1. Tracheostomy Care

2. Definition Tracheotomy Tracheostomy
Surgical incision into the trachea to establish an airway
Tracheostomy
Stoma that results from tracheotomy

5. 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

6. 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
Most patients who require mechanical ventilation are initially managed with an endotracheal tube, which can be quickly inserted in an emergency.
The standard surgical tracheostomy is usually performed in the operating room using general anesthesia. A newer procedure, a percutaneous tracheostomy, can be performed emergently at the bedside using local anesthesia and some sedation/analgesia.

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

8. Parts of a Tracheostomy Tube
A, Parts of a tracheostomy tube.
B, Tracheostomy tube inserted in airway with inflated cuff.
C, Fenestrated tracheostomy tube with cuff, inner cannula, decannulation plug, and pilot balloon.
D, Tracheostomy tube with foam cuff and obturator (one cuff is deflated on tracheostomy tube).
See Table 27-5 and NCP 27-1 for related nursing management.

9. 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.

10. 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.
The cleaning procedure for the inner cannula removes mucus from the inside of the tube. If humidification is adequate, mucus may not accumulate and a tube without an inner cannula can be used.

11. Tracheostomy Care Care involves
Suctioning the airway to remove secretions
Cleaning around stoma
Changing ties
Providing inner cannula care
{See next 2 slides for figures}

12. Changing Tracheostomy Ties
A, A slit is cut about 1 inch (2.5 cm) from the end. The slit end is put into the opening of the cannula. B, A loop is made with the other end of the tape. C, The tapes are tied together with a double knot on the side of the neck. D, A tracheostomy tube holder can be used in place of twill ties to make tracheostomy tube stabilization more secure.
A two-person technique, one to stabilize the tracheostomy and one to change the ties, is best to assure that the tracheostomy does not become accidentally dislodged during the procedure.

13. 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
A tracheostomy tube with an inflated cuff is used if the patient is at risk of aspiration or needs mechanical ventilation.

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

15. 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

16. 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.

17. Tracheostomy Care Deflation
Assess patient’s 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.

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

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

20. 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
The nurse should take care not to dislodge the tracheostomy tube during the first 5 to 7 days when the stoma is not mature (healed).

21. 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

22. 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.

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

24. Tracheostomy Care Initially should receive humidified air.
Tube should be changed monthly.
Patient can be taught to change tube using clean technique at home.
When a tracheostomy has been in place for several months, the healed tract will be well formed.
{See next slide for figure about changing tube at home}

25. 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.

26. 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).
In the first method, deflate the cuff and instruct the patient to swallow a small amount of clear liquid such as grape juice or 30 mL of water that has blue food coloring added. Note any coughing and secretions.
This method may place the patient at risk for allergic reactions to the food coloring and is also very subjective.
Limitations of the second method include false-positive results if the mucus is blood-tinged.

27. 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.

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

29. Speaking Tracheostomy Tubes
A, Fenestrated tracheostomy tube with cuff deflated, inner cannula removed, and tracheostomy tube capped to allow air to pass over the vocal cords.
B, Speaking tracheostomy tube. One tube is used for cuff inflation. The second tube is connected to a source of compressed air or oxygen. When the port on the second tube is occluded, air flows up over the vocal cords, allowing speech with an inflated cuff. (See Table 27-5 and NCP 27-1 for related nursing management.)

30. 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

31. 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
If the patient swallows without aspiration, (1) remove the inner cannula, (2) deflate the cuff, and (3) place the decannulation cap in the tube.
If the patient is not able to tolerate the procedure, remove the cap, replace the inner cannula, and reinflate the cuff.

32. 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.

33. Passy-Muir Speaking Tracheostomy Valve
The valve is placed over the hub of the tracheostomy tube after the cuff is deflated. Multiple options are available and can be used for ventilated and nonventilated patients. The valve contains a one-way valve that allows air to enter the lungs during inspiration and redirects air upward over the vocal cords into the mouth during expiration.

34. 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.
The speaking valve contains a thin plastic diaphragm that opens on inspiration and closes on expiration. During inspiration, air flows in through the valve. During expiration, the diaphragm prevents exhalation and air flows upward over the vocal cords and into the mouth.

35. Speech
Provide patient with writing tools if speaking devices are not used.
i.e., pen and pencil, Magic Slate, word (communication) board

36. 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
The dressing must be changed if it gets soiled or wet.

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

38. 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.