Tracheostomy

Upper and Lower Respiratory System

What is a tracheotomy?

it’s involves surgical creation of an external opening through the 2nd and 3rd or 3rd and 4th

ring of the trachea

A Tracheostomy can be

-Temporary , -Permanent or

-placed during Emergency .

Cricothyrotomy

is an emergency tracheotomy that may also be performed when endotracheal

intubation is impossible

Indications for Tracheostomy :

1. Airway Obstruction

Congenital

Ex: larynx hemangioma Ex: Sub glottic or tracheal stenosis ,

Foreign body aspiration

Ex: Swallowed or inhaled object lodged in upper airway

Infection

Ex: Acute epiglottitis ,

It is an infection of the epiglottis and supraglottic structures.

2 .Airway Clearance:

clears the secretions that cannot be cleared due to weakness and conditions requiring long term airway support, like progressive neurological conditions such as :

Severe brain injury ….ect

3.Long Term Intubation:

What is considered Long Term Intubation for an adult and pediatric

patient???

Adult: Intubated more than two weeks.

Pediatric: Intubated more than 3-4 weeks .

4 .Elective/Prophylactic

1 -During major head and neck surgery 2 -Radiation treatment

What physiological changes occurwith a tracheostomy???

temporary voice loss.loss of the airborne particle

filtration, warming and humidification action of the nose.

potential impairment of swallowing.

Mucociliary transport and cough mechanisms are impaired.

IN 2 WAYS :

1-SURGICAL {OPEN (ST)} (ENT) SURGEON, OR A THORACIC SURGEON.

2- PERCUTANEOUS PERCUTANEOUS DILATATION

TRACHEOSTOMY (PDT) IS DONE USING PERCUTANEOUS DILATATION

TECHNIQUE.

How is a Tracheostomy performed?

Surgical tracheostomy performed in patients with :

1 .Tumors of the upper airway 2 .Previously failed/difficult percutaneous procedure

3 .Major vascular structures at risk 4 .Anatomical abnormality (e.g. goiters)

5 .Short neck 6 .Morbid obesity

7 .Emergency airway

Goiters is a swelling of the thyroid gland, which can lead to a swelling of the neck or larynx (voice box)

Nursing Considerations

In (ST), the pt may come back with stay sutures around the tube - to hold or manipulate the operating area.

In ST sutures are removed after the first tracheostomy tube change - 5-7 days of the insertion, while the stoma is forming or as

ordered by the operating surgeon .

stay sutures done:to prevint accedint accidentally

dislodged.

Percutaneous insertion:

The first tube change should not be performed before 2

weeks of the initial insertion?? because the stoma is very tight and the risk of the tracheotomy

collapsing is high .

Holistic Nursing Considerations

During the first 2-3 days…the patient is uncomfortable due to

trauma of surgery, pain of a fresh incision, choking, presence of a foreign object in his

trachea and inability to communicate through speech.

keep in mind .. the patient is more than a

“trach tube!”

1- pain management.2- reassurance.

3- education

What are the risks involved in tracheostomy?

1-Reactions to medication and

anesthesia .2-Uncontrollable bleeding. 3-Respiratory problems .

4-Possibility of cardiac arrest .

What are the complications of a Tracheostomy?

Early ( Life-threatening ) Late Infection:

1 -stoma site 2 -chest -

50-60% of tracheostomy patients may develop nosocomial pneumonia

Skin breakdown

Tracheal stenosis

Tracheo-esophageal fistula: 1 -Abdominal distention

2 -Liquid food suctioned through tracheostomy tube .

Accidental tube displacement

Blocked tracheostomy tube

Damage during surgery - possible hemorrhage .

Sx emphysema

Trauma

Pneumothorax

What are the parts of the tracheostomy tube?

Parts of Tracheostomy TubeMain features Part

Main body of the tube Outer canula

A balloon at the distal end of the tube, provide seal between the rachea & tube

cuff

External balloon connected to the inflation line to the internal cuff ( vice versa)

Pilot balloon

Support the main tube structure.Tube type, size & coude

Flange/ neck plate

Bevel, smooth rounded dilating tip tipped placed inside the inner canula of the tube during insertion.

( reduce the risk of trauma ) removed once the tube in correct placement

Introducer/ obturator

Allow attachment to ventilation equipment/ ambu-bag

15 mm adaptor

Types of tracheostomy tubes

Single lumen: -Larger inner diameter than double

lumen tube. -Absence of removable inner cannula.

Double lumen: -Removable inner cannula (twist-lock

connection ) prevent build up of secretion.

Cuffed t.t

contraindication indication

Child < 12 years old Risk of aspiration

Risk of tracheal tissue damage from cuff Newly formed stoma ( adult )

PPV

Unstable condition

Indicationcuffless cuff

No risk for aspiration Minemiz aspiration

Pt no longer need PPV Allow PPV ( one way valve )

Pt still need airway access Close system ( upper & lower airway )Minemiz emphysema

Indication Close Suction System:

-Pt regyuireing Highy PEEP, Fio2

-TB, ARDS

-To Avoiding dramatic drop in oxygen.

Fenestration:

Single or multiple holes in the superior curvature of the shaft of outer and inner cannula.

Indication: -Improve speech & swallowing function.

Occlusion cap:

Soolid piece of plasticc can be placed on the end of a 15mm hub.Indication :

Blocks all air flow via tracheostomy (end stage weaning )

Humidification:1 -pt requiring oxygen with excessive

secretion/bedridden ( continuous \ ATM ) with need to be labeled, dated and changed as per PP.

2 -alert mobiles pt with minimal secretion ( HME ) change Q 24hr.

3 -buchannan bib ( contains a special foam (hydrolox) which act as filter & HME. Shoud by

Change/washed up to 3 use’s only .

Nursing Considerations..

Condition of tracheostomy dressing wet/dry

Stoma site should be observed for : -Bleeding

-Increase stoma size -Appearance of stoma edges and tissue

(e.g. maceration, cellulites ) -Evidence of infection (purulent discharge, pain,

offensive odor, tenderness -Allergic reaction to dressing product

-Tube secured to skin, ties are appropriately tight -Patient on oxygen: TM T-piece, humidification

method.

Suctioning Indications for Suctioning

if pt have one or more of the following: Excessive secretions

Decreased oxygen saturations Tachypnea , bradypnea or tachycardia

Restlessness, increased use of intercostal muscles, or sweating

Noisy breath sounds/decreased breath sound

Poor ineffective cough

Change in skin color from baseline Reduced expired air flow from tube during expiration

Collection of sputum specimens

Prior to section:- hyperventelation- hyperoxygenation

to Reduse Hypoxemia.

Caution:COPD: patients should only have 20% increase of oxygenation.

Hyperventelation , will be used for non-spontaneous breather, as it may have significant

adverse effects.

Ex: Reduced venous return and barotraumas

Potential Complications of Suctioning:

-Hypoxemia -Hypotension

-Increased intracranial pressure -Hyper/Hypoventilation

-Cardiac arrhythmias -Increased work of breathing

-Bronchospasm -Infection

-Accidental extubation/decannulation -Cardiac Arrest

Famous People who was tracheostomies

King Fahd bin Abdul Aziz Al Saud(king of SA)

John Fitzgerald Kennedy (U.S. President)

Thank you

done by: Marwah M.Ibrahim

Any Question؟؟؟

:References

-American Journal of Critical Care . -Tracheostomy multiprofessional handbook (1ed

addition ). -Critical Care Nurse.

-http://www.aurorahealthcare.org/yourhealth/healthgate/getcontent.asp?URLhealthgate=%2214874.html%22