tracheostomy-care

Perform Tracheostomy Care

A tracheostomy is a surgical procedure usually either temporary or permanent that involves
creating an opening in the neck in order to place a tube into a person’s wind pipe.
    The tube is inserted through a cut in the neck below the vocal cords( larynx) to allow air to enter the lungs.
Breathing is then done through the tube, bypassing the mouth, nose, and throat. A tracheostomy is
commonly referred to as a stoma. This is the name for the hole in the neck that the tube passes through.

Definition of Terms
>Decannulation: The process whereby a tracheostomy tube is removed once patient no longer
needs it.
> Humidification: The mechanical process of increasing the water vapour content of an inspired
gas.
> Stoma: An opening, either natural or surgically created, which connects a portion of the body
cavity to the outside environment (in this case, between the trachea and the anterior surface of
the neck).
> Tracheostomy: A surgical procedure to create an opening between 2-3 (3-4) tracheal rings into
the trachea below the larynx.
> Tracheal Suctioning: A means of clearing thick mucus and secretions from the trachea and lower
airway through the application of negative pressure via a suction catheter.
> Tracheostomy tube: A curved hollow tube of rubber or plastic inserted into the tracheostomy
stoma (the hole made in the neck and windpipe (Trachea) to relieve airway obstruction, facilitate
mechanical ventilation or the removal of tracheal secretions.

Indications of Tracheostomy Tube
  • A tracheostomy is performed to enhance breathing in conditions involving restricted airways.
    It may be done during an emergency when the airway is blocked or when a disease and other
    problems makes normal breathing impossible.
  • To by-pass an upper airway obstruction
  •  To facilitate removal of secretions and to prevent aspiration of secretions, food into the lungs
    when normal swallowing is impossible because of a reduced state of unconsciousness or
    muscular paralysis
  •  To permit long-term mechanical ventilation in permanent airway obstruction
  •  To permit oral intake and speech in a patient without aspiration.
  •  To provide easier access to the lower airways than possible through the nose or mouth.
Conditions that may require a tracheostomy include:

• Anaphylaxis
• Birth defects of the airway
• Burns of the airway from inhalation of corrosive material
• Cancer in the neck
• Chronic lung disease
• Coma
• Diaphragm dysfunction

• Facial burns or surgery
• Infection
• Injury to the larynx or laryngectomy
• Injury to the chest wall
• Need for prolonged respiratory or ventilator support
• Obstruction of the airway by a foreign body
• Obstructive sleep apnea

Patients who may benefit from tracheostomy:
  1.  Patients requiring prophylactic tracheostomy- as a pre-operative requirement for other surgical
    conditions such as thoracic surgery, etc.
  2.  Apneic patients after stabilizing cardiac arrest
  3.  Unconscious patients with inadequate ventilation
  4.  Patients in respiratory failure and may need respiratory assistance for periods longer than 1-2
    days.
  5.  Patients with head, neck and chest injuries with results of bleeding, oedema, unconsciousness,
    muscular paralysis, fractured larynx and trachea, flail chest, etc
  6.  Patients with fulminating conditions of the mouth, and throat such as diphtheria, Ludwig’s
    angina, tonsillitis, etc
  7.  Patients with upper air way tract obstruction
  8.  Patients with accumulated secretions in the lower tracheobronchial tree which could cause
    hypoxia and Atelectasis.
  9.  Patients with severe burns of the face neck and around the head
  10.  Patients who have had partial thyroidectomy with bleeding in the surrounding neck tissue.
  11.  Patients with neurological disorders which impair the act of swallowing such as head injury
    patients drug over dose, CVA, bulbar paralysis.
  12.  Patients with severe pulmonary oedema who have poor gas transport across the alveolar
    capillary membrane.
Providing Tracheostomy Care

Purposes/Aims
—To maintain airway patency by removing mucus and encrusted secretions.
—To maintain cleanliness and prevent infection at the tracheostomy site
—To facilitate healing and prevent skin excoriation around the tracheostomy incision
—To promote comfort
—To prevent displacement

Equipment of tracheostomy Care

Top Shelf

  • Pack with the following:
    Tracheal dilators of different
    sizes
  • 2 Artery forceps
  • 3 Gallipots
  • 2 Receivers
  • Pair of scissors
  • Tray with 2 small tracheostomy tubes one smaller than the other
  • Appropriate suction
  • catheter
  • Three receivers
  • Sterile dressing pack

Bottom Shelf

  • Sterile gloves
  • Mouth care tray
  • Bell
  • Pen and paper
  • Sodium bicarbonate
  • 2 ml syringe
  • A bottle of Normal saline
  • Protective gears
  • Drum of sterile gauze swabs

