Transcript Tracheostomy August 2009

Tracheostomy Tubes
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Tracheostomy
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Indications
 facilitate prolonged mechanical ventilation and
weaning
 by-pass upper airway obstruction (ex. sleep
apnea, tumor …)
 maintain patent airway in severe head and neck
injury or surgery
 airway anomalies
 secretion removal
 recurrent aspiration
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Contraindications
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coagulopathy
enlarged thyroid
abnormal airway anatomy
lack of patient consent for procedure
poor surgical candidate
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Advantages
 decreased work of breathing
 decreases the risk of upper airway
complications due to endotracheal tube
 increase patient comfort and compliance
 improved oral hygiene
 oral movement for communication
 easier to stabilize and secure compared to
endotracheal tubes
 increased mobility
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Disadvantages
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increased risk of infection
impairs speech
bypasses normal humidification system
invasive surgical procedure
may impair swallowing
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Tracheostomy Terms to
Remember
Flange – Is the part that is attached to the outer
cannula. It assists in stabilizing the tube in the trachea.
It also provides the holes necessary for proper securing
of the tube to the neck of the patient.
Outer Cannula - The outer cannula forms the body of
the tracheostomy tube.
Inner Cannula - Fits into the outer cannula like a liner.
Can be removed for cleaning or changing. (Disposable
and Non-disposable) (Twist lock or Ring-pull inner
cannula) Note - not all tubes have an inner cannula.
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Tracheostomy Terms to
Remember (cont’d)
Obturator - The obturator is only used during insertion
of the tracheostomy tube. It replaces the inner cannula
during insertion. Must always be present at patient
bedside in case of accidental decannulation.
Cuff – Is the balloon around the outer cannula that is
inflated to maintain a seal around the tube.
** Note: not all trachs have cuffs.
Inflation Line – Used to facilitate inflation of the cuff.
Pilot Balloon – Is an external indicator that the cuff is
inflated.
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Tracheostomy Terms to
Remember (cont’d)
Tracheostomy Sutures – 2 Types
– Stay Sutures – Inside the trachea that can be gently
pulled to bring the tracheal opening to the skin in case
of early, unplanned decannulation.
– Skin Sutures – Placed in the O.R. attaching the
tracheostomy flanges to the skin to prevent
decannulation.
Fenestration – Opening in the outer cannula that
allows for more air flow through the upper airway
(facilitates speech).
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Figure 1(Portex Tube)
FLANGE
OUTER
CANNULA
INFLATION
LINE
CUFF
PILOT
BALLOON
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Figure 2
(Inner Cannula/Obturator)
Inner Cannula
Obturator
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Types of Tubes
 Cuffed or uncuffed. **Most pediatric tubes do
not have cuffs and inner cannulas due to
smaller diameter. Most adult tubes have
inner cannula to allow for less frequent
outer cannula changes.
 Metal (Jackson) or plastic (bivona, portex, shiley)
 Single or double cannula
 Fenestrated or non-fenestrated
 Short or long term
 Custom
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Types of Trach Tubes
Shiley® cuffless tube
Bivona® Uncuffed Neonatal and Pediatric Silicone
Tracheostomy Tubes
Shiley® fenestrated cuffless tube
Metal Jackson tube
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Tracheostomy Policies
 Tracheostomy Stoma Care
– Policy Statement – Tracheostomy stoma care should be
performed every shift and on an as needed basis.
 Care of the Inner Cannula
– Policy Statement- Corks and inner cannula should be
cleaned or changed daily as well as PRN. Pediatric and
neonatal inner cannula should be cleaned or changed Q6H
to Q12H and/or PRN. Inner cannula should be checked
Q4H or immediately if patient appears to be in respiratory
distress, the inner cannula needs to be removed and
inspected for encrustation.
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Suctioning
 Oral-Nasal-Tracheal
 Adult 150-200mmHg
 Pediatric 120-150mmHg
 Infant 100mmHg
 Review HHS policy Resp-Suctioning
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Tracheostomy Emergencies
Tube Occlusion
 Signs of tube occlusion include:
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Difficult or laboured breathing
Use of accessory muscles
None or limited expired air from tracheostomy tube
Pale/Cyanosed skin color
Anxiety
Increase Pulse and Respiratory Rate
Clamminess
Cessation of respiration
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Tube Occlusion (cont’d)
PLAN OF ACTION
 ALWAYS STAY CALM AND REASSURE
THE PATIENT
 Call for help immediately, both RN and RT.
 Reposition the patient into the
semi-recumbant position
 Ask patient to cough or attempt to clear
secretions via suctioning
 Manipulate the head and neck to eliminate
kinking or to allow tube reposition
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Tube Occlusion (cont’d)
 Ask person helping you for baseline oxygen
saturation and vital signs, if necessary.
 Administer oxygen via Face mask.
If occlusion is still present:
 Attempt to remove inner cannula and
inspect for blockage.
 Replace inner cannula with a new one, if
blocked.
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Tube Occlusion (cont’d)
If occlusion is still present after removal of
inner cannula.
 Ask patient to cough to clear secretions
 Suction down tracheostomy tube again to
attempt to clear blockage.
 If patient continues to have distress then
entire tracheostomy tube may need to be
changed.
 PAGE PHYSICAN STAT (if they are not
already there).
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Tube Occlusion (cont’d)
 ALWAYS STAY CALM AND REASSURE
THE PATIENT
 DO NOT REMOVE TRACH. Call the RT stat
to perform trach removal.
Note: If upper airway obstruction is
indication for tracheostomy, Call Team
Immediately and DO NOT REMOVE
TRACH.
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Accidental Decannulation
If tracheostomy is partially out:
Note: If upper airway obstruction is
indication for tracheostomy, Call Team
Immediately and DO NOT REMOVE
TRACH.
 ALWAYS STAY CALM AND REASSURE
THE PATIENT
 CALL THE RT STAT
 Ensure that saturation monitor is on
patient.
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Accidental Decannulation
(cont’d)
 Attempt to determine if patient is in
distress.
 Try to prevent them from coughing rest of
tube out.
 If patient coughs tube out, suction stoma
site.
 Temporarily occlude stoma with gauze and
apply oxygen via face mask.
 Observe patient for signs of respiratory
distress. If no signs of distress then
document.
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Accidental Decannulation
(cont’d)
 If signs of distress assist RT in airway
management and call the Emergency team.
 Wait until team arrives and transfer care of
patient.
 IF AT ANY POINT YOU ARE UNSURE OF
WHAT TO DO CALL THE RESP. THERAPIST!!
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Accidental Decannulation
(cont’d)
If tracheostomy is fully out:
 ALWAYS STAY CALM AND REASSURE
THE PATIENT
 CALL THE RT STAT.
 Once tube is removed, suction stoma site.
 Temporarily occlude stoma with gauze and
apply oxygen via face mask.
 Observe patient for signs of respiratory
distress.
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Accidental Decannulation
(cont’d)
 If no signs of distress then inform RT upon
arrival.
 If signs of distress then assist RT with
airway management and call the
Emergency team.
 Wait until team arrives and transfer care of
patient.
 IF AT ANY POINT YOU ARE UNSURE OF
WHAT TO DO CALL THE RESP. THERAPIST!!
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References

