Tracheostomy Care Tracheostomy is done to

Historically • provide mechanical ventilation on a long-term

basis as in cases of neuromuscular disease
The first instance of tracheotomy was portrayed
• Facilitate weaning from mechanical ventilation
way back in 3600 BC on Egyptian artifacts by engravings
by decreasing anatomical dead space
in Abydos and Sakkara regions of Egypt depicting
• To bypass obstruction: Cancer larynx
tracheostomy.
• To maintain an open airway: A comatose patient
Antonio Musa Brasavola, an Italian physician, • To remove secretions more easily: Inability to
performed the first documented case of a successful swallow or cough: stroke patient
tracheotomy in a patient, who suffered from a tonsillar
obstruction and recovered from the procedure. He Types of Tracheostomy
published his account in 1546. Surgical tracheostomy: performed in the OR or at
In 1620, Habicot performed the first pediatric bedside under moderate sedation
tracheotomy. The procedure was performed on a Temporary Tracheostomy versus Permanent
sixteenyear-old boy who had swallowed a bag of gold in
an attempt to keep the gold from being stolen. The bag • Appearance is the same
became lodged in the boy's esophagus and obstructed o Temporary: The upper airway will
his trachea. remain connected to the lower airway if
the tracheostomy tube were to be
Friedrich III, German Emperor (1831 – 1888) dislodged
He had incurable cancer of the larynx, which had o Permanent: The larynx is removed and
been misdiagnosed by the English doctor Morell no connection exists between the upper
Mackenzie (later knighted by Queen Victoria). When the airway and the trachea itself
error was caught, it was too late to operate. Later Potential Short-term Complications
swelling by the tumor caused the prince to begin to
suffocate, and so on February 9, 1888, a tracheotomy was • Subcutaneous emphysema – air escapes around
performed, and a silver tube was put. stoma ; generally of no clinical consequence –
can be palpated around the stoma site
Elizabeth Taylor's Tracheostomy • Dislodgement of the tube Due to excessive
Taylor went to Europe, awaiting production of manipulation of the tracheostomy tube during
Cleopatra. In spring of 1961, she developed a case of coughing or suctioning– (more in the first 48
pneumonia, which led to an emergency tracheotomy and hours)
worldwide talk of her impending death. The swelling of Potential long-term complications Tracheostomy:
sympathy was widely thought to have influenced
Academy voters, who awarded Taylor her first Best • Thinning of the trachea (Trachemalacia)
Actress Oscar award. • Development of granulation of tissue (bump
formation in trachea)
Stephen Hawking (Physicist and Cosmologist)
• Narrowing of the airway above the site of
Stephen Hawking developed motor neurone tracheostomy
disease when he was in his early 20s. Most patients with • Once tracheostomy tube is removed, the
the condition die within five years, and according to the opening may not close on its own
Motor Neurone Disease Association, average life • Dysphagia
expectancy after diagnosis is 14 months. • Tracheal ischemia and necrosis

A tracheostomy is the formation of an opening into the Identifying Tracheostomy Parts

trachea usually between the second and third rings of
Cuffed Tracheostomy Tube
cartilage.
• Consists of three parts:
 o Outer cannula with an inflatable cuff and • Heat moisture exchanger (attached to the
pilot tube outside of a trach tube for long – term trach
o An inner cannula patients) – looks like a t-tube attachment
o An obturator
Nursing Care: Help to thin and mobilize secretions
Cuffless tubes
• Frequent repositioning,
• More suitable for long term ventilation • deep breathing and coughing,
• patient must have effective cough and gag reflex • chest physiotherapy,
to prevent aspiration risk • oral and parenteral hydration
• supplemental humidification
Fenestrated Tube
Nursing Care – Suctioning
• Have an opening on the posterior wall of outer
cannula allowing air to flow through the upper • Necessary for all trach patients to remove
airway and hence allows patient to speak secretions
• Often used during weaning process • Routinely done 2x / day, but more often if a
newly placed tracheostomy or when there is
Communication and Tracheostomies
infection present
• Patients being weaned off trach tubes may have • Suctioning activates psychological and
either a cuffless or fenestrated tube to allow physiological reflexes that make the experience
airflow past the larynx both uncomfortable and frightening
Nursing Care: Examination Selecting a suction catheter

