COMBINED (P.G.

) INSTITUTE OF MEDICAL SCIENCES &

RESEARCH
DEHRADUN, UTTARAKHAND

ADVANCE NURSING PRACTICE

TRACHEOSTOMY

Submitted To:
Submitted by :

Mohamad Dildar

M.Sc Nursing 1st year

CIMSR-DDN

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 Tracheostomy
Introduction: A tracheostomy is a surgical opening into the trachea below the larynx through
which an indwelling tube is placed to overcome upper airway obstruction, facilitate mechanical
ventilator support and/or the removal of tracheo-bronchial secretions.

Definition:  The surgical formation of an opening into the trachea through the neck specially
to allow the passage of air.

Anatomy of the trachea:

 The trachea is a mobile cartilaginous and membranous tube.

 It begins as a continuation of the larynx at the lower border of the cricoid cartilage at the
level of the 6th cervical vertebra.
 Trachea ends at the carina by dividing into right and left principal (main) bronchi at the
level of the sternal angle.

 In adults the trachea is about 4½ in. (11.25 cm) long and 1 in. (2.5 cm) in diameter.

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 Relations of the Trachea in the Neck :

 Anteriorly: Skin, fascia, isthmus of the thyroid gland (in front of the second, third,
and fourth rings), inferior thyroid vein, jugular arch, thyroidea ima artery (if
present), and the left brachiocephalic vein in children, overlapped by the
sternothyroid and sternohyoid muscles.

 Posteriorly: Right and left recurrent laryngeal nerves and the esophagus.

 Laterally: Lobes of the thyroid gland and the carotid sheath and its contents

 The relations of the trachea in the thorax:

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  Anteriorly: The sternum, the thymus, the left brachiocephalic vein, the origins of
the brachiocephalic and left common carotid arteries, and the arch of the aorta.

 Posteriorly: The esophagus and the left recurrent laryngeal nerve.

 Right side: The azygos vein, the right vagus nerve, and the pleura.

 Left side: The arch of the aorta, the left common carotid and left subclavian
arteries, the left vagus and left phrenic nerves, and the pleura

 Blood Supply of the Trachea:

 The upper two thirds are supplied by the inferior thyroid arteries and the lower
third is supplied by the bronchial arteries.

 Lymph Drainage of the Trachea:

 The lymph drains into the pretracheal and paratracheal lymph nodes and the deep
cervical nodes.

 Nerve Supply of the Trachea:

 The sensory nerve supply is from the vagi and the recurrent laryngeal nerves.
 Sympathetic nerves supply the trachealis muscle

Indication:

1. Protection of the lungs from potential threats such as obstruction or aspiration:

 Trauma- accidental and surgical
 Foreign bodies
 Vocal cord paralysis

2. Effective removal of secretions from the trachea and lower airways.

3. To permit long-term ventilator support- Should be done early in case where long –term
support is anticipated:
 Coma
 Neuromuscular disorders
 Chronic obstructive pulmonary disease (COPD)
 Multiple injuries
 Impaired mental status

4. Obstructions in the upper airway caused by oedema, inflammation, infection of the glottis or
by carcinoma of the larynx are few of the important indications for tracheostomy.

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5. Inability to wean from ventilation after intubation.

Contraindication:

1. No absolute contraindications exist to Tracheostomy.

2. Relative contraindication is Laryngeal CA.

Article:
Tracheostomy set containing:
1. Toothed dissecting forceps-1
2. Curved mosquito forceps-2
3. Straight mosquito forceps-2
4. Artery forceps-2
5. Allis forceps-2
6. Needle holder
7. Double hook retractors-2
8. Blunt hook
9. Cricoids hook
10. Sharp scissors
11. Tracheal dilator
12. Gallipots-2
13. Cutting edge suture needle with cotton thread
14. Vaseline gauze
A clean tray containing:
1. Suction catheter with connection (sterile)
2. Hand towel
3. Kidney basin
4. Scalpel blade (sterile)
5. Gloves (sterile)
6. Mask
7. Apron
8. Anticeptic solution
9. Local anesthetic (xylocaine 2%)
10. Syringes (sterile)
11. Needles (sterile)
12. Sandbag
13. Spot light
14. Tracheostomy tube

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Types of tracheostomy tube:-

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Procedure:

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 Nursing action Rationale

1. Explain procedure to the patient if conscious Allays anxiety and facilitates

and get consent from patient and relatives. patient co-operation.
2. Place patient in supine position with full Promote visualization of site of
extension of neck and head. insertion for the procedure.
3. Remove gown and expose neck.
4. Keep suction and oxygen ready for use. Facilitates timely use of articles.
5. Assist in preparing skin and administering Reduces risk of infection.
local anesthetic Reduces sensation of pain.
6. Assist in and support patient as incision is
made and provide suitable Tracheostomy
tube for insertion.
7. Assist in securing Tracheostomy tube to Reduce chance of tube
neck while tying with tape. displacement.
8. Assist while tube is being sutured in place. Reduce chance of tube
displacement.
9. Place Vaseline gauze around tube
10. Assist patient to a comfortable position.
11. Replace equipment.
12. Document time, tube size, purpose of
Tracheostomy and patient’s condition.

