MANAGEMENT OF PATIENTS WITH ARTIFICIAL

AIRWAYS B.1. Indications of Tracheostomy

Tracheostomy Care and Suctioning 1. To maintain a patent airway
2. Bypass an upper airway obstruction
LEARNING OBJECTIVES: 3. Facilitate removal of tracheobronchial secretions
At the end of the discussion, the learners will be able to: 4. Permit long term use of mechanical ventilation
5. Replace an Endotracheal Tube
1. Identify the different artificial airways, its types, 6. Prevent aspiration of oral or gastric secretions in
indications, and complications. unconscious or paralyzed patient (by closing off the
2. Identify the steps for suctioning through an artificial trachea from the esophagus)
airway.
3. Describe the nursing care of a patient with an B.2. Classification of Tracheostomy
endotracheal tube and tracheostomy tube 1. According to duration
4. Use the nursing process as a framework for care of a a. Temporary
patient with ET tube / Tracheostomy tube. b. Permanent
2. According to situation
I. ARTIFICIAL AIRWAYS a. Emergency - relieve respiratory distress / airway
 Maintaining an open and patent airway is an obstruction
important aspect of critical care management. b. Prophylactive - tracheostomy need is anticipated
 Artificial airways (oral and nasal endotracheal tubes,
tracheostomy tubes) are used when a patent airway B.3. Types of Tracheostomy Tubes
cannot be maintained with an adjunct airway device 1. Single-Lumen Tube
for mechanical ventilation or to manage severe  The single-lumen tube is similar to the
airway obstruction. double-lumen tube except that there is no inner
 The artificial airway also protects the lower airway cannula.
from aspiration of oral or gastric secretions and  More intensive nursing care is required with this
allows for easier secretion removal. tube because there is no inner cannula to ensure
 Patients with an artificial airway require constant a patent lumen.
humidification to the airway.
2. Fenestrated Tube
A. Endotracheal Intubation  The fenestrated tube has a precut opening
 Placement of an endotracheal (ET) tube through the (fenestration) in the upper posterior wall of the
mouth or nose into the trachea. outer cannula.
 An ET tube is usually is passed with the aid of a  The tube is used to wean the client from a
laryngoscope by specifically trained medical, nursing, tracheostomy by ensuring that the client can
or respiratory therapy personnel. tolerate breathing through her or his natural
 Adult oral tube sizes: males, 8.0–8.5 internal diameter airway before the entire tube is removed.
(I.D.) (mm); females,  This tube allows the client to speak.
 7.0–8.0. I.D. (mm).
 Placement is 2–3 cm above the carina. Verify by 3. Cuffed Fenestrated Tube
auscultating for breath sounds bilaterally, uniform  The cuffed fenestrated tube facilitates
up-and-down chest movement, CXR, and checking mechanical ventilation and speech and often is
ETCO2 immediately after intubation. used for clients with spinal cord paralysis or
 Cuff pressure: 20–25 mm Hg. neuromuscular disease who do not require
 Intubation provides a patent airway when patient is ventilation at all times.
having respiratory distress that cannot be treated with  When not on the ventilator, the client can have
simpler methods and is the method of choice in the cuff deflated and the tube capped for speech.
emergency care.  A cuffed fenestrated tube is never used in
 The oral route is preferred since oral intubation is weaning from a tracheostomy, because the cuff,
associated with less trauma and lesser rates of even fully deflated, may partially obstruct the
infection. airway.
 If the client requires an artificial airway for longer
than 10 to 14 days, a tracheostomy may be created to
avoid mucosal and vocal cord damage that can be
caused by the endotracheal tube.

B. Tracheostomy
 A tracheostomy is an opening made surgically
directly into the trachea to establish an airway;
 A tracheostomy tube is inserted into the opening and
the tube is attached to the mechanical ventilator or
another type of oxygen delivery device.
 Tracheostomy tubes may be cuffed or uncuffed and
have either a reusable or disposable inner cannula.
Both fenestrated and Passy-Muir valves allow the
patient to speak.
 Size will vary.
 Cuff pressure: 20–25 mm Hg.
 1. Double-lumen cuffed tracheostomy tube with hyperinflations.
disposable inner cannula (A) 6. Gently insert sterile catheter into the opening without
2. Single-lumen cannula cuffed tracheostomy tube applying suction. Insert catheter to the point of slight
(B) resistance, then pull catheter back 1 to 2 cm.
