Specialized Nursing Care
Subtopic:
Tracheostomy Care
A tracheostomy is a surgical procedure, which can be either short-term or long-term, that creates an opening in the neck to place a tube into the windpipe.
- The tube is inserted through an incision in the neck, below the voice box (larynx), allowing air to reach the lungs.
- Breathing then occurs through this tube, bypassing the mouth, nose, and throat. The opening in the neck where the tube is inserted is often called a stoma.
Glossary of Terms
Decannulation: The process of removing a tracheostomy tube when it is no longer required.
Humidification: Adding moisture to inhaled air.
Stoma: A surgically created opening connecting an internal body part to the outside (in this case, between the trachea and the front of the neck).
Tracheostomy: A surgical procedure creating an opening into the trachea, typically between the 2nd and 4th tracheal rings, below the larynx.
Tracheal Suctioning: Using negative pressure via a suction catheter to clear thick mucus and secretions from the trachea and lower airways.
Tracheostomy Tube: A curved, hollow tube made of rubber or plastic inserted into the tracheostomy stoma (the hole in the neck and windpipe) to relieve airway blockage, help with mechanical ventilation, or remove tracheal secretions.
Intubation: Inserting a tube into a body cavity, especially the trachea, to establish or maintain an open airway.
Mechanical Ventilation: Using a machine to support or control breathing.
Artificial Airways: Devices used to keep the airway open, such as endotracheal tubes, tracheostomy tubes, and laryngeal masks.
Respiratory Therapy: The medical field focused on the diagnosis, treatment, and prevention of breathing-related illnesses.
Oxygen Therapy: Providing extra oxygen to patients who cannot get enough oxygen on their own.
Pulmonary Hygiene: Practices to maintain healthy lungs and airways, such as deep breathing exercises, coughing, and methods to clear the airway.
Reasons for Needing a Tracheostomy
Indications for Tracheostomy:
Airway Obstruction:
Foreign objects in the airway: A tracheostomy can be a way to remove airway blockages that can’t be removed otherwise.
Blockage in the upper airway: A tracheostomy might be needed for sudden or ongoing blockages in the upper airway caused by something stuck, swelling, or damage.
Burns to the neck and face: Securing the airway with a tracheostomy may be necessary for patients with severe burns in these areas.
Growths in the air passage: Tracheostomies can help relieve airway obstruction caused by tumors in the voice box, trachea, or bronchi.
Muscle weakness affecting swallowing (Bulbar paralysis): Tracheostomy can help maintain an airway in patients with conditions causing weakness in the muscles of the tongue, palate, and throat.
Severe asthma attacks: When other treatments fail, a tracheostomy might be required in severe asthma cases.
Diphtheria: A tracheostomy can relieve airway obstruction caused by this infection.
Birth-related airway issues: Some congenital problems like laryngeal hypoplasia or vascular webs causing airway obstruction may require a tracheostomy.
Injury: Significant neck injuries affecting cartilage, the hyoid bone, or major blood vessels might necessitate a tracheostomy to secure the airway. It can be life-saving in cases of neck and airway trauma, such as gunshot wounds.
Air trapped under the skin (Subcutaneous Emphysema): If air buildup in the neck tissues compromises breathing, a tracheostomy might be performed.
Facial Fractures: Extensive fractures, especially in the mid-face and jaw, can obstruct the upper airway. A tracheostomy can ensure adequate breathing.
Swelling in the upper airway: Swelling due to trauma, burns, infection, or severe allergic reaction can compromise the airway. A tracheostomy can secure it.
Severe Sleep Apnea: As a last resort, a tracheostomy might be considered for severe sleep apnea not helped by other treatments, to keep the airway open during sleep.
Ventilation & Airway Management:
Reducing dead space in the airway: A tracheostomy can lessen the amount of air that doesn’t participate in gas exchange, making breathing easier.
Bypassing an upper airway blockage: A tracheostomy provides an alternative route for air, bypassing obstructions in the nose, mouth, pharynx, or larynx.
Long-term Artificial Ventilation: Prolonged intubation can damage tissues and increase breathing effort. A tracheostomy lowers this risk, aids communication, and reduces the effort needed to breathe, making it easier to wean off the ventilator.
Inability to Maintain an Airway Alone: Patients with reduced function in certain cranial nerves, brain stem damage, or low consciousness may be unable to keep their airway open. A tracheostomy ensures a secure airway for oxygen and ventilation.
Secretion Management & Aspiration Prevention:
Facilitating secretion removal and preventing aspiration: A tracheostomy can help remove airway secretions and prevent food or secretions from entering the lungs when swallowing is impaired due to unconsciousness or paralysis.
