Informed Consent for Tracheostomy Surgery
Patient and Provider Information
What is a Tracheostomy?
A tracheostomy is a surgical procedure that creates an opening in your neck to place a tube directly into your windpipe (trachea). This tube bypasses your mouth and throat, establishing a direct pathway for air to reach your lungs. This procedure is commonly performed for patients who: (1) need long-term breathing assistance from a ventilator machine (typically more than 10 to 14 days); (2) have a blocked or severely narrowed upper airway due to swelling, trauma, or tumors; or (3) cannot clear thick mucus and secretions from their lungs on their own.
How is the Surgery Performed?
The procedure is performed in an operating room or at the bedside in the intensive care unit (ICU) under sterile conditions. You will receive general anesthesia to ensure you are asleep and pain-free. The surgeon will: (1) Clean the neck and drape the area. (2) Make a small horizontal incision in the skin of the neck, below the vocal cords. (3) Carefully separate the underlying neck muscles and tissue, exposing the thyroid gland and the windpipe (trachea). (4) Create a small opening in the front wall of the trachea. (5) Insert a sterile tracheostomy tube into the windpipe and secure it to your neck using fabric ties or straps to prevent it from sliding out. (6) Connect the tube to a ventilator machine or oxygen source. The surgery takes about 30 to 60 minutes.
Expected Benefits
Provides a safer, more stable airway for patients requiring prolonged ventilator support. Is significantly more comfortable than keeping a breathing tube in the mouth or throat, reducing the need for heavy sedation. Allows patients to talk (using a special speaking valve) and eat mouth-food sooner, if clinically appropriate. Allows nursing staff or caregivers to easily suction and clear mucus directly from the lungs. Risks and Potential Complications
Bleeding: Major blood vessels are located near the windpipe. Bleeding can occur during or after surgery and can occasionally leak into the lungs, requiring surgical revision or blood transfusions. Accidental Tube Displacement: The tracheostomy tube can accidentally slip out of the windpipe. In the first few days after surgery, before the neck tract has healed, this is a serious medical emergency that can cause airway closure. Tube Blockage: Mucus and dried secretions can build up inside the tube, blocking your airway. This requires regular cleaning of the inner tube and frequent suctioning. Infection: Bacterial infection can occur in the skin incision or inside the lungs (pneumonia). This is managed with antibiotics and wound care. Damage to Nearby Organs: Inadvertent damage to the esophagus (food pipe), thyroid gland, or nerves controlling the vocal cords can occur during insertion, potentially causing swallowing or voice issues. Tracheal Narrowing (Stenosis): Over weeks or months, scar tissue can build up inside the windpipe, causing the airway to narrow after the tube is removed. This may require secondary endoscopic dilatation surgery. Alternatives to Tracheostomy Surgery
Continued Endotracheal Intubation: Keeping the breathing tube in place through the mouth. Using a mouth tube for longer than 2 weeks increases the risk of permanent vocal cord damage, breathing tube failure, and severe mouth ulcers. Refusal of Surgery: Choosing not to proceed. If you cannot breathe independently and refuse a tracheostomy, removing the mouth breathing tube will lead to acute respiratory failure, brain injury from lack of oxygen, and death. Patient Acknowledgment and Authorization
I confirm that the surgeon has explained the purpose of the tracheostomy, the steps of the procedure, and the risks of bleeding, tube displacement, and windpipe narrowing. I understand the alternatives and the severe risks of refusing treatment. I have had the opportunity to ask questions, and all my questions have been answered. I voluntarily authorize the surgeon to perform this procedure.
Signatures and Verification
Patient Signature (or Legally Authorized Representative) Relationship to Patient (if Representative) Operating Surgeon Signature Witness Signature (Optional)