tracheostomy care & wean

Tracheostomy

Post-op Management

Dr Shiraz Qamil

Content

• Types of tracheostomy tubes

• Post-op complications

• Post-op expectations

• Post-op care

• Weaning off tracheostomy

Types of tracheostomy tubes

Single Lumen Double Lumen

Cuffed Non-Cuffed Fennestrated

Cuffed Tracheostomy Tube

Uncuffed Tracheostomy tube

Adjustable Flange Tracheostomy Tube

Fennestrated Tracheostomy Tube

Shiley’s™ Double Lumen Tracheostomy Tube

Post op complications

• Post-op complications may be divided into• Immediate• Early• Late


• Immediate complications– Bleeding (thyroid, lacerated vessels)

– Pneumothorax or pneumomediastinum (esp in children)

– Injury to adjacent structures (great vessels and oesophagus)


• Early complications (<48 hours)– Bleeding

• Increased blood pressure, cough reflex

– Mucous plug– Tracheitis– Cellulitis– Displacement– Subcutaneous emphysema


• Late complications (>48 hours)– Bleeding (tracheoinnominate fistula 0.6-0.7%,

granulation tissue)– Tracheomalacia– Stenosis (cricoid cartilage injury)– Tracheoesophageal fistula– Tracheocutaneous fistula– Granulation– Scarring

Post op expectations

• Cuffed tracheostomy initially• Airtight seal for ventilation• Prevent aspiration• Prolong use may irritate stoma & form

granulation tissue

• Intermittent tracheal suction

• Deflate tracheostomy cuff after 2-3 days

• First change to be done by surgeon

Post op care

• Goals of tracheostomy care• Maintain airway patency• Clear lungs / tracheal secretions• Prevent skin and lung infection

• Tube can be blocked by• Blood clot• Copious secretion• Mucous plug

Post op care

• Feel for air blast

• Vapour or misting on mirror

• Movement of cotton fluff

Blocked tracheostomy tube is an emergency.

How to know tracheostomy is patent?

SUCTIONINGSUCTIONING

Bedside equipment for tracheostomy patientBedside equipment for tracheostomy patient

•Use personal protective equipment during suctionUse personal protective equipment during suction

•Suctioning can be done either supine or sittingSuctioning can be done either supine or sitting

• Without applying pressure, suction catheter is insertedWithout applying pressure, suction catheter is inserted

• Advance to end of trachy tubeAdvance to end of trachy tube

• Withdraw tip by 1cm before applying suctionWithdraw tip by 1cm before applying suction

• Avoid tracheal traumaAvoid tracheal trauma

• Do not suction for more than 15 – 20 seconds.Do not suction for more than 15 – 20 seconds.

• Be careful not to cause HypoxiaBe careful not to cause Hypoxia

• In the event of blockage by thick secretions despite In the event of blockage by thick secretions despite suction, tracheostomy tube change may be suction, tracheostomy tube change may be considered considered

vacuum pressure is < -150mmHg.

Size of suction catherter

• Formula:– Size of trachy tube x 2 – 2– I.e.: size 7 trachy tube:

• 7x2-2 = 12• Size 12 suction tube should be used

Tracheostomy change

• Similar sized tracheostomy tube prepared

• Tracheal dilator and one size smaller tube kept as standby

• Personal protective equipment.

• Patient in supine position with neck hyperextended

• Hyperoxygenate if on ventilator

• Tracheal suction

• Deflate cuff tube

• Untie old tube and gently remove

• Insert new tube with obturator/introducer, which is removed once in trachea

• Check patency and secure tube

Dislodged tube

• Do not panic!– Tract is well formed after day 5 of tracheostomy

• Give 100% oxygen (Monitor patients spo2)• Ask the patient to breathe normally via their

stoma • Prepare for insertion of the new

tracheostomy tube • Reinsert tube as per normal change

BLOCKED TUBE

• Deflate cuffed tube if used• Give 100% oxygen and pass a suction catheter• Excessive lung secretion – do suctioning alternate with

hyper-oxygenation• Sterile normal saline instillation to aid clearing• Tube change may be necessary• Inner cannula removal and replacement

Tracheostomy change: when to change?

• Cuffed tube should be changed when not indicated

– Cuff may irritate trachea and cause more secretion

• Double cannula tracheostomy – less freq change

• Tracheostomy tract fully epitheliase by one week

Tracheostomy change

• Causes of difficult tracheostomy change– Early tube change when tract not fully formed– Constricted tracheostoma– Granulation tissue at stoma– Obese neck with deep seated trachea– Restless or anxious patient

CARE

• Inner cannula (double lumen)– Checked intermittently depending on amount of lung secretion

– Inner cannula removed with a curve-down action

– Cleaned under running tap water

• Humidification– Supplementary humidification to moisten air

– - heat-moisture exchange device

• Saline nebuliser– Aid expectoration

• Moist saline gauze veil– Provides moist air and protection from inhaled foreign bodies

HOME CARE

• Patients and their family should be empowered to take responsibility of tracheostomy care

• Normal lifestyles are encouraged• Loose covering over the tracheostoma

WEANING OFF TRACHEOSTOMY

When To Wean:

• Tracheostomy tube should be weaned off once initial cause for airway obstruction has been addressed

• Effective cough and gag reflex• Good respiratory effort


How To Wean:

• Weaning should be done in a controlled setting• Patient to be on continous SPO2 monitoring and to

be nursed in acute/subacute bed

1. Downsizing trachy tubes – Change to smaller tube to reduce dependance to trachy– Sequential reduction by one size, each to be in-situ at

least 48hrs – Usage of 2 different sizes should be adequate– Remove and observe over 24hrs

2. Change to Uncuffed fenestrated tube & spigot– Allows air to flow through the upper airways– Spigot with air tight closure– Allow speech production and train breathing with

own airway– Observed for 15 to 20 minutes with SpO2 monitoring– If well, to maintain spigot for 24 to 48 hours– Tube can be removed if patient is able to tolerate

• Secondary suturing done if stoma persists


• Remember that weaning off takes time.• Need to let patient adjust to normal breathing• Spo2 must be monitored for at least 24 hours

post blocking tube with spigot• Use yellow branulla stopper to spigot trachy

tube.

Care of tracheostomy stoma

• Daily keyhole dressing must be done

• Dressing must be changed if dirty

• Sutures are removed on day 7 post op

• Tracheal stoma will close by day 10 once trachy tube removed

• Daily dressing done untill stoma closes to ensure good wound healing

Please feel free to consult our team Please feel free to consult our team if there are any doubts regarding if there are any doubts regarding your patients on tracheostomy.your patients on tracheostomy.

THANK YOU

tracheostomy care & wean

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