Tracheostomy Flashcards
What information does the flange of a TT provide
type & size of inner cannula
how to tell if TT is cuffed or cuffless?
pilot balloon
when is uncuffed TT used?
pt doesn’t need mechanical ventilation
When is cuffed TT used
pt on mechanical ventilation
–>cuff helps to prevent aspiration
what is the purpose of fenestrated tube
phonation
–>air goes via the tube will pass through the holes and travel to the larynx
INDICATIONS FOR TRACHEOSTOMY?
- Prolonged intubation
- -> put less pressure on larynx
- ->increase comfort - Facilitation of ventilation support
- ->helps with weaning - Inability of patient to manage secretions
- Upper airway obstruction
- Inability to intubate
- Adjunct to major head and neck surgery
- Adjunct to management of major head and neck trauma
What is the Advantages of TRACHEOSTOMY
Reduced laryngeal ulceration Improved nutrition, mobility and speech Improved patient comfort Faster wean, esp. those with COPD
What is the Disadvantages
- more expansive
- ->especially when its a surgery that requires OR
- ->the percutaneous one that is done in the ICU is cheaper - Stomal complications
- Fistula formation
What is the early complication of TT?
Hemorrhage -->nick artery or vein when putting in TT Infection Subcutaneous emphysema Tube obstruction
What is the late complication of TT
- Swallowing complications
- Tracheal stenosis
- Tracheo innominate artery fistula
- Tracheoesophageal
- fistula
- Granuloma
- Persistent stoma
What are the 2 Tracheostomy Methods
Surgical tracheostomy
- permanent or temporary and is performed in OR
- incision made between the second and third
tracheal rings 4 5 cm in length.
Percutaneous Tracheostomy
- temporary and is performed in the ICU etc.
- a small hole between the first and second or
second and third tracheal rings is created then
dilated using specialised equipment.
- site heals quickly, with less scarring and wound
infection
What are needed to be monitored before during and after tracheostomy?
- vital signs
- auscultation
- ABG
- ventilator parameters
- cough effort
- ICP
- Sputum
What is the Complications of surgery?
- Irritation of respiratory tract
- Vaso vagal reflex response
- Cardiac arrhythmia
- Infection
What are the Daily
trach care
i. Cuff pressures
ii. Suctioning
iii. Inner cannula cleaning
iv. Stoma care/cleaning
v. Changing trach ties
vi. Changing trach dressings
how often do we measure cuff pressure
every shift
What is the TT cuff pressure?
20 - 25 mmhg at the peak inspiration
What is the purpose of maintaining the cuff pressure at 20 - 25mmhg?
- too low can lead to aspiration
2. too high may cause ischemia and stenosis
What are the 2 cuff inflation technique?
- minimal leak
2. minimal occlusive volume
How is the MLT performed?
The MLT involves air inflation of the tube cuff until any leak stops; then, a small amount of air is removed slowly until a small leak is heard on inspiration.
**–> can lead to aspiration
How is the minimal occlusive volume performed?
The MOV consists of injection of air into the cuff until no leak is heard, then withdrawal of the air until a small leak is heard on inspiration, and then addition of more air until no leak is heard on inspiration
How is suctioning performed
- insert catheter with proper distance into the trach tube
- ->length of the TT plus 1/4inch
2.Apply suction via putting thumb over the hole in the catheter while pulling out the catheter
What is the purpose of trach care
remove secretion otherwise it obstructs airflow
What are the signs of secretion and indication of trach care?
chest assessment
- ->coarse crackles on expiration
- ->dull percussion
- ->adventitious breath sounds
Inspection/vital
–>increase WOB
Ventilator
- ->increase pressure as inner cannula get clogged
- ->change in waveform
- ->mainstream Co2 increase
ABG
–>deterioration of ABG
What equipment is needed for trach stoma care
Sterile powder-free gloves
Dressing pack
Sterile Normal saline 0.9% and distilled water
Pre-cut keyhole dressing
Hydrogen proxide
Tracheostomy tube holder
Orange clinical waste bag (bioharzard)
Appropriate goggles and mask (droplet PPE)
Emergency equipment
Spare smaller size trach tube
how often is stoma dressing changed??
