Ms Tracheostomy Care

TRACHEOSTOMY CARE By:SOFIA IRENE M. BRIONES, R.N.MAN DESCRIPTIVE TERMS • Tracheotomy: A surgical incision into the trachea for the purpose of establishing an airway. Performed in the OR. A tube is placed in the trachea just below the 2nd and 3rd tracheal ring, bypassing the epiglottis. A tracheostomy may be emergency, temporary, permanent, or prophylactic. • Tracheostomy: A tracheal stoma or opening that results from a tracheotomy. • Trach: A tracheostomy site or tube is often referred to as a "trach". • Inner cannula: A "sleeve" which fits inside the trach tube and may be removed for cleaning. • Flange or neck plate: Holds ties, prevents pressure points and movement. • Obturator: Guides the tube into position without causing trauma to tissues. Is removed once the trach tube is in place. • Cuff: Surrounds the outer cannula. Inflated (with air) inside trachea to prevent aspiration and to seal the trach wall to allow more efficient air exchange, especially with a ventilator. • Fenestration: Hole in trach tube to allow air passage for speaking (trach tube is below larynx, making speech with a cuffed non-fenestrated tube impossible). • Ties: Cotton tie (may or may not have Velcro attachment) around neck to decrease movement of trach tube. • Decannulation: The process of weaning patient from trach use. Considered once a patient has a patent upper airway. Consists of straight removal or "corking" (plugging) the tube for periods of time. TYPES OF TUBES • Metal (Jackson) or plastic (Shiley, Portex) · Single cannula or double cannula · Cuffed or uncuffed · Fenestrated (for speaking) or non-fenestrated · Disposable and permanent · Long-term and short-term TRACHEOSTOMY TUBE The tracheotomy tube consists of three parts: outer cannula, inner cannula, and obturator. 1. The outer cannula is the outer tube that holds the tracheostomy open. A neck plate extends from the sides of the outer tube and has holes to attach cloth ties or velcro strap around the neck. 2. The inner cannula fits inside the outer cannula. It has a lock to keep it from being coughed out, and it is removed for cleaning. 3. The obturator fits inside the tube to provide a smooth surface that guides the tracheotomy tube when it is being inserted.

Cuffed Tracheostomy Tubes

Foam-filled Bivona cuff tracheostomy

tube deflated (left), inflated (right)

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A cuff is a soft balloon around the distal end of the tube that can be inflated to seal the trachea for children needing ventilator support or to help prevent secretions from entering the lungs.

• • Cuff •

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Avoid over inflating the tracheostomy tube cuff. The pressure of the cuff against the wall of the trachea can cause damage if it is too high. Suction the trach tube if needed. After suctioning the tube, suction the mouth and above the trach cuff so that secretions do not go into lungs when cuff is deflated. Deflation Techniques Minimal Occluding Volume Technique: Deflate the cuff, then slowly begin re-injecting air (or sterile water depending on the type of tube) with a luer lock syringe. Place a stethoscope to the side of the child's neck near the trach tube. Inject air into the pilot line until you can no longer hear air going past the cuff. This means the airway is sealed. For children that are totally ventilation dependent, provide breaths with manual resuscitator. Minimal Leak Technique: The same procedure as Minimal Occluding Volume, except that after the airway is sealed, slowly withdraw a small amount (approximately 1cc), so that a slight leak is heard at the end of inspiration.

Trach tube with cuff, pilot inflating balloon and pressure manometer

Periodic measurements of the cuff volume should be noted and any changes reported to the doctor. A pressure manometer may be used to check cuff pressure on balloons filled with air. Generally, cuff pressure should be below 25 cm H2O Indications for a Tracheostomy 1. Maintain a patent airway 2. Facilitate removal of secretions 3. Permit long-term positive pressure ventilation 4. Prevent aspiration of gastric contents 5. Lung / airway / breathing center anomalies secondary to congenital defect 6. Improve patient comfort due to absence of endotracheal (ET) tube 7. Decrease work of breathing and increase volume entering the lungs by reducing anatomical dead space COMPLICATIONS • Immediate: · hemorrhage · pneumothorax · subcutaneous and mediastinal emphysema · respiratory and cardiovascular collapse · dislodged tube • Late: · airway obstruction (obstruction with secretions, constriction of airway by ties, improper tube or placement, overinflated cuff) · infection (nosocomial pulmonary infection rate in patient with a trach is 50-66%; largely due to natural body defenses being bypassed by the trach tube; infection can be pulmonary, stomal) · aspiration (secretions, gastric contents)

