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A tracheostomy is a small opening made in the front of the neck into the windpipe, held open by a short tube. It is used when someone needs a ventilator for a long time, when the upper airway is blocked or unsafe, or when a weak cough means secretions cannot be cleared. Breathing then happens mostly through the neck rather than the nose and mouth, which changes how air is warmed and moistened, how the person speaks, and sometimes how they swallow. Many tracheostomies are temporary and are removed once the original problem improves. This page explains how the tube works, what care it needs, and how physiotherapy helps.
Why a tracheostomy is placed
- Prolonged mechanical ventilation — the most common reason in intensive care; it reduces sedation needs, improves comfort and assists weaning.
- Upper airway obstruction — tumour, trauma, bilateral vocal cord palsy, severe obstructive sleep apnoea unresponsive to other treatment.
- Secretion management — where a weak or absent cough means secretions cannot be cleared safely (neuromuscular disease, high spinal cord injury, bulbar dysfunction).
- Airway protection — recurrent aspiration with an unsafe swallow.
- Long-term ventilation at home in neuromuscular disease or high cervical injury.
Placement may be percutaneous (usually at the bedside in ICU) or surgical. A laryngectomy stoma is different and critically so: after laryngectomy there is no connection at all between the mouth and the lungs, so nothing can be delivered via the mouth or nose in an emergency.
The tube, and why the parts matter
| Feature | What it does | Physiotherapy relevance |
|---|---|---|
| Cuff (inflated) | Seals the trachea for positive-pressure ventilation and reduces gross aspiration | No airflow past the cuff, so no voice; a speaking valve must never be used with the cuff up |
| Cuff (deflated) / cuffless | Allows airflow around the tube to the larynx | Enables voice, speaking valve and upper-airway airflow; a step towards decannulation |
| Inner cannula | Removable liner that can be cleaned or replaced | First to check if the tube seems blocked — remove and inspect it |
| Fenestration | Hole(s) in the outer tube allowing airflow to the larynx | Needs the matching non-fenestrated inner cannula for suction and ventilation |
| Subglottic suction port | Drains secretions pooling above the cuff | Reduces aspiration of pooled secretions; use before cuff deflation |
| Speaking valve | One-way valve — air in through the tube, out through the larynx | Restores voice, improves swallow and cough; cuff must be fully deflated |
A speaking valve or a cap must never be attached while the cuff is inflated. With the cuff up there is no route for exhaled air, and the patient cannot breathe out. Confirm full cuff deflation and adequate airflow around the tube before any valve or cap is applied, and know who in your service is credentialled to do it.
Humidification — not optional
A tracheostomy bypasses the nose and upper airway, which normally warm, filter and humidify inspired gas. Without replacement humidification, secretions thicken, mucociliary clearance fails and the tube blocks. Heated humidification is used for ventilated and high-flow patients; a heat and moisture exchanger ("Swedish nose") suits self-ventilating patients. Thick, crusting secretions are a humidification failure until proven otherwise — the answer is more humidity and better hydration, not more suction.1
Airway clearance and suction
Suction is effective but not benign: it causes hypoxaemia, mucosal trauma, bronchospasm, arrhythmia and raised intracranial pressure, and it is distressing. It should be performed on clinical indication — audible or palpable secretions, a rising ventilator pressure, desaturation, an ineffective cough — not to a schedule.1,2
Where the cough is weak, augmentation is more effective and more comfortable than repeated suction. Mechanical insufflation–exsufflation improves peak cough flow and secretion clearance in neuromuscular weakness and can be delivered via the tracheostomy; lung volume recruitment, manual assisted cough and positioning all contribute. Nebulised saline and adequate systemic hydration matter more than most techniques.3
Speech and swallowing
Loss of voice is one of the most distressing aspects of a tracheostomy, and restoring it is both a communication and a physiological intervention. A one-way speaking valve restores subglottic pressure, which improves voice, cough strength, secretion clearance and swallow, and it is associated with earlier oral intake and shorter time to decannulation as part of a multidisciplinary pathway.4,5
Swallowing is frequently impaired — from the underlying illness, prolonged intubation, reduced laryngeal elevation, desensitisation and loss of subglottic pressure. Assessment is a speech pathology role; physiotherapy contributes positioning, respiratory support, cough strength and coordination of the timing of clearance around meals.
