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What is tracheostomy?
Indications
Types of Tracheostomy Tubes
Tracheostomy Care.
Weaning from tracheostomy tube
Suctioning
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A surgical opening into the trachea through which
a tracheostomy tube can be passed to providean airway, and to remove secretions from the
lungs. This tube is called a tracheostomy tube
or trach tube.
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Records indicate that the first tracheostomy was performed 124years BC by a Roman physician.
During the Dark Ages little mention of the operation is recorded, but
it was felt that the cartilages of the trachea would not heal so thesurgical procedure was not commonly performed.
The tracheostomy tube was first used in the 16th century and bythe 19th century, 28 successful operations had been performed.
The first tracheostomy tube for children was developed in 1880.
In 1936 Davidson, an American doctor, advocated the use of thisoperation for the respiratory support of polio patients. Today,tracheostomy is a common procedure and a lifesaver of manypatients who need airway support.
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Acute respiratoryfailure
IntubationIntubationAirway
Obstruction
Inability toprotect airways
ProlongedProlonged
MechanicalMechanical
VentilationVentilation
TracheostomyTracheostomy
POST TRACHEOSTOMY CAREPOST TRACHEOSTOMY CARE
PhysiciansPhysicians NursesNursesRespiratoryRespiratoryTherapistsTherapists
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Tube Used on all
newborns and most
pediatric patients.
Has one single
passage used forboth air flow and
suctioning.
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Features a removableinner cannula that fitsinside an outercannula.
Inner cannula must bein place to ventilate thepatient
Outer cannula keepsthe stoma open whilethe inner is removedfor cleaning.
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Teaches the patient
to breathe through
the upper airway.
Allows for speech.
Less airway
resistance
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Initial choice
Used during M.V.
Decreases the risk ofaspiration.
Cuffs may be either
foam or balloons.
Used for adults orolder children.
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Early Period Care
Tube Securing Wound Care
Tube Care
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Wound Care
Requires two persons to prevent loss of tracheostomy
Routine wound care risk of infection
Dialy examination of stoma
Clean dressing is inserted under the tracheostomy tube
Precut dressing should be used to reduse the risk of fibersentering the stoma
Wound Care
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Tracheostomy is held in place with either atracheostomy ties or a tracheostomy tubeholder. These ties should be routinely changedwhenever they become wet or soiled. With
infants and active young children, this must bea two-person procedure, as it is important thatthe tube remain stable and not be pulled out.
When retieing the ties, do not pull them too tight
as you may decrease the blood flow to thepatients head and cause undue pressure to theskin of the neck.
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Cleaning double-cannula tracheostomy tube
Tracheostomy tubes on general medical/surgical
wards should have an inner cannula
Non-disposable inner cannula should be cleaneddaily
Disposable inner cannula should be changed
daily.
This reduces the risk of tube blockage bysecretions and thus reduces the frequency of tubechanging
Tube Care
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Late Period Care
Tube Care
Cuff Care
Humidification
Weaning
Feeding
Speech Suctionning
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Humidification is necessary because the
tracheostomy bypasses the upper airway whichnormally moistens the air
The reduction of moisture and heat loss helps to
maintain suitable viscosity of secretions
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Fluid Intake
Patient need adequate amounts of fluid to keep
their mucus loose.
Illnesses associated with fever, diarrhea,
sweating, or vomiting are of special concern.
Humidification Cont.
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Two types of humidifiers for ventilated patients
1) Active: pass inspired gases over heatedwater bath
2) Passive: HME (trap humidity from
patients expired gas)
Humidification Cont.
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Frequency of changing HME
(depends on manufacturers recommendations)
Standard: daily
More frequent if occluded by secretions
Humidification Cont.
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Techniques for promoting speech
in non-ventilated patients
One-way speaking valves
Pneumatic talking tracheostomy tube
Speech
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Complications of Tube Feeding
Aspiration
risk 20% - 70%
independent of consciousness level
Nutrition
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Recommended cuff pressure = 20-25mmHg
Low pressure (25) tracheal mucosal damage
Cuff management
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Non-emergency routine changing (patients on long-term mechanicalventilation)
changing tube type (e.g. cuffed to uncuffed)
Emergency tube blockage
accidental extubation
Changing tracheostomy tube
Indications
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If it is expected to be a difficult change,consider changing in an operatingtheatre/ICU environment.
