This document provides information on percutaneous tracheostomy including its history, indications, complications, procedures, and care. It details techniques such as tracheostomy tube insertion and changing, cuff management, suctioning, and stoma site care. Percutaneous tracheostomy is described as a simpler alternative to surgical tracheostomy with benefits such as being performed at the bedside in the ICU.
A basic overview on the management of intra-operative bronchospasm: the risk factors, triggers, diagnosis, prevention and management. Includes a case scenario – discussion.
mapleson circuits used in anesthesia practice, are in their way out but it is as important to know the mechanism with which the gases flow to and fro through them.
A basic overview on the management of intra-operative bronchospasm: the risk factors, triggers, diagnosis, prevention and management. Includes a case scenario – discussion.
mapleson circuits used in anesthesia practice, are in their way out but it is as important to know the mechanism with which the gases flow to and fro through them.
detailed information about tracheostomy for the medical students , includes difinition, causes, indications, care provided, management, medical and nursing management of opening , complete care of the patient , patient teaching, family teaching and contained other detailled explanation of tracheostomy
An educational material describing the Indications for Tracheostomy-Complications of Tracheostomy-Timing of Tracheostomy-Tracheostomy Technique-Tracheostomy Decannulation and types of Tracheostomy Tubes.
An educational material describing the Indications for Tracheostomy-Complications of Tracheostomy-Timing of Tracheostomy-Tracheostomy Technique-Tracheostomy Decannulation and types of Tracheostomy Tubes. Quite useful for general surgery residents and medical students and also general physicians.
An educational material describing the Indications for Tracheostomy-Complications of Tracheostomy-Timing of Tracheostomy-Tracheostomy Technique-Tracheostomy Decannulation and types of Tracheostomy Tubes
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How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
Telehealth psychology is a digital approach that offers psychological services and mental health care to clients remotely, using technologies like video conferencing, phone calls, text messaging, and mobile apps for communication.
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
1. Dr Nor Hidayah Zainool Abidin
Supervisor: Dr Noryani
Percutaneous Tracheostomy
11/3/2015prepared by Anor Hidayah
2. OUTLINES
• History of Tracheostomy
• Definitions
• Indications
• Complications
• Tracheostomy Tubes & Components
• procedure
• Inner Cannula & Stoma Site Care
• Flange and Stay Suture Care
• Suctioning
• Cuffed Tracheostomy Care
• Changing a Tracheostomy Tube
• Tracheostomy weaning and removal
11/3/2015prepared by Anor Hidayah
3. History of tracheostomy
• Tracheotomy was first depicted
on Egyptian artifacts in 3600 BC
• It was described in the Rigveda,
a Sanskrit text, circa 2000 BC
11/3/2015prepared by Anor Hidayah
4. Ibnu Sina (980-1037)
• Described tracheal intubation in The Canon of
Medicine in order to facilitate breathing.
Ibn Zuhr (1091–1161) in the 12th century
• The first correct description of the tracheotomy
operation for treatment of asphyxiation
11/3/2015prepared by Anor Hidayah
5. • Tracheotomies were used in the early 1800's for
airway inflammation in children due to Diphtheria.
The first documented successful tracheotomy
performed on a child was reported in 1808.
11/3/2015prepared by Anor Hidayah
6. • In 1965, McDonald and Stocks describe the use of
intubation and respiratory support in neonate.
• Many more children surviving with tracheostomies
due to subglottic stenosis
11/3/2015prepared by Anor Hidayah
7. • The percutaneous dilatational tracheostomy (PDT)
introduced by Ciaglia et al. in 1985, which involves
progressive dilatation with blunt-tipped dilators, is
the most frequently used and evaluated in the
literature.
• In 1989, Schachner et al. introduced a rapid PT
technique, Rapitrac, which did not get
considerable acceptance because of
complications associated with, and reservations
towards, the sharp edges of the dilating forceps.
11/3/2015prepared by Anor Hidayah
8. Basic tracheal anatomy
• Trachea lies midline of the
neck
• Extending from cricoid
cartilage (C6) superiorly
• To the tracheal bifurcation
(level of sternal angle T5)
• Comprises of 16 – 20 C
shaped cartilage ring
• Length about 10 -12cm
11/3/2015prepared by Anor Hidayah
9. Definitions
Word tracheostomy is derived from two words meaning “I cut trachea” in Greek
Tracheotomy
• Incision made below the cricoid cartilage through the
2nd – 4th tracheal ring
Tracheostomy
•The opening or stoma made by this incision.
