Tracheostomy Care
Dr. Wesam Farid Mousa
Assisstant Professor Anesthesia & Surgical ICU
Dammam Hospital of the University
Tracheostomy
The Enabling Disability
Historically
The first instance of
tracheotomy was
portrayed way back in
3600 BC on Egyptian
artifacts by engravings
in Abydos and Sakkara
regions of Egypt
depicting tracheostomy.
Antonio Musa Brasavola, an
Italian physician,
performed the first
documented case of a
successful tracheotomy in a
patient, who suffered from
a tonsillar obstruction and
recovered from the
procedure. He published
his account in 1546.
In 1620, Habicot performed
the first pediatric
tracheotomy. The procedure
was performed on a sixteen-
year-old boy who had
swallowed a bag of gold in
an attempt to keep the gold
from being stolen. The bag
became lodged in the boy's
esophagus and obstructed
his trachea. After Habicot
performed the tracheotomy,
he manipulated the bag of
gold so that it would pass. It
was eventually recovered
per rectum.
Friedrich III, German Emperor (1831 – 1888)
He had incurable cancer of the larynx,
which had been misdiagnosed by the
English doctor Morell Mackenzie (later
knighted by Queen Victoria). When the
error was caught, it was too late to
operate. Later swelling by the tumor
caused the prince to begin to suffocate,
and so on February 9, 1888, a
tracheotomy was performed and a silver
tube was put. As a result of this
operation, Friedrich was unable to
speak for the remainder of his life, and
communicated through writing.
Friedrich ruled for only 99 days before
his death, being succeeded by his son
Wilhelm II.
Elizabeth Taylor's Tracheostomy
Taylor went to Europe, awaiting
production of Cleopatra. In spring of
1961, she developed a case of
pneumonia, which led to an
emergency tracheotomy and
worldwide talk of her impending
death. The swelling of sympathy was
widely thought to have influenced
Academy voters, who awarded
Taylor her first Best Actress Oscar —
Elizabeth later commented, I knew it
was a sympathy award, but I was still
proud to get it." Meanwhile, Taylor's
competitor Shirley MacLaine
memorably quipped, "I lost to a
tracheotomy!"
Stephen Hawking (physicist)
Stephen Hawking developed
motor neurone disease when he
was in his early 20s. Most
patients with the condition die
within five years, and according
to the Motor Neurone Disease
Association, average life
expectancy after diagnosis is 14
months.
But Professor Hawking, the
Cambridge University physicist
and cosmologist and author of A
Brief History of Time, has
confounded the statistics and
recently celebrated his 73rd
birthday.
• A tracheostomy is the formation of an opening
into the trachea
usually between the second and third rings of
cartilage.
Tracheostomy is done to
• provide mechanical ventilation on a long-term basis
as in cases of neuromuscular disease
• Facilitate weaning from mechanical ventilation by
decreasing anatomical dead space:A COPD patient on
mechanical ventilation
• To bypass obstruction: Cancer larynx
• To maintain an open airway: A comatose patient
• To remove secretions more easily: Inability to swallow
or cough: stroke patient
Types of Tracheostomy
• Surgical tracheostomy: performed in the OR or
at bedside under moderate sedation
• Percutaneous dilatational tracheostomy is
done at the patient’s bedside, usually in the
ICU setting. contraindicated in anatomical
irregularities or coagulation problems.
Temporary Tracheostomy versus
Permanent
• Appearance is the same
• Temporary: The upper airway will remain
connected to the lower airway if the
tracheostomy tube were to be dislodged
• Permanent: The larynx is removed and no
connection exists between the upper airway
and the trachea itself
Potential short-term complications
• Subcutaneous emphysema
– air escapes around stoma ; generally of no
clinical consequence –can be palpated around the
stoma site
Potential short-term complications
• Dislodgement of the tube
Due to excessive manipulation of the tracheostomy
tube during coughing or suctioning– (more in the
first 48 hours)
Potential long-term complications Tracheostomy:
• Thinning of the trachea (Trachemalacia)
Potential long-term complications Tracheostomy:
• Development of granulation of tissue (bump
formation in trachea)
Potential long-term complications Tracheostomy:
Narrowing of the airway above the site of tracheostomy
Potential long-term complications Tracheostomy:
• Once tracheostomy tube is removed, the opening
may not close on its own
Potential long-term complications Tracheostomy:
Dysphagia
Potential long-term complications Tracheostomy:
Tracheal ischemia and necrosis
Identifying Tracheostomy Parts
Cuffed Tracheostomy Tube
Consists of three
parts:
• Outer cannula
with an
inflatable cuff
and pilot tube
• An inner cannula
• An obturator
Cuffless tubes
• More suitable for long term ventilation
• patient must have effective cough and
gag reflex to prevent aspiration risk
Fenestrated Tube
• Have an opening on the
posterior wall of outer cannula
allowing air to flow through
the upper airway and hence
allows patient to speak
• Often used during weaning
process
Communication and Tracheostomies
• Patients being weaned
off trach tubes may
have either a cuffless
or fenestrated tube to
allow airflow past the
larynx
Nursing Care: Examination
• Be aware of when and why the trach
was inserted , how it was performed, the
type and size of tube inserted
• Examine the patient at the start of visit.
