ATI tracheostomy

tracheotomy
A sterile surgical incision into the trachea through the skin and muscles for the purpose of establishing an airway.
– can be emergency or scheduled and temporary or permanent
– can be placed orotracheally, nasotracheally, or through a tracheostomy to assist with respiration
– diameter of the tracheostomy tube must be smaller than the trachea
– airflow in and out w/o air leakage (a cuffed tracheostomy tube) bypasses the vocal cords, resulting in inability to produce sound or speech.
cuffed tracheostomy tube
it has a balloon that inflates around the outside of the distal segment of the tube to protect the lower airway by producing a seal between the upper and lower airway.
– permits mechanical ventilation
– prevents aspiration of oropharyngeal secretions
– cuffs don’t hold tube in place
– cuff pressures must be monitored to prevent tracheal tissue necrosis
– client unable to speak
– children don’t require a cuffed tube.
uncuffed tracheostomy tube (cuffless)
it has no balloon and is for clients who have long-term airway-management needs.
– client must be at low risk for aspiration
– not for clients on mechanical ventilation
– allows client to speak
fenestrated tracheostomy tube with cuff
it has one large or multiple openings (fenestrations) in the posterior wall of the outer cannula with a balloon around the outside of the distal segment of the tube.
it also has an inner cannula.
– allows for mechanical ventilation
– removing the inner cannula allows for the fenestrations to permit air flow through the openings
– allows client to speak
fenestrated tracheostomy tube w/o cuff
it has one large or multiple openings (fenestrations) in the posterior wall of the outer cannula with no balloon.
it also has an inner cannula.
– holes in the tube help wean the client from the tracheostomy
– removing the inner cannula allows the fenestrations to permit air flow through the openings
– allows client to speak
indications for tracheostomy
– acute or chronic upper airway obstruction
– edema
– anaphylaxis
– burns
– trauma
– head/neck surgery
– copious secretions
– obstructive sleep apnea refractory to conventional therapy
– need for long-term mechanical ventilation or reconstruction after laryngeal trauma or laryngeal cancer surgery
artificial airway tube types
– single-lumen (cannula)
– double-lumen (cannula)
single-lumen (cannula)
– long, single-cannula tube
– for clients who have long or thick necks
– don’t use with clients who have excessive secretions
double-lumen (cannula)
– an outer cannula fits into the stoma and keeps the airway open
– an inner cannula fits snugly into the outer cannula and locks into place
– an obturator is a thin, solid tube the provider places inside the tracheostomy and uses as a guide for inserting the outer cannula, and removes immediately after outer cannula insertion.

– allows removing, cleaning, reusing, discarding, and replacing the inner cannula with a disposable inner cannula.
– useful for clients who have excessive secretions.

