Tracheostomy: Managing Mucus and Breathing Difficulties in Elderly Patients

Q: Tracheostomy: Managing Mucus and Breathing Difficulties in Elderly Patients

Reply： <br>Hello, <br>1. <br>In healthy individuals, the respiratory tract produces a certain amount of mucus daily, which is propelled upward from the deep lung areas to the trachea and even the vocal cords by the cilia on the surface of the respiratory epithelial cells. <br>Thi

Tracheostomy

My grandfather is 92 years old and was recently admitted to the intensive care unit due to choking on food.
The doctors have informed us that they are unable to suction out the mucus from his lungs, and he is also having difficulty breathing on his own.
He has been on suction and a ventilator for ten days, and it seems that they are considering extubation.
Therefore, they are contemplating a tracheostomy to remove the deep mucus.
I would like to ask why the mucus cannot be cleared with medication, and whether the tracheostomy would be very painful for him.
Thank you, doctor, for taking the time to answer my questions.

Danxin de sun nv, 30~39 year old female. Ask Date: 2005/10/14

Dr. Zhuang Ziyi reply Pulmonology

Reply:
Hello,
1.
In healthy individuals, the respiratory tract produces a certain amount of mucus daily, which is propelled upward from the deep lung areas to the trachea and even the vocal cords by the cilia on the surface of the respiratory epithelial cells.
This mucus can be expelled through the cough reflex or swallowed into the esophagus and stomach.
Patients with pneumonia or those who are aging may produce excessive mucus that cannot be effectively cleared, leading to mucus accumulation in the lungs or trachea.
Pneumonia can be treated with antibiotics, and as the inflammatory response decreases, the amount of mucus naturally reduces.
Bronchodilators also have some mucus-clearing effects.
However, currently available expectorants lack clinical evidence to demonstrate efficacy in mucus clearance or expectoration.
Although these medications may reduce mucus volume or aid in expectoration, the ultimate clearance of mucus from the respiratory tract still relies on the patient's own cough reflex.
For intubated patients, it is also necessary for them to cough the mucus into the endotracheal tube, from which nursing staff can then suction the mucus out.
2.
Tracheostomy refers to a surgical or percutaneous procedure to create an opening in the trachea between the cricoid cartilage and the vocal cords to establish an artificial airway.
Typically, two types of patients require tracheostomy: those who are long-term ventilator-dependent and those who cannot maintain a patent upper airway.
Long-term ventilator-dependent patients require an artificial airway connected to the ventilator, as oral intubation can cause significant discomfort for conscious patients, preventing them from eating orally and maintaining oral hygiene, thus necessitating a tracheostomy.
Patients who cannot protect their upper airway are often those with impaired cough reflex or vocal cord function, which also requires a tracheostomy.
After a patient undergoes a tracheostomy, if their condition gradually improves, they may be able to wean off the ventilator, or if the original indications for the tracheostomy resolve, the patient can be trained to wean off the tracheostomy tube.
Generally, this process takes about six months to a year.
3.
Reference materials: Murray and Nader’s Textbook of Respiratory Medicine, 4th ed.
Respiratory Medicine, 3rd ed.

Respectfully, Dr.
Zhuang Zi Yi

Reply Date: 2005/10/14

More Info

Tracheostomy is a surgical procedure that involves creating an opening in the trachea (windpipe) to facilitate breathing when the upper airway is obstructed or when prolonged mechanical ventilation is necessary. In elderly patients, particularly those with underlying health conditions, managing respiratory issues can be complex and challenging. Your grandfather's situation, where he has been unable to effectively clear mucus and breathe independently, highlights the need for careful consideration of his respiratory management.

Why Mucus Cannot Be Cleared with Medication
In normal circumstances, the respiratory system is equipped with mechanisms to clear mucus, primarily through ciliary action and coughing. Cilia are tiny hair-like structures that line the airways and help move mucus upwards towards the throat, where it can be swallowed or coughed out. However, in elderly patients or those with respiratory diseases, these mechanisms can be impaired.
1. Age-Related Changes: As people age, the efficiency of ciliary function may decline, and the ability to cough effectively can diminish. This can lead to mucus accumulation in the lungs, which can become thick and difficult to expel.

2. Underlying Conditions: Conditions such as chronic obstructive pulmonary disease (COPD), pneumonia, or neurological disorders can further compromise the ability to clear mucus. In your grandfather's case, the aspiration of food may have led to pneumonia, which can increase mucus production and inflammation in the lungs.

3. Limitations of Medications: While expectorants and mucolytics are available, their effectiveness can vary. Many over-the-counter medications lack robust clinical evidence supporting their efficacy in clearing mucus. Ultimately, the ability to expel mucus relies heavily on the patient's cough reflex, which may be inadequate in your grandfather's condition.

The Role of Tracheostomy
Given the challenges your grandfather faces, a tracheostomy may be considered a viable option for several reasons:
1. Direct Access to the Airway: A tracheostomy provides a direct route to the trachea, allowing for easier suctioning of mucus that may be lodged deep in the lungs. This can significantly improve respiratory function and comfort.

2. Reduced Work of Breathing: For patients who are on prolonged mechanical ventilation, a tracheostomy can reduce the work of breathing compared to an endotracheal tube. It allows for better airflow and can be more comfortable for the patient.

3. Improved Oral Hygiene: With a tracheostomy, patients can maintain better oral hygiene and potentially reduce the risk of further respiratory infections.

Pain and Discomfort Associated with Tracheostomy
While the thought of a tracheostomy may seem daunting, it is important to understand that the procedure is typically performed under anesthesia, and the immediate pain is managed effectively. Post-operative discomfort can be managed with appropriate analgesics.
1. Adjustment Period: After the procedure, there may be an adjustment period as your grandfather learns to breathe through the tracheostomy. This can be uncomfortable initially, but many patients adapt well over time.

2. Psychological Impact: The psychological aspect of having a tracheostomy can be significant. Patients may feel anxious or distressed about the change in their breathing method. Support from healthcare providers and family can help ease these concerns.

3. Long-Term Considerations: If your grandfather's condition improves, it may be possible to decannulate (remove the tracheostomy tube) after a period of time, allowing him to breathe normally again.

Conclusion
In summary, a tracheostomy can be a valuable intervention for elderly patients like your grandfather who are struggling with mucus clearance and breathing difficulties. While there may be initial discomfort associated with the procedure, the potential benefits in terms of improved respiratory function and quality of life can be significant. It is crucial to have open discussions with the healthcare team about the risks, benefits, and expected outcomes of the procedure to make an informed decision that aligns with your grandfather's health goals and wishes.

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