Tracheostomy
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