Week 2 - Tracheostomy Flashcards
What is in your upper airway?
- nose
- oral cavity
- pharynx
- larynx
what is the function of your upper airway?
- heat/ cool inspired oxygen to body temp
- filter
- humidify
- smell
- phonation
- passage for ventilation
What is included in your lower airway?
- larynx
- trachea
- bronchi
- bronchioles
- alveoli
what is the function of your lower airway?
conducting airway fir ventilation gas exchange
what are the different types of artificial airways?
- oropharyngeal
- nasopharyngeal
- endotracheal tube
- naso-endotracheal tube
can an RN insert an endotracheal or naso-endotracheal tube?
no unless additional (rural) education
what do you need to do after an artificial airway is inserted?
verify placement
how do you verify a placement of an artificial airway is inserted?
assess bilateral breath sounds and auscultate over stomach
define tracheostomy
- incision into the trachea
- creates stoma or through with airway is managed
where is a surgical tracheostomy performed?
- OR
- sometimes pt beside in ICU
what is a percutaneous tracheostomy?
tube introduced with use of scope with light source via needle and guidewire technique
when is a cricothyroidotomy done?
only performed in emergency situations
out of the different types of tracheostomys which is not preferred due to proximity of the vocal cords?
cricothyroidotomy
what are the benefits of a tracheostomy tube vs. endotracheal tube?
- lower risk of laryngeal/ oral injury
- shorter ventilator weaning time
- easier communication
- more comfortable
- easier to secure
- easier to do mouth care
- may start oral feeding sooner
What are the indications for a tracheostomy?
- bypass airway obstruction at or above level of larynx
- long term mechanical ventilation
- facilitate removal of secretions
- protect airway in pt at risk of aspiration
- vocal cord paralysis
- prevention of VAP
what does VAP stand for?
Ventilator Associated Pneumonia
what are the different complications of a tracheostomy?
- abnormal bleeding
- tube dislodgement
- obstructed tube/ mucous plug
- infection
- subcutaneous emphysema
- tracheostomy-esophagel fistula
- tracheal stenosis
- tracheal dilation
in regards to the different complications of a tracheostomy, what causes tube dislodgement?
- to much suctioning
- trach not tied in place properly
- excessive manipulation
in regards to the different complications of a tracheostomy, what causes trachea-esophageal fistula?
- to high cuff pressure
in regards to the different complications of a tracheostomy, what causes tracheal dilation?
long term use of cuffed trach
what is the purpose of the balloon on a cuffed trach?
isolate the lower airway from the upper airway
when a cuffed trach is placed with initial surgery what does it provide?
- stable airway until trach is established
- pt is weaned off ventilator and able to control secretions
why do most cuffed trachs have “barrel” shaped high volume low-pressure cuffs?
minimize pressure on the tracheal mucosa/ complications that occur with pressure necrosis
what does a cuffed trach help prevent?
apsiration
When is a cuff less trach used?
- once patient can protect airway from aspiration
- no longer requires mechanical ventilation (except for long term ventilated patients)
what can a cuff less trach allow the patient to do?
speak if enough air passes above the tracheostomy tube through the vocal cords
what can a cuff less trach facilitate ?
oral feeding when compared to cuffed tubes while still providing access for suctioning
what can a cuff less trach be?
plugged (corked) periodically if pt doesn’t require ventilation/ have upper airway obstruction
can a cuff less trach be used for long or short term ?
long term
if a cuffless trach is used long term what does this decrease the chance of?
less chance of causing trans-tracheal damage
what are the advantages of a cuff less trach?
- more comfortable for pt
- may facilitate speaking/ eating
- progression towards decannnulation
what are the disadvantages of a cuff less trach?
- doesn’t provide protection against aspiration
- cannot provide adequate ventilation in code blue or with surgery
- may dilute O2 received through trach mask or T piece
- increases air leak
what are the different parts of a tracheostomy?
