Tracheotomy: risks after surgery and convalescence

Short review

The tracheotomy is a "surgical operation aimed at guaranteeing" effective ventilation when, due to neoplasms in the throat, masses of mucous secretions, localized edema or other, the patient accuses severe respiratory difficulties (or inability).

The tracheostomy operation consists in making the trachea communicate with the outside by means of a cannula inserted into the tracheal lumen through a hole in the skin (made at the level of the trachea).

Risks of tracheostomy

Unlike what happened in the past, the experience acquired in the field and the current anatomical knowledge of the trachea considerably reduce the risk of post-tracheostomy complications. Thanks to the improvement of the operative techniques and the quality of the cannulae used, the risks associated with a tracheostomy they are almost comparable to those of a simple endotracheal intubation.
This does not mean, however, that the tracheotomy is a surgical act free from risks and dangers: when performed by not particularly experienced personnel, even worse in emergency situations, the tracheotomy can still cause serious injuries to the patient.
It is therefore good to distinguish the risks that the patient may face in the immediate post-surgery from the long-term ones:

Risks in the immediate post-surgery

Long-term risks

Dysphonia: Difficulty expressing oneself in language
Severe bleeding
Subcutaneous emphysema
Injuries of the esophagus
Pneumothorax (collapse of the lung)
Obstruction of the cannula due to blood clots or mucus
Infections that spread from the incision made during surgery (rare)
Tracheo-cutaneous / esophageal fistulas
Tracheal stenosis or dilation
Granulomas
Ulcerations of the skin and tracheal mucosa
Pneumonia

Dysphagia (difficulty swallowing solid or liquid food)
Damage of the trachea
Keloids (abnormal scar tissue formation)
Infections due to the proliferation of bacteria trapped in the tracheal tube
Physiological failure of the stoma to close after removal of the cannula (the risk increases when the tube remains inserted for more than 16 weeks): in such circumstances, the wound can be resealed surgically
Obstruction of the cannula
Skin erosions
Tracheal stenosis (narrowing)

The risk of death of the patient undergoing tracheostomy is less than 5%.
To minimize the adverse events related to tracheotomy, the surgeon must have a complete knowledge of the anatomical-physiological problems connected to the operation, as well as a certain skill in decannulation of the patient and in restoring the natural airways.

In-depth study: tracheotomy and dysphonia

We have seen that one of the risks associated with tracheotomy is the alteration of the voice in the tracheotomized patient and the difficulty in expressing oneself.
In such circumstances, to obtain a satisfactory language it is possible to create a small air leak around the tracheal cannula using a sort of balloon (called cuff or valve) positioned on the same tube, useful for promoting adherence to the tracheal walls. In this way, the air that rises from the tube to the vocal cords (and to the mouth) allows the patient to express himself and speak.
It should be noted, however, that in standard tracheostomy, dysphonia is generally reversible. The disturbance, on the other hand, is accentuated in permanent tracheotomy (tracheostomy), so much so as to cause, in some patients, the total loss of the voice.

Patients at risk

Post-surgery complications increase exponentially in some subjects: for example, children, especially infants or very young ones, require special precautions by the surgeon, given that the risk of injuring anatomical structures adjacent to the trachea is concrete.
Smokers, obese people and alcoholics are also other categories exposed to the risk of post-surgery complications.
It should also be remembered that the presence of chronic diseases and respiratory infections, as well as the concomitant intake of drugs - such as cortisone, tranquilizers or substances to promote sleep - can prolong the recovery time or, in some cases, increase the risk of complications after surgery. For this reason, before the tracheotomy, it is the patient's duty to inform the doctor of any pathologies, chronic disorders or the intake of certain medicinal specialties.

Post surgery: convalescence

The patient must always be assisted during the post-operative period. The tracheal cannula clearly requires some maintenance and thorough cleaning to minimize the risk of bacterial superinfections; for the same reason, the tracheal stoma (the hole made to insert the cannula) must also be kept strictly clean.
The assistance to the tracheostomy patient provides two very important basic rules:

The maintenance of the patency of the upper respiratory tract and the constant monitoring of respiratory mechanics;
The prevention of short and long-term complications (first of all infections and the inhalation of food or drink)

What to do when the tracheostomy patient returns home?

Once home, the tracheostomy patient needs assistance from family members or competent personnel. It is first of all important to manage and keep the tracheal cannula clean, and to respect small but important precautions:

Apply warm compresses near the incision site to alleviate the pain or discomfort felt
Always keep the incision area dry and clean
If necessary (and with medical advice) take pain medication to mask the pain
Avoid any possible contact with dirt particles, food, water and drinks: once aspirated, solid fragments and / or droplets could cause serious respiratory disorders
Wear soft (not too tight) scarves before leaving the house to prevent dirt particles from entering the respiratory canal
Respect any prophylactic antibiotic therapy prescribed by the doctor after the tracheostomy

In the presence of abnormal symptoms, unbearable pain or doubts, the patient undergoing tracheostomy should seek immediate medical attention for further investigation.