Tracheostomy Care Study Notes

Tracheostomy Care

Course Context

  • Course Name: NUR 303: Fundamentals of Nursing

  • Skills Reference: Skills 41-1 & 41-2

Oropharyngeal Suctioning

  • Purpose: To clear secretions from the back of the patient's throat.

  • Anatomical References:

    • Soft Palate

    • Palatine Tonsil

    • Epiglottis

    • Vocal Fold

    • Esophagus

    • Hard Palate

    • Tongue

    • Trachea

Naso-Tracheal Suctioning

  • Purpose: To clear the trachea of secretions via the nasal route.

  • Anatomical References:

    • Soft Palate

    • Palatine Tonsil

    • Epiglottis

    • Vocal Fold

    • Esophagus

    • Hard Palate

    • Tongue

    • Trachea

What is a Tracheostomy?

  • Definition: An incision into the trachea that produces an opening called a tracheotomy. The hole created is referred to as an ostomy, hence "tracheostomy."

Indications for Tracheostomy

  • Reasons for performing a tracheostomy include:

    • Prolonged Intubation

    • Subglottic Stenosis

    • Obstruction from Obesity for Sleep Apnea

    • Congenital Abnormality

    • Severe Neck or Mouth Injuries

    • Inhalation of Corrosive Material, Smoke, or Steam

    • Presence of a Large Foreign Body that Occludes the Airway

    • Paralysis of the Muscles that Affect Swallowing leading to danger of aspiration

    • Long Term Unconsciousness or Coma

Types of Tracheostomy Tubes

  • Double Cannula Tubes: Have a removable inner cannula and a fixed outer cannula; equipped with an obturator to ease insertion. Inner cannula can be removed for cleaning.

Complications of Tracheostomy

Early or Immediate Complications

  • Bleeding

  • Pneumothorax

  • Air Embolism

  • Aspiration

  • Subcutaneous Emphysema

  • Laryngeal Nerve Damage

  • Posterior Wall Penetration

Long-Term Complications

  • Airway Obstruction

  • Infection

  • Rupture of Innominate Artery

  • Dysphagia

Respiratory Distress

  • Commonly caused by a mucus plug.

  • Symptoms include:

    • Difficulty Breathing

    • Tachypnea

    • Retractions

    • Stridor

    • Anxiety

    • Cyanosis

  • Immediate suctioning is necessary to clear airway.

Bleeding

  • Usually caused by:

    • A cannula that is too long or at an improper angle damaging the subclavian artery

    • Vigorous suctioning and tracheal irritation.

Infection

  • Respiratory infections are common in tracheostomy patients.

  • Natural defenses (nasal hair and mucus) are bypassed, allowing easier entry for bacteria.

  • Handwashing: Essential before cleaning or suctioning.

  • Techniques: Sterile technique required with new tracheostomy tubes; clean technique is acceptable thereafter.

Other Complications

  • Tracheal Stenosis: Due to scar tissue formation at stomal site, leading to obstruction.

  • Tracheoesophageal Fistula: Erosion into the esophagus; aspiration may occur as a symptom.

  • Pressure Necrosis: Caused by the faceplate being too tight against the skin or lack of proper cleaning.

Accidental Decannulation

  • Actions to take:

    1. Remain calm.

    2. Attempt to reinsert the cannula (insert the obturator prior to reinsert if available).

    3. Apply oxygen over the stomal opening even if the cannula cannot be reinserted.

    4. Go to the emergency room or call 911 if necessary.

Suctioning the Tracheostomy

  • Technique: Suction intermittently while simultaneously removing the catheter.

  • Duration: Suction no longer than 10 seconds.

Additional Types of Tubes

  • Single-Cannula Tubes: Used primarily in children; do not have a removable inner cannula. Suctioning is used to keep the airway patent.

Composition of Tubes

  • Materials: Tracheostomy tubes can be made from metal, silicone, or plastic.

  • Plastic (Shiley) and Silicone (Bivona): Less likely to cause crusting of secretions.