Bedside

  • Hand washing equipment
  • Oxygen cylinder
  • Screen
  • Suction machine
  • Safety box
Pre-operative care for tracheostomy
  1.  Psychological preparation of the patient and relatives is very important. They must be reassured that
    the artificial opening will make the breathing much easier and a simple explanation given to them about
    the instruments that will be seen around the bed after operation.
  2.  Simple breathing exercise should be encouraged, it’s important to explain to the patient that forcible
    breathing is not necessary when a tracheostomy tube is in position.
    General pre-operative care
    Postoperative management-immediate post-operative care: this care must be done in an intensive care
    unit with enough resuscitation tools.
  3.  Patient is received in a warm bed in a recumbent position. When the patient gains consciousness,
    place in a sitting up position, this prevents chest complications. He should be kept in this position
    for 48 hours.
  4.  Take T, P, R, and B.P and observe for cyanosis, noisy, moist and laboured respirations, increased
    pulse rate and respirations
  5.  The patient’s room should be warm with increased oxygen content discharged in the air if
    possible or humidified oxygen is administered.
  6.  For communication purposes, a pen and a paper should be placed at the side of the bed and a
    bell for calling the nurse, but the patient can be taught to place the finger over the hole if the
    negus tube is not in position.
  7.  The nurse should carefully monitor the patient for vital signs, signs of haemorrhage and other
    complications for the first 24-48 hours.
  8.  Continuous suctioning and cleaning of the inner cannula in the first 12-24hours post-operatively
  9.  Continuous post-operative care:
  10.  Humidification: the tube must be covered by moist clean gauze which should be changed
    regularly if dried or soiled.
  11.  Maintain an open airway: suction and clean the tube as indicated. Prevent aspiration of water
    solutions through the tracheostomy and keep materials that may occlude the tube from the
    opening, e.g. bed-sheets, cover the opening with gauze moistened to prevent flies and insects
    from entering in.
  12.  Keep the appropriate equipment for resuscitation at bed side for any accident/obstruction.
  13.  Assess for obstruction signs, elevate the head of the bed, and auscultate the chest to determine
    the need for suctioning
  14.  Observe the patient for respiratory difficulty: note all the signs of obstructed airway and act
    accordingly. Check on the signs of complications and report immediately while you act to relieve
    the problem.
  15.  Periodically observe the tracheostomy for trauma or infection.
  16.  Practice asepsis: especially when suctioning, dressing the site of stoma to prevent direct
    introduction of micro-organisms into the airway
  17.  Provide adequate hydration: about 3 litres of fluid intake per day orally or intravenously to liquefy
    secretions and to maintain fluid lost. Keep record of input and output of fluids.
  18.  Be gentle: during suctioning since the tracheal mucosa is very delicate and movement of the tube
    during suctioning irritates the site and predisposes to infection, fistula, etc. prevent trauma on
    the tracheobronchial mucosa by frequently releasing the cuff as ordered to relieve pressure on
    the wall.
  19.  Keep the skin: clean and dry after suctioning. To avoid irritation of the skin around the tube, Zinc
    oxide may be applied.
  20.  Change dressings as necessary: in aseptic manner.
  21.  Alleviate a patient’s fear: by reassuring him/her on how to behave with the tracheostomy in place
    and give enough health education on tracheostomy care.
  22.  The rubber tube is changed within 24 – 48 hours by the Dr. and a silver tube after about 5 days.
  23.  The tube should be kept clean and aspiration may be needed almost constantly. The inner tubing
    can easily be changed with a spare inner tube if necessary and the contaminated one washed
    under running water and sterilized.
  24.  Feeding can be by NGT or intravenously until the patient is able to start normal feeding and
    swallowing reflex is tested by giving sterile water. When the patient no longer chokes with this,
    feeds are begun. (Some-times thickened fluids are easily managed than thin fluids.). in the 1st 24
    hours, I.V fluids are recommended, then later oral ones. Observe patient for aspiration.
  25.  Frequent mouth washes and personal hygiene should be carried out constantly. Mouth care is
    helpful in the prevention of inhalation of septic material.
  26.  After 48 hours, the patient may be allowed out of bed to an armchair or allowed to move around
    the room.
  27.  If the patient is up and about, never allow him take a bath unattended. The water should be
    shallow.
  28.  Should the patient slip, the nurse should pull out the plug because of risk of drowning.
Rules for tracheostomy management
  1. Scrub hands; wear disposable gloves and a mask.
  2. Use pre packed sterile disposable catheters.
  3.  Do not allow the catheter touch anything before aspirating the trachea.
  4.  Carryout suctioning as frequent as possible to prevent accumulation of secretions.
  5. Discard the catheter after aspiration.
  6. Replace the inner tube as required. A supply of autoclaved tubes should be available.
  7. Clean the tracheostomy tubes and renew dressing regularly. Keyhole gauze is used.
  8. Always inflate the lungs after the suction session.
Procedure of Tracheostomy care
  1.  Introduce self and verify the client’s identity using agency protocol. Explain to the client
    everything that you need to do, why it is necessary, and how can he cooperate. Eye blinking,
    raising a finger can be a means of communication to indicate pain or distress.
  2.  Observe appropriate infection control procedures such as hand hygiene.
  3.  Provide for client privacy.
  4.  Prepare the client and the equipment.
  5.  To promote lung expansion, assist the client to semi-Fowler’s or Fowler’s position.
  6.  Open the tracheostomy kit or sterile basins. Pour the soaking solution and sterile normal saline
    into separate containers.
  7.  Establish the sterile field.
  8.  Open other sterile supplies as needed including sterile applicators, suction kit, and tracheostomy
    dressing.
  9.  Suction the tracheostomy tube, if necessary
  10.  Clean the inner cannula.
  11. Replace the inner cannula, securing it in place.
  12. Clean the incision site and tube flange.
  13. Apply a sterile dressing.
  14. . Change the tracheostomy ties. Change as needed to keep the skin clean and dry.
  15. Tape and pad the tie knot, Place a folded 4-in. x. 4-in. gauze square under the tie knot, and apply tape over the knot.
    Rationale: This reduces skin irritation from the knot and prevents confusing the knot with the
    client’s gown ties
  16. Check the tightness of the ties. Frequently check the tightness of the tracheostomy ties and position of the tracheostomy tube. Rationale: Swelling of the neck may cause the ties to become too tight, interfering with
    coughing and circulation. Ties can loosen in restless clients, allowing the tracheostomy tube
    to extrude from the stoma
  17. Document all relevant information: Record suctioning, tracheostomy care, and the dressing
    change, noting your assessments.
Home Care Modifications
  •  Emphasize the importance of hand washing before performing tracheostomy care.
  •  Describe the function of each part of the tracheostomy tube.
  •  Explain the proper way on how to remove, change, and replace the inner cannula.
  •  Clean the inner cannula two or three times a day.
  •  Check and clean the tracheostomy stoma.
  •  Suction tracheal secretions if necessary.
  •  Assess for symptoms of infection (i.e., increased temperature, increased amount of secretions,
    change in color or odor of secretions).
  •  Advise and encourage parents to participate with the procedure in an effort to comfort the child
    and promote client teaching.
  •  Provide contact information for emergencies.
  •  Suctioning a Tracheostomy Tube
     Suctioning of tracheostomy tube is only done as necessary. Sterile technique must be observed.
    Nurses should be aware that there is a frequency for the need of suctioning during immediate
    postoperative period.