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Complications:
The four most important immediate surgical complications are:
1. Bleeding around the Tracheostomy tube.
2. Subcutaneous emphysema, mediastinal emphysema and pneumothorax.
3. Aspiration of blood in the airway.
4. Cardiac arrest secondary to hypoxia, acidosis or sudden electrolyte shifts.
Postprocedural care:
1. Connect to ventilator (if needed).
2. Place patient in semi-Fowler’s position.
3. Check vital signs.
4. Administer analgesics and sedative as per order.
5. Watch for complications like bleeding, respiratory failure and blockage of
tracheostomy tube with secretions.
6. If metal tube is inserted, leave the stillate in a sterile tray at the bedside.
7. Keep suction apparatus and suction tube ready at bedside.

Guidelines for nursing care of the Tracheostomy patient (tracheostomy care)

Three major factors must be considered in the care of the Tracheostomy patient:
1. Humidification
2. Mobilization of secretions
3. Airway patency
Purposes

 To maintain airway patency by removing mucus and encrusted secretions.

 To maintain cleanliness and prevent infection at the tracheostomy site
 To facilitate healing and prevent skin excoriation around the tracheostomy incision
 To promote comfort
 To prevent displacement

Assessment

 Respiratory status (ease of breathing, rate, rhythm, depth, lung sounds, and oxygen
saturation level)
 Pulse rate

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 Secretions from the tracheostomy site (character and amount)
 Presence of drainage on tracheostomy dressing or ties
 Appearance of incision (redness, swelling, purulent discharge, or odor)

Equipment

 Sterile disposable tracheostomy cleaning kit or supplies (sterile containers, sterile

nylon brush or pipe cleaners, sterile applicators, gauze squares)
 Sterile suction catheter kit (suction catheter and sterile container for solution)
 Sterile normal saline (Check agency protocol for soaking solution)
 Sterile gloves (2 pairs)
 Clean gloves
 Towel or drape to protect bed linens
 Moisture-proof bag
 Commercially available tracheostomy dressing or sterile 4-in. x -in. gauze dressing
 Cotton twill ties
 Clean scissors

Procedure

1. Explain procedure to the patient.

2. Observe appropriate infection control procedures such as hand hygiene.

3. Provide for patient privacy.

4. Prepare the patient and the equipment.

 To promote lung expansion, assist the patient to semi-Fowler’s or Fowler’s

position.
 Establish the sterile field.
 Open other sterile supplies as needed including sterile applicators, suction kit,
and tracheostomy dressing.
5. Suction the tracheostomy tube, if necessary.

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  Put on a pair of sterile gloves).
 Suction the full length of the tracheostomy tube to remove secretions and
ensure a patent airway.
 Rinse the suction catheter and wrap the catheter around your hand, and peel the
glove off so that it turns inside out over the catheter.
 Unlock the inner cannula with the gloved hand. Remove it by gently pulling it
out toward you in line with its curvature. Place it in the soaking
solution. Rationale: This moistens and loosens secretions.
 Remove the soiled tracheostomy dressing. Place the soiled dressing in your
gloved hand and peel the glove off so that it turns inside out over the dressing.
Discard the glove and the dressing.
 Put on sterile gloves. Keep your dominant hand sterile during the procedure.
6. Clean the inner cannula.

 Remove the inner cannula from the soaking solution.

 Clean the lumen and entire inner cannula thoroughly using the brush or pipe
cleaners moistened with sterile normal saline. Inspect the cannula for
cleanliness by holding it at eye level and looking through it into the light.
 Rinse the inner cannula thoroughly in the sterile normal saline.
 After rinsing, gently tap the cannula against the inside edge of the sterile saline
container. Use a pipe cleaner folded in half to dry only the inside of the
cannula; do not dry the outside. Rationale: This removes excess liquid from
the cannula and prevents possible aspiration by the client, while leaving a film
of moisture on the outer surface to lubricate the cannula for reinsertion.
7. Replace the inner cannula, securing it in place.

