TRACHEOSTOMY

ENT Department
DMC & Hospital
Ludhiana
Punjab.
Tracheotomy
• operative procedure that creates
an artificial opening in the
trachea.

Tracheostomy
• creation of permanent or semi
permanent opening in trachea.
 Anatomy
Trachea lies in midline of the neck
extending from cricoid cartilage (C6)
superiorly to the tracheal bifurcation
at the level of sternal angle (T5).
• Comprises 16-20 C shaped cartilage
rings.
• Length 10-12cm.
• Diameter 15-20mm.
INDICATIONS FOR TRACHEOSTOMY

To bypass acute upper airway obstruction-once the procedure is

performed ,the underlying disease is no longer an immediate threat to
compromise the airway. (now the least common indication )
Chronic upper airway obstruction secondary to cerebrovascular ischemia
or stroke
• Prevention / treatment of retained tracheobronchial secretions.
• Prevention of pulmonary aspiration.
Facilitate weaning from mechanical ventilation by decreasing anatomical
deadspace.
Mechanical respiratory insufficiency-acute respiratory failure requiring
tracheostomy may occur in a variety of diseases including
– drug intoxication,
– head & chest injuries,
– elective surgery,
– neurological disorders & diseases,
– chronic obstructive airway disease,pneumonia
 Indications
1. Upper Airway Obstruction.

2. Pulmonary Ventilation.

3. Pulmonary Toilet.

4. Elective Procedure
1. Upper Airway Obstruction

a. Trauma
b. Foreign body
c. Infections
d. Malignant lesions
2. Pulmonary Ventilation

• Tracheostomy should be
performed in a patient still
requiring ventilation through
an endotracheal tube for
more than a one week.
3. Pulmonary Toilet

• Those who cannot cough and

clear their chest.
• Prevent aspiration by low
pressure high volume cuff
tracheostomy tube.
4. Elective Procedures

• For major head and neck

operations.
 Elective Tracheostomy
Anaesthesia: G A
Position: Supine with sand bag under the
shoulder
Incision:horizontal incision b/w cricoid
cartilage and suprasternal notch.
Division /retraction of thyroid isthmus
Opening of Trachea and insertion of tube
• Emergency
Tracheostomy
Within 2-4 mints with vertical
incision

• Cricothyrotomy/mini
tracheostomy
Transverse incision over the
cricothyroid membrane. Keep
only for 3-5 days
 Pediatric Tracheostomy

Vertical incision in trachea

b/w 2nd and 3rd ring.
No excision of ant. Wall of
trachea
Secure the tube with neck
by two sutures
Percutaneus Dilational Tracheostomy

ICU Bed SideTracheostomy

Use of guide wire and Dilators
Under the vision of Bronchoscope through
endotracheal tube
Less time ,Less Expensive
Not suitable for thick neck and in emergency
Tracheostomy Tubes
Plastic / silver
Cuffed
Plain, unfenestrated
Plain, fenestrated
Long, adjustable flange
Soft cuff
 COMPONANTS 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 patient’s neck.
4. 15mm outer diameter termination: Fits all ventilator and respiratory equipment.
All remaining features are optional
5. 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.
6. Air inlet valve: One way valve that prevents spontaneous escape of the injected air.
7. Air inlet line: Route for air from air inlet valve to cuff.
8. Pilot cuff: Serves as an indicator of the amount of air in the cuff
9. 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.
 BEDSIDE EQUIPMENT
Every patient with a tracheostomy tube should have the following equipment
available at the bedside:
– Spare tracheostomy tubes Same size and type as patient is wearing.
– Smaller size
– Tracheal dilator.
– Suctioning equipment Suction machine fitted with filter; suction tubing;

– suction catheters;
• gloves; bottle of sterile water to rinse tubing - change daily.
• Ensure equipment is assembled and working properly.
– Humidification equipment Equipment depends on method used - Ensure equipment is
assembled and working properly.
• Gloves Non-sterile **

– Sterile gloves (for suctioning)

