What is a tracheotomy? its involves surgical creation of an external opening through the 2 nd and 3 rd or 3 rd and 4 th ring of the trachea A Tracheostomy can be - Temporary, - Permanent or - placed during Emergency. Cricothyrotomy is an emergency tracheotomy that may also be performed when endotracheal intubation is impossible Indications for Tracheostomy :
1. Airway Obstruction
Congenital Ex: larynx hemangioma Ex: Sub glottic or tracheal stenosis, Foreign body aspiration Ex: Swallowed or inhaled object lodged in upper airway
Infection
Ex: Acute epiglottitis,
It is an infection of the epiglottis and supraglottic structures.
2. Airway Clearance:
clears the secretions that cannot be cleared due to weakness and conditions requiring long term airway support, like progressive neurological conditions such as: Severe brain injury .ect 3.Long Term Intubation: Long Term What is considered Intubation for an adult and pediatric patient??? Adult: Intubated more than two weeks.
Pediatric: Intubated more than 3-4 weeks.
4. Elective/Prophylactic
1- During major head and neck surgery 2- Radiation treatment
What physiological changes occur with a tracheostomy??? temporary voice loss. filtration, loss of the airborne particle action of warming and humidification . the nose potential impairment of swallowing. Mucociliary transport and cough mechanisms are impaired. IN 2 WAYS :
1-SURGICAL {OPEN (ST)} (ENT) SURGEON, OR A THORACIC SURGEON.
2- PERCUTANEOUS PERCUTANEOUS DILATATION TRACHEOSTOMY (PDT) IS DONE USING PERCUTANEOUS DILATATION TECHNIQUE. How is a Tracheostomy performed? Surgical tracheostomy performed in patients with:
1. Tumors of the upper airway 2. Previously failed/difficult percutaneous procedure 3. Major vascular structures at risk 4. Anatomical abnormality (e.g. goiters) 5. Short neck 6. Morbid obesity 7. Emergency airway Goiters is a swelling of the thyroid gland, which can lead to a swelling of the neck or larynx (voice box) Nursing Considerations
In (ST), the pt may come back with stay sutures around the tube - to hold or manipulate the operating area.
In ST sutures are removed after the first tracheostomy tube change - 5-7 days of the insertion, while the stoma is forming or as ordered by the operating surgeon. stay sutures done: to prevint accedint accidentally dislodged.
Percutaneous insertion:
The first tube change should not be performed before 2 weeks of the initial insertion?? because the stoma is very tight and the risk of the tracheotomy collapsing is high. Holistic Nursing Considerations
During the first 2-3 daysthe patient is uncomfortable due to trauma of surgery, pain of a fresh incision, choking, presence of a foreign object in his trachea and inability to communicate through speech. keep in mind .. the patient is more than a trach tube!
1- pain management. 2- reassurance. 3- education What are the risks involved in tracheostomy?
1-Reactions to medication and anesthesia. 2-Uncontrollable bleeding. 3-Respiratory problems. 4-Possibility of cardiac arrest. What are the complications of a Tracheostomy? Early ( Life-threatening ) Late Infection : 1- stoma site 2- chest- 50-60% of tracheostomy patients may develop nosocomial pneumonia Skin breakdown Tracheal stenosis Tracheo-esophageal fistula : 1- Abdominal distention 2- Liquid food suctioned through tracheostomy tube.
Accidental tube displacement
Blocked tracheostomy tube Damage during surgery - possible hemorrhage. Sx emphysema Trauma Pneumothorax
What are the parts of the tracheostomy tube? Parts of Tracheostomy Tube Main features Part Main body of the tube Outer canula A balloon at the distal end of the tube, provide seal between the rachea & tube cuff External balloon connected to the inflation line to the internal cuff ( vice versa) Pilot balloon Support the main tube structure. Tube type, size & coude Flange/ neck plate Bevel, smooth rounded dilating tip tipped placed inside the inner canula of the tube during insertion. ( reduce the risk of trauma ) removed once the tube in correct placement Introducer/ obturator Allow attachment to ventilation equipment/ ambu- bag 15 mm adaptor Types of tracheostomy tubes Single lumen: - Larger inner diameter than double lumen tube. - Absence of removable inner cannula. Double lumen: - Removable inner cannula (twist-lock connection ) prevent build up of secretion. Cuffed t.t contraindication indication Child < 12 years old Risk of aspiration Risk of tracheal tissue damage from cuff Newly formed stoma ( adult ) PPV Unstable condition Indication cuffless cuff No risk for aspiration Minemiz aspiration Pt no longer need PPV Allow PPV ( one way valve ) Pt still need airway access Close system ( upper & lower airway ) Minemiz emphysema Indication Close Suction System:
- Pt regyuireing Highy PEEP, Fio2
- TB, ARDS
- To Avoiding dramatic drop in oxygen. Fenestration: Single or multiple holes in the superior curvature of the shaft of outer and inner cannula.
Indication: - Improve speech & swallowing function. Occlusion cap: Soolid piece of plasticc can be placed on the end of a 15mm hub. Indication : Blocks all air flow via tracheostomy (end stage weaning ) Humidification: 1- pt requiring oxygen with excessive secretion/bedridden ( continuous \ ATM ) with need to be labeled, dated and changed as per PP. 2- alert mobiles pt with minimal secretion ( HME ) change Q 24hr. 3- buchannan bib ( contains a special foam (hydrolox) which act as filter & HME. Shoud by Change/washed up to 3 uses only. Nursing Considerations.. Condition of tracheostomy dressing wet/dry Stoma site should be observed for: - Bleeding - Increase stoma size - Appearance of stoma edges and tissue ( e.g. maceration, cellulites) - Evidence of infection (purulent discharge, pain, offensive odor, tenderness - Allergic reaction to dressing product - Tube secured to skin, ties are appropriately tight - Patient on oxygen: TM T-piece, humidification method. Suctioning Indications for Suctioning if pt have one or more of the following : Excessive secretions Decreased oxygen saturations Tachypnea , bradypnea or tachycardia Restlessness, increased use of intercostal muscles, or sweating Noisy breath sounds/decreased breath sound Poor ineffective cough Change in skin color from baseline Reduced expired air flow from tube during expiration Collection of sputum specimens Prior to section: - hyperventelation - hyperoxygenation to Reduse Hypoxemia. Caution:
COPD: patients should only have 20% increase of oxygenation.
Hyperventelation , will be used for non- spontaneous breather, as it may have significant adverse effects .
Ex: Reduced venous return and barotraumas Potential Complications of Suctioning: - Hypoxemia - Hypotension - Increased intracranial pressure - Hyper/Hypoventilation - Cardiac arrhythmias - Increased work of breathing - Bronchospasm - Infection - Accidental extubation/decannulation - Cardiac Arrest Famous People who was tracheostomies
King Fahd bin Abdul Aziz Al Saud (king of SA) John Fitzgerald Kennedy (U.S. President) Thank you done by : Marwah M.Ibrahim Any Question : References
- American Journal of Critical Care. - Tracheostomy multiprofessional handbook (1ed addition ). - Critical Care Nurse.