Prepared By Dr. Hanan Said Ali Tracheostomy Prepared By Dr. Hanan Said Ali

Objectives Define of tracheostomy. List indications, contraindications and cautions of tracheostomy. Explain how to prepare the patient. Explain how to insert the tube. Demonstrate the care of patient with a tracheostomy tube. Perform tracheal suction.

Tracheostomy Definition A surgical incision in the trachea just below the larynx. Indications To establish a definitive airway under the following emergent conditions: Inability to perform endotracheal intubation.

Tracheostomy Indications Cont. Sever laryngotracheal trauma or laryngeal fracture. Epiglottitis, neoplasm, abscess, or foreign body in the pharynx that prevents endotracheal intubation.

Tracheostomy Contraindications and Cautions Complications in the emergency setting are usually due to haste ( quickly) , inadequate lighting, equipment problems, and management of a patient who is struggling ( breath with effort) to breath. The complexity of this procedure mandates that it be performed by an appropriately trained professional.

Tracheostomy Patients with suspected neck injuries Contraindications and Cautions Cont. Patients with suspected neck injuries require spinal stabilization. Universal precautions need to be used all involved because blood is likely to splatter during the procedure.

Equipment Sterile gloves Masks Protective goggles Antiseptic solution Scalpel blades Local anesthetic Mosquito forceps Kelly clamps 5- ml syringe with an 18- G needle and a 27- G needle for anesthesia Tracheostomy tube with an obturator. Metzenbaum scissors Scissors ( sharp and blunt) Tissue forceps ( with and without teet

Equipment Cont. Tracheal dilator and hook Retractors Adhesive tape Gauze dreesing Suction equipment, pharyngeal and tracheal Bag- mask High – flow oxygen source 3-0, 4-0 silk suture.

Patient Preparation The patient should be ventilated through endotracheal tube or another method until the tracheostomy is completed. Unless there may be cervical spine injury, place the patient in a supine position with the neck in extension, and provide support under the shoulders. Inflate the tracheal tube cuff and check for leaks

Patient Preparation Cont. Cleanse the skin from the mandible to below the clavicles with antiseptic solution. Drape the chest and the neck. Infiltrate the skin with a local anesthetic. Provide analgesia. Restrain or sedate the patient as indicated. Bleeding may be significant, prepare the tracheal and pharyngeal suction equipment

Procedural Steps Make a midline skin incision vertically to expose the strap muscles. Retract the strap muscles laterally to expose the pretracheal fascia and thyroid isthmus. Clamp the thyroid and bluntly dissect to divide the isthmus and expose the trachea.

Procedural Steps Cont. Transect the thyroid isthmus and ligate it by means of sutures. Incise through the tracheal rings to enter the trachea through the second to fourth tracheal rings. Suction the tracheal secretions. Insert the tracheal tube and the obturator.

1 - Vocal cords 2 - Thyroid cartilage 3 - Cricoid cartilage 4 - Tracheal cartilages 5 - Balloon cuff

Procedural Steps Cont. Remove the obturator, inflate the cuff with 5 to 8 ml of air, and ventilate the patient with a bag- mask. Auscultate the lungs to assess tube placement, and verify tube position with a chest radiograph.

Procedural Steps Cont. Tie the tracheostomy tube in place around the neck with tracheostomy tape. Clean and dress the insertion site. Deliver humidified oxygen as soon as possible.

Complications Cardiopulmonary arrest secondary to hypoxia. Hemorrhage and injury to the thyroid gland esophagus, laryngeal nerve, trachea. Pneumothorax. False passage of the tube into the pleura, esophagus, or surrounding vessels.

Complications Cont. Bradycardia or hypotension secondary to hypoxia. Inadvertent ( careless) decannulation of the tracheostomy. Late complications include subglottic stenosis, tracheal stenosis, artery erosion, pneumonia, aspiration.

Patient Education Report any respiratory difficulty or tubing disconnections immediately. Do not touch or move the tube. You will not be able to speak with the tube in place.