• Infectious waste bag
• Dry clean container for holding the occlusive cap/button or spare inner cannula when not in
use.
 PROBLEMS DURING
TRACHEOSTOMY CARE
1. Dislocation of tracheostomy tube.
2. Bleeding from stoma or during suction.
3. Blockage of tracheostomy tube.
4. Aspiration and swallowing problems.
5. Speaking problems.
Most problems with tracheostomies can be
anticipated and prevented by good
nursing care
FREQUENCY OF CLEANING
(a) Wash hands.
(b) Wearing unsterile gloves -remove and dispose of the soiled dressing.
(c) Wash hands. Put on sterile gloves.
(d) First, remove and clean the inner cannula using sterile pipe cleaners and
normal saline. Dry. Reinsert.
(e) Secondly, clean the stoma site using gauze and normal saline.
(f) Lastly, if ties are soiled and need changing, have a second nurse hold
the tracheostomy tube securely in place, remove and replace tracheostomy
ties. (Leave 1 finger space between ties and the patient’s neck.)
(g) Ensure patient comfort.
(h) Discard of used equipment as per hospital policy.
(i) Wash Hands.
(j) Document procedure in the patient’s notes.
Note:
Leave first dressing intact for 48hrs if possible as the tracheostomy is a
fresh wound.
 SUCTIONING VIA A TRACHEOSTOMY TUBE
Suctioning is performed only as needed, NOT to a pre-set schedule.
Suction as much as necessary and as little as possible
Be aware that suctioning will be needed more frequently in the immediate post-operative period
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/20kPa
Open / expose only the vacuum control segment of the suction catheter and attach to the suction
tubing, withdraw the sterile catheter from the protective sleeve.
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
• Use a new sterile catheter for each suction pass.
• No more than 3 passes recommended per treatment.
• Circular motion in tracheostomy tube only
On completing procedure, ensure patient comfort, discard of equipment as per hospital policy,
wash hands and document procedure in the patient’s notes.
WORKING OUT SUCTION CATHETER SIZE

Size of trach. tube (mm) x 3

2
E.g. 8 x 3 = size 12 suction catheter
2
This ensures that suction catheter is </=
½ the internal diameter of tracheostomy
tube.
 HUMIDIFICATIONOF INSPIRED GASES
Aims: 1. To prevent drying of pulmonary secretions.
2..To preserve muco-ciliary function.

A) HEATED HUMIDIFIERS - Recommended for:

• patients with new tracheostomy tubes

• dehydrated patients
• immobile patients
• patients with tenacious secretions

B) HEAT MOISTURE EXCHANGE FILTERS - Recommended for:

• patients that are adequately hydrated

• mobile patients
• Not suitable for patients with copious secretions

C) NEBULIZERS - nebulized normal saline is effective in helping to loosen secretions and

