Learn all about managing a trach to protect your patient from complications.

By Elizabeth Neville Regan, RN, MSN, and Lisa Dallachiesa, RN, BS A TRACHEOSTOMY IS an opening in the anterior wall of the trachea 2.0 ANCC inferior to the cricoid CONTACT HOURS cartilage. Made surgically or percutaneously, it provides tracheal access for airway management via a temporary or permanent tracheostomy tube. Patients with tracheostomies arent limited to critical care settings and can be found in all nursing units. No matter where you work, you need a basic understanding of the nursing care required for these patients. In this article, well provide a practical overview. When is a tracheostomy indicated? A tracheostomy can be used to bypass an acute or chronic upper airway obstruction, allow removal of tracheobronchial secretions, and prevent aspiration of oral or gastric secretions in unresponsive patients. For patients with chronic respiratory failure, it may be performed to replace an endotracheal (ET) tube and facilitate longterm mechanical ventilation.1 Upper airway obstruction can result from conditions such as tumors, inflammation, fracture, foreign bodies, or laryngeal spasm. Patients with prolonged unresponsiveness secondary to such conditions as drug intoxication or traumatic brain injury may need a tracheostomy to maintain a patent airway. In addition, patients needing an ET tube for 10 to 14 days or longer should be considered possible candidates for a tracheostomy.2 The most recent American College of Chest Physicians consensus statement recommending a specific time frame for conversion to tracheostomy was published in 1989. These guidelines recommended the translaryngeal route (ET tube) if the need for an artificial airway is

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MEDICAL RF/PHOTOTAKE

tomy
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anticipated to be no longer than 10 days, and favored tracheostomy if an artificial airway is anticipated for longer than 21 days.3 The literature suggests that the earlier the patient undergoes tracheostomy, the more likely hell benefit.3 Benefits of tracheostomy include avoiding further direct laryngeal injury from the ET tube, facilitating airway suctioning and oral care, increasing patient mobility, improving patient comfort, allowing speech, and facilitating oral feedings.4 Complications associated with tracheostomy are largely determined by the technique used. A peek at techniques The standard surgical tracheostomy (ST), also known as an open tracheostomy, is usually performed in the OR under general anesthesia. In percutaneous dilatational tracheostomy (PDT), the tracheal stoma is created through dilation of an incision rather than surgery. PDT may be performed under local anesthesia, moderate sedation/analgesia, or general anesthesia in the OR or at the bedside. Indications for PDT are the same as for ST, but PDT requires careful patient selection to assure a safe and successful outcome. (See Contraindications to PDT.) Advantages of PDT over ST include eliminating the need for general anesthesia and the OR, and lower costs.5 Because the PDT requires a smaller

to the narrow dilated tract and lack of formal stoma creation. Responding to inadvertent decannulation Tracheal tube decannulation (dislodgment) in the first few days after surgery is a medical emergency. Keep supplies for reinserting the tube at the bedside, including suctioning equipment, a new tracheostomy tube with obturator (dilator), and a curved hemostat. Oxygen and equipment for ET intubation also should be readily available. If decannulation occurs, call the emergency response team to attempt reinsertion. Use a bag-valve mask to ventilate your patient through the upper airway. Ventilate gently to prevent air from escaping through the stoma or carefully occlude the stoma with a gloved hand to maximize oxygenation. The patient will be panicked, so stay with him and assure him that help is on the way. When the emergency team arrives, a clinician will try to insert a new tracheostomy tube through the opening, using a hemostat and obturator. If she doesnt succeed and the patients condition worsens, she may place an ET tube through his mouth to establish an airway. If the patient has a disruption between the upper and lower airways (for example, after tumor resection), making mask ventilation and endotracheal intubation through the upper airway impossible, ventilate him through the stoma. Monitor him to make sure hes adequately ventilated and oxygenated before hes prepared for surgery. To prevent accidental tracheal decannulation, make sure the tube is properly secured, minimize manipulation of the tube and traction on the tube from oxygen or ventilator tubing, and teach the patient to move cautiously until the tract is healed.7
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Use the ventilator, not a manual resuscitation bag, to provide hyperoxygenation before suctioning to reduce hemodynamic changes.
skin incision, patients experience less tissue trauma and a lower risk of complications such as wound infection, wound scarring, and peristomal bleeding. And because the procedure can be performed at the bedside in the ICU, PDT reduces the risk associated with transferring critically ill patients to the OR. For a look at the types of tracheostomy tubes available and why theyre used, see Tracheostomy tube design review. What can go wrong? Early complications associated with ST include bleeding, pneumothorax, air embolism, recurrent laryngeal nerve damage, and posterior tracheal wall injury. Long-term complications include airway obstruction from accumulation of secretions or protrusion of the cuff over the opening of the tube, infection, rupture of the innominate artery, dysphagia, tracheoesophageal fistula, tracheal dilation, and tracheal ischemia and necrosis.1 The complication rate of PDT is low and similar to that of ST, especially the rates of major infection or bleeding.6 However, airway loss associated with tracheal tube displacement is significantly more likely to occur in PDT due

