CARE OF THE PATIENT WITH TRACHEOSTOMY

TRACHEOSTOMY

OVERVIEW/ INTRODUCTION

Tracheostomy is a surgically created hole through the anterior wall of the trachea inferior to the cricoids cartilage. The procedure is referred to as a TRACHEOTOMY.

A tracheostomy provides air passage to help the patient to breathe when the usual air passage is obstructed. When a tracheostomy is no longer needed, it is allowed to heal or surgically closed.

TYPES OF TRACHEOSTOMY

·       Temporary tracheostomy

·       Permanent tracheostomy

TYPES OF TRACHEOSTOMY TUBES

The health care market has exploded with tracheostomy tube designs in the last 10 years. Here are some commonly used:

·       Metal tracheostomy tubes: This is not commonly used today due to their expense, rigid construction and lack of a 15 mm connector to attach a ventilator or bag-valve mask.

·       Plastic tracheostomy tubes: This type is softened at body temperature, conforming to the patients’ anatomy and centering the distal tip at the trachea.

·       Uncuffed tracheostomy tubes: These are generally reserved for infants and children because they are less traumatic to the surrounding tissues. They allow airway clearance but provide no protection against aspiration.

·       Dual- cannula tracheostomy: This has a disposable or reusable inner cannula, which can be cleaned and replace regularly. Here the inner cannula can be removed if it becomes obstructed.

·       PDT tubes: These have a tapered tip and are designed for use in percutaneous tracheostomies.

·       Cuffed tracheostomy tubes: This type of tube allows for more airway clearance, offer more protection from aspiration and facilitates positive- pressure ventilation when the cuff is inflated. High volume, low pressure cuffs are most commonly used for adults.  

·       Fenestrated tracheostomy tubes: These are similar in construction to the standard cuffed tube, with the addition of an opening in the posterior portion of the tube above the cuff. They have a removable inner cannula and a plastic plug. With the inner tube removed, the cuff deflated and the normal air passage occluded the patient can inhale and exhale air through the fenestrations and around the tube.

INDICATIONS

·       Upper airway obstruction resulting from conditions such as tumors, inflammation, fracture bass of the skull, foreign bodies, or laryngeal spasm.

·       Patients with prolonged unresponsiveness secondary to conditions such as in drug intoxication or traumatic brain injury.

·       For patient with chronic respiratory failure. Performed to replace an endotracheal tube and facilitate long- term mechanical ventilation.

·       Severe trauma to the neck or head surgery to assist breathing during recovery.

BENEFITS OF TRACHEOSTOMY

·       Avoiding direct laryngeal injury from an endotracheal tube.

·       Facilitating airway suctioning and oral care.

·       Increase patient mobility.

·       Increases patient’ comfort.

BASIC CARE FOR TRACHEOSTOMY

·       Provide tracheostomy care every 4-8 hours. Adequate care must be provided to avoid complication and death.

·       Tracheostomy care includes cleaning or changing of the inner cannula, changing the dressing and tracheostomy tube holder and suctioning if needed.

·       While providing tracheostomy care, inspect the skin for signs of irritation or infection such as erthyma, pain, discharge and wound breakdown.

·       Absorbing secretions help to prevent maceration and skin breakdown. Place a tracheostomy dressing under the tube flanges. Never use/place anything with loose fiber (cotton wool) around the stoma because this can cause skin irritation.

·       Inform your supervisor or the doctor if you notice that the suture used to secure the tube has been removed or is irritating the patient.

·       Maintaining a humidified environment is another nursing responsibility. Normally the nasopharynx humidifiers inhaled air. Because the tracheostomy tube bypasses the upper airway, you may need to provide adequate humidity to keep the air moist.

·       Reusable inner cannula requires careful cleaning. The use of aseptic technique is essential while caring for a tracheostomy tube. Unlock and remove the inner tube and place it in a solution of normal saline unless the manufacturer directs otherwise. Remove encrusted secretions from the cannula and rinse properly. Reinsert and lock it in place.

COMMUNICATION TIPS

Losing the ability to speak is incredibly stressful for a patient with a tracheostomy tube. Non verbal interventions should be employed such as sign language, gestures, lip reading, pointing or eye blinking. The use of call bell and writing material should be encouraged if patient is literate.

