ADULT HEALTH I POWERPOINT: TRACHEOSTOMY – Flashcards

A tracheostomy is a surgically created stoma (opening) in the trachea to establish an airway. • It is used to (1) bypass an upper airway obstruction (2) facilitate removal of secretions, and/or (3) permit long-term mechanical ventilation. Most patients who require mechanical ventilation are initially managed with an endotracheal tube, which can be quickly inserted in an emergency.

operating room using general anesthesia. done electively on patients already intubated who require prolonged mechanical ventilation. When swelling, trauma, or upper airway obstruction prevent endotracheal intubation, an emergent surgical tracheostomy may be performed at the bedside. A minimally invasive percutaneous tracheostomy can also be performed at the bedside using local anesthesia and some sedation/analgesia. A needle is placed into the trachea, followed by a guide wire. The opening is progressively dilated until it is large enough for insertion of a tracheostomy tube.

• A tracheostomy provides a more secure airway and is less likely to be displaced. • It allows more freedom of movement than an endotracheal tube. • There is less risk of long-term damage to the vocal cords. • Airway resistance and work of breathing are decreased, facilitating independent breathing. • Patient comfort may be increased because no tube is present in the mouth. • The patient can eat with a tracheostomy because the tube enters lower in the airway. • Speaking is also permitted once the tracheostomy cuff can be deflated.

-faceplate or flange, which rests on the neck between the clavicles and outer cannula. -obturator, which is used when inserting the tube. During insertion of the tube, the obturator is placed inside the outer cannula with its rounded tip protruding from the end of the tube to ease insertion. After insertion, the obturator must be immediately removed so air can flow through the tube -Keep obturator at bedside in case of accidental decannulation. -Some tracheostomy tubes also have an inner cannula, which can be removed for cleaning. The inner cannula can be disposable or nondisposable. -Both cuffed and uncuffed tracheostomy tubes are available. -A tracheostomy tube with an *inflated cuff is used if the patient is at risk of aspiration or needs mechanical ventilation*. -An external pilot balloon provides a visual of internal cuff inflation.

PA: airway patency, lung sounds, need for suctioning, bleeding around newly formed tracheostomy, mechanical ventilator settings, and neurological assessment. Emergency Equipment: tracheostomy setup at bedside & second tracheostomy tube (same size), forceps taped to head of bed. The obturator from the present trach should be readily available in case of decannulation. Suction equipment also needs to be present.

1. Assess respiratory status 2. Suction prn 3. *Position with HOB elevated 30-40 degrees* 4. Provide *100% humidification of inspired air* 5. Provide adequate systemic hydration 6. Tape a second tracheostomy tube and forceps to head of bed 7. Stoma care and clean inner cannula every 4-8 hours 8. Maintain inflation of tracheostomy cuff with minimal leak 9. Suction oropharynx prn 10. Provide frequent oral care 11. Provide for means of communication.

Complications: Airway obstruction, air leak, aspiration, bleeding, fistula formation, infection, subcutaneous emphysema, tracheal stenosis, tracheal necrosis, tube displacement Every month

1. Assess A.M.'s ability to exchange air and adequately expectorate secretions prior to removal. 2. Close the stoma with tape and apply an occlusive dressing. Change dressing if it gets soiled or wet. Stoma should close within 4-5 days.

• The inner cannula can be disposable or nondisposable. If disposable, replace per manufacturer and institutional guidelines. If nondisposable, the inner cannula is cleaned at least every 8 hours. Cleaning removes mucus from the inside of the tube to prevent airway obstruction. • If humidification is adequate, mucus may not accumulate, and a tube without an inner cannula can be used.

1. Explain procedure to patient. 2. Use tracheostomy care kit or collect necessary sterile equipment (e.g., suction catheter, gloves, water basin, drape, tracheostomy ties, tube brush or pipe cleaners, 4 × 4 gauze pads, sterile water or normal saline, and tracheostomy dressing [optional]). Note: Clean rather than sterile technique is used at home. 3. Position patient in semi-Fowler's position. 4. Assemble needed materials on bedside table next to patient. 5. Wash hands. Put on goggles and clean gloves. 6. Auscultate chest sounds. If rhonchi or coarse crackles are present, suction the patient if unable to cough up secretions. Remove soiled dressing and clean gloves. 7. Open sterile equipment, pour sterile H2O or normal saline into two compartments of sterile container or two basins, and put on sterile gloves. Note: Hydrogen peroxide (3%) is no longer recommended unless an infection is present. If used, the inner cannula and skin must be rinsed with sterile H2O or normal saline afterwards to prevent trauma to tissue. 8. Unlock and remove inner cannula, if present. Many tracheostomy tubes do not have inner cannulas. Care for these tubes includes all steps except for inner cannula care. 9. If disposable inner cannula is used, replace with new cannula. If a nondisposable cannula is used: • Immerse inner cannula in sterile solution and clean inside and outside of cannula using tube brush or pipe cleaners. • Rinse cannula in sterile solution. Remove from solution and shake to dry. • Insert inner cannula into outer cannula with the curved part downward and lock in place. 10. Remove dried secretions from stoma using 4 × 4 gauze pad soaked in sterile water or saline. Gently pat area around the stoma dry. Be sure to clean under the tracheostomy faceplate, using cotton swabs to reach this area. 11. Maintain position of tracheal retention sutures (if present) by taping above and below the stoma. 12. Repeat care 3 times/day and as needed.