- outer cannula
- inner cannula
- obturator
- tracheal plug
- flag/ face plate
- pilot line/ cuff inflation line
- pilot valve
- pilot balloon
- trach cuff
what is the purpose of the outer cannula for a tracheostomy?
maintains patency of stoma
what can the outer cannula be?
fenestrated
what is the purpose of the outer cannula being fenestrated?
allows air into larynx and facilitate speech
if the outer cannula is fenestrated what does the tracheostomy require in order to be suctioned?
requires non-fenestrated inner cannula
what is the definition of the inner cannula?
removable tube which secures inside the outer cannula
the inner cannula can be what?
- disposable
- reusable
- high or low profile
- fenestrated
what does the inner cannula provide for the tracheostomy?
- protects patency of trach tube with proper cleaning
- can be removed to restore patent airway
- safety purposes
what is the purpose of the obturator?
reduce trauma during tracheostomy tube insertion
describe an obturator
- blunt tip
- fits inside outer cannula
- rounded tip
- kept as part of emergency kit
When is the obturator removed?
immediately after tracheostomy tube insertion
what is the purpose of a tracheal plug?
occludes tracheostomy tube to redirect air around instead of through tracheostomy tube for weaning
What are the different forms of a tracheal plug?
- sealed inner cannula
- cap
- separate plug
what is the purpose of a flange/ face plate?
stabilizes trach tube by preventing outer cannula from descending further into trach
what does the flange/ face plate allow/ have?
- place for ties/ sutures to attach
- trach tubę specs written on it
- may have locking indicator
what do some flange/ face plates have?
adjustable flanges
what is included in the trach tube specs?
- tube code
- type
- size
what is the purpose of the pilot line/ cuff inflation line?
connects pilot balloon to cuff
what is the purpose of the pilot valve? What does it have?
- spring loaded
- keeps air from leaning out of balloon/ cuff
- spring needs to be depressed in order to add/ remove air from cuff
what is the purpose of the pilot balloon?
- external balloon connect to cuff via pilot line
- indicates whether cuff is inflated/ deflated
where is the balloon located in a trach cuff?
at the distal end of the tube
what does the trach cuff provide?
- seal between tube and tracheal wall when inflated
- protects against aspiration
What is included in emergency airway equipement?
- ambu bag
- mask
- oral airway
- non-disposable inner cannula
- if pt has cuffless, plugged tube in situ
what is included in emergency airway supplies?
- cuffed tracheostomy tube
- trach dilator set
- 10cc syringe
- trach tubę exchanger
- 1 pack water-soluble lube
- obturator
in the emergency trach airway supplies what size(s) are included for cuffed trach tubes?
same size and one size smaller
if a pt is unstable and has to go to an appointment does the primary RN have to go with them?
yes, unless pt stable and doctor has ordered it’s okay not to go with them
define atelectasis
complete or partial collapse of the entire lung or lobe of lung
what is the purpose of suctioning?
- maintain airway patency
- promote optimal gas exchange
- decrease chance of infection through retained secretions
when should you suction a patients trach?
prn basis when indicated
who can perform suctioning a trach?
- RT
- RN
after a tracheostomy is surgically put in place, what must be at the pts bedside at all times?
emergency supply kit
after a trach has been surgically inserted what must you monitor?
VS per hospital standards
after a trach has been surgically inserted what must you assess?
- sedative use
- shock
- hemorrhage
- resp insufficiency
- complications related to surgical/ medical condition
what can sedative use cause?
respiratory depression
what do you need to assess when looking at secretions?
- amount
- colour
- consistency
what should be applied to a fresh tracheostomy after surgery? why?
- humidified air/ oxygen
- loosens secretions/ prevent mucous plugging/ infection
what must you maintain after a pt has a fresh tracheostomy surgically implanted? why?
- hydration
- help thin secretions
why should you frequently change the pts position post trach insertion?
- increase motility of secretions
- prevent atelectasis
will a pt be able to speak right after a trach is surgically implanted?
no
what should be within easy reach of the pt post tracheostomy insertion? what should the pt be taught about this?
