Tracheostomy

Post-op Management

Dr Shiraz Qamil

Content

Types of tracheostomy tubes Post-op complications Post-op expectations Post-op care Weaning off tracheostomy

Types of tracheostomy tubes

Single Lumen Double Lumen

Cuffed

Non-Cuffed

Fennestrated

Cuffed Tracheostomy Tube

Uncuffed Tracheostomy tube

Adjustable Flange Tracheostomy Tube

Fennestrated Tracheostomy Tube

Shileys Double Lumen Tracheostomy Tube

Post op complications

Post-op complications may be divided into

Immediate Early Late

Post op complications

Immediate complications
Bleeding (thyroid, lacerated vessels) Pneumothorax or pneumomediastinum (esp in children) Injury to adjacent structures (great vessels and oesophagus)

Post op complications

Early complications (<48 hours)

Bleeding
Increased blood pressure, cough reflex

Mucous plug Tracheitis Cellulitis Displacement Subcutaneous emphysema

Post op complications

Late complications (>48 hours)

Bleeding (tracheoinnominate fistula 0.6-0.7%, granulation tissue) Tracheomalacia Stenosis (cricoid cartilage injury) Tracheoesophageal fistula Tracheocutaneous fistula Granulation Scarring

Post op expectations

Cuffed tracheostomy initially

Airtight seal for ventilation Prevent aspiration Prolong use may irritate stoma & form granulation tissue

Intermittent tracheal suction Deflate tracheostomy cuff after 2-3 days First change to be done by surgeon

Post op care

Goals of tracheostomy care

Maintain airway patency Clear lungs / tracheal secretions Prevent skin and lung infection

Tube can be blocked by

Blood clot Copious secretion Mucous plug

Post op care

How to know tracheostomy is patent? Feel for air blast Vapour or misting on mirror Movement of cotton fluff Blocked tracheostomy tube is an emergency.

SUCTIONING

Bedside equipment for tracheostomy patient

Use personal protective equipment during suction Suctioning can be done either supine or sitting Without applying pressure, suction catheter is inserted

Advance to end of trachy tube Withdraw tip by 1cm before applying suction Avoid tracheal trauma

Do not suction for more than 15 20 seconds. Be careful not to cause Hypoxia In the event of blockage by thick secretions despite suction, tracheostomy tube change may be considered

Size of suction catherter

Formula:
Size of trachy tube x 2 2 I.e.: size 7 trachy tube:
7x2-2 = 12 Size 12 suction tube should be used

vacuum pressure is < -150mmHg.

Tracheostomy change Similar sized tracheostomy tube prepared Tracheal dilator and one size smaller tube kept as standby Personal protective equipment. Patient in supine position with neck hyperextended Hyperoxygenate if on ventilator Tracheal suction Deflate cuff tube Untie old tube and gently remove Insert new tube with obturator/introducer, which is removed once in trachea Check patency and secure tube

Dislodged tube
Do not panic!
Tract is well formed after day 5 of tracheostomy

Give 100% oxygen (Monitor patients spo2) Ask the patient to breathe normally via their stoma Prepare for insertion of the new tracheostomy tube Reinsert tube as per normal change

BLOCKED TUBE

Deflate cuffed tube if used Give 100% oxygen and pass a suction catheter Excessive lung secretion do suctioning alternate with hyper-oxygenation Sterile normal saline instillation to aid clearing Tube change may be necessary Inner cannula removal and replacement

Tracheostomy change: when to change?

Cuffed tube should be changed when not indicated Cuff may irritate trachea and cause more secretion Double cannula tracheostomy less freq change Tracheostomy tract fully epitheliase by one week

Tracheostomy change

Causes of difficult tracheostomy change

Early tube change when tract not fully formed Constricted tracheostoma Granulation tissue at stoma Obese neck with deep seated trachea Restless or anxious patient

CARE Inner cannula (double lumen)

Checked intermittently depending on amount of lung secretion Inner cannula removed with a curve-down action Cleaned under running tap water

Humidification
Supplementary humidification to moisten air - heat-moisture exchange device

Saline nebuliser
Aid expectoration

Moist saline gauze veil

Provides moist air and protection from inhaled foreign bodies

HOME CARE

Patients and their family should be empowered to take responsibility of tracheostomy care Normal lifestyles are encouraged Loose covering over the tracheostoma

WEANING OFF TRACHEOSTOMY

When To Wean: Tracheostomy tube should be weaned off once initial cause for airway obstruction has been addressed Effective cough and gag reflex Good respiratory effort

WEANING OFF TRACHEOSTOMY

How To Wean: Weaning should be done in a controlled setting Patient to be on continous SPO2 monitoring and to be nursed in acute/subacute bed 1. Downsizing trachy tubes
Change to smaller tube to reduce dependance to trachy Sequential reduction by one size, each to be in-situ at least 48hrs Usage of 2 different sizes should be adequate Remove and observe over 24hrs

2. Change to Uncuffed fenestrated tube & spigot

Allows air to flow through the upper airways Spigot with air tight closure Allow speech production and train breathing with own airway Observed for 15 to 20 minutes with SpO2 monitoring If well, to maintain spigot for 24 to 48 hours Tube can be removed if patient is able to tolerate

Secondary suturing done if stoma persists

WEANING OFF TRACHEOSTOMY

Remember that weaning off takes time. Need to let patient adjust to normal breathing Spo2 must be monitored for at least 24 hours post blocking tube with spigot Use yellow branulla stopper to spigot trachy tube.

Care of tracheostomy stoma

Daily keyhole dressing must be done Dressing must be changed if dirty Sutures are removed on day 7 post op Tracheal stoma will close by day 10 once trachy tube removed Daily dressing done untill stoma closes to ensure good wound healing

Please feel free to consult our team if there are any doubts regarding your patients on tracheostomy.

THANK YOU