Exam 1: Tracheostomy Flashcards
What is a tracheotomy?
The surgical procedure of making an incision into the trachea to create an airway
What is a tracheostomy?
The tracheal opening from the tracheotomy
Name some indications for needing a tracheostomy (9):
- Acute Respiratory Failure/expected needs for prolonged mechanical ventilation
- Copious secretions/airway protection
- Laryngeal trauma
- Facial trauma
- Prolonged unconsciousness
- Acute airway obstruction
- Head/neck surgery with airway involvement
- Paralysis
- Inability to be weaned from mechanical ventilator
Talk me through the steps of the surgery/procedure of placing a trach:
- Neck is extended and an endo-tracheal tube is placed by provider to maintain airway
- Incisions are made through the neck and trachea rings to enter the trachea
- ET tube is removed at the same time the tracheostomy tube is inserted
- Tracheostomy tube is secured in place
- Chest x-ray to verify placement
What is the main focus of trach post-operative care?
Focus is on maintaining patent airway
Name some complications for which we are assessing after a trach is placed?
- Tube obstruction
- Tube dislodgement: W/in 72 hours → emergency
- Pneumothorax
- Subcutaneous emphysema
- Bleeding
- Infection
What are two common things that cause tube obstruction?
Secretions or cuff displacement
What are 3 things you might notice that would indicate a tube obstruction?
- Difficulty breathing
- Loud breathing
- Difficultly inserting a suction catheter
What are 4 actions we could take to help PREVENT a tube obstruction?
- Pulmonary hygiene
- Inner cannula care
- Suction as needed
- Humidified oxygen
You get report on your patient at the bedside from the day nurse. Your patient has a #8 XL Shiley tracheostomy tube, which was placed two days ago. The day nurse tells you she just did tracheostomy care about an hour ago, and other than a scant amount of serosanginous drainage, everything looks great. The CRNA had a difficult time placing the patient’s airway, so the patient has a “Difficult Airway” sign hanging above his bed. As you scan the patient and the room, what observation would you be most concerned about:
A) The patient’s tracheostomy is only secured with ties, not sutures
B) There is a #9 XL Shiley tracheostomy tube on the bedside table with an obturator nearby.
C) There are no suction catheter kits in the room
D) The patient has audibly rhonchorous breath sounds and is coughing
B) There is a #9 XL Shiley tracheostomy tube on the bedside table with an obturator nearby.
What needs to be by the bedside always with a trach?
Potential SATA er Messer!
O2, suction, correct size tubes
(were there more things?)
What do we can when air pushes down on the lung, allowing no gas exchange?
Pneumothorax
Why can this be a complication of a trach placement?
Occurs as a result of tracheostomy placement if the provider inadvertently enters the chest cavity
How do we fix a pneumothorax (well, not US per say, but what will SOMEONE do? Someone like Matt.)
CHEST TUBE –> Recreates the negative pressure
What are 4 things you might note on assessment if that could lead you to believe there might be a pneumothorax?
- Subcutaneous emphysema (get chest x-ray if find this)
- Pain
- Unilateral breath sounds
- Breathing problems (absent breath sounds)
Tell us about some different kinds of trach tubes you might see?
- Disposable or nondisposable
- Plastic or metal
- Cuffed or uncuffed
- Inner cannula
- Fenestrated (don’t see this as much anymore)
What is a big injury we are concerned for with trachs?
Pressure ulcers –> Tissue damage
What is the best way to help prevent pressure ulcers?
Monitor cuff pressure
Also: Good nutritional status and steroid use
Cuff pressure should be below _______ mm Hg on the anemometer?
<14-20 mm Hg
Two other tools we can use to make someone with a trach more comfortable?
Suction and warm, humidified air
Which patients with a tracheostomy need to be suctioned?
A) Everyone with a tracheostomy should be suctioned routinely
B) The patient with mucus in the artificial airway
C) The patient with noisy secretions
D) The restless patient with tachycardia and tachypnea
Have them cough first!
B, C, D
We only suction patients when?
When they need it, silly!
Name 5 complications that can occur as a result of suctioning:
- Hypoxia
- Pain
- Trauma/ Bleeding
- Vagal stimulation → STOP if this happens
- Infection
- Bronchospasm
You have just finished one pass at suctioning your patient’s trach tube. You note bradycardia, hypotension, and dysrhythmias. What is possibly happening?
Vagal stimulation → STOP
How often should you suction each time? And how long (seconds)?
Suction for 15 seconds/3 times at most
Name a bunch of things that can help prevent complications with suctioning (9):
- Hyperoxygenate
- Catheter size
- Avoid prolonged suctioning
- Lubricate the catheter
- Limit suction time
- Sterile technique
- Monitor for dysrhythmias –> Stop if vagal stimulation occurs
- Pre-medicate for pain (but Messer doesn’t)
- Talk your patient through suctioning
You are observing your preceptor perform tracheostomy suctioning. You become concerned when he
A) Tells the patient that he is going to perform tracheostomy suctioning, letting the patient know that it may be painful and may cause coughing
B) Uses a sterile kit, remaining sterile through the entire process of suctioning
C) During suctioning, the patient’s heart rate drops from 89 to 53 and the nurse reassures the patient that he is almost done
E) Suctions for about 10-15 seconds, only during withdrawal of the catheter
C) During suctioning, the patient’s heart rate drops from 89 to 53 and the nurse reassures the patient that he is almost done
He needs to wrap it up NOW.
How often do we perform tracheostomy care during the first 24 hours?
- Hourly for the first 24 hours
–> Lots of bleeding happens, make sure it doesn’t “plug off” (nothing is moving through it – mucus plug or blood clot)
How often do we perform tracheostomy care after the first 24 hours?
Per institution policy but often once per shift
What does performing trach care look like (specifically working with the trach itself) (4)?
- Change dressing and clean site
- Replace/clean inner cannula
- Change ties as needed
- Only remove old ties after new ties are secured
What does performing trach care look like (specifically working with the patient, family, etc) (6)?
- Pulmonary hygiene
- Oral hygiene
- Assess oral mucosa for breakdown
- Aspiration precautions
- Facilitate communication
- Address psychosocial issues
How does one go about a trach collar trial?
- Deflate the cuff
- Makes people have to work harder! If they can do this, great!
- Change to an uncuffed tracheostomy tube
- Reduce size of tube
- Cap the tube (air moves through upper airway)
- Tube can be removed after 24 hours of tolerating capped tube
Which respiratory disease can be hard to wean?
COPD
What things do we need to ensure before sending a patient home with a tracheostomy?
- The patient can perform self-care or has resources they need for living at home (family assistance, home health care)
- Follow-up visits
- Equipment for home
- Support groups
What are some interdisciplinary teams needed to coordinate when sending a patient home with a tracheostomy?
- Speech pathology
- Social work
