Tracheostomy Manual Flashcards
tracheostomy indications (5)
1) alleviate upper airway obstruction (e.g. tumor, foreign bodies, vocal cord paralysis, congenital a/w anomalies, OSA)
2) provide long term ventilation (failure to wean, SCI, neuromuscular weakness - Guillian-Barre syndrome, MS)
3) facilitate removal of secretions (paralysis/weakness of chest muscles or diaphragm, unconscious/semiconscious, severe bronchitis or pna)
4) protect airway (unconscious Pt, Pt at risk of aspirating, elective for major head or neck surgery)
5) improve Pt comfort and oral hygiene
List equipment required at bedside for tracheostomy (incl emergency equipment)
suction, bagger + mask + OPA, O2 and humidification system, emergency resp equipment bag: 2 cuffed trachs (one size same and smaller), obturator of trach tube insitu, tracheal dilator set, 10mL syringe, trach tube exchanger, sterile gloves, lubricating jelly, scissors), ties/securing devices, gauze, tweezers
There are 2 categories of trach complications. List 7 IMMEDIATE tracheostomy complications
hemorrhage (5% incidence); pneumothorax (0.9% incidence - mostly with children and COPD Pts) due to laceration of pleural apices; subq and mediastinal emphysema - due to laceration of pleural apices, excessive cervical dissection, accidental decannulation; resp + CV arrest - due to asphyxia, cardiac arrhythmias; false passage of tube/malposition; laceration of posterior trach wall, esophagus, arterial or venous injury; recurrent laryngeal nerve injury
there are 2 categories of trach complications. List 7 LATE trach complications
a/w obstruction - from tube migrating out of position or from dried secretions; infection - poor cleaning or suction; aspiration - impaired cough/gage reflex or inadequate seal between cuff and trachea; tracheal erosion; TE fistula; tracheo-innominate fistula - erosion through anterior tracheal wall into innominate artery is life threatening… resolve by replacing the trach tube with an ETT and finger pressure held against fistula + call CODE BLUE; tracheal stenosis, subglottic stenosis, tracheomalacia due to chronic mucosal ischemia, inflammation, repeated healing
4 areas most commonly affected by a/w trauma associated with intubation
- posteromedial portion of vocal cords
- posteromedial portion of arytenoids cartilage
- posterolateral portion of cricoid carilage
- tracheal rings 2 - 7
6 etiologies of laryngeal lesions/airway trauma from intubation
pressure necrosis, trauma during intubation, length of time of intubation, movement of tube, rxn of material of tube in some pts, excessive weight on the tube
symptoms of glottic edema and vocal cord inflammation
hoarseness, inspiratory stridor
treatment for inspiratory strior
nebulized epinephrine (5mL of 1:1000 solution) +/- steroid aerosolized to reduce inflammation
treatment to reduce edema development in Pts who had prolonged intubation or failed prior to extubation due to glottic edema
steroids IV 24 hours prior to extubation
6 laryngeal lesions (due to intubation)
glottic edema + vocal cord inflammation, laryngeal + vocal cord ulcerations, vocal cord polyps + granulomas, vocal cord paralysis, laryngeal web, laryngeal stenosis
describe the nature of laryngeal + vocal cord ulcerations and therapy if indicated
acute in nature, resolves spontaneously so not therapy indicated. occurs in 20 - 50% extubated Pts and can occur as soon as 7 hrs of intubation. symptom might be hoarseness.
describe the symptoms and nature of vocal cord polyps and granulomas + therapy if indicated
nature = due to healing of epithelium after ulceration takes few weeks.
symptoms = difficulty swallowing, hoarseness, stridor, resolves spontaneously.
long term may include dry cough, difficulty raising sputum, orthopnea, lower resp infections. therapy may be surgical intervention to remove granulomas.