A slit is cut about 1 inch (2.5 cm) from the end. The slit end is put into the opening of the cannula. A loop is made with the other end of the tape. The tapes are tied together with a double knot on the side of the neck. A tracheostomy tube holder can be used in place of twill ties to make tracheostomy tube stabilization more secure. A two-person technique, one to stabilize the tracheostomy and one to change the ties, is best to ensure that the tracheostomy does not become accidentally dislodged during the procedure. Place two fingers underneath the ties to assure they are not too tight around the neck. *Do not change tracheostomy ties for 24 hours after the tracheostomy procedure*

Assess the need for suctioning q2hr. Indications include: coarse crackles or rhonchi over large airways moist cough increase in peak inspiratory pressure on mechanical ventilator restlessness or agitation if accompanied by decrease in SpO2 or PaO2 *Do not suction routinely or if patient is able to clear secretions with cough*

0. Explain procedure to patient. 1. Collect necessary sterile equipment: suction catheter (no larger than half the lumen of the tracheostomy tube) gloves sterile water cup drape If a closed tracheal suction system is used, the catheter is enclosed in a plastic sleeve and reused . 2. Check suction on source and regulator. Adjust suction on pressure until the dial reads −120 to −150 mm Hg pressure with tubing occluded 3. Assess SpO2 and heart rate and rhythm to provide baseline for detecting change during suctioning.

4. Wash hands & goggles. Sterile technique to open package, fill cup with sterile water, sterile gloves, and connect catheter to suction tubing. 5. Designate one hand as contaminated for (1) connecting/disconnecting the tubing at the suction catheter (2) using the resuscitation bag (3) operating the suction control. 6. Suction sterile water through the catheter to test the system. 7. Provide preoxygenation for a minimum of 30 seconds by (1) adjusting ventilator to deliver 100% O2 (2) using a reservoir-equipped manual resuscitation bag (MRB) connected to 100% oxygen (3) asking the patient to take 5-6 deep breaths while administering oxygen 8. The method chosen will depend on the patient's underlying disease and acuity of illness. The patient who has had a tracheostomy for an extended period of time and is not acutely ill may be able to tolerate suctioning without use of an MRB or the ventilator. 9. Gently insert catheter *without suction* to minimize the amount of oxygen removed from the lungs. Insert the catheter to the point where the patient coughs, resistance is met, or 0.5-1.0 cm beyond the length of the artificial airway. *Withdraw the catheter 0.5-1.0 cm* before applying suction to prevent trauma to the carina. 10. Apply suction intermittently, while withdrawing catheter in a rotating manner. If secretion volume is large, apply suction continuously. Suction should be applied for as short amount of time as possible to minimize decreases in arterial oxygenation levels. 11.*Limit suction time to 10 seconds*. *Discontinue suctioning* if heart rate decreases from baseline by 20 beats/min, increases from baseline by 40 beats/min, a dysrhythmia occurs, or SpO2 decreases to less than 90%. 12. After each suction pass, oxygenate for at least 30 seconds with 5-6 breaths by ventilator, MRB, or deep breaths with oxygen. 13. Rinse catheter with sterile water between suction passes. 14. Repeat procedure until airway is clear. Limit insertions of suction catheter to as few as needed. *If airway is not clear after 3 suction passes, allow the patient to rest before additional suctioning*. 15. Return oxygen concentration to prior setting. 16. Rinse catheter and suction the oropharynx or use mouth suction.

17. Dispose of catheter by wrapping it around fingers of gloved hand and pulling glove over catheter. Discard equipment in proper waste container. 18. Auscultate to assess changes in lung sounds. Record time, amount, and character of secretions and response to suctioning.

