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What is a Tracheotomy? A tracheotomy is an incision into the trachea for the purpose of establishing an airway A tube is placed in the trachea, just below the second and third tracheal ring, bypassing the epiglottis May be an emergency, temporary , permanent or prophylactic

What is a Tracheostomy? A tracheal stoma (opening) resulting from a tracheotomy Often referred to as a “trach”

Indications for a Tracheostomy Tumor Subglottic stenosis, tracheomalacia Congenital abnormalities of the airway- large tongue or small jaw Broncho-pulmonary dysplasia Chest wall injury Long term ventilation Neuromuscular diseases, paralysis or weakening chest muscles and diaphragm Tracheomalacia (TM) is diffuse or segmental tracheal weakness; result in exaggerated luminal narrowing during expiration and widening during inspiration; airway narrowing can be extensive – can be congenital or caused by trauma (intubation, secretion pooling above balloon), emphysema, chronic inflammation, etc. Bronchopulmonary dysplasia: chronic lung disorder common in premies who received prolonged ventilation to Rx respiratory distress

Parts of a Tracheostomy All tracheostomy tubes consist of : A main shaft or outer cannula- Holds the tracheostomy open A neck plate (flange)- Stabilizes the trach tube, preventing it from migrating inward. Has holes on each side to allow attachment of ties to secure the trach in place. Has important information (manufacturer, model, size) An inner cannula- Fits inside the outer cannula to facilitate cleaning of the tracheostomy The obturator- Assists with the insertion of the tracheostomy tube. Provides a smooth surface to guide the tube during insertion

Types of Tracheostomy Tubes Cuffed Inflated cuff creates a seal between the trach and the trachea (air cannot pass around the trach) Used to obtain a closed circuit for ventilation Cuff must be deflated if using a speaking valve Patient should NOT have a cuffed trach on the ward

Types of Tracheostomy Tubes Cuffless Used for patients with tracheal problems or who are ready for decannulation May be able to add a speaking valve to allow patient to talk Note: This trach is unable to maintain a seal in an emergency situation (air moves around the trach)

Types of Tracheostomy Tubes Fenestrated Can be cuffed or un-cuffed The shaft of the tube has an opening that allows air to pass the vocal cords for vocalisation May cause increased granulation at the fenestration site and surgical decannulation may be required Note: In order to suction a fenestrated trach you must always use a solid, spare inner cannula as the suction catheter can pass through the fenestration and hit the tracheal wall causing trauma

Tracheostomy Care New Trach-First 24 hours(PAT-5-125) Special precautions must be taken to avoid causing trauma, bleeding or infection at the surgical site Do not change dressing unless severely soiled Remove and clean inner cannula with saline q 4-6h and prn. Do not change trach ties for 7 days unless severely soiled, taut, or loose Assess respiratory status q2h Special precautions: Assess Q2H (?resp distress, require suctioning, lung sounds, agitation, Sa02)

Tracheostomy Care After 24 hours – Every 4 hours Assess trach ties and skin integrity under ties (only one finger between ties and neck) Assess if patient requires suctioning (suction only if required) Remove and clean inner cannula with N/S Keep inner cannula in place at all times, remove only when cleaning Assess trach dressing q4h, clean stoma with NS and change dressing under aseptic technique at least daily Assess respiratory status q4h After 7-10 days ask MD to assess suture removal (if applicable)

Tracheostomy Safety Obturator at bedside Have spare tracheostomy, one size smaller at bedside Suction source available at all times Keep trach cuff inflated, unless ordered differently Humidification is required regardless of whether patient requires oxygen (except for patients with long term trach) Ensure corrugated tubing is free of excess water and sterile water bottles are replaced(not refilled) q48h or when dry. PPE must be worn at all times when providing trach care SAF-2-24 Show blue corrugated tubing, trach hood, humidification bottle Demonstrate how to adjust oxygen flow rate (on bottle and not on the…)

Suctioning Indications Patient is unable to clear secretions Difficulty breathing, changes in breathing, stridor Low O2 saturations Evidence of cyanosis Suctioning complications Hypoxemia Dysrhythmia, hypotension, cardiac arrest Atelectasis or lung collapse Mucosal damage Bronchospasm Pneumonia Demonstrate using equipment how to properly suction: Suctioning: PPE Suction Kit Pre-oxygenate – deep breaths or manual ventilation Wet tip in sterile saline (not sterile if long term trach) and gently insert till resistance felt or cough Apply suction on withdrawal of catheter – max 10 seconds Rinse catheter Allow patient to ‘catch their breath’ between suctions if more than one required

Accidental Decannulation DO NOT attempt to re-insert the tracheostomy tube Stay calm Observe and assess the patient to see if he/she can breathe through the stoma/mouth itself Apply oxygen over mouth (or stoma as appropriate) if required, call MD/RT If patient is unable to breath or in distress, cover stoma with occlusive dressing and provide manual ventilation at 100% over mouth (use bag valve mask and oral airway if needed) RT/MD may re-insert tracheostomy tube May need obturator from bedside Ensure that spare trach one-size smaller is available at bedside

TBRHSC Policies Tracheostomy Care- PAT-5-125 Tracheostomy Speaking Valve- PAT-5-128 Oxygen Titration- PAT-5-139 Review Oxygen Titration Algorithm