Tracheostomy care

Dr. Wesam Farid MousaAssisstant Professor Anesthesia &

Surgical ICUDammam Hospital of the University

Tracheostomy Care

Tracheostomy The Enabling Disability

Historically

The first instance of tracheotomy was portrayed way back in 3600 BC on Egyptian artifacts by engravings in Abydos and Sakkara regions of Egypt depicting tracheostomy.

Antonio Musa Brasavola, an Italian physician, performed the first documented case of a successful tracheotomy in a patient, who suffered from a tonsillar obstruction and recovered from the procedure. He published his account in 1546.

In 1620, Habicot performed the first pediatric tracheotomy. The procedure was performed on a sixteen-year-old boy who had swallowed a bag of gold in an attempt to keep the gold from being stolen. The bag became lodged in the boy's esophagus and obstructed his trachea. After Habicot performed the tracheotomy, he manipulated the bag of gold so that it would pass. It was eventually recovered per rectum.

Friedrich III, German Emperor (1831 – 1888)

He had incurable cancer of the larynx, which had been misdiagnosed by the English doctor Morell Mackenzie (later knighted by Queen Victoria). When the error was caught, it was too late to operate. Later swelling by the tumor caused the prince to begin to suffocate, and so on February 9, 1888, a tracheotomy was performed and a silver tube was put. As a result of this operation, Friedrich was unable to speak for the remainder of his life, and communicated through writing. Friedrich ruled for only 99 days before his death, being succeeded by his son Wilhelm II.

Elizabeth Taylor's Tracheostomy

Taylor went to Europe, awaiting production of Cleopatra. In spring of 1961, she developed a case of pneumonia, which led to an emergency tracheotomy and worldwide talk of her impending death. The swelling of sympathy was widely thought to have influenced Academy voters, who awarded Taylor her first Best Actress Oscar —Elizabeth later commented, I knew it was a sympathy award, but I was still proud to get it." Meanwhile, Taylor's competitor Shirley MacLaine memorably quipped, "I lost to a tracheotomy!"

Stephen Hawking (physicist)

Stephen Hawking developed motor neurone disease when he was in his early 20s. Most patients with the condition die within five years, and according to the Motor Neurone Disease Association, average life expectancy after diagnosis is 14 months.But Professor Hawking, the Cambridge University physicist and cosmologist and author of A Brief History of Time, has confounded the statistics and recently celebrated his 73rd birthday.

• A tracheostomy is the formation of an opening into the trachea

usually between the second and third rings of cartilage.

• provide mechanical ventilation on a long-term basis as in cases of neuromuscular disease

• Facilitate weaning from mechanical ventilation by

decreasing anatomical dead space:A COPD patient on mechanical ventilation

• To bypass obstruction: Cancer larynx

• To maintain an open airway: A comatose patient

• To remove secretions more easily: Inability to swallow or cough: stroke patient

Tracheostomy is done to

Types of Tracheostomy

• Surgical tracheostomy: performed in the OR or at bedside under moderate sedation

• Percutaneous dilatational tracheostomy is done at the patient’s bedside, usually in the ICU setting. contraindicated in anatomical irregularities or coagulation problems.

• Appearance is the same• Temporary: The upper airway will remain

connected to the lower airway if the tracheostomy tube were to be dislodged

• Permanent: The larynx is removed and no connection exists between the upper airway and the trachea itself

Temporary Tracheostomy versus Permanent

• Subcutaneous emphysema – air escapes around stoma ; generally of no clinical consequence –can be palpated around the stoma site

Potential short-term complications

• Dislodgement of the tube Due to excessive manipulation of the tracheostomy tube during coughing or suctioning– (more in the first 48 hours)

Potential short-term complications

• Thinning of the trachea (Trachemalacia)

Potential long-term complications Tracheostomy:

• Development of granulation of tissue (bump formation in trachea)


Narrowing of the airway above the site of tracheostomy


• Once tracheostomy tube is removed, the opening may not close on its own


Dysphagia


Tracheal ischemia and necrosis


Identifying Tracheostomy Parts

Cuffed Tracheostomy TubeConsists of three parts:• Outer cannula

with an inflatable cuff and pilot tube

• An inner cannula• An obturator

• More suitable for long term ventilation• patient must have effective cough and

gag reflex to prevent aspiration risk

Cuffless tubes

• Have an opening on the posterior wall of outer cannula allowing air to flow through the upper airway and hence allows patient to speak

• Often used during weaning process

Fenestrated Tube

• Patients being weaned off trach tubes may have either a cuffless or fenestrated tube to allow airflow past the larynx

Communication and Tracheostomies

• Be aware of when and why the trach was inserted , how it was performed, the type and size of tube inserted

• Examine the patient at the start of visit. Observe for signs of hypoxia, infection or pain

• Chest: Auscultate breath sounds

• Examine trach tube, as well as stoma site for redness, purulent drainage, and bleeding around the stoma

Nursing Care: Examination

• The nose provides warmth, moisture and filtration for the air we breath.

