TRACHEOSTOMY

• Tracheostomy is a
surgical opening that
surgeons make through to
the front of the neck and
into the windpipe
(trachea) for the  purpose
of airway management. It
can be temporary or
permanent and performed
as an emergency or
elective procedure. 
•A tracheostomy tube is
placed into the hole to
keep it open for breathing.
It provides an air passage
to help you breathe when
the usual route for
breathing is somehow
blocked or reduced. 
Tracheostomy care 

•The care which is provided

to avoid bacterial
contamination and
obstruction of tracheostomy
tube is known as
tracheostomy care. It
frequently varies depending
on the amount of secretions.
 Purpose of tracheostomy

TO MAINTAIN A TO PROMOTE TO SUBSTITUTE FOR TO OBTAIN A TO BYPASS AN

PATENT AIRWAY ADEQUATE EFFECTIVE SPECIMEN FOR OBSTRUCTED
THROUGH EXCHANGE OF COUGHING. ANALYSIS. UPPER AIRWAY.
REMOVAL OF OXYGEN AND
SECRETIONS. CARBONDIOXIDE.
 • Need for artificial airway.
• Upper airway obstruction
• Altered level of consciousness, such as
increasing lethargy obtundation,
producing inability to protect the lower
airway.
• Inability to clear lower airway secretions.
Indication  • Long-term unconsciousness or coma
• Disorders of respiratory control such as
congenital central hypoventilation or
central apnea.
• Foreign body obstruction.
• Diaphragm dysfunction.
• Chest wall injury.
 •No absolute contraindication exist to
tracheostomy.
Contraindication  •Relative 
• Skin infection
• Prior major neck surgery
• Laryngeal carcinoma
Tracheostomy kit
• One tracheostomy tube of the same size as insitu (with
introducer/obturator if applicable)
• One tracheostomy tube one size smaller (with introducer if
applicable)
• Spare inner tubes for double lumen trachea tube (if
applicable)
• Spare ties (cotton and/or velcro)
•  Scissors
•  Resuscitation bag and mask (appropriate size for patient)
•  One way valve (community use only - for resuscitation)
•  Wall or portable suction equipment
Contd............
•  Appropriate size suction catheters
•  0.9% sodium chloride ampoule and 1 ml syringe
•  One heat moisture exchanger filter (HME) or tracheostomy
bib
•  Fenestrated gauze dressing
•  Cotton wool applicator sticks
•  Water based lubricant for tube changes
•  Mucous trap with suction catheter for emergency suction
•  Occlusive tape (i.e. sleek)
•  5 or 10 ml syringe if cuffed to insitu 
Sterile gloves
Tracheostomy
tube
Spare inner tubes
Resuscitation
bag and mask
One way
valve
Wall or portable suction equipment
Suction catheters
Tracheostomy
bib
Mucous
trap
suction
catheter
Fenestrated
gauze
dressing
Occlusive
tape
Procedure 

Positioning
The patient's neck is extended over a
shoulder roll (Unless there is a
contraindication).

The anesthesiologist stands at the head

end of the bed, and under direct
laryngoscopy positions the endotracheal
tube (ETT) so that the cuff is midway at
the vocal cord level.
Incision

•We  routinely inject the skin

with 1% lidocaine with
1:100,000 epinephrine solution.
• A horizontal or vertical
incision centered on the inferior
border of cricoid cartilage may
be used. We routinely use a 3 - 4
cm vertical incision.
•  Placement of introducer needle
• A minimal dissection is performed onto the the
pretracheal tissue in order to push the thyroid isthmus
downward.
• The larynx is stabilized and pulled cephalad with the
operator’s hand.
• A bronchoscopy is then performed and the light reflex is
used to select the best site for the introducer needle.
• Placing the needle at the inferior edge of the light reflex,
the tip of the needle is directed caudad into the tracheal
lumen avoiding the posterior tracheal wall at all cost. 
• Placement of the tracheostomy tube

•  A tracheostomy tube is loaded onto the dilator.

