Comprehensive Study Guide for Tracheostomy Care and Management

Tracheostomy Overview and Indications

• Definition: A tracheostomy is an artificial airway created through a surgical incision in the neck into the trachea to provide a secure and patent airway.
• Indications for Tracheostomy:     - Prolonged Mechanical Ventilation: Typically defined as patients needing a ventilator for more than $7-10\,days$ on an Endotracheal Tube (ETT).     - Upper Airway Obstruction: Caused by tumors, trauma, or severe angioedema.     - Neuromuscular Disease: Conditions resulting in the inability to protect the airway.     - Trauma/Surgery: Severe head and neck trauma or complex neck surgeries.     - Weaning Facilitation: Helps in transitioning patients off mechanical ventilation.     - Chronic Aspiration: Used to protect the lower airway from persistent aspiration risks.
• Advantages Over Endotracheal Tubes (ETT):     - Patient Comfort: Eliminates oral and nasal pressure associated with ETTs.     - Oral Hygiene: Allows for easier mouth care and hygiene procedures.     - Communication: Enables the patient to mouth words and possibly speak (especially with fenestrated tubes).     - Secretion Clearance: Provides better access for suctioning to clear the airway.     - Weaning: Facilitates easier weaning from the ventilator due to decreased dependence.     - Long-term Management: Considered a safer option for permanent or long-term airway needs.
• Types of Tracheostomy Procedures:     - Surgical (Open): Performed in the Operating Room (OR) under general anesthesia.     - Percutaneous Dilational (PDT): A bedside procedure typically performed in the ICU setting.

Components of a Tracheostomy Tube

• Outer Cannula (OC):     - Represents the main body of the tube.     - It sits permanently in the stoma to provide the structural airway.     - Safety Note: It is removed only by a physician for scheduled tube changes or acute emergencies.
• Inner Cannula (IC):     - A removable insert that fits inside the outer cannula.     - It can be removed for cleaning (if non-disposable) or discarded (if disposable).     - Requirement: It must be clicked and locked in place when inserted.
• Obturator (OB):     - A blunt-tipped solid insert used ONLY during the initial insertion of the tracheostomy tube to guide it into the stoma.     - CRITICAL: It must be removed IMMEDIATELY after insertion because it is solid and completely blocks the airway.     - Management: Tape it to the bedside (usually the head of the bed) for emergency reinsertion access.
• Cuff (CF):     - An inflatable balloon located at the distal end of the tube.     - Function: When inflated, it creates a seal between the tube and the tracheal wall to prevent aspiration.     - Mandatory for patients on mechanical ventilation.
• Pilot Balloon (PB):     - An external balloon attached to the cuff inflation line.     - Function: An inflated pilot balloon indicates the internal cuff is also inflated.     - Action: Squeeze it to assess cuff pressure; maintain pressure at precisely $20-30\,cmH_2O$.
• Flange / Neck Plate (FL):     - A flat plate resting on the patient's neck with holes for securing ties or holders.     - It is marked with the specific tube size and type.     - Caring: Must be kept clean and dry to prevent skin breakdown.
• Bedside Safety Essentials:     - Spare tracheostomy tube of the SAME SIZE.     - Spare tracheostomy tube ONE SIZE SMALLER (in case of stoma narrowing).     - Obturator.     - $10\,mL$ syringe for the cuff.     - Bag-Valve Mask (BVM/Ambu bag) with $O_2$ source.     - Full suction equipment.

Fenestration and Cuff Variations

• Fenestrated Tubes:     - Feature: Contains a small hole (or multiple holes) in the shaft of the outer cannula.     - Mechanism: Allows airflow through the upper airway and past the vocal cords.     - Benefit: Patient can speak when the cuff is deflated and the inner cannula is removed OR when a speaking valve is used.     - Application: Used for weaning, speech therapy, and transitioning off mechanical ventilation.     - Note: If a non-fenestrated inner cannula is used, it covers the holes, making it act like a standard tube.
• Non-Fenestrated Tubes:     - Feature: Solid outer cannula with no holes.     - Application: Standard for patients requiring mechanical ventilation.     - Limitation: Air cannot pass through the upper airway; the patient cannot speak.     - EMERGENCY WARNING: If a patient with a non-fenestrated tube is able to speak, the tube is likely displaced or the cuff is deflated. This requires immediate verification of position.
• Cuffed vs. Uncuffed Tubes:     - Airway Seal: Cuffed tubes create a seal; uncuffed tubes allow air to flow around the tube.     - Aspiration Risk: Cuffed tubes protect the airway; uncuffed tubes present a higher aspiration risk.     - Mechanical Ventilation: Mandatory to use cuffed tubes for positive pressure ventilation.     - Speech: Not possible with an inflated cuff; possible with uncuffed tubes as air flows past vocal cords.     - Population: Cuffed tubes are for ICU/MV/High-risk patients; uncuffed tubes are for chronic, spontaneously breathing, or weaning patients.

Tracheostomy Care Procedures

• General Pre-Procedure Principles:     - Use $2$ patient identifiers.     - Suction BEFORE care: This clears secretions to improve oxygenation during the procedure.     - Hyperoxygenate the patient before and during care.     - Open sterile kits using aseptic technique on a clean surface.     - Prepare Gauze: Pour sterile saline over one pack (wet gauze for cleaning); leave the second pack dry (for drying the site).     - Sterile Gloves: Maintain the dominant hand as sterile throughout the procedure.
• Procedure A: Non-Disposable Inner Cannula:     - Remove the inner cannula with the non-dominant hand and drop it into the sterile saline basin.     - Scrub the cannula with a small brush and sterile saline to remove all secretions.     - Rinse and shake to remove excess saline.     - Replace and LOCK the cannula back into the outer cannula (listen for the click).     - Clean the stoma site with sterile Normal Saline ($NS$) and cotton-tip applicators using outward circular motions.     - DRY the stoma site completely to prevent infection and skin breakdown.     - Replace trach ties one side at a time; ensure $1-2$ fingers fit snugly under the strap.     - Apply a split trach dressing and document the procedure, secretion character, and site appearance.
• Procedure B: Disposable Inner Cannula:     - Key Difference: Remove the old inner cannula with the non-dominant hand and DISCARD it immediately.     - Insert a NEW disposable inner cannula and lock it.     - Follow identical stoma cleaning and tie replacement steps as Procedure A.     - Policy Note: Some facilities (e.g., BHS/Tenet) require $2$ staff members to be present when replacing ties.

