Nursing of tracheostomized patient

1. Nursing of tracheostomized
patient

2. Outline
• Suctioning
• Dressing
• Change of trachy tube
• Decannulation
• Emergency in trachy tube

3. Suctioning

5. • Suctioning policy applies to all patients undergoing laryngectomy and
tracheostomy.
• All additional care will be directed by the otolaryngologist who
performed the original laryngectomy and/or tracheostomy or by the
surgeon’s designee.
• Protocol guideline
• First 24 hours postsurgery: Patients who received laryngectomy and/or
tracheostomy will be suctioned every 2 hours (and as needed) with 3
to 5 cc normal saline with a sterile bullet.
• 24 to 48 Hours postsurgery: Patients will be suctioned every 4 hours
(and as needed) unless otherwise directed by an otolaryngologist.
• More than 48 hours postsurgery: Patients will still require suction every
2 hours, every 4 hours, and/or as needed as directed by the
otolaryngologist or secretion production.

6. Catheter size
• Tracheostomy size (inner diameter) ÷ 2 x 3 = FG of suction catheter
• Change in negative pressure in the lungs
can be related to the ratio of diameter of
the suction catheter to the inside
diameter of tube.
• to reduce the risk of total occlusion of
tracheostomy tube during suctioning.
• A large catheter will occlude the
tracheostomy tube which may cause
hypoxia

7. Catheter Type
• Closed suction catheter for patient on ventilator
• Multiple eyed catheter

8. • Suctioning pressure
• Adult: 100mmHg-120mmHg
• Paeds:80-100 mmHg
• Neonates: 60-80 mmHg
• Duration
• Should not exceed more than 15 seconds
• With or without normal saline?
• Depends on the situation
• How deep suctioning should be done?

9. • Cuff pressure
• Check the cuff pressure using a hand pressure gauge every shift or a
minimum of eight-hourly.
• Maintain the cuff pressure between 15-25 cm H2O, unless medically
indicated.
• Deflate cuff if patient not ventilated
• Over inflation of the cuff can cause trauma to the tracheal mucosa.
• Under inflation of the cuff fails to make an adequate seal and the
patient is at risk of aspiration.

10. Dual cannula tracheostomy tube
• Should be inspected at least once
every six hours
• Inspection should include if there is
any crack, blockage or any defect that
may go unnoticed
• Avoid rinse under tap water

11. Dressing

12. • Frequency
• Daily
• Whenever soiled
• Depend on type of dressing used
• Always inspect for:
- excessive leakage of secretion
- foul smell
- erythema around the stoma site
- erosion of stoma site
- Bleeding from stoma

14. Change of tracheostomy tube
• Indications
• Tube malfunctions
• Duration:
• Single lumen tube -> 2 weeks, up to one months
• Double lumen tube -> 6 months up to one year
• Change to different size or different type

15. What to prepare?
• Trachy tube
• Oximeter
• Tracheal dilator
• Headlight/torchlight
• Lubricant
• Dressing set
• Ryle’s tube

16. Procedure
• Prepare all required equipment at the bed side
• Oyxgenated patient adequately prior procedure
• Make sure neck slightly extended
• Perform suctioning
• Insert ryles tube as a guide wire
• Removed old tracheostomy tube while maintaining ryles tube in
stoma
• Insert new tracheostomy tube,remove ryles tube once tracheostomy
tube in situ
• Tie tracheostomy tube using Velcro tie or ribbon tie

17. Things to watchout!
• Avoid blindly inserting trachy tube
• Avoid hyper extending the neck
• Avoid force manipulation of trachy tube
• Make sure patient SPO2 sustained during the procedure
• Make sure tracheostomy tie not too loose or not too tight
• Always ensure sterility

18. Decanulation
• When to decannulate
• Reversal of the medical condition that originally necessitate intubations
• Adequate ventilatory reserve
• Patent upper airway
• Adequate nutritional state
• Ability to cough and clear airway secretions
• Absence of respiratory infection
• Presence of psychosocial support

19. • Spigot tracheostomy tube for one night
• Monitor SPo2 overnight, make sure sustained above normal level
• Make sure no stridor

22. • Cover stoma with gauze
• Avoid water into stoma
• Make sure stoma is dry and clean

23. Emergency in tracheostomized patient
Tube dislodgement
• Tube dislodgement is displacement of tracheostomy tube by
unintentional and unplanned tube removal.
• The displacement or dislodgement can be a partial or complete tube
come out of the stoma or out of the trachea into the soft tissue of the
neck

26. • Signs of tube dislodgement
• No airflow from tracheostomy tube
• Awkward tube placement
• Increase in respiratory rate
• Drop in SPO2

27. What to do
• Check whether patient is breathing or not
• Ensure cuffed is deflated

28. Yes, patient is breathing
• Continuous monitoring
• Supplement oxygen via face mask
• Do not ventilate patient via trachy tube unless placement of tube is
confirm
• Inform doctor, prepare new tracheostomy tube or oral intubation

29. No, patient is not breathing
• Continuous monitoring
• Bag and mask the patient
• Standby tracheal dilator
• Inform doctor, prepare new tracheostomy tube or oral intubation

30. Emergency in tracheostomized patient
Tube blockage
• Could be partial or complete blockage
• Most common symptoms of blockage:
• Presence of upper airway noise
• Increase in respiratory rate
• Drop in SPO2
• Difficulties in passing suction catheter
• None or minimum air flow felt

31. What to do
Reposition patient neck
Ask patient to cough
Rinse inner canula(doule lumen)
Symptoms persist End
no
Introduce suction catheter
yes
No resistance experience
• Monitor patient
• Find other cause of
symptoms
Resistance experienced
• Prop up patient
• Deflate cuff
• Monitor patient
• Supplement oxygen
• Inform doctor for trachy tube
change or oral intubation
presence of breathing
• Place patient in supine
position
• Deflate cuff
• Bag and mask patient
• Inform doctor for trachy
tube change or oral
intubation
Absence of breathing