• Female: a size 6 cuffed shiley tracheostomy tube is loaded onto
the 26  FR dilators.
•      Male: a size 8 cuffed shiley tracheostomy tube is loaded onto
the 28 FR dilators.

•  The dilator is then loaded on the safety ridge of the  stylet and
placed into the  tracheal lumen under direct visualization.
•            
  Confirmation of placement
● The bronchoscope is withdrawn from the ETT and introduced
via the tracheostomy tube. The placement is confirmed by
visualising the  carina.

   Securing the tube

● We routinely secure the tube with two sutures of  2 - 0 nylon on
each side of the flange. In addition, a tracheostomy tape is used
to hold the tube in place. 
Pre-procedure interventions

• Auscultate the chest to assess need

for suctioning.

• Assemble equipment:
tracheostomy care kit or individual
supplies.
Interventions during procedure
• Put on sterile gloves.
• Dip cotton tipped applicator H2O2 and clean skin around stoma.
Repeat as many times as needed to remove mucus from the skin.
Clean area behind the neck plate. Observe the condition of the
skin.
• Dip another applicator into normal saline. Rinse H2O2 and mucus
from skin.
• Use a dry 4x4 gauze sponge to wipe area if necessary.
• Hold neck plate steady with the fingers of one hand and remove
inner cannula with the other. Tracheostomy tube motion may
stimulate a cough or produce an uncomfortable sensation similar to
choking.
Continued steps of Interventions during procedure
● Place inner cannula in H2O2.  Use small brush or pipe cleaners
to scrub mucus from the inside of the cannula. If the mucus is
very thick, let the inner cannula soak at least 3 minutes. Repeat
process until the inner cannula is cleaned.
● Carefully reinsert inner cannula and lock it in place.
● If a tracheostomy dressing is needed, use pre-cut one in the
trach care kit, use a pre-cut drain dressing, or fold a 4x4
dressing into a V shape. Do not cut standard 4x4’s unless they
are tightly woven and do not fray or leave gauze filaments when
cut. 
Intervention of change tracheostomy ties
• Changing tracheostomy ties always required two people. At
least one person must be experienced in this procedure and
capable of handling accidental extubation. The tube is easily
dislodged by coughing when the tracheostomy tube is
manipulated.
• One person holds the tracheostomy tube in place by placing two
fingers directly on the neck plate. Apply firm pressure. Never
remove fingers until the new ties are tied and secured.
• 3/4 inch twill tape it is most comfortable for ties.
Contd...
• Always tie the twill with a square knot.
• Never position knots directly over the carotid artery or the
spinal cord.
• Tie knots with tension that allows two fingers to slip between
the skin and the tapes.
• Change tracheostomy ties when soiled and at least every 8
hours, initially. people with permanent tracheostomies
usually need them changed once a day.
Post procedure intervention

● Discard soiled disposable supplies, solutions and equipment.

Send non-disposable items for decontamination.
● Note the size and type of tracheostomy tube. Make sure there is
an identical tube placed at the head of the bed.
● Make sure the obturator is taped in an easily visible place.
● Replace equipment used.
CONTD.....
Document procedure. Note quality and quantity of any blood or mucus, and the skin
integrity. Document any unusual observation and notify physician.

If the person or significant others are being taught the procedure, document the progress.

Ensure that emergency situations may be handled appropriately e.g. of tracheal dilator or
tracheal hook kept in the room to assist in emergency tracheostomy tube replacement.
(this is not usually needed when the stoma has become well established). 
REFERENCES

Mandal.G.N.(2016).A Textbook of Medical Surgical

Nursing.(5th edition).Dillibazar Kathmandu :Makalu
Publication House.Page:114-117
Rai.L(2076-077).Textbook of Medical Surgical I and
II.(2nd edition).Kathmandu Nepal:Akshav
Publication.Page:106-107