Tracheostomy care & management

Tracheostomy care & management

1. Tracheostomy Care
&
Management
Maria Monteiro, CNE
Revised: January 2015

2. Objectives Review of Evidenced-Based Guidelines in the Care & Maintenance
Review Definition, Types of Tracheostomies & their uses
Potential Complications
Nursing Care Guidelines at NYGH:

Assessment,

Suctioning,

Dressing changes,

Inner cannula changes,

Other nursing considerations

Documentation in powerchart
Emergency Scenarios

3. Definitions T
Tracheotomy:Incision made below the cricoid
cartilage through the 2
nd
-4
th
tracheal rings
T
Tracheostomy:the opening or stoma made by this
incision
T
Tracheostomy Tube: Artificial airway inserted into
the trachea

4. Why does your patient have a
tracheostomy?
I
To maintain a patent airway when the ability to do
this is temporarily or permanently compromised
I
Bypass Obstructed airway
I
Tumor
I
Laryngeal edema
I
Foreign body obstruction
I
Facilitate removal of secretions
I
Permit long-term ventilation/prevent aspiration with prolonged
coma I
Decrease work of breathing---severe COPD

5. Anatomy

6. Types
I
Cuffed or Un-cuffed
I
Fenestrated or Non-fenestrated
I
Disposable or Non-disposable inner cannula
I
NYGH uses ‘Shiley’ tubes with disposable inner
cannulas

7. Parts of a Trach 3
1. Flange-secured with trachties, stabilizes the trach
3
2. Outer Cannula-tube connected to flange
3
3. Inner Cannula-removable for cleaning
3
4. Obturator-a plastic guide with a smooth rounded tip
that is used to guide the outer cannula during insertion
3
5. Cuff-Soft balloon around the end of the
trachthat can be inflated to allow for
mechanical ventilation
3
1
5
4

8. Cuffed
Purpose: T
Increase or improve ventilation/oxygenation
T
Prevent aspiration with feeding tubes, decreased
gag reflex, gastro-esophageal reflux
Identification:
DCT-disposable cannula
DFEN-disposable cannula fenestrated

9. Cuff Complications
Pressure from the cuff can cause damage the trachea
Necrosis
Low pressure cuffs are used
RT will inflate/deflate and monitor pressure

10. Un-cuffed T
Plastic or metal
T
Allows air to flow freely around the tracheostomy
tube through the larynx T
Reduces the risk of tracheal damage
Identification: DCFS-disposable cannula cuffless
DCFN-disposable cannula fenestrated cuffless

11. Fenestration I
Permits speech through the upper airway when the
external opening is corked and the cuff is deflated
I
Restores more of a normal airflow by allowing air
to pass up and down the airway from the nose &
mouth
I
Allows secretions to be coughed out through mouth

12. Inner Cannula
I
Allows maintenance of tube patency
I
Changing or cleaning the inner cannula helps to
clear secretions
I
Can be non-disposable or disposable
I
At NYGH disposable cannulas come in a box of 10
and will be changed Q8 hours & PRN

13. Caps and Plugs
T
Occlude proximal end of trachtube to permit breathing
through fenestration and upper airway
“CORKING”
T
Disposable DecannulationPlug (DDCP) closes proximal end of
DCFS, DCFN and DFEN
T
DecannulationPlug (DCP) closes proximal end of FEN and
CFN tubes

14. Tracheostomy Information
What should I know about my patient’s trach: I
What type is it?
I
What number?
I
Cuffed or cuff less—balloon inflated or deflated
I
Fenestrated/non-fenestrated?
I
Inner cannula disposable or reusable
I
Corked? For how long? What is the goal?
I
Is the TrachNYGH information sheet in the room and visible?