Tracheostomy Tube
• Artificial airway inserted into the trachea during
tracheotomy.
11/3/2015prepared by Anor Hidayah
11. Indications of Tracheostomy
• Acute upper airway obstruction
• Chronic upper airway obstruction
• Injury or post head and neck surgery To obtain and
maintain a patent airway when compromised
• To facilitate weaning from mechanical ventilation
• To prevent and /or treat retained tracheobronchial
secretions
• To reduce the risk of pulmonary aspiration
11/3/2015prepared by Anor Hidayah
12. Timing of Tracheostomy
<3weeks
Early
> 3 weeks
Late
• Early tracheostomy was associated :
o Similar survival at one month
o Improve short term clinical outcome
o early tracheostomy did not change any outcomes at one year
11/3/2015prepared by Anor Hidayah
13. Adverse events occurred in 39%
hypoxemia
stoma
inflammation
stoma
infection
bleeding
•A higher likelihood of weaning from the ventilator77 vs 68 %
• A higher likelihood of being discharged from the ICU within 28
days48 vs 39%
• A trend towards a lower rate of pneumonia14 vs 21%
Multicenter trial (419 patients) that randomly early (mean 7 days) VS late
tracheostomy (mean 14 days)
11/3/2015prepared by Anor Hidayah
15. Decision for tracheostomy
• Mechanical ventilation anticipated to last between 10 and 21 days
• After an initial period of stabilization on the ventilator (generally,
within 3–7 days)
• Daily assessment for ventilatory weaning
o need for continued intubation
o readiness to wean
o When apparent that the patient will require prolonged ventilator
assistance
• Individualized according to the clinical circumstances and the patient's
preference
• The decision left to the attending Specialist/Intensivist
11/3/2015prepared by Anor Hidayah
16. Advantages of tracheostomy
1. Reduced laryngeal damage
Reduced laryngeal stenosis
Less voice damage
2. Better secretion removal with suctioning
3. Lower incidence of tube obstruction
4. Less oral injury (tongue, teeth, palate)
5. Improved patient comfort
Less sedation/analgesia required
6. Better oral hygiene
7. Enhance nursing care
11/3/2015prepared by Anor Hidayah
18. 1. Improved ability to communicate lip reading
2. Preservation of glottic competence
1. Less aspiration risk
3. Better preserved swallowing, earlier oral feeding
4. Lower resistance to gas flow
5. Less tube dead space better weaning from
mechanical ventilation
6. Ease of reinsertion if displaced
7. Allows less skilled care
Advantages of tracheostomy
11/3/2015prepared by Anor Hidayah
19. Disadvantages of Tracheostomy
• Tracheal complications
• Aggressive procedure
• Risk of stomal infection
• Esthetic sequelae
• Bleeding
• Psychological trauma
• Organizational difficulties
• Increased risk in ward
11/3/2015prepared by Anor Hidayah
20. Nosocomial pneumonia
• A retrospective study of 137 patients who underwent
tracheostomy
• significant bacterial colonization
(>100,000 cfu/mL)
• fever on the day of tracheostomy
• the need for sedation beyond 24
hours after tracheostomy
There was a 26% incidence of pneumonia in the study population, occurring
at a mean of 9 days after the tracheostomy.
Nosocomial pneumonia
11/3/2015prepared by Anor Hidayah
21. Study reports – Nosocomial
infection
Lower
rate
six-fold
increase
Prospective cohort study of over
800 mechanically ventilated
Case-control study of 354 patients
who were mechanically
ventilated for more than seven
days
The timing of tracheostomy (early versus late) does not appear
to impact the rate of nosocomial pneumonia following
tracheostomy 11/3/2015prepared by Anor Hidayah
23. Advantages of Percutaneous
Dilatation Technique
• Simple technique
• Can be done at the bedside in ICU
• Reduces the risks associated with the possible need to
transfer a critically ill patient out of the ICU
• Does not require operating theatre less expensive in
terms of human and material resources
• Possibly less waiting time for patient
• Early tracheostomy
• Associated with less peristomal bleeding
11/3/2015prepared by Anor Hidayah
24. Contraindications
• Age < 15 yrs
• Gross distortion of the neck due to haematoma, tumor,
thyromegaly or scarring from previous neck surgery
• Un-correctable bleeding diathesis
• Obese, short or bull neck that obscures the anatomical
landmarks in the neck
• Inability to extend the neck because of cervical fusion,
rheumatoid arthritis, or other cervical spine instability
11/3/2015prepared by Anor Hidayah
25. Percutaneous Insertion
• Procedure to be done in ICU
Landmark
Needle
injection
Guidewire
insertion
Introducer Dilatation
Trachy tube
insertion
11/3/2015prepared by Anor Hidayah
26. Patient preparation
• Take GSH, Latest FBC, BUSE and Coagulation profile
• Withhold anticoagulants
• Draw bedside curtains
• The procedure is explained in full to the patient and/or
significant others.
