reusable parts require regular cleaning and support for patients. With the new generation of Shiley flex tubes, the risk of complications arising or making the patient uncomfortable is still considerably high.
Summary
Tracheostomy is an essential medical procedure in emergencies or for patients living with tracheal obstruction and other respiratory disorders. The choice of a tracheostomy tube is vital in the care of such patients. The new generation Shiley Flex tubes provide new and improved features which make them safer, easier to use and ideal for tracheostomy. These new tubes still have many demerits, and further improvements would go a long way in improving the quality of tracheostomy as an operative procedure and patient care.
References
Durbin, C. G. (2005). Techniques for performing a tracheostomy. Respiratory care, 50(4), 488-496.
Galli, A., Giordano, L., Biafora, M., Tulli, M., Di Santo, D., & Bussi, M. (2019). Voice prosthesis rehabilitation after total laryngectomy: are satisfaction and quality of life maintained over time? Acta Otorhinolaryngologica Italica, 39(3), 162.
Bourke, S. C., Piraino, T., Pisani, L., Brochard, L., & Elliott, M. W. (2018). Beyond the guidelines for non-invasive ventilation in acute respiratory failure: implications for practice. The Lancet Respiratory Medicine, 6(12), 935-947.
Hess, D. R. (2005). Tracheostomy tubes and related appliances. Respiratory care, 50(4), 497-510.
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