Tracheostomy Tracheostomy CareCare

What is a Tracheostomy?What is a Tracheostomy?

“ “ A surgical opening in the anterior wall A surgical opening in the anterior wall of the trachea to facilitate ventilation”of the trachea to facilitate ventilation”

SurgicalSurgicaloror

PercutaneousPercutaneous

TracheostomyTracheostomy

Anatomy of the tracheaAnatomy of the tracheaThe trachea is a fibromuscular tube supported by 20 hyaline cartilages which are The trachea is a fibromuscular tube supported by 20 hyaline cartilages which are opened posteriorly.opened posteriorly.The soft tissue posterior wall is in contact with the oesophagus.The soft tissue posterior wall is in contact with the oesophagus.Three layers of tissue clothe the cartilages:Three layers of tissue clothe the cartilages:

– A fibrous elastic outer layer.A fibrous elastic outer layer.– A middle layer of cartilage and bands of smooth muscle that wind around the trachea. A middle layer of cartilage and bands of smooth muscle that wind around the trachea.

There is some tissue containing blood and lymph vessels and autonomic nerves.There is some tissue containing blood and lymph vessels and autonomic nerves.– An inner lining consisting of delicate ciliated columnar epithelium containing mucous An inner lining consisting of delicate ciliated columnar epithelium containing mucous

secreting globlet cells.secreting globlet cells.

The blood supply is primarily supported by the bracheocephalic artery and through The blood supply is primarily supported by the bracheocephalic artery and through the inferior thyroid and bronchial arteries.the inferior thyroid and bronchial arteries.The nerve supply is by parasympathetic and sympathetic fibres.The nerve supply is by parasympathetic and sympathetic fibres.The sympathetic system acts in the flight or fight response stimulated by adrenaline. The sympathetic system acts in the flight or fight response stimulated by adrenaline. It causes an increase in heart rate and relaxes the bronchi and muscle of the gut wall.It causes an increase in heart rate and relaxes the bronchi and muscle of the gut wall.The parasympathetic supply to the trachea is by the recurrent laryngeal nerve – a The parasympathetic supply to the trachea is by the recurrent laryngeal nerve – a branch of the vagus nerve – it can slow the heart rate, increase the acidity to the branch of the vagus nerve – it can slow the heart rate, increase the acidity to the stomach and constrict the bronchi. stomach and constrict the bronchi. (Brunt, (1986), p33-34)(Brunt, (1986), p33-34)

PositionPositionThe trachea begins just below the larynx at approximately the 6th The trachea begins just below the larynx at approximately the 6th cervical vertebra.cervical vertebra.It is flexible to accommodate varying depths of ventilation, coughing It is flexible to accommodate varying depths of ventilation, coughing and speech. The length and width is continually changing to and speech. The length and width is continually changing to accommodate head, neck and diaphragmatic movements.accommodate head, neck and diaphragmatic movements.In adults it is 12-16 cm long and 13-16 mm wide in women and 16-In adults it is 12-16 cm long and 13-16 mm wide in women and 16-20 mm wide in men. 20 mm wide in men. (Minsley and Wren 1996)(Minsley and Wren 1996)It is slightly to the right of the midline and divides at the carina into It is slightly to the right of the midline and divides at the carina into the right and left bronchi.the right and left bronchi.The carina lies under the junction of the sternum at the level of the The carina lies under the junction of the sternum at the level of the 4th thoracic vertebra. 4th thoracic vertebra. (Kumar and Clark, 1994 p 631)(Kumar and Clark, 1994 p 631)

TracheostomyTracheostomy

TRACHEOSTOMY TUBESAll tracheostomy tubes consist of a main shaft and a neckplate or flange. The

flange rests between the clavicles. Holes on each side allow you to attach tracheostomy ties to secure the tube in place.

Tubes are made of semi-flexible plastic, rigid plastic or metal. Semi-flexible plastic tubes conform to the patients’ anatomy during movement – good for patients with tracheal deviations. Rigid tubes are typically used when neck swelling is a problem. The tubes don’t bend or collapse with local oedema.

Plastic tubes have a built-in 15mm adaptor that extends from the neck plate. This allows respiratory equipment e.g. an ambubag, a T piece oxygen delivery system or a mechanical ventilator, to be attached. Synthetic tubes are made

from a non-irritant substance.

