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Tracheostomy anyone?
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me50 Offline

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Post: #11
RE: Tracheostomy anyone?
(10-06-2013 06:21 PM)DocWils Wrote:  I cannot stress enough that having a tracheotomy is no trivial matter and should only be entered into after a long and concentrated effort for CPAP compliance has failed and no other non surgical techniques have proven successful.

When done correctly, a tracheotomy will bypass the area of collapse, if that is indeed the problem, but it opens itself up to any manner of other problems down the road and is open to infections and a variety of other problems. And, should the reason for your Apnoea not be based in the upper throat, as in CSA, it will have no effect at all.

This isn't a quick fix, and if the only reason for it is because you find the CPAP onerous, let me assure you that maintaining the opening after a tracheotomy will be far more onerous, and can be medically dangerous if you slack on the maintenance of it, unlike slacking on cleaning your CPAP.

Before you consider this, read up on all the side effects and the care and maintenance post-op, something you will have to do every day for the rest of your life. Twice daily, actually. I really would think long and hard about any form of surgical treatment for Apnoea, and even then only after it has proven impossible for you to get benefit from conservative therapies, like CPAP, either due to physical problems or to non compliance issues. And once you are old, it will lead to far more problems and infections than if you stuck with a PAP device.

But if it is simply because you hate the mask, trust me you will hate this even more. As for advancements in T-section techniques and post operative care, no, there is little advance to in now from my days in med school back when dinosaurs ruled the earth. We have better knives and some neat emergency T-section devices, but that is the extent of if. The basic technique is the same as 100 years ago.

About the "button" - that is probably a voder you are referring to, which is used when the vocal chords are damaged - to speak after a T-section, you have to close the hole, either by slipping a flap of skin over it by hand, or having a plug in the hole during the day. Some people can speak without need of closing the hole, depending on where the hole is made and other factors. The hole is prone to infection, and must be kept rigorously clean. Because the air intake bypasses much of the nose and throat, the air taken in is less humid and this can cause throat problems and lung infections, which can be even worse due to the fact that you are bypassing the body's first line of cleansing the air taken in, the mucous and hairs in the nose.

The operation itself isn't complicated, but easy enough to screw up in the wrong hands, and we have an emergency "punch" kit when doing it in the field, but that is a quick and dirty method for a temporary solution. The type of method used for longer term solutions, like you are looking at, requires considerably greater surgery, and sometimes painful post operative recovery, if the surgeon elects to create a skin flap to close the hole when speaking is needed.

Risks include the development of an oesophageal fistula, where a hole opens between your breathing tube and your eating tube, allowing fluids and foods to enter into your trachea and lungs, tracheoinnominate fistula, the generation of a a passage between the trachea and the innominate artery which can create life threatening bleeding, bacterial colonisation of the wound and tube insert, which can lead to pneumonia and other lung infections, some of them fatal, and a myriad of other types of infections, not to mention blockage of the tube itself due to excess mucous coughed up from the lungs because of the drier air you will be breathing.

Do this only if there is no other choice. If you can tolerate a PAP device and it works to alleviate your symptoms, then it is a far better, safer and more comfortable solution than ANY surgical solution. Period.

The only upside is that a tracheostomy can be closed up and healed, unlike a messed up MMA, so if you don't like it, or it threatens your life, you have an out, but you will have spent a great deal of money and have assaulted your body in a very non trivial way, and that will not give you good odds at prolonging your life.

awesome answer and information and is exactly why I would only consider this as and absolute last resort after all else has failed! Thanks you for this information!
10-06-2013 06:29 PM
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Sleepster Offline
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Post: #12
RE: Tracheostomy anyone?
(10-06-2013 03:30 PM)Tim M Wrote:  My AHI was 6.6 on my last study but I am symptomatic. I am thinking of having either MMA or tracheostomy.

I doubt you could find a doctor who would perform a tracheotomy. It's a last resort, and comes with a whole host of risks and problems.

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10-06-2013 07:50 PM
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Peter_C Offline

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Post: #13
RE: Tracheostomy anyone?
(10-06-2013 03:30 PM)Tim M Wrote:  Trach on the other hand is no picnic either and then there is having a hole in my throat but the payoff is supposed to be that 100%, it will cure apnea. At least that's what the surgeon says and he really is an apena expert.

If it's the same surgery I was told about years ago, even then they flat out said it was a *cure* for sleep apnea. I know that if I worsen and they don't have other ideas, this is what I am looking at. But if I can safely keep from doing it, I hope to.

*I* am not a DOCTOR or any type of Health Care Professional. My thoughts/suggestions/ideas are strictly only my opinions.

"Only two defining forces have ever offered to die for you. Jesus Christ and the American Soldier. One died for your Soul, the other for your Freedom."
10-06-2013 10:38 PM
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me50 Offline

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Post: #14
RE: Tracheostomy anyone?
(10-06-2013 10:38 PM)Peter_C Wrote:  
(10-06-2013 03:30 PM)Tim M Wrote:  Trach on the other hand is no picnic either and then there is having a hole in my throat but the payoff is supposed to be that 100%, it will cure apnea. At least that's what the surgeon says and he really is an apena expert.

