Tracheostomy and its post op care last

dr jameel kifayatullah khyber college of dentistry

1. Tracheostomy and its post
operative care23 feb 2011

2. Tracheostomy
 An artificial airway just below the larynx in the
trachea, bypassing the mouth and upper airway
or
A tracheostomy is the formation of an
opening( stoma) into the trachea usually
between the second and third rings of
cartilage.

3. Stoma

4. Types of tracheostomy
A temporary tracheostomy can be formed when patients require
long term respiratory support or are unable to protect their own
airways. A tracheostomy tube will be inserted to maintain the
patency of the airway. This can be removed when the patient
recovers. A temporary tracheostomy may become long term if the
patient’s condition requires this.
A permanent tracheostomy is created where the trachea is brought
out to the surface of the skin and sutured to the neck wall. This
stoma is kept open by the rigidity of the tracheal cartilage. The
patient will breathe through this stoma for the remainder of his/her
life. As a result, there is no connection between the nasal passages
and the trachea.
This procedure is elective and the patients need to be carefully
prepared for the consequences of the procedure.
 (nepian hospital sydney)

5. Tracheotomy
tracheotomy refers to the formation of a
surgical opening in the trachea. It refers
strictly to a temporary procedure.
incision of the trachea( tracheotomy)

6. ANATOMY

7. Anatomy

8. Anatomy
Skin sc tissuesplatysmaanterior jugular
veins deep cervical fasciastrap muscles
Within the visceral compartment lies isthmus

9. Tracheotomy procedure
Neck skin over 2
nd
tracheal ring identified.
vertical incision about 2–3 cm(skin)
Sharp dissection to cut the platysma
muscle
Blunt dissection parallel to the long axis of
the trachea used to spread the
submuscular tissues until thyroid isthmus
is identified

10. tracheotomy
If the gland lies superior to the 3rd
tracheal ring, bluntly undermine and
retract superiorly to gain access to the
trachea

11. tracheotmy
If the isthmus overlies the 2nd and 3rd ring
of the trachea, it must be mobilized and
either a small incision made to
clear a space for the tracheostomy.

12. thyroid isthmus is
mobilized with a hemostat

13. small incision to allow access

14. 3
rd
option:complete transection of isthmus

15. Tracheal entry.
1) 2nd tracheal ring divided laterally,
anterior portion removed.lateral sutures for
countertraction.

16. Creating the tracheal portal:tracheal wall flap (Bjork flap)
2) tracheal ring not resected but instead a
flap is created which can be attached to
skin.

17. Indications of tracheostomy
 To facilitate weaning from mechanical
ventilation by decreasing anatomical dead
space.
To remove retained tracheo-bronchial
secretions.
To bypass upper airway obstruction

18. advantages
reduce the upper airway dead space by up
to 150 ml (50%) reduced effort in breathing
compared to the naso- or oropharyngeal
route consequently significantly reduced
airway resistance and increased alveolar
ventilation [alveolar ventilation= tidal
volume - dead space volume.

19. disadvantages
warming, humidification and filtering of air do not take
place  drying out of the tracheal and bronchial
epithelium response of epithelium  increased
mucus, also increased production of mucus in response
to a foreign body (the tube) within the trachea-
Disruption to swallowing mechanismsplinting of larynx-
normal upward movement prevented
Loss of normal cough reflex and positive intralaryngeal
pressure.

20. complications
Complications of tracheostomy
Immediate (operative)
Haemorrhage, air embolism, damage to adjacent structures such
as the cricoid cartilage, pleural domes, recurrent laryngeal nerves
Intermediate (within 2 weeks)
Blockage or displacement of the tube, pneumothorax,
Neck emphysema, chest or wound infection
Delayed
Subglottic and tracheal stenosis, tracheocutaneous fistula,
Tracheomalacia, Tracheoinnominate-artery fistula,
Tracheoesophageal fistula, Pneumonia, Aspiration.

21. Types and Uses of Tracheostomy Tubes
1) Universal
double-lumen or double-cannula tube.
three parts
 outer cannula with cuff and pilot tube
inner cannula
 obturator
Tracheostomy tubes with an inner cannula are called dual
cannula tracheostomy tubes.

22. The outer cannula keeps the airway open
The outer cannula is placed in the stoma
to keep the hole from closing.
the inner cannula has a universal adaptor
for use with a ventilator and other
respiratory equipment.
Some inner cannulas are disposable;
others must be removed, cleaned and
reinserted.