Other Indications:
Long-term mechanical ventilation for permanent airway obstruction: A tracheostomy can provide long-term ventilation for ongoing airway blockages.
Allowing oral intake and speech without aspiration: Patients unable to swallow normally can eat and drink safely without the risk of aspiration with a tracheostomy in place.
Easier access to lower airways: Tracheostomy provides direct access for suctioning and other airway management procedures.
Conditions Potentially Requiring a Tracheostomy
Conditions that may necessitate a tracheostomy include:
Anaphylaxis: Severe allergic reactions can cause airway swelling and constriction.
Birth Defects of the Airway: Some congenital abnormalities can affect the airway’s structure or function.
Burns of the Airway from Inhaling Harmful Substances: Inhaling corrosive materials can damage the airway.
Cancer in the Neck: Tumors can press on or block the airway.
Long-term Lung Conditions: Conditions like COPD or BPD can lead to long-term breathing problems.
Coma: Unconscious individuals may need a tracheostomy for airway maintenance and ventilation.
Diaphragm Problems: Weakness or paralysis of the diaphragm can impair breathing.
Facial Burns or Surgery: These can cause airway swelling or obstruction.
Infection: Severe airway infections like epiglottitis can compromise breathing.
Injury to the Larynx or its Removal (Laryngectomy): Trauma or surgery can necessitate a tracheostomy.
Injury to the Chest Wall: Severe chest injuries can impair breathing.
Need for Extended Breathing or Ventilator Support: Some individuals with chronic conditions may need a tracheostomy.
Airway Blockage by a Foreign Object: When an object cannot be removed by other means.
Obstructive Sleep Apnea: In severe cases where breathing repeatedly stops during sleep.
Airway Obstruction: Caused by foreign objects or congenital conditions like Pierre Robin Sequence.
Bronchopulmonary Dysplasia (BPD): A lung condition affecting premature babies.
Chronic Obstructive Pulmonary Disease (COPD): Tracheostomy may be considered in advanced cases.
Haemangioma: A collection of blood vessels that can obstruct the airway.
Infection: Certain infections, like epiglottitis, can cause airway obstruction.
Neck and Spine Injuries: Trauma can lead to breathing problems.
Neuromuscular Disorders: Conditions causing muscle weakness that may require ventilation.
Tracheal Stenosis: Narrowing of the trachea.
Tracheomalacia: Soft cartilage in the trachea that can collapse.
Tumors: Growths in the respiratory tract that obstruct airflow.
Who Might Benefit from a Tracheostomy
1. Prophylactic Tracheostomy:
Pre-operative Requirement: To ensure a secure airway during and after certain surgeries, particularly chest surgeries.
2. Patients with Breathing Difficulties:
Apneic Patients: Those who have stopped breathing after cardiac arrest.
Unconscious Patients: With inadequate breathing.
Respiratory Failure: Patients needing long-term mechanical ventilation (more than a day or two).
3. Trauma and Injury:
Head, Neck, and Chest Injuries: Resulting in bleeding, swelling, unconsciousness, paralysis, or fractures affecting the airway.
4. Infections and Inflammatory Conditions:
Severe Mouth and Throat Infections: Like diphtheria or Ludwig’s angina, causing upper airway blockage.
Upper Airway Obstruction: Regardless of the cause.
5. Secretions and Obstruction:
Excessive Secretions: In the lower airways, leading to low oxygen and lung collapse.
6. Burns and Trauma:
Severe Burns: Of the face, neck, and head that can cause airway obstruction.
Thyroidectomy Complications: Bleeding after thyroid surgery causing airway compression.
7. Neurological Disorders:
Impaired Swallowing: Due to head injury, drug overdose, stroke, or bulbar paralysis, to prevent aspiration.
8. Pulmonary Conditions:
Severe Pulmonary Edema: To facilitate ventilation and improve oxygenation.
Types of Tracheostomies
Based on Timing:
Planned Tracheostomy: Scheduled in advance for non-emergency situations, often for long-term ventilation in chronic conditions like ALS or spinal cord injuries. This allows for better planning and care.
Emergency Tracheostomy: Performed immediately to secure the airway in life-threatening situations like severe airway blockage from trauma or allergic reactions. Speed is critical.
Based on Duration:
Long-Term Tracheostomy: Intended for ongoing airway management due to permanent conditions preventing independent breathing. Examples include severe spinal cord injuries, muscular dystrophy, cerebral palsy, certain laryngeal cancers, and severe birth defects affecting the airway.
