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8/8/2019 Tracheostomy Semi Final

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What is tracheostomy?

Indications

Types of Tracheostomy Tubes

Tracheostomy Care.

Weaning from tracheostomy tube

Suctioning


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A surgical opening into the trachea through which

a tracheostomy tube can be passed to providean airway, and to remove secretions from the

lungs. This tube is called a tracheostomy tube

or trach tube.


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Records indicate that the first tracheostomy was performed 124years BC by a Roman physician.

During the Dark Ages little mention of the operation is recorded, but

it was felt that the cartilages of the trachea would not heal so thesurgical procedure was not commonly performed.

The tracheostomy tube was first used in the 16th century and bythe 19th century, 28 successful operations had been performed.

The first tracheostomy tube for children was developed in 1880.

In 1936 Davidson, an American doctor, advocated the use of thisoperation for the respiratory support of polio patients. Today,tracheostomy is a common procedure and a lifesaver of manypatients who need airway support.


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Acute respiratoryfailure

IntubationIntubationAirway

Obstruction

Inability toprotect airways

ProlongedProlonged

MechanicalMechanical

VentilationVentilation

TracheostomyTracheostomy

POST TRACHEOSTOMY CAREPOST TRACHEOSTOMY CARE

PhysiciansPhysicians NursesNursesRespiratoryRespiratoryTherapistsTherapists


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Tube Used on all

newborns and most

pediatric patients.

Has one single

passage used forboth air flow and

suctioning.


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Features a removableinner cannula that fitsinside an outercannula.

Inner cannula must bein place to ventilate thepatient

Outer cannula keepsthe stoma open whilethe inner is removedfor cleaning.


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Teaches the patient

to breathe through

the upper airway.

Allows for speech.

Less airway

resistance


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Initial choice

Used during M.V.

Decreases the risk ofaspiration.

Cuffs may be either

foam or balloons.

Used for adults orolder children.


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Early Period Care

Tube Securing Wound Care

Tube Care


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Wound Care

Requires two persons to prevent loss of tracheostomy

Routine wound care risk of infection

Dialy examination of stoma

Clean dressing is inserted under the tracheostomy tube

Precut dressing should be used to reduse the risk of fibersentering the stoma

Wound Care


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Tracheostomy is held in place with either atracheostomy ties or a tracheostomy tubeholder. These ties should be routinely changedwhenever they become wet or soiled. With

infants and active young children, this must bea two-person procedure, as it is important thatthe tube remain stable and not be pulled out.

When retieing the ties, do not pull them too tight

as you may decrease the blood flow to thepatients head and cause undue pressure to theskin of the neck.


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Cleaning double-cannula tracheostomy tube

Tracheostomy tubes on general medical/surgical

wards should have an inner cannula

Non-disposable inner cannula should be cleaneddaily

Disposable inner cannula should be changed

daily.

This reduces the risk of tube blockage bysecretions and thus reduces the frequency of tubechanging

Tube Care


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Late Period Care

Tube Care

Cuff Care

Humidification

Weaning

Feeding

Speech Suctionning


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Humidification is necessary because the

tracheostomy bypasses the upper airway whichnormally moistens the air

The reduction of moisture and heat loss helps to

maintain suitable viscosity of secretions


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Fluid Intake

Patient need adequate amounts of fluid to keep

their mucus loose.

Illnesses associated with fever, diarrhea,

sweating, or vomiting are of special concern.

Humidification Cont.


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Two types of humidifiers for ventilated patients

1) Active: pass inspired gases over heatedwater bath

2) Passive: HME (trap humidity from

patients expired gas)



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Frequency of changing HME

(depends on manufacturers recommendations)

Standard: daily

More frequent if occluded by secretions



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Techniques for promoting speech

in non-ventilated patients

One-way speaking valves

Pneumatic talking tracheostomy tube

Speech


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Complications of Tube Feeding

Aspiration

risk 20% - 70%

independent of consciousness level

Nutrition


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Recommended cuff pressure = 20-25mmHg

Low pressure (25) tracheal mucosal damage

Cuff management


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Non-emergency routine changing (patients on long-term mechanicalventilation)

changing tube type (e.g. cuffed to uncuffed)

Emergency tube blockage

accidental extubation

Changing tracheostomy tube

Indications


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If it is expected to be a difficult change,consider changing in an operatingtheatre/ICU environment.

