Tracheostomy tubes

 

Tracheal tubes may be permanent or temporary.

The artificial airway is inserted into the trachea through a hole in the patient’s neck.

Indications:

  • maintenance of a secure airway
  • prevent upper airway obstruction
  • post neck or facial trauma
  • for mechanical ventilation purposes
  • an alternative to endotracheal intubation
  • aspiration pneumonia prevention
  • secretion removal facilitation
  • due to bilateral vocal cord paralysis
  • breathing center abnormalities (sever sleep apnea c/ decreased LOC)

 

Tracheal tube types:

  1. Single cannula tracheal tube
  • no inner cannula
  • for longer duration intubation

 

  1. Fenestrated tracheal tube
  • outer cannula has precut openings
  • when inner cannula is removed the cuff is deflated and the pt can speak
  • speech pathologist must evaluate pt for aspiration risk prior to cuff deflation and inner cannula removal
  • long term intubation
  • those being weaned from intubation

 

Tracheostomy patient assessement:

  1. q15min then q30 min after patient comes up to unit
  2. respiratory assessment
  • O2 stats
  • hypoxemia
  • resp status changes
  • confusion
  • restlessness
  1. Airway patency
  • signs of upper or lower airway obstruction
  • wheezes
  • crackles
  • gurgling
  • inspiration or expiration
  • restlessness
  • ineffective coughing
  • unilateral, segmental or lobular absent or diminished breathing sounds
  • tachypnea
  • hypertension
  • hypotension
  • cyanosis
  • decreased LOC
  • acute, excess nasal secretions
  • drooling, gastric secretions or vomit in mouth
  1. Secretions
  • clearance
  • changes in secretion quality, quantity and colour
  • new trach tubes will have blood tinged secretions for 2-3 days post Sx
  • have blood tinged secretions for 24hrs after each trachostomy tube change
  1. Assessment for hypoxia
  • apprehension
  • anxiety
  • decreased concentration
  • lethargy
  • decreased LOC
    increased fatigue
  • dizziness, irritability
  • decreased deep breathing
  • elevated BP
  • cardiac dysrhythmias

 

  1. incision site, drainage
  2. assess aspiration prevention – head of bed 30 degree or higher, ability to cough
  3. vitals
  4. pain
  5. hydration, nutrition, O2 humidification
  6. encourage mobilization, portable suction
  7. assess for fear or anxiety d/t airway or communication
  8. Swallow assessment
  • to determine aspiration risk if cuff is deflated
  • after the 24h NPO orders to switch to PO
  • PO = thick fluids, sitting upright, chin forward, small amounts at a time
  1. bowel care
  • , constipation prevention as patient is unable to perform valsalva maneuver

Complications:

  1. Tracheal wall necrosis
  2. Air escaping around tube – verify cuff inflation, reposition prn
  3. Skin breakdown at the site – skin integrity assessment, increase skin care frequency
  4. Unequal breath sounds – suction, evaluate tube placement and depth – confirm placement with x-ray
  5. Tracheoesophageal fistula or tracheomalacia (occurs d/t overinflated cuff)
  6. Innominate artery erosion
  7. tracheal dilation
  8. tracheal stenosis
  9. infection
  10. tracheal obstruction
  • misalignment
  • herniated cuff
  • occlueded inner canula

 

Patient care plan:

  1. Ensure tube is secure
  2. Ensure cuff pressure is appropriate
  3. Maintain patency – suctioning
  4. communication board or use speaking valve to allow speech
  5. oral hygiene
  6. skin integrity
  7. assess for granulation tissue accumulation on vocal cords, epiglottis, trachea

 

Weaning:

  • requires an order
  • deflate cuff or use a smaller diameter trach.
  • Review nose and mouth breathing techniques with the pt
  • takes 2-5 days

 

Documentation:

  • respiratory, skin integrity and other assessements
  • type and size of tracheostomy tube
  • suctioning frequency
  • secretions colour and amt
  • skin integrity
  • cuff pressure level (volume of air injected into cuff)
  • presence of minimal air leak?
  • pt tolerance of procedure
  • placement, patency and integrity of tube
  • continual assessement
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