O13 Tracheotomy, Tracheostomy EXAM 3

Question 1

What is a tracheotomy?

Answer 1

Opening the trachea at any level/any point in order to create an airway.

Question 2

T/F: a tracheotomy is almost always an emergency procedure to open the airway.

Answer 2

True!

Question 3

What is the difference between a tracheotomy and tracheostomy?

Answer 3

A TRACHEOTOMY is a temporary emergency procedure to create an airway for someone who can’t breathe.

A TRACHEOSTOMY is a long-term option - cutting a flap off of the tracheal cartilage below the larynx and inserting a tube (the stoma will be closed at a later date unless it is a laryngectomy patient, in which case it is permanent).

Question 4

What are the two major criteria for deciding whether to do a tracheotomy or tracheostomy?

Answer 4

1. Pump failure - diaphragm or intercostal muscle failure.

• Flail chest: cibcage will get smaller upon muscle contraction of inhaling, so rather than air coming in, it goes out.
• Injury to brain, brainstem, or spinal cord at the cervical level; results in paralysis or paresis.

2. Blockage that won’t resolve quickly enough to maintain an airway.
   - Crushed larynx or stenosis of larynx
   - may require mechanical assistance to breathe until the pump or lungs can function correctly

Question 5

What is stenosis of the larynx?

Answer 5

Broken or swollen larynx - needs tracheostomy

Question 6

What is a ventilator and what is it used for?

Answer 6

It is a tube to maintain the airway that breathes for the patient, allowing more oxygen to get through the lungs, because you can raise the oxygen content of the air going into the lungs.
-Air pressure can also be raised.

Question 7

Where does the ventilator tube go?

Answer 7

It is pushed through the mouth, up through the vocal folds, and into the trachea.

Question 8

Having a ventilator placed between the vocal folds long-term is damaging to them as well as damaging to ________.

Answer 8

CN X - Vagus

Question 9

a) What is the maximum amount of time you want to a patient to use a ventilator for?
b) If needed longer than this amount of time, what should you consider doing?
c) What are some side-effects of being ventilated longer than this amount of time?

Answer 9

5-7 days

• If needed longer than 5-7 days, consider a tracheostomy.
• Can cause vocal fold edema (swelling) and dental abscesses, which can be fatal in a hospital-setting because the mouth is close to the brain.

Question 10

What are 4 indications that a tracheostomy is needed?

Answer 10

a) Length of time on ventilator
b) Difficulty mobilizing secretions
c) Airway trauma that won’t resolve quickly
d) Surgical indications

Question 11

Talk about why difficulty mobilizing secretions is an indication of needing a tracheostomy.

Answer 11

Because if you cannot clear the mucous that your body is constantly creating, it will build up and you will develop pneumonia.
A tracheostomy will allow the mucous to be cleared out easier through suctioning, etc…

Question 12

What are the 4 surgical indications of a tracheostomy being necessary?

Answer 12

1. Skull or dural surgeries (outermost layer of meninges)
2. Head and neck cancers causing:
   - Pressure on brainstem;
   - tumor interfering with the larynx or airway;
   - laryngectomy
3. TBI - tracheostomy instead of intubation
4. A patient who is going to start going downhill needs a tracheostomy BEFORE they become highly medically fragile and close to death.

Question 13

Managing secretions: what is suctioning?

Answer 13

Removal of secretions from the airway; keeping the airway patient (open)

Question 14

What do you need to remember when suctioning a patient?

Answer 14

1. Suctioning is not sterile but you must use a clean technique.
2. WASH YOUR HANDS BEFORE AND AFTER SUCTIONING!
3. Suctioning is not a painful or distressing procedure, so if your patient is in distress, you are sticking the suctioning tube farther than the canula/suction catheter and touching the trachea (ouch).

Question 15

T/F: suctioning can be performed outside of an acute setting (at home).

Answer 15

True

Question 16

Why do you need to be aware of the size of the suction catheter?

Answer 16

Because you need to not stick the suction catheter deeper than the length of the tube - you will poke them in the trachea.

Question 17

During suctioning, observe the secretions… Be aware of/watch out for:

Answer 17

o Be aware of what normal-looking mucous looks like

o Should be clear, runny, without many bubbles

o Yellow, thick snot is not healthy; GREEN is INFECTION – go to doctor!

o Note if you are having to suction more often than usual.

o Be aware of how it smells – should not have a smell

o Check sight, thickness, smell, and whether there is any blood.

Question 18

After looking at the fluid that you are suctioning, what do you need to do?

Answer 18

• Always chart what you do, saw, noticed, who you told, etc…
• Tell someone if the mucous is not healthy-looking, and then chart that you told someone (name the person you told, and give the time you told them).

Question 19

What are the equipment you need/may need before suctioning?

Answer 19

1. suction unit
2. suction catheters
3. suction unit connecting tubes
4. bowl or bottle of tap water to flush the suction tube

Question 20

What are the 10 instructions for suctioning?

