Friday , March 23 2018
Tracheostomy Care Cricotomy

What is Tracheostomy

A tracheostomy is an opening created, at the front of the neck so a special tube can be inserted into the windpipe (trachea) to help person to breathe.

A tracheotomy or a tracheostomy is an opening surgically created on the neck into the trachea or windpipe which  allow direct access to the breathing tube.This procedure commonly done in an operation theatre under general anesthesia. A special tube is called tracheostomy tube, it usually placed through this opening to provide an airway and also remove secretions from the lungs.

Once tracheostomy placed, breathing is done through the tracheostomy tube rather than through the nose and mouth. The term “tracheotomy” refers to the incision into the trachea or windpipe that forms a temporary or permanent opening, which is called a “tracheostomy,”

Tracheostomy care includes changing a tracheostomy inner tube, cleaning tracheostomy site and changing dressing around the site.

Parts of Tracheostomy Tube

Outer Cannula with Flange (neck plate)

The outer cannula is the outer tube which holds the tracheostomy open. A neck plate extends from the sides of the outer tube and have holes to attach cloth ties / velcro strap around the neck.

Inner Cannula

The inner cannula fits inside outer cannula. It has a lock to keep it from being coughed out, and it can be removed for cleaning.

An Obturator

An obturator is used to insert a tracheostomy tube which is  fits inside the tube to provide a smooth surface that guides the tracheostomy tube,when it is being inserted.

What are the Reasons for Tracheostmy

  • Obstruction of upper airway;
  • If airway blocks with secretion then clean and remove secretions from the airway;
  • If person unable to take oxygen more easily, more safely and deliver oxygen to the lungs.
  • Tumors, eg. cystic hygroma
  • If person go through the Laryngectomy operation
  • Infection present such as epiglottitis or croup
  • If Subglottic Stenosis occurs
  • If Subglottic Web occurs
  • Tracheomalacia
  • Paralysis of Vocal cord  (VCP)
  • If Laryngeal injury or gets spasms to larynx
  • Any Congenital abnormalities present in the airway
  • If person is having Large tongue or small jaw that blocks airway
  • Treacher Collins and Pierre Robin Syndromes is present
  • Severe neck or mouth injuries occurs
  • If Airway burns from inhalation of corrosive material, smoke or steam
  • Obstructive sleep apnea is present
  • Foreign body obstruction in the throat
  • Neuromuscular diseases paralyzing or weakening chest muscles, trachea and diaphragm
  • Aspiration related to muscle or sensory problems found in the throat
  • Got Fracture of cervical vertebrae with spinal cord injury
  • Long-term unconsciousness or coma where person felt difficulty to breath
  • Any Facial surgery and facial burns
  • Anaphylaxis shock (severe allergic reaction)
  • Need for prolonged respiratory support, such as Bronchopulmonary Dysplasia (BPD)
  • Any Chronic pulmonary disease to reduce anatomic dead space
  • Any Chest wall injury
  • Diaphragm dysfunction present

How to Perform Tracheostomy

  • Indentation to be find out between the Adam’s apple (thyroid cartilage) and the Cricoid cartilage on neck.
  • Made a half-inch horizontal incision about one half inch deep.
  • Pinch the incision and insert the finger inside the slit to open it.
  • Tracheostomy  tube tobe done into the incision, roughly one-half to one inch deep.

How to Proceed

  • Assess the person’s Adam’s apple (thyroid cartilage) before procedure.
  • Move the finger about one inch down the neck until you feel another bulge.  It is the cricoid cartilage. Indentation to be found  between the two is the cricothyroid membrane, where the incision would be made.
  • Take the surgical or stab blade or knife and make a half-inch horizontal incision.  The cut should be about half an inch deep. There should not be too much blood present on incision site.
  • Incision to be pinched for open or place your finger inside the slit to open it.
  • Tracheostomy tube to be inserted in the incision, roughly one-half to one inch deep.
  • Inform person to breathe into the tube with two quick breaths.  Pause for five seconds, then give one breath every five seconds.
  • You would observe the chest rise and the person should regain consciousness if you have performed the procedure correctly.  The person should be able to breathe on their own, albeit with some difficulty, until help arrives.

How to Take Care of Tracheostomy

  • Give comfortable position the person lying supine with head elevated to not more that 30 degree.
  • Ensure suction equipment is ready for use.
  • Perform thorough hand-washing.
  • Put on non-sterile gloves and remove dressing from tracheostomy site, ensuring that the tube is not displaced while doing so.
  • Discard dirty dressing by holding it in one gloved hand and removing the glove over the dressing, the enclosed dressing may then be discarded.
  • Wear Sterile Gloves.
  • With sterile gauze and sterillium well squeezed till almost dry use aseptic technique to clean around the stoma and the flange of the tracheostomy tube.
  • Use a sterile scissors to cut a key hole dressing in a sterile piece of gauze, apply dressing carefully between the tracheostomy and skin.
  • Cut and remove ties and replace with clean ties.
  • Ensure that the tube is tied firmly but should not be too tightly.
  • Position the person comfortably.

Tracheostomy Suctioning

  • Take a sterile suction catheter.
  • Wear sterile gloves.
  • Portable suction machine to be checked whether it is working or not.
  • Attached suction catheter to suction machine tube or central suction.
  • Pinch the tube and insert in the trachea with aseptic technique
  • Rotate the tube gently and then pull the catheter gradually after sucking out the secretion.
  • Do not suck for more than 10 seconds, it damage the mucus membrane or person would be suffocated.
  • If the secretions are thick, instill 2-3 ml of distilled water or normal saline solution and then do suction with using ambu bag
  • If the secretions are thick instill 2-3 ml of sterile water or normal saline solution and then do suction or Tablet Kanthsudharak Vati (3 tablet four times a day) is started to  that person,ithelps to liquifies the secretion.
  • Perform suction every half hourly and SOS or as and when required depending upon the amount of secretions.

Care of the Metal Tracheostomy Tube

  • Remove the inner metal tube wearing plastic gloves and receive it in a clean tray.
  • Wash the tube thoroughly well, using soap and water.

Note – If the secretions are thick – can soak it in soda bicarbonate solution for 15-20 minutes (Use brush to clear the inner wall of the tube).

  • Autoclave the tube as required.
  • If the person has only one tube, can boil it in the sterilizer for 15-20 mins.
  • Then, place it in the tracheostomy opening after cooling it wearing sterile gloves.
  • If the person has two sets of tracheostomy tubes then wrap it in the small tray and send it for autoclaving.

Note – The frequency of cleaning the inner tube will depend on the amount of secretions present.

  • In case, if the outer tube needs to be changed, always ensure that the tracheal dilator / artery forceps is kept ready.

General Points

  • Chest physiotherapy to be performed every 4 hourly.
  • Provide nursing care related to back mouth, eyes, etc.
  • Deflate the tube balloon for 5 minutes every 2 hourly.
  • Do not deflate when the patient is on Ryles tube feeding (actually feeding).
  • Always suction the person properly before you deflate the Ryle’s tube.