23. Universal tracheostomy tube

24. Dual-Cannula Tracheostomy Tubes
An example of an inner cannula in which the 15-mm ventilator
attachment is connected to the inner cannula. If the inner
cannula is removed, it is not possible to attach the ventilator.

25. Obturator:
The obturator is only used when putting
the outer cannula into the stoma.

26. 2)Single Canula tube
Slightly longer than the universal tube.
Long or thick necks.
Requires additional humidification to
prevent the accumulation of secretions

27. Single Canula tube

28. 3)Fenestrated
fenestration (hole) in the middle of the upper
aspect of the outer tube (cannula).
Allows air to flow through the upper airway and
tracheostomy opening
Allows the patient to speak and produce more
effective cough
Used during weaning

29. Fenestrated tube

30. Airflow occurs through
mouth and nose.

31. Tracheostomy Button

32. Tracheostomy Button
Short straight tube fitting into
tracheostomy stoma after trac tube
removal.
Doesnot enter the tracheal lumen
Indications: 1) weaning because it creates
less airway resistance
2) obstructive sleep apnoea

33. Cuffed tube
On inflation seals the airway and prevents
the aspiration of oral or gastric secretions
Advantages:
1)Allow for airway clearance,
2) offer some protection from aspiration,
3) positive-pressure ventilation

34. Cuffed tracheostomy tube
cuffed

35. Cuff pressure
Tracheal capillary perfusion pressure is normally 25–35
mm Hg.
High tracheal-wall pressurestracheal mucosal injury
Cuff pressure too low---- silent aspiration
cuff pressure be maintained at 20–25 mm Hg (25–35 cm
H2O) to minimize the risks for both tracheal-wall injury
and aspiration.

36. Cuff over inflation demonstrated on
model.

37. Cuffless tubes
Usually double lumen tubes
Used for long term management of
patients
Effective cough and gag reflexes to
prevent themselves from aspiration

38. Cuffless tubes

39. Metallic tube

40. Dimensions
T-tube selected on the basis of its size or
diameter.
Jackson sizes - used for Shiley
tubes(outer dia)
European standard/ISO: tracheostomy
tubes sized according to functional internal
diameter(ID) at the narrowest point.
SINGLE CANNULA TUBES: id of outer
canula tube is quoted.

41. Dual-cannula tracheostomy tubes also use the
International Standards Organization method. The ID of
the tube is the functional ID. If an inner cannula is
required for connection to the ventilator, the published ID
is the ID of the inner cannula.
most adult females accommodate a tube with an OD of
10mm, whilst a tube with an OD of 11mm for most adult
males.

42. dimensions
When selecting a tracheostomy tube, the
ID and OD must be considered. If the ID is
too small, it will increase the resistance
through the tube, make airway clearance
more difficult, and increase the cuff
pressure required to create a seal in the
trachea.

43. The sizes of some tubes are given by
Jackson size, and refers to the length and
taper of the OD. These tubes have a
gradual taper from the proximal to the
distal tip. The Jackson sizing system is still
used for most Shiley dual-cannula
tracheostomy tubes.

44. sizeInner
diamet
er with
inner
tube
(mm)
Inner
diamte
r
without
inner
tube
(mm)
Outer
diamet
er(mm)
4 5 6.7 9.4
6 6.4 8.1 8.1
8 7.6 9.1 12.2
10 8.9 10.713.8

45. Angled versus curved tracheostomy tubes.
angled tube has a straight portion and a curved portion, whereas the curved tube has a uniform angle of curvature.

46. Tracheostomy care
Cleaning the Inner Cannula
clean at least three times a day
If sputum is thick or sticky clean it as often as
ten times a day.
Supplies
 hydrogen peroxide
 clean bowl
 pipe cleaners or cotton-tipped swabs

47. 1. Wash your hands.

48. 2. Remove the inner cannula.

49. 3. Place the inner cannula in bowl and
cover with hydrogen peroxide. Let it soak
in the peroxide solution for at least one
minute.

50. 4. Pick the inner cannula up and clean the
inside and outside with pipe cleaners or
cotton-tipped swabs.

51. 5. After you scrub off all the sputum, hold
the inner cannula under running tap water
briefly.

52. 6. Shake the excess water off the inner
cannula.

53. 7.Dry the inner cannula using a sterile
gauze sponge

54. 8. Reinsert the inner cannula into
tracheostomy and lock in place.