Care of the Patient With a Tracheostomy Tube Steps Rational Gather the needed equipment including Sterile gloves Hydrogen peroxide, Normal saline solution or sterile water, Cotton tipped Applicators Dressing and twill tape Everything needed to care for a tracheostomy should be readily on hand for the most effective care.

Care of the Patient With a Tracheostomy Tube Steps Rational Perform hand hygiene. Hand hygiene reduces bacteria on hands. Explain procedure to patient and family as appropriate. A patient with a tracheostomy is apprehensive and requires ongoing assurance and support. Put on clean gloves; remove and discard the soiled dressing in a biohazard container. Observing body substance isolation reduces cross-contamination from soiled dressings.

Care of the Patient With a Tracheostomy Tube Steps Rational Prepare sterile supplies, including hydrogen peroxide, normal saline solution or sterile water, cotton-tipped applicators, dressing, and tape. Having necessary supplies and equipment readily available allows the procedure to be completed efficiently. Put on sterile gloves. Sterile equipment minimizes transmission of surface flora to the sterile respiratory tract.

Care of the Patient With a Tracheostomy Tube Steps Rational Cleanse the wound and the plate of the tracheostomy tube with sterile cotton-tipped applicators moistened with hydrogen peroxide. Rinse with sterile saline solution. Hydrogen peroxide is effective in loosening crusted secretions. Rinsing prevents skin residue.

Care of the Patient With a Tracheostomy Tube Steps Rational Soak inner cannula in peroxide and rinse with saline solution or replace with a new disposable inner cannula. Soaking loosens and removes secretions from the inner lumen of the tracheostomy tube. Remove soiled twill tape with clean tape, after the new tape is in place.

Steps Rational Place clean twill tape in position to secure the tracheostomy tube by inserting one end of the tape through the side opening of the outer cannula. This taping technique provides a double thickness of tape around the neck, which is needed because the tracheostomy tube can be dislodged by movement or by a forceful cough if left unsecured. Take the tape around the back of the patient’s neck and thread it through the opposite opening of the outer cannula.

Care of the Patient With a Tracheostomy Tube Steps Rational Bring both ends around so that they meet on one side of the neck. Tighten the tape until only two fingers can be comfortably inserted under it. .

Care of the Patient With a Tracheostomy Tube Steps Rational Secure with a knot. For a new tracheostomy, two people should assist with tape changes Remove old tapes and discard in a biohazard container. Tapes with old secretions may harbour bacteria.

Performing Tracheal Suction Equipment • Suction catheters • Gloves • Goggles for eye protection • Basin for sterile normal saline solution for irrigation • Manual resuscitation bag with supplemental oxygen • Suction source

Performing Tracheal Suction Procedure 1. Explain the procedure to the patient before beginning and offer reassurance during suctioning; the patient may be apprehensive about choking and about an inability to communicate. Begin by carrying out hand hygiene. Turn on suction source (pressure should not exceed 120 mm Hg). Open suction catheter kit.

Performing Tracheal Suction Procedure Cont. Fill basin with sterile normal saline solution. Ventilate the patient with manual resuscitation bag and highflow oxygen. Put sterile glove on dominant hand. Pick up suction catheter in gloved hand and connect to suction.

Performing Tracheal Suction Hyperoxygenate the patient’s lungs for several deep breaths. Instill normal saline solution into airway only if there are thick, tenacious secretions. Insert suction catheter at least as far as the end of the tube without applying suction, just far enough to stimulate the cough reflex.

Performing Tracheal Suction Apply suction while withdrawing and gently rotating the catheter 360° (no longer than 10 to 15 seconds, because hypoxia and dysrhythmias may develop, leading to cardiac arrest). Reoxygenate and inflate the patient’s lungs for several breaths.

Performing Tracheal Suction Repeat previous three steps until the airway is clear. Rinse catheter in basin with sterile normal saline solution between suction attempts if necessary. Suction oropharyngeal cavity after completing tracheal suctioning. Rinse suction tubing. Discard catheter, gloves, and basin appropriately.

Thank You