Short-Term Tracheostomy: Used temporarily for breathing issues like airway obstruction from infection or trauma, to aid ventilation after surgery, to help clear secretions, or to manage airway problems after removing a breathing tube.
Based on Placement:
High Tracheostomy: Performed at the 2nd or 3rd tracheal ring. Often used for blockages higher up in the larynx or upper trachea or for long-term ventilation.
Mid Tracheostomy: Placed between the high and low positions. Less common, chosen based on individual anatomy.
Low Tracheostomy: Performed at the 4th or 5th tracheal ring. Often used for lower airway obstructions, long-term ventilation, or when surgery around the head and neck requires bypassing the upper airway
Tracheostomy Tubes
Tracheostomy tubes are crucial for individuals needing long-term airway support. These tubes come in different styles and sizes to fit different patient needs and body structures.
Types of Tracheostomy Tubes:
With a Cuff: These tubes have an inflatable part that creates a seal in the windpipe to prevent air leaks and fluids from entering the lungs. They are used for patients on a breathing machine or those with a high chance of aspiration. It’s important to monitor the cuff pressure to prevent damage to the windpipe.
Without a Cuff: These tubes don’t have an inflatable part, allowing air to move around the tube. They are suitable for patients who can breathe on their own and are at low risk of aspiration. These tubes also make speaking and coughing easier.
With Openings (Fenestrated): These tubes have holes on the outer part, allowing air to pass through the vocal cords when the inner part is taken out. They are used when someone is getting off a ventilator or for speech therapy.
Without Openings (Non-fenestrated): These tubes don’t have these holes, so air can’t go through the vocal cords when the inner part is removed. These are usually for patients needing a ventilator or who are at high risk of aspiration.
With Two Parts (Double-Lumen): These tubes have an outer, fixed part and a removable inner part. The inner part keeps the airway clear and reduces the risk of blockage.
With One Part (Single-Lumen): These tubes only have the outer part (no inner part). Most children’s tracheostomy tubes are this type because they are too small for an inner part. If a blockage occurs inside, the entire tube needs to be replaced.
Components of a Tracheostomy Tube:
Flange: This flat plate rests on the neck, holding the tube in place. It has holes for securing the tube with ties or straps.
Obturator: A cone-shaped device inserted into the tube during insertion to guide it and prevent tracheal wall injury. It is removed once the tube is in
place.
Pilot Balloon: A small balloon connected to a valve, used to inflate or deflate the cuff and indicates its status.
Suction Port: An opening on the tube that allows connection to a suction catheter for removing secretions.
Tracheostomy Tube Materials
Tracheostomy tubes are made from different materials:
Plastic: Often made of PVC or polyurethane.
Good things: They are usually the cheapest option and are designed to be used once and thrown away, which helps prevent the spread of germs. They are also easy to find in hospitals.
Not-so-good things: They can be less bendy, which might not be as comfortable, especially for people with smaller airways. Some people might find them irritating or be allergic to them.
Silicone:
Good things: They are soft and bendable, making them good for children and people with sensitive skin. They are also good at resisting buildup, which is why they often don’t have an inner part. They can be cleaned and used again by the same person.
Not-so-good things: They tend to cost more than plastic ones and might not last as long.
Metal (like Jackson Tubes): Made from silver or stainless steel.
Good things: They are very strong and resistant to damage. They can be cleaned and reused for different people.
Not-so-good things: They are stiff and might be uncomfortable. They can also be heavy, which might be harder to manage, especially for people with smaller airways. They are not as commonly used in hospitals nowadays because they are heavy and stiff. Also, many don’t fit standard breathing equipment.
Providing Tracheostomy Care
Goals of Tracheostomy Care:
Keep the Airway Clear: This involves removing mucus buildup to prevent blockages.
Prevent Infection: Maintain cleanliness around the tracheostomy and use sterile methods during procedures. Watch for infection signs like redness or discharge.
Help Healing: Support wound healing around the tracheostomy site and protect the skin from irritation.
Ensure Comfort: Make the patient comfortable by proper positioning and addressing any pain.
Prevent Tube Coming Out: Secure the tube to avoid accidental removal and check its position regularly.
Help Communication: Provide ways for patients to communicate if they can’t speak.
Improve Life Quality: Help the patient breathe and communicate better, encouraging independence.
Before the Tracheostomy:
Emotional Support: It’s important to reassure the patient and their family, explaining how the tracheostomy will help them breathe easier. Explain the equipment they will see and that they don’t need to force their breathing with the tube in place.
Immediately After Surgery:
ICU Care: Initial care happens in the intensive care unit with resuscitation equipment available.
