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Fundamentals of Respiratory Care

TRACHS

  • Course Code: RC121
  • Subject: Fundamentals of Respiratory Care

TERMS

  • Tracheostomy (stoma): An artificial opening (incision) made in the neck into the trachea, typically placed between the 2nd and 3rd tracheal rings.
  • Tracheotomy: The surgical procedure conducted to create the tracheostomy.

ANATOMY RELEVANT TO TRACHEOSTOMY

  • Spine: Provides structural support.
  • Esophagus: A tubular structure that runs to the stomach, posterior to the trachea.
  • Inflatable cuff: Device on the tracheostomy tube that can be inflated to seal the airway.
  • Collarbone (clavicle): Connects the arm to the body and provides stability.
  • Vocal cords (vocal chords): Essential for sound production; located in the larynx.
  • Larynx: Voice box that routes air and generates sound.
  • Tracheostomy tube: Tubing inserted into the trachea for airway maintenance or mechanical ventilation.
  • Tubing to ventilator: Connective tubing that allows for the delivery of mechanical ventilation.
  • Cuff inflation: Process of inflating the cuff on the tracheostomy tube to secure the airway.
  • Trachea (windpipe): The passageway for air to enter the lungs.
  • Valve: Device that allows or restricts airflow.

TRACHEOSTOMY TUBE INDICATIONS

  • Maintaining a secure airway: Essential for patients with compromised airways.
  • Facilitates suctioning: Allows for removal of secretions from the airway.
  • Prevents aspiration: Provides a direct airway, minimizing the risk of food or liquid entering the lungs.
  • Seals airway for mechanical ventilation (MV)/continuous positive airway pressure (CPAP): Essential for ventilator support.
  • Indicated for patients with upper airway obstruction or facial trauma: When intubation is not possible.
  • Long-term mechanical ventilation: Supports chronic respiratory failure.

ADVANTAGES OF TRACHEOSTOMY TUBES

  • Long-term mechanical ventilation: Provides a viable option for prolonged respiratory support.
  • No upper airway complications: Reduces risk of damage associated with endotracheal tubes (ETTs).
  • Removable inner cannula: Can be cleaned, ensuring tube hygiene.
  • More comfortable than ETTs: Less invasive feel for the patient.
  • Patients can eat, drink, and speak: Especially with the use of a Passy Muir speaking valve.
  • Less airway resistance: Improves work of breathing (WOB).
  • No mainstem intubation: Reduces the likelihood of airway misplacement.
  • Improved mobility: Allows for more easy movement of the patient.
  • Easier passage of bronchoscope: Facilitates airway procedures.
  • Easier reinsertion: If the tube is dislodged, it can be reinserted more easily than an ETT.

COMPLICATIONS/HAZARDS OF TRACHEOSTOMY

Immediate Complications (1st 24 hours)

  • Bleeding: Considered a major hazard.
  • Pneumothorax: Air leaks into the pleural space.
  • Air embolism: Presence of air bubbles in the bloodstream.
  • Subcutaneous emphysema: Air trapped under the skin.

Late Complications (24-48 hours)

  • Infection: Risk of wound infection or pneumonia.
  • Hemorrhage: Continued bleeding beyond the initial period.
  • Obstruction: Blockage of the tracheostomy tube.
  • Tracheoesophageal fistula: Abnormal connection between the trachea and the esophagus.

TRACHEOSTOMY SIZES

  • Measured by inner diameter (ID) in mm, similar to endotracheal tube (ETT) sizes.
  • Adult Male: Average size range is 8.0 - 9.0 mm ID.
  • Adult Female: Average size range is 7.0 - 8.0 mm ID.
  • Consideration should be given to using the largest tube that can be inserted without causing harm.
  • Always prepare to have tubes that are one size larger or smaller than the anticipated size.

PARTS OF A TRACHEOSTOMY SET

  • Cuff: Forms a seal against the trachea after inflation.
  • Pilot Line: Thin plastic tubing for cuff inflation and deflation.
  • Pilot Balloon: Small balloon indicating the cuff's inflation status.
  • Luer Valve: Connection point for the syringe for cuff inflation.
  • 15 mm Connector: Standard connector for attaching ventilators or other equipment.
  • Neck Flange: Part of the tube secured around the patient's neck.
  • Outer Cannula: Main tube inserted into the trachea.
  • Inner Cannula: Removable component that may assist airflow and can be cleaned.
  • Obturator: Guide used during tube insertion.
  • Trach Ties: Cloth or Velcro straps for securing the tube in place around the neck.

SHILEY TRACHEOSTOMY TUBE

  • Can be either cuffed or uncuffed.
  • Available in fenestrated or unfenestrated forms.
  • Comes in standard or extra-long sizes.
  • Most commonly used for mechanical ventilation.
  • Disposable with inner cannula mandatory for ventilation compatibility.

FENESTRATED TRACHEOSTOMY TUBES

  • Definition: "Fenestrated" means that the tube has windows or openings that allow airflow through.
  • Purpose: Enhances speaking and weaning processes from ventilation.
  • Benefit: Provides reduced work of breathing for the patient.
  • Hazard: Risk of tissue granulations developing through the fenestrations.

PORTEX TRACHEOSTOMY TUBE

  • Commonly used for long-term tracheostomy needs (considered a lifetime option).
  • Not suitable for fresh tracheostomies (recommended only after 3 days).
  • Can be cuffed or uncuffed, fenestrated or unfenestrated, and offered in extra-long sizes.
  • Features color-coded inner cannulas that indicate the tracheostomy size.

