TRACHEOSTOMY CARE – Definition, Use of Tracheostomies, Parts of the Tracheostomy, Indications for Tracheostomy, Complications of Tracheostomy, Care of the Tracheostomy Patient and Cleansing the Inner Cannula
DEFINITION
A tracheostomy is an incision into the trachea the 2nd, 3rd, or 4th tracheal ring
USE OF TRACHEOSTOMIES
- To facilitate prolonged artificial ventilation
- To bypass serious upper respiratory obstructions
- To prevent aspiration of blood, secretions or food into the lungs
- To provide easier access to the lower airways than that is possible through nose or mouth
PARTS OF THE TRACHEOSTOMY TUBE
- Outer tube or outer cannula
- The inner tube or inner cannula
- The obturator or pilot. It is used as a guide to the outer tube
INDICATIONS FOR TRACHEOSTOMY
- Apnea
- Respiratory obstruction
- Circulatory arrest
- Exsanguinating hemorrhage
- Carcinoma of the larynx
- Diphtheria, Ludwig’s angina
- Head injury, neck injury or chest injuries
- Respiratory failure
- Fracture of the larynx or trachea
- In case of foreign body in hypopharynx or larynx
- Patient with severe burns, especially around hand, neck, and face
- Patients who have had thyroidectomy or radical neck resection
- Patients with neurological disorders, drug overdose, bulbar paralysis, or cerebrovascular accidents
- Patients with severe pulmonary edema
- Patients with severe emphysema
- Weak, feeble patients
- Canine biting
COMPLICATIONS OF TRACHEOSTOMY
- Subcutaneous emphysema
- Pneumothorax
- Mediastinal emphysema
- Obstruction of tracheostomy tube
- Respiratory insufficiency
- Displacement of the tube from its position on the tracheal turner
- Hemorrhage
- Pulmonary infection
- Atelectasis
- Tracheoesophageal fistula
Tracheomalacia
Constant pressure exerted by the cuff causes tracheal dilation and erosion
Signs and Symptoms
- An increased amount of air is required in the cuff to maintain the seal
- A large tracheostomy tube is required to prevent air leak at the stone
- Food particles are seen is tracheal secretions
- The client does not receive the set tidal volume of the ventilator
Management
No special management is needed unless bleeding occurs
Prevention
- Use and uncuffed tube as soon as possible
- Monitor cuff pressure and air volumes closely and detect changes
Tracheal Stenosis
Narrowed tracheal lumen is due to scar formation from irritation of tracheal mucosa by the cuff
Signs and Symptoms
Stenosis usually is seen after the cuff is deflated or the tracheostomy tube is removed. The client has increased coughing, inability to expectorate secretions or difficulty in breathing or talking
Management
Tracheal dilation or surgical intervention is used
Prevention
- Prevent pulling of and traction on the tracheostomy tube
- Properly secure the tube in the midline position
- Maintain proper cuff pressure
- Minimize oronasal intubation time
Tracheoesophageal fistula (TEF)
Excessive cuff pressure causes erosion of the posterior wall of the trachea. A hole is created between the trachea and the anterior esophagus. The client at highest risk also has a nasogastric tube present
Signs and Symptoms
- Manually administer oxygen by mask to prevent hypoxemia
- A small soft feeding tube is used instead of a nasogastric tube for tube feedings
- A gastrostomy or jejunostomy may be performed
- Monitor the client with a nasogastric tube closely; assess for TEF and aspiration
Prevention
- Maintain cuff pressure
- Monitor the amount of air needed for inflation and detect changes
- Progress to a deflated cuff or cuffless tube as soon as possible
Trachea-innominate artery fistula
A malpositioned tube causes its distal tip to push against the lateral wall of the tracheostomy. Continued pressure causes necrosis and erosion of the innominate artery. This is a medical emergency
Signs and Symptoms
The tracheostomy tube pulsates in synchrony with the heartbeat. There is heavy bleeding from the stoma. This is a life-threatening complication
Management
- Remove the tracheostomy tube immediately
- Apply direct pressure to the innominate artery at the stoma site
- Prepare the client for immediate surgical repair
Prevention
- Use correct tube size and maintain tube in midline position
- Prevent pulling or tugging on the tracheostomy tube immediately notify the physician of the pulsating tube
