RT’s Role in Tracheostomy Management

Introduction

• Host: Shawna Strickland, respiratory therapist, asthma educator, associate executive director at AARC.

• Presentation Title: "Taking Charge: The RT's Role in Tracheostomy Management."

• Objectives:

  • Identify indications for tracheostomy in adults and pediatrics.

  • Discuss selection criteria for tracheostomy types based on patient needs.

  • Identify factors in tracheostomy management.

  • Discuss challenges for patients and caregivers in various settings.

  • Explain the respiratory therapist's role in tracheostomy management.

Speakers

• Miss Julia Lawrence: Registered respiratory therapist, neonatal pediatric specialist, Texas Children's Hospital.

• Mr. Ankit Patel: Registered respiratory therapist, adult critical care specialist, Rush University Medical Center.

• Disclosure: No conflicts of interest for speakers; educational focus, not an endorsement of products.

Indications for Tracheostomy

Adult Indications

• Prolonged Intubation: Necessary for patients requiring extended airway support.

• Upper Airway Obstruction: Causes include:

  • Vocal paralysis

  • Airway trauma

• Difficult Airway: Conditions that complicate endotracheal tube insertion, often due to neurological injury.

Pediatric Indications

• Similar to adults, including:

  • Upper airway obstruction

  • Prolonged mechanical ventilation

  • Facial infections and craniofacial surgeries

• Early tracheostomies beneficial for premature infants to support growth.

Benefits of Tracheostomy

• Improved patient comfort and management of secretions.

• Reduced sedation requirements.

• Enhanced ability to communicate with caregivers.

• Facilitates quicker weaning from ventilators.

• Promotes patient mobilization and physical therapy involvement.

Timing of Tracheostomy

• Studies on Timing:

  • Observational studies suggest early tracheostomy aids quicker liberation from mechanical ventilation.

  • Meta-analysis indicates no significant impact on mortality or length of hospital stay.

  • The Trackman study demonstrated similar mortality rates for early vs late tracheostomy.

Complications Post-Tracheostomy

Immediate Complications

• Bleeding: Common in early stages.

• Loss of airway: Serious risk associated with tube dislodgement.

Long-term Complications

• Tracheal Stenosis: Narrowing of the airway over time.

• Granulation Tissue: Excess tissue formation causing complications.

Tracheostomy Techniques

Surgical vs Percutaneous

• Surgical Tracheostomy: More invasive, performed in the OR.

• Percutaneous Dilation Technique: Performed at the bedside using bronchoscopy. Less invasive, quicker recovery.

Criteria for Percutaneous Technique

• Minimum one cm distance between inferior cricoid cartilage and suprasternal notch.

• Contraindications include need for emergency airway or known bleeding disorders.

Types of Tracheostomy Tubes

Materials and Features

• Older metal tubes, current options include PVC, silicone, polyurethane.

  • PVC softens at body temperature.

  • Silicone resists biofilm accumulation.

Types of Tubes

• Single/Dual Cannula: Options based on patient needs.

• Cuffed vs Uncuffed: Cuffed tubes suited for positive pressure ventilation.

• Fenestrated Tubes: For weaning; risks during suctioning.

Management of Tracheostomy Patients

Equipment Needs

• Essential bedside supplies include:

  • Suction canisters and catheters.

  • Spare tracheostomy tubes (one same size, one smaller).

  • Resuscitation bag and humidification setup.

Post-operative Care

• Secure tube with ties or sutures; monitor for complications like pressure sores.

• Regular changes recommended based on stoma establishment (every 30 days).

• Cuff pressure management: keep at 20-25 cm water.

Humidification and Suctioning

• Types: Cool humidity, heated humidity based on secretions.

  • Heated for tenacious secretions.

• Suctioning Technique: Use a catheter < half the inner diameter of tube, suction at 100-150 mmHg.

Speech and Communication

• Importance of speech therapy evaluations for swallowing and communication.

• Options for communication include digital occlusion or the Passy-Muir Valve.

Home Management of Tracheostomy

• Similar requirements as in hospital: training for caregivers is crucial.

• Identify primary caretakers and plan for equipment and emergency handling.

• Education should cover care procedures and emergency response.

Decannulation Criteria

• Criteria include:

  • Patent upper airway.

  • Ability to maintain airway spontaneously.

  • Discontinuation of mechanical ventilation needs.

  • Stable condition and no signs of infection.

Pediatric Tracheostomy Considerations

Historical Context

• First pediatric tracheostomy: 1976 for throat inflammation.

Unique Challenges

• Selecting appropriate tube sizes and types based on patient condition.

• Consider use of cuffed vs uncuffed tubes carefully.

Multidisciplinary Approach to Care

• Importance of team collaboration among respiratory therapists, nurses, and specialists.

• Education and checklists for caregivers before discharge essential.

Questions and Answers

• Q&A session addressed nuances of education delivery, equipment needs, and emergency procedures for tracheostomy patients.

• Highlights importance of tailored education for each family to ensure competency.

Conclusion

• Tracheostomy management requires comprehensive care models and ongoing education.

• Essential for caregivers to grasp emergency protocols before transitioning to home care.