Changing tracheostomy tube Cont.


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Tracheostomy Tube Emergencies

include:

obstruction of the tube

displacement of the tube

Tracheostomy Emergencies


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Determining Patient Readiness

1. Adequate ventilatory reserve

2. Adequate nutritional state

3. Patient upper airway

4. Absence of serious bronchopulmonary infection

5. Absence of impending need for mechanical ventilation

Weaning from tracheostomy tube


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6. Adequate cough

7. Minimal aspiration

8. Reversal of the condition that requiredtracheostomy

9. Patient off ventilator for > 48 hour

10. Gag reflex

11. Absence of excessive secretions

Determining Patient Readiness Cont.


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Equipments:

Suction catheter

Suction source Sterile gloves

Clean gloves

Ambubag with oxygen source

Normal saline 0.9% Blue sheet

Artificial airway

Syringe 5-10 cc


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MONITOR HEART RATE SUCTION MY

CAUSE

A. HYPOXEMIA, INITIALLY TRACHCARDIAANDHYPERTENTION, CARDIAC ECTOPY,BRADYCARDIA, HYPOTENTION, CYANOSIS

B. VAGAL STIMULATION CAUSING BRADYCARDIA

AUSCULTATE BREATH SOUNDS REVIEW ABGRESULTS


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7.Place blue sheet on the patient chest.

8.Open suction catheter package.

9.Open sterile gloves.

10.Don sterile gloves.

11. With the assistance of another nurse,remove the suction catheter from thepackage. Curling the catheter around thegloved fingers.

12. Connect suction source to suction fittingof the catheter by the second nurse.


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13.Disconnect from oxygen source ofventilator.

14. Ventilate the patient by Ambubag.Compress firmly about 4 5 times. Thisprocedure is called bagging the patient.

15.Lubricate the tip of the suction catheter

16.Gently insert the catheter into the artificialairway without applying suction.

17.Most patient will cough when touched thecarina.


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18. Withdraw the catheter2-3 cm and applysuction. Quickly rotate the catheter while itis being withdrawn.

19.Limit suction time not more than 10seconds.Discontinue if heart decreases 20beats/minute or increases 40 beats/minute

or if cardiac ectopy is observed.20. Bag patient between suction passes.

21. Instill 3-5 ml PNSS into artificial airwayduring spontaneous inspiration


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1. Note any change in vital signs or

patients intolerance to procedure.

2. Record amount and consistency ofsecretions.

3. Assess the need for further suction at

least every 2 hours or more.


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Effective coughing is necessary for the

patient to clear secretions.

The objective of deep breathing is topromote the lung expansion, mobilize

secretions and prevent side effects ofretained secretions.

Have the patient positioned sitting

upright on the edge of the bed or chairwith the feet supported .


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Instruct the patient to take a slow, deep

breath, hold it for2-3 seconds and

exhale slowly for auscultation. Teach the patient use of incentive

spirometry to provide encouragement to

increase the volume and immediatevisual feedback on the breath depth.


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A towel of pillowcase is draped over the

area to be percussed and is performed 3to 5 minutes per position.

Percussion is never performed over the

spine, breast, sternum or below the

thoracic cage only on the rib cagebecause this can cause organ injury.

Never tap over the kidneys as this can

cause them to begin bleeding internally.


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After tapping on the chest for

percussion, have your patient remain

sitting to assist the lungs in draining the

mucus. Use pillows to prop their head up

if they can not remain sitting forprolonged periods of time.

Repeat the procedure at least everyeight hours or as ordered by the

physician.


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VIBRATION takes place during a

prolonged pursed-lip exhalation. It increases the turbulence of exhaled air

to loosen secretions.

It is done by placing the hands side by

side with the fingers extended and

applying the flat of the palm over the

affected chest area. The patient inhales

deeply and then slowly exhales.


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While the patient exhales, the nursevibrates the patients chest by quickly

contracting and relaxing arm and

shoulder muscles.

Vibration is used instead of percussionwhen the chest wall is extremely painful.


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