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NT SKILLS UPDATE - ADULT TRACHEOSTOMY CARE

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WHAT IS IT?

Abstract

VOL: 99, ISSUE: 09, PAGE NO: 29

WHAT IS IT?
- A tracheostomy is a permanent or temporary stoma formed by a surgical procedure (tracheotomy). In theatre a transverse incision is made below the cricoid cartilage between the 2nd, 3rd and 4th tracheal rings and a tracheostomy tube is inserted to form an artificial airway. However, most trachestomies are made between the 2nd and 3rd rings at the bedside in intensive care.

INDICATIONS
- To bypass acute/chronic upper airway occlusion. - Poor respiratory function requiring reduced anatomical dead space (areas not involved in gaseous exchange) and artificial ventilation. - To remove/prevent retained tracheobronchial secretions. The tube is suctioned frequently to keep it free from tracheobronchial secretions using a suction catheter. The catheter is rotated and intermittent suction is applied for no more than 10 seconds. - To replace an endotracheal tube to enable weaning from a ventilator. - A mini-tracheostomy is sometimes formed for the removal of secretions.

TYPES OF TRACHEOSTOMY TUBE
- Adult tracheostomy tube size is about 7-9mm. Cuffed disposable tubes are for temporary use. - Longer-term tubes may be fenestrated and have outer and inner cannulae with a posterior hole. - Fenestration improves airflow over the vocal chords and ameliorates swallowing and speech. Valves can be fitted over long and short-term tracheostomies to aid speech.

RISKS
- Psychological implications (altered body image/communication issues). - Impaired ability to cough and discomfort when swallowing. - Dry, ulcerated oral mucosa. - High cuff pressures cause tracheal pressure sores and stenosis. - Air may leak at low cuff pressures. - Tube may become displaced. - Stoma may become excoriated, infected or may haemorrhage. - Ties holding the tube in place could cause pressure damage. - Suctioning at high pressures damages tracheal mucosa. - Infection could be introduced into the lungs. - Tenacious secretions cause airway obstruction. - Staff could become contaminated by respiratory pathogens.

NURSING CONSIDERATIONS
- The following emergency equipment should be kept to hand: two spare tracheostomy tubes (one the same size as the patient’s and a smaller size); tracheal dilators; suction and appropriately-sized suction catheters; 10ml syringe to inflate/deflate the cuff; scissors; gloves (sterile and disposable), aprons and goggles; fluid, in accordance with local policy, such as sterile water to flush suction tubing. - A calm manner reduces patient anxiety and assists psychological support. - Oral hygiene prevents mucosal damage. - Prescribe analgesia if appropriate. - Cuff pressures should be <25mmHg and checked using a manometer. - Warmed, humidified oxygen and balanced fluid intake prevents tenacious secretions and aids oxygen uptake. - Assess, clean and dress the stoma at each shift or on strikethrough. Take great care in the first 48 hours after formation to prevent haemorrhage. - One finger should be able to fit under a tube tie. Check this and ensure two nurses are present when replacing. - Suction pressures should not exceed 150mmHg (20kPa) with suction catheters half the diameter of the tracheostomy. - Familiarise yourself with local infection control policies.

EMERGENCIES
- In the event of cardiac arrest, leave the tube in place. Attach the ambu-bag directly to the tracheostomy tube. - If the tube is displaced or pulled out, get medical help quickly. Do not leave the patient. Encourage patients to continue breathing through their stoma. Use tracheal dilators to maintain the airway if necessary.

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