Transcript Tracheostomy Care

Tracheostomy
Care
What is a Tracheostomy?
“ A surgical opening in the anterior wall of
the trachea to facilitate ventilation”
Surgical
or
Percutaneous
Tracheostomy
Anatomy of the trachea
The trachea is a fibromuscular tube supported by 20 hyaline cartilages which are
opened posteriorly.
The soft tissue posterior wall is in contact with the oesophagus.
Three layers of tissue clothe the cartilages:
–
–
–
A fibrous elastic outer layer.
A middle layer of cartilage and bands of smooth muscle that wind around the trachea.
There is some tissue containing blood and lymph vessels and autonomic nerves.
An inner lining consisting of delicate ciliated columnar epithelium containing mucous
secreting globlet cells.
The blood supply is primarily supported by the bracheocephalic artery and through
the inferior thyroid and bronchial arteries.
The nerve supply is by parasympathetic and sympathetic fibres.
The sympathetic system acts in the flight or fight response stimulated by adrenaline.
It causes an increase in heart rate and relaxes the bronchi and muscle of the gut wall.
The parasympathetic supply to the trachea is by the recurrent laryngeal nerve – a
branch of the vagus nerve – it can slow the heart rate, increase the acidity to the
stomach and constrict the bronchi. (Brunt, (1986), p33-34)
Position
The trachea begins just below the larynx at approximately the 6th
cervical vertebra.
It is flexible to accommodate varying depths of ventilation, coughing
and speech. The length and width is continually changing to
accommodate head, neck and diaphragmatic movements.
In adults it is 12-16 cm long and 13-16 mm wide in women and 1620 mm wide in men. (Minsley and Wren 1996)
It is slightly to the right of the midline and divides at the carina into
the right and left bronchi.
The carina lies under the junction of the sternum at the level of the
4th thoracic vertebra. (Kumar and Clark, 1994 p 631)
Tracheostomy
TRACHEOSTOMY TUBES
All tracheostomy tubes consist of a main shaft and a neckplate or flange. The
flange rests between the clavicles. Holes on each side allow you to attach
tracheostomy ties to secure the tube in place.
Tubes are made of semi-flexible plastic, rigid plastic or metal. Semi-flexible
plastic tubes conform to the patients’ anatomy during movement – good for
patients with tracheal deviations. Rigid tubes are typically used when neck
swelling is a problem. The tubes don’t bend or collapse with local oedema.
Plastic tubes have a built-in 15mm adaptor that extends from the neck plate.
This allows respiratory equipment e.g. an ambubag, a T piece oxygen delivery
system or a mechanical ventilator, to be attached. Synthetic tubes are made
from a non-irritant substance.
The most commonly used cuffed tube
in the hospital is the Portex Blue-Line
Profile Cuffed Tube, available from
stores – cost approximately £13 each.
Cuffed Portex tubes, with inner tubes
are now available in stores and cost
approximately £35.
Types of Tubes
Cuffed tubes
Un-cuffed
Fenestrated
Inner cannula
Adjustable flange
PVC, Silver, Silicone and Rubber
Mini Tracheostomies
Cuffed Tubes
Allows ventilation and
prevents aspiration
High cuff pressure can
be damaging
Check pilot cuff
DO NOT BLOCK THIS
TUBE
Cuffed Tubes
Tubes with inflatable cuffs
Inflatable cuffs are used when an air-tight seal is required around
the tube. The cuff is not to hold the tube in position – it is
usually required:
when the patient is unable to breathe on their own and requires
artificial respiration. Unless there is an air-tight seal around the
tube, the air being blown into the lungs by the respirator escapes
around the sides of the tubes.
or
when an air-tight seal is necessary to prevent blood and other
secretions from running down the sides of the tracheostomy tube
into the lungs. During and following surgery to the head and neck,
such complications are a real danger and it is for this reason that a
cuffed polythene tube is used for the first couple of days postoperatively.
Cuffed Tubes
Cuffed tubes have an inflation line leading to the
cuff and pilot balloon that inflates when the cuff
contains air, giving an indication of the volume of
air in the cuff. What the pilot balloon does not
tell you is how much air pressure is in the
cuff. You can confirm the correct inflation by
listening for air leak or by measuring intracuff
pressure with a manometer, (Weilitz and
Dettenmeiir, 1994). The presence of an air leak
may indicate that the cuff is inadequately
inflated.
Disadvantages of Cuffed Tubes
Traditionally single tubes with no inner tubes are used. These can easily
become blocked. Initially, medical staff prefer tubes to be in situ for 7-10
days before changing, to allow a tract to be established for ease of
changing.
The cuff exerts a pressure on the surrounding tissues when it is inflated. In
time, this pressure can cause damage to the tissues, resulting in necrosis, a
fistula or stenosis in the trachea.
