The windpipe, which is also known as the trachea, begins under the larynx and extends as far as the chest, where it is spread out into the bronchial system of the lungs. The windpipe is a stable, fixed tube through which inhaled air is conducted into the lungs. During a tracheotomy, access is created to the windpipe by bypassing the upper airways in order to guarantee unimpeded breathing or respiration or in order to shorten the airway. This is done using a tracheostomy tube, with or without a cuff1.
Sometimes, a tracheostomy tube is also inserted if the patient has massive dysphagia with a risk of aspiration2. The deep airways can be protected against aspiration with a blocked (cuffed) tube.
Tracheostomy tubes come in different shapes and sizes which can be selected individually. The tracheostomy tube is changed every four weeks by skilled personnel. The tracheostomy tube is a foreign body, and the patient may have to get used to it.
Possible complications with the tracheostomy tube
Despite taking all the necessary safety precautions, there are always certain risks of complications during any medical intervention. In particular:
- Slight bleeding around the tube – this can generally be controlled with compressions and dressings.
- Infected wounds may have to be treated with antibiotics.
- Air trapped in cutaneous tissue (= subcutaneous emphysema), which makes a crackling noise when pressure is applied to it, is generally harmless.
- Blood flows into the lungs, and this can lead to pneumonia.
- Tube blockages can be prevented by regularly clearing the tracheostomy tube.
- Displacement of the tube, which is why it must be properly fixed in place.
- Rare complications: Paralysis of the vocal cords or heavy bleeding
Tracheostomy tube with a cuff
A cuffed tracheostomy tube is used if the person is unable to swallow independently or in order to guarantee effective artificial respiration. The cuff is an inflatable balloon around the tube which seals this tracheostomy tube to the windpipe. This prevents saliva and secretions from entering the airway unhindered from the oronasal area.
It is impossible to speak with a cuffed tracheostomy tube because the respiratory air bypasses the larynx. It is also impossible to clear your throat or to cough because the air escapes without any build-up of pressure. Smelling is also greatly impaired because the person can no longer inhale through their nose.
In the case of spontaneous breathing without the support of an apparatus, the cuffed tracheostomy tube is combined with a filtre known as an “artificial nose”. It retains the warmth and moisture of air being expelled, and releases it the next time the person breathes in. Furthermore, the artificial nose cleans the air and protects the lungs against particles of dirt.
Speaking with a tracheostomy tube
Speech is very important for communication between people. To ensure that this is also possible with a tracheostomy tube, a speech valve is attached. The speech valve is a one-way valve that allows the inhaled air to flow in and which seals when the person exhales. Consequently, the entire airflow is only conducted via the upper airways during exhalation (larynx, pharynx, mouth, nose), making it possible to speak. Resistance may also build up through the one-way valve, enabling the person to cough.
This processes is only possible with an unblocked (uncuffed) tracheostomy tube. With a blocked tracheostomy tube, the airflow can no longer escape via the upper airways.
If the speech valve is used all day long, there is a risk that the tracheal secretion will become very dry in the absence of an artificial nose. In the worst case scenario, the tracheostomy tube may become closed off as it is encrusted or clogged with secretion. Therefore, it is important to moisten the airways regularly by inhaling.
The speech therapist will help with practising speaking with the speech valve.
Swallowing / eating with a tracheostomy tube
With a cuffed tracheostomy tube, the secretion that runs into the airways through the larynx and that collects above the cuff cannot be coughed out actively because the airflow passes completely through the tracheostomy tube. Over time, this leads to reduced sensitivity, which means that when the person starts to consume food and liquids orally again, he or she responds too late, if at all, with reflective coughing, increasing the risk of aspiration. The first time the person attempts to swallow, intensive assistance and support will be provided by the speech therapist.
In order to keep the tracheal secretion liquid or to make coughing easier, regular inhalation is required. This is done using a saline solution or possibly using medication to loosen the secretion. To make inhalation more effective, it is performed with a blocked tracheostomy tube.
1 Also called a balloon
2 Ingress of material into the airways