3. Double-lumen cuffed fenestrated tracheostomy 7. Apply suction as the catheter is withdrawn.
tube with plug (red cap). (C) 8. Each suctioning pass should not exceed 10 seconds in
duration.
B.4. Parts of Double Lumen Tracheostomy Tube 9. Reconnect client to oxygen source and evaluate whether
1. Outer cannula one suctioning episode was sufficient to remove
 fits into the stoma and keeps the airway open. The secretions.
face plate indicates the size and type of tube and has
small holes on both sides for securing the tube with SAFETY ALERT When there is difficulty passing the
tracheostomy ties or another device. catheter, ask patient to cough or say “ahh” or try to
2. Inner cannula advance the catheter during inspiration. Both
 fits snugly into the outer cannula and locks into place. measures help to open the glottis to permit passage of
It provides the universal adaptor for use with the ventilator the catheter into the trachea.
and other respiratory therapy equipment.
 Some may be removed, cleaned, and reused;others III. COMPLICATIONS OF SUCTIONING
are disposable. 1. Hypoxia
3. Obturator  If possible, preoxygenate with high percentage of O2
 a stylet with a smooth end used to facilitate the before and after suctioning.
direction of the tube when inserting or changing a 2. Dysrhythmias
tracheostomy tube.  Limit suctioning to 10 seconds; monitor rhythm
 The obturator is removed immediately after tube during suctioning; if bradycardia or tachycardia
placement; an obturator is always kept with the client develops, discontinue suctioning immediately.
and at the bedside in case of accidental decannulation. 3. Bronchospasm
4. Cuff  Try to time the suctioning with client’s own cycle;
 when inflated, seals the airway. The cuffed tube is insert tube during inspiration.
used for mechanical ventilation, preventing aspiration 4. Airway trauma
of oral or gastric secretions,  Maintain suction level below 120 mmHg. Never force
 or for the client receiving a tube feeding to prevent the suction catheter.
aspiration. A pilot balloon attached to the outside of 5. Infection
the tube indicates the presence or absence of air in the  Use sterile technique; assess the color and quantity of
cuff. sputum suctioned.
6. Atelectasis
II. PREVENTING COMPLICATIONS ASSOCIATED  Use suction catheters that are approximately one-third
WITH ENDOTRACHEAL AND TRACHEOSTOMY or less of the diameter of tube
TUBE
1. Administer adequate warmed humidity. IV. TRACHEOSTOMY CARE
2. Maintain cuff pressure at appropriate level.  Some patients with a tracheostomy tube are able to
3. Suction as needed per assessment findings. cough secretions out of the tube completely, whereas
4. Maintain skin integrity. Change tape and dressing as others are only able to cough secretions up into it.
needed or per protocol.  Standards for care include properly securing the tube,
5. Auscultate lung sounds. Monitor for cyanosis. inflating the cuff to an appropriate pressure,
6. Monitor for signs and symptoms of infection. maintaining patency by suctioning, and providing
7. Administer prescribed oxygen and monitor O2 oral hygiene.
saturation.
8. Use sterile technique when suctioning and performing ASSESSMENT
tracheostomy care. 1. Establish a way of communicating with a tracheostomy
patient.
III. SUCTIONING THROUGH AN ARTIFICIAL 2. Assess breathing pattern.
AIRWAY 3. Listen to breath sounds.
1. Determine that the client needs to be suctioned. 4. Obsesrve for hypoxia
a. Auscultate lungs to detect presence of secretions. 5. Assess the needs of the patient with a tracheostomy for
b. Observe to see whether client is experiencing suctioning and cleaning.
immediate difficulty with removal of secretions.
c. Monitor O2 saturation (pulse oximetry) and arterial PLANNING
blood gases (ABGs). 6. Obtain functional equipment and materials needed.
d. Monitor for increased anxiety and restlessness. - Tracheostomy tube (Shiley)
2. Explain procedure if client is not familiar with it, or - Humidifier
simply indicate you are going to assist with the removal of - Self inflating breathing bag (AMBU bag)
the secretions. - Mask
3. All equipment introduced into the trachea or the - Sterile and clean gloves
endotracheal (ET) tube must be sterile. - 2 sterile suction catheter (oral and tracheal
4. Attach the suction catheter to the suction source while suctioning)
maintaining sterile technique. - 2 NSS for irrigation
5. If client is not in immediate danger of airway occlusion, - Hydrogen Peroxide Solution
hyper-oxygenate with 100% O2 for three to four - Suction Machine
 - 4x4 Sterile gauze before the removal of the old one.