describe symptoms + treatment for vocal cord paralysis
symptoms = stridor refractory to nebulized epinephrine treatment = if obstructive sypmtoms do not resolve and full movement not returned after few days, tracheostomy may be indicated
describe nature, symptoms and treatment for laryngeal web
result of necrotic fibrinous tissue incorporating cellular debris, develops over days/months and attaches to vocal folds and connects them
- symptom = stridor or abrupt total airway obstruction
- treatment = aspirating web with suction catheter if pliable or laryngoscopy
T/F tracheostomy tubes can cause laryngeal lesions
false; bc trach tubes bypass the larynx. Only ETTs from the oral or nasal passages can cause laryngeal lesions/airway trauma
List the tracheal lesions that can be caused by trach tubes or ETT tubes
tracheal granulomas, tracheomalacia, tracheal stenosis
etiology of tracheal granuloma
due to movement of the tube, occurs in trachea close to tip of trach tube
signs of possible tracheal damage prior to extubation
difficulty sealing trachea with cuff, tracheal dilation on CXR, difficulty expectorating (mild damage), dyspnea at rest (Severe damage), stridor, pulmonary function studies
compare PFT results of tracheal stenosis v. tracheomalacia v. vocal cord paralysis
tracheal stenosis = fixed obstructive pattern, flattened on both inspo and expo limbs of flow volume loop
tracheomalacia = variable intrathoracic upper a/w obstruction with expo affected
vocal cord paralysis = variable extrathoracic upper a/w obstruction with inspo affected
describe the phases of a cough
1) irritation - inflammatory/infxn, mechanical/foreign body aspiration, chemical/inhaling toxic gas, thermal/cold air provokes sensory fibers to send impulse to brain medullary cough center
2) inspiration - afferent impulse received, cough center generates reflex stimulation to initiate deep inspo 1 - 2L in adults
3) compression - reflex nerve impulses cause glottic closure + forceful contraction of expiratory muscles, 0.2 seconds long and causes rapid rise in pleural + alv pressures > 100mmHg
4) expulsion - glottis opens, large pressure gradient between alveoli + a/w opening = air expulsively flows with high velocity + shearing forces to displace mucous from airway walls
mechanisms that can impair irritation phase of cough reflex
anesthesia, CNS depression, narcotic-analgesics
mechanisms that can impair inspiration phase of cough reflex
neuromuscular dysfunction, pain, abdominal restriction, pulmonary restriction
mechanisms that can impair the compression phase of cough reflex
abdominal muscle weakness, abdominal surgery, artificial airway, laryngeal nerve damage
mechanisms that can impair the expulsion phase of cough reflex
airway compression, airway obstruction, inadequate lung recoil (e.g. emphysema), abdominal weakness
T/F aspiration is more likely to occur in spont breathing Pts than positive pressure ventilation
TRUE - bc negative pressures created during spont breathing can cause aspiration
T/F aspiration more likely using trach tubes vs. ETT tubes
true - due to anatomical considerations (maybe bc trach cuff sits lower/in wider part of the trachea than the ETT cuff?)
T/F absence of a gag reflex influences the risk of aspiration
false - absence of presence of gag reflex doesnt influence risk for aspiration
8 aspiration risk factors
poor oral hygiene, impaired LOC from sedation or illness, neurologic injury (brain injury, stroke, seizures), bolus feeds (vs. continuous feeds), use of OG or NG tubes, age > 60 y.o., GERD or vomiting, supine position
describe how to test for aspiration
- methylene blue dye added to food/water then ingested by Pt, if blue secretions obtained from tracheal suctioining, can indicate aspiration
- not recommended for large doses of feeding (i.e. tube feeding) due to adverse events + toxicity
- not sensitive for microaspirations; better used for macro aspiration detection
- Pt must be able to tolerate deflated cuff to do the test
- Modified barium swallow assessment used for micro-aspiration and performed under fluoroscopy
6 actions to minimize aspiration
subglottic suction (EVA OETT or portex suctionaid trach), regular oropharyngeal suctioning/mouth care, HOB at >/= 30 degrees, feeding tube placed in duodenum, maintain appropriate cuff inflation pressure, restore positive subglottic pressure
safe cuff pressure in mmHg and cmH2O
25 - 30 cmH2O, or 20 - 25mmHg
how to detect cuff leaks?
gradual decreasing cuff pressures over time = small cuff leak, gurgling over trachea with Pt on PPV = large cuff leak
how to resolve leaks at valve or in pilot line?
place needle and stopcock or pilot balloon repair kit in the pilot line distal to leak
site + reason of surgical trach vs. percutaneous trach vs. cricothyroidotomy
surgical trach (cut) = 2nd and 3rd tracheal rings; elective procedure in OR or bedside ICU percutaneous (needle + dilators) = 1st and 2nd tracheal rings; beside ICU with Pt sedated and fully monitored, NOT for emergency cricothyroidotomy = b/w thyroid and cricoid cartilage; emergency airway
benefits of using PMV
1) tracheostomy weaning (improves secretion clearance + use of upper airway)
2) swallowing/aspiration (opportunity to evaluate cuff deflation tolerance + work on swallowing technique)
3) secretion management (restores subglottic air pressure and flow through glottis = more effective cough)
4) verbal communication
5) olfaction (increased smell)
how to provide humidity with trach?
