Tracheostomy care

Gives a good account of tracheostomy care for doctors and other health care professionals

1. TRACHEOSTOMY CARE
Dr. Vasanthika Thuduvage
Consultant ENT Surgeon

2. Definition
Tracheotomy
Making a surgical opening in the trachea
Tracheostomy
Creation of a stoma at the skin surface
which lead in to the trachea

4. Types
Temporary tracheostomy
Elective
Emergency
Permanent

5. Temporary: THE UPPER AIRWAY WILL REMAIN
PATENT IF THE TRACH TUBE WERE TO BE
DISLODGED
Permanent: THE LARYNX IS REMOVED AND AN
ARTIFICAL TRACHEOSTOMY IS CREATED –NO
CONNECTION BETWEEN THE PATIENT’S UPPER
AIRWAY AND THE TRACHEA ITSELF!
Temporary Tracheostomy versus
Permanent Laryngectomy

6. Indications
Upper airway obstruction
Congenital
Trauma
Infections
Tumours
Vocal cord paralysis

7. Indications cont,
Protection of tracheobronchial tree
Neurological diseases
Following trauma
Coma
Head and neck surgery
Prolonged ventilation

8. Anesthesia
Local anesthesia
General anesthesia

9. Types of tube
Metal tubes
Synthetic tubes
Cuffed tubes
Uncuffed tubes
Fenestrated tubes
Double lumen tubes
Adjustable flange tubes

20. Heat moisture exchanger
Humidification examples

21. Complications
Immediate
Anaestheticcomplications
Haemorrhage
Air embolism
Apnoea
Cardiac arrest
Damage to local structures

22. Intermediate
Displacement of the tube
Surgical emphysema
Pneumomediastinum
Infection
Tube obstrution
Tracheal necrosis
Tracheo-oesophageal fistula
Tracheo-arterial fistula
Dysphagia

23. Long term
Stenosis
Decanulation problems
Tracheocutaneous fistula
Disfiguring scar

24. Nursing Care

25. Must conduct a thorough assessment of patient at the start
of visit
Observe for signs of hypoxia, infection, excessive
secretions, pain, etc.
Examine trach tube, any attached tubing and
equipment, as well as stoma site
Auscultatebreath sounds
Ensure that appropriate emergency trach supplies
and CPR equipment is at bedside
Be aware of when and why the trach was inserted
, how it was performed, the type and size of tube
inserted
Nursing Care

26. Tracheostomy Care Kit

27. Equipments
Portable or wall suction with tubing and
reservoir.
Sterile suctioning kit containing:
Appropriate-sized suction catheter
Pair of gloves
Container of saline to flush and lubricate
the suction catheter
Drape
Pulse oximeter
Ambu(10-15 liters)
Tracheal dilator

28. Post operative management
A trained nurseshould be in attendance
Patient should be close to nurses station
Writing materieland a bellshould be with
the patient
Tube should be stitched to skin
Tapes should be tied with a reef knoton
both sides of neck when the head in the
neutral position

29. Tracheostomy trayshould be with the
patient
Keep the cuff inflated for 12 hours while
deflating the cuff for 5 min every hour
Then deflate the cuff if no risk of aspiration
or if not ventilating
Humidification of air
Breathing exercises

30. Removal of secretions
Every half hour or more in first 48 hrs
Then at least 4 hrly/ as required
Should be done in sterile conditions
Can use normal saline up to 5ml/ sodium
bicarbanate for crust removal
Should not suck more than 10 sec
continuously

31. 1.Wash handsto prevent transmission of
micro-organisms/cross contamination.
2. Explain procedure to patient to reduce
anxiety & encourage cooperation.

32. 4. Turn on suction (adults: 100-120mm Hg).
Secure connecting tube to suction source.
(Excessive negative pressure traumatizes
mucosa & can induce hypoxia.)
5. Open and prepare suction catheter kit.
6. Preoxygenatepatient with 100% oxygen to
prevent hypoxemia. Hyperinflatewith ambuto
decrease atelectasis.

33. 7.Pick up catheter with dominant hand and the
connecting tube with non-dominant hand.
8.Attach catheter to tubing using sterile technique.
9.Place catheter end into saline. Test equipment
by applying thumb from non-dominant hand
over open port to create suction.
10. Insert catheter into tracheostomy tube without
applying suction, using sterile technique.
11. Advance catheter for premeasured length /until you feel
resistance.
Retract catheter 1cm before applying suction.

34. 12. Apply intermittent suction while withdrawing
the catheter. Limit suctioning time to 10
seconds to prevent hypoxemia.
13. Hyperoxygenateand hyperinflateif needed.
14. Rinse catheter with saline to clear secretions.
15. Repeat Steps 10-14 until airway is clear.
16. Discontinue if HR drops by 20; increases by
40, produces arrhythmias, or decreases 02 <
90%

35. Divide the internal diameter of the
tracheostomy by two, and multiply the
answer by three to obtain the French
gauge suction catheter:
Size 8 tracheostomy tube (patient);
(8mm/2) x 3 = 12; therefore, a size 12F
gauge catheter is suitable for suctioning
Selecting a suction catheter

37. To lower the risk of accidental
decannulation (the trach tube coming out)
the tie changes should be performed by
two people or with new ties secured
BEFORE old ties are removed.
Tracheostomy Ties

38. The majority of trach tubes have inner
cannulas that require cleaning one to
three times daily unless they are
disposable
Use sterile technique to clean the
reusable cannula with ½ strength hydrogen
peroxide and normal saline or just NS
Reinsert and lock back into place within a
15 minute time frame
Maintenance of the inner
cannula

39. Cuff pressure (balloon) should be maintained
between 10 to 20 mmHg of pressure via a
manometer –should be assessed daily;
if you don’t have a manometer measuring device –
check with the patient/family –to evaluate how
many cc’s of cuff pressure they have been utilizing
(generally 5-8 cc) depending on trach size
With a stethoscope placed on the neck, inflate the
cuff until you no longer hear hissing; deflate the cuff
in tiny increments until a slight his returns….
Nursing Care –Trach cuff pressure

40. When a patient has had a tracheostomy for
several months, the stoma is well formed
and tube changes can be done safely on a
monthly basis using a clean technique; the
initial tube change is usually performed by
the surgeon
Smaller size tracheostomytubes, tracheal
dilator, oxygen, suction
How to rail -road in difficultintubation
Nursing Care: Changing the Trach
tube

41. How to discharge a patient with
tracheostomy
Patient and family education normally starts in
hospital setting
Patient should be thorough in tube
change, a relative also should be taught.
Additional tubes, ribbons, gauze should be
provided
When to come to the hospital immediately –
block tube, broken tube, bleeding from the
stoma, difficult intubation.
Not to be without the tube for more than 2
days, the stoma closes rapidly.

42. Wearing a scarf over trachopening to keep dry and
clean
Trachpatient’s avoid:
Deep bathing water
Fine particles such as powders, chalk, sand, dust,
mold and smoke
Loose fibers and fair found on fuzzy toys and pets
Persons with contagious illnesses
Cold air and wind
Portable suction equipment is available for travel and
should be tested PRIOR to use
GREAT RESOURCE TEACHING SITE:
http://www.tracheostomy.com
Patient Instructions

43. Removal of tube
If no longer indication exist can consider
tube removal
Should be done in a step wise fashion
Uncuffedfenestrated small size tube
should be inserted
Close the tube during day time
Tube close during day and night time
(24Hrs)
If patient tolerate can decannulate

45. THANK YOU