Contraindications to PDT5
Absolute Uncorrected coagulopathy Infection over the site Extreme ventilatory and oxygenation demands Tracheal obstruction Relative Unfavorable neck anatomy Emergency airway management

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Tracheostomy care basics Provide tracheostomy care every 4 to 8 hours.8 Knowing how to properly care for a patient with a tracheostomy is vital because inappropriate or inadequate care may lead to complications and even death. Although details vary depending on the type of tracheostomy tube, tracheostomy care includes cleaning or changing the inner cannula, changing the dressing and tracheostomy tube holder, and suctioning if needed. Most tracheostomy tubes have disposable inner cannulas, which are replaced and secured using aseptic technique. Never clean and reuse a disposable cannula. Reusable inner cannulas require careful cleaning. Perform hand hygiene, don a face shield (or goggles and mask) and sterile gloves, and maintain aseptic technique during the procedure. Unlock and remove the inner cannula and place it in a solution of equal parts hydrogen peroxide and 0.9% sodium chloride unless the manufacturer directs otherwise. Remove encrusted secretions from the lumen with sterile pipe cleaners. After cleaning, rinse the cannula thoroughly with sterile 0.9% sodium chloride solution. Reinsert the inner cannula and securely lock it into place. While providing tracheostomy care, inspect the skin for signs of irritation or infection, such as erythema, pain, or discharge. Thoroughly assess the skin around the tracheostomy for evidence of skin breakdown related to the tracheostomy device, tube securement device, or mucus and secretions.7 Clean the area around the tracheostomy tube with a noncytotoxic cleanser using a sterile cotton-tipped applicator. Then rinse the skin with water and dry it gently with sterile gauze.6 If you see skin breakdown, consult a wound/ostomy/continence nurse for an individualized patient plan of care.
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Tracheostomy tube design review11

The healthcare market has exploded with tracheostomy tube designs in the last 10 years. Heres a quick look at how some of the various options compare. Metal tracheostomy tubes arent commonly used today due to their expense, rigid construction, the lack of a cuff, and the lack of a 15 mm connector to attach a ventilator or bag-valve mask. Plastic tracheostomy tubes soften at body temperature, conforming to patient anatomy and centering the distal tip in the trachea. Uncuffed tracheostomy tubes are generally reserved for infants and children because they are less traumatic to surrounding tissue. They allow airway clearance but provide no protection from aspiration. Cuffed tracheostomy tubes allow for airway clearance, offer some protection from aspiration, and facilitate positive-pressure ventilation when the cuff is inflated. High-volume, low-pressure cuffs are most commonly used for adults. Dual-cannula tracheostomy tubes have a disposable or reusable inner cannula, which is cleaned or replaced regularly; the inner cannula can be removed if the tracheostomy tube becomes occluded. PDT tubes have a tapered distal tip and are designed for use with percutaneous tracheostomies. Minitracheostomy tubes are small bore, generally uncuffed, and used primarily for secretion clearance. Theyre inserted into the trachea through the cricothyroid membrane or the tracheal stoma after decannulation for administration of oxygen. Theyre used primarily for patients who have problems with airway clearance because they allow bronchial lavage and suctioning with a 10 Fr suction catheter. Theyre generally unsuitable for positive pressure ventilation.12 Foam cuff tracheostomy tubes are self-inflating with a large diameter highresidual-volume cuff composed of polyurethane foam covered by a silicone sheath. The foam cuff addresses the issue of high lateral tracheal-wall pressures that lead to complications such as tracheal necrosis and stenosis. Before insertion, air in the cuff is removed by attaching a syringe to the pilot port. Once the tube is in place, the syringe is removed to allow the pilot port to open to atmospheric pressure (room air) and the cuff self-inflates. Once inflated, it conforms to the size and shape of the patients trachea. Be sure to keep the pilot port open to prevent cuff deflation. Adjustable flange tracheostomy tubes have a spiral wire reinforced flexible design with a longer proximal length facilitating placement in patients with a large neck. The adjustable flange allows bedside adjustments to meet extralength tracheostomy needs. Because the locking mechanism on the flanges tends to deteriorate over time, these tubes are usually reserved for temporary use. Fenestrated tracheostomy tubes are similar in construction to the standard cuffed tube, with the addition of an opening in the posterior portion of the tube above the cuff. They have a removable inner cannula and a plastic plug. With the inner cannula removed, the cuff deflated, and the normal air passage occluded, the patient can inhale and exhale through the fenestrations and around the tube. This tube allows clinicians to assess the patients ability to breathe through the normal oral/nasal route (preparing the patient for decannulation) and permits air to pass by the vocal cords (allowing phonation).