• Consent obtained. Record in the medical notes.
• Fast patient for 6 hours
• Discontinue deeding 6 hours prior to the procedure
• Aspirate the nasogastric tube again immediately prior to the
procedure.
• Prepare all required equipment
• Proper position the patient supine
• Ensure the head of the bed area is free from obstruction
11/3/2015prepared by Anor Hidayah
27. Patient preparation
• To facilitate the procedure the patient is administered a
combination of Propofol and +/- an opioid via an IV
infusion.
• Full monitoring is instituted, and ventilatory parameters
altered
• Fio2 increased to 100%
• Tidal volume increased to compensate for airleak
around deflated ETT cuff
• Adjust peak airway pressure alarm to allow for the
raised pressures during ETT manipulation.
• The patient’s eyes are taped closed
11/3/2015prepared by Anor Hidayah
31. Inner Cannula & Stoma Site
Care
• To help maintain a patent airway
To prevent infection
To maintain skin integrity
To help prevent tube displacement
Objective
•Inner cannula must be checked at least every 4hrs
•Stoma site must be checked at least daily or when
attending cannula. Site must be kept clean and dry
•Ties: ensure they are clean and dry
Frequency
11/3/2015prepared by Anor Hidayah
32. Securing Tracheostomy Ties
Velcro Ties
• Bring longer piece
o (B) around neck and underneath section
o (A) Leave 1 finger space between ties and
patients neck.
11/3/2015prepared by Anor Hidayah
33. Securing Tracheostomy Ties
Cotton Ties
• Bring one long end around the neck and tie to short end
in single knot.
• Repeat on the other side ensuring that 1 finger space is
remaining between the ties and the patient’s neck
• Tracheostomy ties changed when wet or soiled and
routinely at least once a week.
• 2 person involve
11/3/2015prepared by Anor Hidayah
34. Flange and Stay Suture Care
• Most surgically inserted tracheostomy tubes and
occasionally percutaneous tubes are secured in position
with silk sutures
• Removal time:
o at the time of the first tube change
o i.e. approximately 5 - 7 days post insertion
Observe suture sites for signs of infection
and treat accordingly
11/3/2015prepared by Anor Hidayah
35. Suctioning
• to remove endotracheal secretions maintain patent
airway
• as needed pulmonary secretions
• Selecting appropriate catheter size.
o ensure the suction catheter is < /= 1/2 the internal diameter of
tracheostomy tube.
Tube
size
4
8 + 4
=12
(Tube size x 3)
/ 2
8 x 3 /2
= 12
11/3/2015prepared by Anor Hidayah
36. Suctioning Procedure
1. vacuum pressure is > 20Kpa’s / 100- 150mmHg
2. Ventilated patient hyper-oxygenated (i.e. increase FiO2 to
100%) for > 30 seconds prior to suctioning, to minimise
hypoxia during and after the suctioning event.
3. Maintaining sterility
4. Insert the suction catheter to approximately 15cm without
applying suctioning
5. Smoothly withdraw catheter from the airway applying
continuous suction.
6. = / < 15secs.
7. 3 times per-session.
The Nurse must undertake the following:
Explain the procedure to the patient
Perform hand hygiene and apply sterile gloves
Apply apron and fluid shield mask
11/3/2015prepared by Anor Hidayah
37. Cuffed Tracheostomy Care
• Indications for Cuffed Tube Use:
o The patient required mechanically ventilation
o Less than 24/48hours post insertion.
o high risk aspiration from gastric or oral secretions
o Unstable condition
• Stabilises the tracheostomy tube in the trachea.
