06: Tracheostomies Flashcards
Where is the trach incision made?
Below larynx, through 2nd and 3rd cartilage ring (one finger below cricoid)
-otomy
Incision into
-ostomy
Forming a new opening
Stoma
Hole in trachea without tube in place
Advantages of trach v ETT
Long term
More comfortable for pt
Less intratracheal movement
Speaking/eating
More efficient suctioning
Less Raw
Shorter weaning
Less sedation
Primary indication for trach
Projected 10-14 days pt needing artificial airway/vent support
Other indications for trach
Suctioning efficiency
Bypass upper aw obstruction
Vocal cord paralysis
Tracheal instability
Parts of trach tube
Outer cannula (radiopaque line)
Inner cannula (15mm)
Flange
Obturator
Cuff
Inflation pilot balloon
Trach ties
Locking reusable inner cannula
End rotated to remove/secure
Disposable inner cannula (DIC)
Tabs squeezed for removal/placement
Obturator must always be left
At bedside
Obturator
Minimizes trauma to tracheal mucosa during insertion
Only used to put outer cannula in stoma
Trach sizing
ID
6.0-8.0
Percutaneous dilation placement (perc trach)
At bedside
Reduced cost
Pt must be able to tolerate a large leak around ETT for duration of procedure
Post trach placement assessment
4-6 cm above carina
Vitals/ventilation
Palpate for subq emphysema
Ensure holder secure
Proper cuff pressure measurements
15-25 mmHg
20-30 cmH2O
Cuff pressure increasing when using the same volume of air?
Edema at tracheal cuff site
Tracheostomy complications
Tracheal stenosis
Tracheomalacia
Tracheal granulomas
Tracheoesophageal fistula
Tracheoinnominate artery fistula
Tracheal stenosis
Narrowing of the lumen of trachea associated w fibrous scarring
Tracheomalacia
Softening of tracheal cartilage
Causing collapse of trachea during inspiration
Tracheal granuloma
Abrasion of tube tip at stoma site
TE fistula
Hole between trachea and esophagus to due tracheal erosion
Minimizing infection of stoma
Sterile technique
Regular aseptic cleaning
Q8
Hydrogen peroxide is used to clean only the
Inner cannula
How to prevent tracheal stenosis
Maintain correct position, trach holder tension, and cuff pressure
Three options for weaning trach
Red cap, fenestrated tube, gradual smaller sizes
Maintain/prevent infection in stoma
Disposable IC: changed daily
Sterile technique
Regular aseptic cleaning
Q8/PRN
Bedside percutaneus trach advantages
Decreased cost
No transport
**pt must be able to tolerate large leak
Fenestrated trach tubes
Weaning
How to test upper aw function with fenestrated trach tube
Remove IC
Deflate cuff
Place cap
Hi-lo eval cuff pressure number and continuous suction number
40 cmH2O
-20 mmHg
Jackson metal trach
Long term use
Bivona foam cuff
NOT for weaning
Long term care
Fills with ambient pressure
Bivona TTS
Sterile water
Single cannula
Weaning
Single cannula trachs
Pediatrics/long-term ventilation
XLT trach
No MRI
Temporary
Obesity
Adjustable neck flange
How often to change out trach
Monthly
When do therapists not perform trach change out
Trach is <5 days old
Pt unstable
Edema
Cuffless
Kids
Decannulation assessment
Adequate cough
No active infection
Reduced secretions
Patent upper aw
Adequate swallow
Passy-Muir speaking valve
One way valve
Closes on exhalation
Ways to communicate
Lip reading
Written communication
Letter/phrase/picture board
Cell phone
Speaking valve
Way to communicate with artificial larynx
Electrolarynx
1 indication for laryngectomy
Laryngeal cancer
Total laryngectomy
No direct access to trachea via mouth, nose, or upper aw
Partial laryngectomy
May be access to lungs via upper aws
Displacing the tongue
Sniffing position
Jaw thrust
Use w suspected injury to c spine
Chin lift
Does not extend c spine
LMA characterisitics
Inserted blindly
Low pressure seal (vent pressure >20cmH2O)
LMA indications
Difficult intubation
Poor mask fit (BVM)
Elective surgeries w no aspiration risk
LMA contraindications
> 14-16 wks pregnant
GERD
OP/abdominal surgery
Prone/obesity
Conscious
LMA no chest rise?
Reposition
King airway indications
Unconscious/Apneic pts
Short-term ventilation
King airway characteristics
No interruption of CPR
Little/no spinal movement
**must be placed in esophagus
King airway contraindications
Responsive patients (gag reflex)
Esophagageal varicose/disease/trauma
Caustic substance ingestion
Obstructed aw
King airway insertion
Tongue-jaw lift (neutral head)
Sniffing unless C spine injury
Combo tube descriptions
Functional aw regardless of placement in trachea or esophagus
Combitube insertion
Blind
Combitube indications
Unconscious/apneic adults
Difficult intubation
C spine injury
Bleed
Combitube contraindications
Children
Aspiration/regurgitation
Combitube insertion checking/method
1 (blue/tall) first, check for BS, then #2 (clear/small)
No BS: retract 2cm
Double-Lumen Endotracheal Tube
Right and left lung to be ventilated separately
Cricothyroidotomy
Incision through cricothyroid membrane
