Tracheostomy Care

Tracheostomy Care What is a Tracheostomy? A surgical procedure performed to open an artificial airway in the neck through an incision in the trachea A 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 rings May be either temporary or permanent

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ties or Velcro strap around the neck Inner cannula: Acts as a removable liner for the more permanent outer tube can be withdrawn for brief periods to be cleaned lock into place to avoid being coughed out Single-Cannula Tubes Do not have an inner tube For infants and small children Generally not cuffed (even if mechanical ventilation is required) Cuffs An inflatable attachment of the tube Occludes space between trachea walls and tube Permits effective mechanical ventilation Minimizes risk of aspiration Pressure maintained less than 25cm H20 to prevent injury more than 20cm H20 to prevent aspiration

Tracheostomy Care How to clean a trach site: Cleanse wound and plate with hydrogen peroxide and rinse with saline Remove inner cannula and soak in hydrogen peroxide and rinse in saline solution Apply new trach dressing Change tape, secure new tape before removing old tape, for new trachs two people should remove tapes.

1 – Vocal Cords 2 – Thyroid Cartilage 3 – Cricoid Cartilage 4 – Tracheal Cartilage 5 – Balloon Cuff

Tracheostomy Suctioning WHY? Decreased effectiveness of cough mechanism Increased mucous production due to bypass of upper airway WHEN? Assess for need: Adventitious breath sound present Signs and symptoms with hypoxia present Secretions are obvious or present Unnecessary suctioning can cause bronchospasm and cause trauma to tracheal mucosa HOW? Sterile procedure: Any equipment to come in contact with lower air way Suction should not exceed 120mm Hg Hyperoxygenate for several deep breaths with adequate ventilation before, between and after suctioning Insert tube without suction about 20 cm in adults Apply suction while withdrawing and gently rotating catheter (prevents injury or mucosa) no longer then 10 seconds Reoxygenate and inflate lungs for a few deep breaths Repeat steps until air way is clear Assess respiration status before and after suctioning

Speech With a Tracheostomy Plug the tracheostomy tube by holding a finger over the tube for short periods of time Fenistrated trach tube: Fenestration usually on greater curve of outer tube When cuff is deflated and inner cannula is removed exhaled air passes over the vocal cords allowing client to talk Indicated for client who have ability to speak and do not require mechanical ventilation A 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

Complications Early Complications: Long-term Complications: Bleeding e.g. from divided thyroid isthmus Pneumothorax Air embolism Aspiration Subcutaneous or Mediastinal emphysema (presence of gas or air in these areas) Recurrent laryngeal nerve damage Posterior tracheal wall penetration Long-term Complications: Airway obstruction from secretions and mucus plugging or protrusion of cuff over opening of tube Infection Rupture 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) Dysphagia Tracheoesophageal fistula Trachea dialation or ischemia and necrosis Tracheal stenosis may occur after tube removal Preventing Complications Administer adequate warmed humidity Maintain cuff around tube Assess respiratory status Suction as needed using sterile technique Maintain skin integrity: using sterile cleans site and tubing, change dressings and tape Monitor signs and symptoms of infection Administer oxygen as ordered, monitor O2 sats and signs of cyanosis

Teaching Client Self Care Teach client and caregiver: Emergency care and suctioning: clear airway and handle secretions Proper technique for trach and stoma care, mouth care Importance of humidification at home and avoiding air conditioning Importance 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 showering Protect against breathing in really hot or cold air Signs, symptoms and prevention of infections