Altered or loss of voice Speech & language delays (young children) Loss of smell & taste Compromised nutritional status Impaired swallowing/increased risk of aspiration Secretion control issues/infection Psychological distress Loss of physiologic PEEP
Absence of airflow often creates Frustration Anxiety Psychological distress For children: delayed speech & language development
Absence of airflow decreases sensations Smell Taste Poor appetite Skin health Supplemental feeding Difficulty swallowing Risk of aspiration
Three phases of normal swallowing: 1) Oral phase 2) Pharyngeal phase 3) Esophageal phase
Normal swallowing (pharyngeal phase): Oral & nasal cavities sealed Vocal cords close Positive pressure generated below cords Air prevented from entering larynx Larynx elevates & moves forward Acts as a lever (mechanical event) Epiglottis seals larynx Food/liquid directed into esophagus
Swallowing with Trach Tube Inserted: Vocal cords close Air flows through trach tube No subglottic positive pressure Reduced sensations in larynx & pharynx Pooling of airway secretions Increase risk of aspiration Most patients OK!!
Absence of upper airway airflow (inability to nose-breathe) compromises: Heat/moisture exchange Increased secretion viscosity Increased secretion volume Frequent suctioning Increase risk of airway trauma/infection Presence of trach tube stimulates secretions
With cuff inflated: No physiologic PEEP Possible micro-atelectasis Decreased alveolar ventilation Compromised oxygenation
Cuff deflatedCuff inflated Physiologic PEEP Present Physiologic PEEP Absent
Inspect stoma daily: irritation/inflammation. Tracheostomy care is done every 8 to 12 hours and PRN. Avoid dressings trapping moisture. Check secretions: white & clear; greenish-yellow Odor often indicates infection. Assess need for suctioning q2h.
TRACHEOSTOMY CARE Signs of Infection: Yellow or green secretions (pink or blood-tinged) Thicker mucus Greater volume of mucus Stoma site bleeding Foul odor from stoma Febrile patient Pulmonary congestion Increased RR Listlessness Discomfort with trach/tender stoma site
1. Loosen inner cannula. 2. Hold outer cannula with one hand. Turn inner cannula to right with other hand to unlock.
3. Remove the inner cannula by steadily pulling it down and toward your chest until it is out.
4. Place inner cannula in the solution of hydrogen peroxide & normal saline, and don sterile gloves.
5. Use trach brush, or pipe cleaner, to clean inner cannula of mucus and dried secretions.
6. Place it in bowl of normal saline (NS). 7. Shake off excess NS. Moisture will act as lubricant during inner cannula reinsertion.
9. Lock inner cannula into position. 10. Wash bowls thoroughly and allow to air dry. Soak trach brush soak in hydrogen peroxide-NS solution &, rinse with NS. Air to dry. Discard pipe cleaners.
Goal: maintain cuff pressure below tracheal mucosal capillary perfusion pressure which is: 25 to 30 mm Hg. Cuff pressure maintained: 20 to 25 mm Hg, or 25 to 35 cm H 2 O Higher cuff pressures Cut off tracheal mucosal blood flow Tracheal wall damage (necrosis/tracheomalcia)
Caregivers must receive CPR training. Suction if indicated. Change trach tube if clogged. Spare tubes (cuffless &/or cuffed): same size & 1 size smaller Pinch nose & mouth (cuffless trach). 2 breaths with manual resuscitator/mouth-to- trach/mouth-to-stoma: STOMA LEAK Mouth-to-mouth/bag-mask with finger over stoma: STOMA LEAK
Some space around tube Snug fit: tube too large non-fenestrated: poor or no speech
Use extreme caution with baths and water No swimming Avoid powder, talc, chlorine bleach, ammonia, aerosol sprays, or colognes and perfumes Prevent foreign objects from entering trach tube
Avoid dust Avoid sand and beach Watch play with other children to assure toys, fingers or other foreign bodies are not put into trach and trach is not pulled No contact sports Frequent hand washing
Teach airway anatomy Teach about equipment Teach CPR Teach infection control Teach humidification Teach suctioning Teach about speaking valves/fenestrated trach tubes Teach communication through speech therapy