Indications for cuff re-inflation:
1. Desaturation (must check inner cannula first)
2. Respiratory or cardiovascular distress
3. Constant oral drooling
4. No swallows observed
11/3/2015prepared by Anor Hidayah
38. Cuff Pressure Measurement
• An underinflated cuff i.e. pressure too low, can lead
to
o inadequate seal around the cuff
o increasing risk of aspiration
o causing loss of positive pressure where the patient is
ventilated
• The recommended cuff pressure 25cmH2O
• Cuff pressures should not exceed 32cmH20.
• If leak present increase tube size
• Palpation of the external balloon is not an
adequate method of pressure estimation
11/3/2015prepared by Anor Hidayah
39. • Cuff deflation procedure:
o Explain procedure to the patients.
o Suction oropharynx to remove any secretions
o With the assistance of a 2nd nurse, suction via
tracheostomy tube while the second nurse slowly
aspirates air from air inlet port.
o Once deflated, expiratory noises may be heard as air
passes up around the tracheostomy tube reassure
the patient that this is normal and will settle
11/3/2015prepared by Anor Hidayah
40. Stoma Care
• At least once a day or more frequently reduce the risk
of skin irritation and peri-stomal infection.
Stoma Cleaning Procedure
• Remove and dispose of any soiled dressings
• Using aseptic technique, clean the stoma site using
gauze and normal saline
• apply a skin barrier cream on patient’s skin is excoriated
i.e. soft paraffin
11/3/2015prepared by Anor Hidayah
41. Changing a Tracheostomy
Tube
• The recommended minimum time before the first tube
change or decannulation is
o 5-7days following surgical tracheostomy
o 7- 10days following percutaneous tracheostomy.
Rationale: To enable the tract to become established and minimise risk of occlusion.
• Changed every 28-30 days
• For weaning purposes i.e. downsizing,
change to cuffless or fenestrated.
Elective
Indications
• Tube dislodgement or accidental removal
• Tube obstruction (decreased risk when
using double lumen tubes).
Emergency
Elective
11/3/2015prepared by Anor Hidayah
42. • Document the type of tube, size, the date it was
performed and last changed
• Ventilated patient fast patient for 4 hours before tube
changed.
• Emergency equipment
1st Tube
change
•must always be carried out by a doctor
•The track from the skin to the trachea may not be
well formed
Subsequent
tube changes
• Registered competent nurse
11/3/2015prepared by Anor Hidayah
48. Tracheostomy weaning and
removal
o Medically stable
o The primary indication for tracheostomy has been resolved.
o Spontaneously breathing off the ventilator for 24-48 hours.
o Effective cough reflex
o Free from serious bronchopulmonary infection
o Minimal pulmonary secretions (suctioning < 4-6 hourly)
o O2 Therapy is less that 40% (FiO2 < .4)
o Successfully tolerating cuff deflation.
o Adequate nutritional intake
11/3/2015prepared by Anor Hidayah
49. Weaning Procedure
Stage 4
Patient tolerance to Decannulation cap (not routine)
Stage 3
Patient tolerance to use of Passy Muir Speaking Valve
Stage 2
Patient tolerance to Downsizing the Tracheostomy tube (not routine at present)
Stage 1
Patient tolerance for Cuff deflation
11/3/2015prepared by Anor Hidayah
50. Stage 1- Cuff Deflation
• This is usually carried out 24 – 48 hrs after tube insertion
Why?
• To assess if patient can manage their own airway and
manage their own oral secretions despite alteration in
tracheal airflow.
11/3/2015prepared by Anor Hidayah
51. Stage 2- Downsizing
• Usually undertaken 5-7 days after the original tube
insertion
• Rationale: Airflow is increased either around or through
the tracheostomy tube and this reduces the work of
breathing for the patient.
11/3/2015prepared by Anor Hidayah
52. Stage 3- Speaking valve
• at least 48-72 hours post
tracheostomy, prior to the initial
placement
• allowing air in through the valve
on inspiration, but closing on
expiration
• Where speaking valve is tolerated
the patient and valve:
o Ensure Cuff is deflated prior to applying / using
the speaking valve
o Do Not Leave the Speaking Valve on overnight
unless specifically ordered
11/3/2015prepared by Anor Hidayah
53. Stage 4 - Decannulation
• Decannulation Cap
• blocks the tracheostomy tube
• patient breathe through nose and mouth
Rationale
• The use of a decannulation cap increases patient
confidence and gradually increases respiratory muscle
strength and avoids over exertion.