T-piece or trach mask; ensure PMV removed to prevent “gumming” of PMV
T/F HMEs can be used with PMV
false bc exhaled air goes through upper airway so HME will never saturate with exhaled warm air
tracheal vs laryngeal button
tracheal button is sealed and just keeps the stoma maintained in case a trach tube needs to be reinserted (Pt cant breathe through the button); laryngeal button has a hole and stents the laryngectomy stoma open (Pt still breathes through it)
describe cuff deflation trial
- requires order, usually done when Pt moves from ICU to wards and has been weaned off ventilator
- Pt should be on minimal FiO2 requirements <0.4
- stop feeds with NG tube 1 hr prior to cuff deflation
- assess Pt cough, gag, and strength
- after cuff deflation, wait 10 minutes to let Pt settle with air movement into upper airway, raise HOB 45 degrees and also suction to see consistency and colour of secretions
- if OK, leave cuff deflated for 1 hr and check back to see if increased secretions and if they are being suctioned or can cough it out
- aware of silent aspirators (may see change in oxygenation, change in consistency and amount of secretions)
- can order methylene blue for enteral feeds if questioning aspiration
3 mechanisms of trach tube impairing swallow
overinflation of cuff can compress esophagus and cause build up above this obstruction + spilling over into larynx/aspiration; tracheal mucosa damage + air diversion through the stoma decreases laryngeal sensation and swallow can be delayed; trach tube attached to strap muscles and skin of neck + inflated cuff limits laryngeal elevation = less closure of the epiglottis
2 reasons for swallow assessment
1) Pt is on enteral feeds and ready to begin eating
2) determine extent of silent aspiration
describe the swallow assessment
-done by OT or SLP; dye given in food and suction sees if they are aspirating or swallowing properly
-trach tube should be downsized from 8 to 6 if possible; better if it is a cuffless trach
-Pt needs to be alert, suctioned during and 0.5 - 2 hrs after test to check for absence of dye in sputum
-Pt needs to be able to sit up 45 degrees post assessment
-low FiO2 < 0.4
-RT assess amount + frequency of secretions and any changes w/ cuff deflated post swallow assessment
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describe plugging trials
- Pt needs to have cuffless tube + stable and tolerated >24-48hrs
- if Pt has no leak/no tolerance for cuff deflation = alert physician, downsize tube and repeat cuff deflation
- once Pt has proper tube to plug, ensure they can breathe comfortable around tube with RT’s finger plugging the inner cannula
- if stridor evident with plugging it could be from VC paralysis, granuloma, swelling or tube too large and needs to be downsized
- initial plugging trial 1 -4hrs, if tolerated continue for 12 hrs, if tolerated then continue plugging overnight
- if not tolerated, remove plug and try again following morning
- decannulation with physicians order is OK if Pt tolerates plugging at least 24-48 consecutive hours
describe decannulation
- only with order + once deflation and plugging trials passed
- Pt must effectively cough, clear secretions and ventilate prior to decannulation
- ensure no remaining sutures, clean + inspect stoma site, then cover with 4x4 gauze folded twice + 2 strips tape
- instruct Pt to cover stoma with fingers when speaking or coughing to help healing
- should close ~2 days (longer if on steroids)
- if difficulty coughing or clearing secretions post decannulation, use a DL trach tube reinserted for suctioning
9 common trach problems
1) obstruction of trach tube against tracheal wall
2) obstructed tube by secretions (mucus plug)
3) ruptured cuff
4) herniated cuff
5) tracheoesophageal fistula
6) Pt has thick neck tissue
7) tracheomalacia
8) tracheal stenosis
9) erosion of innominate artery