Weaning and decannulation
Weaning is a staged, multidisciplinary process rather than a single decision. It generally progresses through: resolution of the original indication → ventilator weaning → cuff deflation trials → speaking valve use → downsizing → capping trials → decannulation. The prerequisites are a patent upper airway, an effective cough, manageable secretion load, adequate conscious state and a safe swallow.
Structured, protocolised multidisciplinary tracheostomy teams reduce time to decannulation, length of stay and adverse events — the organisational intervention outperforms any individual technique.6,7 Peak cough flow and secretion frequency are among the more useful objective predictors of successful decannulation.8
Emergencies
Every service caring for tracheostomy patients should follow the National Tracheostomy Safety Project algorithms, with bed-head signs identifying the tube type and whether the upper airway is patent.9
- Blocked tube — remove and inspect the inner cannula first; if still obstructed, suction; escalate immediately.
- Displaced tube — may be partially out or in a false passage; suspect it if the patient can speak unexpectedly, if suction will not pass, or if ventilation is suddenly ineffective. Call for help.
- In a patient with a patent upper airway, oxygen is applied to both the face and the stoma while help arrives; in a laryngectomy patient, the stoma is the only route.
- Bleeding — minor bleeding is common; brisk or pulsatile bleeding may herald a tracheo-innominate fistula and is a surgical emergency.
- Surgical emphysema around the neck suggests malposition or airway injury.
Living with a tracheostomy
For long-term patients the priorities shift from acute care to living well: reliable humidification and suction equipment at home, carer training, communication strategies, showering and stoma care, travel planning, and psychological support. Loss of voice, altered appearance, disturbed sleep and dependence on equipment all carry a significant psychological burden that is frequently under-addressed. Many patients and families become highly expert in their own management — listen to them.
Prognosis
Where the tracheostomy was placed for a reversible problem — prolonged ventilation after critical illness, temporary airway obstruction — decannulation is achieved in the majority, and the stoma closes within days to weeks. Recovery of the underlying condition, particularly ICU-acquired weakness, usually determines timing more than the airway itself. Long-term tracheostomy in progressive neuromuscular disease is a different situation, where the goal is stable, comfortable, well-supported management at home rather than removal. Complications after decannulation — tracheal stenosis, granulation tissue, a persistent stoma, voice change — occur in a minority and warrant ENT review.
Role of the physiotherapist
The physiotherapist's contribution to tracheostomy care sits across three domains. Airway: humidification advocacy, indication-based suction rather than routine suction, cough augmentation, lung volume recruitment and positioning — with the explicit goal of suctioning less by clearing better. Function: early mobilisation, including of ventilated patients, sitting balance, transfers and progressive rehabilitation, because most of these patients also have profound critical-illness weakness. Weaning: contributing objective data — peak cough flow, secretion load, respiratory pattern, exercise tolerance — to the multidisciplinary decannulation decision, and delivering cuff-deflation and speaking-valve tolerance work alongside speech pathology and nursing. Underpinning all three is competence in the emergency algorithm, because the physiotherapist is frequently the clinician alone in the room when a tube blocks.
Evidence summary
Framing. Tracheostomy care is a systems problem more than a technique problem. The interventions with the clearest outcome data are organisational — multidisciplinary teams, standardised protocols, bed-head signage and staff training — rather than any single physiotherapy manoeuvre, and they reduce decannulation time, length of stay and adverse events.6,7,9 Physiotherapy contributes most by operating inside that structure and supplying objective weaning data.