• Having a tracheostomy tube by-passes these mechanisms

• so humidification must be provided to keep secretions thin and to avoid mucus plugs

Tracheostomy Humidification

• Ideal room air temperature is 22C,10mmH2O/L

• Larynx: 31-33C, 26-32 mmH2O/L

• Mid-trachea: 34C, 34-38 mmH2O/L

• Main bronchi: 37C, 44mmH2O/L

Ambient water humidification

Heat moisture exchanger (attached to the outside of a trach tube for long-term trach patients) – looks like a t-tube attachment

Types of tracheostomy humidification systems

• Frequent repositioning,• deep breathing and coughing,• chest physiotherapy,• oral and parenteral hydration• supplemental humidification

Nursing Care: Help to thin and mobilize secretions

• Necessary for all trach patients to remove secretions

• Routinely done 2x / day, but more often if a newly placed tracheostomy or when there is infection present

• Suctioning activates psychological and physiological reflexes that make the experience both uncomfortable and frightening

Nursing Care - Suctioning

• Selection of the appropriate size suction catheter is vital in reducing the risk of trauma during suctioning

• Divide the internal diameter of the tracheostomy by two, and multiply the answer by three to obtain the French gauge suction catheter:– Size 8 tracheostomy tube (patient); (8mm/2) x 3 =

12; therefore, a size 12F gauge catheter is suitable for suctioning

Selecting a suction catheter

• PPE – (mask, goggles, gloves)• Bottle of normal saline• Appropriately sized suction

catheter• Trach care kit• Disposable inner cannula if

appropriate• Oxygen source – connected

to patient • Suction equipment regulator

set at 80-120 mmHg• Ambu bag to ventilate patient

prior to suctioning if appropriate

Gathering equipment for suctioning

• Place patient in semi-fowler’s position• Select appropriate sized suction catheter• Hyper oxygenate BEFORE each suction pass (except patients with long-term tracheostomy)• Insert catheter to a pre-measured depth• Apply suction on withdrawal of catheter• Limit suctioning to 5 seconds• Use suction pressure between 80 – 120 mmHg• Limit suctioning to 3 passes

• Discontinue if HR drops by 20; increases by 40, produces arrhythmias, or decreases 02 < 90%

Procedure for suctioning

• Ties are generally changed daily

• To lower the risk of accidental trach tube coming out, tie changes should be:-

performed by two people or with new ties secured BEFORE old ties are removed.

Tracheostomy Ties

• The majority of trach tubes have inner cannulas that require cleaning one to three times daily unless they are disposable

• Use sterile technique to clean the reusable cannula with ½ strength hydrogen peroxide and normal saline

Maintenance of the inner cannula

• Cuff pressure (balloon) should be maintained at 20 mmHg of pressure via a manometer – should be assessed daily;

• if you don’t have a manometer measuring device – check With a stethoscope placed on the neck, inflate the cuff until you no longer hear hissing; deflate the cuff in tiny increments until a slight his returns….

Nursing Care – Trach cuff pressure

• Assess and evaluate how the cuff is working• Periodically relieve pressure on the trachea• Let secretions above the cuff drain down so

you can suction them

Why?

• Tube changes can be done safely on a 1-3 month basis using a clean technique

• Silicon tubes can crack and tear; soft PVC tubes can stiffen with time

Nursing Care: Changing the Trach tube

• Clean stoma with Q-tip moistened with NS;

• Avoid using hydrogen peroxide unless infection present (as it can impair healing) –

• Dressings around the stoma are changed

Nursing care: Tracheostomy Site Care and Dressing

• Can a patient eat with a Tracheostomy:

– Yes…generally speaking (patient may need an evaluation by a speech pathologist to determine swallowing ability)

FAQs

• Why can’t we use the Passey Muir valve with the cuff inflated?– The speaking valve is a one-way

airflow mechanism. The patient inhales air through the speaking valve but exhales it around the tracheostomy tube and then through the nose or mouth.

– If the cuff is inflated with a speaking valve, the patient will only be able to inhale air and will not be able to exhale since there will not be any room around the tracheostomy

FAQs

• What is the tracheostomy plug Used for ?– two purposes:• Decannulation of the

tracheostomy tube– Used to plug trach tube for 12

hours the first day and 24 hours the second day – if the patient tolerates plugging, then decannulation can take place

• It can be used for speech, but not as a speaking valve

FAQs

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Tracheostomy care