 

Suctioning

Suctioning of the tracheostomy tube is necessary to remove mucus, maintain a patent airway, and avoid tracheostomy tube blockages. The frequency of suctioning varies and is based on individual patient
assessment.
Indications for suctioning include:
• Audible or visual signs of secretions in the tube
• Signs of respiratory distress
• Suspicion of a blocked or partially blocked tube
• Inability by the child to clear the tube by coughing out the secretions
• Vomiting                                            • Desaturation on pulse oximetry
• Changes in ventilation pressures (in ventilated children)
• Request by the child for suction (older children)

Procedure Preparation

• Ensure Tracheostomy Kit is present
• Appropriate size suction catheters (with graduations if available)
• Tape measure with depth required for tracheostomy tube suctioning
• Appropriate suction pressure: correct suction pressure for use on a tracheostomy tube is 80-120mmHg
maximum when occluded. The Medigas suction gauges used on the wards are measured in kPa. The
equivalent of 80- 120mmHg is 10-16kPa.

Procedure

• Explain to the patient and their family that you are going to suction the tracheostomy tube.
• Apply eye protection
• Perform hand hygiene, apply non-sterile gloves
• Remove the mask or breathing circuit.
• Peel open suction catheter end and attach to suction tubing, check and adjust suction pressure gauge
to between 80 – 120 mmHg.
• Utilizing a non-touch technique gently introduce the suction catheter tip into the tracheostomy tube
to the pre-measured depth.
• Apply finger to suction catheter hole & gently rotate the catheter while withdrawing. Each suction
should not be any longer than 5-10 seconds.
• Assess the patient's respiratory rate, skin colour and/or oximetry reading to ensure the patient has not
been compromised during the procedure.
• Repeat the suction as indicated by the patient's individual condition.
• Look at the secretions in the suction tubing – they should normally be clear or white and
move easily through the tubing. Document changes from normal color and consistency
and notify the treating team if the secretions are abnormal color or consistency.
• Rinse the suction catheter with sterile water decanted into container (not directly from bottle).• Replace suction catheter into the packaging
• Dispose of waste, remove gloves and perform hand hygiene
Note:
• Suction catheters are to be routinely replaced every 24 hours or at any time if contaminated or
blocked by secretions.
• Suction water/and the container to be replaced every 24 hours.
• Routine use of 0.9% sodium chloride is not recommended as there is little clinical evidence to support
this. However, in situations where this may be of benefit e.g., thick secretions and/or to stimulate a
cough 0.5ml of 0.9% sodium chloride can be instilled into the tracheostomy tube immediately prior to
the suction procedure. 

Special safety considerations

Some patients may require assisted ventilation before and after suctioning. If required, this will be requested by the parent medical team or Respiratory
CNC.If the correct size suction catheter does not pass easily into the tracheostomy tube, suspect a
blocked or partially blocked tube and prepare for immediate tracheostomy tube change.

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