The most commonly used cuffed tube The most commonly used cuffed tube in the hospital is the Portex Blue-Line in the hospital is the Portex Blue-Line Profile Cuffed Tube, available from Profile Cuffed Tube, available from stores – cost approximately £13 each. stores – cost approximately £13 each. Cuffed Portex tubes, with inner tubes Cuffed Portex tubes, with inner tubes are now available in stores and cost are now available in stores and cost approximately £35.approximately £35.

Types of TubesTypes of Tubes

Cuffed tubesCuffed tubes

Un-cuffedUn-cuffed

FenestratedFenestrated

Inner cannulaInner cannula

Adjustable flangeAdjustable flange

PVC, Silver, Silicone and RubberPVC, Silver, Silicone and Rubber

Mini TracheostomiesMini Tracheostomies

Cuffed TubesCuffed Tubes

Allows ventilation and Allows ventilation and prevents aspirationprevents aspirationHigh cuff pressure can High cuff pressure can be damagingbe damagingCheck pilot cuffCheck pilot cuffDO NOT BLOCK THIS DO NOT BLOCK THIS TUBETUBE

Cuffed TubesCuffed Tubes

Tubes with inflatable cuffsTubes with inflatable cuffsInflatable cuffs are used when an air-tight seal is required around Inflatable cuffs are used when an air-tight seal is required around the tube. the tube. The cuff is not to hold the tube in positionThe cuff is not to hold the tube in position – it is – it is usually required:usually required:when the patient is unable to breathe on their own and requires when the patient is unable to breathe on their own and requires artificial respiration. Unless there is an air-tight seal around the artificial respiration. Unless there is an air-tight seal around the tube, the air being blown into the lungs by the respirator escapes tube, the air being blown into the lungs by the respirator escapes around the sides of the tubes.around the sides of the tubes.ororwhen an air-tight seal is necessary to prevent blood and other when an air-tight seal is necessary to prevent blood and other secretions from running down the sides of the tracheostomy tube secretions from running down the sides of the tracheostomy tube into the lungs. During and following surgery to the head and neck, into the lungs. During and following surgery to the head and neck, such complications are a real danger and it is for this reason that a such complications are a real danger and it is for this reason that a cuffed polythene tube is used for the first couple of days post-cuffed polythene tube is used for the first couple of days post-operatively.operatively.

Cuffed TubesCuffed Tubes

Cuffed tubes have an inflation line leading to the Cuffed tubes have an inflation line leading to the cuff and pilot balloon that inflates when the cuff cuff and pilot balloon that inflates when the cuff contains air, giving an indication of the volume of contains air, giving an indication of the volume of air in the cuff. air in the cuff. What the pilot balloon does not What the pilot balloon does not tell you is how much air pressure is in the tell you is how much air pressure is in the cuff. cuff. You can confirm the correct inflation by You can confirm the correct inflation by listening for air leak or by measuring intracuff listening for air leak or by measuring intracuff pressure with a manometer, pressure with a manometer, (Weilitz and (Weilitz and Dettenmeiir, 1994). Dettenmeiir, 1994). The presence of an air leak The presence of an air leak may indicate that the cuff is inadequately may indicate that the cuff is inadequately inflated.inflated.

Disadvantages of Cuffed TubesDisadvantages of Cuffed Tubes

Traditionally single tubes with no inner tubes are used. These can easily Traditionally single tubes with no inner tubes are used. These can easily become blocked. Initially, medical staff prefer tubes to be in situ for 7-10 become blocked. Initially, medical staff prefer tubes to be in situ for 7-10 days before changing, to allow a tract to be established for ease of days before changing, to allow a tract to be established for ease of changing.changing.The cuff exerts a pressure on the surrounding tissues when it is inflated. In The cuff exerts a pressure on the surrounding tissues when it is inflated. In time, this pressure can cause damage to the tissues, resulting in necrosis, a time, this pressure can cause damage to the tissues, resulting in necrosis, a fistula or stenosis in the trachea.fistula or stenosis in the trachea.Hourly deflation of the cuff was thought to lessen tracheal damage but this Hourly deflation of the cuff was thought to lessen tracheal damage but this was shown to be ineffective.was shown to be ineffective.(Powaser, 1976, Bryant et al, 1971, Jenicek, (Powaser, 1976, Bryant et al, 1971, Jenicek, 1973). 1973). Over inflation of low pressure cuffs, even by the addition of only a Over inflation of low pressure cuffs, even by the addition of only a few mls of air above the minimal occluding volume can dramatically raise few mls of air above the minimal occluding volume can dramatically raise intracuff pressures, intracuff pressures, (Regan, 1988).(Regan, 1988). If an adequate seal cannot be obtained If an adequate seal cannot be obtained with such pressures it may be necessary to switch to a larger sized with such pressures it may be necessary to switch to a larger sized tracheostomy. An accurate way of checking the pressure is to use a tracheostomy. An accurate way of checking the pressure is to use a manometer manometer (Caruna 1990).(Caruna 1990).The patient cannot speak when the cuff is inflated as no air can go past the The patient cannot speak when the cuff is inflated as no air can go past the vocal cords – this has a massive psychological impact on the patient.vocal cords – this has a massive psychological impact on the patient.If a patient with a cuffed tube can speak it could be a sign that the tube is If a patient with a cuffed tube can speak it could be a sign that the tube is displaced, or the cuff inadequately inflated.displaced, or the cuff inadequately inflated.