Timing and airway management- Early versus late tracheostomy does not change mortality. TracMan found no 30-day mortality difference between tracheostomy within four days and after ten days, though early tracheostomy reduced sedation requirement; timing is therefore individualised rather than protocolised.10
- Suction should be indication-based, not scheduled, and carries documented risks of hypoxaemia, mucosal trauma, arrhythmia and raised intracranial pressure; pre-oxygenation and appropriate catheter sizing mitigate but do not remove them.1,2
- Humidification is a clinical necessity, not comfort care: inadequate humidification is the principal cause of tube occlusion and thickened secretions in tracheostomised patients.1
- Mechanical insufflation–exsufflation increases peak cough flow and improves secretion clearance in neuromuscular weakness and can be delivered via tracheostomy, reducing suction frequency.3
- One-way speaking valves restore subglottic pressure, improving voice, cough effectiveness and swallow, and are associated with earlier oral intake and communication within multidisciplinary pathways.4,5
- Peak cough flow and secretion frequency are among the more useful objective predictors of decannulation success and are readily measured by physiotherapists.8
- Structured multidisciplinary tracheostomy services reduce time to decannulation and length of stay, and improve safety incident rates, across quality-improvement studies.6,7
- Early mobilisation of tracheostomised, ventilated patients is feasible and safe against agreed criteria and addresses the coexisting critical-illness weakness that usually determines the recovery trajectory.11
- Never apply a speaking valve or cap with the cuff inflated, and confirm upper-airway patency and airflow before doing so; this is the highest-consequence error in tracheostomy care.9
- Treat thick secretions as a humidification and hydration failure first, and escalate suction frequency last.1
- Aim to suction less by clearing better — cough augmentation, lung volume recruitment, positioning and mobilisation reduce the need for instrumented suction.3
- Know the tube in front of you: cuffed or cuffless, fenestrated or not, inner cannula present, subglottic port, and crucially whether the patient has a patent upper airway or is a laryngectomee.9
- Contribute measured data to the weaning decision — peak cough flow, secretion frequency, cuff-deflation tolerance, exercise capacity — rather than a subjective impression.8
- Rehabilitate the whole patient. Most tracheostomised ICU survivors have profound weakness, and airway management alone will not restore function.11
- Be competent in the emergency algorithm and know where the equipment is before you need it; physiotherapists are frequently alone with the patient during clearance.9
- A tube that will not pass a suction catheter is displaced or blocked until proven otherwise — remove the inner cannula first, then escalate.
- Unexpected phonation in a cuffed, ventilated patient suggests cuff deflation or tube displacement, not improvement.
- Failure to wean with clear lungs is usually neuromuscular weakness, secretion load or swallow safety rather than a respiratory problem.8
- Brisk or pulsatile stomal bleeding is a tracheo-innominate fistula until excluded — a surgical emergency, not a nursing observation.
- Optimal airway clearance regimen, technique selection and frequency in tracheostomised patients have never been trialled directly.2,3
- Decannulation criteria remain largely consensus-based, with no validated multivariable prediction tool.8
- The independent contribution of physiotherapy within multidisciplinary tracheostomy teams has not been isolated.6
- Long-term functional, communication and quality-of-life outcomes after decannulation are poorly described.
References & evidence base
- Restrepo RD, Walsh BK. AARC clinical practice guideline: humidification during invasive and noninvasive mechanical ventilation: 2012. Respir Care 2012;57(5):782–788.
- American Association for Respiratory Care. AARC clinical practice guideline: endotracheal suctioning of mechanically ventilated patients with artificial airways 2010. Respir Care 2010;55(6):758–764.
- Chatwin M, Toussaint M, Gonçalves MR, et al. Airway clearance techniques in neuromuscular disorders: a state of the art review. Respir Med 2018;136:98–110.
- Freeman-Sanderson AL, Togher L, Elkins MR, Phipps PR. Return of voice for ventilated tracheostomy patients in ICU: a randomized controlled trial of early-targeted intervention. Crit Care Med 2016;44(6):1075–1081.
- Sutt AL, Cornwell P, Mullany D, Kinneally T, Fraser JF. The use of tracheostomy speaking valves in mechanically ventilated patients results in improved communication and does not prolong ventilation time in cardiothoracic intensive care unit patients. J Crit Care 2015;30(3):491–494.
- Speed L, Harding KE. Tracheostomy teams reduce total tracheostomy time and increase speaking valve use: a systematic review and meta-analysis. J Crit Care 2013;28(2):216.e1–216.e10.
- Cetto R, Arora A, Hettige R, et al. Improving tracheostomy care: a prospective study of the multidisciplinary approach. Clin Otolaryngol 2011;36(5):482–488.
- Bach JR, Saporito LR. Criteria for extubation and tracheostomy tube removal for patients with ventilatory failure: a different approach to weaning. Chest 1996;110(6):1566–1571.
- McGrath BA, Bates L, Atkinson D, Moore JA. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia 2012;67(9):1025–1041.
- Young D, Harrison DA, Cuthbertson BH, Rowan K. Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial. JAMA 2013;309(20):2121–2129.
- Hodgson CL, Stiller K, Needham DM, et al. Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults. Crit Care 2014;18(6):658.
References are numbered in citation order (Vancouver/BMJ style) and were current at the time of writing. Guidelines are living documents — verify against the latest version before clinical use.
Physiotherapy around major chest, cardiac and upper abdominal procedures — from open surgery to bronchoscopic, catheter-based and bedside treatments — aims to reduce chest complications and shorten the return to normal function.
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