TRACHEOSTOMY CARE

Antonio Musa , an
Italian physician
performed , the first
documente case of a
d
successful tracheotomy in
a patient, who suffered
from a tonsillar
obstruction and recovered
from the
procedure. He
published his account in
1546.
In 1620, Habicot
performed the first
pediatric tracheotomy.
The procedure was
performed on a sixteen-
year-old boy who had
swallowed a bag of gold
in an attempt to keep the
gold from being stolen. The
bag became lodged in the
boy's esophagus and
obstructed his trachea.
After Habicot performed
the tracheotomy, he
manipulated the bag of
gold so that it would pass. It
was eventually recovered
per rectum.
 Friedrich III, German Emperor (1831 – 1888)
He had incurable cancer of the
larynx, which had been misdiagnosed
by the English doctor Morell
Mackenzie.When the error was
caught, it was too late to operate.
Later swelling by the tumor caused
the prince to begin to suffocate, and
so on February 9, 1888, a
tracheotomy was performed and a silver
tube was put. As a result of this
operation, Friedrich was unable
to speak for the remainder of his life,
and communicated through
writing. Friedrich ruled for only 99
days before his death.
 Elizabeth Taylor's
Taylor Tracheostomy
went to Europe,
awaiting production of Cleopatra. In
spring of 1961, she developed a
case of pneumonia, which led
to an emergency
tracheotomy and worldwide
talk of her impending death. The
swelling of sympathy was widely
thought to have influenced
Academy voters, who
awarded Taylor her first Best
Actress Oscar — Elizabeth later
commented, I knew it was a
sympathy award,
competitor but I MacLaine
Shirley was still
proud to quipped,
memorably get it." "I Meanwhile,
lost to
Taylor's
tracheotomy!" a
 Stephen Hawking (physicist)

Stephen Hawking developed

motor neurone disease when he
was in his early 20s.
Most patients with the
condition die within five years,
and according to the Motor
Neurone Disease Association,
average life expectancy
after diagnosis is 14 months.
But Professor Hawking,
the Cambridge University
physicist and cosmologist and
author of A Brief History of
Time, has confounded the
statistics and recently
celebrated his 73rd birthday.
• A tracheostomy is the formation of an opening
into the trachea
usually between the second and third rings of
cartilage.
 Tracheostomy is done to
• provide mechanical ventilation on a long-term basis
as in cases of neuromuscular disease

• Facilitate weaning from mechanical ventilation by

decreasing anatomical dead space:A COPD patient on
mechanical ventilation

• To bypass obstruction: Cancer larynx

• To maintain an open airway: A comatose patient

• To remove secretions more easily: Inability to swallow

or cough: stroke patient
 Types of Tracheostomy

• Surgical tracheostomy: performed in the OR or

at bedside under moderate sedation
• Percutaneous dilatational tracheostomy
is done at the patient’s bedside,
usually in the ICU setting.
contraindicated in anatomical
irregularities or coagulation problems.
Temporary Tracheostomy versus
Permanent
• Appearance is the same
• Temporary: The upper airway will
remain connected to the lower airway if
the tracheostomy tube were to be
dislodged

• Permanent: The larynx is removed and no

connection exists between the upper
airway and the trachea itself
 Nasociliary
clearance and
humidification
lost Redundant
Laryngeal area between
bypass stoma and
larynx

Disruption of
Reduction
normal
in
swallowing
respiratory
mechanism
dead space
 Upper airway obstruction
Congenital Laryngeal web/cysts, B/L choanal atresia,
Tracheo- esophageal fistula, Subglottic/tracheal
stenosis
Infective Acute epiglottitis, Diphtheria, Acute
layngotracheobronchitis, Ludwig’s angina
Trauma External injury to larynx/trachea, maxillofacial
injury, inhalational injury
Neoplasm Tumours of larynx, pharynx, tongue, upper trachea

Foreign Body Foreign body lodged in larynx

Vocal cords B/L abductor paralysis

 Removal of secretions and protection
of tracheobronchial tree from
aspiration
 Neurological diseases- GBS
 Coma- head injury, poisoning, tumour
 In such situations- laryngeal/pharyngeal
incompetence
 Respiratory failure
 Tracheostomy- dead space, effort of
breathing, alveolar ventilation
 Ease of removal of secretions
 Pulmonary diseases- exacerbation of chronic
bronchitis, emphysema, severe pneumonia
 Severe chest injury- flail chest
 Prolonged ventilation
 T-tube more secure than ET tube; easier to wean
off vent
 >3wks of intubation
 length of ventilation and hospital stay

 As a part of another procedure

 Temporary tracheostomy in head and
neck surgeries
 TEMPORARY/PERMANENT:
 Temporary tracheostomy- elective or
emergency
 Permanent tracheostomy-as part of operation
involving removal of larynx

 HIGH/MID/LOW:
 High- above isthmus via 1st
tracheal ring
 Mid- through 2nd-3rd tracheal
 cuffed or uncuffed
 Single or double lumen tubes
 Adjustable flange long tube
 Suction aid tracheostomy tube
 Tracheostomy with speaking
valve
Identifying Tracheostomy
Parts
 Cuffed Tracheostomy Tube
Consists of three
parts:
• Outer
cannula with
an inflatable
cuff and pilot
tube
• An inner
cannula
• An obturator
 Fenestrated Tube

• Have an opening on the

posterior wall of outer
cannula allowing air to flow
through the upper airway and
hence allows patient to speak

