Tracheostomy Care and

Management Compiled and Presented by:

Walaa Nasser

OUTLINEDefinition of terms

Indications

Contraindications

Proper placement according to anatomy

Management and Care

References

Definition of TermsDecannulation: 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.

Tracheostomy isA tracheostomy is an opening into the trachea through the neck just below the larynx through which an indwelling tube is placed and thus an artificial airway is created. It is used for clients needing long-term airway support.

how does it look likeTracheostomy tubes have an outer cannula that is inserted into the trachea and a flange that rests against the neck and allows the tube to be secured in place with tape or ties.

IndicationsTracheostomy tubes may be inserted for a number of reasons

Congenital anomaly (eg, laryngeal hypoplasia, vascular web)

Upper airway foreign body that cannot be dislodged with Heimlich and basic cardiac life support maneuvers

Supraglottic or glottic pathologic condition (eg, infection, neoplasm, bilateral vocal cord paralysis)

Neck trauma that results in severe injury to the thyroid or cricoid cartilages, hyoid bone, or great vessels

Subcutaneous emphysema

Facial fractures that may lead to upper airway obstruction (eg, comminuted fractures of the mid face and mandible)

Upper airway edema from trauma, burns, infection, or anaphylaxis

Prophylaxis (as in preparation for extensive head and neck procedures and the convalescent period)

Severe sleep apnea not amendable to continuous positive airway pressure devices or other less invasive surgery

Complications to Tracheostomy placementEarly Complications:

Bleeding

Air trapped around the lungs (pneumothorax)

Air trapped in the deeper layers of the chest(pneumomediastinum)

Air trapped underneath the skin around the tracheostomy (subcutaneous emphysema)

Damage to the swallowing tube (esophagus)

Injury to the nerve that moves the vocal cords (recurrent laryngeal nerve)

Tracheostomy tube can be blocked by blood clots, mucus or pressure of the airway walls. Blockages can be prevented by suctioning, humidifying the air, and selecting the appropriate tracheostomy tube.

Later Complications that may occur while the tracheostomy tube is in place include:

Accidental removal of the tracheostomy tube (accidental decannulation)

Infection in the trachea and around the tracheostomy tube

Windpipe itself may become damaged for a number of reasons, including pressure from the tube; bacteria that cause infections and form scar tissue; or friction from a tube that moves too much

Proper Placement

Purpose of care★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

Assessment★Respiratory status (ease of

breathing, rate, rhythm, depth, lung sounds, and oxygen saturation level)

★Pulse rate

★Secretions from the tracheostomy site (character and amount)

★Presence of drainage on tracheostomy dressing or ties

★Appearance of incision (redness, swelling, purulent discharge, or odor)

equipments usedSterile disposable tracheostomy cleaning kit or supplies (sterile containers, sterile nylon brush or pipe cleaners, sterile applicators, gauze squares)

Sterile suction catheter kit (suction catheter and sterile container for solution)

Sterile normal saline (Check agency protocol for soaking solution)

Sterile gloves (2 pairs)

Clean gloves

Towel or drape to protect bed linens

Moisture-proof bag

Commercially available tracheostomy dressing or sterile 4-in. x -in. gauze dressing

Cotton twill ties

Clean scissors

PROCEDUREstep by step

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.

1

2 Observe appropriate infection control procedures such as hand

hygiene.

3Provide for client privacy.

4Prepare the client and the equipment.

To promote lung expansion, assist the client to semi-Fowler’s or Fowler’s position.

Open the tracheostomy kit or sterile basins. Pour the soaking solution and sterile normal saline into separate containers.

Establish the sterile field.

Open other sterile supplies as needed including sterile applicators, suction kit, and tracheostomy dressing.

5 Suction the tracheostomy tube, if necessary.

Put a clean glove on your nondominant hand and a sterile glove on your dominant hand (or put on a pair of sterile gloves).

Suction the full length of the tracheostomy tube to remove secretions and ensure a patent airway.