Metal Tubes

  • Made from stainless steel and usually have a removable inner cannula.

Tracheal Button

  • Placed in tracheal stoma; does not extend into the trachea.

  • Used for obstructive sleep apnea; typically kept closed during the day and opened at night. Patients can speak normally.

Cuffed Tracheostomy Tubes

  • Description: Have a soft balloon around the cannula.

  • Function: The balloon is inflated to prevent air escaping during mechanical ventilation; must be deflated before the patient can speak.

Maintaining Airway Patency

  • The upper airway normally warms, moistens, and cleans the air.

  • A trach prevents this, leading to increased mucus production and heavy secretions initially (which decrease over time).

  • Suctioning: Must be performed periodically to ensure a patent airway.

Suctioning Protocol

Preparation

  • Wash hands, don clean gloves, and set suction machine to appropriate setting: 100-120 mmHg for adults, 10-15 mmHg for portable devices.

Positioning

  • Place patient in Semi-Fowler's position.

  • Place a waterproof drape across the patient's chest.

Sterile Field Setup

  • Set up a sterile field:

    • Necessary supplies include:

    • Normal Saline

    • Sterile cup

    • Sterile suction catheter

    • Suction machine

Testing the Suction Catheter

  • Test the suction catheter by dipping it in normal saline (this also moistens the tip for easier insertion).

Hyperoxygenation

  • Hyperoxygenate the patient by having them take 3 deep breaths while on oxygen; an ambu bag can also be used for this purpose.

Suctioning Process

  • With suction OFF, insert the suction tip into the trach about 4-5 inches or until the patient coughs.

Cleaning the Tracheostomy

  • After suctioning, the inner cannula can be removed for cleaning if necessary (1-2 times a day).

  • Check to ensure the patient has a tracheostomy with a removable inner cannula and one that can be cleaned; some are disposable.

Remove Soiled Dressing

  1. Assemble supplies:

    • Normal Saline

    • Ambu bag or oxygen

    • Tracheostomy care kit

  2. Wash hands.

  3. Don clean gloves.

  4. Remove the soiled dressing.

Sterile Field for Dressing Change

  • Open the kit.

  • Pour supplies onto the sterile field.

  • Fill one basin with hydrogen peroxide and the other with normal saline.

Rinse Inner Cannula

  • Use an agitation motion to rinse the inner cannula in normal saline solution, ensuring all secretions are removed.

Dry Inner Cannula

  • Use a pipe cleaner bent in the center to double it to dry the inner cannula (dry only the inside).

  • Leave a small amount of moisture on the outside to ease insertion.

Replace Inner Cannula

  • Replace and lock the inner cannula into place.

  • Handle the outer cannula gently to avoid irritation of the patient's trachea.

Clean Stoma and Faceplate

  • Clean around stoma beneath the faceplate using normal saline (unless secretions are dried, then use hydrogen peroxide).

  • Clean secretions from the faceplate and rinse with normal saline.

Apply Dressing

  • Apply a split dressing beneath the faceplate.

  • Change ties or trach collar holder if soiled.

  • Remove gloves, discard equipment, wash hands.

Replace Oxygen Source

  • Reapply the oxygen source and hyperoxygenate the patient if needed.

  • Assess breath sounds and for any respiratory difficulty.

Documentation

General Guidelines

  • Chart procedure and observations:

    • Time

    • Characteristics and amount of secretions

    • Character of respirations and breath sounds before and after the procedure.

Specific Documentation Examples

  • Suctioning:

    • RR 28 and labored; rhonchi noted bilaterally in upper lobes; suctioned tracheostomy x 1 using sterile technique; copious clear secretions removed; hyperoxygenated prior to procedure; post-procedure RR 24 and labored; rhonchi noted in Right Upper Lobe; O2 sat 95% RA.

  • Cleaning:

    • Tracheostomy tube cleaned with hydrogen peroxide using sterile technique; moderate amount of thick yellow secretions removed; rinsed with normal saline; tube replaced and locked; clean dressing applied; RR 22 and unlabored post-procedure; O2 sat 98%.