• Often used during weaning

process
 Communication and
Tracheostomies

• Patients being
weaned off trach
tubes may have either
a cuffless or
fenestrated tube to
allow airflow past the
larynx
 Types of tubes based on
material:
 PVC
 Silicone
 Siliconed PVC
 Silastic
 Silver
 Armoured
 Fullers tube
 Immediate
 Haemorrhage
 Local injury-cricoid cartilage,
1st tracheal ring, carotid artery
recurrent laryngeal nerve
 Air embolism
 Apnoea
 Cardiac arrest
 Intermediate (1st few hours or days)
 Secondary haemorrhage
 Tube displacement
 Tube blockage
 Subcutaneous emphysema
 Pneumothorax
 Infection
 Tracheal necrosis
 Late complications
 Haemorrhage
 Granuloma formation
 Tracheo-oesophageal fistula
 Tracheo-cutaneous fistula
 Laryngotracheal stenosis
 Difficult decannulation
 Tracheostomy scar
Cont…

Narrowing of the airway above the site of tracheostomy

cont:

Tracheal ischemia and

necrosis
 Suction
 Regular suctioning
 Frequency depends on
individual basis
 Indications
 Appropriate size
of
 Suction catheter
 Method
 Tracheostomy tube change
 1st tube change- 5-7 days
 Frequency of tube change- no standard interval
 ‘if you can hear a tube, you should change it’
 Bougies or guidewires
 Nursing Care: Examination
• Be aware of when and why the trach was inserted , how it
was performed, the type and size of tube inserted

• Examine the patient at the start of visit.

Observe for signs of hypoxia, infection
or pain

• Chest: Auscultate breath sounds

• Examine trach tube, as well as stoma site for redness,

purulent drainage, and bleeding around the stoma
Tracheostomy Humidification
• The nose provides
warmth, moisture and
filtration for the air we
breath.
• Having a tracheostomy
tube by-passes these
mechanisms
• so humidification must be
provided to keep
secretions thin and to
avoid mucus plugs
Nursing Care: Help to thin and mobilize
secretions

• Frequent repositioning,
• deep breathing and coughing,
• chest physiotherapy
• supplemental humidification
 Nursing Care - Suctioning
• Necessary for all trach patients
to remove secretions

• Routinely done 2x / day, but more

often if a newly placed
tracheostomy or when there is
infection present

• Suctioning activates
psychological and physiological
reflexes that make the
experience both uncomfortable
and frightening
Selecting a suction catheter
• Selection of the appropriate size suction
catheter is vital in reducing the risk of
trauma during suctioning
• Divide the internal diameter of the
tracheostomy by two, and multiply the
answer by three to obtain the French
gauge suction catheter:
– Size 8 tracheostomy tube (patient); (8mm/2) x
3
= 12; therefore, a size 12F gauge catheter is
suitable for suctioning
 Gathering equipment for suctioning
• PPE – (mask, goggles, gloves)
• Bottle of normal saline
• Appropriately sized suction
catheter
• Trach care kit
• Disposable inner cannula if
appropriate
• Oxygen source – connected
to patient
• Suction equipment regulator set at
80-120 mmHg
• Ambu bag to ventilate patient prior
to suctioning if appropriate
 Procedure for suctioning
• Place patient in semi-fowler’s position
• Select appropriate sized suction catheter
• Hyper oxygenate BEFORE each suction pass
(except patients with long-term tracheostomy)
• Insert catheter to a pre-measured depth
• Apply suction on withdrawal of catheter
• Limit suctioning to 5 seconds
• Use suction pressure between 80 – 120 mmHg
• Limit suctioning to 3 passes

• Discontinue if HR drops by 20; increases by 40,

produces arrhythmias, or decreases 02 < 90%
 Tracheostomy Ties

• Ties are generally changed daily

• To lower the risk of accidental trach tube

coming out, tie changes should be:-

performed by two people or

with new ties secured BEFORE old ties are
removed.
Maintenance of the inner cannula

• The majority of trach tubes have inner

cannulas that require cleaning one to three
times daily unless they are disposable
• Use sterile technique to clean the reusable
cannula with ½ strength hydrogen peroxide
and normal saline
Nursing Care – Trach cuff pressure
• Cuff pressure (balloon)
should be maintained at
20 mmHg of pressure via a
manometer – should be
assessed daily;

• if you don’t have a

manometer measuring
device – check With a
stethoscope placed on the
neck, inflate the cuff until
you no longer hear hissing;
deflate the cuff in tiny
increments until a slight
his returns….
Nursing care changing the Trach tube

• Tube changes can be

done safely on a 1-3
month basis using a clean
technique

• Silicon tubes can crack

and tear; soft PVC tubes
can stiffen with time
Nursing care: Tracheostomy Site Care and Dressing

• Clean stoma with

NS;
• Avoid using
hydrogen
peroxide unless
infection present
(as it can impair
healing) –
• Dressings
around the
stoma are
changed
 FAQs
• Can a patient eat with a
Tracheostomy:

– Yes…generally speaking (patient may need an

evaluation by a speech pathologist to
determine swallowing ability)
 FAQs
• Why can’t we use the
Passey Muir valve with the
cuff inflated?
– The speaking valve is a one-way
airflow mechanism. The
patient inhales air through the
speaking valve but exhales it
around the tracheostomy tube
and then through the nose or
mouth.

– If the cuff is inflated with a

speaking valve, the patient
will only be able to inhale air
and will not be able to exhale
since there will not be any
room around the
tracheostomy