Rinse the suction catheter and wrap the catheter around your hand, and peel the glove off so that it turns inside out over the catheter.

Unlock the inner cannula with the gloved hand. Remove it by gently pulling it out toward you in line with its curvature. Place it in the soaking solution. Rationale: This moistens and loosens secretions.

Remove the soiled tracheostomy dressing. Place the soiled dressing in your gloved hand and peel the glove off so that it turns inside out over the dressing. Discard the glove and the dressing.

Put on sterile gloves. Keep your dominant hand sterile during the procedure

6 Clean the inner cannula

Remove the inner cannula from the soaking solution.

Clean the lumen and entire inner cannula thoroughly using the brush or pipe cleaners moistened with sterile normal saline. Inspect the cannula for cleanliness by holding it at eye level and looking through it into the light.

Rinse the inner cannula thoroughly in the sterile normal saline.

After rinsing, gently tap the cannula against the inside edge of the sterile saline container. Use a pipe cleaner folded in half to dry only the inside of the cannula; do not dry the outside. Rationale: This removes excess liquid from the cannula and prevents possible aspiration by the client, while leaving a film of moisture on the outer surface to lubricate the cannula for reinsertion.

7Replace the inner cannula, securing it in place.

Insert the inner cannula by grasping the outer flange and inserting the cannula in the direction of its curvature.

Lock the cannula in place by turning the lock (if present) into position to secure the flange of the inner cannula to the outer cannula.

8Clean the incision site and tube flange.

Using sterile applicators or gauze dressings moistened with normal saline, clean the incision site. Handle the sterile supplies with your dominant hand. Use each applicator or gauze dressing only once and then discard. Rationale: This avoids contaminating a clean area with a soiled gauze dressing or applicator.

Hydrogen peroxide may be used (usually in a half-strength solution mixed with sterile normal saline; use a separate sterile container if this is necessary) to remove crusty secretions. Check agency policy. Thoroughly rinse the cleaned area using gauze squares moistened with sterile normal saline. Rationale: Hydrogen peroxide can be irritating to the skin and inhibit healing if not thoroughly removed.

Clean the flange of the tube in the same manner.

Thoroughly dry the client’s skin and tube flanges with dry gauze squares

9Apply a sterile dressing.

Use a commercially prepared tracheostomy dressing of non- raveling material or open and refold a 4-in. x 4-in. gauze dressing into a V shape. Avoid using cotton-filled gauze squares or cutting the 4-in. x 4-in. gauze. Rationale: Cotton lint or gauze fibers can be aspirated by the client, potentially creating a tracheal abscess.

Place the dressing under the flange of the tracheostomy tube.

While applying the dressing, ensure that the tracheostomy tube is securely supported. Rationale: Excessive movement of the tracheostomy tube irritates the trachea.

10Change the tracheostomy ties.

Change as needed to keep the skin clean and dry.

Twill tape and specially manufactured Velcro ties are available. Twill tape is inexpensive and readily available; however, it is easily soiled and can trap moisture that leads to irritation of the skin of the neck. Velcro ties are becoming more commonly used. They are wider, more comfortable, and cause less skin abrasion.

sample documentation

12/23/2012 0900H Respirations 18-20/min. Lung sounds clear. Able to expectorate secretions requiring little suctioning. Large amount of thick secretions cleansed from inner cannula. Inner cannuLa changed. Trach dressing changed. Skin around trach is intact but slightly red in color 0.2 cm around entire opening. No broken skin noted in the reddened area. — G. Wayne, RN

References http://nurseslabs.com/tracheostomy-nursing-management/

http://www.nhsggc.org.uk/about-us/professional-support-sites/shock-team/guidelines-for-care-of-patients-with-a-tracheostomy-tube/indication-for-a-tracheostomy/

http://www.nursebuff.com/2014/06/tracheostomy-care/

http://emedicine.medscape.com/article/865068-overview

http://www.hopkinsmedicine.org/tracheostomy/about/complications.html