Tracheostomy

BSC NURSING III YEAR - NURSING PROCEDURE

1. Tracheostomy
Mr. Manikandan.T,
RN., RM., M.Sc(N)., D.C.A .,(Ph.D)
Assistant Professor,
Dept. of Medical Surgical Nursing,
VMCON, Puducherry.

2. Definition
A Artificial (Usually) surgically created
airway fashioned by making a hole in the
anterior wall of the trachea & the insertion
of a tracheostomytube, which may or
may not be permanent

3. Types of Surgical airway
1.Elective Tracheostomy
2.Emergency Tracheostomy
3.Cricothyroidotomy (Mini Tracheostomy)
4.Percutaneous Dilational Tracheostomy

4. Tracheostomy
Indications
•Upper Airway Obstruction.
•Pulmonary Ventilation.
•Pulmonary Toilet.
•Elective Procedure

5. 1.Upper Airway Obstruction
a.Trauma
b.Foreign body
c.Infections
d.Malignant lesions
e.Vocal cord palsy

6. 2.Pulmonary Ventilation
Tracheostomyshould be performed in a
patient still requiring ventilation through
an endotrachealtube for more than a one
week.

7. 3.Pulmonary Toilet
•Those who cannot cough and clear their
chest.
•Prevent aspiration by low pressure high
volume cuff tracheostomytube.

8. 4.Elective Procedures
•For major head and neck operations.

9. Anatomy
•Trachea lies in midline of the neck
extending from cricoidcartilage (C6)
superiorly to the tracheal bifurcation at
the level of sternalangle of Luis (T4).
•Comprises 16-20 C shaped cartilage
rings.
•Length 10-12cm.
•Diameter 15-20mm.

10. 2
nd
3
rd

13. Patient preparation
Cardiac monitor
Intravenous line
with saline
Oxygen
Pulse oximeter
Ambubag for
ventilating patient
Setup
Povidineiodine
solution
Surgical drapes to
enclose the field
Sterile gown
gloves, and mask

14. Procedure
Local anesthesia
10 mLsyringe
1%lidocaine
18/25 gauge needle
#11 scalpel blade and
handle
Two skin forceps
Eight small curved
hemostats
Sterile 4x4 gauze
squares, two dozen
Two Kocher forceps
(if needed, to clamp
the thyroid)
Frazier suction
catheter with suction
tubing

15. Cont
Suture ligatures (3–0
chromic, 3–0 silk, 3–
0 nylon)
Tracheostomytube,
appropriate size for
patient
Water-soluble
lubricant or
anesthetic jelly
Suction source and
tubing
Two pairs of scissors,
one straight and one
curved
Two tissue forceps
without teeth
Two Allis forceps, to
grasp the trachea
Two small rakes, for
exposure
Mastoid retractor
Trousseau dilator
Two tracheal hooks
Umbilical tape
Needle holder

16. Procedure –Elective Tracheostomy
Proper analgesia and Sedation along
with local anesthesia
Good illumination, preferably head
light
Look for any anatomical distortion
Check the Tracheostomytray
Position: Supine with sand bag under
the shoulder

17. Skin –5 cm incision midway b/w cricoidcartilage and
suprasternalnotch (Horizontal cosmetically better &
vertical avoids injuring vessel and bleeding)
Subcutaneous tissue & deep fascia–use
electrocoagulation
Anterior jugular vein–may require ligation (extend
the incision to entire length up to two edges of skin
and do not work in a small hole)

18. Cont
Pretrachealmuscle–split it at midline
Thyroid isthmus–Retract upward and
may require ligation & division
Pretrachealfascia-dissect it with
electrocoagulationand expose 2
nd
–5
th
rings
Secure 2 stay sutures with prolene2-0
on either side of trachea over 3
rd
or 4
th
ring

20. Cont
Place the hook to 1
st
ring & pull it forward
and upward, along with 2 stay sutures
Deflate the ET tube now
Trachea is incised with no.11 blade
between 2
nd
and 4
th
ring by 3 ways (never
use electrocoagulationas O2 contact may
lead to explosion)

21. Cont

22. Pull ET tube under direct vision just above
the level of incision
Insert no.8 size tube, Remove the introducer
and inflate then fix around the neck
Before removing ET tube check the air entry