NUTRITIONAL NEEDS

A dietician should be involved in the nutritional needs of the patient. Since patient cannot tolerate solid diets, this should be made available in liquid form containing high calorie and protein.

NURSING PROCESS

NURSING DIAGNOSIS

Ø Ineffective breathing pattern related to presence of tracheostomy tube and difficulty expectorating sputum as evidence by tenacious secretions, ineffective or absent cough reflex.

Ø Impaired verbal communication related to use of artificial airway and cuff as evidenced by inability to speak and signs of frustration.

Ø Risk for infection related to bypass of the airway defense mechanism and loss of skin integrity.

Ø Imbalance nutrition: less than body requirement related to reduce oral intake and dysphagia as evidence by loss of weight.

OBJECTIVES

1      Maintenance of patent airway; secretions expectorated without need of suction and normal SPO2 [95-100%]

2      Ability to communicate effectively and assist in his own care.

3      Maintenance of normal WBC [5000-11000cm3], maintain normal body temperature, nil erythma / purulent discharge from the stoma.

4      Normal appetite and maintenance of normal body weight during hospital stay.

INTERVENTIONS AND RATIONALE

·       Assess for respiratory distress [abnormal breath sounds, dyspneoa] to determine need for intervention.

·       Elevate head of bed 30-40 degree to allow a more forceful cough and to relieve dyspneoa.

·       Provide humidified air and proper hydration- to liquefy secretions.

·       Encourage deep breathing exercise; early ambulation- improves expectoration of mucus and secretions.

·       Keep tracheostomy tube tied securely, allowing one finger between ties and the skin- to secure tube from dislodging.

·       Monitor V/S and SPO2 using pulse oximeter- to note reduced O2 concentration.

2.     

·       If alert provide call bell for the patient- call bell helps patient to call the nurse when in distress.

·       Assess patients ability to read and write and provide materials- this aids easy communication.

·       Reassure patient that speech will return [if not permanent] - alleys patients anxiety that his condition is not permanent.

·       Encourage gesturing to communicate needs and desires.

3 

·       Monitor and report any rise in body temperature- rise in temperature indicates infection.

·       Use aseptic technique during suctioning and wound care - reduces risk for infection.

·       Change tiers regularly to avoid medium for infection.

·       Change O2 delivery equipments based on the hospital protocols.

·       Keep stoma clean and dry- to avoid wound breakdown and infection.

4

·       Perform mouth care PRN- to promote patients comfort and improves appetite.

·       Monitor weight to note progress.[evaluation]

·       Assess for swallowing reflex to determine risk for aspiration.

·       Provide high calorie, protein and beverages to maximize nutritional intake.

·       Pass an NG Tube for easy feeding.

DECANULATION

When the patient has adequately exchange air and expectorated secretions, the tracheostomy tube can be removed. The stoma is closed with a tape strip and covered with an occlusive dressing. The patient should be instructed to splint the stoma with the fingers when coughing, swallowing or speaking.

Epithelial tissues begin to grow24-48 hours and the opening of the stoma closes several days afterwards. SURGICAL PROCEDURE IS NOT NECESSARILY REQUIRED.

COMPLICATIONS

Tracheotomies are generally safe, but they do have risks. Some complications are likely during or shortly after surgery.

IMMEDIATE: Bleeding, infection, damage to the trachea, emphysema.

LONG TERM: Displacement of the tracheostomy tube from the trachea, narrowing of the trachea, obstruction of the tracheostomy tube, development of a fistula [trachea- esophageal fistula].

REFERENCES

Brunner and suddarth (2004). Medical surgical Nursing 10^th   

         ed. Lippincott and wilkins Philadelphia.

Elaina N. (2002) Human Anatomy and Physiology 2^nd ed.

         Lippincott williams and wilkins Philadelphia.

Famakinwa (2006) Synopsis of medical and surgical

         Nursing, Pon Publishers limited Ekpoma.

www.nursingcenter.com/ library / journal

www.mayor foundation medical/tracheostomy