55. Cleaning the Stoma
Clean the skin around your stoma at least
once a day to remove sputum crusts and
prevent skin irritation.
Supplies
clean wash cloth
mild soap
cotton-tipped swabs
hydrogen peroxide
petroleum jelly
4 x 4 gauze or pre-cut dressing

56. Steps in cleaning the stoma
1. Wash hands.

57. 2. Clean around stoma with soapy
washcloth, then rinse.

58. 3. If the stoma is covered with dried
sputum crusts, remove the crusts with a
cotton tipped swab soaked in hydrogen
peroxide. Hold your breath while removing
crusts so that you do not inhale them.

60. 4. If dried crusts are a problem, apply petroleum jelly
around the stoma.
5. If you do not have a problem with mucus collecting
around your stomano need of dressing.
6. If you need a dressing, buy pre-cut dressings or make
them from a 4 x 4 gauze. Do not cut your dressing. loose
fragments lodge in stoma.

61. How to Make a tracheostomy dressing
 To make a tracheostomy dressing from a 4 x 4 gauze,
open gauze to an 8” x 4”size, then fold lengthwise.

62. Fold gauze corners up.

63. Slide folded gauze under tracheostomy
strings.

64. Changing the Outer Cannula
Replace if mucus is plugging the end of the outer cannula.
Materials necessary for changing the outer cannula:
 second complete tracheostomy tube with obturator and inner
cannula to replace the current one in your neck.
 Water-soluble lubricants, such as K-Y Jelly® or Surgilube®.
 Clean tracheostomy ties.
 tracheostomy dressing

65. Changing the outer cannula
Procedure:
1. Wash your hands.
2. Prepare the clean tracheostomy tube.
a. Remove the inner cannula.
b. Attach the tracheostomy ties to the
outer cannula.
c. Place the obturator in the outer cannula.
d. Run clean water over the tubes

66. e. Apply a thick coat of water-soluble lubricant to
the outside of the clean tracheostomy tube.
3. Loosen the ties of the old tracheostomy tube.
4. With a smooth, quick motion, slide the old
trach forward and out.

67. 5. Insert the clean tube into your tracheostomy
stoma using a gentle, inward motion. If it is
difficult to insert the cannula into the stoma, lift
patients chin up. This may better align the stoma
with the hole in the trachea.
6. Stabilize the neck plate of the outer cannula
with one hand and immediately remove the
obturator with the other hand.

68. 7. Tie the neck ties to one side in a square
knot.
8. Replace inner cannula and lock in
place.
9. Wash your hands.

69. Cleaning the Outer Cannula
1. same method described as for cleaning
the inner cannula.
2. After cleansing and drying the outer
cannula thoroughly, place clean trach ties
on the outer cannula.
3. Store the cannula in a clean container

70. Changing the Tracheostomy Ties
need to be changed when they become
dirty
Ask another person to hold the
tracheostomy tube in place while changing
the ties
Supplies
½ inch wide twill tape
scissors
a friend

71. 1. Cut two strips of twill tape about 8 inches long.

72. 2. Cut a small slit at one end of each strip.

73. 3. Cut and remove the old ties while your
friend holds the tracheostomy in place.

74. 4. Pull the slit end of each tie through the
opening in the neck plate. Then, thread
the unslit end through the slit.

75. 5. Tie the ends together in a double knot to one side of
your neck. Make the ties loose enough to slip one finger
under them.

76. HUMIDIFICATION
Measures to Provide Humidity
1. Put normal saline solution into your trachea as often as needed to
keep secretions loose.
2. Keep a ten gallon humidifier in your main living area during the
day.
3. Keep a small humidifier at your bedside at night.
4. If you have radiators, place pans of water on top of them.
5. Maintain a relative humidity of 50 percent in your home.
6. The most important way to keep your sputum thin is to drink
plenty of fluids – at least six glasses of water a day.

77. humidifier

78. humidifier

79. humidification
Instilling Saline Solution
Supplies
 clean syringe
 saline solution at room temperature
 tissues
1. Fill syringe with 2 cc of saline solution.
2. While breathing in deeply, squirt saline into inner cannula. This
will make you cough immediately, so have tissues ready to catch the
sputum.
3. Repeat this whenever needed to keep secretions loose.
4. Clean syringe with soap and water and dry thoroughly, then place
in a clean container.
Replace the syringe with a new one every week.

