Tracheostomy

A tracheostomy is a type of artificial airway consisting of a small, plastic tube that’s inserted through a surgically created opening, or stoma, in the anterior neck, known as a tracheotomy.

Typically, a tracheostomy is placed when a patient can’t keep their own airway open. It can be placed urgently when intubation by other means isn’t possible, or as a planned procedure, if the patient requires long-term airway assistance.

Now, patients with a tracheostomy typically have a short tube that protrudes from the anterior of their neck, which is usually stabilized with a flange and ties that encircle the neck.

Many tracheostomy tubes have an outer cannula, which keeps the airway patent, and an inner cannula, which can be disposable or non-disposable and is removed for cleaning.

The tube may or may not be connected to a mechanical ventilator or another source of oxygen; and depending on the type of tracheostomy tube your patient has, they may or may not be able to talk.

Okay, so tracheostomy tubes come in various sizes and configurations. First, tubes can be cuffed, meaning there is a balloon that can be inflated to provide a leak-proof connection; or uncuffed, where there is no balloon.

Cuffed tubes are usually used short-term because they occlude the upper trachea and pharynx, and the pressure exerted can compress tracheal capillaries, limit blood flow, and predispose the patient to tracheal necrosis.

On the other hand, uncuffed tubes are used for patients with long-term tracheostomies to decrease the risk to surrounding tissues.

It’s also important to note that tracheostomy tubes can be fenestrated or non-fenestrated. A fenestrated tube has a hole on its dorsal surface, which helps promote spontaneous breathing.

When patients have a cuffed, fenestrated tracheostomy tube, the cuff can be deflated and inner cannula removed. This allows air to pass from their lungs through the opening in the tube, enabling them to breathe spontaneously and speak.

Now, some patients may have a Passey-Muir valve, or PMV. The Passey-Muir valve is a one-way valve placed on the end of their tracheostomy, that allows them to speak by redirecting exhaled air through the vocal cords, rather than back through the tube.

It’s important to remember that if a patient has a Passey-Muir valve in place, the cuff should be fully deflated, or they won’t be able to fully exhale.

Alright, now the nursing care you’ll provide for your patient with a tracheostomy involves promoting oxygenation and providing tracheostomy care.

To promote oxygenation, make sure your patient is receiving humidified air. Humidification not only warms and moisturizes secretions, but it helps thin secretions and decreases the formation of mucus plugs.

If your patient’s tracheostomy tube requires suctioning, be sure to always use sterile technique. During suctioning, observe the amount, color, and clarity of secretions, as well as how well they tolerate suctioning.

If your patient has a newly placed tracheostomy tube, you should avoid suctioning in the first few hours after the procedure, as it can be painful and cause bleeding.

Okay, so you’ll also perform care to prevent infection and promote comfort. At a minimum, you should assess the tracheostomy site and confirm patency of the tracheostomy every shift, observing the site for any redness, inflammation, edema, ulceration, or signs of infection.

Notify the health care provider immediately if any of these signs are present. To perform tracheostomy care, complete sterile dressing changes per facility policy and, due to the risk of tube dislodgement, you should always have another staff member in the room to assist you.

First remove the old dressing and ties, and then clean around the stoma with normal saline. Then, you’ll apply a sterile pre-cut dressing around the tracheostomy site.

Then, be sure to secure the trach ties. Now, if your patient has a tracheostomy with a disposable inner cannula, remove the inner cannula and dispose of it appropriately and insert a new one using sterile technique.

If your patient has a non-disposable inner cannula, remove the cannula using sterile technique and cleanse it with sterile saline, then reinsert the cannula.

Because an inflated tracheostomy cuff exerts pressure on the tracheal mucosa, cuff pressure should be measured at least every 8 hours with a cuff manometer.

Also, remember that certain activities, like turning and repositioning your patient, can cause the tracheostomy tube to become dislodged.

Importantly, a replacement tube of equal size and one size smaller should always be kept at the bedside, in case the original tube is unable to be re-inserted.

If dislodgement occurs, stay at the bedside and immediately call for help. While waiting for help to arrive, assess your patient’s ability to breathe and their level of consciousness.

If respiratory distress is present, and if it’s within the facility policy, you can insert a new tracheostomy tube. If the tube can’t be replaced, you should immediately place the patient in a semi-Fowler position to decrease dyspnea and the stoma should be covered with a sterile dressing.

Then you should initiate bag-valve mask ventilation over their nose and mouth until help arrives. Alright, as a quick recap....

A tracheostomy is a type of artificial airway that’s inserted through a stoma, in the anterior neck and is placed when a patient can’t keep their own airway open.

When caring for your patient with a tracheostomy, you’ll promote oxygenation and perform tracheostomy assessment and care.

Emergency equipment should always be kept at the bedside, including a bag valve mask, suctioning equipment, and a replacement tube in an equal and smaller size.

If the tube becomes dislodged, you should quickly assess your patient’s breathing and level of consciousness. If facility policy allows, you may insert a replacement tube.

If not, you should initiate bag valve mask respirations