tracheostomy care in hospitalized patient

About tracheostomy care

1. TRACHEOSTOMY CARE Naing Aung Linn

2. Topic Outlines Tracheostomy Functions Indications Postoperative Care Of Tracheostomy Changing Tracheostomy Tubes Decannulation July 2023 2

3. TRACHEOSTOMY Tracheostomy is making an opening in the anterior wall of trachea and converting it into a stoma on the skin surface . July 2023 3

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5. FUNCTIONS OF TRACHEOSTOMY Alternative pathway for breathing. This circumvents any obstruction in the upper airway from lips to the tracheostome . Improves alveolar ventilation . In cases of respiratory insufficiency , alveolar ventilation is improved by: (a) Decreasing the dead space by 30–50% (normal dead space is 150 mL). (b) Reducing the resistance to airflow. Protects the airways. By using cuffed tube, tracheobronchial tree is protected against aspiration of: Pharyngeal secretions and Blood. July 2023 5

6. 4. Permits removal of tracheobronchial secretions. When patient is unable to cough as in coma, head injuries, respiratory paralysis; or when cough is painful, as in chest injuries or upper abdominal operations, the tracheobronchial airway can be kept clean of secretions by repeated suction through the tracheostomy. Intermittent positive pressure respiration ( IPPR ). If IPPR is required beyond 72 h, tracheostomy is superior to intubation. To administer anaesthesia . In cases where endotracheal intubation is difficult or impossible as in laryngopharyngeal growths or trismus . July 2023 6

7. INDICATIONS OF TRACHEOSTOMY There are three main indications. 1. Respiratory obstruction . Retained secretions . Respiratory insufficiency . July 2023 7

8. 1. Respiratory Obstruction Infections Trauma Neoplasms Foreign body larynx Oedema larynx due to steam, irritant fumes or gases, allergy ( angioneurotic or drug sensitivity), radiation Bilateral abductor paralysis (g) Congenital anomalies – Laryngeal web, cysts, tracheo-oesophageal fistula – Bilateral choanal atresia July 2023 8

9. 2. Retained Secretions (a) Inability to cough Coma of any cause, e.g. head injuries, cerebrovascular accidents, narcotic overdose Paralysis of respiratory muscles, e.g. spinal injuries, polio , Guillain – Barre syndrome, myasthenia gravis Spasm of respiratory muscles, tetanus, eclampsia , strychnine poisoning (b) Painful cough (c) Aspiration of pharyngeal secretions July 2023 9

10. 3. Respiratory Insufficiency Chronic lung conditions, viz. emphysema, chronic bronchitis, bronchiectasis , atelectasis. July 2023 10

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12. POSTOPERATIVE CARE OF TRACHEOSTOMY Constant supervision. Suction. Prevention of crusting and tracheitis . Care of tracheostomy tube. Skin care July 2023 12

13. 1. Constant Supervision After tracheostomy, constant supervision of the patient for bleeding, displacement or blocking of tube and removal of secretions is essential. A nurse or patient’s relative should be in attendance . Patient is given a bell or a paper pad and a pencil to communicate . July 2023 13

14. 2. Suction Depending on the amount of secretion , suction may be required every half an hour or so; use sterile catheters with a Y-connector to break suction force. Suction injuries to tracheal mucosa should be avoided. This is done by applying suction to the catheter only when withdrawing it. Use the lowest pressure needed ,usually less than 120 mmHg and definitely not beyond 200mmHg. Suctioning should be performed less than 10 seconds . July 2023 14

15. 3. Prevention Of Crusting And Tracheitis This is achieved by Proper humidification , by use of humidifier, steam tent , ultrasonic nebulizer or keeping a boiling kettle in the room . If crusting occurs, a few drops of normal or hypotonic saline are instilled into the trachea every 2–3 h to loosen crusts. A mucolytic agent such as acetylcysteine solution can be instilled to liquify tenacious secretions or to loosen the crusts. July 2023 15

16. 4. Care Of Tracheostomy Tube Inner cannula should be removed and cleaned as and when indicated for the first 3 days. Outer tube , unless blocked or displaced, should not be removed for 3–4 days to allow a track to be formed when tube placement will become easy. If cuffed tube is used, it should be periodically deflated to prevent pressure necrosis or dilatation of trachea . Tracheal mucosa capillary perfusion pressure is approximately 25 to 30 mmHg. ( high-volume/low-pressure cuffs ) July 2023 16

17. 5. Skin care The wound heals by secondary intention and eventually the tract becomes lined with squamous epithelium and organized scar tissue. The tape used to secure the tube in place can lead to ulceration of the neck skin if they are left too tight or for too long. It is important that the patient’s head is flexed when the tapes are tied. Usually a dry gauze or form dressing is inserted between the peritracheostomy skin and the flange of the tube. July 2023 17

18. A trolley must be placed by the bed containing a tracheal dilator, duplicate tubes and introducers, retractors and dressings, oxygen and suction machine with a catheter attached. July 2023 18

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21. Changing Tracheostomy Tubes H azardous , failing to change one when required also carries risks. Guidance from Intensive Care Society points out that recommendation regarding the timing of tube changes – inconsistent and not evidence based . T racheostomies without inner tubes be changed every 7-14 days , with frequency decreasing as the stoma becomes better formed and pulmonary secretion decrease. Tracheostomies with inner tubes may be left in place for up to 30 days The first change should not occur within 72 hours of the tracheostomy being sited. July 2023 21

22. Decannulation Tracheostomy tube should not be kept longer than necessary (If the patient possesses an adequate level of alertness to protect the airway and does not require intubation for any additional procedures) Prolonged use of tube leads to tracheobronchial infections, tracheal ulceration, granulations, stenosis and unsightly scars. Fiberoptic endoscopy is helpful. To decannulate a patient, tracheostomy tube is plugged and the patient is closely observed. If the patient can tolerate it for 24 hours , tube can be safely removed . July 2023 22

23. Decannulation Technique Day Procedure 1 Admission, downsized/ deflated. 2 Block for 12 hours from 8am, if successful continue overnight for a further 12 hours 3 Decannulate , occlude stoma with adhesive tape and dressing. Observe on the ward . 4 Observe off the ward. 5 Discharge. July 2023 23

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