soothing irritable airways.
 CARE OF CUFFED TRACHEOSTOMY TUBE

To prevent aspiration of blood or serous fluid from the wound

To seal the trachea during mechanical ventilation
To prevent aspiration of leakage from tracheo-oesophageal fistula
To prevent aspiration due to laryngeal incompetence
NURSING MANAGEMENT
It is unusual for ward patients to need their cuff inflated.
• Tracheostomy cuff is inflated only - (a) if the patient is being mechanically ventilated, (b) if inflation
is specifically ordered by doctor.
• Check with doctor that it is OK to do so , and then proceed with cuff deflation......
• Patients can be extremely sensitive to changes in cuff pressure. A little coughing is not unusual
during manipulation. Take care to explain the procedure to the patient and to inflate / deflate the
cuff slowly.
• To deflate cuff: First, suction the oropharynx to remove any secretions that may have pooled on top
of the inflated cuff. Then, using a syringe, slowly aspirate air from the air inlet port. Once
deflated, expiratory noises may be heard as air passes up around the tracheostomy tube.
Reassure the patient that these are normal and will settle.
• To inflate cuff: Inject approximately 5-7mls of air via the air inlet port to achieve airway seal. A one-
way valve system prevents injected air from escaping.
 Complications of overinflation of the trach cuff include
(due to excess pressure on tracheal wall):
Tracheitis
Bleeding
Tracheal erosion/necrosis
Tracheomalacia
Tracheal stenosis
Tracheoesophageal fistula
Tracheoinnominate artery fistula
Cuff herniation
 NURSING CONSIDERATIONS WHEN USING
FENESTRATED TUBES.
A fenestrated tracheostomy tube can only function as such if both the outer and inner cannulas
contain a fenestration (hole)!
The fenestration allows secretions as well as air to pass up and down the patient’s airway. If
needed, give the patient a sputum container or tissues and bag for secretions.
Speaking: Speech is facilitated by inserting the fenestrated inner cannula, and occluding the
tracheostomy tube opening by using one of the following: (CUFF SHOULD BE DEFLATED)
– a) the patients finger
– b) a speaking valve
– c) a decannulation plug / cap / button.
Suctioning: If suctioning is required, change to a non-fenestrated inner cannula. This is to
prevent the suction catheter passing through the fenestration and traumatising the delicate
lining of the posterior tracheal wall.
Eating: While using a fenestrated tube restores some of the normal swallow protection
mechanisms, nurses should be aware of and observe for signs of aspiration. Swallowing is
further improved by having the cuff deflated and the tracheostomy opening occluded at the
moment of swallow - methods outlined above.
Cleaning of a fenestrated inner cannula is the same as for non-fenestrated tube.
Store cleaned speaking valve, cap and spare inner cannula in a sealed, clean, dry container at
the patient’s bedside
Complications of Tracheostomy

Intraopertaive Complications.
Bleeding and injury to big vessels
Injury to tracheoesophageal wall
Pneumothorex
Early Complications
Bleeding
Tracheostomy tube obstruction
Tracheostomy tube displacement
Infection
 Late Complications

Tracheal Stenosis
Granulation tissue
Tracheocutaneus fistula
Tracheo - inominate fistula
 Immediate Post-op Care
Airway

Breathing

Circulation

One to one nursing

– Humidification

– Suction
– Observation
 Tube trouble?
Is patient’s breathing effortless?

Is patient confused/aggressive?
Is patient able to speak without occluding tube?
Is breathing noisy?
Wet - excess secretions?
Dry - crusted mucus?
Can you pass a suction catheter past the end of the tube (tube
length approx 7 - 9cm)?
 IF THE TRACHEOSTOMY TUBE FALLS
OUT !!...
Once the tracheostomy tube has been in place for about 5 days the tract is well formed
and will not suddenly close.
• Reassure the patient
• Call for medical help.
• Ask the patient to breathe normally via their stoma while waiting for the doctor.
• The stay suture (if present) or tracheal dilator may be used to help keep the stoma open if
necessary.
• Stay with patient.
• Prepare for insertion of the new tracheostomy tube
• Once replaced, tie the tube securely, leaving one finger-space between ties and the
patient’s neck.
• 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 patient’s exhalation.
 Changing the Tube 1
First change by ENT surgeon
(unless an emergency)

Rarely difficult

“Railroad” technique
recommended for first and
difficult subsequent changes
Changing the Tube – railroad
technique
Cut both ends off largest possible suction
catheter
Insert suction catheter down trache tube
(warn patient re coughing)
Remove tube over catheter, maintaining
catheter position in airway
Insert new tube over catheter
Remove catheter
if tube blocked – need to use introducer
Changing the Tube 2
Insert introducer into new tube
Patient sits upright or lies supine with neck
extended
Observe track followed by old tube as it is
removed and follow it when inserting new
tube
Fasten tapes with one finger between tape
and patient’s neck
Check tube position
Beware false track anterior to trachea
 Checking tube position
Feel air flow from tube on your arm as patient exhales
Observe patient’s breathing - noisy? difficult? use of
accessory muscles?
Observe patient’s colour
If any doubt, fibreoptic scope can be passed down tube
for direct vision of position
X-ray not generally helpful
 Tracheostomy Complications
1. Displaced Tube
Can be fatal
May be accidental or due to confused patient

