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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 clients 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


1. Outer tube
2. Inner tube: Fits snugly into outer tube, can be easily removed for cleaning.
3. Flange: Flat plastic plate attached to outer tube lies flush against the
patients neck.
4. 15mm outer diameter termination: Fits all ventilator and respiratory
equipment.

via:
http://www.tracheostomy.com/images/equipment/bivona.jpg
All remaining features are optional

1. 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
2. Air inlet valve: One way valve that prevents spontaneous escape of the
injected air.
3. Air inlet line: Route for air from air inlet valve to cuff.
4. Pilot cuff: Serves as an indicator of the amount of air in the cuff
5. 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.
6. 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


o Place client in semi-Fowlers or Fowlers position. This will promote
lung expansion.
o 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.


o Insert the inner cannula by grasping the outer flange and inserting
the cannula in the direction of its curvature.
o 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.

1. 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.
2. Open / expose only the vacuum control segment of the suction catheter and
attach to the suction tubing.
3. Put on disposable sterile gloves over the non-sterile gloves and withdraw the
sterile catheter from the protective sleeve.
4. 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
5. Use a new sterile catheter for each suction pass.
6. No more than 3 passes recommended per treatment.
7. 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

1. DONT PANIC!
2. Once the tracheostomy tube has been in place for about 5 days the tract is
well formed and will not suddenly close.
3. Reassure the patient
4. Call for medical help.

5. Ask the patient to breathe normally via their stoma while waiting for the
doctor.
6. The stay suture (if present) or tracheal dilator may be used to help keep the
stoma open if necessary.
7. Stay with patient.
8. Prepare for insertion of the new tracheostomy tube
9. Once replaced, tie the tube securely, leaving one finger-space between ties
and the patients neck.
10. 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 patients 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:

1. ASK THE PATIENT TO COUGH: A strong cough may be all that is needed to
expectorate secretions.
2. 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.
3. 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.
4. 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:

1. Step 1: Expose the patients neck. Remove any clothing covering the
tracheostomy tube and the neck area. Do not remove tracheostomy.
2. 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.
3. Step 3: Ventilate. Use the ambu-bag directly to the t-tube.
4. If unable to ventilate:
o Try to suction. To remove or clear the secretions blocking the tube.
o If still unable to ventilate. The tube may be displaced and the doctor
may:

Change the tube

Intubate orally

Other Information
The schematic diagram below is created by Joel St. Clair in which you can see his
research here

References and Sources:

What Is Coronary Heart Disease?


Coronary heart disease (CHD) is a disease in which a waxy substance called plaque (plak) builds
up inside the coronary arteries. These arteries supply oxygen-rich blood to your heart muscle.
When plaque builds up in the arteries, the condition is called atherosclerosis (ATH-er-o-skler-Osis). The buildup of plaque occurs over many years.
Atherosclerosis

Figure A shows the location of the heart in the body. Figure B shows a normal
coronary artery with normal blood flow. The inset image shows a cross-section of a
normal coronary artery. Figure C shows a coronary artery narrowed by plaque. The
buildup of plaque limits the flow of oxygen-rich blood through the artery. The inset
image shows a cross-section of the plaque-narrowed artery.

Over time, plaque can harden or rupture (break open). Hardened plaque narrows the coronary
arteries and reduces the flow of oxygen-rich blood to the heart.
If the plaque ruptures, a blood clot can form on its surface. A large blood clot can mostly or
completely block blood flow through a coronary artery. Over time, ruptured plaque also hardens
and narrows the coronary arteries.

Overview
If the flow of oxygen-rich blood to your heart muscle is reduced or blocked, angina (an-JI-nuh or
AN-juh-nuh) or a heart attack can occur.
Angina is chest pain or discomfort. It may feel like pressure or squeezing in your chest. The pain
also can occur in your shoulders, arms, neck, jaw, or back. Angina pain may even feel like
indigestion.
A heart attack occurs if the flow of oxygen-rich blood to a section of heart muscle is cut off. If
blood flow isnt restored quickly, the section of heart muscle begins to die. Without quick
treatment, a heart attack can lead to serious health problems or death.
Over time, CHD can weaken the heart muscle and lead to heart failure and arrhythmias (ahRITH-me-ahs). Heart failure is a condition in which your heart can't pump enough blood to meet
your bodys needs. Arrhythmias are problems with the rate or rhythm of the heartbeat.

Outlook
CHD is the most common type of heart disease. In the United States, CHD is the #1 cause of
death for both men and women. Lifestyle changes, medicines, and medical procedures can help
prevent or treat CHD. These treatments may reduce the risk of related health problems.