KURSUS

PEMENTORAN
DALAM
KEJURURAWATAN
21/3/2023
DR NAJLAA RAIHANA JUHARI
PAKAR ORL HOSP. KUALA LIPIS​
AGENDA
• MANAGEMENT AND CARE OF
PATIENT WITH TRACHEOSTOMY IN
WARD

• PRACTICAL SESSION
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INTRODUCTION
• A tracheostomy is an opening through the neck into
the trachea. A tracheostomy opens the airway and
aids breathing.

• A tracheostomy may be done in an emergency, at the

patient’s bedside or in an operating room.

• Anaesthesia may be used before the procedure.

Depending on the person’s condition, the
tracheostomy may be temporary or permanent.
INDICATIONS FOR
TRACHEOSTOMY
• Obstruction of the mouth or throat
• Breathing difficulty caused by edema ,injury or pulmonary
conditions
• Airway reconstruction following tracheal or laryngeal
surgery
• Airway protection from secretions or food because of
swallowing problems
• Airway protection after head and neck surgery
• Long-term need for ventilator support
• Poor GCS recovery
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PARTS OF TRACHEOSTOMY TUBE

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TYPES OF TRACHEOSTOMY
TUBES-MATERIAL
• Tracheostomy tubes can be metal or plastic.
• Metal tubes are constructed of silver or stainless steel.
• Plastic tubes are most commonly used and can be made from polyvinylchloride or silicone.
• Polyvinyl chloride softens at body temperature (thermolabile), conforming to patient
anatomy and centering the distal tip in the trachea.
• Silicone is naturally soft and unaffected by temperature.
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TYPES OF TRACHEOSTOMY
TUBES-MATERIAL
Brands
 Portex- PVC
 Shiley - PVC
 TRACOE - PVC
 Bivona – silicone
 SUMI – PVC
 Chevaliar Jackson –
metal
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TYPES OF TRACHEOSTOMY
TUBES-DIMENSION
• The dimensions of tracheostomy tubes are given by their ID, OD, length, and curvature.
• When selecting a tracheostomy tube, the ID and OD must be considered.
• If the ID is too small, it will increase the resistance through the tube, make airway
clearance more difficult, and increase the cuff pressure required to create a seal in the
trachea.
• A tube with a larger OD will be more difficult to pass through the stoma.
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TYPES OF TRACHEOSTOMY
TUBES-LUMENS
• Single lumen vs double lumen.
• Inner cannula: 
• Some tracheostomy tubes are designed to be used with an inner cannula, and these are
called double lumen tracheostomy tubes.
• It has the safety advantage of being easily and quickly removed to relieve life threatening
obstruction due to blood clots or secretions
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TYPES OF TRACHEOSTOMY
TUBES-LENGTH
• Tracheostomy tubes are available in standard length or extra-length.
• Extra-length tubes are constructed with extra- proximal length (horizontal extra length) or
with extra-distal length (vertical extra length).
• This design also allows the cuffs to be alternatively inflated and deflated, which may
reduce the risk of tracheal-wall injury
• Differences in length exist between tubes of the same ID.
• Extra-proximal length facilitates tracheostomy tube placement in patients with a large
neck(eg, obese patients).
• Extra -distal length facilitates placement in patients with trachealmalacia or tracheal
anomalies.
• Care must be taken to avoid inappropriate use of these tubes, which may induce distal
obstruction of the tube
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TYPES OF TRACHEOSTOMY
TUBES-LENGTH
• Flexibility and adjustable flange: 
• Several tube designs have a spiral wire reinforced flexible design.
• These also have an adjustable flange design to allow bedside adjustments to meet extra
length tracheostomy tube needs.
• This is useful in obese patients or those with local tissue swelling, where the soft tissue
depth is increased.
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TYPES OF TRACHEOSTOMY
TUBES-CUFF
• Tracheostomy tubes can be cuffed or uncuffed.
• The cuff reduces aspiration and leakage of air during anaesthesia and positive
pressure ventilation.
• Specific types of cuffs used on tracheostomy tubes include high-volume low-
pressure cuffs,tight-to-shaft cuffs (low-volume high pressure),and foam cuffs.
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TYPES OF TRACHEOSTOMY
TUBES-FENESTRATION
• Fenestrations may be single or multiple and are sited at the site of maximum curvature of
the tracheostomy tube. With the inner cannula removed, the cuff deflated, and the normal
air passage occluded, the patient can inhale and exhale through the fenestration and
around the tube .
• This allows for assessment of the patient’s ability to breathe through the normal oral/nasal
route (preparing the patient for decannulation) and permits air to pass by the vocal cords
(allowing phonation)
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NURSING CARE FOR

TRACHEOSTOMY PATIENT
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PURPOSES OF NURSING 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
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ROLE FOR NURSING

• Observation – bleeding, respiration and oxygen saturation

• Suction - By small catheter, Intermittent, Every ½ H, Saline instillation, clean
inner tube
• Dressing – normal saline- passed under the shoulder of outer tube, never remove
the tube for dressing
• Periodic cuff deflation/inflation

• Never change the tie around the neck/ remove main tube- Except under doctor‘s observation
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WHAT TO OBSERVE?

