TRACHEOSTOMY

ENT Department

DMC & HospitalLudhianaPunjab.

Tracheotomy • operative procedure that

creates an artificial opening in the trachea.

Tracheostomy • creation of permanent or semi

permanent opening in trachea.

AnatomyTrachea lies in midline of the neck

extending from cricoid cartilage (C6) superiorly to the tracheal bifurcation at the level of sternal angle (T5).

• Comprises 16-20 C shaped cartilage rings.

• Length 10-12cm.• Diameter 15-20mm.

INDICATIONS FOR TRACHEOSTOMY

To bypass acute upper airway obstruction-once the procedure is performed ,the underlying disease is no longer an immediate threat to compromise the airway. (now the least common indication )Chronic upper airway obstruction secondary to cerebrovascular ischemia or stroke

• Prevention / treatment of retained tracheobronchial secretions. • Prevention of pulmonary aspiration.

Facilitate weaning from mechanical ventilation by decreasing anatomical deadspace. Mechanical respiratory insufficiency-acute respiratory failure requiring tracheostomy may occur in a variety of diseases including

– drug intoxication,– head & chest injuries,– elective surgery,– neurological disorders & diseases,– chronic obstructive airway disease,pneumonia

Indications1. Upper Airway Obstruction.

2. Pulmonary Ventilation.

3. Pulmonary Toilet.

4. Elective Procedure

1. Upper Airway Obstruction

a. Traumab. Foreign bodyc. Infectionsd. Malignant lesions

2. Pulmonary Ventilation

• Tracheostomy should be performed in a patient still requiring ventilation through an endotracheal tube for more than a one week.

3. Pulmonary Toilet

• Those who cannot cough and clear their chest.

• Prevent aspiration by low pressure high volume cuff tracheostomy tube.

4. Elective Procedures

• For major head and neck operations.

Elective TracheostomyAnaesthesia: G APosition: Supine with sand bag

under the shoulderIncision:horizontal incision b/w

cricoid cartilage and suprasternal notch.

Division /retraction of thyroid isthmus

Opening of Trachea and insertion of tube

• Emergency TracheostomyWithin 2-4 mints with vertical

incision

• Cricothyrotomy/mini tracheostomy

Transverse incision over the cricothyroid membrane. Keep only for 3-5 days

Pediatric Tracheostomy Vertical incision in trachea b/w 2nd and 3rd ring.No excision of ant. Wall of tracheaSecure the tube with neck by two sutures

Percutaneus Dilational Tracheostomy

ICU Bed SideTracheostomyUse of guide wire and DilatorsUnder the vision of Bronchoscope through endotracheal tubeLess time ,Less ExpensiveNot suitable for thick neck and in emergency

Tracheostomy Tubes

Plastic / silver

Cuffed

Plain, unfenestrated

Plain, fenestrated

Long, adjustable flange

Soft cuff

COMPONANTS OF TRACHEOSTOMY TUBE

1. Outer tube 2. Inner tube: Fits snugly into outer tube, can be easily removed for cleaning. 3. Flange: Flat plastic plate attached to outer tube - lies flush against the patient’s neck. 4. 15mm outer diameter termination: Fits all ventilator and respiratory equipment. All remaining features are optional 5. Cuff: Inflatable air reservoir (high volume, low pressure) - helps anchor the

tracheostomy tube in place and provides maximum airway sealing with the least amount of local compression.

6. Air inlet valve: One way valve that prevents spontaneous escape of the injected air. 7. Air inlet line: Route for air from air inlet valve to cuff. 8. Pilot cuff: Serves as an indicator of the amount of air in the cuff 9. Fenestration: Hole situated on the curve of the outer tube - used to enhance airflow in

and out of the trachea. Single or multiple fenestrations are available.

BEDSIDE EQUIPMENT Every patient with a tracheostomy tube should have the following equipment available at the bedside:

– Spare tracheostomy tubes Same size and type as patient is wearing. – Smaller size – Tracheal dilator. – Suctioning equipment Suction machine fitted with filter; suction tubing;

– suction catheters; • gloves; bottle of sterile water to rinse tubing - change daily. • Ensure equipment is assembled and working properly.

– Humidification equipment Equipment depends on method used - Ensure equipment is assembled and working properly.

