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.

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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.