CARE OF THE TRACHEOSTOMY PATIENT
- Maintain an open airway. Suction and clean the tube as indicated. Prevent aspiration, e.g. of water, solutions, etc. through the tracheostomy. Keep materials which may occlude the tracheostomy, away from the opening, e.g. clothing, bedsheets
- Observe the patient carefully for indication of respiratory difficulty, e.g. noisy respirators, restlessness, cyanosis, intercostals and substernal retraction, alternations in respiratory rate, labored respiration
- Practice asepsis. Strict aseptic technique should be followed while suctioning, cleaning and dressing the wound
- Observe for complications of tracheostomy. If the airway is obstructed, do suctioning, if the tracheostomy outer tube has come out, put the tracheal dilator inside and inform the doctor. Never try to push a blown out tracheostomy tube back into its place. Tracheal dilator and tracheal hook, sterile, should be present near the patient all the time
- Ensure maximal humidification of the inspired air and approximately warm inspired air. Sterile wet gauze covering the tracheostomy will help in humidification
- Provide adequate hydration to help liquefy pulmonary secretions. At least 3,000 ml of intravenous fluids are ordered daily if adequate oral intake is not possible
- Maintain fluid and electrolyte balance. Keep an accurate intake and output chart
- Be gentle. The tracheal mucosa is easily traumatized during suctioning
- Keep the necessary articles like extra sterile inner tracheostomy tube, tracheal dilator, tape, Vaseline, gauze, sterile gauze pieces, suction nozzles, sterile water and suction apparatus nearby
- Prevent pressure and trauma to the tracheobronchial tree. If a cuffed tube is being used, see that the cuff is deflated, as ordered, to relieve pressure periodically on the tracheal wall
- Periodically inspect the tracheostomy for trauma or infection
- Ensure use of a fresh tracheostomy tube as needed. Clean the inner cannula of mucus and encrustations as indicated. The inner tube is changed by nurses and outer tube by doctors
- Change the dressings and tracheostomy tube as necessary
- Provide appropriate skin care. Keep skin clean and dry
- Provide adequate nourishment
- Provide frequent mouth care to minimize possible infection. Plenty of water should be given orally
- Administer medications as ordered. Narcotics and sedatives are usually avoided. To minimize apprehension, only mild tranquilizers are given
- For long-term cases, the patient and his relatives are taught how to take care of the tube
- Alleviate the patient’s apprehension by closely observing him, providing care in a calm but efficient manner and helping him communicate by providing a call bell
The suction procedure is as follows:
- Auscultate the chest before and after suctioning
- Wash hands and use sterile gloves
- Place a sterile towel across the patient’s chest just below the tracheostomy tube
- Clean the skin around the tube and the adaptors with a recommended antiseptic
- Select the catheter, attach it to the suction apparatus and lubricate it with sterile normal saline, gently insert into the tracheostomy tube and do the suctioning. It should not be continued more than 5 seconds at a time
- After suctioning, discard the catheter and gloves and also the saline. Note the amount and the character of the secretions aspirated
- Wash hands after completion of the procedure
Cleansing the Inner Cannula
It is changed every 2 to 4 hour, but in some cases, only twice. It can be cleaned with cold water and soap and also with hydrogen peroxide solution. After cleaning, it can be sterilized and can be used again. Do not leave the inner cannula out for longer than 5 to 10 m while removing or cleaning it
If left out for longer periods, secretions and crust begin to form in the outer cannula, making it difficult to reinsert the inner cannula
The following conditions should be reported to the doctor if they occur during the postoperative period:
- Tube displacement
- Indications of shock, hemorrhage, respiratory insufficiency and hypoxia
- Respiratory obstruction
- Excessive restlessness or apprehension
- Cyanosis, in case of cyanosis, oxygen should be given
- Rhinorrhea
- Development of tracheoesophageal fistula