• Capping is tolerated for at least 24 consecutive hours
11/3/2015prepared by Anor Hidayah
54. Stage 5
• Decannulation
(Removal of the Tracheostomy Tube)
INDICATION
• The decision to decannulation / remove tube is based on
the ability of the patient to maintain their own airway
without the tracheostomy tube insitu.
11/3/2015prepared by Anor Hidayah
55. Stage 5
• Decannulation Predictors
o Patient has successfully completed the latter 4 stages
of weaning. (not all patients will go through each stage of
the process)
o Patient is able to expectorate pulmonary secretions
effectively
o Patient is not myopathic
11/3/2015prepared by Anor Hidayah
56. Summaries
• 2 methods of Tracheostomy – surgical open
tracheostomy and percutaneous tracheostomy
• Percutaneous tracheostomy offer many benefits and a
good alternative
• Timing of tracheostomy does not have clear association
with better outcome but its clearly have many benefit in
term of patient comfort and nursing care
• Percutaneous tracheostomy does not have clear
association with nosocomial pneumonia
• Tracheostomy care knowledge and skills is important for
both doctors and nurses
• 4 stages of weaning and decanulation of tracheostomy
11/3/2015prepared by Anor Hidayah
57. References
• St. James’s Hospital : Nursing Tracheostomy Care
Guidelines - Guidelines Number: SJH:N(G):009
• Uptodate - Overview of tracheostomy
11/3/2015prepared by Anor Hidayah
Editor's Notes
This revolutionized neonatal care… the use of intubation and respiratory support for neonatal patients was described by
some evidence suggests that tracheostomy performed at seven days may improve some short-term clinical outcomes
419 mechanically ventilated patients
The timing of tracheostomy did not appear to impact 30 day or 2 year mortality or ICU length of stay
Data from,, and have been unhelpful in determining a benefit from early tracheostomy in
2 arms oppinion
It is unclear whether tracheostomy alters the because there are conflicting data:
●Suggesting that tracheostomy is associated with a higher rate of nosocomial pneumonia, a prospective cohort study of over 800 mechanically ventilated patients found that tracheostomy was independently associated with a six-fold increase in the risk of nosocomial pneumonia [22].
●Suggesting that tracheostomy is associated with a lower rate of nosocomial pneumonia, a case-control study of 354 patients who were mechanically ventilated for more than seven days found a lower rate of nosocomial pneumonia following tracheostomy (4.8 versus 9.2 episodes per 1000 ventilator days in patients ventilated for an equivalent duration who did not undergo tracheostomy) [23]. These findings were supported by a retrospective cohort study [24].
The timing of tracheostomy (early versus late) does not appear to impact the rate of nosocomial pneumonia following tracheostomy, according to a randomized trial and two observational studies [25-28].
The traditional method of performing tracheostomies in critically ill patients usually requires transport from the intensive care unit (ICU) to the operating department, where a surgical team performs an open or surgical tracheostomy.
this involves dissection of the pretracheal tissues and insertion of the tracheostomy tube into the trachea under direct vision
Cotton ties patient who is at risk of dislodging tube i.e. confused and agitated patients or any patient with an anatomically difficult neck and whose airway would be severely compromised if the tube dislodged.
Velcro ties are advocated and are less inclined to cause skin
maceration to the neck
Multiplying the tracheostomy tube size by three and dividing the total by 2 e.g. with a size 8 tube the calculated suction catheter is 8 x 3 = 24 /2 = Size 12 suction catheter
Adding 4 to the tracheostomy tube size e.g. with a size 8 tube the calculated suction catheter is 8+4 =12 suction catheter
On completing the procedure
ensure patient comfort
return FiO2 to baseline
discard equipment as per hospital policy
perform hand hygiene
document procedure in the patient's Tracheostomy Monitoring Sheet
An over-inflated cuff i.e. cuff pressure is too high, can lead to trauma of the tracheal mucosa which cam cause ulceration or stenosis.
In the event cuff re-inflation is indicated the Nurse must undertake the following procedures:
Inject approximately 5-7mls of air via the air inlet port to achieve airway seal
Check cuff pressure
(but not all patients will go through each stage of the process).
Rationale:
This is a one way valve which covers the opening of the tracheostomy, , thus diverting the air past the vocal cords and out through the nose and mouth of the patient.