Tracheostomy Care

Report
Tracheostomy Care
Adapted from various resources (see reference slide) by
Ambercare Education Department
April 14, 2014
Tracheostomy Facts
 Tracheotomy is a surgical procedure that
creates an opening in the cervical trachea
(windpipe) allowing direct access to the
breathing tube – rarely done as an
emergency – secondary to oral or nasal
intubation which is must faster and less
complicated when managing respiratory
arrest
Why is a Tracheostomy performed?
 To bypass obstruction
 To maintain an open airway
 To remove secretions more easily
 To oxygenate and/or provide
mechanical ventilation on a long-term
basis
Types of patients requiring
tracheostomies
 A comatose patient
 A patient with cancer of the larynx or neck
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 Blockage of airway
Inability to swallow or cough
A burn patient with inhalation damage
A COPD patient on mechanical ventilation
A pediatric patient with a congenital airway obstruction
ALS patients
Plegic patients
 To name a few….
Tracheostomy Anatomy
Tracheostomy Anatomy
Landmarks
Definition of Terms
 Decannulation: Removal of a tracheostomy tube
 HME: Heat, moisture exchange (have pictorial)
 Humidification: the mechanical process of increasing the
water vapor content of an inspired gas
 Stoma: a permanent opening between the surface of the
body and an underlying organ (trachea and anterior
surface of neck)
 Tracheal suctioning: a means to clear the airway of
secretions or mucus through the application of a negative
pressure via a suction catheter
Temporary Tracheostomy versus
Permanent Laryngectomy
 Appearance may be the same
 Temporary: THE UPPER AIRWAY WILL REMAIN
PATENT IF THE TRACH TUBE WERE TO BE DISLODGED
 Permanent: THE LARYNX IS REMOVED AND AN
ARTIFICAL TRACHEOSTOMY IS CREATED – NO
CONNECTION BETWEEN THE PATIENT’S UPPER
AIRWAY AND THE TRACHEA ITSELF!
Risks / PCs
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Medication reaction
Uncontrollable bleeding
Respiratory problems
Possibility of cardiac arrest
Pneumothorax
SC and/or mediastinal emphysema
Tracheo-oesophageal fistula (development of a
small connection between trachea and esophagus)
 Infection
Potential Complications with Longterm Tracheostomy:
 Thinning (erosion) of the trachea (trachemalacia)
 Development of granulation of tissue (bump
formation in trachea
 Narrowing or collapse of the airway above the site of
tracheostomy
 Once tracheostomy tube is removed, the opening
may not close on its own
 Dysphagia; airway obstruction from secretions;
 Tracheal ischemia and necrosis
Assessment / SE after tracheostomy
placement
 Respiratory secretions will often temporarily increase
 Observe for s/sx of impaired gas exchange (mucus plugs
for example) – encourage patient to breathe deep and
cough – ensure adequate humidification and NS fluid
bullets to loosen secretions if needed (suctioning)
 A small amount of bleeding from the stoma is expected for
a few days after trach placement – constant oozing, is
abnormal – may need intervention ( a blood vessels may
need surgical litigation)
 Slight inflammation at site (redness, pain, drainage for the
first few days)
Continued Assessment/SE after
tracheostomy placement
 Subcutaneous emphysema (SCE) around stoma – air escapes into
the tracheostomy incision creating SCE; generally of no clinical
consequence – but can be palpated around the stoma site
 Excessive manipulation of the trach tube during coughing or
suctioning can break improperly secured ties and dislodge the tube –
(within the first 48 hours the freshly created stoma has a potential
to close shut, constituting a medical emergency) – to minimize this
risk, trach ties are not usually changed for 24 hours –
 First tube change is generally done by a physician after
approximately one week (should have detailed Dr’s orders to always
have a spare trach tube on hand – size should be indicated
Endotracheal Tube Verses
Tracheostomy Tube
Cuffed Tracheostomy Tube
Consists of three
parts:
• Outer cannula
with an
inflatable cuff
and pilot tube
• An inner
cannula
• An obturator
Cuffless tubes
 Rarely used in acute care settings
 More suitable for long term ventilation
 Cuffless tube is usually double-lumen – patient must
have effective cough and gag reflex to prevent
aspiration risk
Fenestrated Tube
 Have an opening on the
posterior wall of outer
cannula – allows for air flow
through the upper airway
and trach opening;
 Allows patient to speak and
produce a more productive
cough
 Often used during weaning
process
Identifying Tracheostomy Parts
Identifying Trach Parts
Identifying Trach Parts
Communication and Tracheostomies
 Some trach tubes are designed to allow patients to
speak
 Patients being weaned off trach tubes may have
either a cuffless, fenestrated tube or a trach button
that does not extend into the trachea enough to
restrict airflow past the larynx
For long-term Trach patients
 Speaking is possible with these options:
 A fenestrated inner cannula inside a cuffed outer
cannula – allows for speech when cuff is deflated (some
tubes expand on inspiration and deflate on expiration
versus manually deflated cuffs)
 A tracheostomy speaking valve is a device that attaches
to the trach tube – it contains a diaphragm that opens
on inspiration and closes on expiration so that air is
exhaled through the vocal cords and upper airway – the
cuff must be COMPLETELY deflated during speaking
valve to allow for exhalation through the upper airway
Tracheostomy Care Kit
Trach Care Kit / Portable Suction
Machine
Trach Care Kit
Thermo Trach
Tracheostomy Collar connected to
ventilator – notice sutures
Nursing Care
Nursing Care
 Must conduct a thorough assessment of patient at the start of
visit
 Observe for signs of hypoxia, infection, excessive secretions, pain,
etc.
