Respiratory Update for SCC Nursing Faculty

1. Respiratory Update for SCC Nursing Faculty Tracheostomy Tubes and their Care Presented by Cynthia Fouts June, 2012

2. Learning Objectives: • After viewing this presentation, the learner will be able to: • Identify different types of tracheostomy tubes • Identify parts of a tracheostomy tube and their purpose • Demonstrate the correct steps in providing tracheostomy care • Recognize the steps to perform sterile suctioning of the patient’s airway via a tracheostomy.

3. Tracheostomy Facts • defined as a surgical introduction of a tube into the trachea • bypasses the upper airway and thereby bypasses the normal functions of humidification, warming, and filtering of air • placed for the following reasons • to bypass an obstruction • provide airway for mechanical ventilation on a long-term basis • maintain an open airway • provide access for removal of secretions

4. Placement of a Trach Tube • Surgical tracheotomy – performed in the operating room under general anesthesia • Percutaneous dilatational tracheotomy (PDT) – done at the patient’s bedside under local anesthesia and sedation. • Usually placed at the 2nd or 3rd tracheal ring

5. Post-procedural care • most patients report feeling like they are “choking” • ensure that the patient has enough humidity and fluids to keep secretions thin • keep manipulation of the trach tube at a minimum to keep from dislodging the new tube • do not change trach ties for the first 24 hours • any trach changes necessary during the first week MUST be performed by a physician

6. Types of Tubes • Silver Jackson • Standard Cuff Tube • Flexible Tube • Fenestrated Tube • Foam Cuff Tube • Uncuffed Tube • Speaking Trach Tube • Extended Length Tubes

7. The Jackson tube is the oldest tracheostomy tube. It is made of silver, and therefore very rigid. There is not a connection to be used with mechanical ventilation. This type of tube is not often seen in use anymore.

8. The low-pressure cuffed tracheostomy tube is the most common tube seen in use. It has an inner cannula which may be disposable or non-disposable.

9. The flexible trach tube is also referred to as a reinforced trach tube. It is not preformed, thus allowing it to conform to any anatomical configuration.

10. The fenestrated tube is useful in assessing how well the patient will do when decannulated. Like a non-fenestrated tube, it has an outer and inner cannula. When the inner cannula is removed, the cuff is deflated, and the tube is capped, the patient is able to breathe through his upper airway.

11. The foam cuff tracheostomy tube has a cuff which is filled with foam. Leaving the cuff open to the atmosphere, air fills the foam to expand until it reaches the inside of the trachea. This minimizes tracheal necrosis and stenosis. It is important to choose the correct size prior to insertion to ensure good contact with the tracheal wall.

12. The uncuffed tracheostomy tube are used primarily in infant and pediatric patients. The anatomical differences in younger patients make tracheal stenosis more of a problem with cuffed tubes. Uncuffed tubes may also be used in adult patients who require an airway but not mechanical ventilation.

13. The speaking tracheostomy tube allow mechanically ventilated patient to orally communicate. A separate flow of gas at 4-6 L/m is directed through the larynx via a thumb port the patient occludes. The cuff around the trach tube stays inflated, separating mechanical ventilation from speech.

14. Extended length tubes are available to fit all anatomical configurations. The length may be extended proximal or distal to the curve.

15. Parts of a tracheostomy tube: • Outer Cannula – stays in all the time • Inner Cannula – removed for cleaning or replacement • Obturator – used to insert the trach tube • Neck flange – has product information and holes for securing neck ties • Connector – part that sticks out to connect to ventilator tubing, a resuscitation bag, or a speaking valve • Cuff – balloon that is inflated to form a seal against the tracheal wall • Pilot tube and balloon – used to inflate the cuff by securing a luer lock syringe to end

16. Why perform tracheostomy care? • Maintain airway patency • Promote cleanliness • Prevent infection • Prevent skin breakdown

17. Assessment • Assess for excess secretions • Soiled tracheostomy dressing and ties • Assess respiratory status • Identify type of tracheostomy tube • Assess client’s ability for self-care • Identify factors that influence tracheostomy care

18. Supplies needed for trach site care: • sterile gloves • sterile gauze • cotton tip applicators • normal saline solution • hydrogen peroxide • clean ties or tube holder • trach dressing • container to mix normal saline solution with hydrogen peroxide • Trach care kits contain any combination of the above. • Also have a manual resuscitator and suction equipment and supplies available.

19. Tracheostomy Care Procedure • Wash hands and don gloves • Explain procedure to patient • Place patient in Fowler’s position • Hyper-oxygenate the patient • Suction the tracheostomy tube if needed • Discard soiled tracheostomy dressing • Replace oxygen/humidity on the patient • Gather supplies

20. Tracheostomy Care Procedure, cont’d. • Visually inspect the stoma for sign of infection or skin breakdown. • Using sterile gauze or cotton applicators moistened with normal saline solution, begin at the top of the trach and clean the area around the stoma, moving in one direction away from the stoma. • Hardened, crusty secretions can be teased loose with a sterile cotton-tipped applicators moistened with normal saline solution. • Clean the outside of the flange and tube connector.

21. Tracheostomy Care Procedure, cont’d. • Do not use hydrogen peroxide unless there are signs of an infection. If necessary, dilute hydrogen peroxide with saline in a 1:1 ratio. • Place a clean tracheostomy dressing under the flange • Replace the tube holder/ties with clean holder/ties using the buddy system. The trach should always have someone holding it in place until resecured by the holder/ties. • Reassess patient breath sounds and air movement • Remove gloves and wash hands • Document

22. Please follow the link below to watch a very good video of trach suctioning and trach care. One point to keep in mind is, although the nurse in the video is replacing a disposable inner cannula, some tracheostomy tubes have non-disposable inner cannulas which need to be cleaned with a hydrogen peroxide/normal saline solution, rinsed and replaced. http://www.youtube.com/watch?v=gtKc9pe9HCw&feature=related

23. These supplies must be available in the trached patient’s room at all times: • new trach tube • obturator to replace dislodged tube • bag/valve/mask assembly • suction equipment

24. Bibliography Hess, D. et al. (2012) Respiratory Care Principles and Practice, 2nd Ed. Sudbury, MA: Jones and Bartlett Learning LLC., pg. 402-415 Nancy-Floyd, B. (2011). Tracheostomy Care: An evidence-based guide to suctioning and dressing changes. American Nurse Today, Vol 6. No. 7. Retrieved from http://www.americannursetoday.com/article.aspx?id=8022&fid=7978 Tracheostomy Care, (2007) UPMC. Retrieved from http://www.upmc.com/patients-visitors/education/documents/tracheostomycare.pdf Update on Tracheostomy Care (2004). RN.com. Retrieved from http://www.rn.com/getpdf.php/615.pdf