34 | Nursing2009 | August www.nursing2009.com

A TRACHEOSTOMY ISan opening in the ante-rior wall of the tracheainferior to the cricoidcartilage. Made surgical-

ly or percutaneously, it provides tra-cheal access for airway managementvia a temporary or permanent tra-cheostomy tube. Patients with tra-cheostomies aren’t limited to criticalcare settings and can be found in allnursing units. No matter where youwork, you need a basic understandingof the nursing care required for thesepatients. In this article, we’ll provide apractical overview.

When is a tracheostomyindicated?A tracheostomy can be used to bypassan acute or chronic upper airwayobstruction, allow removal of tracheo-bronchial secretions, and prevent aspi-ration of oral or gastric secretions inunresponsive patients. For patientswith chronic respiratory failure, it maybe performed to replace an endotra-cheal (ET) tube and facilitate long-term mechanical ventilation.1

Upper airway obstruction can resultfrom conditions such as tumors,inflammation, fracture, foreign bodies,or laryngeal spasm. Patients with pro-

longed unresponsiveness secondary tosuch conditions as drug intoxicationor traumatic brain injury may needa tracheostomy to maintain a patentairway.

In addition, patients needing an ETtube for 10 to 14 days or longer shouldbe considered possible candidates for atracheostomy.2 The most recentAmerican College of Chest Physiciansconsensus statement recommendinga specific time frame for conversionto tracheostomy was published in1989. These guidelines recommendedthe translaryngeal route (ET tube)if the need for an artificial airway is

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Learn all about managing a “trach” to protect your patient from complications.By Elizabeth Neville Regan, RN, MSN, and Lisa Dallachiesa, RN, BS

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How to care for a patient with a

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tomy

anticipated to be no longer than 10days, and favored tracheostomy if anartificial airway is anticipated forlonger than 21 days.3

The literature suggests that the earli-er the patient undergoes tracheostomy,the more likely he’ll benefit.3 Benefitsof tracheostomy include avoiding fur-ther direct laryngeal injury from the ETtube, facilitating airway suctioning andoral care, increasing patient mobility,improving patient comfort, allowingspeech, and facilitating oral feedings.4

Complications associated with trache-ostomy are largely determined by thetechnique used.

A peek at techniquesThe standard surgical tracheostomy(ST), also known as an open tra-cheostomy, is usually performed in theOR under general anesthesia. In percu-taneous dilatational tracheostomy(PDT), the tracheal stoma is createdthrough dilation of an incision ratherthan surgery. PDT may be performedunder local anesthesia, moderate seda-tion/analgesia, or general anesthesia inthe OR or at the bedside. Indicationsfor PDT are the same as for ST, butPDT requires careful patient selectionto assure a safe and successful out-come. (See Contraindications to PDT.)

Advantages of PDT over ST includeeliminating the need for general anes-thesia and the OR, and lower costs.5

Because the PDT requires a smaller

skin incision, patients experience lesstissue trauma and a lower risk of com-plications such as wound infection,wound scarring, and peristomal bleed-ing. And because the procedure can beperformed at the bedside in the ICU,PDT reduces the risk associated withtransferring critically ill patients tothe OR.

For a look at the types of tra-cheostomy tubes available and whythey’re used, see Tracheostomy tubedesign review.

What can go wrong?Early complications associated with STinclude bleeding, pneumothorax, airembolism, recurrent laryngeal nervedamage, and posterior tracheal wallinjury. Long-term complicationsinclude airway obstruction from accu-mulation of secretions or protrusion ofthe cuff over the opening of the tube,infection, rupture of the innominateartery, dysphagia, tracheoesophagealfistula, tracheal dilation, and trachealischemia and necrosis.1

The complication rate of PDT is lowand similar to that of ST, especially therates of major infection or bleeding.6

However, airway loss associated withtracheal tube displacement is signifi-cantly more likely to occur in PDT due

to the narrow dilated tract and lack offormal stoma creation.

Responding to inadvertentdecannulationTracheal tube decannulation (dislodg-ment) in the first few days after surgeryis a medical emergency. Keep suppliesfor reinserting the tube at the bedside,including suctioning equipment, a newtracheostomy tube with obturator(dilator), and a curved hemostat.Oxygen and equipment for ET intuba-tion also should be readily available.

If decannulation occurs, call theemergency response team to attemptreinsertion. Use a bag-valve mask toventilate your patient through theupper airway. Ventilate gently to pre-vent air from escaping through thestoma or carefully occlude the stomawith a gloved hand to maximize oxy-genation. The patient will be panicked,so stay with him and assure him thathelp is on the way.