Sterility Rules and Tube Dislodgement

• Time-Based Sterility Rules:     - First $24\,hours$: The entire site is treated as a sterile surgical wound; strict sterile technique is required for all care. High risk of false passage.     - $24-72\,hours$: Transitional period. Outside neck skin transitions to clean technique; the inner airway remains sterile.     - $>72\,hours$ (Mature): Outside site uses clean technique. The stoma tract is epithelialized/stable. Inner airway/suctioning remains sterile.
• Critical Decision Tree for Dislodgement:     - Within $72\,hours$ (Immature Stoma):         - DO NOT REINSERT: Risk of misplacement into a false tract resulting in suffocation.         - Action: Call for help (RRT or Code Blue) immediately.         - Assess breathing and apply supplemental $O_2$ over the stoma and mouth/nose.         - Use bag-mask ventilation if necessary; cover stoma loosely.     - After $72\,hours$ (Mature Stoma):         - DO REINSERT: Stoma is stable; reinsertion is usually successful.         - Action: Assess $SpO_2$ and breathing; apply immediate supplemental $O_2$.         - Insert the obturator into the spare tube, gently reinsert into the stoma, and remove the obturator IMMEDIATELY.         - Confirm placement, inflate the cuff, and secure ties.

Suctioning Procedure and Complications

• Indications for Suctioning:     - Audible gurgling or visible secretions.     - Decreased $SpO_2$.     - Increased work of breathing or tachypnea.     - High-pressure alarms on the ventilator.     - Note: Never suction on a fixed schedule; only when clinically indicated.
• Procedural Steps:     - Suction Pressure: Set to $80-120\,mmHg$ for adults.     - Catheter Size: $10-14\,Fr$ for adults.     - Hyperoxygenate: Increase FiO$_2$ to $100\%$ or use BVM for $30-60\,seconds$.     - Insertion: Insert WITHOUT applying suction until resistance is felt (at the carina), then pull back $1\,cm$.     - Suctioning: Occlude the thumb port and withdraw with continuous rotation for a maximum of $10-15\,seconds$.     - Frequency: Limit to a maximum of $3$ passes per episode.
• Secretion Assessment:     - Color: White/clear (normal), yellow/green (infection), bloody (trauma), frothy (pulmonary edema).     - Consistency: Thin (normal) vs. Thick (dehydration/infection).
• Complications of Suctioning:     - Hypoxia: Prevented by limiting time to $15\,seconds$ and pre-oxygenating.     - Bradycardia: Caused by a vagal response; stop suctioning immediately.     - Mucosal Trauma: Avoid forcing the catheter.     - Bronchospasm: May require a smaller catheter or pre-suction bronchodilators.     - Increased ICP: Limit suction time for head injury patients.

Long-term Nursing Care and Communication

• Shift Assessment Checklist:     - Monitor bilateral breath sounds, $SpO_2$, and accessory muscle use.     - Verify inner cannula is locked and tube has not migrated.     - Check cuff pressure ($20-30\,cmH_2O$) and tie tightness ($1-2$ fingers).     - Keep Head of Bed (HOB) at $30-45^\circ$ to prevent VAP/aspiration.
• Humidification:     - Essential because the tracheostomy bypasses the natural humidification of the upper airway.     - Methods: Heated humidifiers or Heat-Moisture Exchangers (HME/"Swedish nose").     - Lack of humidification leads to mucous plugging and tube occlusion.
• Communication Strategies:     - Cuff Inflated: Use yes/no questions, picture boards, whiteboards, or text-to-speech apps.     - Cuff Deflated (with Fenestrated Tube/Valve): Use a Passy-Muir Valve (PMV). WARNING: Always deflate the cuff before applying a PMV to avoid respiratory distress.
• Clinical Complications & Actions:     - Tube Occlusion: Suction immediately; clean/replace inner cannula.     - Cuff Leak: Re-inflate to $20-30\,cmH_2O$; check pilot balloon.     - Subcutaneous Emphysema: Check for crepitus around the neck; notify provider.     - Tracheo-innominate Fistula: Emergency sentinel bleed followed by massive hemorrhage; apply digital pressure in the stoma; call Code Blue.

Decannulation and Patient Teaching

• Weaning Process:     - 1. Cause of tracheostomy must be resolved.     - 2. Downsizing: Gradual reduction in tube size.     - 3. Cuff Deflation Trials: Monitoring for aspiration and $SpO_2$ stability.     - 4. Capping Trials: Placing a cap over the hub for $24-48\,hours$; the patient breathes entirely through the upper airway.
• Patient/Family Teaching:     - Demonstrate sterile vs. clean technique for home suctioning.     - Bedside supplies: Keep spare tubes, obturator, and BVM available.     - Daily Life: Use shower shields to protect the stoma; avoid swimming; avoid loose fibers or powders.     - Emergency Education: Teach signs of blockage and how to perform emergency reinsertion (if stoma is mature).     - Medic Alert: Bracelet should say "NECK BREATHER — Do NOT perform mouth-to-mouth. Ventilate via neck stoma."