13 Tracheotomy Flashcards
Tracheotomy
Opening the trachea at any level (not the larynx)
You perform a tracheotomy to create what?
to create an airway
T/F a tracheotomy is an emergency incision?
True there’s so much damage to the larynx that the individual cannot breathe
- inhale a fish
- Hitting the wire on your throat
Once decision for tracheotomy, there’s a further decision that needs to be made. What is it?
it may then be necessary to determine if a more long term arrangement has to be made vs. temporary
when it is a permanent arrangement what is it called?
long term airway = tracheostomy
What is the criteria for tracheotomy?
a. Pump failure
=breathing mechanism, torso, lungs, diaphragm, intercostal)–the muscles fail not the tissue
b. Flail chest
=Rather than air going in it goes out on contraction
=the bony structure is broken so, on contraction the ribcage can get smaller
c. Paralysis
=Injury to the brain, brainstem, or spinal cord at the cervical level
=disease process
=the muscles no longer engage because they’re no longer innervated
***some disruption of the mechanism
d. Blockage in the airway that will not resolve quickly enough
=stenosis of the larynx
=larynx is broken or swollen
What is a condition that a tracheotomy need to become more permanent?
Flail chest because so many ribs and/or sternum breaks so
a tracheostomy with an external pump for breathing will be needed so the body could rest
What are the 2 big
Pump failure or Block airway
What is a ventilator?
A tube to maintain the airway is either pushed through the larynx itself (Pushed through the mouth and VF and into the trachea)
Ventilator is done through intubation
Why do you use a ventilatory?
IF the lungs aren’t working optimally
Both the pump and the lungs can be managed
i. The ventilator is going to do the breathing for the pump
ii. More oxygen will flow into the lungs (air can be manipulated by raising the oxygen content to the bloodstream)
Air pressure through the ventilator can be raised to take the place of the pump
What are the indications of tracheostomy ?
a. Length of time on the ventilator
b. Airway edema in the glottis
c. Dental Abscessed
d. Difficulty mobilizing secretions
e. Airway trauma that won’t resolve quickly.
What is the maximum length of time to keep someone ventilated?
o5-7 days is the longest you want the patient with a tube
Why is 5-7 days the longest time you want to have a ventilator in?
to remember that the larynx is a whole collection of really tiny soft tissues—over long term the tube damages them as well to the entire Vagus (CN X) nerve complex in the larynx
T/F a ventilator can cause damage to the vocal folds that is absolute
•Results in cumulative nerve damage over time
•Granulomas in the posterior commissure caused by intubation
-They try to defend themselves by creating this hard rock on the surface of the tissue on the larynx
Explain why edema in the glottis is in an indication for tracheostomy?
oSwelling at the level of the VF
oMay not directly affect breathing because of the intubation BUT that’s the body’s way of saying they’ve had enough of the tube—it’s time to pull
Explain why dental abscessed indication for tracheostomy?
o Have the potential of being fatal
o Infection in the head—direct root to the brain
•Mouth to sinus where infection travels → sinus to the brain
Explain why difficulty mobilizing secretion are an indication for tracheostomy?
oMucous at the level of the larynx that carry away germs, bacteria, pollen, and dust (microscopic bits)
oWhen the respiratory system is under duress it’s difficult to clear that mucous
oIf we have no mechanism to move it out = pneumonia
oTracheostomy makes a direct route for coughing and suctioning
If the airway trauma that won’t resolve quickly what should you do?
skip to tracheostomy
There can be surgical indications of a tracheostomy being necessary, what are they?
a. Skull or dural surgeries
b. Head and neck cancers.
c. Traumatic brain injury.
Explain how skull or dural surgeries are surgical indications of tracheostomy ?
oTracheostomy may performed because patients who have this surgery have swelling—which may result pressure on the brain stem which will affect the ability to breath
•It may decimate breathing
oRemember: Dural layer=outermost layer of the meninges
Explain how Head and neck cancers are surgical indications of tracheostomy ?
oPressure is exerted on brain stem on the tumor
oWhich may result pressure on the brain stem which will affect the ability to breath
oOr the cancer is interfering with the larynx
oOr tumor in the throat, jaw etc. is closing in on the air way
Explain how TBI’s are surgical indications of tracheostomy ?
oIt will be a while for resolution so they’ll jump to tracheostomy
oYou cannot take a fragile patient and wait for an emergency in the air way to happen to make a tracheostomy
oGive them the best chance to breathe easily
What happens in a treachostomy ?
a.Create a flap
b.Cut off a flap of trachea cartilage below the level of the larynx and insert a tube
c.Cut off a piece of tissue and insert a tube
oThe hole is cut and canula is placed
d.The stoma or hole may be closed at a later date
e.Stoma = permanent hole
What is suctioning?
