Down The Gurgler

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Down The Gurgler

• Tracheostomies and Nursing Care
• Presented By Nicholas Oorloff

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Tracheostomies and Nursing Care

• Included in my presentation
• What is a tracheostomy?
• Tracheostomy tubes and their insertion
• The operation
• Following surgery
• Equipment Required
• Suctioning
• Precautions with a tracheostomy

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What Is A Tracheostomy?

• A surgical opening into the trachea below the
  voicebox
• it provides an alternative airway, bypassing the
  upper passages

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Tracheostomy Tubes

• a tracheostomy tube is
• inserted through the tracheostomy to maintain a
  patent airway
• secured in place by tapes tied around the neck

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Velcro Tracheostomy Ties
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Some Indicators For Tube Insertion

• Subglottic Stenosis
• an area of thickened scar tissue on the inner
  linning of the trachea, just below the vocal
  cords (subglottic region)
• Subglottic Haemangioma
• highly vascular mass just below the vocal cords
  (subglottic region)
• Vocal Cord Paralysis
• inability of vocal cords to open and close
  properly during breathing

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Indicators For Tube Insertion (cont)

• subglottic stenosis
• subglottic haemangioma
• vocal cord paralysis
• all of the above result in narrowing or complete
  blockage of upper airways resulting in difficulty
  breathing
• insertion of the tube below the level of the
  blockage allows upper airway to be bypassed

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The Operation

• Takes about thirty minutes
• Procedure involves
• horizontal incision made into the skin
• vertical incision made through the rings of
  trachael cartilage
• layers of skin and muscle are sutured to provide
  a path for the trache tube to follow
• sutures remain for about 10 days

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The Operation (cont)
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Following Surgery

• child spends next 4-5 days in ICU or until the
  first tube change has been performed
• a doctor performs the first tube change to
  prevent false tracts from developing, due to
  incorrect insertion procedure, as the opening
  into the airway or stoma is not well formed at
  this stage

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Following Surgery (cont)

• When the baby cries little or no voice will be
  heard
• as air no longer passes across the vocal cords
  which creates voice
• However, some children may have a slight leak
  around tube allowing some air to pass and vibrate
  the vocal cords creating a softer voice

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Equipment (to be with child at all times)

• Two tracheostomy tubes attached to the bed
• one the same size as the childs
• one a size smaller
• This is in case the tube becomes blocked and
  needs to be changed in an emergency
• Trachael dilators attached to the bed
• to open stoma
• suction equipment

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Nasal Breathing

• Normally nasal breathing
• humidifies
• filters and
• warms air before it enters our lungs
• the tracheostomy bypasses these mechanisms so
  that the air is cooler, dryer and not as clean.
  In response to these changes the body produces
  more mucous, which may require humidification to
  aid expulsion

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Humidified Oxygen Via Tracheostomy
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Humidified CPAP Via Tracheostomy
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Suctioning a Tracheostomy

• Procedure requires
• wall suction
• suction catheters (size of catheter determined by
  doubling the size of the tracheostomy tube in
  French Gauge i.e size 3.5 trache requires size
  7.0 suction tubing)
• 0.9 normal saline and syringe
• Procedure involves
• washing your hands
• attach suction catheter to tubing
• measure suction catheter against pre measured
  tape - prevents suction catheter being passed too
  deep and causing trauma to tissue

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Suctioning a Tracheostomy (cont)

• pass suction catheter into tubing and suction
• observe type of secretions removed
• i.e colour and consistency
• allow child five breaths before repeating
• rinse suction tubing with clean water
• Saline Instillations
• 0.2-0.3ml of normal saline can be instilled into
  the tracheostomy to thin secretions, suction
  should follow immediately

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Tracheostomy Tube Changes

• tracheostomy tubes are routinely changed weekly
  or any time a blockage is suspected
• tubes are changed to prevent build up of
  secretions on the wall of the tube
• the change occurs before the child has a feed to
  minimise the risk of aspiration
• to be demonstrated in video

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Eating With A Tracheostomy
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Eating With A Tracheostomy

• a tracheostomy will not usually affect the
  ability of a child to swallow
• encouraging fluids helps to thin secretions

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Some Precautions With a Tracheostomy

• water is a serious threat
• child has lost ability to protect airway, as the
  gag reflex is bypassed
• no swimming
• no showering
• avoid clothing that blocks the tracheostomy
• accidental decannulation- most common cause of
  death in children with tracheostomies

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Tracheostomy Complications

• children with tracheostomies are more prone to
  respiratory infections
• tracheostomy tube bypases bodies defence
  mechanisms
• some signs of infection
• febrile
• inflammed stoma site
• foul odour emitted from tracheostomy

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In Summary

• tracheostomies are often created to bypass upper
  airway obstructions
• the child must have in their vicinity at all
  times, one tube the same size and one a size
  smaller incase of blockage
• children with tracheostomies must be supervised
  around water
• children with tracheostomies are more prone to
  respiratory infections

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References

• internet
• www.tracheostomy.com
• http//wellness.ucdavis.edu/child
• www.rch.unimelb.edu.au/intranet/handbook/trach.htm
  
• texts
• Myer.C, Cotton.R, Shott.S,1995 The Pediatric
  Airway, J.B Lippincott company Pennyslvannia