Tracheostomy Care

Definition
Tracheotomy

Surgical incision into the trachea to establish an airway Stoma that results from tracheotomy

Tracheostomy

Indications for a Tracheostomy

Tumor Stenosis: subglottic, tracheomalacia Congenital abnormalities of the airway: large tongue or small jaw Broncho Pulmonary Dysplasia Chronic pulmonary disease Chest wall injury Diaphragm dysfunction

Indications
Bypass upper airway obstruction Facilitate removal of secretions Long-term mechanical ventilation Permit oral intake and speech in patient who requires long-term mechanical ventilation

Advantages
Less risk of long-term damage to airway Increased comfort Patient can eat. Increased mobility because tube is more secure

Parts of a Tracheostomy Tube

Tracheostomy Care
Tubes contain a faceplate or flange.

Rest on neck between clavicles and outer cannula

During insertion, obturator is placed inside outer cannula, with rounded tip protruding from end to ease insertion.

Tracheostomy Care
After insertion, obturator must be immediately removed to allow airflow. Keep obturator near bedside in case of decannulation. Some tubes have a removable inner cannula for easier cleaning.

Tracheostomy Care
Care involves
Suctioning the airway to remove secretions Cleaning around stoma Changing ties Providing inner cannula care

Changing Tracheostomy Ties

Tracheostomy Care
Tube with inflated cuff is used for risk of aspiration or in mechanical ventilation.

Inflate cuff with minimum volume required to create an airway seal.

Should not exceed 20 mm Hg or 25 cm H2O

Tracheostomy Care
Excessive cuff pressure can
Compress tracheal capillaries Limit blood flow Predispose to tracheal necrosis

Tracheostomy Care
Minimal leak technique (MLT)
Inflate cuff with minimum amount of air to form seal. Then withdraw 0.1 mL of air. Risk for aspiration Not used if trach is bypassing upper airway construction

Tracheostomy Care
Deflation
To remove secretions accumulating above the cuff Patient should cough up secretions before deflation to avoid aspiration. Suction mouth and tube. During exhalation as gas helps propel secretions into mouth Patient should cough and be suctioned again.

Tracheostomy Care
Deflation
Assess patients ability to protect airway from aspiration. Remain with patient when cuff is initially deflated, unless patient can protect against aspiration and breathe without respiratory distress. When patient can protect against aspiration and does not require mechanical ventilation, a cuffless tube is used.

Tracheostomy Care
Reinflation
During inspiration Monitor inflation volume daily as it may with tracheal dilation from cuff pressure.

Tracheostomy Care
Retention sutures
Placed in tracheal cartilage during tracheostomy Free ends taped to skin and left accessible in case tube is dislodged

Tracheostomy Care
Precautions for tube replacement

Tube of equal or smaller size kept at bedside for emergency reinsertion Tapes not changed for at least 24 hours after insertion First change by physician no sooner than 7 days after tracheostomy

Tracheostomy Care
Accidental dislodging
Immediately replace tube. Spread opening with retention sutures grasped or hemostat. Insert obturator into replacement tube.

Lubricated with saline poured over tip Inserted at 45 degrees to neck

Tracheostomy Care
Another method for reinsertion
Insert suction catheter to allow for air passage and to serve as a guide for obturator. Tube should be threaded over catheter and suction catheter removed.

Tracheostomy Care
If tube cannot be replaced
Assess level of respiratory distress Minor dyspnea may be alleviated with semiFowlers position Severe distress may progress to respiratory arrest Cover stoma with sterile dressing and ventilate with bag-mask until help arrives

Tracheostomy Care
Initially should receive humidified air. Tube should be changed monthly. Patient can be taught to change tube using clean technique at home.

Swallowing Dysfunction
Inflated cuff
Interferes with normal function of muscles used to swallow Evaluate risk of aspiration with cuff deflated, or substitute with a cuffless tube.

Swallowing Dysfunction
Evaluate aspiration
Add blue coloring to clear liquid and evaluate coughing and secretions, or suction trachea for blue fluid. Test tracheobronchial secretions for glucose (mucus is generally very low).

Speech
Techniques to promote speech
Spontaneously breathing patient may deflate cuff, allowing exhaled air to flow over vocal cords. Patient on mechanical ventilation can allow constant air leak around cuff.

Speech
Techniques to promote speech
Tracheostomy tubes and valves have been designed to facilitate speech. Promote use to provide psychologic benefit and self-care.

Speaking Tracheostomy Tubes

Speech
Fenestrated tube has opening on surface of outer cannula to permit airflow over vocal cords to allow
Spontaneous breathing through larynx Speech Secretion expectoration with tube in place

Speech
Fenestrated tube
Requires frequent suctioning Ability to swallow is determined before use. Frequently assess for signs of respiratory distress on first use. Potential for development of tracheal polyps

Speech
Speaking tracheostomy has two pigtail tubings
One connects to cuff for inflation. Other connects to opening just above cuff. When second tube is connected to low-flow air source, this permits speech.

Passy-Muir Speaking Tracheostomy Valve

Speech
Ability to tolerate cuff deflation without aspiration or respiratory distress must be evaluated.

If no aspiration, cuff is deflated and valve is placed over opening.

Speech
Provide patient with writing tools if speaking devices are not used.

Decannulation
When patient can adequately exchange air and expectorate
Stoma closed with tape and covered with occlusive dressing Instruct patient to splint stoma with fingers when coughing, swallowing, or speaking

Decannulation
Tissue forms in 24 to 48 hours. Opening will close in several days without surgical intervention.

After Decannulation
The stoma begins closing as soon as the trach tube is removed. This may take months to achieve final closure. Until closed by nature or surgery, need to keep opening covered. Bandaids work nicely for this; change as needed.