• Be aware of when and why the trach was • Selection of the appropriate size suction catheter
inserted , how it was performed, the type and is vital in reducing the risk of trauma during
size of tube inserted suctioning
• Examine the patient at the start of visit. Observe • Divide the internal diameter of the tracheostomy
for signs of hypoxia, infection or pain Chest: by two, and multiply the answer by three to
Auscultate breath sounds obtain the French gauge suction catheter:
• Examine trach tube, as well as stoma site for o Size 8 tracheostomy tube (patient);
redness, purulent drainage, and bleeding around (8mm/2) x 3 = 12; therefore, a size 12F
the stoma gauge catheter is suitable for suctioning

Tracheostomy Humidification Gathering equipment for suctioning

• The nose provides warmth, moisture and • PPE – (mask, goggles, gloves)
filtration for the air we breath. • Bottle of normal saline
• Having a tracheostomy tube by-passes these • Appropriately sized suction catheter
mechanisms • Trach care kit
• so humidification must be provided to keep • Disposable inner cannula if appropriate
secretions thin and to avoid mucus plugs • Oxygen source – connected to patient
✓ Ideal room air temperature is 22C, 10mmH2O/L • Suction equipment regulator set at 80-120
✓ Larynx: 31-33C, 26-32 mmH2O/L mmHg
✓ Mid-trachea: 34C, 34-38 mmH2O/L • Ambu bag to ventilate patient prior to suctioning
✓ Main bronchi: 37C, 44mmH2O/L if appropriate
Types of tracheostomy humidification systems Procedure for suctioning
• Ambient water humidification • Place patient in semi-fowler’s position
• Select appropriate sized suction catheter
 • Hyper oxygenate BEFORE each suction pass FAQs
(except patients with long-term tracheostomy)
Can a patient eat with a Tracheostomy?
• Insert catheter to a pre-measured depth
• Apply suction on withdrawal of catheter Yes, generally speaking (patient may need an evaluation
• Limit suctioning to 5 seconds by a speech pathologist to determine swallowing ability)
• Use suction pressure between 80 – 120 mmHg What is the tracheostomy plug Used for?
• Limit suctioning to 3 passes two purposes:
• Discontinue if HR drops by 20; increases by 40, 1. Decannulation of the tracheostomy tube – Used
produces arrhythmias, or decreases 02 < 90% to plug trach tube for 12 hours the first day and
Tracheostomy Ties 24 hours the second day – if the patient
tolerates plugging, then decannulation can take
• Ties are generally changed daily place
• To lower the risk of accidental trach tube coming 2. It can be used for speech, but not as a speaking
out, tie changes should be: valve
o performed by two people or with new Practice Questions
ties secured BEFORE old ties are A ____ is the formation of an opening or stoma into the
removed. trachea. Tracheostomy
Maintenance of the inner cannula
• The majority of trach tubes have inner cannulas What are the two types of tracheostomy?
that require cleaning one to three times daily • Surgical tracheostomy
unless they are disposable • Percutaneous Dilatational Tracheostomy
• Use sterile technique to clean the reusable
cannula with ½ strength hydrogen peroxide and Give at least two potential short-term complications of
normal saline tracheostomy.
Nursing Care – Trach cuff pressure
1. Subcutaneous Emphysema
• Cuff pressure (balloon) should be maintained at 2. dislodgement of the trach tube
20 mmHg of pressure via a manometer – should 3. Trachemalacia
be assessed daily;
• if you don’t have a manometer measuring device For client safety and quality care, which technique is best
– check With a stethoscope placed on the neck, for the nurse to use when suctioning the client with a
inflate the cuff until you no longer hear hissing; tracheostomy tube?
deflate the cuff in tiny increments until a slight
A. Hyperoxygenate before and after suctioning
his returns….
B. Repeat suctioning until the tube is clear
Why?
C. Apply suction during insertion of the tube
• Assess and evaluate how the cuff is working D. Suction for 30 seconds
• Periodically relieve pressure on the trachea
• Let secretions above the cuff drain down so you Hyperoxygenate before and after suctioning
can suction them
The client with a new tracheostomy has a soiled dressing.
Nursing Care: Changing the Trach tube
What is the best nursing intervention?
• Tube changes can be done safely on a 1-3 month
basis using a clean technique A. Cut sterile 4 x 4 gauze to fit around the
• Silicon tubes can crack and tear; soft PVC tubes tracheostomy tube
can stiffen with time B. Reinforce the dressing with sterile 4 x 4 gauze
Nursing care: Tracheostomy Site Care and Dressing C. Replace the dressing with clean, folded 4 x 4
• Clean stoma with Q-tip moistened with NS; gauze
• Avoid using hydrogen peroxide unless infection D. Replace the dressing with sterile, folded 4 x 4
present (as it can impair healing) – gauze
• Dressings around the stoma are changed Replace the dressing with sterile, folded 4 x 4 gauze