JACKSON TRACHEOSTOMY TUBE

  • Type of cuffless tracheostomy tube made of surgical stainless steel.
  • Designed for long-term or permanent use.
  • More comfortable with reduced secretions but lacks an adaptor for ventilation or bagging.

BIVONA FOAM CUFF

  • Utilizes foam instead of air for cuff inflation.
  • Maintenance: Do not add air; aspirate the cuff every 12 hours to maintain form and function.
  • Allow the inflation line to remain open to atmospheric air for self-filling.

KISTNER TRACH BUTTON

  • Purpose: A hard plastic tube inserted to keep the stoma open after the trach tube is removed.
  • Advantages: Allows normal eating, talking, and coughing.
  • Components:
    • Outer cannula
    • Closure plug
    • Spacers to ensure proper inner cannula depth
    • Hollow inner cannula fitted with a 15 mm adapter
    • Optional one-way valve for normal speaking capabilities.
  • In emergencies, the trach button allows for suctioning or ventilation.

PASSY-MUIR VALVE

  • Type: A speaking valve that attaches to trach tubes or trach buttons.
  • Function: A one-way valve that opens on inhalation to allow air in and closes on exhalation, facilitating speech by forcing exhaled volume through the vocal cords.
  • Cuff Requirements: The cuff must be deflated to utilize the speaking function. If the patient is ventilator dependent, using the valve will result in reduced tidal volume delivery.

TRACHEAL CUFFS

  • Found on both endotracheal tubes and tracheostomy tubes.
  • Primary Purposes:
    • To seal the airway during positive pressure ventilation, preventing loss of tidal volume.
    • To prevent aspiration of oral or gastric secretions.
  • Note: Cuff anchoring is not a function of the cuff.

CUFF PRESSURE

  • For the cuff to work effectively, it must exert sufficient pressure against the tracheal wall.
  • Recommended Cuff-to-Tracheal Wall Pressure:
    • Low enough to prevent excessive pressure damaging the trachea.
    • High enough to prevent air leaks and aspiration.
  • Goal Pressure Range: 20-25 mmHg or equivalently 25-30 cmH₂O.

CUFF DESIGNS

  • High-Pressure, Low-Volume Cuffs:
    • Spherical shape.
    • Can exert pressures ranging from 40-200 mmHg, demanding caution due to a high incidence of tracheal damage.
  • High-Volume, Low-Pressure Cuffs:
    • Preferred for safety, conforming better to tracheal contours.
    • Disadvantage includes potential for folds permitting aspiration or pooling of secretions leading to infection.

PATHOPHYSIOLOGY OF TRACHEAL INJURY

  • Estimated capillary perfusion pressure in the tracheal mucosa is between 25-30 mmHg.
  • Consequences:
    • High cuff pressure can cut off blood flow to the mucosa resulting in tissue damage.
    • A cuff pressure that exceeds tracheal perfusion pressure can lead to tracheal injury.

HAZARDS OF HIGH CUFF PRESSURES

  • Mucosal Ischemia: Insufficient blood flow leads to tissue damage.
  • Mucosal Inflammation: Can result in hemorrhage and ulceration.
  • Tracheomalacia: Softening of cartilage rings, compromising airway integrity.
  • Stenosis: Scarring causing narrowing of the airway.
  • Necrosis: Cell death in tracheal tissues due to prolonged high pressure.

HAZARDS OF UNDERINFLATION

  • Air Leak: Loss of tidal volume and inadequate ventilation.
  • Aspiration: Increased risk for Ventilator-Associated Pneumonia (VAP).

MEASURING AND ADJUSTING CUFF PRESSURE

  • Initial Inflation: Inflate cuff with 5-7 cc.
  • Target Pressure: Keep cuff pressure within 20-25 mmHg or 25-30 cmH₂O.
  • Cuff Pressure Manometer: Device used for actual pressure measurement in the cuff.
  • Posey Cuffalator: An apparatus for assessing cuff pressure with a syringe and pressure gauge connected to a three-way stopcock.

MEASURING AND ADJUSTING CUFF PRESSURE PROCEDURE

  • Use view perspectives to visualize the setting of pressure gauges and syringes in relation to the cuff and stopcock.

CUFF PRESSURE MONITORING TIMELINE

  • Perform cuff pressure measurements:
    • As soon as possible after intubation.
    • After patient transfer from different hospitals or units.
    • Following anesthesia procedures.
    • At least once per shift to ensure proper maintenance.

CUFF INFLATION TECHNIQUES

Minimal Leak Technique (MLT)

  • Purpose: Ensure cuff maintains a seal while minimizing pressure.
  • Procedure:
    • Place a stethoscope over the laryngeal area and slowly inflate the cuff until flow is halted.
    • Once sealed, reduce the volume by 0.25-0.5 ml to find minimal leak, reducing aspiration risk.
    • Note that risk of aspiration slightly increases with this method.

Minimal Occlusion Volume (MOV)

  • Similar to MLT, maintaining seal while decreasing risk of aspiration with pressure monitoring required for effectiveness.
  • Technique: Place a stethoscope in the same fashion and adjust volume accordingly.
  • Highlights the necessity of measuring cuff pressure to validate technique effectiveness.