Answer 20

**Prestep: Make sure you have EVERYTHING necessary! (previous card)

1. have a new suction catheter in case you need to suction in a hurry, and ensure that the pump is ready to use at all times.
2. Wash or gel your hands!
3. Turn on pump and check pressure to make sure pump works!
4. Gently inert catheter into tracheostomy tube (make sure your thumb is off of the catheter port)
5. Apply suction by covering the port with your thumb, and slowly withdraw the catheter (do not rotate or twirl catheter as you remove it)
6. Repeat if patient still needs suction - give patient time to catch breath between suctions
7. Disconnect the catheter from the tubing and dispose of it safely.
8. Clear tube by suctioning a small amount of water through it.
9. Discuss waste management with the ward staff - different arrangements may need to be made when patient is at home.
10. Attach a new catheter for next time.

Question 21

What does the side port on the catheter do?

Answer 21

Controls airflow

Question 22

Remember, don’t plug the tracheostomy tube while suctioning!! If so…

Answer 22

…your patient won’t be able to breathe!

Question 23

How is a patient’s suitability for a speaking valve determined?

Answer 23

The SLP evaluates this by judging the patient’s ability to maintain reasonable oxygen saturation levels in the blood.

Question 24

In the hospitals, why do we see tracheostomy patients?

Answer 24

Because they are having issues with speech or swallow! NOT simply because they have a tracheostomy.

Question 25

What is oxygenation?

Answer 25

refers to the levels of oxygen (O2) in the body (in the case of a speaking valve, it refers to the level of oxygen in a patient’s blood)

Question 26

What color is well-oxygenated blood? Oxygen depleted blood?

Answer 26

well oxygenated blood is red, and oxygen-deprived blood is bluish/dark-purplish

Question 27

What is the lowest benchmark for O2 stats?

Answer 27

95% is the lowest benchmark for O2 stats; below 95%, people start feeling bad.

Question 28

How do you measure oxygen saturation level?

Answer 28

From the finger-clips - the tips of the fingers should appear red

Question 29

T/F: If the patient can’t tolerate a speaking valve, he or she may still be able to achieve a voice because of air leaking around the tube.

Answer 29

True (although voicing will be stronger if they obturate/plug the tracheostomy with their thumb)

o The patient will not be able to voice for as long at a time
o Voice quality without a speaking valve is quieter because there is less air going around the tube
o The patient may be more difficult to understand BUT this is better than having them die from depleted blood-oxygen levels

Question 30

WHat do you need to consider/remember if the tracheostomy tube is really big?

Answer 30

the patient will not be able to get air around the tube and up to the vocal folds, and thus will not be able to speak (the tube needs to be small enough that it does not occlude the trachea – need to get air around the tube to talk)

Question 31

What are the five types of tracheostomy tubes discussed in class?

Answer 31

i. Single cannula, cuffed.
ii. Single cannula, non-cuffed.
iii. Double cannula, cuffed: used for longer-term
iv. Metal cannula, non-cuffed.
v. Fenestrated, cuffed - window

Question 32

What is the fenestrated cuffed tracheostomy tube used for?

Answer 32

Can be used as experimental final step before decannulaiton because this tube can function with normal breathing; patient can speak, cough, etc…

Question 33

What is a bronchoscopy?

Answer 33

An examination of the inside of the trachea and of the large air passages leading to the lungs.

Usually done as a way of assessing the degree of narrowing of the trachea and the overall general condition of the trachea and the air passageways.

Question 34

T/F: most babies, children, & adults have no problem eating with a tracheostomy tube in place.

Answer 34

True

However, some will have difficulty, finding it hard to swallow saliva, cough, and food or fluid can potentially come out of the tracheostomy tube

Question 35

If a patient does have trouble swallowing with a trach tube in, what are some possible reasons? What should you do to find out the reason?

Answer 35

Leakage or a tear between the trachea and esophagus (AKA tracheal deterioration)

Do a swallow study

Question 36

Why does the cannula need to be centered in the airway?

Answer 36

It lessens the risk of aspiration and helps to keep the tube from rubbing the airway, which can lead to tracheal deterioration (which will lead to aspiration)

Question 37

What should you NEVER do with a baby who has a tracheostomy?

Answer 37

Leave them alone with a bottle, because if the baby chokes, the tube can be plugged and the airway will close.

Question 38

Before feeding (adults or babies), what should you do?

Answer 38

Suction them so that the airway is as patent as possible.

Question 39

T/F: secretions decrease as we eat.

Answer 39

FALSE - secretions INCREASE as we eat! This is normal.

Question 40

Why is it important that the tracheostomy patient stays hydrated?

Answer 40

Dehydrated snot production is susceptible to plugging the tube

Question 41

What is decannulation?

Answer 41

The gradual process of removing the trach tube.

Question 42

What is the issue with decannulation?

Answer 42

Making sure the patient is maintaining oxygen (O2) stats

Question 43

T/F: decannulation must happen at the hospital, NOT at the patient’s home.

Answer 43

True - must be closely monitored

Question 44

Describe the process of decannulation.

Answer 44

1. Process starts with placement of a smaller trach tube.
2. The stoma will gradually close around the smaller tube.
3. Once the smallest possible trach tube is used, they will plug it for about 24 hours to see if the patient can breathe around it.
4. If the patient tolerates 24 hours of the tube being plugged with their oxygen stats remaining high, they will pull the tube.
5. The stoma hole will be covered with an airtight dressing (similar to saran-wrap)
6. After complete decannulation, the patient will be kept for 1-2 more days to make sure the patient can truly breathe without issue
7. May be a small surgery to cut the edges of the stoma and sew them together if the patient’s stoma does not close on its own.