When the emergency team arrives,a clinician will try to insert a new tra-cheostomy tube through the opening,using a hemostat and obturator. If shedoesn’t succeed and the patient’s condi-tion worsens, she may place an ETtube through his mouth to establishan airway.

If the patient has a disruptionbetween the upper and lower airways(for example, after tumor resection),making mask ventilation and endotra-cheal intubation through the upperairway impossible, ventilate himthrough the stoma. Monitor him tomake sure he’s adequately ventilatedand oxygenated before he’s preparedfor surgery.

To prevent accidental trachealdecannulation, make sure the tube isproperly secured, minimize manipula-tion of the tube and traction on thetube from oxygen or ventilator tubing,and teach the patient to move cau-tiously until the tract is healed.7

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Use the ventilator, not a manualresuscitation bag, to provide

hyperoxygenation beforesuctioning to reduce

hemodynamic changes.

Contraindications to PDT5

Absolute• Uncorrected coagulopathy• Infection over the site• Extreme ventilatory and oxygena-tion demands• Tracheal obstruction

Relative• Unfavorable neck anatomy• Emergency airway management

Tracheostomy care basicsProvide tracheostomy care every 4 to 8hours.8 Knowing how to properly carefor a patient with a tracheostomy isvital because inappropriate or inade-quate care may lead to complicationsand even death.

Although details vary depending onthe type of tracheostomy tube, tra-cheostomy care includes cleaning orchanging the inner cannula, changingthe dressing and tracheostomy tubeholder, and suctioning if needed. Mosttracheostomy tubes have disposableinner cannulas, which are replaced andsecured using aseptic technique. Neverclean and reuse a disposable cannula.

Reusable inner cannulas requirecareful cleaning. Perform handhygiene, don a face shield (or gogglesand mask) and sterile gloves, andmaintain aseptic technique during theprocedure. Unlock and remove theinner cannula and place it in a solu-tion of equal parts hydrogen peroxideand 0.9% sodium chloride unless themanufacturer directs otherwise.Remove encrusted secretions from thelumen with sterile pipe cleaners. Aftercleaning, rinse the cannula thorough-ly with sterile 0.9% sodium chloridesolution. Reinsert the inner cannulaand securely lock it into place.

While providing tracheostomy care,inspect the skin for signs of irritationor infection, such as erythema, pain, ordischarge. Thoroughly assess the skinaround the tracheostomy for evidenceof skin breakdown related to the tra-cheostomy device, tube securementdevice, or mucus and secretions.7

Clean the area around the trache-ostomy tube with a noncytotoxiccleanser using a sterile cotton-tippedapplicator. Then rinse the skin withwater and dry it gently with sterilegauze.6 If you see skin breakdown,consult a wound/ostomy/continencenurse for an individualized patientplan of care.

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Tracheostomy tube design review11

The healthcare market has exploded with tracheostomy tube designs in the last10 years. Here’s a quick look at how some of the various options compare.• Metal tracheostomy tubes aren’t commonly used today due to their expense,rigid construction, the lack of a cuff, and the lack of a 15 mm connector toattach a ventilator or bag-valve mask.• Plastic tracheostomy tubes soften at body temperature, conforming to patientanatomy and centering the distal tip in the trachea.• Uncuffed tracheostomy tubes are generally reserved forinfants and children because they are less traumatic to sur-rounding tissue. They allow airway clearance but provideno protection from aspiration.• Cuffed tracheostomy tubes allow for airway clearance,offer some protection from aspiration, and facilitatepositive-pressure ventilation when the cuff is inflated. High-volume, low-pressure cuffs are most commonlyused for adults.• Dual-cannula tracheostomy tubes have a disposable orreusable inner cannula, which is cleaned or replaced regularly; the inner cannu-la can be removed if the tracheostomy tube becomes occluded.• PDT tubes have a tapered distal tip and are designed for use with percuta-neous tracheostomies.• Minitracheostomy tubes are small bore, generally uncuffed, and used primarilyfor secretion clearance. They’re inserted into the trachea through the cricothyroidmembrane or the tracheal stoma after decannulation for administration of oxy-gen. They’re used primarily for patients who have problems with airway clear-ance because they allow bronchial lavage and suctioning with a 10 Fr suctioncatheter. They’re generally unsuitable for positive pressure ventilation.12