• Gloves Non-sterile **

– Sterile gloves (for suctioning) • Infectious waste bag • Dry clean container for holding the occlusive cap/button or spare inner cannula when not in

use.

PROBLEMS DURING TRACHEOSTOMY CARE

1. Dislocation of tracheostomy tube.2. Bleeding from stoma or during

suction.3. Blockage of tracheostomy tube.4. Aspiration and swallowing

problems.5. Speaking problems.Most problems with tracheostomies can be

anticipated and prevented by good nursing care

FREQUENCY OF CLEANING

(a) Wash hands. (b) Wearing unsterile gloves -remove and dispose of the soiled dressing. (c) Wash hands. Put on sterile gloves. (d) First, remove and clean the inner cannula using sterile pipe cleaners and normal saline. Dry. Reinsert. (e) Secondly, clean the stoma site using gauze and normal saline. (f) Lastly, if ties are soiled and need changing, have a second nurse hold the tracheostomy tube securely in place, remove and replace tracheostomy ties. (Leave 1 finger space between ties and the patient’s neck.) (g) Ensure patient comfort. (h) Discard of used equipment as per hospital policy. (i) Wash Hands. (j) Document procedure in the patient’s notes. Note: Leave first dressing intact for 48hrs if possible as the tracheostomy is a fresh wound.

SUCTIONING VIA A TRACHEOSTOMY TUBE Suctioning is performed only as needed, NOT to a pre-set schedule.

Suction as much as necessary and as little as possible

Be aware that suctioning will be needed more frequently in the immediate post-operative period Explain the procedure to the patient - wash hands, put on gloves. Put on apron and fluid shield mask if necessary for standard (universal) precautions. Turn on suction apparatus and test that vacuum pressure is < -150mmHg/20kPaOpen / expose only the vacuum control segment of the suction catheter and attach to the suction tubing, withdraw the sterile catheter from the protective sleeve. Maintaining sterility, insert the suction catheter with NO suction applied until resistance is met, then pull back about 1-2 cms before applying continuous suction as the catheter is smoothly withdrawn from airway. NOTE: Recommended suction time (i.e. from insertion to removal of suction catheter) = <15secs

• Use a new sterile catheter for each suction pass. • No more than 3 passes recommended per treatment. • Circular motion in tracheostomy tube only

On completing procedure, ensure patient comfort, discard of equipment as per hospital policy, wash hands and document procedure in the patient’s notes.

WORKING OUT SUCTION CATHETER SIZE

Size of trach. tube (mm) x 3 2

E.g. 8 x 3 = size 12 suction catheter 2

This ensures that suction catheter is </= ½ the internal diameter of tracheostomy tube.

HUMIDIFICATIONOF INSPIRED GASES Aims: 1. To prevent drying of pulmonary secretions. 2..To preserve muco-ciliary function.

A) HEATED HUMIDIFIERS - Recommended for:

• patients with new tracheostomy tubes • dehydrated patients • immobile patients • patients with tenacious secretions

B) HEAT MOISTURE EXCHANGE FILTERS - Recommended for:

• patients that are adequately hydrated • mobile patients • Not suitable for patients with copious secretions

C) NEBULIZERS - nebulized normal saline is effective in helping to loosen secretions and soothing irritable airways.

CARE OF CUFFED TRACHEOSTOMY TUBE To prevent aspiration of blood or serous fluid from the wound To seal the trachea during mechanical ventilation To prevent aspiration of leakage from tracheo-oesophageal fistula To prevent aspiration due to laryngeal incompetence

NURSING MANAGEMENT It is unusual for ward patients to need their cuff inflated.

• Tracheostomy cuff is inflated only - (a) if the patient is being mechanically ventilated, (b) if inflation is specifically ordered by doctor.

• Check with doctor that it is OK to do so , and then proceed with cuff deflation...... • Patients can be extremely sensitive to changes in cuff pressure. A little coughing is not unusual

during manipulation. Take care to explain the procedure to the patient and to inflate / deflate the cuff slowly.

• To deflate cuff: First, suction the oropharynx to remove any secretions that may have pooled on top of the inflated cuff. Then, using a syringe, slowly aspirate air from the air inlet port. Once deflated, expiratory noises may be heard as air passes up around the tracheostomy tube. Reassure the patient that these are normal and will settle.