PRN
how often should stoma be cleaned?
daily with normal saline
How to tighten ties correctly
One to two fingers
should fit between
the pt’s neck and
the ties
What is the possible outcome if the TT ties are too loose?
Ventilator circuit can pull out the TT
–> causing accidental decannulation
What are 3 types of humidification use for TT?
Heated humidity
–> 37 - 40 degree
Cool humidity
–> delivery of 50% of relative humidity at ambient temperature
HME
–>make sure no water gets accumlated inside the tubing
how to deal with Patient able to speak & shouldn’t ?
Cuff is either partially inflated or not inflated at all
-air is able to travel via patient larynx
- ->fenestration is left open
- ->pilot line is broken
- ->trach tube is too small
How to deal with accidental decannulation?
caused by loose tie
–>tighten the tie otherwise ventilator circuit can dislodge the tube
What cause and how to deal with difficulty in removing and re inserting inner cannula?
caused by dried secretion around stoma, thus creating friction, make TT hard to pull out
–> clear the skin surrounding the stoma
What cause difficulty in inserting suction catheter?
- granuloma
- mucus plug
- wrong size of suction catheter
What causes high pressure alarms
mainly tube obstruction
What causes low pressure alarm
accidental decannulation or circuit disconnection
What are the causes of tube obstruction?
- Kink
- Herniation
- Obstruction by tissue
- Obstruction by secreations
What is the problem of kinking of TT
–> suction catheter cannot pass through
What is the problem of herniation?
when old trach tube with low elasticity is overinflated, the cuff might fold on itself, obstructing the bottom of the TT
What are the 4 ways to check for tube patency?
- pass suction catheter through trach tube to measure the length that is or isn’t blocked
- check the inner cannula
- squeezes BVM to assess patient compliance and resistances
- auscultate to listen for abnormal breath sounds at the apices of lung (crackles, wheezing)
How can TT position affect the passage of suction catheter ?
- TT sitting up the tracheal wall
- ->reposition the flange - Cuff herniation
- ->deflate the cuff and pass the catheter through
- ->if it passes, reinflate the cuff to reassess herniation
- ->if it doesnt pass , code blue, prepare for a new TT
What are the indication for tube changes
- around a month or as indicatied by the manufacturere or as needed
- evidence of obstruction and cannot resolve obstruction
- infection around stoma site
- downsizing of part of weaning process
- -> a new type of TT is needed
- ->a smaller tube of the same type of TT is needed - when its soiled
- malfunction
- ->cuff is herniated
What are the processing of changing trach tube
- assemble equipment
- explain to patient and get consent!
- Prepare equipment
- lay out supplies using sterile technique
- check cuff of trach tube - Prepare patient
- put pillow other patient shoulder to flatten patient - Remove old
- ->inspect stoma and clean - Insert new
- Secure tube
- ->check Co2 with Etco2 with BVM
- ->auscultate to confirm placement
- ->put new dressing on - Reassess patient
How to insert the tube when performing trach change
place tube with
obturator to prevent
injury to tracheal
tissue
What causes speaking with a trach tube?
- cuff deflation
- Fenestrated tracheostomy tubes with a 1) fenestrated TT
- Smaller tracheostomy tube
- One-way speaking valves
- Intermittent finger occlusion
What are 2 types of Tracheostomy Speaking Valves?
Passy-Muir: non vented
Passy-Muir: ventilated
how does the passy muir work
Attaches with 15mm connector
Valve opens on inspiration to allow air into lungs
Valve closes on exhalation and redirects flow into
trachea and up through vocal cords to permit speech
What is the advantages of speak valve?
Eliminates need for finger occlusion to talk
allow for phonation
Restores intrinsic PEEP
Improves swallow
What kind of TT can speaking valve not used with?
A speaking valve must never be placed
on the 15mm connector of a nonfenestrated tube when the cuff is
inflated as the patient will not be able to
exhale.