considerations
– keep two extra tubes (one client’s size and one size smaller, in case of accidental decannulation), the obturator for the existing tube, an oxygen source, suction catheters and a suction source, and a BVM at the bedside.
– provide methods to communicate. and call light.
– provide adequate humidification and hydration to thin secretions and reduce the risk of mucous plugs.
– give oral care every 2 hours
– provide tracheostomy care every 8 hours to reduce risk of infection and skin breakdown:
1. suction tube
2. remove soiled dressings and excess secretions
3. apply oxygen loosely if SpO2 decreases
4. use cotton-tipped applicators and gauze to clean exposed outer cannula. clean in circular motion from the stoma outward.
5. use surgical asepsis to remove and clean inner cannula. use new inner cannula if disposable.
6. clean the stoma site and then tracheostomy plate
7. place fresh split-gauze tracheostomy dressing of nonraveling material under and around the tracheostomy holder and plate.
8. replace tracheostomy ties if wet or soiled. (secure with new ones before removing soiled ones to prevent accidental decannulation).
9. if knot needed, tie a square knot that’s visible on the side of the neck. check that one or two fingers fit between the tie and the neck.
– change nondisposable tubes every 6-8 weeks
– reposition client every 2 hours to prevent atelectasis and pneumonia
– minimize dust in room. don’t shake bedding.
– if permitted to eat, position client upright and tip chin to chest to enable swallowing.
– assess for aspiration
complications
– accidental decannulation
– damage to the trachea
accidental decannulation (in first 72 hours)
if occurs in the first 72 hours after surgery is an emergency b/c the tracheostomy tract has not matured, and replacement can be difficult. (VENTILATE CLIENT W/ BVM. CALL FOR ASSISTANCE)
– always keep the obturator and two spare tracheostomy tubes at the bedside
– if unable to replace tube, administer oxygen through the stoma.
– if unable to administer oxygen through stoma, occlude stoma and administer through the nose and mouth.
accidental decannulation (after first 72 hours)
– immediately hyperextend the neck and with the obturator inserted into the tracheostomy tube, quickly and gently replace the tube and remove the obturator.
– secure the tube
– assess tube placement by auscultating for bilateral breath sounds.
damage to the trachea
TRACHEAL STENOSIS: narrowing of the tracheal lumen due to scar formation resulting from irritation of the tracheal mucosa from the tracheal tube cuff.
– keep the cuff pressure between 14-20
– check cuff pressure at least once every 8 hours
– keep the tube in the midline position and prevent pulling or traction on the tube.

TRACHEAL WALL NECROSIS: tissue damage that results when the pressure of the inflated cuff impairs blood flow to the tracheal wall.

suctioning
suction orally, nasally, or endotracheally when clients have early signs of hypoxemia:
– restlessness
– confusion
– tachypnea
– tachycardia
– decreased SpO2 levels
– adventitious breath sounds
– audible or visible secretions
– cyanosis
– absence of spontaneous cough
suctioning considerations
– PPE
– position in semi-fowlers or fowlers
– encourage deep breathing and coughing to attempt to clear secretions w/o artificial suctioning
– obtain breath sounds, vitals, SaO2-pulse oximeter
– for oropharyngeal suctioning, use a yankauer or tonsil-tipped rigid suction catheter and move the catheter around the mouth, gum line, and pharynx.
– use medical asepsis for mouth suctioning/ use surgical asepsis for all other suctioning
– use suction pressure no higher than 120-150
– limit each suction attempt to no longer than 10-15 seconds to avoid hypoxemia and the vagal response.
– limit total suctioning time to 5 minutes.
nasopharyngeal and nasotracheal suctioning
– use a flexible catheter and lubricate the distal 6-8 cm (2-3 in) with water-soluble lubricant
– insert into naris during inhalation
– don’t apply suctioning while inserting
– follow natural course of naris and slightly slant downward while advancing it.
– advance approx. distance from tip of nose to base of earlobe.
– apply suction intermittently by covering and releasing the suction port with the thumb for 10-15 seconds
– apply suction only while withdrawing and rotating it w/ thumb and forefinger
– don’t perform more than 2 passes.
– allow at least 1 minute between passes for ventilation and oxygenation
endotracheal suctioning
– use a suction catheter, shouldn’t exceed 1/2 of the internal diameter of endotracheal tube to prevent hypoxia.
– use no larger than 16 French suction when suctioning an 8mm tube
– hyperoxygenate the client using a bag-valve-mask (BVM) or specialized ventilator function with FiO2 of 100%
– remove bag or ventilator from tracheostomy or tube and insert catheter into lumen of airway.
– advance catheter until resistance met. should reach level of the carina (location of bifurcation into the mainstem bronchi).
– pull catheter back 1 cm prior to applying suction to prevent mucosal damage.
– apply suction intermittently by covering and releasing suction port with thumb for 10-15 seconds.
– apply suction only when withdrawing and rotating with thumb and forefinger.
– reattach the BVM or ventilator and administer 100% oxygen
– rinse catheter and suction tubing with sterile saline until clear
– don’t reuse suction catheter for subsequent suctioning sessions.