tracheostomy and its post op care last
TRANSCRIPT
Tracheostomy and its post operative care23 feb 2011
Tracheostomy
An artificial airway just below the larynx in the trachea, bypassing the mouth and upper airway
orA tracheostomy is the formation of an
opening( stoma) into the trachea usually between the second and third rings of cartilage.
Stoma
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)
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)
ANATOMY
Anatomy
Anatomy
Skin sc tissuesplatysmaanterior jugular veins deep cervical fasciastrap muscles Within the visceral compartment lies isthmus
Tracheotomy procedure
Neck skin over 2nd tracheal ring identified.vertical incision about 2–3 cm(skin)Sharp dissection to cut the platysma
muscleBlunt dissection parallel to the long axis of
the trachea used to spread the submuscular tissues until thyroid isthmus is identified
tracheotomy
If the gland lies superior to the 3rd tracheal ring, bluntly undermine and retract superiorly to gain access to the trachea
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.
thyroid isthmus is mobilized with a hemostat
small incision to allow access
3rd option:complete transection of isthmus
Tracheal entry.
1) 2nd tracheal ring divided laterally, anterior portion removed.lateral sutures for
countertraction.
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.
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
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.
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 mechanismsplinting of larynx-normal upward movement prevented
Loss of normal cough reflex and positive intralaryngeal pressure.
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.
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.
The outer cannula keeps the airway openThe 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.
Universal tracheostomy tube
Dual-Cannula Tracheostomy TubesAn example of an inner cannula in which the 15-mm ventilatorattachment is connected to the inner cannula. If the inner
cannula is removed, it is not possible to attach the ventilator.
Obturator:The obturator is only used when putting
the outer cannula into the stoma.
2)Single Canula tube
Slightly longer than the universal tube.Long or thick necks.Requires additional humidification to
prevent the accumulation of secretions
Single Canula tube
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
Fenestrated tube
Airflow occurs throughmouth and nose.
Tracheostomy Button
Tracheostomy Button
Short straight tube fitting into tracheostomy stoma after trac tube removal.
Doesnot enter the tracheal lumenIndications: 1) weaning because it creates
less airway resistance 2) obstructive sleep apnoea
Cuffed tube
On inflation seals the airway and prevents the aspiration of oral or gastric secretionsAdvantages:1)Allow for airway clearance, 2) offer some protection from aspiration,3) positive-pressure ventilation
Cuffed tracheostomy tube
cuffed
Cuff pressure
Tracheal capillary perfusion pressure is normally 25–35 mm Hg.
High tracheal-wall pressurestracheal 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.
Cuff over inflation demonstrated on model.
Cuffless tubesUsually double lumen tubesUsed for long term management of
patientsEffective cough and gag reflexes to
prevent themselves from aspiration
Cuffless tubes
Metallic tube
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.
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.
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.
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.
size Inner diameter with inner tube(mm)
Inner diamter without inner tube(mm)
Outer diameter(mm)
4 5 6.7 9.46 6.4 8.1 8.18 7.6 9.1 12.210 8.9 10.7 13.8
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.
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
1. Wash your hands.
2. Remove the inner cannula.
3. Place the inner cannula in bowl and cover with hydrogen peroxide. Let it soak in the peroxide solution for at least one minute.
4. Pick the inner cannula up and clean the inside and outside with pipe cleaners or cotton-tipped swabs.
5. After you scrub off all the sputum, hold the inner cannula under running tap water
briefly.
6. Shake the excess water off the inner cannula.
7.Dry the inner cannula using a sterile gauze sponge
8. Reinsert the inner cannula into tracheostomy and lock in place.
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
Steps in cleaning the stoma
1. Wash hands.
2. Clean around stoma with soapy washcloth, then rinse.
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.
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 stomano 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.
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.
Fold gauze corners up.
Slide folded gauze under tracheostomy strings.
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
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
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.
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.
7. Tie the neck ties to one side in a square knot.
8. Replace inner cannula and lock in place.
9. Wash your hands.
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
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
1. Cut two strips of twill tape about 8 inches long.
2. Cut a small slit at one end of each strip.
3. Cut and remove the old ties while your friend holds the tracheostomy in place.
4. Pull the slit end of each tie through the opening in the neck plate. Then, thread the unslit end through the slit.
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.
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.
humidifier
humidifier
humidification
Instilling Saline SolutionSupplies 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.
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
Suction machine
Suction machine
supplies
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)
Attach connecting tubing and suction catheter to suction machine.
`
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
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
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.
Place the catheter in the water and suction to rinse tubing.
DECANNULATIONTracheostomy Decannulation is the
process of the removal of the tracheostomy tube from the stoma or opening in the trachea
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
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
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.
PMV
OCCUSIVE CAP
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.
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
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.