Suctioning is the removal of secretions directly from the airway
- Keeping the airway patent and improve inhalation & oxygenation
- We potentially suction a patient before we begin working with that patient on speech
T/F Suction procedures is a clean technique it is not sterile
True it can be done away from an acute care setting
- Can be done by a patient in her own home
- Wash your hands before, you do not have to wear gloves while suctioning, and wash your hands after
What are important things to remember about suctioning?
- You’re parents should never wait for suctioning it should be on a schedule
- The catheter should be discarded if it is contaminated
- Suctioning is not a painful or distressing procedure.
- What’s distressing is having your airway closed because of built up mucous
- If a patient is distressed then stop and look at your technique, it’s not the suction
- Most kids will stay asleep if you do it while they’re sleeping
What are short term and long term things to consider for kids?
You need to be aware of size of suction catheters, suctioning technique and pre-oxygenation requirements depend on the size, style and length of tracheostomy tube.
What are the two rules with suctioning?
Wash your hands
Always chart what you did, saw, noticed etc.
You do not want to suction catheter deeper than what?
deeper than where the cannula is placed—or you’ll suction the trachea
•This is when you’ll distress someone
•You suction the tube not the trachea!
-Or you’ll damage the trachea
During suctioning, what should you be observing about the secretions ?
Site, color –sickness, smell, and blood
- Snot should be mostly clear and runny
- Green is infection
- How long does it take you to pull the snot in compared to the previous days
- Snot should NOT smell
What equipment do you use for suctioning?
- Suction unit
- Suction catheters
- Suction unit connecting tubes
- Bowl or bottle of tap water to flush the suctioning tube when you’re done
- It is a good idea to have a new suction catheter
- Make sure all the parts and pieces function
Explain the procedures for sunctioning
- Insert the tube at the right distance
Depends on the length of the tracheostomy tube – this will be explained to you while you are in hospital.
2.You find out what size tracheostomy tube you’re client is wearing - Gently insert the catheter into the tracheostomy tube (with your thumb off the side port of the suction catheter).
- Apply suction, and when you are done cover the port with your thumb, and slowly withdraw the catheter.
- Do not rotate or twirl the catheter as you remove it.
- Don’t panic as long as you do not go past the level of the tracheostomy tube, your patient will be quite comfortable
- Repeat if the patient still needs suction. Give your patient time to catch a breath between suctions.
- Disconnect the catheter from the tubing and dispose of it safely or put it back in it’s upholster
The lining of the trachea is very sensitive and can be damaged easily by the suction catheter. In order to minimize the trauma to the trachea, pass the catheter just to the end of _________
end of the tracheostomy tube. This removes the secretions and reassures you that the tube is not blocked.
why?
This removes the secretions and reassures you that the tube is not blocked.
We see these patients because of what two reasons?
speech and or swallow
What are the types of speaking valves?
one way
two way
Single cannula, cuffed.
Explain a one-way eval
•Opens when the patient breathes in and closes when they exhale
•Thus, allowing your patient to breathe
=You inhale but exhale through VF up to the nose and mouth
•Can be placed at the end of a tracheostomy tube
=Can occlude with thumb
What is the issue with a one-way valve?
Not enough seal
If the tracheostomy tube is big and fills the trachea the patient will not be able to get air around the tube = no speech
What is a two way valve?
can inhale and exhale
How do assess a patient for a speaking valve?
This is determined by the patient’s ability to tolerate a speaking valve.
Tolerance is judged by the patient’s ability to _________?
maintain reasonable oxygen saturation levels in the blood.
define oxygenation
the level of O2 in the tissues of the body—specifically lungs
•O2 stats measure the percentage of hemoglobin binding sites in the blood stream that are occupied by oxygen
•Level of oxygen in the blood, but specifically the % hemoglobin binding sites
T/F 95-100% are loaded with oxygen
True
What is the lowest benchmark for O2 stats
95% is the lowest benchmark for O2 stats
If the patient can’t tolerate a speaking valve, he or she may still be able to achieve a voice because what?
voice because of air leaking around the tube.
oYou’re going to get more air if you can plug the tracheostomy tube
tracheostomy tube
•It depends on the patient and the size of the tube
T/F If the patient doesn’t have a speaking valve, they occlude the tracheostomy tube (stoma) with thumb just like a laryngectomee occludes the stoma to speak.
True
Voice quality without the speaking valve may be more difficult to understand. What are some of the qualities that are impacted?
- Won’t be able to voice as long
- Won’t be able to be understood that well either
- Pitch, prosody, and duration will be affected
What are the types of tracheostomy tubes?
Single cannula, cuffed Single cannula, non-cuffed Double cannula, cuffed. Metal double cannula, non-cuffed Fenestrated, cuffed
What are the basic parts of single cannula, inflatable cuff tracheostomy tubes ?
oThey need to be tied in placed because they can come out with a good cough
oSingle layer of tube that goes down the patients layer of throat
oThe flanges are the tie spots where the tube is tied in place with
oCuff can be permanent, inflated
•It’s for sealing the air way
•The cuff is used to hold the tube in place
oThere’s a inflation line where it can be fluffed up
oObturator: extra piece to plug the tracheostomy tube
oSide port connector is used if you’re attached to a ventilator
double cannula, cuffed can be used for what type of patients?
