22.13a Managing Patients with Stoma Sites

Patients who have had a laryngectomy (removal of the larynx) or tracheostomy (surgical opening into the trachea) might breathe through a stoma, an opening in the anterior neck that connects the trachea with the ambient air.

These patients frequently have in place tracheostomy tubes, which consist of an inner and outer cannula, to keep the soft tissue stoma open (Figure 22-126).

Patients with long-standing stomas cannot use a tracheostomy tube.

Although practitioners often have anxiety about managing a patient with a stoma, this is usually unwarranted because these patients have a secure airway.

Potential problems include clogging of the tracheostomy tube with secretions, a dislodged tube, bleeding, and respiratory distress.

Tube clogging is a common problem because a laryngectomy produces a less effective cough, making it more difficult to clear secretions.

If these secretions organize, they form a mucus plug that can occlude the stoma.

A clogged tube can usually be managed easily by removing the inner cannula from the fixed outer cannula and cleaning it.

The outer cannula should not be removed because the stoma can begin closing and it can be difficult to replace the outer cannula (Figure 22-127).

If a tracheostomy tube becomes completely dislodged, it should be replaced as soon as possible.

This is particularly critical if a tracheostomy is less than a few weeks old.

If another tube is not available, an endotracheal tube can be used temporarily.

In this case, choose the largest diameter ETT that will pass through the stoma to maintain the airway before complete obstruction occurs.

Lubricate the ETT, instruct the patient to exhale, and gently insert the ETT to about 1 to 2 cm beyond the distal cuff.

Inflate the cuff, and then confirm comfort, patency, and proper placement.

Be certain to suspect and check for improper placement into the surrounding subcutaneous tissue, which will produce a false lumen.

Subcutaneous emphysema as well as the lack of clinical improvement in the patient indicates a false lumen.

If difficulty persists and the patient is in extremis, an endotracheal tube introducer can be passed into the stoma to gently confirm proper intratracheal positioning and the tracheostomy or endotracheal tube passed over the introducer, much as with a bougie-aided cricothyrotomy.

Bleeding can come from irritation of the skin externally around the stoma site or internally.

External bleeding is usually minor, although it can scare the patient, especially if the tracheostomy is new or bleeding has not occurred previously.

Internal bleeding, on the other hand, can be catastrophic.

This warrants very expeditious transport and contact with medical direction.

If the patient is complaining of respiratory distress, first make sure the tracheostomy is patent.

If it is, the distress is probably unrelated to the tracheostomy, and you should perform your usual history and physical exam.

Other stoma-related problems to consider are excessive secretions that are not obstructing the lumen of the tube but are nevertheless causing respiratory problems.

You can suction the airway through the stoma, but you must use extreme caution because the process itself can cause soft tissue swelling.

Begin by preoxygenating the patient with 100 percent oxygen and then inject 3 mL sterile saline down the trachea through the stoma.

Gently insert a sterile catheter until it meets resistance.

While the patient coughs or exhales, suction the airway during withdrawal of the catheter.

Supplemental oxygen can be delivered by placing an oxygen mask over the stoma or tracheostomy tube.

If this is insufficient or if the patient requires positive-pressure ventilation, it is very easy to attach a bag-valve device to the tracheostomy tube.

If the patient has a stoma but no tracheostomy tube, gently insert a lubricated endotracheal or tracheostomy tube to perform ventilation.