Post-op, tube stitched (and taped) in place

so shouldn’t happen
Need to get tube into tracheostomy ASAP
Call for help
Insert tracheal dilators into tracheal stoma
Insert new tube over dilators and into stoma
 Tracheostomy Complications
2. Tube blockage
Remove inner cannula

Apply tracheal suction

Instil 2 – 3mls sterile normal saline

Fibreoptic view may be helpful

If unavoidable, change tube using

introducer and dilators
 Tracheostomy Complications
3. Bleeding
Likely to be small amount of oozing from
tracheostomy wound
Inflate cuff on tracheostomy tube to protect
airway until bleeding settled
If minor bleeding apply pressure or
adrenaline-soaked gauze pack
Large bleed uncommon and usually in
emergency situation
 Tracheostomy Complications
4. Surgical emphysema

Usually due to too tight closure of

tracheostomy wound

May require removal of sutures to let

trapped air escape
 ACUTE DYSPNOEA
..is most commonly caused by partial or complete blockage of the tracheostomy tube
by retained secretions. To unblock the tracheostomy tube.....
– 1. ASK THE PATIENT TO COUGH: A strong cough may be all that is needed to
expel 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 the secretions are lower down the patients airway. Use the suction machine
to remove the 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.
RESUSCITATION VIA A TRACHEOSTOMY TUBE
IN THE EVENT OF A CARDIOPULMONARY ARREST, TREAT
TRACHEOSTOMY PATIENTS AS ANY OTHER PATIENTS
Remove any clothing covering the tracheostomy tube DO NOT remove
tracheostomy
VENTILATE - by using ambu-bag attached directly to tracheostomy tube

IF UNABLE TO VENTILATE:
..TRY SUCTIONING: This will clear any secretions blocking the airway below the
end of the tracheostomy tube.
..IF STILL UNABLE TO VENTILATE: The tracheostomy tube may have become
displaced. Doctor should:
1) Change tracheostomy tube - if unsuccessful......
2) Orally intubate
 DECANNULATION : REMOVAL OF
TRACHEOSTOMY TUBE
STEP 1-Downsizing of the tracheostomy tube
• (at least 5-7 days after original tube insertion)
• means changing to smaller size, cuffless, tube. (Check with doctor if fenestrated tube to be inserted
at this time.)
• This first tube change is ALWAYS carried out by a doctor.
• Sometimes a second downsizing is necessary, before proceeding to....
STEP 2-Capping of the tracheostomy tube
• This is achieved by applying an occlusive cap to the front of the tracheostomy tube.
• Once capping is tolerated for at least 24 consecutive hours the doctor will decide if decannulation
can occur.
STEP 3-Decannulation
• The tracheostomy tube is removed, stoma edges are approximated, and an occlusive gauze +
sleek dressing is applied
• It takes approximately 10 days for the tracheotomy to heal.
 DECANNULATION
Leakage of air +/- secretions around the new tracheostomy tube may be noticed after smaller tube
has been inserted. This is expected and will settle once the stoma reduces in size around the
tube.
Once capped, the patient must breathe through their nose and mouth again. (Give 02
and nebulizers by face-mask now)
• CLOSE OBSERVATION is essential in case of respiratory difficulty.
• While many patients can tolerate continuous wearing of the cap, some find that it may
takes getting used to. Therefore wear -time needs to be increased as tolerated.
• PATIENTS MUST BE TAUGHT TO REMOVE THE CAP THEMSELVES IF THEY
EXPERIENCE ANY BREATHING DIFFICULTY.
• If breathing does not settle with removal of cap - inform doctor.

Encourage patient to press on the stoma dressing when coughing to prevent it being
“coughed off”, and to prevent secretions escaping via the stoma.
• Change dressing if loose or soiled.
 HOME CARE PLAN

1. Education and training of the

attendant.
2. Supply of dressing, suction catheters
and suction machine.
3. When to come to the hospital.
4. Visit by community nurse.