This document provides information on tracheostomy care, including:
- Definitions of tracheotomy and tracheostomy and types including temporary, permanent, and emergency procedures.
- Indications for tracheostomy such as airway obstruction, protection of the tracheobronchial tree, and prolonged ventilation.
- Details of the procedure, tubes, nursing care, suctioning, humidification, complications, and decannulation.
- Key aspects of nursing care including assessment, equipment, tube changes, cuff pressure maintenance, education, and discharge instructions.
2. Definition
Tracheotomy
Making a surgical opening in the trachea
Tracheostomy
Creation of a stoma at the skin surface
which lead in to the trachea
5. Temporary: THE UPPER AIRWAY WILL REMAIN
PATENT IF THE TRACH TUBE WERE TO BE
DISLODGED
Permanent: THE LARYNX IS REMOVED AND AN
ARTIFICAL TRACHEOSTOMY IS CREATED – NO
CONNECTION BETWEEN THE PATIENT’S UPPER
AIRWAY AND THE TRACHEA ITSELF!
Temporary Tracheostomy versus
Permanent Laryngectomy
25. Must conduct a thorough assessment of patient at the start
of visit
Observe for signs of hypoxia, infection, excessive
secretions, pain, etc.
Examine trach tube, any attached tubing and
equipment, as well as stoma site
Auscultate breath sounds
Ensure that appropriate emergency trachy
supplies and CPR equipment is at bedside
Be aware of when and why the trachy was
inserted , how it was performed, the type and size
of tube inserted
Nursing Care
27. Equipments
Portable or wall suction with tubing and
reservoir.
Sterile suctioning kit containing:
Appropriate-sized suction catheter
Pair of gloves
Container of saline to flush and lubricate
the suction catheter
Drape
Pulse oximeter
Ambu (10-15 liters)
Tracheal dilator
28. Post operative management
A trained nurse should be in attendance
Patient should be close to nurses station
Writing materiel and a bell should be with
the patient
Tube should be stitched to skin
Tapes should be tied with a reef knot on
both sides of neck when the head in the
neutral position
29. Tracheostomy tray should be with the
patient
Keep the cuff inflated for 12 hours while
deflating the cuff for 5 min every hour
Then deflate the cuff if no risk of aspiration
or if not ventilating
Humidification of air
Breathing exercises
30. Removal of secretions
Every half hour or more in first 48 hrs
Then at least 4 hrly/ as required
Should be done in sterile conditions
Can use normal saline up to 5ml/ sodium
bicarbanate for crust removal
Should not suck more than 10 sec
continuously
31. 1.Wash hands to prevent transmission of
micro-organisms/cross contamination.
2. Explain procedure to patient to reduce
anxiety & encourage cooperation.
32. 4. Turn on suction (adults: 100-120mm Hg).
Secure connecting tube to suction source.
(Excessive negative pressure traumatizes
mucosa & can induce hypoxia.)
5. Open and prepare suction catheter kit.
6. Preoxygenate patient with 100% oxygen to
prevent hypoxemia. Hyperinflate with ambu to
decrease atelectasis .
33. 7.Pick up catheter with dominant hand and the
connecting tube with non-dominant hand.
8. Attach catheter to tubing using sterile technique.
9. Place catheter end into saline. Test equipment
by applying thumb from non-dominant hand
over open port to create suction.
10. Insert catheter into tracheostomy tube without
applying suction, using sterile technique.
11. Advance catheter for premeasured length /until you feel
resistance.
Retract catheter 1cm before applying suction.
34. 12. Apply intermittent suction while withdrawing
the catheter. Limit suctioning time to 10
seconds to prevent hypoxemia.
13. Hyperoxygenate and hyperinflate if needed.
14. Rinse catheter with saline to clear secretions.
15. Repeat Steps 10-14 until airway is clear.
16. Discontinue if HR drops by 20; increases by
40, produces arrhythmias, or decreases 02 <
90%
35. Divide the internal diameter of the
tracheostomy by two, and multiply the
answer by three to obtain the French
gauge suction catheter:
Size 8 tracheostomy tube (patient);
(8mm/2) x 3 = 12; therefore, a size 12F
gauge catheter is suitable for suctioning
Selecting a suction catheter
36.
37. To lower the risk of accidental
decannulation (the trach tube coming out)
the tie changes should be performed by
two people or with new ties secured
BEFORE old ties are removed.
Tracheostomy Ties
38. The majority of trach tubes have inner
cannulas that require cleaning one to
three times daily unless they are
disposable
Use sterile technique to clean the
reusable cannula with ½ strength hydrogen
peroxide and normal saline or just NS
Reinsert and lock back into place within a
15 minute time frame
Maintenance of the inner
cannula
39. Cuff pressure (balloon) should be maintained
between 10 to 20 mmHg of pressure via a
manometer – should be assessed daily;
if you don’t have a manometer measuring device –
check with the patient/family – to evaluate how
many cc’s of cuff pressure they have been utilizing
(generally 5-8 cc) depending on trach size
With a stethoscope placed on the neck, inflate the
cuff until you no longer hear hissing; deflate the cuff
in tiny increments until a slight his returns….
Nursing Care – Trach cuff pressure
40. When a patient has had a tracheostomy for
several months, the stoma is well formed
and tube changes can be done safely on a
monthly basis using a clean technique; the
initial tube change is usually performed by
the surgeon
Smaller size tracheostomy tubes, tracheal
dilator, oxygen, suction
How to rail - road in difficult intubation
Nursing Care: Changing the Trach
tube
41. How to discharge a patient with
tracheostomy
Patient and family education normally starts in
hospital setting
Patient should be thorough in tube
change, a relative also should be taught.
Additional tubes, ribbons, gauze should be
provided
When to come to the hospital immediately –
block tube, broken tube, bleeding from the
stoma, difficult intubation.
Not to be without the tube for more than 2
days, the stoma closes rapidly.
42. Wearing a scarf over trach opening to keep dry and
clean
Trach patient’s avoid:
Deep bathing water
Fine particles such as powders, chalk, sand, dust,
mold and smoke
Loose fibers and fair found on fuzzy toys and pets
Persons with contagious illnesses
Cold air and wind
Portable suction equipment is available for travel and
should be tested PRIOR to use
GREAT RESOURCE TEACHING SITE:
http://www.tracheostomy.com
Patient Instructions
43. Removal of tube
If no longer indication exist can consider
tube removal
Should be done in a step wise fashion
Uncuffed fenestrated small size tube
should be inserted
Close the tube during day time
Tube close during day and night time
(24Hrs)
If patient tolerate can decannulate
Please note: When a trach is inserted, the natural warming, humidification and filtering of inhaled air (from nares / mouth) is lost. Therefor it is essential to provide an alternate form of humidification. Many forms exist – see next slide…
Various ties are available on the market today such as velcro tape and twill tape. Maintain two finger breaths between patient neck and ties for ease and comfort….
Important: make sure your patient HAS NOT eaten or receiving tube feeding for at least ONE hour prior to trach tube change! For cuffed tubes, test the cuff by inflating and deflating before inserting it! Always use the trach obturator for a smooth guide to insertion!