Tracheostomy is used for clients needing long-term airway support. A tracheostomy is an opening into the trachea through the neck. A tube is usually inserted in this opening and thus an artificial airway is created.
Tracheostomy tubes have an outer cannula that is inserted into the trachea and a flange that rests against the neck and allows the tube to be secured in place with tape or ties. Tracheostomy tubes also have an obturator whichi s used to insert the outer cannula which is then removed afterwards. The obturator is kept at the client’s bedside in case the tube becomes dislodge and needs to be reinserted.
Nurses provide tracheostomy care for clients with new or recent tracheostomy to maintain patency of the tube and minimize the risk for infection (since the inhaled air by the client is no longer filtered by the upper airways). Initially a tracheostomy may need to be suctioned and cleaned as often as every 1 to 2 hours. After the initial inflammatory response subsides, tracheostomy care may only need to be done once or twice a day, depending on the client.
A. Components of Tracheostomy Tube
- Outer tube
- Inner tube: Fits snugly into outer tube, can be easily removed for cleaning.
- Flange: Flat plastic plate attached to outer tube – lies flush against the patient’s neck.
- 15mm outer diameter termination: Fits all ventilator and respiratory equipment.
All remaining features are optional
- Cuff: Inflatable air reservoir (high volume, low pressure) – helps anchor the tracheostomy tube in place and provides maximum airway sealing with the least amount of local compression. To inflate, air is injected via the…
- Air inlet valve: One way valve that prevents spontaneous escape of the injected air.
- Air inlet line: Route for air from air inlet valve to cuff.
- Pilot cuff: Serves as an indicator of the amount of air in the cuff
- Fenestration: Hole situated on the curve of the outer tube – used to enhance airflow in and out of the trachea. Single or multiple fenestrations are available.
- Speaking valve / tracheostomy button or cap: Used to occlude the tracheostomy tube opening (a) former – during expiration to facilitate speech and swallow, (b) latter – during both inspiration and expiration prior to decannulation.
Bed Side Equipment
- Spare Tracheostomy Tubes. Should be of same size as what the patient is wearing.
- Tracheal Dilator.
- Suctioning equipment. Suction machine fitted with filter; suction tubing;suction catheters (see suctioning page for sizes); gloves (as below); bottle of sterile water to rinse tubing – change daily. Ensure that the equipment is assembled and working properly.
- Humidification Equipment.
Gloves. Clean gloves and sterile gloves (for suctioning).
B. Providing Tracheostomy Care
Goals of Tracheostomy Care
- To maintain patent airway
- To maintain skin integrity
- To prevent infection
- To prevent displacement
Before Tracheostomy Care
- Introduce self, verify patient and explain the procedure.
- Perform hand hygiene and other appropriate infection control measures.
- Prepare the client and the equipment
- Place client in semi-Fowler’s or Fowler’s position. This will promote lung expansion.
- Open necessary supplies and establish a sterile field
- Suction as necessary.
Clean The Inner Cannula
- Remove inner cannula from the soaking solution
- Clean the lumen and entire inner cannula thoroughly using the brush or pipe cleaners moisten with sterile normal saline.
- Rinse the inner cannula thoroughly with the sterile NSS.
- Afterwards, tap the cannula against the inside edge of the sterile saline container. Use a pipe cleaner folded in half to dry the inside of the cannula only.
- Replace the inner cannula and secure 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 into position to secure the flange of the inner cannula to the outer cannula.
Clean Incision Site and Tube Flange
- Using sterile applicators or gauze dressings moistened with NSS, clean the incision site.
- Secure the tube by holding it with your other hand, thus preventing it from moving
- Use dressing only once and then discard.
- hydrogen peroxide may be used to remove crusty secretions. Rinse thoroughly using gauze squares.
- Clean the flange of the tube in the same manner.
C. Suctioning of Tracheostomy Tube
Suctioning of tracheostomy tube is only done as necessary. Sterile technique must be observed. Nurses should be aware that there is a frequency for the need of suctioning during immediate post-operating period.
- Explain the procedure to the patient – wash hands, put on gloves. Put on apron and fluid shield mask if necessary for standard (universal) precautions). Turn on suction apparatus and test that vacuum pressure is < -150mmHg.
- Open / expose only the vacuum control segment of the suction catheter and attach to the suction tubing.
- Put on disposable sterile gloves over the non-sterile gloves and withdraw the sterile catheter from the protective sleeve.
- Maintaining sterility, insert the suction catheter with NO suction applied until resistance is met, then pull back about 1-2 cms before applying continuous suction as the catheter is smoothly withdrawn from airway. NOTE: Recommended suction time (i.e. from insertion to removal of suction catheter) = <15secs
- Use a new sterile catheter for each suction pass.
- No more than 3 passes recommended per treatment.
- On completing procedure, ensure patient comfort, discard of equipment as per hospital policy, wash hands and document procedure in the chart.
D. Dealing with Emergencies
If the tracheostomy tube falls out
- DON’T PANIC!
- Once the tracheostomy tube has been in place for about 5 days the tract is well formed and will not suddenly close.
- Reassure the patient
- Call for medical help.
- Ask the patient to breathe normally via their stoma while waiting for the doctor.
- The stay suture (if present) or tracheal dilator may be used to help keep the stoma open if necessary.
- Stay with patient.
- Prepare for insertion of the new tracheostomy tube
- Once replaced, tie the tube securely, leaving one finger-space between ties and the patient’s neck.
- Check tube position by (a) asking the patient to inhale deeply – they should be able to do so easily and comfortably, and (b) hold a piece of tissue in front of the opening – it should be “blown” during patient’s exhalation.
Patient is having Acute Dyspnea
Acute dyspnea for patient with tracheostomy is most commonly caused by partial or complete blockage of the tracheostomy tube retained secretions. To unblock the tracheostomy tube:
- ASK THE PATIENT TO COUGH: A strong cough may be all that is needed to expectorate secretions.
- REMOVE THE INNER CANNULA: If there are secretions stuck in the tube, they will automatically be removed when you take out the inner cannula. The outer tube – which does not have secretions in it – will allow the patient to breath freely. Clean and replace the inner cannula.
- SUCTION: If coughing or removing the inner cannula do not work, it may be that secretions are lower down the patients airway. Use the suction machine to remove secretions.
- If these measures fail – commence low concentration oxygen therapy via a tracheostomy mask, and call for medical assistance.
It is possible that the tracheostomy may have become displaced. Stay with the patient until assistance arrives. Prepare for change of tracheostomy tube.
Patient needing Cardiopulmonary Resuscitation
In the event of cardiopulmonary arrest, treat tracheostomy patients as other patients:
- Step 1: Expose the patient’s neck. Remove any clothing covering the tracheostomy tube and the neck area. Do not remove tracheostomy.
- Step 2: Check the patency of the inner cannula. To check inner cannula: Wearing a non-sterile glove, remove inner cannula. If clean, reinsert and lock into place. If soiled – replace. Continue resuscitation.
- Step 3: Ventilate. Use the ambu-bag directly to the t-tube.
- If unable to ventilate:
- Try to suction. To remove or clear the secretions blocking the tube.
- If still unable to ventilate. The tube may be displaced and the doctor may:
- Change the tube
- Intubate orally
The schematic diagram below is created by Joel St. Clair in which you can see his research here
References and Sources:
Tracheostomy Care Guidelines by St. James Hospital--A very good eBook simplifying the concepts about tracheostomy care.