Un-cuffed TubesUn-cuffed Tubes

Maintains airway once Maintains airway once aspiration risk has aspiration risk has passedpassed

Increase airflow to the Increase airflow to the larynx larynx

Which patients:Which patients:– Long term Long term

tracheostomy ptstracheostomy pts– PPatientsatients who do not who do not

require a sealrequire a seal– PaediatricsPaediatrics

Uncuffed TubesUncuffed Tubes

Unable to maintain seal in an emergency Unable to maintain seal in an emergency situationsituation

Fenestrated TubeFenestrated Tube

Increases airflow to larynx/ Increases airflow to larynx/ vocalisationvocalisationCuffed or un-cuffedCuffed or un-cuffedThese are used for weaningThese are used for weaningEnables phonation (speaking)Enables phonation (speaking)The fenestrated tube can be The fenestrated tube can be used as such if the patient is used as such if the patient is tolerating the cuff downtolerating the cuff downTo suction always use the non To suction always use the non fenestrated inner tube for fenestrated inner tube for suctioningsuctioningFenestrated are the only tubes Fenestrated are the only tubes (when inner fenestrated tube (when inner fenestrated tube insitu and cuff is down) that insitu and cuff is down) that can be intentionally occludedcan be intentionally occluded

Inner CannulaInner Cannula

Allows maintenance ofAllows maintenance of tube patency tube patency – Aids tube hygieneAids tube hygiene– Close observationClose observation

Allows fenestrated Allows fenestrated tubes to be used earliertubes to be used earlier

Inner CannulaInner Cannula

Use of an inner cannula:Use of an inner cannula:

The inner cannula provides a vital safeguard The inner cannula provides a vital safeguard against life-threatening complications of tube against life-threatening complications of tube obstruction in a cuffed tube and must be present obstruction in a cuffed tube and must be present at all times. Tracheostomy tubes without an at all times. Tracheostomy tubes without an inner cannula should be avoided wherever inner cannula should be avoided wherever possible particularly in the ward environment; possible particularly in the ward environment; this may, however, be impossible to achieve with this may, however, be impossible to achieve with all patients.all patients.

Changing the Inner CannulaChanging the Inner Cannula

If copious secretions- check every 4 hours If copious secretions- check every 4 hours (more if indicated)(more if indicated)

Remove and clean using sterile water and Remove and clean using sterile water and replace as soon as possiblereplace as soon as possible

If tube is kinked or damaged replace with If tube is kinked or damaged replace with new sterile inner tubenew sterile inner tube

Other issues- brushes, cleaning fluids, Other issues- brushes, cleaning fluids, infection and storage of inner cannulainfection and storage of inner cannula

Adjustable FlangeAdjustable Flange

Provide a longer tube – offer secure placement of tube in Provide a longer tube – offer secure placement of tube in a deep-set tracheaa deep-set tracheaEssential for patients with difficult anatomy and on whom Essential for patients with difficult anatomy and on whom the insertion will be complicated; insertion of this tube is the insertion will be complicated; insertion of this tube is usually via the surgical technique (considered to be an usually via the surgical technique (considered to be an unsuitable tube for the percutaneous insertion technique)unsuitable tube for the percutaneous insertion technique)The Portex PVC adjustable flange tube does not have an The Portex PVC adjustable flange tube does not have an inner cannula.inner cannula.These tubes are inserted in patients with very These tubes are inserted in patients with very difficult anatomy and therefore subsequent tube difficult anatomy and therefore subsequent tube changes should be considered carefully.changes should be considered carefully.