80. suctioning
Initially, a suction machine needed to clear sputum from
airway. Eventually secretions will probably decrease,
airway adjusts to the presence of the tracheostomy tube.
Supplies
 suction machine
 suction catheter
 clean container
 saline solution
 connecting tubing
 syringe

81. Suction machine
Suction machine

82. supplies

83. WORKING OUT SUCTION CATHETER SIZE
Size of trach. tube (mm) x 3
2
E.g. 8 x 3 = size 12
2
Suction catheter size (Fg) = 2 x (Size of
tracheostomy tube – 2)

84. Attach connecting tubing and suction
catheter to suction machine.

85. `
Turn suction machine on.
Pour about half a cup of saline solution into the clean container.
 Draw 2 cc of saline solution into the syringe and squirt the saline
solution into your trachea.
 Wet the end of the suction catheter with normal saline

86. 7. Take three deep breaths. Then gently insert
the suction catheter 4-8 inches through your
tracheostomy tube. Do not apply suction while
you are inserting the catheter.
Once you feel resistance, withdraw the catheter
slightly

88. Cover the suction control vent with your
thumb to apply suction. Do not apply
suction for more than ten seconds. As you
apply suction, gently rotate the catheter
while you withdraw it.
 Do not suction more than three times a
session. If you need more suctioning, rest
at least five minutes before repeating.
Take three deep breaths after you finish.

89. Place the catheter in the water and suction to
rinse tubing.

90. DECANNULATION
Tracheostomy Decannulation is the
process of the removal of the
tracheostomy tube from the stoma or
opening in the trachea

91. TRACHEOSTOMY WEANING AND DECANNULATION
PROTOCOL
Physician orders protocol and patient meets minimal
medical criteria per protocol
Minimal criteria
1. Five to seven days postoperative, to ensure a mature
stoma, following a temporary tracheostomy.
2. No acute respiratory problems (such as pneumonia,
shortness of breath, respiratory insufficiency)
3. Minimal secretions (suctioning less than every 4-6
hours) with a strong cough reflex sufficient to clear
secretions
4. Oxygen saturation in range ordered by MD
5. Not on mechanical ventilation
6. No anatomical upper airway obstruction or limitation

92. Decannulation protocol
Deflate cuff following suction procedure
Observe and monitor patient
Cuff Deflation Successful
FAST TRACK PATHWAY
Change to cuffless and/or smaller trach and begin
plugging trial
Observe and monitor patient for 5-10 minutes
Plugging Successful
Observe and monitor patient every 2 hours for 24-48
hours
Plugging Successful decannulation

93. EXTENDED PATHWAY
unsuccessful plugging trial
Contact physician for extended tracheostomy
weaning plan:
Speaking valve (Passy-Muir)
 Tracheostomy tube change to a fenestrated uncuffed
tube to facilitate speaking valve trials.
Recommendation for ENT or Pulmonary
Medicine consults in the event of recurring
trial failures.

94. PMV

95. OCCUSIVE CAP

96. Do’s:
1. Do prevent water from entering the stoma when bathing or showering.
Methods are:
 Sit or stand with your back towards the shower head (face away from the shower
head).
Use a hand shower hose to avoid getting water into your stoma.
 Tie a baby bib around your neck with plastic side out and terry cloth against your neck.
 Drape a washcloth from your mouth.
 Place your hands securely over your stoma.
2. Do wear a medic alert bracelet (if trach is long term) indicating you have a tracheostomy,
since CPR must be performed mouth to stoma and not mouth to mouth.
3. Do be careful when shaving since the neck area may still be numb and you may cut
yourself without knowing it, and be careful of the whiskers that they don’t fall into your
stoma. You should caution your hairdresser to avoid getting hair particles into your stoma.

97. 4. Do keep your stoma covered when outdoors to prevent
anything in the air from being inhaled.
5. Do remember to cover your stoma when coughing.
6. In the event of an extended power failure you may consider
one of the following:
Purchasing a generator for backup power.
Purchasing equipment with a battery backup system.
Go to your nearest hospital emergency department.
7. Keep the humidifier tubing above the level of the machine. If
water accumulates in the tubing, manually drain the water from the
tubing

98. Do Not’s:
1. Do not swim or participate in other water sports because you could
get water into your stoma and drown. \
2. Do not use substances that will irritate your airway (ex: powders, hair
sprays, etc.).
3. Do not use over-the-counter antihistamines
4. Do not use Kleenex other than for coughing into or wiping sputum away
from stoma because they may shred and be inhaled.
5. It is strongly recommended that you refrain from smoking and avoid
exposure to environmental/second hand smoke.