TRACHEOSTOMY

A procedure where an artificial opening is created in the throat to assist with patient’s breathing or to
create an alternate way.

A tracheostomy is usually done for one of three reasons:

1) To bypass an obstructed upper airway.
2) To clean and remove secretions from the airway.
3) to more easily, and usually more safely, deliver oxygen to the lungs.

INDICATION:
 Some sort of upper airway obstruction (e.g cancer of the larynx & laryngeal edema)
 If patient is unable to remove respiratory secretions (e.g coma & respiratory muscles paralysis):
Tracheostomy allow suctioning and the cuff of tracheostomy reduces further aspiration of
secretions
 If patient has respiratory insufficiency (e.) chronic lung disease): tracheostoy might help oxygen
ventilation by reducing respiratory dead space.
 Prophylactic measures: In a patient with prolonged mechanical ventilation via endotracheal
tube. So in such patient, tracheostomy is done.
 As part of another procedure: Sometimes tracheostomy is done to gain access to airway for
general anesthesia or as precautionary measure in some patient who undergone extensive neck
surgery.

TYPES OF TRACHEOSTOMY PROCEDURE
1. Emergency Tracheotomy
2. Elective Tracheotomy
3. Permanent Tracheotomy
4. Percutaneous Tracheotomy
5. Mini Tracheotomy (Cricothyroidotomy)

PARTS OF TRACHEOSTOMY
A commonly used tracheostomy tube consists of three parts: outer cannula with flange (neck
plate), inner cannula, and an obturator. The outer cannula is the outer tube that holds the
tracheostomy open. A neck plate extends from the sides of the outer tube and has holes to attach
cloth ties or velcro strap around the neck. The inner cannula fits inside the outer cannula. It has a lock
to keep it from being coughed out, and it is removed for cleaning. The obturator is used to insert a
tracheostomy tube. It fits inside the tube to provide a smooth surface that guides the tracheostomy
tube when it is being inserted.

DIFFERENT VARITIES OF TRACHEOSTOMY TUBES INCLUDE:

 Cuff - have a soft balloon around the distal end of the tube which inflates to seal the airway. This
is for patients that requires positive pressure ventilator and airway protection
 Non-cuffed - Uncuffed tubes do not have a cuff that can be inflated inside the trachea and tend
to be used in longer term patients who require ongoing suction to clear secretions. These tubes
will not allow sustained effective positive pressure ventilation as the gas will escape above the
tracheostomy tube.
 Minitrach tubes - They are primarily designed to allow airway toilet (suction) but can facilitate
delivery of oxygen. They are too small to provide any ventilation or removal of carbon dioxide
and so can only be considered an emergency method of oxygenation.
 Fenestrated tubes have an opening(s) on the outer cannula, which allows air to pass through the
patient’s oral/nasal pharynx as well as the tracheal opening. The air movement allows the
patient to speak and produces a more effective cough.

PROCEDURE:
It is usually done general anesthesia but emergency case may necessitates local anesthesia only.
1. The patient is put in a supine position with neck extended.
2. Skin incision which may be transverse or longitudinal is given on the neck.
3. Subcutaneous fat and platysma are cut.
4. Strap muscles of the neck are retracted or dissected away.
5. If thyroid gland is encountered, it is displayed upward or may be cut.
6. Any blood vessels encountered along the way are ligated
7. Incision is given on a tracheostomy tube inserted preferably through the second or third tracheal
ring.
8. Skin incision is closed and tracheostomy tube is secured in the skin via stitches or simply tied
around the neck.

TRACHEOSTOMY CARE
Certain procedure is done to ensure proper functioning at the tracheostomy tube and to preven
complications.
 Suctioning of secretions: suction secretions through tracheostomy tube
 Humidification of air: humidified air attached to the tracheostomy tube placing a humidifier or
steam near the patient’s bed or applying wet porous gauge onto the tracheostomy tube
 Keep patient under regular supervision: supervise regularly and ensure that the tube is
functioning and not dislodged.
 Provide notepad and pen to the patient; The patient can’t speak well because he has a tube on
his throat so this will allow the patient to communicate effectively with their healthcare
providers.
 Change tube twice a day

COMPLICATIONS
 Surrounding structures may be damaged while performing the procedure therefor there could
be bleeding on the tracheostomy site and tracheostomy may get blocked by secretions or clots
or it may get dislodged.
 Infection of surgical wounds

DECANNULATION
Removal of the tracheostomy tube and shifting the patient back to normal breathing.
If the patient improved and the healthcare team determines that tracheostomy is no longer necessary
the a trial of decannulation should be attempted.
 The tube is occluded for 24 hours, when the patient can tolerate it and can breath normally, the
tube will be removed and they will close the wound.
 If the patient cannot tolerate the tube occlusion, they will change the tube to a smaller
tracheostomy tube until the patient can tolerate and breath normally.

Additional Nursing Responsibility

 If signs of redness or excessive exudate present consider using a non-adhesive hydro cellular
foam dressing e.g. Allevyn®.
 If visible signs of infection are present - discuss with parent medical team and consider obtaining
a swab specimen for culture and sensitivity.
 If there are any signs of granulation tissue liaise with the Respiratory Nurse Consultants for
appropriate management.
 The care of the stoma includes routine (minimum - daily) observation of the site and accurate
documentation of the findings including the presence of any of the following:
 Redness
 Swelling
 Evidence of granulation tissue
 Exudate
 Increased discomfort or pain at the site
 Offensive odour
*Refer to Respiratory Clinical Nurse Consultant for advice on the frequency and type of dressing
required.