• Foam cuff tracheostomy tubes are self-inflating with a large diameter high-residual-volume cuff composed of polyurethane foam covered by a siliconesheath. The foam cuff addresses the issue of high lateral tracheal-wall pressuresthat lead to complications such as tracheal necrosis and stenosis. Before inser-tion, air in the cuff is removed by attaching a syringe to the pilot port. Once thetube is in place, the syringe is removed to allow the pilot port to open toatmospheric pressure (room air) and the cuff self-inflates. Once inflated, it con-forms to the size and shape of the patient’s trachea. Be sure to keep the pilotport open to prevent cuff deflation.• Adjustable flange tracheostomy tubes have a spiral wire reinforced flexibledesign with a longer proximal length facilitating placement in patients with alarge neck. The adjustable flange allows bedside adjustments to meet extra-length tracheostomy needs. Because the locking mechanism on the flanges tendsto deteriorate over time, these tubes are usually reserved for temporary use.• Fenestrated tracheostomy tubes are similar in construction to the standardcuffed tube, with the addition of an opening in the posterior portion of thetube above the cuff. They have a removable inner cannula and a plastic plug.With the inner cannula removed, the cuff deflated, and thenormal air passage occluded, the patient can inhale andexhale through the fenestrations and around the tube. Thistube allows clinicians to assess the patient’s ability tobreathe through the normal oral/nasal route (preparing thepatient for decannulation) and permits air to pass by thevocal cords (allowing phonation).

Absorbing secretions helps preventmaceration and skin breakdown. Placea prepackaged, sterile tracheostomydressing under the tube flanges. Alwaysuse a manufactured split sponge ratherthan cutting a gauze pad. Never placeanything with loose fibers around thestoma or tracheostomy tube becausethey can cause irritation.

Inform the healthcare provider ifsutures used to secure the tube afterinsertion are irritating the skin or pre-venting routine maintenance. Obtainan order for suture removal 7 daysafter tracheostomy tube insertion. Iftwill tape was used, change it to aVelcro-securing device as soon as pos-sible because it’s more comfortable andless likely to abrade the skin.7

Maintaining humidification isanother key nursing responsibility.Normally, the nasopharynx humidifiesinhaled air. Because the tracheostomytube bypasses the upper airway, youneed to provide adequate humidity tokeep the airway moist. In hospitalizedpatients, this can be accomplished by aheat and moisture exchanger on amechanical ventilator or a T-piece ortracheostomy mask. In addition, yourpatient must be properly hydrated; forexample, with I.V. fluids.

Monitor and record cuff pressuresevery shift and more often if the tube ischanged or repositioned, if the volume

of cuff air changes, or a leak occurs(see Maintaining safe, effective cuffpressures).

Suctioning tips and precautionsBecause the patient can’t cough effec-tively to clear secretions, be preparedto suction him as needed. Suctioningraises the risk of hypoxemia, bron-chospasm, and other adverse reactions,so suction only when needed, not on aset schedule, and suction for the short-est time necessary to clear secretions.Indications for suctioning includecoughing, secretions in the airway, res-piratory distress, presence of rhonchion auscultation, increased peak airwaypressures on the ventilator, anddecreasing SaO2 or PaO2.9

Besides hypoxemia and bron-chospasm, complications associatedwith suctioning include atelectasis,dysrhythmias (including bradycardia),increased intracranial pressure, and air-way trauma. Bradycardia is attributedto vagal nerve stimulation. Atelectasismay occur when the outer diameter ofthe suction catheter is greater thanone-half of the inner diameter of thetracheostomy tube, which can preventairflow around the catheter. Choosinga catheter that’s the right size can helpprevent greater negative pressures inthe airway and potentially minimizefalls in PaO2.10 Some tracheostomy

tube manufacturers provide a chart tohelp you choose the most appropriatesuction catheter for your patient, basedon the internal diameter of the trache-ostomy tube.

Suctioning can be an uncomfortableand scary experience for the patient, sothoroughly explain the procedure tohim before you start. Maintain aseptictechnique while suctioning.

To help prevent hypoxemia, hyper-oxygenate him before and after suc-tioning. As you suction, look for signsof hypoxemia, such as hypertension,dysrhythmias, and a drop in SpO2 bypulse oximetry. If this occurs, stopsuctioning and hyperoxygenate thepatient. Limit the duration of eachsuction pass to 10 to 15 seconds orless, and make only 1 or 2 passes.10

Limit suction pressure to 120 mm Hgor less to minimize airway trauma.

