Tracheostomy
Def :
A surgical opening or stoma made through the second or third and fourth cartilaginous ring of trachea
* Indication :
*prolonged need for artificial airway ( more than 3
weeks )
*Acute upper airway obstruction
*Chronic upper airway obstruction including obstructive sleep apnea
*Intolerance to endotraceal tube
*Retention of bronchopulmonary secretion
*Predisposition to pulmonary secretion
*prophylaxis in anticipation of acute airway
management problem ( burn , radial neck surgery )
*Post laryngectomy
*Congenital anomalis of the face and neck that make intubation impossible
* Purpose :
* Maintain patent airway
* Improve patient comfort
* Permit speech for the patient
* Increase patient mobility
* Facilitate oral nourishment
* Facilitate transfer from ICU
* Types:
* Disposable or reusable
* Cuffed or non cuffed
plastic or metal
* Temporary or permenant
* Components :
Outer tube
Inner tube
Flang ( wings )
Pilot cuff
Inflated ballon
Spaeking valve
Air inlet line
Tracheostomy button or cap
* Tracheostomy care :
Elevate head of the bed 30-40 degree unless
contraindicated
Change p.t position frequently
Avoid excessive cough pressure
Keep the O2 heated and humidified
Make chest physiotherapy every 2 hours
Suction only if necessary
Check ventilator tubing or T-tube frequently to ensure
that is no pulling on the tracheostomy tube
Do all tracheostomy care procedure with aseptic
technique
Use the smallest possible feeding tube
Check placement of feeding tube every 4 hours
Monitor fluid and Wt regularly
Communicate with the p.t even unconscious
Keep the tracheostomy ties tight enough
If the p.t has a disposable inner cannula , remove and
replace it with another sterile one every 24 hrs
If he doesn't have a disposable inner cannula , follow
procedure for cleaning the iner cannula
If tracheostomy ties doesn't have an inner cannula concentrate exclusively on wound care
Keep the p.t well hydrated 2-3 litres of fluid per day
uless contraindicated ( Renal disease , CHF , pULMONARY EDEMA , Increased intracranial pressure )
Clean the wound around tracheostomy tube and inner cannulaat least every 8hrs
* Changing the tube :
* The physician change the first tube 2-7 days after surgery
The tube is changed once a week in acute setting &* about once every month or every two months for the clinic or home
The acute care p.t is (NPO) for afew hours before the tube changes
* Extubation :
Removal of the tracheostomy when the indication for intubation is no longer present and when the p.t is able to clear his own secretion and protect the airway from secretion and protect the airway from aspiration
* post extubation care :
Stay with the p.t until he feels confident that he can breathe on his own without dificulty
Obseve the presence of stridor , which indicate airway narrowing to less than 5 mm which can be treated with corticosteroids and reintubation as ordered
Observe signs indicating laryngospasm , supraglottic edema , SIgns of aspiration and hoarsness of voice
Report immediately if there is any abnormality
* Complication :
Hemorrhage : May occur within 48 hrs after tube insertion
Trauma : during tube insertion ( hemorrhage , s.c emphysema , thyroid gland injury , pneumothorax )
Hypoxemia : & segal nerve stimulation
Stoma ifection
Tracheo-esophageal fistula due to excessive cuff pressure
Agitation : Arises from pain and discomfort