• To inflate cuff: Inject approximately 5-7mls of air via the air inlet port to achieve airway seal. A one-way valve system prevents injected air from escaping.

Complications of overinflation of the trach cuff include (due to excess pressure on tracheal wall):

TracheitisBleedingTracheal erosion/necrosisTracheomalaciaTracheal stenosisTracheoesophageal fistulaTracheoinnominate artery fistulaCuff herniation

NURSING CONSIDERATIONS WHEN USING FENESTRATED TUBES.

A fenestrated tracheostomy tube can only function as such if both the outer and inner cannulas contain a fenestration (hole)! The fenestration allows secretions as well as air to pass up and down the patient’s airway. If needed, give the patient a sputum container or tissues and bag for secretions. Speaking: Speech is facilitated by inserting the fenestrated inner cannula, and occluding the tracheostomy tube opening by using one of the following: (CUFF SHOULD BE DEFLATED)

– a) the patients finger – b) a speaking valve – c) a decannulation plug / cap / button.

Suctioning: If suctioning is required, change to a non-fenestrated inner cannula. This is to prevent the suction catheter passing through the fenestration and traumatising the delicate lining of the posterior tracheal wall. Eating: While using a fenestrated tube restores some of the normal swallow protection mechanisms, nurses should be aware of and observe for signs of aspiration. Swallowing is further improved by having the cuff deflated and the tracheostomy opening occluded at the moment of swallow - methods outlined above. Cleaning of a fenestrated inner cannula is the same as for non-fenestrated tube. Store cleaned speaking valve, cap and spare inner cannula in a sealed, clean, dry container at the patient’s bedside

Complications of Tracheostomy

Intraopertaive Complications.Bleeding and injury to big vesselsInjury to tracheoesophageal wallPneumothorex

Early ComplicationsBleedingTracheostomy tube obstructionTracheostomy tube displacementInfection

Late Complications

Tracheal StenosisGranulation tissueTracheocutaneus fistulaTracheo - inominate fistula

Immediate Post-op Care

Airway

Breathing

Circulation

One to one nursing – Humidification

– Suction– Observation

Tube trouble?

Is patient’s breathing effortless?

Is patient confused/aggressive?

Is patient able to speak without occluding tube?

Is breathing noisy?Wet - excess secretions?Dry - crusted mucus?

Can you pass a suction catheter past the end of the tube (tube length approx 7 - 9cm)?

IF THE TRACHEOSTOMY TUBE FALLS OUT !!...

Once the tracheostomy tube has been in place for about 5 days the tract is well formed and will not suddenly close.

• Reassure the patient • Call for medical help. • Ask the patient to breathe normally via their stoma while waiting for the doctor. • The stay suture (if present) or tracheal dilator may be used to help keep the stoma open if

necessary. • Stay with patient. • Prepare for insertion of the new tracheostomy tube • Once replaced, tie the tube securely, leaving one finger-space between ties and the

patient’s neck. • Check tube position by (a) asking the patient to inhale deeply - they should be able to do

so easily and comfortably, and (b) hold a piece of tissue in front of the opening - it should be “blown” during patient’s exhalation.

Changing the Tube 1First change by ENT surgeon (unless an emergency)

Rarely difficult

“Railroad” technique recommended for first and difficult subsequent changes

Changing the Tube – railroad technique

Cut both ends off largest possible suction catheterInsert suction catheter down trache tube(warn patient re coughing)Remove tube over catheter, maintaining catheter position in airwayInsert new tube over catheterRemove catheterif tube blocked – need to use introducer

Changing the Tube 2Insert introducer into new tubePatient sits upright or lies supine with neck extendedObserve track followed by old tube as it is removed and follow it when inserting new tubeFasten tapes with one finger between tapeand patient’s neckCheck tube positionBeware false track anterior to trachea

Checking tube positionFeel air flow from tube on your arm as patient exhalesObserve patient’s breathing - noisy? difficult? use of accessory muscles?