If patient is on a ventilator, the use of a closed system suction catheter is preferred in order to minimize breaks in the system and decrease the risk of ventilator-associated pneumonia. Nonsterile gloves are worn during the suctioning procedure as sterility of the suction catheter is maintained within the closed system.

Inflate cuff with minimum volume required to create an airway seal A tracheostomy tube with an inflated cuff is used if the patient is at risk of aspiration or needs mechanical ventilation. Because an inflated cuff exerts pressure on the tracheal mucosa, it is important to inflate the cuff with the minimum volume of air required to obtain an airway seal. Cuff inflation pressure should not exceed 20 mm Hg or 25 cm H2O because *higher pressures may compress tracheal capillaries, limit blood flow, and predispose to tracheal necrosis*

MOV (minimal occlusion volume): slowly inject air into the cuff until no leak (sound) is heard at peak inspiratory pressure (end of ventilator inspiration) when a stethoscope is placed over the trachea. MLT (minimal leak technique) inflate the cuff to minimal occlusion pressure and then withdrawing 0.1 mL of air.

Verify pressure is within accepted range (≤20 mm Hg or ≤25 cm H2O) with a manometer. Record cuff pressure and volume of air used for cuff inflation in chart. Monitor and record cuff pressure q8hr (every 8 hr) Cuff pressure should be ≤20 mm Hg or ≤25 cm H2O to allow adequate tracheal capillary perfusion. If needed, remove or add air to the pilot tubing using a syringe and stopcock. Afterward, verify cuff pressure is within accepted range with manometer.

Inability to keep the cuff inflated or need to use progressively larger volumes of air to keep cuff inflated Potential causes include tracheal dilation at the cuff site or a crack or slow leak in the housing of the one-way inflation valve. If the leak is due to tracheal dilation, the physician may intubate the patient with a larger tube. Cracks in the inflation valve may be temporarily managed by clamping the small-bore tubing with a hemostat. The tube should be changed within 24 hr.

Routine cuff deflation is no longer recommended. When the patient is not at risk for aspiration, the cuff may be deflated to allow the patient to talk and make swallowing easier. Before deflation, have the patient *cough* up secretions, if possible, and suction the tracheostomy tube and then the mouth. This step is important to prevent secretions from being aspirated during deflation. The cuff is deflated during exhalation because the exhaled gas helps propel secretions into the mouth. Have the patient cough and then suction the tube after cuff deflation. Assess the ability of the patient to protect the airway from aspiration. Remain with the patient when the cuff is initially deflated. If needed, reinflate the cuff during inspiration.

Retention sutures may be placed in the tracheal cartilage when the tracheostomy is performed. -If present, tape the free ends to the skin in a place and manner that leaves them accessible if the tube is dislodged. Take care not to dislodge the tracheostomy tube during the first 5 to 7 days when the stoma is not mature (healed).

Keep a replacement tube of equal or smaller size at the bedside, readily available for emergency reinsertion. Do not change tracheostomy tapes for at least 24 hours after the insertion procedure. A physician performs the first tube change, usually no sooner than 7 days after the tracheostomy.

Immediately attempt to replace it. Grasp the retention sutures (if present) or use a hemostat to spread the opening to facilitate replacing the tube. Insert the obturator in the replacement tube, lubricated with saline poured over the tip, and insert the tube into the stoma at a 45-degree angle to the neck. Once inserted, remove the obturator immediately so that air can flow through the tube. Another method is to insert a suction catheter to allow passage of air and to serve as a guide for insertion. Thread the tracheostomy tube over the catheter and remove the suction catheter.

Assess the level of respiratory distress. Position the patient in the *semi-Fowler's* position to alleviate minor dyspnea until assistance arrives. Severe dyspnea may progress to respiratory arrest. If respiratory arrest occurs, cover the stoma with a sterile dressing and ventilate the patient with bag-mask ventilation over the nose and mouth until help arrives. If a patient has had a total laryngectomy, there will be complete separation between the upper airway and the trachea--> *Ventilate this patient through the tracheostomy stoma.*

Initially, tracheostomy patients should receive humidified air to compensate for the loss of the upper airway to warm and moisturize secretions. Humidification is essential to keep prevent retention of tenacious secretions and formation of mucous plugs. *Change the tube approximately once a month after the first tube change*. When a tracheostomy has been in place for several months, the healed tract will be well-formed. *Teach the patient to change the tube using a clean technique at home*. Monitor the patient for potential complications

1. airway obstruction 2. air leak 3. altered body image 4. aspiration 5. bleeding 6. fistula formation 7. impaired cough 8. infection 9. subcutaneous emphysema 10. tracheal stenosis 11. tracheal necrosis 12. and/or tube displacement.