If it's the same surgery I was told about years ago, even then they flat out said it was a *cure* for sleep apnea. I know that if I worsen and they don't have other ideas, this is what I am looking at. But if I can safely keep from doing it, I hope to.

there are reasons that a person can worsen with apnea and it could be a simple fix comparatively speaking. I hope that you fight for yourself to where any type of surgery is the last resort.

Example: First, I have to say that I am all for holistic treatment above all else rather than chemo/radiation but I am in the minority I think.

But, if one is diagnosed with cancer and is told that surgery and radiation is the course of action, I would choose to make surgery the last resort. Why? Because of there is a way that the tumor(s) can shrink prior to surgery, the less extensive the surgery could be. When my spouse was diagnosed with Stage 4 cancer, it was elected to do surgery first and I can tell you that a lot was lost due to the size of the tumor and what body parts was encased in the tumor. My spouse was afraid that doing rads first would cause such weakness that recovery from surgery would be a long process. The repercussions of surgery first is ongoing and while remission was achieved, the cost has been high.

I learned a lot from this ordeal. So, I encourage all of us to use surgical procedures as a last resort and only if by not dolng a surgical procedure would create a sure death sentence.

If you hate your machine, do whatever you have to do to fall in love with it. The alternatives are worse and sometimes, just like with my spouse, the repercussions will decrease the quality of life.

I also know of someone that had surgery for her apnea and her recovery has been long in coming and they weren't sure she would live b/c her esophagus was nicked during surgery. I know this isn't the norm, but even after she recovered from this surgery, she still has to use her machine.
10-06-2013 11:40 PM
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DocWils Offline

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Post: #15
RE: Tracheostomy anyone?
Me50

I am very sorry to hear that your spouse had stage 4 cancer. At this stage there is little hope of recovery, and, depending on the type of cancer, there are different treatment procedures (excision first, then radiation, radiation first, then excision, aggressive chemo first, then excision, etc). That your spouse has achieved remission is a remarkable feat at this stage. The determination of in which order to do things, established by your oncologist, is based largely on precedent, which is measured in mean 5 year survival rates, meaning that the statistics are constantly evolving and as such the recommended approach is constantly being tweaked and adjusted for the best chance of long term survival. Trends tend to show up very fast, and the given method would have been considered the best chance for an extended survival period. I certainly know that the recovery period is hellish either way, and you and your spouse have my sympathy and my best wishes for continued recovery and a long and happy life.

Returning to the topic, I have made myself pretty clear as to my views of surgical intervention of any type when using or readjusting PAP usage will suffice. MMA is a wildly inconsistent procedure with results that can only be described as iffy - it may work, it may not, most often it reduces symptoms but does not cure them, meaning that you would still need the PAP, so why do it anyway if the PAP works? A tracheotomy will often deal with the symptoms, if it is an upper trachea or above problem, but the life style afterwards is so bloody difficult, I can't imagine anyone choosing it over a mask.

The best way to avoid your condition worsening is to lose weight and get fit. I makes a heckuva difference in almost every case except CSA events or events caused by nasal and soft palate problems, which are not affected by weight gain or loss. For the latter, if the problem is ballooning or softening, and not extensive length, a simple insertion of plastic rods helps, although that method is now being replaced by "scarring" of the region, either being a method of making the region less flexible. For some a mouth insert does the trick, particularly if the problem is the shape or direction of the jaw, for others a nose clip is sufficient if the main cause is the collapse of nasal wall, but such cases rarely have AHIs that rise above a 10. All of these would fall under conservative therapy methods, and non or minimal invasive approaches.

I know that we live in a society that wants quick and permanent fixes, but medicine rarely offers them, and when it does, like magic, it comes at a huge cost. So before undergoing the knife for anything, and I DO mean anything, get a second opinion and a third and read up on the procedure and the post op long term results and effects (these are published online for almost every type of procedure). If there is really a good reason to then abandon conservative therapy, such as CPAP, then do so, but "I want it fixed!" or " I hate having to wear a mask the rest of my life!" isn't sufficient cause. The end results may be far worse than just learning to accept and love your mask. In those cases, see a head shrinker and get cognitive behavioural training. It has proven results, especially with PAP compliance where mask wearing was unbearable to the patient, almost always for psychological reasons that may have manifested themselves in physical reactions to the mask.