Changing tracheostomy tube Cont.
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Tracheostomy Tube Emergencies
include:
obstruction of the tube
displacement of the tube
Tracheostomy Emergencies
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Determining Patient Readiness
1. Adequate ventilatory reserve
2. Adequate nutritional state
3. Patient upper airway
4. Absence of serious bronchopulmonary infection
5. Absence of impending need for mechanical ventilation
Weaning from tracheostomy tube
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6. Adequate cough
7. Minimal aspiration
8. Reversal of the condition that requiredtracheostomy
9. Patient off ventilator for > 48 hour
10. Gag reflex
11. Absence of excessive secretions
Determining Patient Readiness Cont.
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Equipments:
Suction catheter
Suction source Sterile gloves
Clean gloves
Ambubag with oxygen source
Normal saline 0.9% Blue sheet
Artificial airway
Syringe 5-10 cc
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MONITOR HEART RATE SUCTION MY
CAUSE
A. HYPOXEMIA, INITIALLY TRACHCARDIAANDHYPERTENTION, CARDIAC ECTOPY,BRADYCARDIA, HYPOTENTION, CYANOSIS
B. VAGAL STIMULATION CAUSING BRADYCARDIA
AUSCULTATE BREATH SOUNDS REVIEW ABGRESULTS
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7.Place blue sheet on the patient chest.
8.Open suction catheter package.
9.Open sterile gloves.
10.Don sterile gloves.
11. With the assistance of another nurse,remove the suction catheter from thepackage. Curling the catheter around thegloved fingers.
12. Connect suction source to suction fittingof the catheter by the second nurse.
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13.Disconnect from oxygen source ofventilator.
14. Ventilate the patient by Ambubag.Compress firmly about 4 5 times. Thisprocedure is called bagging the patient.
15.Lubricate the tip of the suction catheter
16.Gently insert the catheter into the artificialairway without applying suction.
17.Most patient will cough when touched thecarina.
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18. Withdraw the catheter2-3 cm and applysuction. Quickly rotate the catheter while itis being withdrawn.
19.Limit suction time not more than 10seconds.Discontinue if heart decreases 20beats/minute or increases 40 beats/minute
or if cardiac ectopy is observed.20. Bag patient between suction passes.
21. Instill 3-5 ml PNSS into artificial airwayduring spontaneous inspiration
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1. Note any change in vital signs or
patients intolerance to procedure.
2. Record amount and consistency ofsecretions.
3. Assess the need for further suction at
least every 2 hours or more.
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Effective coughing is necessary for the
patient to clear secretions.
The objective of deep breathing is topromote the lung expansion, mobilize
secretions and prevent side effects ofretained secretions.
Have the patient positioned sitting
upright on the edge of the bed or chairwith the feet supported .
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Instruct the patient to take a slow, deep
breath, hold it for2-3 seconds and
exhale slowly for auscultation. Teach the patient use of incentive
spirometry to provide encouragement to
increase the volume and immediatevisual feedback on the breath depth.
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A towel of pillowcase is draped over the
area to be percussed and is performed 3to 5 minutes per position.
Percussion is never performed over the
spine, breast, sternum or below the
thoracic cage only on the rib cagebecause this can cause organ injury.
Never tap over the kidneys as this can
cause them to begin bleeding internally.
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After tapping on the chest for
percussion, have your patient remain
sitting to assist the lungs in draining the
mucus. Use pillows to prop their head up
if they can not remain sitting forprolonged periods of time.
Repeat the procedure at least everyeight hours or as ordered by the
physician.
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VIBRATION takes place during a
prolonged pursed-lip exhalation. It increases the turbulence of exhaled air
to loosen secretions.
It is done by placing the hands side by
side with the fingers extended and
applying the flat of the palm over the
affected chest area. The patient inhales
deeply and then slowly exhales.
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While the patient exhales, the nursevibrates the patients chest by quickly
contracting and relaxing arm and
shoulder muscles.
Vibration is used instead of percussionwhen the chest wall is extremely painful.
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