Positioning: Keep the patient lying down initially, then sitting up once awake to help prevent chest issues. Maintain this upright position for about 2 days.
Monitor Vitals: Regularly check temperature, pulse, breathing, and blood pressure. Watch for signs like bluish skin, breathing difficulties, and changes in pulse/breathing rate.
Environment: Keep the room warm and consider adding extra oxygen with moisture.
Communication: Provide tools like pen and paper or a call bell. If using a specific type of tube (Negus), teach them to cover the opening if needed.
Close Monitoring: Nurses should closely watch vital signs and for any bleeding or other problems for the first 1-2 days.
Suctioning: Frequent suctioning and cleaning of the inner tube will be needed in the beginning (around the first 12-24 hours).
Ongoing Care:
Humidification: Cover the tube with moist gauze, changing it when it gets dry or dirty.
Keep Airway Clear: Suction and clean the tube as needed. Prevent liquids from going into the tube and keep objects away that could block it. Cover the opening with moist gauze to keep out insects.
Resuscitation Ready: Keep emergency equipment nearby in case of problems.
Watch for Blockage: Look for signs of blockage, raise the head of the bed, and listen to the chest to see if suctioning is needed.
Watch for Breathing Issues: Observe for any breathing difficulties and address any signs of blockage. Check for and report any complications.
Check the Site: Regularly look at the tracheostomy site for trauma or infection.
Keep it Clean: Use sterile methods, especially during suctioning and dressing changes.
Stay Hydrated: Ensure the patient gets enough fluids (oral or IV) to thin secretions. Track fluid intake and output.
Gentle Suction: Be careful during suctioning to avoid irritating the windpipe. Release the cuff on the tube as directed to reduce pressure.
Skin Care: Keep the skin around the tube clean and dry. You can use zinc oxide to prevent irritation.
Change Dressings: Change dressings as needed using sterile technique.
Reduce Anxiety: Reassure the patient about managing with the tracheostomy and teach them about its care.
Managing the Tracheostomy Tube:
Tube Changes: Doctors will change the initial tube (usually rubber) within 1-2 days, and then to a silver tube after about 5 days.
Cleaning: Keep the tube clean and suction as needed. The inner tube can be replaced with a spare if needed and the dirty one cleaned and sterilized.
Feeding: Initially, feeding might be through a tube or IV until the patient can swallow safely (checked with sterile water). Thickened liquids are sometimes easier to swallow. IV fluids are common in the first 24 hours, then oral fluids. Watch for aspiration.
Hygiene: Frequent mouth cleaning and personal hygiene are important to prevent inhaling bacteria.
Getting Back to Movement:
Mobility: After about 2 days, the patient can usually sit up or move around.
Bath Safety: Never leave a patient unattended in the bath and keep the water shallow.
Prevent Drowning Risk: Be ready to remove the tube plug immediately if the patient slips in the water.
Key Rules for Management:
Clean Hands: Wash hands thoroughly, use gloves and a mask.
Sterile Supplies: Use sterile, single-use suction catheters.
Avoid Contamination: Don’t let the catheter touch anything before suctioning.
Frequent Suctioning: Suction often to prevent mucus buildup.
Discard Catheters: Throw away catheters after each use.
Replace Inner Tube: Change the inner tube as needed and keep sterilized spares available.
Clean and Dress: Regularly clean the tubes and change dressings (keyhole gauze is common).
Inflate Lungs: Help the patient take deep breaths after each suctioning.
Tracheostomy Care Procedure
General Rules:
Introduce and Verify: Tell the patient who you are and double-check their identity.
Explain the Process: Tell the patient what you’re going to do, why, and how they can help (like blinking for yes/no or raising a finger if they’re uncomfortable).
Prevent Infection: Wash your hands and take other steps to avoid spreading germs.
Respect Privacy: Make sure the patient has privacy.
Prepare Patient and Supplies:
Help the patient sit up slightly to make breathing easier.
Open the tracheostomy kit, pour cleaning solution and sterile saline into separate containers.
Set up a sterile workspace.
Open other sterile items you’ll need, like swabs, suction supplies, and dressing.
Steps for Tracheostomy Care:
Suction if Needed: If there’s mucus, suction the tube using sterile technique.
Clean Inner Tube: Take out the inner tube and clean it with the cleaning solution using a sterile brush. Rinse well with sterile saline.
Put Inner Tube Back: Carefully put the clean inner tube back in place.
Clean Skin Around Opening: Use sterile saline and swabs to gently clean the skin around the tracheostomy.
Apply Clean Dressing: Place a clean, dry sterile dressing around the tube.