Observe patient’s colour

If any doubt, fibreoptic scope can be passed down tube for direct vision of position

X-ray not generally helpful

Tracheostomy Complications1. Displaced Tube

Can be fatalMay be accidental or due to confused patient

Post-op, tube stitched (and taped) in place so shouldn’t happen

Need to get tube into tracheostomy ASAPCall for help

Insert tracheal dilators into tracheal stoma

Insert new tube over dilators and into stoma

Tracheostomy Complications2. Tube blockage

Remove inner cannula

Apply tracheal suction

Instil 2 – 3mls sterile normal saline

Fibreoptic view may be helpful

If unavoidable, change tube using introducer and dilators

Tracheostomy Complications3. Bleeding

Likely to be small amount of oozing from tracheostomy wound Inflate cuff on tracheostomy tube to protect airway until bleeding settledIf minor bleeding apply pressure or adrenaline-soaked gauze packLarge bleed uncommon and usually in emergency situation

Tracheostomy Complications4. Surgical emphysema

Usually due to too tight closure of tracheostomy wound

May require removal of sutures to let trapped air escape

ACUTE DYSPNOEA ..is most commonly caused by partial or complete blockage of the tracheostomy tube by retained secretions. To unblock the tracheostomy tube.....

– 1. ASK THE PATIENT TO COUGH: A strong cough may be all that is needed to expel secretions.

– 2. REMOVE THE INNER CANNULA: If there are secretions stuck in the tube, they will automatically be removed when you take out the inner cannula. The outer tube - which does not have secretions in it - will allow the patient to breath freely.

Clean and replace the inner cannula. – 3. SUCTION: If coughing or removing the inner cannula do not work, it may be

that the secretions are lower down the patients airway. Use the suction machine to remove the secretions.

– 4. If these measures fail - commence low concentration oxygen therapy via a tracheostomy mask, and call for medical assistance.

It is possible that the tracheostomy may have become displaced. Stay with the patient until assistance arrives. Prepare for change of tracheostomy tube.

RESUSCITATION VIA A TRACHEOSTOMY TUBE IN THE EVENT OF A CARDIOPULMONARY ARREST, TREAT TRACHEOSTOMY PATIENTS AS ANY OTHER PATIENTS Remove any clothing covering the tracheostomy tube DO NOT remove tracheostomy VENTILATE - by using ambu-bag attached directly to tracheostomy tube

IF UNABLE TO VENTILATE: ..TRY SUCTIONING: This will clear any secretions blocking the airway below the

end of the tracheostomy tube. ..IF STILL UNABLE TO VENTILATE: The tracheostomy tube may have become

displaced. Doctor should: 1) Change tracheostomy tube - if unsuccessful...... 2) Orally intubate

DECANNULATION : REMOVAL OF TRACHEOSTOMY TUBE

STEP 1-Downsizing of the tracheostomy tube • (at least 5-7 days after original tube insertion) • means changing to smaller size, cuffless, tube. (Check with doctor if fenestrated tube to be inserted

at this time.) • This first tube change is ALWAYS carried out by a doctor. • Sometimes a second downsizing is necessary, before proceeding to....

STEP 2-Capping of the tracheostomy tube • This is achieved by applying an occlusive cap to the front of the tracheostomy tube. • Once capping is tolerated for at least 24 consecutive hours the doctor will decide if decannulation

can occur.

STEP 3-Decannulation • The tracheostomy tube is removed, stoma edges are approximated, and an occlusive gauze +

sleek dressing is applied • It takes approximately 10 days for the tracheotomy to heal.

DECANNULATIONLeakage of air +/- secretions around the new tracheostomy tube may be noticed after smaller tube has been inserted. This is expected and will settle once the stoma reduces in size around the tube. Once capped, the patient must breathe through their nose and mouth again. (Give 02 and nebulizers by face-mask now)

• CLOSE OBSERVATION is essential in case of respiratory difficulty. • While many patients can tolerate continuous wearing of the cap, some find that it may

takes getting used to. Therefore wear -time needs to be increased as tolerated. • PATIENTS MUST BE TAUGHT TO REMOVE THE CAP THEMSELVES IF THEY

EXPERIENCE ANY BREATHING DIFFICULTY. • If breathing does not settle with removal of cap - inform doctor.

Encourage patient to press on the stoma dressing when coughing to prevent it being “coughed off”, and to prevent secretions escaping via the stoma.

• Change dressing if loose or soiled.

HOME CARE PLAN

1. Education and training of the attendant.

2. Supply of dressing, suction catheters and suction machine.

3. When to come to the hospital.4. Visit by community nurse.