From time to time in the medical profession you’ll hear the
term trach mentioned, pronounced as
“trake." So what is meant by this term? Trach is shorthand doctor-speak for
tracheotomy, which is the creation of an opening into the trachea or
windpipe. Before getting into more
details of a tracheotomy, let’s clarify some nomenclature (fancy lingo for
“highly technical terms that took years of schooling to learn”).
The “What”
Tracheotomy is the
name of the surgery done to make an opening into the trachea. The suffix “-otomy” is defined as to make a
cut into something. Thus tracheotomy =
cut into the trachea. Let’s add to the
confusion: a tracheostomy is the
actual opening into the trachea (“-ostomy” means a surgically created hole or opening). Then there is the tracheostomy tube which is the actual device inserted into the
trachea after a tracheotomy is done to create a tracheostomy. As I said, that’s why medical school is four
long years, and then you have a residency afterwards that can be even longer.
The “Why”
So what are the indications for this procedure? Or in layman’s terms, “What the heck? A hole
in the neck for a breathing tube?”
For some serious illnesses, a patient will have a breathing
tube (known as an endotracheal tube)
in his/her mouth that goes into the throat, through the voice box and into the trachea, which is then
attached to a ventilator—a mechanical device that breathes for the
patient. These people are too
debilitated to breathe on their own.
Once the patient no longer needs mechanical ventilation, then the
endotracheal tube can be removed.
However, some patients require prolonged help with their breathing,
needing the ventilator for a longer period of time. If this occurs for seven or more days, then a
tracheotomy with placement of a trach tube might is indicated.
Why? There are
several reasons for doing this surgical procedure:
1. An endotracheal tube can be very irritating to
the larynx (or voice box) as well as the area below the larynx knows as the
subglottis. The subglottis is comprised
of a fixed, nonexpendable ring of cartilage.
Scarring of both can occur. If
so, this can cause narrowing of the larynx or subglottis, obstructing the
airway, making breathing difficult once the endotracheal tube is removed. On the other hand, the trachea is composed of
partial cartilage rings stacked one on top of the other, each ring being fused
to the next with thick fibrous tissue.
As the diagram below shows, the back (posterior) wall of the trachea is
soft, expandable tissue, and the tracheal cartilage forms a partial “C”-shaped
ring. The cricoid is a complete ring,
and if pressure and irritation from a tube inside that ring for an extended time,
that ring becomes scarred and narrowed.
This increases resistance to airflow which in turn increases the work to
breath. A tracheostomy places the
breathing tube below these structures and thus prevents the scarring.
2. An endotracheal
tube that goes through the mouth, throat, voice box and then into the trachea
is very comfortable. Imagine having
something like that when you’re wide awake—most of us would choke, gag and struggle
and attempt to pull the darn tube out. Many
patients need to be sedated to calm them down.
Believe it or not, placing a tube below the voice box is more
comfortable; the mild pain from the incision in the neck is less than the
discomfort of having a tube sitting in your throat, and the sedation medication
often is reduced or even eliminated.
3. The work of breathing
can be easier with a trach tube. There’s
this mathematical formula in physics that shows the resistance to flow of a
substance (such as air or fluid) is increased when the length of the tube in
which the substance flowing needs to pass is increased. In other words, trying to pass air in a tube becomes
more difficult as the length of the tube increases. Imagine breathing through a very long straw. The work to do this would tire you out, such
that you’d eventually stop breathing altogether out of sheer exhaustion. Not-breathing is not good. The trach tube is much shorter than the
endotracheal tube which decreases the resistance, making the work of breathing easier. Sometimes a patient starts no longer needs
the assistance of a ventilator much sooner, and I’ve seen patients come off the
ventilator within 24 hours after placing their trach tube.
4. Clearing of
secretions is easier. For patients with
weak lungs, clearing mucous from the lungs can be quite a chore, and if unable
to do this, those secretions can trap in the lungs causing bad things like
pneumonia, which is an infection of the lungs.
Gross as it sounds, a trach tube allows for “pulmonary toilet,” meaning
one can clean the lungs and trachea by passing a flexible suction tube into the
trach tube, down into the trachea to suction all those nasty secretions.
These are just a few of the indications. Of course, with any surgery there are risks
such as bleeding, infection, injury to the larynx, trachea, lungs or esophagus
behind the trachea. However, as with
most things done in medicine, a tracheotomy and tube placement is recommend if
the perceived benefits outweigh the potential risks.
The “How”
The diagram at the beginning shows the relevant anatomy and
location of the surgical opening. An incision is made into the neck, sometimes
a piece of the thyroid gland that covers the trachea (the thyroid isthmus) is incised to move it out of the way, and an incision
is made into the trachea between the cartilage rings. Many surgeons create a rectangular flap of
cartilage—a door that opens into the trachea—which I sutured to the soft tissue
under the skin. This allows the opening
to be more stable, allows the trach tube to slide in easier, and provides
easier access should the darn tube accidentally falls out. The trach tube is inserted as the old
endotracheal tube is removed.
You may have heard of an emergent cricothyroidotomy or “crike”),
or have seen this in the movies or on T.V., when some doctor-figure emergently
cuts a hole into some guy’s neck with his teeny little pocket knife and inserts
a straw or writing pen to save the day.
If you plan on practicing this on yourself just for kicks and giggles,
please do us all a favor and don’t. You might cut a major blood vessel and mess
up the bathroom. In reality, this typically is not a tracheotomy,
but a cricothyroidotomy. The cricothyroid membrane is a thick fibrous
tissue that extends from the thyroid cartilage (which houses the voice box) and
the cricoid cartilage below. In emergent
situations, it can be much easier to identify and then cut through this
structure to gain access to someone’s airway or trachea. This is done if there is an obstruction at or
below the larynx that will not allow air to pass through the mouth and throat
via conventional means. If the tube is
needed for an extended period of time, this is later converted to a tracheotomy
to prevent narrowing of the cricoid ring.
So there you go, and impress your family and friends with
this newfound knowledge.
©Randall S. Fong, M.D.
Nice post. Well what can I say is that these is an interesting and very informative topic on otomy vs ostomy
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