Harkin, H. & Russell, C. (2001) Tracheostomy Patient Care. Nursing Times, Volume 97, No. 25,
pages 34-36.

Serra, A. (2000) Tracheostomy Care. Nursing Standard. Volume 14, No. 42, pages 45-52.
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Smith, S., Duell D., Martin, B. (2000) Clinical Nursing Skills, 5th Edition, Chapter 25, page 776.
Prentice-Hall.
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Kacmarek, R.M. et al. The Essentials of Respiratory Therapy, 2nd Edition, Chapter 25, pgs381-390.
1985. Year Book Medical Pubishers Inc.
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Endotracheal Suctioning of Mechanically Ventilated Adults and Children with Artificial Airways.
AARC Clinical Practice Guideline Reprinted from Respiratory Care (respir Care 1993; 38:500-504)
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Interdisciplinary Clinical Practice Guideline on Suctioning: Adult Patients. May 14, 1999
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Interdisciplinary Clinical Practice Guideline on Suctioning: Infants and Children. May 14, 1999
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Guidelines for Prevention of Nosocomial Pneumonia. MMWR 46(RR-1); 1-79, 01/03/97
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Nasotracheal Suctioning AARC Clinical Practice Guideline

Respiratory Care (Respir Care 1999;44(1):99-104)
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Respiratory Care (Respir Care 1992;37:898-901)
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Suctioning of the Patient in the Home AARC Clinical Practice Guideline
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St. George’s Healthcare NHS Trust August 2000 published by Sims Portex Ltd.
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http://www.portex.com/airway/products/select5.asp?autonum=25
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http://www.portex.com/airway/products/select5.asp?autonum=44
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http://www.tracoe.de/pix/prod/twist/r306.gif
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http://www.supportnet.us/trach_pics/sh_cfs.jpg
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http://faculty.icc.edu/gcarr/images/equip/gc40.jpg
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http://www.tracheostomy.com/images/trach4.gif
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