30. •Within 2-4 mints with vertical incision
Emergency Tracheostomy

31. Cricothyroidotomy/ Mini tracheostomy
Transverse incision over the cricothyroidmembrane.
Needle or tube Cricothyroidotomy

32. PercutaneusDilational
Tracheostomy
ICU Bed SideTracheostomy
Use of guide wire and Dilators
May be under the vision of Bronchoscope
through endotrachealtube
Less time ,Less Expensive
Not suitable for thick neck and in
emergency situation

33. PERCUTANEOUS TRACHEOSTOMY
INSERTION KIT

34. PERCUTANEOUS TRACHEOSTOMY KIT

35. Complications of Tracheostomy
IntraopertaiveComplications:
Loss of airway
Bleeding and injury to big vessels
Injury to tracheoesophagealwall
Pneumothorax
Aspiration

36. Early Complications:
Bleeding and local hematoma
Tracheostomytube obstruction and desaturation
Tracheostomytube displacement
Infection
Surgical emphysema

37. Late Complications:
Tracheal or subglotticStenosis
Granulation tissue
Tracheocutaneusfistula
Tracheo–esophageal fistula
Dislocation of tracheostomytube
Bleeding from stoma or during suction
Blockage of Tracheostomytube
Laryngeal injury or alteration of phonation

39. Tracheostomy Tubes
Plastic (Protex) / Metal
Fenestrated / Nonfenestrated
Cuffed / Uncuffed

40. TYPES OF TRACHEOSTOMY
TUBE
Uncuffed

41. TYPES OF TRACHEOSTOMY
TUBE
Cuffed

42. TYPES OF TRACHEOSTOMY
TUBE
Fenestrated

43. Components of Tracheostomy Tube
SIZES RANGE FROM
2.5MM TO 11 MM
CURVED TUBE
INFLATABLE CUFF
FLANGES WITH HOLES
TUBE BLADDER

53. Suction technique
Suction pressure (20kPa/150mmHg)
Suction OFF on entry, ON for withdrawal
of catheter
Quickly –patient can’t breathe!
Circular motion in tracheostomy tube only

55. Care Of The Patient With A
Tracheostomy
SAFETY FIRST
CARE OF THE STOMA
COMMUNICATION
PSYCHOLOGICAL
NUTRITION
INFECTION CONTROL

56. SAFETY FIRST
When caring for a patient with a tracheostomyyou must
ensure that:-
There Are Spare TracheostomiesAvailable
close by 1 The same size and the other a size
smaller
A Tracheal dilitationkit is close by
Suction Equipment is available
Different size suction catheters available
Oxygen is available
Emergency equipment is available including
a resuscitation Bag and Mask and
defibrillator and emergency drugs

57. Care of the stoma / Infection control
It needs to be cleaned and
inspected 2-3 times a day
It should be cleaned using
aseptic technique and
appropriate dressings applied
to aid healing
Once tube is removed the
stoma will close
spontaneously over a few
days

58. PSYCHOLOGICAL /
COMMUNICATION
Patientsand family require
reassurance and support
Alternative methods of
communication should be
sought
Provide stimulation in the form
of television, radio,
newspapers, etc

59. NUTRITION
Check local policy on eating and drinking
with tracheostomies
some trusts allow patients to eat and
drink
Others DO NOT!!
Usual ways of feeding include oral,
nasogastric or parenteral.

60. Changing the Tube –railroad
technique
Cut both ends off largest possible suction catheter
Insert suction catheter down trache tube
(warn patient re coughing)
Remove tube over catheter, maintaining catheter
position in airway
Insert new tube over catheter
Remove catheter
Beware false track anterior to trachea

61. Checking tube position
Feel air flow from tube on your arm as patient exhales
Observe patient’s breathing -noisy? difficult? use of
accessory muscles?
Observe patient’s colour
If any doubt, fibreoptic scope can be passed down tube
for direct vision of position
X-ray not generally helpful

65. HOME CARE PLAN
1.Education and training of the attendant.
2.Supply of dressing, suction catheters and
suction machine.
3.When to come to the hospital.
4.Visit by community nurse.