Topic Outline: Content Summary I.Definition A tracheostomy is a surgically created opening in the trachea.

A tracheostomy tube is placed in the incision to secure an airway and to prevent it from closing. Tracheostomy care is generally done every eight hours and involves cleaning around the incision, as well as replacing the inner cannula of the tracheostomy tube. After the site heals, the entire tracheostomy tube is replaced once or twice per week, depending on the physician's order. II. Key Terms Tracheotomy Incision made below the cricoid cartilage through the 2nd - 4th tracheal rings. Tracheostomy - The opening or stoma made by this incision. Tracheostomy Tube Artificial airway inserted into the trachea during tracheotomy III. Purpose The goals of tracheostomy care are to maintain the patency of the airway, prevent breakdown of the skin surrounding the site, and prevent infection. Sterile technique should be used during the procedure. IV. Indications Bypass acute upper airway obstruction. Chronic upper airway obstruction. Facilitate weaning from mechanical ventilation by decreasing anatomical deadspace. Prevention / treatment of retained tracheobronchial secretions. Prevention of pulmonary aspiration. V. Precautions Extra precautions should be taken when performing site care during the first few days after the tracheostomy is surgically created. The site is prone to bleeding and is sensitive to movement of the tracheostomy tube. It is recommended that another health care professional securely hold the tube while site care is performed. Tracheostomy care should not be done while the patient is restless or agitated, since this increases the chance that the tube may be pulled out and the airway lost. VI. Preparation All supplies needed for tracheostomy care should be at the bedside prior to beginning the procedure. There are prepackaged tracheostomy care kits available that contain gauze pads, cotton-tipped applicators, a tracheostomy dressing, and hydrogen peroxide. In addition, a container of 0.9% sodium chloride solution, a suction kit, and sterile gloves are needed. The velcro strap that holds the tracheostomy tube in place may be soiled and need to be replaced as well. VII. Procedure 1. Explain procedure to patient. 2. If tracheostomy tube has been suctioned, remove soiled dressing from around tube and discard with gloves on removal. 3. Perform hand hygiene and open necessary supplies. Cleaning a Nondisposable Inner Cannula 1. Prepare supplies before cleaning inner cannula. a. Open tracheostomy care kit and separate basins, touching only the edges. If kit is not available, open two sterile basins.

b. Fill one basin fraction -inch (1.25 cm) deep with hydrogen peroxide. c. Fill other basin fraction -inch (1.25 cm) deep with saline. d. Open sterile brush or pipe cleaners if they are not already in cleaning kit. Open additional sterile gauze pad. 2. Don disposable gloves. 3. Remove oxygen source if one is present. Rotate lock on inner cannula in a counterclockwise motion to release it. 4. Gently remove inner cannula and carefully drop it in basin with hydrogen peroxide. Remove gloves and discard. 5. Clean inner cannula. 6. Don sterile gloves. 7. Remove inner cannula from soaking solution. Moisten brush or pipe cleaners in saline and insert into tube, using back-and-forth motion. 8. Agitate cannula in saline solution. Remove and tap against inner surface of basin. 9. Place on sterile gauze pad. 10. Suction outer cannula using sterile technique. 11. Replace inner cannula into outer cannula. Turn lock clockwise and make sure that inner cannula is secure. Reapply oxygen source if needed. Replacing Disposable Inner Cannula 1. Release lock. Gently remove inner cannula and place in disposable bag. Discard gloves and don sterile ones to insert new cannula. Replace with appropriately sized new cannula. Engage lock on inner cannula. Applying Clean Dressing and Tape 1. Dip cotton-tipped applicator in saline and clean stoma under faceplate. Use each applicator only once, moving from stoma site outward. 2. Apply hydrogen peroxide to area around stoma, faceplate, and outer cannula if secretions prove difficult to remove. Rinse area with saline. 3. Pat skin gently with dry 4 x 4 gauze. 4. Slide commercially prepared tracheostomy dressing or prefolded non-cotton-filled 4 x 4 dressing under faceplate. 5. Change tracheostomy tape. a. Leave soiled tape in place until new one is applied. b. Cut piece of tape that is twice the neck circumference plus 4 inches (10 cm). Trim ends on the diagonal. c. Insert one end of tape through faceplate opening alongside old tape. Pull through until both ends are even. d. Slide both tapes under patients neck and insert one end through remaining opening on other side of faceplate. Pull snugly and tie ends in double square knot. Check that patient can flex neck comfortably. e. Carefully remove old tape. Reapply oxygen source if necessary. 6. Remove gloves and discard. Perform hand hygiene. Assess patients respirations. Document assessments and completion of procedure. VIII. Aftercare After tracheostomy care is finished, the soiled dressing and supplies should be discarded, either in the garbage or in a biohazard container if there is a large amount of blood. The patient may need to be suctioned again, and his or her respiratory status should be reassessed. Again, pain medication should be offered as appropriate. IX. Complications Tracheostomy care is a relatively benign procedure. The greatest risk is that the tube may be inadvertently removed and the airway lost.

X.

Results

The anticipated outcomes of tracheostomy care include continual patency of the airway, prevention of skin breakdown around the stoma, and prevention of infection.

XI. Health Care Team Roles The nurse has the primary role in tracheostomy care, as he or she is responsible for doing it in the acute care setting. The respiratory therapist may assist the nurse during the procedure and during respiratory assessment. Some patients may be sent home with a tracheostomy. In this case, the nurse and respiratory therapist are both responsible for teaching the patient and the family how to perform site care at home.