Trach

Question 1

tracheotomy vs tracheostomy

Answer 1

Tracheotomy= A surgical incision into the trachea to create an airway
Tracheostomy = The tracheal opening from the tracheotomy

Question 2

are all trachs emergent? are all trachs permanent?

Answer 2

• Emergent (trauma) or Scheduled (laryngeal cancer)
• Temporary or permanent

Question 3

is there less or greater risk of pneumonia with a tracheal intubation when compared to oral intubation?

Answer 3

-less risk for pneumonia with trach vs oral intubation

Question 4

indications for trach

Answer 4

• 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

Question 5

preoperative care for trachs

Answer 5

• Education
◦ home management- do procedures/care as clean at home (sterile in hospital)
• Self management of airway
◦ Suctioning
• Pain control
◦ require less analgesics than endotracheal tube
◦ suctioning is most painful part !
• Critical care environment
• Nutrition support
• Feeding tubes
• Discharge plans
• Communication/speech- ask yes or no questions, picture board, write
• Include the multi-disciplinary team

Question 6

top concerns with trachs for nurses

Answer 6

-gas exchange
-communication
-nutrition
-infection

Question 7

how do we verify a trach placement after surgical placement?

Answer 7

xray

Question 8

top priority for post op trach?

Answer 8

maintain patent airway

Question 9

how do we know a trach patient has a patent airway after surgery?

Answer 9

◦ breathing is better (if look worse something is wrong!), looks more comfortable, normal depth
◦ clear breath sounds, some secretions that clear with suctioning
◦ O2 saturation normal

Question 10

what happens if trach becomes dislodged within first 72 hours post op of placement?

Answer 10

emergency! call a code

Question 11

complications from trach? top one?

Answer 11

-tube dislodgement
-pneumothorax
-bleeding
-infection
-tube obstruction**

Question 12

____ _____ is a sign of pneumothorax realted to trach placement

Answer 12

subcutaneous emphysema

Question 13

signs of tube obstruction

Answer 13

• Difficulty breathing
• Loud breathing
• Difficult to insert a suction catheter

Question 14

prevention for complications re: tube obstruction?

Answer 14

• Pulmonary Hygiene: mobility! - dangling
• Inner Cannula Care - changed , 1/shift
• Suction as needed- not routinely
• Humidified Oxygen

PISH

Question 15

how often do we suction trach?

Answer 15

as needed only!

Question 16

how often should the inner cannula be changed/cleaned?

Answer 16

changed 1/day , 1/shift

Question 17

what kind of oxygen do trachs need?

Answer 17

humidfied

Question 18

how do trach patients end up with a pneumothorax?

Answer 18

◦ Occurs as a result of tracheostomy placement if the provider inadvertently enters the chest cavity
‣ need chest tube to regulate pressure to pull the lung back to inflation
◦ Subcutaneous emphysema - sign of pneumothorax
‣ sounds like rice crispies

Question 19

signs of pneumothorax?

Answer 19

◦ Pain
◦ Unilateral breath sounds- absent breath sounds on side with pneumothorax
◦ Breathing problems

Question 20

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

Answer 20

B) There is a #9 XL Shiley tracheostomy tube on the bedside table with an obturator nearby.
◦ need one size smaller NOT bigger! + need obturator + suction set up + O2 + ambu bag

Question 21

cuffed vs non cuffed trach- whats the difference?

Answer 21

◦ cuffed = resp failure –> do not want any air escaping up
◦ non-cuffed = permanent trach, weaning

Question 22

this ind of trach has a little hole so people can talk when it is in

Answer 22

fenestrated

Question 23

concerns for trach cuff pressure?

Answer 23

can cause pressure ulcer in trach if too much pressure!

Question 24

trach cuff pressure should be < ____ - ____mmHG

Answer 24

‣ <14-20 mm Hg

Question 25

• 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

Answer 25

B) The patient with mucus in the artificial airway
C) The patient with noisy secretions
D) The restless patient with tachycardia and tachypnea

Question 26

suctioning complications?

Answer 26

• Hypoxia
• Pain
• Trauma/ Bleeding
• Vagal Stimulation
◦ Bradycardia
◦ Hypotension
◦ Dysrhythmias
• Infection
• Bronchospasm

Question 27

what do we do before and between suctioning passes?

Answer 27

give 100% o2! hyperoxygenate that fool

Question 28

max time suctioning down the trach hole

Answer 28

10 seconds

Question 29

sterile or clean technique for suctioning

Answer 29

sterile

Question 30

max # times you can go down with catheter?

Answer 30

3

Question 31

what do we do if vagal stimulation occurs when suctioning? what are the signs of vagal stimulation?

Answer 31

stop suctioning !!

◦  Bradycardia
◦  Hypotension
◦  Dysrhythmias

Question 32

in addition to pre oxygenating patient what else might we do before sucking snot out of their neck hole?

Answer 32

pre-medicate for pain!

Question 33

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 heartrate drops from 89 to 53 and the nurse reassures the patient that he is almost done
D) Suctions for about 10-15 seconds, only during withdrawal of the catheter

Answer 33

C) During suctioning, the patient’s heartrate drops from 89 to 53 and the nurse reassures the patient that he is almost done

Question 34

steps in weaning from a trach?

Answer 34

->Interdisciplinary process that should include the patient and family
• Deflate the cuff –> makes pt lungs have to work harder
• Change to an uncuffed tracheostomy tube
• Reduce size of tube
• Cap the tube (air moves through upper airway) –> never put cap over a cuffed tube!
• Tube can be removed after 24 hours of tolerating capped tube

Question 35

after tolerating the a capped trach for _____ hours the tube can be removed

Answer 35

24 hours

Question 36

which specialists/care team people might a someone with a trach need?

Answer 36

• Speech pathology
• Social Work