Tracheotomy is one of the most often performed procedures on severely unwell patients. More likely to get a tracheostomy, the longer a patient requires mechanical ventilation. Indications, benefits, probable risks, and tracheostomy nursing care ill be discussed in this article.

The most common rationale for tracheostomy is chronic respiratory failure necessitating long-term mechanical ventilation. Other grounds for tracheostomy include serious facial or neck damage or significant surgery, congenital defects, or obstruction of the upper airway.

Compared to an endotracheal tube, a tracheostomy facilitates oral hygiene, promotes patient comfort, provides a more secure airway, and reduces the risk of tracheal necrosis.

Some physicians believe that a tracheostomy offers additional benefits, such as a shorter duration of time in the intensive care unit (ICU), a lower death rate, and quicker weaning from artificial breathing, however, these benefits have not been demonstrated.

Despite the numerous advantages of tracheostomy, complications are also associated with it.

Nursing Care

The majority of nurses learned tracheostomy nursing care in nursing school. (For further information, see Tracheostomy tubes.) When caring for a patient with a tracheostomy, nurses must suction the patient, clean the skin around the stoma, provide oral hygiene, and assess for problems. Normal upper airway functions include warming, filtering, and humidifying inhaled air. These capabilities are lost when a patient has a tracheostomy, as the upper airway is bypassed. Providing humidified air or oxygen through a t-piece or trache collar, in conjunction with an adequate fluid intake, will enhance the thinning and mobility of secretions and aid in the prevention of mucus plugs. Due to the alien nature of the tracheostomy, secretions will develop around the tracheostomy tube. To prevent skin deterioration, the peristomal region must be kept clean and dry.

Suctioning

Suctioning should only be conducted when necessary. Always hyper oxygenate patients before and after suctioning to prevent hypoxemia and its attendant hazards. Closed or in-line suctioning aids in maintaining oxygenation during mechanical breathing and reduces the likelihood of aerosolizing secretions. When suctioning a tracheostomy, use a catheter that is no larger than half the inner diameter of the tube and insert it till just beyond the tube’s end. A #12 French suction catheter is suitable for most individuals. Read also nursing interventions for tracheostomy nursing care.

Cleaning the Inner Cannula

Care for a tracheostomy tube necessitates a sterile method and the use of proper personal protection equipment, such as a gown and eye protection. Your institution may offer tracheostomy cleaning kits that include a brush and pipe cleaners for inner cannula cleaning. You must remove any secretions with a sterile solution, typically salt water.

Some institutional rules recommend the use of full-strength or diluted hydrogen peroxide to clean non-disposable inner cannulas, however, it should not be used to clean the skin around the stoma because it might cause tissue damage.

Hydrogen peroxide can destroy portions of a metal tracheostomy, hence it should not be used to clean it.

If your patient has a tracheostomy tube with a disposable inner cannula, you will need a replacement of the same type and size. Because the standard connector for all respiratory equipment, including the mechanical ventilator, is part of the inner cannula, certain tracheostomy tubes will require a temporary inner cannula while the inner cannula is being cleaned. Additionally, you can use a new inner cannula while cleaning the one you removed. Place the cleaned inner cannula in a sterile container to be used for the subsequent tracheostomy tube cleaning. Rinse the inner cannula with sterile water or saline solution before reinserting it into the tracheostomy tube. The inner cannula will rotate to secure itself in place. See also pediatric tracheostomy nursing care.

Stoma Care

To clean the stoma, the outer cannula, and the faceplate, moisten cotton swabs or a gauze pad with sterile physiologic saline. The peristomal region should be cleaned using an inward-to-outward semicircular motion. To avoid disintegration, pat dry the skin with gauze pads. Examine the epidermis for evidence of infection or inflammation. With the assistance of a teammate, replace the tracheostomy ties if they are moist or dirty. One of you can hold the tube while the other adjusts the trachea holder or ties. Examine the skin behind the trachea ties for anomalies. Refer to your facility’s policy regarding the replacement of trachea holders and ties.

When fastening tracheostomy tube ties, there should be only enough space for one finger between the patient’s neck and the knot. Take a length of twill tape twice the diameter of the patient’s neck, attach the ties to one flange, place both ends around the neck through the other flange, and tie a square knot close to the flange. Place a clean, precut dressing beneath the faceplate to conclude treatment. Under the faceplate, gauze should not be cut, as the ragged edges might cause irritation. The results of a recent short study evaluating the use of a solid pectin-based skin barrier instead of gauze were positive, although the majority of trache care technique suggestions are anecdotal or unsupported. Peristomal care should be provided every 8 hours, although dressings should be changed as necessary.

Include the look of the peristomal skin and if you changed the trache ties and inner cannula in your documentation of trache care. Notate the nature, quantity, hue, and odor of secretions, as well as the frequency of suctioning. See also the tracheostomy nursing care skill template.

Keep Emergency Supplies on Hand

To protect your patient from the difficulties associated with unintentional decannulation or tube dislodgement, certain emergency supplies should be promptly accessible at the patient’s bedside and accompany the patient when he leaves the room for whatever reason. Emergency supplies include a tracheostomy tube of the same type and size as the one presently in place, as well as a smaller tracheostomy tube. If the tracheotomy is less than seven days old, it may be difficult to replace the tube in the event of inadvertent decannulation; therefore, an endotracheal tube of the proper size and lubricant should be on hand. Suction equipment, gloves, and a bag-valve mask, in addition to tracheostomy tube ties or another securing device, should be readily available.