· tracheal damage (progressive, fistula) · dislodged tube • Psychosocial impact: Alteration in body image Alteration in communication Risk for unmet needs INSTILLING • Instilling is the introduction of normal saline into the bronchial tree via the trach tube to aid in the removal of thick, tenacious secretions. • The only consistent benefit in instilling seems to be in causing the patient to cough strongly and subsequently loosen secretions. • For this reason, as well as certain safety issues, instilling is considered a last resort measure. • Viscosity and expectoration of lung secretions is best managed by: · systemic hydration · humidity · chest physiotherapy · suctioning, coughs and assisted coughs · mucolytic agents Cleaning Inner Cannula and Changing Dressing Purpose: Cleaning the inner cannula clears the airway of accumulated secretions. • It also rids the trach of bacteria that can be harmful to the patient. • Cleaning the tracheostoma removes accumulated secretions from the stoma as well as decreases the risk of infection of the stoma by removing bacteria using sterile technique. • Indications: In most institutions cleaning the inner cannula is done at least twice per day. Cleaning the tracheostoma is done at this time and sometimes more frequently, depending on the patient's condition (accumulated secretions, infection, level of acuity and so forth). • Note: Depending on the agency, equipment and procedures will vary. Also, depending on the recency of the tracheostomy, sometimes procedures are considered clean, and not sterile. EQUIPMENT • Minor dressing tray (or trach dressing tray, if available) Sterile pipe cleaners (3 or 4) (or trach brush) Sterile Q-tips (6 to 8) Tracheostomy dressing (trach sponge) (Note: A modified or cut 4x4 cannot be used as a trach sponge, as small cut fibers could enter the stoma and trach.) Hydrogen peroxide Sterile normal saline Clean gloves Sterile gloves Garbage container near patient bedside Trach ties Scissors • Procedural goal is to: 1. Clean the inner cannula. 2. Clean the stoma and apply new dressing. 3. Maintain sterile technique. PROCEDURES 1. Wash hands. 2. Explain procedure to patient. Suction patient as necessary. 3. Assemble equipment and prepare dressing tray: a) Pour hydrogen peroxide in the largest compartment. b) Pour normal saline in one of the smaller compartments.

c) Open trach sponge onto sterile field. d) Open Q-tip package(s). Place stems at the edge of the sterile field, ready for use. Maintain sterility of distal end of Q-tip. e) Open pipe cleaner package(s) and drop into center of sterile field. Maintain complete sterility. f) Open outer package of sterile gloves. 4. Don clean gloves. 5. Remove the inner cannula from the trach tube. 6. Immerse in hydrogen peroxide. 7. Remove used trach sponge and assess for secretions. Discard. Assess site. 8. Clean tracheostomy site with sterile Q-tips and normal saline. Use only a single sweep with each Q-tip. Move from the stoma and outwards (clean to dirty principle). Dry the stoma area, if necessary, using a sterile 2x2. These measures serve to: a) maintain skin integrity of stoma b) decrease risk of infection 9. Change the trach ties if they are soiled, or as per agency policy or order. > Leave the previous trach tube ties secured to the flange and patient while attaching a new trach tie. > Removing the old ties before the new ties are on puts the patient at risk for dislodging the trach tube > Thread the new tie through the flange tie holes and around the back of the patient's neck. Tie it in a reef or square knot at the side of the patient's neck. > Ties should be loose enough to slip two fingers between the ties and neck, and secure enough to ensure the trach tube will not dislodge. > Cut off the old tie and discard it. 10. Don sterile gloves. 11. Using sterile technique, use a pipe cleaner to clean inside the inner cannula and remove secretions. 12. Once all secretions are removed, rinse the inner cannula well with normal saline. This is done by dipping one end into the saline and then tipping the cannula the other direction, so the saline runs through it and rinses it. Maintain sterile technique. Shake cannula to remove excess saline, or tap gently on inside surface of dressing tray. 13. Reinsert inner cannula. Lock into place. 14. Apply new trach sponge. This is generally considered to be a clean procedure. 15. Assess patient. 16. Dispose of equipment. Wash hands. 17. Document care given including assessment of secretions, dressing and stoma, as well as the patient's tolerance of the procedure.