Tracheostomy and its care

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Tracheostomy and its care
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Included in my presentation

• What is a stridor brief DD
• tracheostomy
• History
• Tracheostomy tubes and their insertion
• The operation
• Following surgery
• Equipment Required
• Suctioning
• Precautions with a tracheostomy

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Stridor

• It is a audible sound produced as a result of
  turbulent airflow
• obstruction to the passage of air in and out of
  the respiratory tract results in stridor which is
  a cardinal sign of this obstruction
• Bernoulli,s Principle
• Stridor is usually high pitched and inspiratory
  but can be expiratory or biphasic

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types

• Laryngeal supraglottic stridor is usually
  inspiratory
• Glottic stridor may be inspiratory or
  expiratory
• Subglottic are always fixed and present with
  biphasic
• bronchial stridor are expiratory

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Causes

• Nasopharyngeal choanal atresia,DNS,turbinate
• Facial skeletal abnormality cleft palate
• Oropharyngeal tongue,tumors
• Laryngeal supra,glottic,sub
• Tracheal stenosis,fistula
• Bronchial LTB,FB

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Congenital causes

• Web,Cysts
• Subglottic stenosis
• Laryngomalacia
• Vocal cord paralysis
• Cleft palate
• Vascular anamolies
• Lymphangioma,haemangioma

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Acquired Apyrexial causes

• foreign bodies
• trauma
• scalds
• papillomas
• malignancy

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Acquired Pyrexial causes

• acute epiglotitis
• acute laryngitis
• acute laryngo tracheo bronchitis LTB
• diphtheria

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Stertor

• Limited or complete cessation of airflow but is
  reversible
• Is produced because of problems above the level
  of larynx
• Low pitched sound with snoring
• Indicate a pharyngeal or nasopharyngeal
  obstruction

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What Is A Tracheostomy ?

• A surgical opening into the trachea below the
  larynx providing an alternative airway, bypassing
  the upper passages

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History

• 3600 BC A tracheotomy was found pictured on
  egyptian tablet
• 100 BC Asclepiades of Greece first
  surgeon
• 16th century Antonius Musa saved a patient
• 1718 Lorenz Heister coined the term
  tracheotomy
• 1855-1936 indicated in polio epidemic
• 1940 Diphtheria the most important
  indication
• Chevalier Jackson refined operative technique to
  an art and standardized it by reducing the
  operative mortality rate from 25 to 2

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History cont
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Indications

• 1. Upper Airway obstruction
• Congenital,traumatic,infective,paralytic,ne
  oplastic
• 2. Respiratory insufficiency
• Respiratory failure,emphysema,head
  injuries,drugs,cppv
• 3. Tracheobronchial protection
• Retained secretion,inability to
  cough,coma,trauma,ccf,pul.oedema
• 4. Elective to other procedures
• Any major surgery on mouth ,pharynx or
  larynx

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procedure

• 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

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Tracheostomy Tubes

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

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Types of trache tubes

• Metal tubes outer and inner
• inner tubes little
  longer
• easy cleaning
• cant produce airtight
  seal
• Non metal made of silastic
• cuffed or noncuffed
• can be connected to
  anaesthesia
• less traumatic

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Cleaning Reusable Inner Cannula

• The inner cannula is one of the most important
  parts of the tracheostomy tube. Its presence in
  the outer tube ensures that the tube is kept
  clear of secretion buildup, since it can be
  removed and cleaned.
• Generally, it should be removed and cleaned every
  two to three hours for the first two days
• Inner cannula care always requires strict aseptic
  technique.

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Cuffed Tracheostomy Tube

• designed to provide minimal trauma to the
• mucosa and trachea.
• Cuff inflation is necessary to provide a seal for
  mechanical ventilation of your patient.
• It is also indicated to protect the lower airway
  from the aspiration of gastric contents.

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Complications

• Immediate
• Intermediate
• Delayed

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complications

• The incidence of operative and early hemorrhage
  is reported to be approximately 5. Major
  hemorrhage during the procedure is rare but even
  minor bleeding can be life-threatening if it
  interferes with the identification of the trachea
  or gaining access to the airway.

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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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complications

• Pneumothorax and pneumomediastinum are
  well-recognized complications following
  tracheotomy. The incidence in adults has been
  reported at 2 to 5. In children, the incidence
  may be as high as 17 and is the single most
  fatal complication

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complications

• Obstruction of the tracheotomy tube is common.
  Obstruction in the first 24 hours is because of
  tube impingement on the posterior tracheal wall,
  a blood clot, or mucous plug. Obstruction and
  decannulation are the most common serious early
  complication in children. The gravity of
  decannulation in the first 24 hours is emphasized
  in the fact that this event is associated with a
  25 mortality

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complications

• the rate of stomal infection has been reported to
  be as high as 36.
• the incidence of cellulitis and purulence has
  generally been reported at 3 to 8.
• the mortality rate has remained less than 5 with
  a total complication rate of 14 to as high as 66

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complications

• Most dramatic and fatal complication of
  tracheotomy is massive hemorrhage and is usually
  related to erosion of the innominate artery
• The incidence of tracheoinnominate artery fistula
  has been reported to be 0.4 to 4.5. Innominate
  artery rupture has been associated with tracheal
  necrosis secondary to infection and from erosion
  from the tracheotomy tube.

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complications

• Tracheoesophageal fistula complicating
  tracheotomy occurs with an incidence of 0.01.
• while the complications of tracheotomy may be
  severe, with proper precautions and prompt
  management, the mortality and morbidity of this
  procedure may be minimized

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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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Suctioning procedure.

• 1. A tracheostomy is an open surgical wound and
  strict asepsis and universal precautions should
  be observed.
• 2. A clear explanation of the procedure with
  reassurance will help to decrease the patients
  anxiety and fears.

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Promoting comfort

• Give analgesics for pain. Remember that an
  incision created the tracheostomy.
• Be calm and reassuring. Patients with a
  tracheostomy report sensations of choking

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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 in the child occurs before feed to
  minimise the risk of aspiration
• to be demonstrated in video

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Eating With A Tracheostomy

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

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Following Surgery

• patient requires vigilant observation 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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Psychological Care

• Many tracheostomy patients are totally dependent
  upon the
• caregivers and can do little for themselves.
• Since the patient, especially with an
  inflated cuffed tube, will be unable to speak,
  every word and action of the staff is carefully
  observed.
• It is imperative that an atmosphere of calmness
  and confidence be created for the patient since
  emotional status will influence breathing pattern
  and acceptance

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Skin Care

• The care of the skin around the stoma site should
  be considered one of the more important
  procedures in the care of the tracheostomy
• The new surgical site needs to be cleaned and
  dressed frequently as it heals.

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Decannulation Procedure

• When the patient is being weaned from mechanical
  ventilation or from the tracheostomy tube itself,
  the use of a fenestrated tracheostomy tube may
  facilitate the decannulation procedure

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In Summary

• tracheostomies are often created to bypass upper
  airway obstructions
• the patient must have in their vicinity at all
  times, one tube the same size and one a size
  smaller in case 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