 Examine trach tube, any attached tubing and equipment, as well as
stoma site
 Observe for redness, purulent drainage, and abnormal bleeding around
the stoma – note the amount, color, consistency, and odor of secretions
 Auscultate breath sounds
 Ensure that appropriate emergency trach supplies and CPR
equipment is at bedside
 Be aware of when and why the trach was inserted , how it was
performed, the type and size of tube inserted
Tracheostomy Humidification
 As mentioned previously, the nose and mouth
provide warmth, moisture and filtration for the air
we breath. Having a tracheostomy tube, however,
by-passes these mechanisms so humidification must
be provided to keep secretions thin and to avoid
mucus plugs
Types of tracheostomy
humidification systems
 Heated humidification (increased heat and water
vapor inhaled) –
 Ambient or cold water humidification
 Heat and moisture exchangers
 Stoma protectors
 Heat moisture exchanger (attached to the outside of
a trach tube for long-term trach patients) – looks like
a t-tube attachment
Humidification examples
 Heat moisture exchanger
Nursing Care: Mobilizing Secretions
 Many trach patients have acute or chronic disease that
predispose to stagnation of secretions
 Frequent repositioning, deep breathing and coughing,
chest physiotherapy, postural drainage, oral and parenteral
hydration and supplemental humidification all help to thin
and mobilize secretions
 Tubing from an external moisture source accumulates
moisture and will need frequent draining – ensure the
tubing is positioned LOWER than the patient to avoid
aspiration risk!
Nursing Care - Suctioning
 Necessary for all trach patients to remove secretions and
assess for airway patency
 Acute care patients need to be assessed every two hours
(teach family members)…
 Routinely done 2x / day, but more often if needed –
particularly a newly placed tracheostomy or when there is
infection present
 Suctioning activates psychological and physiological
reflexes that make the experience both uncomfortable
and frightening
Indications for Suctioning
 Dyspnea: Flared nostrils, chest retractions and/or
prolonged wheezing
 Noisy breathing
 Cyanosis and clammy skin
 Restlessness and agitation
 Copious secretions; moist cough
 Low oxygen saturation
 Increased peak inspiratory pressure on mechanical
ventilator
U tube video on suctioning
 http://www.youtube.com/watch?v=gtKc9pe9HCw
(copy and paste URL);
 15 minute video on suctioning tracheostomy –
excellent example….worth the time to view –
particularly those staff members who are not well
versed on tracheostomy care
Selecting a suction catheter
 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
Gathering equipment for suctioning –
open system
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PPE – (mask, goggles, gloves)
Bottle of normal saline
Appropriately sized suction catheter
Trach care kit
Disposable inner cannula
02 source – connected to patient (suction equipment)
regulator set at 80-120 mmHg
 Ambu bag to ventilate patient prior to suctioning if
appropriate
I RECOMMEND YOU VIEW THE U TUBE VIDEO TO
UNDERSTAND APPROPRIATE SUCTIONING TECHNIQUE AND
HOW TO UTILIZE THE EQUIPMENT ABOVE….
Closing suctioning system – ballard
suctioning
Procedure for suctioning
 Place patient in semi-fowler’s position
 Select appropriate sized suction catheter
 Hyper oxygenate BEFORE each suction pass (exceptions to
hyper oxygenation are children and patients with long-term
tracheostomies)
 Insert catheter to a pre-measured depth or (to point of
resistance if deep suctioning)
 Apply suction on withdrawal while slowly removing suction
catheter
 Limit suctioning to 5 seconds for pre-measured depth and 10-15
seconds for deep suctioning
 Use suction pressure between 80 – 120 mmHg
 Limit suctioning to 3 passes and discontinue if HR drops by 20;
increases by 40, produces arrhythmias, or decreases 02 < 90%
Tracheostomy Ties
 To lower the risk of a new trach tube accidentally
dislodging, ties are usually not changed within the
first 24 HOURS FOLLOWING INSERTION; thereafter,
ties are generally changed daily
 To lower the risk of accidental decannulation (the
trach tube coming out) the tie changes should be
performed by two people or with new ties secured
BEFORE old ties are removed.
