Tracheostomy care

1. Tracheostomy Care Bill Wojciechowski, MS, RRTDepartment of Cardiorespiratory CareUniversity of South AlabamaMobile, Alabama

2. Upper airway functions bypassed when patient has tracheotomy performed. Tracheostomy care

3. Heat/moisture exchange Thermoregulation Gustation (taste) Olfaction (smell) Filtration Upper airway functions

4. Altered or loss of voice Speech & language delays (young children) Loss of smell & taste Compromised nutritional status Impaired swallowing/increased risk of aspiration Secretion control issues/infection Psychological distress Loss of physiologic PEEP Clinical Complications

5. Absence of airflow often creates • Frustration • Anxiety • Psychological distress • For children: delayed speech & language development ClinIcal Complications

6. Absence of airflow decreases sensations • Smell • Taste • Poor appetite • Skin health • Supplemental feeding • Difficulty swallowing • Risk of aspiration Clinical Complications

7. Cuffed trach tubes anchor larynx & sometimes interfere with: • Laryngeal elevation • Epiglottic inversion • Airway protection Cuffed trach tubes secure larynx, Deflated cuff: more freedom. Clinical Complications

8. Three phases of normal swallowing: 1) Oral phase 2) Pharyngeal phase 3) Esophageal phase

12. Normal swallowing (pharyngeal phase): • Oral & nasal cavities sealed • Vocal cords close • Positive pressure generated below cords • Air prevented from entering larynx • Larynx elevates & moves forward • Acts as a lever (mechanical event) • Epiglottis seals larynx • Food/liquid directed into esophagus Upper airway functions

13. Swallowing with Trach Tube Inserted: Vocal cords close Air flows through trach tube No subglottic positive pressure Reduced sensations in larynx & pharynx Pooling of airway secretions Increase risk of aspiration Most patients OK!! Upper airway functions

14. Absence of upper airway airflow (inability to nose-breathe) compromises: • Heat/moisture exchange • Increased secretion viscosity • Increased secretion volume • Frequent suctioning • Increase risk of airway trauma/infection • Presence of trach tube stimulates secretions Clinical complications

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17. With cuff inflated: • No physiologic PEEP • Possible micro-atelectasis • Decreased alveolar ventilation • Compromised oxygenation Clinical complications

18. Cuff deflated Cuffinflated Physiologic PEEP Present Physiologic PEEP Absent

19. Inspect stoma daily: irritation/inflammation. Tracheostomy care is done every 8 to 12 hours and PRN. Avoid dressings trapping moisture. Check secretions: white & clear; greenish-yellow Odor often indicates infection. Assess need for suctioning q2h. Tracheostomy Care

20. Signs of Infection: • Yellow or green secretions (pink or blood-tinged) • Thicker mucus • Greater volume of mucus • Stoma site bleeding • Foul odor from stoma • Febrile patient • Pulmonary congestion • Increased RR • Listlessness • Discomfort with trach/tender stoma site TracheostomyCare

21. PROCEDURE Cleaning inner cannula

22. Clean inner cannula 1. Loosen inner cannula. 2. Hold outer cannula with one hand. Turn inner cannula to right with other hand to unlock.

23. Clean inner cannula 3. Remove the inner cannula by steadily pulling it down and toward your chest until it is out.

24. Clean inner cannula 4. Place inner cannula in the solution of hydrogen peroxide & normal saline, and don sterile gloves.

25. Clean inner cannula 5. Use trach brush, or pipe cleaner, to clean inner cannula of mucus and dried secretions.

26. Clean inner cannula 6. Place it in bowl of normal saline (NS). 7. Shake off excess NS. Moisture will act as lubricant during inner cannula reinsertion.

27. Clean inner cannula 8. Reinsert inner cannula, keeping curved portion facing downward.

28. Clean inner cannula 9. Lock inner cannula into position. 10. Wash bowls thoroughly and allow to air dry. Soak trach brush soak in hydrogen peroxide-NS solution &, rinse with NS. Air to dry. Discard pipe cleaners.

30. Goal: maintain cuff pressure below tracheal mucosal capillary perfusion pressure which is: 25 to 30 mm Hg. Cuff pressure maintained: 20 to 25 mm Hg, or 25 to 35 cm H2O Higher cuff pressures Cut off tracheal mucosal blood flow Tracheal wall damage (necrosis/tracheomalcia) Cuff Pressure

31. Caregivers must receive CPR training. • Suction if indicated. • Change trach tube if clogged. • Spare tubes (cuffless &/or cuffed): same size & 1 size smaller • Pinch nose & mouth (cufflesstrach). • 2 breaths with manual resuscitator/mouth-to-trach/mouth-to-stoma: STOMALEAK • Mouth-to-mouth/bag-mask with finger over stoma: STOMA LEAK CPR- Tracheostomy

32. Fenestrated: Weaning Speech Granuloma formation Increased risk of aspiration Tracheostomy & Speech

33. Some space around tube • Snug fit: tube too large • non-fenestrated: poor or no speech Tracheostomy & Speech

34. Tracheostomy& Speech

36. Use extreme caution with baths and water • No swimming • Avoid powder, talc, chlorine bleach, ammonia, aerosol sprays, or colognes and perfumes • Prevent foreign objects from entering trach tube Tracheostomy Tube Precautions

37. Avoid dust • Avoid sand and beach • Watch play with other children to assure toys, fingers or other foreign bodies are not put into trach and trach is not pulled • No contact sports • Frequent hand washing Tracheostomy tube precautions

38. Teach airway anatomy Teach about equipment Teach CPR Teach infection control Teach humidification Teach suctioning Teach about speaking valves/fenestrated trach tubes Teach communication through speech therapy Education