And one more thing - no surgery is trivial, even something as fast and relatively easy as a tracheotomy. So think carefully before doing it. Some surgeons and some doctors are very enthusiastic about cut and stitch, others, like me, tend to realise it is a necessary thing, but neither a picnic nor desirable if at all avoidable. Every surgery is fraught with perils, even minor ones, and you do it advisedly. Sometimes the perils are minor (infection, scarring, etc) but sometimes, like long term tracheostomies, the perils are quite major and can even be life threatening. So think before you cut. Think hard, and then take a walk, and think hard again. Yes, you OSA may be "cured" (it isn't, it is bypassed but still there), but at what cost, especially compared to not having a permanent physical change to your body and lifestyle?
(This post was last modified: 10-07-2013 04:27 AM by DocWils.)
10-07-2013 04:23 AM
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skyler Offline

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Post: #16
RE: Tracheostomy anyone?
The trach will stop all obstructive apneas, but will not touch central apnea. However since cpap therapy precipitates central apneas it may be a moot point.
I think it's a pretty drastic solution to something that could be inexpensive and control your apnea like cpap or a MMAD. There was a doc on another forum who had one and loved the freedom.
10-07-2013 08:29 AM
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DocWils Offline

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Post: #17
RE: Tracheostomy anyone?
We did a televised study of various anti-snoring methods, including MAD last year for the national television station's weekly health series. MAD was effective in several cases where moving the jaw forward did the trick, but be aware, there are side effects as well, including altered bite, a shift in the teeth positions and all that such a shift would entail, dry lips, excessive salivation and pain, and some reports of TMJ like symptoms. So it is also not entirely without problems, but if faced with the choice between the knife and MAD and CPAP doesn't work for you for some reason, if MAD works, go for it. It is relatively safe, and effective. Statistically if has been shown long term to be far more effective and long lasting than UPPP, which with changes to the body due to weight gain or other factors, including age, will lose its effectiveness after a while. Make sure that you are working with a dentist or an orthodontist rather than a sleep specialist for actual the fitting, since they are more able to diagnose and head off potential problems for your bite. You will also have to regularly see the orthodontist or dentist to ensure that all is well in your mouth.

The best treatment method for Apnoea depends on multiple factors, including the type of apnoea, the shape of your throat, mouth, nose and tongue, the severity of the apnoea, other medical conditions that could weigh in on the choice of treatment, and of course, personal preference. Be bolshy, not meek and accepting of whatever you are handed - do your research and be clear about the best choices and the no-gos for you, even when it comes to mask type. For instance, they wanted to fit me with a nasal mask - I knew that my nasal walls collapse on the out breath and as such, it would be less effective than nasal pillows, so I insisted, and got my way. You should, too, but be willing to listen to reason as well, your doctors should know the best methods for you, and be able to explain why your particular choice would be less effective - if I had been a mouth breather, for instance, then a nasal pillow would not have done the trick, even with a chin strap, and either a hybrid or full face mask would have been in my future.
However, I shall stand by my advice that any form or surgical intervention should be a last resort after all conservative options have been tried and found ineffective, and not a first.
10-07-2013 10:31 AM
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terp1984 Offline

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Post: #18
RE: Tracheostomy anyone?
Here are my for-whatever-they-may-be-worth comments:
There is no such thing as a 100% cure for anything. Please understand that a surgeon who wants to perform a surgery has a natural (albeit not necessarily deliberate) bias toward convincing you to submit to the surgery. I had UPPP about 2.5 years ago and was told I had a 50% chance of a complete cure, 80% chance of at least some improvement and 0% chance of it getting worse. Well, it got worse.

Also, someone made a comment about the benefits of losing weight in treating OSA. I lost 30 pounds and saw no improvement in that regard (I will readily admit to multiple other improvements, so it was definitely not a wasted effort).

As always, your results probably will vary.

The Tracheotomy is so incredibly severe (and life-impacting in other ways), I just can't imagine anyone having it done except as a last resort. I actually considered it (somewhat) after my UPPP failed. Fortunately, I came to my senses.
10-07-2013 12:48 PM
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Peter_C Offline

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Post: #19
RE: Tracheostomy anyone?
Just like the 'patellectomy' (sp?) they wanted to do to me many years ago (I heard that procedure isn't even done any longer), I hope to avoid surgery whenever possible. Not only do I love (well, like) my mask, I can't even nap without it after so many years. In my case, the Trac was discussed as a *possible* last ditch effort, that thankfully was not done or (yet) needed.

FYI - In the last 2+ yrs I've lost some 70 pounds (still need to lose more), with no noticeable benefit to my OSA (although it hasn't gotten worse either).

*I* am not a DOCTOR or any type of Health Care Professional. My thoughts/suggestions/ideas are strictly only my opinions.

"Only two defining forces have ever offered to die for you. Jesus Christ and the American Soldier. One died for your Soul, the other for your Freedom."
10-07-2013 05:43 PM
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Sleepster Offline
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Post: #20
RE: Tracheostomy anyone?
(10-07-2013 04:23 AM)DocWils Wrote:  A tracheotomy will often deal with the symptoms, if it is an upper trachea or above problem, but the life style afterwards is so bloody difficult, I can't imagine anyone choosing it over a mask.

Very few people would even be given that choice. I can't imagine a reputable doctor or surgical institution performing that operation on a patient who is a candidate for CPAP therapy.

There are new robotic surgeries, but even in those cases CPAP therapy is often going to be required afterwards anyway.

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10-07-2013 05:59 PM
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