What kind of TT can speaking valve used with?
on a uncuffed TT with or without fenestration OR
on a cuffed tube with fenestration
What are the contraindication to speaking valve
Inability to tolerate cuff deflation --> high risk of aspiration Airway obstruction Unstable medical/pulmonary status Laryngectomy -->patient can only exhale with the LT Severe anxiety/cognitive dysfunction Severe tracheal/laryngeal stenosis -->patient wont be able to exhale as airway becomes more narrow End stage pulmonary disease Excessive secretions -->aspiration
How does a Speaking Trach Tube work?
requires secondary gas source pt uses thumb port control to permit gas to flow out a special port above the cuff and up through vocal cords for speech patient can speak during inspiration and exhalation
what is a cork and how does it work?
a plug in the proximal end of trach tube
Patient must now inhale and exhale
entirely through upper airway
What equipment is needed for changing trach tube?
- difficult airway cart
- intubation kit
- smaller TT
- trach change box
- towel or pillow
- PPE
- BVM
- suctioning
- ->suction catheter and yankeur
Where to suction when performing a trach change
- inside the tube
- suction via the subglottic drainage port
- if TT doesn’t has subglottic drainage port, need yankeur to suction above cuff
What are the progression of weaning?
- cuffed
- Cuffed fenestrated
- cuffless
- ->passy muir
- ->cork - Cuffless fenestrated
how does downsizing work for weaning?
allow more surface area for patient to breath via the upper airway
how does corking help with weaning?
- cuff is deflated with corking
- patient has to breath via the upper airway
What are the criteria for decannulation?
- downsized to smaller tube and/or change to cuffless trach tube to encourage more use of upper airway
- successful corking trials (may require
intermediate step by using one way speaking valve)
What is the outcome of speaking valve in place?
- allow for phonation
- patient can work on their inspiratory muscle
- restores intrinsic Peep
- phonation
- helps with coughing and swallon because larynx can close tightly
where is speaking value must not be placed?
A speaking valve must never be placed on the 15mm connector of a non fenestrated tube when the cuff is inflated as the patient will not be able to exhale.
What is the precauton of corking?
making sure the cuff is deflated or cuffless
What type of O2 therapy can i use for speaking valve?
high flow trach mask
O2 adjuncts: low flow O2 that enrich the speaking valve
What type of O2 therapy can i use for cork
- face mask
2. nasal prong
What are the Patient assessment prior to
decannulation
- Resolution of condition
- Adequate LOC
- Effective cough
- Able to manage secretions
- Adequate oxygenation
- ->patient shouldn;t need a fio2 of 50 or 60 percent as that means their saturation isn’t optimized for decannulation
- Swallow intact
- Able to tolerate trach tube occlusion
What are the steps of deccannulation?
- Mechanical ventilation no longer required
2. Tolerate tracheostomy tube occlusion
What is the step of patient dont Tolerate tracheostomy tube occlusion
Fiberoptic airway management; complex airway management
What is the step after Fiberoptic airway management; complex airway management?
check airway patency reestablishment
If yes–> decannulation
If no –> long term trach tube
How does TT prevent swollening?
Tracheostomy tube prevents normal upward movement of the larynx during swallowing and hinders glottic closure
–> lead to aspiration
How to facilitate effective feeding with TT?
Keep head elevated to 45 during periods of
tube feeding
What are the Speech language pathologist
assessments?
- evaluation of swallow and airway
protective mechanisms - Blue Dye Test
how does the blue dye test work?
- patient swallow a
teaspoon of blue dyed
fluid/paste
2.then observe for risk signs
What are the risk signs that patient larynx doesnt close tightly?
- blue dye is found in trach suctioning
- significant decrease in O2 sat levels
- immediate or delayed coughing
What is the action if there are risk signs ?
need to reinflate the cuff because larynx isn’t completely closed, thus there is still risk of aspiration
What are some disadvantages of jackson tube
jackson has no 15 mm connector
cannot attach a BVM to it
cannot do MRI
What is the purpose of foam TT?
Prevents damage to tracheal mucosa if long term ventilation
What is removed in laryngectomy?
pharynx
larynx
what is the purpose of montogomery T-tube
a discrete device to keep tracheal open in case of tracheal stenosis
What is a tracheal button?
- it maintains airway patency
- fit from skin to just inside the anterior wall of the tracheal
what is the purpose of a tracheal button?
- used last step in the weaning process
- has an outer plug that can completely close off the “button” airway and allow you to breathe, talk and cough normally via the upper respiratory trach
goal: keep button plugged at all times or as long as possible
