Transcript Slide 1
TRACHEOSTOMY CARE BILL WOJCIECHOWSKI, MS, RRT DEPARTMENT OF CARDIORESPIRATORY CARE UNIVERSITY OF SOUTH ALABAMA MOBILE, ALABAMA TRACHEOSTOMY CARE Upper airway functions bypassed when patient has tracheotomy performed. UPPER AIRWAY FUNCTIONS Heat/moisture exchange Thermoregulation Gustation (taste) Olfaction (smell) Filtration CLINICAL COMPLICATIONS Altered or loss of voice Speech & language delays (young children) Loss of smell & taste Compromised nutritional status Impaired swallowing/increased risk of aspiration Secretion control issues/infection Psychological distress Loss of physiologic PEEP CLINICAL COMPLICATIONS Absence of airflow often creates Frustration Anxiety Psychological distress For children: delayed speech & language development CLINICAL COMPLICATIONS Absence of airflow decreases sensations Smell Taste Poor appetite Skin health Supplemental feeding Difficulty swallowing Risk of aspiration CLINICAL COMPLICATIONS Cuffed trach tubes anchor larynx & sometimes interfere with: Laryngeal elevation Epiglottic inversion Airway protection Cuffed trach tubes secure larynx, Deflated cuff: more freedom. Three phases of normal swallowing: 1) Oral phase 2) Pharyngeal phase 3) Esophageal phase UPPER AIRWAY FUNCTIONS Normal swallowing (pharyngeal phase): Oral & nasal cavities sealed Vocal cords close Positive pressure generated below cords Air prevented from entering larynx Larynx elevates & moves forward Acts as a lever (mechanical event) Epiglottis seals larynx Food/liquid directed into esophagus UPPER AIRWAY FUNCTIONS Swallowing with Trach Tube Inserted: Vocal cords close Air flows through trach tube No subglottic positive pressure Reduced sensations in larynx & pharynx Pooling of airway secretions Increase risk of aspiration Most patients OK!! CLINICAL COMPLICATIONS Absence of upper airway airflow (inability to nose-breathe) compromises: Heat/moisture exchange Increased secretion viscosity Increased secretion volume Frequent suctioning Increase risk of airway trauma/infection Presence of trach tube stimulates secretions http://www.brucemedical.com/filandcov.html CLINICAL COMPLICATIONS With cuff inflated: No physiologic PEEP Possible micro-atelectasis Decreased alveolar ventilation Compromised oxygenation Cuff deflated Physiologic PEEP Present Cuff inflated Physiologic PEEP Absent TRACHEOSTOMY CARE Inspect stoma daily: irritation/inflammation. Tracheostomy care is done every 8 to 12 hours and PRN. Avoid dressings trapping moisture. Check secretions: white & clear; greenish-yellow Odor often indicates infection. Assess need for suctioning q2h. TRACHEOSTOMY CARE Signs of Infection: Yellow or green secretions (pink or blood-tinged) Thicker mucus Greater volume of mucus Stoma site bleeding Foul odor from stoma Febrile patient Pulmonary congestion Increased RR Listlessness Discomfort with trach/tender stoma site CLEANING INNER CANNULA PROCEDURE CLEAN INNER CANNULA 1. Loosen inner cannula. 2. Hold outer cannula with one hand. Turn inner cannula to right with other hand to unlock. CLEAN INNER CANNULA 3. Remove the inner cannula by steadily pulling it down and toward your chest until it is out. CLEAN INNER CANNULA 4. Place inner cannula in the solution of hydrogen peroxide & normal saline, and don sterile gloves. CLEAN INNER CANNULA 5. Use trach brush, or pipe cleaner, to clean inner cannula of mucus and dried secretions. CLEAN INNER CANNULA 6. Place it in bowl of normal saline (NS). 7. Shake off excess NS. Moisture will act as lubricant during inner cannula reinsertion. CLEAN INNER CANNULA 8. Reinsert inner cannula, keeping curved portion facing downward. CLEAN INNER CANNULA 9. Lock inner cannula into position. 10. Wash bowls thoroughly and allow to air dry. Soak trach brush soak in hydrogen peroxide-NS solution &, rinse with NS. Air to dry. Discard pipe cleaners. CUFF PRESSURE Goal: maintain cuff pressure below tracheal mucosal capillary perfusion pressure which is: 25 to 30 mm Hg. Cuff pressure maintained: 20 to 25 mm Hg, or 25 to 35 cm H2O Higher cuff pressures Cut off tracheal mucosal blood flow Tracheal wall damage (necrosis/tracheomalcia) CPR - TRACHEOSTOMY Caregivers must receive CPR training. Suction if indicated. Change trach tube if clogged. Spare tubes (cuffless &/or cuffed): same size & 1 size smaller Pinch nose & mouth (cuffless trach). 2 breaths with manual resuscitator/mouth-totrach/mouth-to-stoma: STOMA LEAK Mouth-to-mouth/bag-mask with finger over stoma: STOMA LEAK TRACHEOSTOMY & SPEECH Fenestrated: Weaning Speech Granuloma formation Increased risk of aspiration TRACHEOSTOMY & SPEECH Some space around tube Snug fit: tube too large non-fenestrated: poor or no speech TRACHEOSTOMY & SPEECH TRACHEOSTOMY TUBE PRECAUTIONS Use extreme caution with baths and water No swimming Avoid powder, talc, chlorine bleach, ammonia, aerosol sprays, or colognes and perfumes Prevent foreign objects from entering trach tube TRACHEOSTOMY TUBE PRECAUTIONS Avoid dust Avoid sand and beach Watch play with other children to assure toys, fingers or other foreign bodies are not put into trach and trach is not pulled No contact sports Frequent hand washing EDUCATION Teach airway anatomy Teach about equipment Teach CPR Teach infection control Teach humidification Teach suctioning Teach about speaking valves/fenestrated trach tubes Teach communication through speech therapy