 Insert the inner cannula by grasping the outer flange and inserting the cannula
in the direction of its curvature.
 Lock the cannula in place by turning the lock (if present) into position to
secure the flange of the inner cannula to the outer cannula.
8. Clean the incision site and tube flange.

 Using sterile applicators or gauze dressings moistened with normal saline,

clean the incision site. Handle the sterile supplies with your dominant hand.
Use each applicator or gauze dressing only once and then
discard. Rationale: This avoids contaminating a clean area with a soiled gauze
dressing or applicator.
 Hydrogen peroxide may be used (usually in a half-strength solution mixed with
sterile normal saline; use a separate sterile container if this is necessary) to
remove crusty secretions. Check agency policy. Thoroughly rinse the cleaned

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 area using gauze squares moistened with sterile normal
saline. Rationale: Hydrogen peroxide can be irritating to the skin and inhibit
healing if not thoroughly removed.
 Clean the flange of the tube in the same manner.
 Thoroughly dry the client’s skin and tube flanges with dry gauze squares.
9. Apply a sterile dressing.

 Use a commercially prepared tracheostomy dressing of non- raveling material

or open and refold a 4-in. x 4-in. gauze dressing into a V shape. Avoid using
cotton-filled gauze squares or cutting the 4-in. x 4-in. gauze. Rationale: Cotton
lint or gauze fibers can be aspirated by the client, potentially creating a tracheal
abscess.
 Place the dressing under the flange of the tracheostomy tube.
 While applying the dressing, ensure that the tracheostomy tube is securely
supported. Rationale: Excessive movement of the tracheostomy tube irritates
the trachea.
10. Change the tracheostomy ties.

 Change as needed to keep the skin clean and dry.

 Twill tape and specially manufactured Velcro ties are available. Twill tape is
inexpensive and readily available; however, it is easily soiled and can trap
moisture that leads to irritation of the skin of the neck. Velcro ties are
becoming more commonly used. They are wider, more comfortable, and cause
less skin abrasion.
11. Tape and pad the tie knot.

Place a folded 4-in. x. 4-in. gauze square under the tie knot, and apply tape over the
knot. Rationale: This reduces skin irritation from the knot and prevents confusing the
knot with the client’s gown ties.

12. Check the tightness of the ties.

Frequently check the tightness of the tracheostomy ties and position of the tracheostomy
tube. Rationale: Swelling of the neck may cause the ties to become too tight, interfering
with coughing and circulation. Ties can loosen in restless clients, allowing the
tracheostomy tube to extrude from the stoma.

13. Document all relevant information.

Record suctioning, tracheostomy care, and the dressing change, noting your assessments.

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 NURSING RESPONSIBILITY
1. Tracheostomy dressing should be done every 8 hours or whenever dressing is soiled.
2. If disposable inner cannula is present, then replace the one that is inside with a new
one.
3. If only single lumen is present, clean the neck plate and tracheostomy site.
4. Emphasize the importance of handwashing before performing tracheostomy care.
5. Proper way on how to remove, change and replace the inner cannula.
6. Check and clean the tracheostomy stoma.
7. Assess for symptoms of infection.

Conclusion 
 Tracheostomy is a safe procedure and gives a good alternative to delayed endotracheal
extubation in post-operative patients expected to have respiratory failure in places where
post-operative anaesthetic care is lacking.

 The most common indications for Tracheostomy is mechanical ventilation with

prolonged tracheal intubation.

 Tracheostomy: emergency and elective, improve quality of life.

 Meticulous surgical technique.

 Appropriate post-operative Tracheostomy care to reduce complications.

Summary
A tracheostomy is a surgical procedure that involves making a cut in the trachea
(windpipe) and inserting a tube into the opening. A tracheostomy may be temporary or
permanent, depending on the reason for its use. Certain groups, including babies, smokers
and the elderly, are more vulnerable to complications.
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 Bibliography

 Goel Ashish, joshi Rajnish, jain AP; ICU manual, 3rd Edition,2013, Paras Medical
Publiser; 62-66.
 Clinical nursing procedure: the art of nursing practice.2nd edition,2011, jaypee
publishers;page- 422-424
 Jacob annmma;Rekha R;clinical nursing procedures.
 Anatomy images; http://www.annalscts.com/article/view/16463/16669;
https://healthiack.com/encyclopedia/trachea-diagram/attachment/trachea-diagram-503.
 Procedure Images; https://www.practo.com/health-wiki/tracheostomy-symptoms-
complications-and-treatment/264/article;
https://www.doereport.com/generateexhibit.php?ID=10089.
 Part of Tracheostomy tube images;
https://www.pinterest.com/pin/199847302193183933/;
https://www.slideshare.net/surgerymgmcri/tracheostomy-class.

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