Hourly deflation of the cuff was thought to lessen tracheal damage but this
was shown to be ineffective.(Powaser, 1976, Bryant et al, 1971, Jenicek,
1973). Over inflation of low pressure cuffs, even by the addition of only a
few mls of air above the minimal occluding volume can dramatically raise
intracuff pressures, (Regan, 1988). If an adequate seal cannot be obtained
with such pressures it may be necessary to switch to a larger sized
tracheostomy. An accurate way of checking the pressure is to use a
manometer (Caruna 1990).
The patient cannot speak when the cuff is inflated as no air can go past the
vocal cords – this has a massive psychological impact on the patient.
If a patient with a cuffed tube can speak it could be a sign that the tube is
displaced, or the cuff inadequately inflated.
Un-cuffed Tubes
Maintains airway once
aspiration risk has
passed
Increase airflow to the
larynx
Which patients:
– Long term
tracheostomy pts
– Patients who do not
require a seal
– Paediatrics
Uncuffed Tubes
Unable to maintain seal in an emergency
situation
Fenestrated Tube
Increases airflow to larynx/
vocalisation
Cuffed or un-cuffed
These are used for weaning
Enables phonation (speaking)
The fenestrated tube can be
used as such if the patient is
tolerating the cuff down
To suction always use the non
fenestrated inner tube for
suctioning
Fenestrated are the only tubes
(when inner fenestrated tube
insitu and cuff is down) that can
be intentionally occluded
Inner Cannula
Allows maintenance of
tube patency
– Aids tube hygiene
– Close observation
Allows fenestrated
tubes to be used earlier
Inner Cannula
Use of an inner cannula:
The inner cannula provides a vital safeguard
against life-threatening complications of tube
obstruction in a cuffed tube and must be present
at all times. Tracheostomy tubes without an
inner cannula should be avoided wherever
possible particularly in the ward environment;
this may, however, be impossible to achieve with
all patients.
Changing the Inner Cannula
If copious secretions- check every 4 hours
(more if indicated)
Remove and clean using sterile water and
replace as soon as possible
If tube is kinked or damaged replace with
new sterile inner tube
Other issues- brushes, cleaning fluids,
infection and storage of inner cannula
Adjustable Flange
Provide a longer tube – offer secure placement of tube in
a deep-set trachea
Essential for patients with difficult anatomy and on whom
the insertion will be complicated; insertion of this tube is
usually via the surgical technique (considered to be an
unsuitable tube for the percutaneous insertion technique)
The Portex PVC adjustable flange tube does not have an
inner cannula.
These tubes are inserted in patients with very
difficult anatomy and therefore subsequent tube
changes should be considered carefully.
Adjustable Flange
Silver Negus
Metal Tracheostomy Tubes
These are made of silver because the metal is inert and does not irritate the
tissues. The most commonly used silver tube is the ‘Silver-Negus’. The
sizes of the tubes for adults vary from 28-36 FG. The letters FG stand for
‘French gauge’. The number represents the circumference of the inner tube
measured in millimetres. As a rough guide, the FG size is 4 times the
portex size.
The tubes have a normal inner tube and a speaking tube with a small valve
on.
Speaking tubes should not be used to sleep in because of the danger of the
valve blocking and occluding the airway. Silver tubes cost approximately
£200 each. Each set is individual and pieces are not interchangeable. If a
piece is lost it can cost £100 at least to replace. The tubes also need
repairing and maintaining occasionally. Manufacturers of plastic tubes claim
silver tubes are not as comfortable as plastic but they have no evidence to
support this.
Tracheostomy (antique)
Mini Tracheostomy
Minitracheostomy (cricothyroidotomy) is
for the treatment or prevention of sputum
retention after thoracotomy, laparotomy or
neurological insult. It is an alternative to
naso-laryngeal suction or regular flexible
bronchoscopy.
A cannula with an internal diametre of 4
mm is inserted.
Mini Tracheostomy
Patient able to breathe normally
Patient can talk and eat / drink
The tube does not prevent expectoration
Use only size 10 or less suction catheter.
Suction will take longer but patient can
breathe during the procedure
Portex minitracheostomy
Mini Tracheostomy
Deflating the Cuff
Why?
To assess the patient’s ability to maintain their own
airway.
To assess the patient’s ability to cope with their
secretions.
Follow trache guidelines ie. Cuff down 24 hours prior
to decannulation
Blue dye test should be performed at this stage to
assess swallow.
Deflating the Cuff
Who?
Doctor, nurse or physio, who are
competent.
How?
Removing the Tracheostomy Tube
When?
Joint decision with doctor, nurses + physio.
Following tracheostomy guidelines:
(1) able to expectorate independently.
(2) minimum of 1 deep suction per shift.
(3) no sign of chest infection.
(4) FiO2 of less than 60%.
(5) Deflation of cuff for more than 24 hours.
Removing the Tracheostomy Tube
Who?
Doctor, Nurse or Physio who are competent.
How?
Ensure cuff fully deflated
Explanation to patient
Equipment – dressing, gauze, O2 mask, stitch
cutter.
Oximeter