To reduce morbidity and mortality, a multidisciplinary team approach is suggested while caring for a patient with a tracheostomy. Consider calling a speech pathologist within 24 to 48 hours following the tracheostomy if they were not notified beforehand. Speech pathologists can facilitate communication as well as swallowing function. This can facilitate successful decannulation. Read also tracheostomy nursing care steps.

Speaking After a Tracheostomy

When confronted with a tracheostomy, patients are most frequently concerned about impaired verbal communication. Inability to communicate causes worry and frustration. When a patient is unable to talk, the nurse should collaborate with the patient, the patient’s family, and other staff members to develop an appropriate alternative method of communication. Alternatives include the use of simple yes/no questions, a communication board, pencil, and paper, or a small dry-erase board. You can also consult with speech and respiratory therapists to assess if the patient is a candidate for a speech aid.

There are numerous ways to achieve speech with a tracheostomy. These include deflating the cuff and allowing the patient to breathe through the larynx, deflating the cuff and capping the tube with a finger or speaking valve, or utilizing a specific tube with a talk connection for patients who require mechanical ventilation. If the patient is no longer in need of artificial breathing, a fenestrated tube with no cuff inflation can facilitate speaking.

For lengthier conversations and if the patient can tolerate room air, a speaking valve without an inflated cuff can be used. This one-way valve allows the patient to inhale via the tracheostomy and exhale via the vocal cords. See also the tracheostomy nursing care PowerPoint.

Anterolateral View of the Trachea and Surrounding Structures

Early education regarding tracheostomy nursing care is advised for patients and their families. When possible, nurses should involve the patient in tracheostomy nursing care. This will assist in a smooth transfer to the subsequent care level. Caregivers should be provided the time and assistance necessary to obtain and become comfortable with emergency equipment for the home. Early and consistent instruction to support discharge planning will increase the patient’s and family’s level of comfort.

Conclusion

A patient with a tracheostomy is best cared for using a team-based approach. Everyone should collaborate to maintain the site clean and dry through routine dressing changes and suctioning as needed. Maintaining emergency supplies on hand at all times will allow you to give superior care to your patients.

Tracheostomy Complications

Complications following a tracheostomy may arise shortly following the procedure or much later. A tracheotomy can be performed surgically in the operating room, or percutaneously at the bedside.

Some bleeding is to be expected immediately after the tracheostomy nursing care procedure, but continuous oozing may necessitate further action; the care provider should be called promptly. Bleeding pulses may indicate a tracheoinnominate fistula. This can be treated promptly by overinflating the tracheostomy cuff to apply pressure to the artery, but the patient will require surgical repair to prevent exsanguination. The nurse should palpate the peristomal region for subcutaneous emphysema, which may suggest a malpositioned tracheostomy tube, which is a medical emergency.

Obstruction of the airway is a problem that can arise at any time following tube implantation. Typically, it is due to a mucus plug. The nurse can remove and clean the inner cannula if the patient has one. Suctioning can also assist with blockage removal.

Infection and tracheal difficulties such as granuloma formation, dilation, and ischemia might develop over time. These can be reduced with diligent tracheostomy nursing care, including cleaning and appropriate cuff pressure management.

In addition, tracheoesophageal fistulas and tracheal stenosis are further complications. This can be caused by excessive cuff pressure or an injury sustained during tube installation.

Once a patient no longer requires mechanical ventilation, it is advised to deflate the cuff to prevent complications. Some consequences may not manifest until the tracheostomy tube is removed, including difficulties with swallowing or speaking.

Tracheostomy Tubes

An obturator is used to implant a tracheostomy tube in place of the inner cannula. The rounded end of the obturator improves stability during insertion. Flanges are utilized on the faceplate or neck-plate of the outer cannula to bind the device to the patient with twill tape or a tube holder. A fenestrated tracheostomy tube can be used to assist the patient with speech and tracheostomy tube weaning.

Tracheostomy tubes are available in various sizes. The diameter, length, and even curve of each tube may vary. Varied manufacturers have different sizing specifications, thus a replacement tube should come from the same manufacturer. For usage with a mechanical ventilator, tubes may be cuffed or un-cuffed. A tracheostomy tube may be made of metal or plastic, and its inner cannula may or may not be detachable. According to the American Thoracic Society, “selection of the best tube for any patient will depend on the collective experience of the tracheostomy team” because there is no study on the optimal options. Some tracheostomy tubes contain an inflatable cuff that creates a closed system to protect the airway and permit adequate ventilation. A cuff that is inflated can also inhibit aspiration. The recommended cuff pressure ranges from 20 to 25 cm H2O. Higher cuff pressures can induce tracheal irritation and injury, such as tracheal ulcerations and necrosis. A manometer should be used to monitor tracheostomy tube cuff pressure to limit the risk of problems. When a patient no longer requires artificial breathing, if there is no risk of aspiration, the tracheostomy tube cuffs should be deflated.

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