What are indications for tracheostomy in adults?

·         Obstructive sleep apnea, trauma, bleeding, tissue swelling, infections, burns (chemical or inhalation)

·         Access for continuous ventilation, with the inability to wean (greater than 2 weeks of ventilation)

·         Promotion of pulmonary hygiene by accessing airway for secretion removal

·         Bilateral vocal chord paralysis

·         Inability to protect own airway

Pre-op teaching for the patient receiving a tracheostomy

should include:

·         Reinforcing education provided by the physician

·         Looking at anatomical diagrams

·         Handling a tracheostomy tube

·         Explaining postoperative changes in ability to speak and eat

·         (if  it will be permanent) information about living a productive life with modifications in clothing and possibly meeting with someone who is already living with a permanent tracheostomy

·         In case of emergency tracheostomy provide teaching to the family

Complications of tracheostomy include:

·         Airway obstruction

·         Ineffective airway clearance

·         Impaired gas exchange

·         Infection

·         Aspiration

·         Accidental decannulation

·         Tracheal stenosis (narrowing of the trachea)

·         Tracheomalacia (softening of the trachea due to pooled secretions)

·         Subcutaneous emphysema (air escapes into the tissue causing face, neck, or upper body puffiness)

·         Tracheal dilation

Decannulation is:

when a tracheostomy tube is accidently dislodged from the stoma

Post-op care for tracheostomy should include:

·         Frequent assessment of amount, color, consistency of secretions

·         Observe for indications of shock, hemorrhage, respiratory insufficiency, or complications of surgery or client’s general condition

·         Change pt position frequently

·         Provide humidification and hydration

Cuffed (tube has inflatable cuff inside the trachea)

·         Permits mechanical ventilation

·         Deters upper airway secretions from leaking into the lower airway

·         Does not provide an absolute barrier

·         Does not hold the tube in place

·         Can be filled with sterile water, air, or foam

·         Increases the risk for tracheal wall necrosis

·         Is on the outer cannula of a standard tracheostomy tube

Non-cuffed

·         Allows air to pass into the upper airway

·         Are used in most permanent tracheostomies

Inner cannulas:

·          are used when intermittent manual cleaning is desired.

·          can be removed, inspected, cleaned, and put back or exchanged

Suctioning procedure for adults

• If cuffed, use oral suction for secretions collected above the cuff
• Suction based on assessments not routinely
• Routine suctioning can traumatize the airway
• Use sterile technique, preoxygenate and hyperinflate
• If pt is unable to cough, suction through the tracheostomy tube
• For adults, suctioning should require no more than 10-12 seconds

Suctioning procedure in pediatrics

• Vacuum pressure should be 60-100 mm Hg for infants and children
• Vacuum pressure should be 40-60 mm Hg for preterm infants
• Unless secretions are thick, the lower range of pressure is recommended
• Suction cath should be ½ the diameter of the tracheostomy tube
• Cath is inserted 0.5 cm beyond the end of the tube or just to the end
• Hyperoxygenate with 100% O2 before and after
• Do not instill saline to loosen secretions
• Allow child to rest for 30-60 after each aspiration
• Use aseptic technique
• For pediatrics, suctioning should require no more than 5 seconds

Signs the patient may need suctioning are:

• ↑ heart rate
• ↑respiratory effort
• ↓O2 saturation
• Cyanosis
• ↑ in positive inspiratory pressure on the ventilator

Closed suctioning systems

• No need to disconnect pt from ventilator
• Reduces caregiver exposure to secretions
• Allows for suction with uninterrupted oxygenation

Pediatric indications for short term tracheostomy

• Epiglottitis
• Croup
• Foreign body aspiration

Pediatric indications for long term tracheostomy

• Need for long term ventilator support
• Tracheomalacia
• Tracheostenosis
• Vocal chord paralysis

The most common tubes used for pediatric tracheostomy

• Are made without an inner cannula
• Resist the formation of crusty respiratory secretions
• Have a more acute angle than adult tubes
• Are  Hollinger, Jackson, Aberdeen, or Shiley tubes

Pre-op teaching for pediatric tracheostomy

• Include the child in the teaching (if age appropriate)
• If possible, allow child and family to examine a tube and supplies
• Explain that removal of sutures should not be painful
• Explain possible complications to family

Post-procedure complications for peds include:

• Hemorrhage
• Edema
• Aspiration
• Accidental decannulation
• Tube obstruction
• Entrance of free air into the pleural cavity

Pediatric post-op care focus

• Maintain patent airway
• Removal of pulmonary secretions
• Providing humidified air or O2
• Comfort care
• Cleansing of stoma
• Monitoring child’s ability to swallow
• Teaching while preventing complications

Pediatric post-op care in the first 24 hours

• Direct observation of child and cardiac or respiratory monitors
• Respiratory assessments include (breath sounds, vital signs, work of breathing, type and amount of secretions, tightness of tracheostomy ties)
• Respiratory assessments are performed every 15 minutes until pt is stable, then every 1-2 hours for the first 24 hours, then every 2-4 hours or more as needed

Prevention of Ventilator Acquired Pneumonia (VAP) (Black: pg. 1650)

• Prevent gastric reflux (HOB elevated at 30-45 degrees)
• Prevent aspiration (suctioning of secretions)
• Provide oral care
• Wash hands and use gloves