Tracheostomy Care After Cancer

A tracheostomy is a surgical opening through the front of the neck into the windpipe. The opening itself is called a stoma. MedlinePlus describes what follows: "After the hole is made, a plastic tube is placed in the hole to keep it open. A ribbon is tied around the neck to keep the tube in place."

In cancer care there are two common reasons for one. MedlinePlus lists "cancer of the neck, which can restrict breathing by pressing on the airway." The other is surgery in or around the voice box, where the airway needs protecting while things heal.

Most of what follows applies to anyone with a tracheostomy. One distinction comes first, because it changes what happens in an emergency.

These are not the same, and mixing them up can kill someone.

With many tracheostomies, the mouth and nose still connect to the lungs. Air can travel the old way as well as the new one.

A total laryngectomy removes that option permanently. StatPearls explains that after the operation "the entirety of the trachea is diverted to a stoma in the anterior neck, and the pharyngeal remnant is closed on itself." The consequence is absolute: "All respiration, including any needed oxygen supplementation or intubation, is via the anterior neck stoma." MedlinePlus says the same in plainer words. "After surgery you will breathe through your stoma." That stoma is permanent and "will never be removed."

So a person after total laryngectomy cannot breathe through the nose or mouth at all. Rescue breaths given to the face do nothing. StatPearls records the hospital practice: "Signs should be placed at the head of the bed and the room door indicating that the patient is a permanent neck breather and cannot be intubated orally or nasally."

Outside hospital, that sign is you. Carry a medical alert card and wear a bracelet that says permanent neck breather. Make sure the people you live with can say that sentence to a paramedic.

If the tube comes out, or blocks, or breathing becomes difficult, call 911 straight away. Make the call first, or have someone else make it while you act. MedlinePlus says to call 911 if the tube comes out and you cannot put it back in, but do not read that as a reason to wait: a blocked or displaced tube is a blocked airway. Only put a tube back in if your own team has trained you or your carer to do it, and only following the plan they wrote for this tube. A stoma that is only days old, a cuffed or specialist tube, or a person who depends on a ventilator all change what is safe to attempt, and forcing a tube in can make things much worse. That written airway plan and the spare tube MedlinePlus tells you to carry, "in case your tube gets plugged", should travel with you.

Call your team the same day for any of these, which MedlinePlus lists for tracheostomy care:

• Fever or chills. CDC's threshold for people with cancer is a temperature of "100.4ºF (38ºC) or higher." CDC adds that "fever may be the only sign that you have an infection."
• Redness, swelling or pain around the stoma that is getting worse.
• Bleeding or drainage from the hole, especially drainage that is thick, colored or smells bad.
• A sudden increase in mucus, or mucus that turns thick and hard to clear.
• A cough that will not settle, or shortness of breath.
• Nausea, or anything else that is simply not usual for you.

For comparison, the American Cancer Society notes a healthy stoma "should look pink or red. It's warm, moist, and produces mucus." That is your baseline.

Nursing Skills, an NIH-hosted teaching text, sets out the components.

The outer cannula is the tube itself, sitting through the stoma. The inner cannula slides inside it and comes out for cleaning. It exists precisely because it "becomes occluded with secretions and must be cleaned or replaced frequently." The obturator is a solid plug used to guide the tube in during insertion. The flange is the plate at the neck that the ties attach to. Some tubes have a cuff, a small balloon inflated through a pilot balloon to seal the airway.

Some tubes are fenestrated, meaning they have an opening that lets air reach the voice box for speech. These carry a specific hazard. Nursing Skills warns that "suctioning should never be performed through a fenestrated tube without first inserting a nonfenestrated inner cannula, or severe tracheal damage can occur."

Write down four things and keep them with you: the make, the size, whether it is cuffed, and whether it is fenestrated.

Nursing Skills lists the emergency kit: spare tracheostomy tubes in the same size and one size smaller, the obturator, a bag valve mask, lubricant, and a syringe for the cuff.

The smaller spare is the part people skip. If the stoma starts to close, the usual size may no longer fit.

MedlinePlus is blunt about leaving the house: "You should always carry an extra tube with you in case your tube gets plugged."

Nursing Skills sets the minimum for the inner cannula: cleaning "should be performed every 12-24 hours at a minimum." The method is sterile technique, a brush in saline, a rinse, and drying with pipe cleaners before it goes back in.

For the stoma itself, MedlinePlus says that once the area is no longer sore from surgery, "clean the hole with a cotton swab or a cotton ball at least once a day." Change bandages and ties whenever they are soiled. Nursing Skills adds a warning: avoid hydrogen peroxide, because it "can impair healing."

Check the skin for redness, drainage and swelling every time you clean.

Ask your team to write your own instructions down. These are the general limits Nursing Skills gives.

Depth: shallow suctioning goes to the length of the tube. Deep suctioning goes in until you meet resistance, then withdraws 1 cm before suction is applied.

Time: no more than 15 seconds per pass, to avoid dropping oxygen levels. Allow 30 to 60 seconds between passes.

Pressure for adults: 100 to 150 mm Hg. Lower for children and infants.

Extra oxygen before and during suctioning may be needed for some people.

Before reaching for the catheter, MedlinePlus offers a gentler first step: "A few drops of salt water (saline) will loosen a plug of thick mucus. Put a few drops in your tube and windpipe, then take a deep breath and cough."

Do not change your depth or pressure on your own.

MedlinePlus explains the problem in one line: "Your nose will no longer keep the air you breathe moist."

Your nose used to warm and humidify every breath. Now air goes straight to the windpipe, dry. Dry air thickens mucus, thick mucus forms plugs, and plugs are what block tubes. Most tracheostomy emergencies start here.

MedlinePlus suggests humidifiers and keeping gauze moist over the tube opening. Ask what your team wants you using, and use it overnight too.

MedlinePlus is specific: "Do not breathe in water, food, powder, or dust. When you take a shower, cover the hole with a tracheostomy cover. You will not be able to go swimming."

That rules out aerosol sprays, talcum powder and sanding dust. Showers are fine with the cover on and the water aimed away.

MedlinePlus says most people need "1 to 3 days to adapt to breathing through a tracheostomy tube," and that speech usually returns with training and a speaking valve.

After a total laryngectomy the route is different. StatPearls notes that a tracheoesophageal puncture may be made during the operation, which later allows speech through a voice prosthesis. MedlinePlus says speech rehabilitation with a speech therapist helps you relearn how to speak, and that about two weeks after the procedure you will most likely be able to return to eating by mouth.

Ask for the speech and language therapist by name before you leave hospital.

• MedlinePlus — Tracheostomy care
• MedlinePlus — Tracheostomy
• MedlinePlus — Laryngectomy
• NIH StatPearls (NCBI Bookshelf) — Total Laryngectomy
• NIH NCBI Bookshelf — Nursing Skills: Tracheostomy Care and Suctioning
• American Cancer Society — About Tracheostomies
• CDC — Watch Out for Fever (Preventing Infections in Cancer Patients)