Tracheostomy

INFORMATION A. DESCRIPTIVE TERMS Tracheotomy: A surgical incision into the trachea for the purpose of establishing an airway. Performed in the operating room. 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.” This term will be used frequently in the manual. 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 nonfenestrated 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. B. 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 C. INDICATIONS FOR A TRACHEOSTOMY 1. Maintain a patent airway • bypass upper airway obstruction (foreign bodies, traumatic injuries, vocal cord paralysis, surgical edema, tumors, burns) 2. Facilitate removal of secretions • severe bronchitis in a debilitated patient, neuromuscular disease, paralysis of chest muscles and diaphragm 3. Permit long-term positive pressure ventilation • massive chest wall trauma, respiratory failure, high lesion spinal cord injury, prolonged coma, neuromuscular disease 4. Prevent aspiration of gastric contents • prolonged unconsciousness 5. Lung / airway / breathing centre anomalies secondary to congenital defect 6. Improve patient comfort due to absence of endotracheal (ET) tube • enables eating, speaking; increased mobility due to tube security • in general, if extubation (ET) not possible, tracheotomy performed after 7 to 10 days for long-term ventilation 7. Decrease work of breathing and increase volume entering the lungs by reducing anatomical dead space • severe COPDhwlo D. 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 Complications associated with suctioning: • hypoxemia → dysrhythmia, hypotension, cardiac arrest

• atelectasis or lung collapse • mucosal damage • broncho spasm • tracheobronchial bacterial growth Psychosocial impact • alteration in body image • alteration in communication • risk for unmet needs E. EMERGENCY EQUIPMENT These items should be kept at the patient’s bedside at all times and to be with the patient when transported off the unit: Suction equipment 10mL syringe for cuff inflation/deflation Obturator for tube now in situ Replacement trach tube in specially marked bag (one size smaller than in situ) Scissors (for post-laryngectomy patient) Ambu bag (manual resuscitation bag) Oxygen equipment (optional) Tracheal dilator set (for post-trach patient with new stoma; in PAR) (optional)

the airway, respiratory insufficiency, and stasis of secretions. •

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Nasotracheal suction is a blind, high-risk procedure with uncertain outcome. Complications include mechanical trauma, hypoxia, dysrhythmias, bradycardia, increased blood pressure, vomiting, increased intracranial pressure (ICP), and misdirection of catheter. Contraindications include: Bleeding disorders such as disseminated intravascular coagulation, thrombocytopenia, leukemia.

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Laryngeal edema, laryngeal spasm.

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Esophageal varices.

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Tracheal surgery.

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Gastric surgery with high anastomosis.

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Myocardial infarction.

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Occluded nasal passages or nasal bleeding.

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Epiglottitis.

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Head, facial, or neck injury.

May cause trauma to the nasal passages. ○

Do not attempt to force the catheter if resistance is met.

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Report if significant bleeding occurs.

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Insert a nasal airway if repeated suctioning is necessary to protect the nasal passages from trauma.

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Be alert for signs of laryngeal edema due to irritation and trauma. ○

Stop if suctioning becomes difficult or if the patient develops new upper airway noise or obstruction.

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Duration of the suctioning should be limited to less than 15 seconds.

Suctioning Through an Endotracheal or Tracheostomy Tube

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Maintain sterile technique while suctioning (see Procedure Guidelines 10-10, pages 234 to 236). Administer supplemental 100% oxygen through the mechanical ventilator or manual resuscitation bag before, after, and between suctioning passes to prevent hypoxemia.

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Closed system suctioning may be done with the suction catheter contained in the mechanical ventilator tubing. Ventilator disconnection is not necessary so time is saved, sterility is maintained, and risk of exposure to body fluids is eliminated.

Community and Home Care Considerations Intended to remove accumulated secretions or other materials that cannot be moved by the patient's spontaneous cough or less invasive procedures. Suctioning of the tracheobronchial tree in a patient without an artificial airway can be accomplished by inserting a sterile suction catheter lubricated with water-soluble jelly through the nares into the nasal passage, down through the oropharynx, past the glottis, and into the trachea (see Procedure Guidelines 10-9, pages 232 to 234).

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Ventilation with a manual resuscitation bag will facilitate auscultation and may stimulate coughing, decreasing the need for suctioning.

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Nasotracheal Suctioning

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Assess the need for suctioning at least every 2 hours through auscultation of the chest.

Ineffective coughing may cause secretion collection in the artificial airway or tracheobronchial tree, resulting in narrowing of

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Teach caregivers to suction in the home situation using clean technique, rather than sterile. Wash hands well before suctioning.

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Put on fresh examination gloves for suctioning, and reuse catheter after rinsing it in warm water.

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Be aware that appropriate and aggressive airway clearance will assist in preventing pulmonary complications, thus lessening the need for hospitalization.

For children, nebulization is one of the easiest and most effective ways to administer asthma medicine.2 Using appropriately sized masks that fit infants, or mouthpieces for older children and adults, patients simply breathe normally until all the medicine has been inhaled. Another advantage of nebulization, particularly for young children, is that it requires no special technique to get the medicine into the lungs. By contrast, MDIs require proper technique that may be hard for young children to master, and in many cases a significant portion of the medicine does not reach the child's lungs.3 Nebulizer – is a respiratory device tat delivers medicine to the lungs as a fine mist.