• 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
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EQUIPMENTS USED
• Sterile 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/hydrogen peroxide 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
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STEP BY STEP –
PROCEDURES FOR
TRACHEOSTOMY CARE
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PROCEDURES

INTRODUCE HAND HYGIENE PREPARE PATIENT SUCTION AND REPLACE &

AND EQUIPMENT
AND EXPLAIN CLEAN DRESSING
Eye blinking,
Observe Suction , Clean the
raising a finger Open other Replace and secure
appropriate inner cannula,
can be a means of sterile supplies as inner cannula,
infection control incision site and tube
dressing under flange
communication to needed, position flange
procedures such as applied
indicate pain or the patient
hand hygiene.
distress
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PREPARE PATIENT AND

EQUIPMENTS
• Assist patient to a semi fowlers position
• Place sterile towel on patient’s chest
• Maintains aseptic
• Put on sterile gloves
• Assemble equipment’s,
a. Open the sterile tracheostomy kit, pour clorhexidine and sterile normal saline in separate gallipots.
b. Open other sterile supplies as needed including sterile applicators, suction kit and tracheostomy care kit
c. Put on face mask and eye shield.
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SUCTION
Why?
• Excessive mucous
• Ineffective cough
How frequently?
• Frequency of airway suctioning should be determined on a patient level, taking into
account factors such as viscosity and quantity of mucus, neurological and muscular
performance and presence of active cough reflexes and efforts.
When?
•  Noisy breathing (the sound of air bubbling through secretions, or a dry whistling)
•  Visible secretions at the tracheostomy tube opening
•  Cough with the sound of secretions in the tube
•  Rapid breathing or laboured breathing
•  Restlessness, crying in a child
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HOW TO DETERMINE
APPROPRIATE SIZE CATHETER?
• 2x (size of tracheostomy tube) – 2

• Ie : (2 x (7)) – 2 = 14-2=
• 12F FOR SIZE 7 TRACHEOSTOMY TUBE
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HOW DO YOU MEASURE FOR A

TRACHEOSTOMY SUCTION?
• Depth of insertion of the suction catheter needs to be
determined prior suctioning

• Using a spare tracheostomy tube of the same type and size

and insert suction catheter to measure the distance until just
about 10-15mm beyond the distal end
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CLEAN
• Unlock the inner cannula and remove it by gently pulling it out towards you in the line with its
curvature. Place the inner cannula in the bowl with hydrogen peroxide/sodium bicarbonate solution
• Remove the soiled tracheostomy dressing,discard the dressing
• Clean the flange of the tube using sterile applicators or gauze moistened with hydrogen peroxide
/chlorhexidine and then with normal saline. Use each applicator once only.
• Using the applicator or gauze once only, avoids contaminating a clean area with a soiled gauze.
• Remove the inner cannula from the soaking solution.
• Clean the lumen and entire cannula thoroughly using the brush.
• Rinse the cleaned cannula by rinsing it with sterile normal saline.
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REPLACE

• Replace the inner cannula and secure it in place

• Insert the inner cannula by grasping the outer
• Lock the cannula in place by turning the lock into position.
• This secure the flange of the inner cannula to the outer cannula
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DRESSING
• Apply sterile dressing.
• Open and refold a 4*4 gauze dressing into a ‘V’shape and place under the flange
on the tracheostomy tube. Do not cut gauze pieces.
• Ensure that the tracheostomy tube is securely supported while applying dressing.
• Change ties if needed (under doctor’s observation)
• Tracheostomy dressing should be done every 8 hours or whenever dressing are
soiled
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CUFFED TRACHEOSTOMY TUBE

Why the cuff?
• Bleeding
• Assisted ventilation
• Aspiration
Disadvantages of cuff
• Pressure on tracheal walls
• Suprastomal sump/collection
• Voice?
• Periodic cuff deflation
• Every 2 hours – for at least 5 minutes
• Tracheotomy tube cuffs require monitoring to maintain pressures in a range of 20-
25mmHg.
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ADDITIONAL NOTES ON
TRACHEOSTOMY NURSING CARE
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ASSIST IN CHANGING
TRACHEOSTOMY TUBE
When?
• Every1-4 weeks
How?
• Mask
• Patient’s position
• Suction & cuff deflation
• Old tube removal
• Local antiseptic cleaning – followed by drying
• New tube preparation; cuff inflation & deflation
• Tube insertion – from the side; jelly?
• Remove obturator/stilette, secure tube & inflate cuff
• Repeat suction, if required
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ASSIST IN CHANGING TIE/TAPE

• As shown during practical session

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PROBLEMS DURING
TRACHEOSTOMY CARE IN WARD
• Dislocation of tracheostomy tube.
• Bleeding from stoma or during suction.
• Blockage of tracheostomy tube.
• Aspiration and swallowing problems.
• Speaking problems.
• Subcutaneous emphysema
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HOW TO ASSESS BLOCKAGE OF

TUBE?
• Cotton wool
• Misting using mirror
• Airblast – hand
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