A tracheostomy is an operation to create an artificial opening into the trachea, the windpipe. The opening is then held patent by the tracheostomy tube. Once surgery is performed, your child will breathe through the tracheostomy tube rather than the mouth and nose. Have a look at the stridor page to help you understand the anatomy of the airway.
Tracheostomy is a significant undertaking for the child and their family, but at the same time also a life-saving measure for many.
Why is a tracheostomy needed?
Different children have tracheostomies for different reasons.
A common cause is airway obstruction ABOVE the windpipe, for example severe subglottic stenosis. Because the tracheostomy sits in the windpipe, the tracheostomy tube effectively by-passes the airway passages higher up. Instead of your child struggling to breathe through a narrowed segment (for example subglottic stenosis), they breathe straight through the tracheostomy tube. A tracheostomy is an effective treatment for airway blockages due to numerous different causes.
The other common reason for needing tracheostomy is requirement for long-term ventilation support. Some children are unable to breathe for themselves, perhaps due to neurological abnormality, poor muscle function, or tracheomalacia. These children require a machine to help them breathe. The tracheostomy then becomes part of the breathing support, as the breathing machine attaches direct to the tracheostomy tube to deliver the breathing support.
There are other reasons also why a tracheostomy may be needed, for example as part of another surgical procedure, or as part of a child's intensive care stay.
What are the alternatives to tracheostomy?
A tracheostomy is usually a last resort for airway obstruction, but a life saving one. If there are other ways to help relieve airway obstruction, almost always they will be considered before the tracheostomy. However, sometimes it is not possible to correct the obstruction, or a decision is made that corrective surgery should be done at a later stage, or the child is too unwell to tolerate major airway surgery. In those circumstances, a tracheostomy is relatively more straightforward.
It sounds odd to say that tracheostomy is more straightforward than other options, but in some circumstances it really is the better option with fewer risks.
The decision to perform the tracheostomy tends to come in two ways.
It may be required on an urgent or emergency basis, in a child with major breathing difficulties. In those circumstances, we often have little other alternative, as the tracheostomy is then a life saving measure.
The other common scenario will be discussion about a tracheostomy in a child with long standing airway or breathing problems, when the child struggles from day to day but somehow just about manages. It is often more difficult to make the decision to go ahead with surgery in those circumstances. Having the time to think is a good thing on one hand, but on the other it can lead to people trying to put the decision off for as long as possible, which is understandable. In general terms, once parents come to the realisation that the child has a problem and something needs to be done, they are usually delighted with the increased quality of life that the tracheostomy offers. So although it may be a last resort, parents usually appreciate the benefits that it brings.
The doctors and nurses will discuss tracheostomy with you and explain the procedure to you. If you have questions, make sure that you ask.
What are the risks of tracheostomy surgery?
Usually all goes well, but any surgery has risks. In tracheostomy, these include:
-collapsed lung (pneumothorax)
-formation of granulation tissue (excess tissue growth) either on the outside of the skin or inside the windpipe
-narrowing or floppiness of the windpipe at the site of the tracheostomy surgery
-if tracheostomy tube becomes no longer required and is removed, there may be a persistent hole between the skin and the windpipe which may require corrective surgery
-tracheostomy affects the child's communication - see communication
What to expect after surgery
Your child will be in intensive care until the first time that the tracheostomy tube is changed; if your child will need long-term ventilation, the intensive care stay is likely to be significantly longer. The nurses will be looking after the tracheostomy to start with, but will gradually teach you how to look after your child. It will all be incredibly daunting at first, but over time the team will teach you the skills that you need.
Before going home, the nurses will make sure that you know exactly what to do, you have all the equipment that you need, and all the support that you need. Children having tracheostomy will spend a minimum of two weeks in hospital following surgery, with a month being more usual. If long-term ventilation is needed, the hospital stay is usually several months.
Tracheostomy is a complex undertaking. For many children it is a life-saving measure, and for others it can bring a great increase in the quality of life. The healthcare team will discuss options with you, and explain the process throughout your stay. Different hospitals will have different details on the exact management of tracheostomies, but all will put the needs of your child and you at the centre of their actions. It will be a daunting experience, but you need to remember that it is necessary and will be done because it is the best thing for your child.