- call bell > instruct pt how to pull bell out of wall if they can’t breath
- writing board
- pens/ paper
why should you check the patency and cleanliness of the inner cannula regularly after a pt has a tracheostomy inserted
to avoid airway obstuctions
how often should the inner cannula of a tracheostomy be changed/ cleaned after being surgically inserted? Who does this?
- Q12H
- may require more frequent checks with thick secretions
- done by RT or RN
what are some indications for suctioning a trach?
- rattling/ gurgling resp sounds
- ineffective cough
- visible secretions
- change in resp status
- dyspnea/ restlessness
- irregular breathing pattern
- accessory muscle use
- pale/ dusky color/ clammy
- may be requested by pt, physio or swallowing assessments
what are rattling, gurgling respiratory sounds indicative of?
secretions in or bellow the tracheostomy tube?
what could cause an ineffective cough?
- muscle weakness
- decreased LOC
- thick secretions
if a pt is pale or dusky color and clammy and they have a trach what is this indicating?
poor perfusion/ oxygenation potentially due to decreased respiratory efficiency
what is included in tracheostomy suction supplies?
- suction source
- container
- suction tubing
- non-sterile gloves
- sterile gloves
- sterile suction catheters
- sterile disposable bowls for saline
- normal saline/ sterile water
- PPE
what do you need to include in your documentation about sputum?
- purulent
- mucoid
- bloody
- frothy
- amount
when documenting about sputum what do you need to include about purulent?
- consistent with infection
- may be yellow, green, gown in color
when documenting about sputum what could bloody sputum look like?
- frank blood
- serosanginous in appearance
what does it mean if someone has frothy sputum what is this consistent with?
pulmonary edema and has pinkish tinge
what are some possible complications of suctioning?
- tracheal mucosal damage
- hypoxia
- dysrhythmia
- lung collapse
- infections
- bronchospasm
- low blood pressure
- increased ICP pressure
- intra abdominal pressure
- intrathoracic pressure
in regards to complications that occur with suctioning what causes tracheal mucosal damage?
vigorous deep and prolonged suctioning at excessive pressures
in regards to complications that occur with suctioning what causes hypoxia?
secondary to oxygen desaturation
in regards to complications that occur with suctioning what causes dysrhythmias?
- lack of O2
- stimulation of vagus nerve from tracheal irritation
in regards to complications that occur with suctioning what causes lung collapse?
excessive suction pressure
in regards to complications that occur with suctioning what causes infection
airway contamination
in regards to complications that occur with suctioning what causes low blood pressure
vagal stimulation
in regards to complications that occur with suctioning what causes increased ICP, intra abdominal and intrathoracic pressures?
- generated with coughing
- stimulation or instillation of saline
- installation of topical anesthetic
how do you provide care for a tracheostomy stoma?
- keep tube free of secretions
- keep stoma free of infection
- check inner cannula patency with every dressing change prn
how often do you need to change an inner cannula?
minimum Q24Hrs
how often do you need to complete dressing changes and tracheostomy care?
at least twice daily (q12hr) and/ or prn
how often do you need to change/ readjust trach ties?
when needed
how can you secure tracheostomy tubes?
with sutures or ties
when do you need to change or adjust tracheostomy ties? How tight should they be?
- become to tight
- become to loose
- snug but not to tight allow 1 or 2 fingers to fit between the ties/ pt neck
what do you need to always make sure of prior to letting go of the flange when changing ties for a trach?
new ties are secured prior to removing old ties
why do you need to be aware of the location of the pilot balloon if present when securing a tracheostomy ?
to prevent inadvertent cutting of the line when cutting the ties
how long can weaning a person off of a tracheostomy take?
anywhere from a few days to several months
what is the ultimate goal of weaning weaning someone off of a tracheostomy?
decantation and their own airway maintenance
when would a cuffed tracheostomy tube be used rather than an uncuffed?
- aspiration risk
- difficulty coughing independently
- provides tight seal
- use immediately after insertion of trach