For patients who have trouble with single canula
•You can use an inner canula and this is removed instead of the whole tube (aka double canula)
•For long periods of time so the tracheostomy does not need to be removed
What is an obturator?
is also called an introducer
oWhen you are placing the tube you’re going to have the introducer in it
oThe edge of it looks like a bullet so the canula places much gentler and easier instead of being placed along the sides
oProblem?
•You’re patient can’t breathe!
•Remind them they cant breath
Metal double cannula, non-cuffed are more likely to be placed in whom?
in laryngectomee’s
oIt’s metal so it’s more easily to be cleaned
oPlastics tend to be more colonized by bacteria and yeast
•It can be scrubbed, boiled, and left to soak in hydrogen peroxide
•This mechanism is designed for patients to take out and cleaned themselves
oThis is something that someone can have for a long time, keep it clean, put it in the stoma if they think it’s closing
T/F single cannula, non-cuffed can be used for speaking
True
What is a fenestrated cannula?
Trach tube that has a tube with a window in it
It imitates normal function without the tube
A fenestrated cannula may consist of what?
oSingle cannula oAn inner and outer canula oThere may be a cuff oThere may not be a cuff oBUT it will also have an obturator/introducer
If you place the inner cannula in a fenestrated tracheostomy tube it’s going to plug the fenestra. When it plugs what does that mean?
So an inner tracheostomy tube inside this outer canula is going to plug the window
So you could potentially use this as your speaking valve
Take out the inner canula, plug the tube, and your patient can speak just through this particular tracheostomy
What is the advantage of using a fenestrated tracheostomy tube?
fenestrated has openings in outer canula
- You could potentially use this as your speaking valve
- Take out the inner canula, plug the tube, and your patient can speak just through this particular tracheostomy
- Air from the lungs pass through the VF through the nose and mouth
SO potentially you can breath in and out normally
a fenestrated tracheostomy tube is used as a _______ before decannulation
as the final step before decannulation—because this tube can function with normal breathing in and out
•The patient can speak and cough
•It’s an experimental step before finally pulling the tracheal tube and closing up the stoma
oImitates normal function without the tube
What can you use the flow chart for?
decision tree for assessing voicing ability
T/F If it’s cuffed you do not need permission to deflate the cuff
False
What is the biggest thing to remember when downsizing the tracheostomy tube ?
- If a patient cannot phonate it may be better to downsize
* BUT if you have a smaller tube = smaller airway
What is Bronchoscopy?
oOne of the last things in assessing air way status
oAn examination of the inside of the trachea and the larger main stem bronchi
oHas the trachea stenosed? Are the bronchi stenosing?—Is the airway getting narrow?
oLook at the overall general condition of the trachea and the air passageways.
For swallowing the cannula needs to be centered in the airway. why?
It lessens the risk of aspiration and it helps to keep the tube from rubbing the airway which can lead to tracheal deterioration
What is tracheal deterioration?
When the walls of the trachea dissolve around the tracheostomy tube
T/F Most babies/children/adults have no problem eating with a tracheostomy tube in place
True
However, they may find it hard to swallow their own saliva or cough
When assessing the patient with swallowing difficulties what should you ask yourself?
oIs there leakage from the top? Out the tube?
oCould there be a tare between trach and esophagus
oSwallow eval to determine if they’re aspirating, because the larynx isn’t functioning correctly
IF your patient has a trach tube, and you find orange juice coming out of the trach tube you have to find determine if …..
- There is a tare in tracheal wall
- Is the trach tube centered
- Is the trach tube too big, or aspiration
When should you suction?
It’s a good idea to suction a baby before feeding so they have a clear airway
•You want the secretions to be gone because when you eat you secrete more
•Especially baby suction before hand so potentially you have a longer time after they eat before you need to suction them again
What is a big issue with any tracheostomy patient ?
oThese tubes affect the amount of secretions
oDehydrated snot production is susceptible to making a cork in their tracheostomy tube
What is decannulation?
The eventual goal is to remove the tracheostomy tube
What is the process like to remove the tube?
oCan use fenestrated tube as a midstep but typically it’s a process that should be
closely supervised in the hospital
Make sure the patient is strong enough so the pump works
What is WARD decanulation?
Over a number of days to make sure patient can maintain O2 stats
Starts with placement of a smaller trach tube
•Also when you place a smaller trach tube the stoma closes gradually around the tube
Once the smallest trach tube is placed they plug it for 24 hours
They will put an airtight dressing over this remaining stoma and make sure you’re breathing from nose and mouth
Once they decannulate they will still keep them for one or two days and make sure they’re breathing okay
T/F the stoma normally does not close on it’s own
False, it does but in the case that it does they’ll have a small surgery cutting off the healed tissue