- Suction trap if sputum specimen is needed 39. Ensure that the tracheostomy tube is securely
- Kidney basin #3 supported while applying the dressing of non raveling
- Sterile Nylon Brush material around the incision site.
- Tracheostomy tie / tape 40. Remove gloves
- Towel 41. Do after care.
-Cherry balls 42. Wash hands.
- Kelly #1 43. Provide oral hygiene according to hospital policy.
- Stethoscope
- Waste Basket EVALUATION
44. Evaluate using the following criteria:
IMPLEMENTATION - Tracheostomy tube in place
7. Identify the patient - Respiratory rate and depth normal
8. Nebulize the patient with saline irrigation - Oxygen saturation
9. Wash hands. - Breath sounds clear.
10. Explain the procedure.
11. Provide Privacy DOCUMENTATION
12. Place patient in a supine or Mid-Fowler’s position. 45. Record the procedure done and observation on the
Place an unconscious patient in lateral position facing you. patient’s chart.
13. Wear eye protection and mask, clean gloves. - Amount and characteristic of secretions
14. Open the tracheostomy care set and prepare the - Patient’s response to the procedure.
equipment.
15. Prepare solutions needed on the 2 kidney basins V. SUMMARY
- Half strength H₂O₂ DEALING WITH EMERGENCIES - IF THE
- Saline Solution TRACHEOSTOMY TUBE FALLS OUT !!...
16. Place the drape from the kit or a clean towel over the NOTE: Tracheostomies are usually sutured in place for the
patient’s chest. first week after insertion and so are unlikely to be
- Most kits contain a pocket of solution, sterile gloves, displaced.
sterile suction catheter, and sterile gauze squares.  Stay with patient.
17. Attach the breathing bag to the tracheostomy tube and  Prepare for insertion of the new tracheostomy tube
provide 3 deep breaths coordinated with the patient’s  Once replaced, tie the tube securely, leaving one
breathing pattern if patient is on O2. finger-space between ties and the patient’s neck.
- If patient is on ventilator increase FIO₂ to 100%.  Check tube position by
18. Suction the patient for a minimum of 15 seconds. (a) asking the patient to inhale deeply - they should be
19. Provide ventilation immediately after the suction able to do so easily and comfortably, and
catheter is removed. (b) hold a piece of tissue in front of the opening - it
20. With your hand, unlock the inner cannula by turning should be “blown” during patient’s exhalation.
the lock about 90 degrees counterclockwise.
21. Soak the inner cannula in Hydrogen Peroxide for REFERENCES
several minutes (on a separate kidney basin)  Sharma, M.P. Comprehensive Textbook of Medical
22. Place the replacement cannula holding only the upper Surgical Nursing. 1st ed. 2016
portion and lock it.  Silvestri, A., et.al. Saunders Comprehensive Review
23. Remove the dressing with nondominant hand/forceps for the NCLEX RN Examination. 8th ed. 2020.
and discard.  Zerwekh, J. Illustraded Study Guide for the NCLEX
24. Remove the clean gloves then don sterile gloving. RN Exam. 10th ed. 2019
25. Clean around the incision site with gauze squares  Cheever, K., Hinkle, J. & Overbaugh, K. Brunner and
damped in hydrogen peroxide followed by PNSS. Suddarth's Textbook of Medical-Surgical Nursing.
26. Clean the flange of the tube in the same manner. 15th ed. 2022
27. Thoroughly dry the client’s skin and tube flanges with
dry gauze squares.
28. Using the applicator stick, apply antibiotic ointment
around the incision site if recommended.
29. Remove the cannula from the soaking solution.
30. Clean the lumen and the entire cannula thoroughly
using pipe cleaners or brush with sterile solution.
31. Agitate the cannula in saline for a few seconds.
32. Inspect the cannula for cleanliness by holding it at eye
level.
33. Dry the inside of the cannula with pipe cleaners. Do
not dry the outer surface.
34. Dry the glove hands using the towel after cleaning.
35. Remove replacement cannula then replace it with the
clean cannula by grasping the flange while inserting it.
36. Lock the inner cannula in place by turning the lock
clockwise about 90 degrees.
37. Gently pull the inner cannula to ensure that the
position is secure.
38. Change the tracheostomy tie by securing a new tie