If the patient is on mechanical venti-lation, allow time for the increasedoxygen percentage to come throughthe ventilator tubing and reach thepatient. Use the ventilator, not a manu-al resuscitation bag, to provide hyper-oxygenation before suctioning toreduce hemodynamic changes.10

Don’t instill 0.9% sodium chloridebefore suctioning adults with an artifi-cial airway. Although irrigating thetube before suctioning was once stan-dard to help remove secretions, thispractice is no longer recommended forroutine care. Ensuring patients are ade-quately hydrated can facilitate removalof respiratory secretions.10

Document the patient’s responseeach time you suction, including hisvital signs, cardiac rhythm, oxygen sat-uration, amount and consistency ofsecretions, breath sounds, and the fre-quency of needed suctioning.

Communication tipsLosing the ability to communicate isincredibly stressful for a patient witha tracheostomy tube. Nonverbal inter-

38 | Nursing2009 | August www.nursing2009.com

Maintaining safe, effective cuff pressures The maximum acceptable tracheostomy tube cuff pressure is 25 mm Hg. Trachealcapillary perfusion pressure is normally 25 to 35 mm Hg; higher pressure exertedby the inflated cuff can produce tracheal ischemia and mucosal injury.

Cuff pressure management is an important aspect of care to prevent compli-cations associated with incorrect cuff pressures. The clinician who manages thetracheal cuff pressure will vary depending on the institution and the location ofthe patient. Low cuff pressure can lead to silent aspiration. Silent aspiration canbe defined as foreign material entering the trach or lungs without an outwardsign (coughing or respiratory difficulty). High cuff pressure could lead to trachealerosion or fistula. A common reason for high cuff pressure is a tube that’s toosmall in diameter, resulting in overfilling of the cuff to achieve a seal in the tra-chea. Another common cause of high cuff pressure is malposition of the tube.

ventions that can help facilitate commu-nication include sign language, gestures,lip reading, pointing, facial expressions,or eye blinking. Use simple devices,such as pencil and paper, magic slates,magnetic boards with plastic letters,symbol boards, and flashcards to helpthe patient communicate. Teach himand his family communication methodsappropriate for his condition. Considera consultation with a speech therapist toaid in communication.

Nutrition is an important aspect oftracheostomy care as well. The tra-cheostomy tube may impair swallow-ing and compromise the patient’snutritional status. He may also have aloss of appetite due to his altered air-way, which affects his sense of smell.Consult with a nutritionist to ensurehis nutritional needs are being met.

Breathe easyKnowing how a tracheostomy is per-formed, what equipment is used, andhow to respond if complications arisecan help you maintain your patient’srespiratory function and keep him safeand comfortable. ✧

REFERENCES

1. Smeltzer S, Bare B, Hinkle J, Cheever K.Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. 11th ed. Philadelphia, PA:Lipincott Williams and Wilkins; 2008:738-741.

2. Zollinger Jr, RM, Zollinger Sr, RM. Zollinger’sAtlas of Surgical Operations. 8th ed. New York,NY: McGraw-Hill; 2003.

3. Clum S, Rumbak M. Mortality and trache-ostomy. Crit Care Med. 2007;35(3):963-964.

4. Angel LF, Im S. Timing of tracheotomy andthe comparison of surgical vs. percutaneous di-lational tracheotomy. Pulmon Crit Care Update.2003;13(12).

5. Ernst A, Silvestri CA, Johnstone D. Interven-tional pulmonary procedures: guidelines fromthe American College of Chest Physicians.Chest. 2003;123(5):1693-1717.

6. Bhatti N, Mirski M, Tatlipinar A, Koch WM,Goldenberg D. Reduction of complication ratein percutaneous dilation tracheostomies. Laryn-goscope. 2007;117(1):172-175.

7. Dixon B, Tasota FJ. Inadvertent tracheal de-cannulation. Nursing. 2003;33(1):96.

8. Dennis-Rouse MD, Davidson JE. An evidence-based evaluation of tracheostomy care practices.Crit Care Nurs Q. 2008;31(2):150-160.

9. Higgins KM, Punthakee X. Meta-analysiscomparison of open versus percutaneoustracheostomy. Laryngoscope. 2007;117(3):447-454.

10. Joanna Briggs Institute. Tracheal suctioningof adults with an artificial airway. Best Practice.2000;4(4):1-6.

11. Hess D. Tracheostomy tubes and relatedappliances. Respir Care. 2005;50(4):497-510.

12. Urden L, Stacy K, Lough M. Thelan’s CriticalCare Nursing Diagnosis and Management. 5th ed.St. Louis, MO: Mosby; 2006:662-670.

Elizabeth Neville Regan is a nursing educator coordi-nator and Lisa Dallachiesa is a nursing educator atSuburban Hospital in Bethesda, Md.

The authors have disclosed that they have no financialrelationships related to this article.

www.nursing2009.com August | Nursing2009 | 39

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