16. Potential Complications
R
Hemorrhage
R
Pneumothorax
R
Subcutaneous emphysema
R
Dislodged tube
R
Airway obstructions
R
Infection
R
Aspiration
R
Tracheal damage
Obstruction Clinical Presentation: R
Skin colour—pallour, cyanotic
R
Increase respiratory rate, P,
BP,DecreasedO2 Sat
R
Use of accessory muscles, flared
nostrils, inability to lie flat
R
Labored breathing
R
Clammy appearance/cyanosis
R
Decreased LOC or changes to
behaviour(i.e.)
Distress/anxiety/restlessness
Recognizing early S & S will allow early
intervention & prevent negative outcomes

17. Prevention is Key
I
Trachpatients are at high risk for airway obstructions, i mpaired
ventilation, and infection as well as other complications I
Altered body image, requiring emotional/psychological support
I
Skilled and timely nursing assessment and care can prevent
these complications
Goals in care will include maintaining a patent airway a s well as
ventilation/oxygenation:
I
Suctioning
I
Humidity
I
Trach care & maintenance

18. Nursing Assessment
I
Beginning of each shift and prn
I
Look and listen
I
Vital signs & SpO2 –pulse oximetry
I
Oxygen/Humidity
I
Respiratory assessment = breath sounds
I
Secretions-amount, color, consistency
I
Cough, ability to clear own secretions
I
Trachsite

19. Equipment in Room **emergency equipment** Each Shift the nurse responsible for the pt must che ck and document that
equipment is present and in working order
T
Functioning Suction & O2/Air for humidity
T
Ambubag
with trach adaptor/connector
T
Trach set of same size and type—VISIBLE
TO ALL
T
Trach Info sheet with pt info.
T
Obturator
T
Box of disposable Inner Cannulas or trach tray for c leaning non-disposable
T
Suction catheters
T
Normal saline bottle
T
Hydrogen peroxide (for non-disposable inner cannula s cleaning)
T
Small ampules of normal saline for suctioning
T
Mouth swabs
T
Occlusive drsg—tegaderm
T
Trach 4X4 sponges for dressing changes

20. T
Trachcare to be entered in powerchartby nurse
T
Q 8 hours ( 0600-1400-2200) & PRN
T
Suction ptprior to trachcare
T
Assess skin around trachfor redness, drainage, secr etions,
bleeding, maceration or excoriation and skin breakd own
caused by flange pressure
T
Clean around stoma & flange with Q -tips/ 2X2 moistened
with NS T
dry stoma area if needed and apply 4X4 gauze
T
With newly established trach-are sutures still in pl ace? Can
they be removed? T
trachties secure?? Should be able to fit one finger under the
tie
TrachCare Guidelines

21. Changing/Cleaning Inner Cannula T
NYGH uses Shileytrachtubes with disposable inner cannulas
T
If a ptdoes have a trachfrom home or other institution, it is crucial
to know if the inner cannula is disposable or reusable T
Non-disposable
inner cannulas are cleaned with Normal Saline
diluted hydrogen peroxide, rinsed off with N/S remove excess
fluid before re-inserting
T
Disposable
inner cannulas are replaced with trachcare Q8 hours
& PRN( come in a box of 10)
Trachties-are changed only when wet or soiled and 2 people should
assist with this procedure---
Leave one finger between ties and
neck--
Velcro hooks attach easily to tracheostomy tube flange

22. Decision to Suction
Frequency of suction will vary and must be
individually assessed & not done on a schedule
Factors to Consider: T
Is the ptable to cough &/or clear secretions?
T
Increased work to breath?
T
Changes to respiratory rate
T
Amount and consistency of secretions
T
Decreased O2 saturation
T
Secretions are audible
T
Ptrequest
T
Other Respiratory S & S (i.e. SOB, cyanosis, restle ss,
anxiety)

23. Complications with Suctioning I
Hypoxemia—dysrhythmia
I
Atelectasis or lung collapse
I
Mucosal trauma/damage---bleeding
I
Bronchospasm
I
Dysrhythmias
I
Nosocomial pulmonary tract infection
I
Sepsis
I
Cardiac arrest

24. Procedure Considerations T
Suctioning removes secretions,
& also O2
T
Suction pressure
too high
(>120mmHg) can cause
mucosa damage & bleeding
T
Suction pressure
too low
may not clear secretions & be
ineffective
T
Suction mouth with a (yankauer)
not
the same suction
catheter as trachea to avoid cross contamination
T
Do not
apply suction while inserting the catheter
T
May be necessary to pre-oxygenate the patient prior to
and after suctioning T
Use personal protective equipment (i.e. goggles, ma sk,
face shield)

25. Suctioning
Insert catheter until you meet resistance &/or pt coughs forcibly then pull back slightly &
start suctioning
Carina

