Tracheostomy

Upper and Lower Respiratory System

What is a tracheotomy?
its involves surgical creation of an external
opening through the 2
nd
and 3
rd
or 3
rd
and 4
th
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:
Long Term What is considered
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 occur
with a tracheostomy???
temporary voice loss.
filtration, loss of the airborne particle
action of warming and humidification
. 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 daysthe 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 Tube
Main 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
Indication
cuffless 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 uses 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/health
gate/getcontent.asp?URLhealthgate=%2214874.html
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