*inflated cuff may result in swallowing dysfunction* because the cuff interferes with the normal function of muscles used to swallow. EVALUATE SWALLOWING ABILITY and risk for aspiration with the cuff deflated. Clinical assessment of the patient's ability to swallow is assessed by a speech therapist, videofluoroscopy, or fiberoptic endoscopic evaluations. If the patient is able to swallow without aspirating when the cuff is deflated, the cuff may be left deflated or a cuffless tube substituted.

The spontaneously breathing patient may be able to talk by deflating the cuff, which allows exhaled air to flow upward over the vocal cords. This can be enhanced by the patient occluding the tube. However, this method is discouraged because bacteria from the fingers can lead to infection. Specialized tracheostomy tubes and speaking valves are available to facilitate speech. Advocating for the use of these devices will provide psychologic benefits and facilitate self-care for the patient with a tracheostomy.

• A fenestrated tube has openings on the surface of the outer cannula that permit air from the lungs to flow over the vocal cords. • A fenestrated tube allows the patient to breathe spontaneously through the larynx, speak, and cough up secretions while the tracheostomy tube remains in place.

• Air passes from the lungs through the openings in the tracheostomy into the upper airway and out the mouth and nose. • Only patients who can swallow without risk of aspiration can use this tube.

The inner cannula can be fenestrated or non-fenestrated. Use a non-fenestrated inner cannula when suctioning to decrease risk of tracheal damage caused by the suction catheter going through the openings. The non-fenestrated inner cannula is also used whenever the patient needs to be mechanically ventilated.

Before using the fenestrated tube, determine the patient's ability to swallow without aspiration. If there is no aspiration (1) remove the inner cannula (if non-fenestrated), (2) deflate the cuff (3) place the decannulation cap in the tube. *It is important to perform the steps in order* because severe respiratory distress may result if the tube is capped before removing the inner cannula and deflating the cuff. When a fenestrated cannula is first used, frequently assess the patient for signs of respiratory distress. If the patient is not able to tolerate the procedure, remove the cap, insert a non-fenestrated inner cannula, and reinflate the cuff.

A disadvantage of fenestrated tubes is the potential for development of tracheal polyps from tracheal tissue granulating into the fenestrated openings.

• A speaking tracheostomy tube has two pigtail tubings. • One tubing connects to the cuff and is for cuff inflation, and the second connects to an opening just above the cuff. • When the second tubing is connected to a low-flow (4 to 6 L/min) air source, sufficient air moves up over the vocal cords to permit speech. • This device allows a patient at risk for aspiration to speak with the tracheostomy cuff inflated. • However, speech quality is typically poor, with the patient barely speaking above a whisper. *can be used on patients at risk for aspiration*

These valves contain a thin plastic diaphragm that opens on inspiration and closes on expiration. During inspiration, air flows in through the valve. During expiration, the valve prevents exhalation, and air flows upward over the vocal cords and into the mouth, allowing normal speech patterns.

When a speaking tracheostomy valve is used, a cuffless tube must be in place, or the cuff needs to be deflated to allow exhalation. Prior to attaching a speaking valve, it is important to evaluate the patient's ability to tolerate cuff deflation without aspiration or respiratory distress. Once the speaking valve is in place, carefully assess the patient's ability to breath. The patient may initially only be able to tolerate short periods of use until becoming acclimated to exhaling through the mouth. Remove the valve immediately if the patient demonstrates any signs of respiratory distress.

If speaking devices are not used, provide the patient with a paper and pencil or Magic Slate. A communication board with pictures of common needs and an alphabet for spelling words is useful for patients who are weak and/or have difficulty writing. Magic slate, picture board, Alphabet board, paper and pencil

When the patient can adequately exchange air and expectorate secretions, the tracheostomy tube can be removed.

• The stoma is closed with tape strips and covered with an occlusive dressing. • The dressing must be changed if it gets soiled or wet. • Instruct the patient to splint the stoma with the fingers when coughing, swallowing, or speaking. • Epithelial tissue begins to form in 24 to 48 hours, and the opening will close within 4 to 5 days. • Surgical intervention to close the tracheostomy is not required.

tracheostomy care kit or collect necessary sterile equipment (e.g., suction catheter, gloves, water basin, drape, tracheostomy ties, tube brush or pipe cleaners, 4 × 4 gauze pads, sterile water or normal saline, and tracheostomy dressing [optional]). Note: Clean rather than sterile technique is used at home.