2 Tracheostomy Care What is a Tracheostomy? A surgical procedure performed to open an artificial airway in the neck through an incision in the tracheaA Tracheostomy is given when the pt is unable to maintain a patent airway and is at risk for severe respiratory distress.Opening is made in the 2nd and 3rd tracheal ringsMay be either temporary or permanent
4 Tracheostomy Tubes Double Cannula Tube Single-Cannula Tubes Cuffs Outer cannual:Holds the tracheostomy open, neck plate extends from the sides and has holes to attach cloth ties or Velcro strap around the neckInner cannula:Acts as a removable liner for the more permanent outer tube can be withdrawn for brief periods to be cleaned lock into place to avoid being coughed outSingle-Cannula TubesDo not have an inner tubeFor infants and small childrenGenerally not cuffed (even if mechanical ventilation is required)CuffsAn inflatable attachment of the tubeOccludes space between trachea walls and tubePermits effective mechanical ventilationMinimizes risk of aspirationPressure maintained less than 25cm H20 to prevent injury more than 20cm H20 to prevent aspiration
5 Tracheostomy Care How to clean a trach site: Cleanse wound and plate with hydrogen peroxide and rinse with salineRemove inner cannula and soak in hydrogen peroxide and rinse in saline solutionApply new trach dressingChange tape, secure new tape before removing old tape, for new trachs two people should remove tapes.
7 Tracheostomy Suctioning WHY?Decreased effectiveness of cough mechanismIncreased mucous production due to bypass of upper airwayWHEN?Assess for need:Adventitious breath sound presentSigns and symptoms with hypoxia presentSecretions are obvious or presentUnnecessary suctioning can cause bronchospasm and cause trauma to tracheal mucosaHOW?Sterile procedure: Any equipment to come in contact with lower air waySuction should not exceed 120mm HgHyperoxygenate for several deep breaths with adequate ventilation before, between and after suctioningInsert tube without suction about 20 cm in adultsApply suction while withdrawing and gently rotating catheter (prevents injury or mucosa)no longer then 10 secondsReoxygenate and inflate lungs for a few deep breathsRepeat steps until air way is clearAssess respiration status before and after suctioning
9 Speech With a Tracheostomy Plug the tracheostomy tube by holding a finger over the tube for short periods of timeFenistrated trach tube:Fenestration usually on greater curve of outer tubeWhen cuff is deflated and inner cannula is removed exhaled air passes over the vocal cords allowing client to talkIndicated for client who have ability to speak and do not require mechanical ventilationA tracheostomy speaking valve is a one-way valve that allows air in, but not out. This forces air around the tracheostomy tube, through the vocal cords and out the mouth upon expiration, enabling the client to vocalize. Speaking valves obviously cannot be used for complete airway obstruction.Electrolarynx or Artificial larynx is a hand held device placed on the neck surface that vibrates when activated and mechanically resonates when words or sounds are mouthed.A talking tracheostomy tube. Speech is obtained through a line directly above the cuff. An outside air source is used to force air through the vocal cords
10 Complications Early Complications: Long-term Complications: Bleeding e.g. from divided thyroid isthmusPneumothoraxAir embolismAspirationSubcutaneous or Mediastinal emphysema (presence of gas or air in these areas)Recurrent laryngeal nerve damagePosterior tracheal wall penetrationLong-term Complications:Airway obstruction from secretions and mucus plugging or protrusion of cuff over opening of tubeInfectionRupture of innominate artery (a short artery that arises from the arch of the aorta and divides into the carotid and subclavian arteries of the right side)DysphagiaTracheoesophageal fistulaTrachea dialation or ischemia and necrosisTracheal stenosis may occur after tube removalPreventing ComplicationsAdminister adequate warmed humidityMaintain cuff around tubeAssess respiratory statusSuction as needed using sterile techniqueMaintain skin integrity: using sterile cleans site and tubing, change dressings and tapeMonitor signs and symptoms of infectionAdminister oxygen as ordered, monitor O2 sats and signs of cyanosis
11 Teaching Client Self Care Teach client and caregiver:Emergency care and suctioning: clear airway and handle secretionsProper technique for trach and stoma care, mouth careImportance of humidification at home and avoiding air conditioningImportance of wearing loose fitting protective cloth at the stoma to prevent foreign objects from entering the trach tube,Prevent water form entering stoma e.g. cover when showeringProtect against breathing in really hot or cold airSigns, symptoms and prevention of infections