Adjustable FlangeAdjustable Flange

Silver NegusSilver Negus Metal Tracheostomy TubesMetal Tracheostomy TubesThese are made of silver because the metal is inert and does not irritate the These are made of silver because the metal is inert and does not irritate the tissues. The most commonly used silver tube is the ‘Silver-Negus’. The tissues. The most commonly used silver tube is the ‘Silver-Negus’. The sizes of the tubes for adults vary from 28-36 FG. The letters FG stand for sizes of the tubes for adults vary from 28-36 FG. The letters FG stand for ‘French gauge’. The number represents the circumference of the inner tube ‘French gauge’. The number represents the circumference of the inner tube measured in millimetres. As a rough guide, the FG size is 4 times the measured in millimetres. As a rough guide, the FG size is 4 times the portex size.portex size.The tubes have a normal inner tube and a speaking tube with a small valve The tubes have a normal inner tube and a speaking tube with a small valve on.on.Speaking tubes should not be used to sleep in because of the danger of the Speaking tubes should not be used to sleep in because of the danger of the valve blocking and occluding the airway. Silver tubes cost approximately valve blocking and occluding the airway. Silver tubes cost approximately £200 each. Each set is individual and pieces are not interchangeable. If a £200 each. Each set is individual and pieces are not interchangeable. If a piece is lost it can cost £100 at least to replace. The tubes also need piece is lost it can cost £100 at least to replace. The tubes also need repairing and maintaining occasionally. Manufacturers of plastic tubes claim repairing and maintaining occasionally. Manufacturers of plastic tubes claim silver tubes are not as comfortable as plastic but they have no evidence to silver tubes are not as comfortable as plastic but they have no evidence to support this.support this.

Tracheostomy (antique)Tracheostomy (antique)

Mini TracheostomyMini Tracheostomy

Minitracheostomy (cricothyroidotomy) is Minitracheostomy (cricothyroidotomy) is for the treatment or prevention of sputum for the treatment or prevention of sputum retention after thoracotomy, laparotomy or retention after thoracotomy, laparotomy or neurological insult. It is an alternative to neurological insult. It is an alternative to naso-laryngeal suction or regular flexible naso-laryngeal suction or regular flexible bronchoscopy.bronchoscopy.

  A cannula with an internal diametre of 4 A cannula with an internal diametre of 4 mm is inserted.mm is inserted.

Mini TracheostomyMini Tracheostomy

Patient able to breathe normallyPatient able to breathe normally

Patient can talk and eat / drinkPatient can talk and eat / drink

The tube does not prevent expectorationThe tube does not prevent expectoration

Use only size 10 or less suction catheter.Use only size 10 or less suction catheter.

Suction will take longer but patient can Suction will take longer but patient can breathe during the procedurebreathe during the procedure

Portex minitracheostomyPortex minitracheostomy

Mini TracheostomyMini Tracheostomy

Deflating the CuffDeflating the Cuff

Why?Why?To assess the patient’s ability to maintain their To assess the patient’s ability to maintain their own airway.own airway.To assess the patient’s ability to cope with their To assess the patient’s ability to cope with their secretions.secretions.Follow trache guidelines ie. Cuff down 24 hours Follow trache guidelines ie. Cuff down 24 hours prior to decannulationprior to decannulationBlue dye test should be performed at this stage to Blue dye test should be performed at this stage to assess swallow.assess swallow.

Deflating the CuffDeflating the Cuff

Who?Who?

Doctor, nurse or physio, who are Doctor, nurse or physio, who are competent.competent.

How?How?

Removing the Tracheostomy TubeRemoving the Tracheostomy Tube

When?When?

Joint decision with doctor, nurses + physio.Joint decision with doctor, nurses + physio.

Following tracheostomy guidelines:Following tracheostomy guidelines:

(1) able to expectorate independently.(1) able to expectorate independently.

(2) minimum of 1 deep suction per shift.(2) minimum of 1 deep suction per shift.

(3) no sign of chest infection.(3) no sign of chest infection.

(4) FiO2 of less than 60%.(4) FiO2 of less than 60%.

(5) Deflation of cuff for more than 24 hours.(5) Deflation of cuff for more than 24 hours.

Removing the Tracheostomy TubeRemoving the Tracheostomy Tube

Who?Who?Doctor, Nurse or Physio who are competent.Doctor, Nurse or Physio who are competent.

How?How?Ensure cuff fully deflatedEnsure cuff fully deflatedExplanation to patientExplanation to patientEquipment – dressing, gauze, O2 mask, stitch Equipment – dressing, gauze, O2 mask, stitch cutter.cutter.Oximeter Oximeter