Observe for signs of hypoxia, infection
or pain
• Chest: Auscultate breath sounds
• Examine trach tube, as well as stoma
site for redness, purulent drainage, and
bleeding around the stoma
Tracheostomy Humidification
• The nose provides
warmth, moisture and
filtration for the air we
breath.
• Having a tracheostomy
tube by-passes these
mechanisms
• so humidification must
be provided to keep
secretions thin and to
avoid mucus plugs
• Ideal room air temperature is 22C,10mmH2O/L
• Larynx: 31-33C, 26-32 mmH2O/L
• Mid-trachea: 34C, 34-38 mmH2O/L
• Main bronchi: 37C, 44mmH2O/L
Types of tracheostomy humidification systems
Ambient water
humidification
Heat moisture
exchanger (attached
to the outside of a
trach tube for long-
term trach patients) –
looks like a t-tube
attachment
Nursing Care: Help to thin and mobilize secretions
• Frequent repositioning,
• deep breathing and coughing,
• chest physiotherapy,
• oral and parenteral hydration
• supplemental humidification
Nursing Care - Suctioning
• Necessary for all trach
patients to remove
secretions
• Routinely done 2x / day,
but more often if a
newly placed
tracheostomy or when
there is infection present
• Suctioning activates
psychological and
physiological reflexes
that make the
experience both
uncomfortable and
frightening
Selecting a suction catheter
• Selection of the appropriate size suction
catheter is vital in reducing the risk of trauma
during suctioning
• Divide the internal diameter of the
tracheostomy by two, and multiply the
answer by three to obtain the French gauge
suction catheter:
– Size 8 tracheostomy tube (patient); (8mm/2) x 3
= 12; therefore, a size 12F gauge catheter is
suitable for suctioning
Gathering equipment for suctioning
• PPE – (mask, goggles, gloves)
• Bottle of normal saline
• Appropriately sized suction
catheter
• Trach care kit
• Disposable inner cannula if
appropriate
• Oxygen source – connected
to patient
• Suction equipment regulator
set at 80-120 mmHg
• Ambu bag to ventilate
patient prior to suctioning if
appropriate
Procedure for suctioning
• Place patient in semi-fowler’s position
• Select appropriate sized suction catheter
• Hyper oxygenate BEFORE each suction pass
(except patients with long-term tracheostomy)
• Insert catheter to a pre-measured depth
• Apply suction on withdrawal of catheter
• Limit suctioning to 5 seconds
• Use suction pressure between 80 – 120 mmHg
• Limit suctioning to 3 passes
• Discontinue if HR drops by 20; increases by 40,
produces arrhythmias, or decreases 02 < 90%
Tracheostomy Ties
• Ties are generally changed daily
• To lower the risk of accidental trach tube
coming out, tie changes should be:-
performed by two people or
with new ties secured BEFORE old ties are
removed.
Maintenance of the inner cannula
• The majority of trach tubes have inner
cannulas that require cleaning one to
three times daily unless they are
disposable
• Use sterile technique to clean the
reusable cannula with ½ strength
hydrogen peroxide and normal saline
Nursing Care – Trach cuff pressure
• Cuff pressure (balloon)
should be maintained at 20
mmHg of pressure via a
manometer – should be
assessed daily;
• if you don’t have a
manometer measuring
device – check With a
stethoscope placed on the
neck, inflate the cuff until
you no longer hear hissing;
deflate the cuff in tiny
increments until a slight his
returns….
Why?
• Assess and evaluate how the cuff is working
• Periodically relieve pressure on the trachea
• Let secretions above the cuff drain down so
you can suction them
Nursing Care: Changing the Trach tube
• Tube changes can be
done safely on a 1-3
month basis using a clean
technique
• Silicon tubes can crack
and tear; soft PVC tubes
can stiffen with time
Nursing care: Tracheostomy Site Care and Dressing
• Clean stoma with
Q-tip moistened
with NS;
• Avoid using
hydrogen peroxide
unless infection
present (as it can
impair healing) –
• Dressings around
the stoma are
changed
FAQs
• Can a patient eat with a Tracheostomy:
– Yes…generally speaking (patient may need an
evaluation by a speech pathologist to determine
swallowing ability)
FAQs
• Why can’t we use the Passey
Muir valve with the cuff
inflated?
– The speaking valve is a one-way
airflow mechanism. The patient
inhales air through the speaking
valve but exhales it around the
tracheostomy tube and then
through the nose or mouth.
– If the cuff is inflated with a
speaking valve, the patient will
only be able to inhale air and
will not be able to exhale since
there will not be any room
around the tracheostomy
FAQs
• What is the tracheostomy
plug Used for ?
– two purposes:
• Decannulation of the
tracheostomy tube
– Used to plug trach tube for 12
hours the first day and 24
hours the second day – if the
patient tolerates plugging,
then decannulation can take
place
• It can be used for speech,
but not as a speaking valve