Maintenance of the inner cannula
 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
or just NS
 Reinsert and lock back into place within a 15 minute
time frame
Trach parts…
 Trach parts – inner cannula example
Nursing Care – Trach cuff pressure
 Cuff pressure (balloon) should be maintained between 20
to 20 mmHg of pressure via a manometer – should be
assessed daily;
 if you don’t have a manometer measuring device – check
with the patient/family – to evaluate how many cc’s of cuff
pressure they have been utilizing (generally 5-8 cc)
depending on trach size
 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….
Deflating and inflating the cuff is a
way to:
 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
Nursing Care: Changing the Trach
tube
 Trach tubes, (both single cannula type and the outer
cannula of a universal type) are changed one to four
weeks (check physicians order – consult if needed)
 Silicon tubes can crack and tear; soft PVC tubes can
stiffen with age and metal tubes can develop cracks
 When a patient has had a tracheostomy for several
months, the stoma is well formed and tube changes
can be done safely on a monthly basis using a clean
technique; the initial tube change is usually
performed by MD
Nursing care: Trach Site care and
Dressing changes
 Assess the stoma for s/sx of infection and skin
breakdown
 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 when
excessive exudate is present – keep CDI
 Please refer to the following U tube video entitled
“home trach care” = 5.08 (time)
http://www.youtube.com/watch?v=swTLAokDnq8
Nursing Care: Nutrition and
Communication
 A tracheostomy WILL NOT prevent a patient from eating –
although some patients may have concurrent swallowing
problems that may need evaluation by an otolaryngologist
or speech pathologist
 Patients may have poor appetite because of disease
progression or reaction to copious secretions; suctioning
PRIOR to meals is helpful
 Inability to speak is anxiety-provoking for most patients –
you will need to evaluate alternative methods of
communication for your patient until long-term speaking
solutions are initiated
Possible Trach Complications
 Can arise the first few days or within several weeks;
initially, the most common complications are:
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Inflammation and edema of the trachea
Infection and abscess of stoma and/or pulmonary tree
Bleeding associated with suctioning
If humidity is insufficient, mucous membranes dry out and the
irritation of an inserted catheter will cause small amounts of
bleeding during routine suctioning
 Long-term complications from the presence of a trach are due
to tracheal scarring and erosion
 Stenosis, the narrowing of the trachea from scar tissue occurs
in 5 to 15% of patients
 Scarring can occur at the stoma, the cuff site, or at the point
where the distal end of the tube presses on the tracheal wall
– possible granuloma….
Home Trach Care
 Patient and family education normally starts in
hospital setting
 Initial care may consist of:
 Warm compress to the incision site to help relieve
discomfort
 Humidified air
 Wearing a scarf over trach opening to keep dry and
clean
 Follow up with Dr. for any concerns or changes
Patient Instructions
 Trach patient’s avoid:
 Deep bathing water
 Fine particles such as powders, chalk, sand, dust, mold and
smoke
 Loose fibers and fair found on fuzzy toys and pets
 Persons with contagious illnesses
 Cold air and wind
 Portable suction equipment is available for travel and should
be tested PRIOR to use
GREAT RESOURCE TEACHING SITE:
http://www.tracheostomy.com
FAQs
 Can a patient eat with a Tracheostomy:
 Yes…generally speaking (patient may need an
evaluation by a speech pathologist to
determine swallowing ability)
 The primary exception is if the patient wears a
tracheostomy speaking valve (Passy Muir
Valve) and needs one type of inner cannula
when the speaking valve is in place
 Swallowing is safer with the cuff down and
speaking valve on
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
 How often should a tracheostomy tube be changed?
 Every seven days to remove the dried or old secretions
and maintain adequate hygiene of the trach tube and
airway
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
 A speaking valve is a one-way valve unlike a trach plug
which completely obstructs the air flow
FAQs
 Why do you need the inner cannula with a
tracheostomy:
 Easier to remove inner cannula for cleaning and to
maintain hygiene of the airway
 If patient develops a mucus plug, the inner cannula can
be removed for cleaning or a replaced with a disposable
one - the outer cannula would serve as the airway
 Changing the entire outer cannula is more difficult than
managing the airway with an inner cannula
Questions?
References
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AMN healthcare education services (rn.com)
http://www.rch.org
http://www.hopkinsmedicine.org
http://my.clevelandclinic.org
Various U tube videos as noted

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