Change Neck Ties (if needed): Change the ties holding the tube in place to keep the skin clean and dry.
Secure Tie Knot: Put a folded gauze pad under the knot of the neck ties and tape over it to prevent skin irritation and mixing them up with gown ties.
Check Tie Tightness: Regularly check if the ties are too tight (can cause swelling) or too loose (tube could come out).
Document: Write down when you did suctioning, tracheostomy care, and dressing change, and what you observed.
Home Care Adjustments:
Emphasize Handwashing: Stress the importance of washing hands before care.
Explain Tube Parts: Show the patient or caregiver the different parts of the tube and what they do.
Demonstrate Inner Tube Care: Show how to remove, clean, and replace the inner tube.
Cleaning Schedule: Instruct on cleaning the inner tube 2-3 times a day.
Teach Stoma Care: Show how to check and clean the skin opening.
Teach Suctioning (if needed): Explain how to suction at home if necessary.
Watch for Infection: Explain signs of infection like fever, more secretions, or changes in color/smell of secretions.
Involve Parents (for kids): Encourage parents to be involved to make the child comfortable and for learning.
Provide Emergency Info: Give contact information for emergencies.
Suctioning a Tracheostomy Tube:
Only When Necessary: Suction only when needed, not routinely.
Use Sterile Technique: Keep everything sterile during suctioning.
More Frequent Initially: Be aware that suctioning might be needed more often right after surgery.
Moistening and Filtering the Air: (This seems like an incomplete thought – it likely refers to the importance of humidification, which was already covered)
Suctioning a Tracheostomy
Suctioning the tracheostomy tube is needed to clear mucus, keep the airway open, and prevent the tube from getting blocked. How often suctioning is required depends on the individual patient’s needs.
When to Suction:
If you can hear or see mucus in the tube.
If the patient shows signs of difficulty breathing.
If you think the tube might be fully or partly blocked.
If the patient can’t cough up secretions on their own.
If the patient vomits.
If the oxygen level in their blood drops (as shown on the pulse oximeter).
If there are changes in the pressure needed for breathing (for patients on a ventilator).
If an older child asks to be suctioned.
Getting Ready to Suction:
Make sure you have a tracheostomy kit.
Have the right size suction catheters ready (some have markings for depth).
Have a tape measure to check how far to insert the suction catheter.
Set the suction machine to the correct pressure. The recommended range is 80-120 mmHg, with a maximum of 120 mmHg when the suction is blocked. Some machines measure in kPa, where the equivalent range is 10-16 kPa.
Detailed Suctioning Steps:
Explain to Patient and Family: Let the patient and their family know you are going to suction the tracheostomy tube.
Protect Your Eyes: Put on eye protection.
Clean Hands and Gloves: Wash your hands and put on non-sterile gloves.
Remove Breathing Device: Take off any mask or breathing circuit attached to the tracheostomy.
Prepare Suction Catheter: Open the suction catheter packaging and attach it to the suction tubing. Check and adjust the suction pressure to between 80 and 120 mmHg.
Insert Catheter Gently: Using a clean technique (avoiding touching the catheter unnecessarily), carefully slide the suction catheter into the tracheostomy tube to the measured depth.
Apply Suction and Withdraw: Put your finger over the suction control hole and gently twist the catheter as you pull it out. Each suction pass should only take 5-10 seconds.
Check Patient’s Condition: Observe the patient’s breathing rate, skin color, and/or oxygen level to make sure they are doing okay after the suctioning.
Repeat as Needed: Suction again if the patient’s condition indicates it’s necessary.
Observe Secretions: Look at the mucus in the suction tubing. It should usually be clear or white and flow easily. Note any changes in color or thickness and inform the medical team if they look unusual.
Rinse Catheter: Rinse the suction catheter with sterile water that has been poured into a container (don’t pour directly from the bottle).
Repackage Catheter: Put the suction catheter back into its packaging.
Dispose and Clean Up: Throw away the waste, remove your gloves, and wash your hands.
Important Notes:
Suction catheters should be replaced every 24 hours or if they get dirty or blocked.
Suction water and the container for the water should be changed every 24 hours.
Routinely using saline solution is generally not recommended as it’s not proven to be very helpful. However, a small amount (0.5ml) of saline might be used if the secretions are very thick or to encourage coughing right before suctioning.
Special Safety Considerations:
Some patients might need help with their breathing using a machine before and after suctioning. The medical team will order this if needed.
If the suction catheter doesn’t go into the tracheostomy tube easily, suspect a blockage and get ready to change the tracheostomy tube immediately.