26. Suctioning
I
Test suction pressure before instilling catheter 60-120 mm H g
I
Suction catheter: £½ diameter of tube
I
Prepare clean cup with NS to lubricate and clear secretions fr om
suction catheter I
Dominant hand remains sterile with clean glove, and will be
inserting the catheter, while the non-dominant gloved hand gr asps
the suction port
I
Apply suction only on removal of catheter no during insertion
I
Suction efficiently and quickly depending on secretion amount,
consistency I
Do not exceed 3 attempts and allow 20 to 30 seconds between
each, oxygenate ptbetween PRN

27. Inducing Cough T
If you suction and don’t obtain secretions you can instill
normal saline (sterile ampule) to loosen secretions
( induce cough reflex) for suctioning
Note: this should not be done as a routine (may flush particles into resp system, increase infection, asp iration pneumonia) T
Secretions may build up within the inner cannula, a nd
narrow the passage----pull out cannula and observe if
copious secretions discard (if disposable) and pla ce new
one (if not disposable) clean and reapply

28. Additional Nursing Considerations
I
Good mouth care
I
Brush teeth
I
Yankeursuction
I
Prevent pneumonia
Communication
I
Alteration in
communication
I
Lip reading
I
Communication
board I
Corking for
speech
Hygiene

29. Dysphagia
I
May not be able to eat
orally
I
May have difficulty
swallowing, require puree
or thickened fluids
I
May have N/G or G-
tube
I
Risk for aspiration
I
Risk of
pneumonia/respiratory
infections increased
I
Humidity applications
I
Clean equipment
I
Change suction
catheters/tubes I
Clean trach
I
Hand washing
I
Cough etiquette
Infection Control

30. Documentation/Communication T
A good report must be presented at change of shifts and prior to breaks
T
Documentation should include:
T
A thorough resp. assessment minimally Q4 hrsregardless of shift,
including:
T
trach care
T
changing of inner cannula
T
how pt is tolerating interventions
T
suctioning frequency
T
Detailed assessment of secretions, consistency, amount, colour
T
Pts LOC
T
Other systems potentially compromised: mobility, sk in integrity, nutrition
(N/G feed), communication

33. Scenario I I
Ptincreasingly SOB, respirations 28, lips cyanotic,
ptrestless, unable to lie flat, O2 sat 89%, Trach
type Fenestrated #6
I
What do you do?

34. Interventions I
Reassure patient
I
suction pt quickly and efficiently monitor O2 Sat co ntinuously– if no
improvement
I
apply N/S 1cc & suction again
I
Evaluate, anxiety,O2 Sat, colour of skin
I
If pt has a Fenestrated trach tube
I
keep a non fenestrated inner cannula of the same si ze close at hand
I
Remove fenestrated inner cannula, Replace with non- fenestrated one and
bag pt with 100% O2
I
Call RT stat

35. Scenario II I
Ptis coughing vigorously and the trachde-
cannulatesand flies across the room……….
I
what do you do?

36. Intervention I
Do not panic this will also help keep the pt calm
I
do not leave the pt, call your colleagues, Call RT stat
I
Assess your pt, are they in immediate distress?
I
Do not attempt to re-site or change the tube withou t previous experience
I
Cover the stoma with an occlusive drsg
I
provide O2 by face mask
I
Place O2 sat for continuous monitoring, keep assessing your pt
I
Access the new Trach of the same size, provide to RT
I
Assisted ventilation may be required with chin/lift jaw thr ust until help arrives
I
Have the Crash Cart outside the room
I
if pt desaturates or starts going into distress ventilate wit h ambubag over
mouth as any other pt---call code if necessary

37. References N
Nance-Floyd, B. Tracheostomy care:An evidence-based guide to suctioning
and dressing changes. American Nurse Today. 2011;6 (7):14-16.
N
Higgens, D. (2009). Basic nursing principles of car ing for patients with a
trachestomy, Nursing Times. 105 (3), 14-15
N
Reference Perry & Potter (2006), Clinical Nursing S kills & Techniques 6th
Edition, Elsevier Mosby, Missouri, USA.
N
Tyco-Healthcare (2004) Tracheostomy Tube: Adult Hom e Care Guide
(Shiley tracheostomy tubes)
N
SIMS Portex Inc. (1998). Tracheostomy Care Handbook: Guide for the
health care provider
N
These guidelines were developed based on current research & ar e subject to updates &
change

38. THANK YOU
QUESTIONS??