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Absorbing secretions helps prevent maceration and skin breakdown. Place a prepackaged, sterile tracheostomy dressing under the tube flanges. Always use a manufactured split sponge rather than cutting a gauze pad. Never place anything with loose fibers around the stoma or tracheostomy tube because they can cause irritation. Inform the healthcare provider if sutures used to secure the tube after insertion are irritating the skin or preventing routine maintenance. Obtain an order for suture removal 7 days after tracheostomy tube insertion. If twill tape was used, change it to a Velcro-securing device as soon as possible because its more comfortable and less likely to abrade the skin.7 Maintaining humidification is another key nursing responsibility. Normally, the nasopharynx humidifies inhaled air. Because the tracheostomy tube bypasses the upper airway, you need to provide adequate humidity to keep the airway moist. In hospitalized patients, this can be accomplished by a heat and moisture exchanger on a mechanical ventilator or a T-piece or tracheostomy mask. In addition, your patient must be properly hydrated; for example, with I.V. fluids. Monitor and record cuff pressures every shift and more often if the tube is changed or repositioned, if the volume

of cuff air changes, or a leak occurs (see Maintaining safe, effective cuff pressures). Suctioning tips and precautions Because the patient cant cough effectively to clear secretions, be prepared to suction him as needed. Suctioning raises the risk of hypoxemia, bronchospasm, and other adverse reactions, so suction only when needed, not on a set schedule, and suction for the shortest time necessary to clear secretions. Indications for suctioning include coughing, secretions in the airway, respiratory distress, presence of rhonchi on auscultation, increased peak airway pressures on the ventilator, and decreasing SaO2 or PaO2.9 Besides hypoxemia and bronchospasm, complications associated with suctioning include atelectasis, dysrhythmias (including bradycardia), increased intracranial pressure, and airway trauma. Bradycardia is attributed to vagal nerve stimulation. Atelectasis may occur when the outer diameter of the suction catheter is greater than one-half of the inner diameter of the tracheostomy tube, which can prevent airflow around the catheter. Choosing a catheter thats the right size can help prevent greater negative pressures in the airway and potentially minimize falls in PaO2.10 Some tracheostomy

Maintaining safe, effective cuff pressures

The maximum acceptable tracheostomy tube cuff pressure is 25 mm Hg. Tracheal capillary perfusion pressure is normally 25 to 35 mm Hg; higher pressure exerted by the inflated cuff can produce tracheal ischemia and mucosal injury. Cuff pressure management is an important aspect of care to prevent complications associated with incorrect cuff pressures. The clinician who manages the tracheal cuff pressure will vary depending on the institution and the location of the patient. Low cuff pressure can lead to silent aspiration. Silent aspiration can be defined as foreign material entering the trach or lungs without an outward sign (coughing or respiratory difficulty). High cuff pressure could lead to tracheal erosion or fistula. A common reason for high cuff pressure is a tube thats too small in diameter, resulting in overfilling of the cuff to achieve a seal in the trachea. Another common cause of high cuff pressure is malposition of the tube.

tube manufacturers provide a chart to help you choose the most appropriate suction catheter for your patient, based on the internal diameter of the tracheostomy tube. Suctioning can be an uncomfortable and scary experience for the patient, so thoroughly explain the procedure to him before you start. Maintain aseptic technique while suctioning. To help prevent hypoxemia, hyperoxygenate him before and after suctioning. As you suction, look for signs of hypoxemia, such as hypertension, dysrhythmias, and a drop in SpO2 by pulse oximetry. If this occurs, stop suctioning and hyperoxygenate the patient. Limit the duration of each suction pass to 10 to 15 seconds or less, and make only 1 or 2 passes.10 Limit suction pressure to 120 mm Hg or less to minimize airway trauma. If the patient is on mechanical ventilation, allow time for the increased oxygen percentage to come through the ventilator tubing and reach the patient. Use the ventilator, not a manual resuscitation bag, to provide hyperoxygenation before suctioning to reduce hemodynamic changes.10 Dont instill 0.9% sodium chloride before suctioning adults with an artificial airway. Although irrigating the tube before suctioning was once standard to help remove secretions, this practice is no longer recommended for routine care. Ensuring patients are adequately hydrated can facilitate removal of respiratory secretions.10 Document the patients response each time you suction, including his vital signs, cardiac rhythm, oxygen saturation, amount and consistency of secretions, breath sounds, and the frequency of needed suctioning. Communication tips Losing the ability to communicate is incredibly stressful for a patient with a tracheostomy tube. Nonverbal interwww.nursing2009.com

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ventions that can help facilitate communication include sign language, gestures, lip reading, pointing, facial expressions, or eye blinking. Use simple devices, such as pencil and paper, magic slates, magnetic boards with plastic letters, symbol boards, and flashcards to help the patient communicate. Teach him and his family communication methods appropriate for his condition. Consider a consultation with a speech therapist to aid in communication. Nutrition is an important aspect of tracheostomy care as well. The tracheostomy tube may impair swallowing and compromise the patients nutritional status. He may also have a loss of appetite due to his altered airway, which affects his sense of smell. Consult with a nutritionist to ensure his nutritional needs are being met.

Breathe easy Knowing how a tracheostomy is performed, what equipment is used, and how to respond if complications arise can help you maintain your patients respiratory function and keep him safe and comfortable.
REFERENCES 1. Smeltzer S, Bare B, Hinkle J, Cheever K. Brunner & Suddarths Textbook of MedicalSurgical Nursing. 11th ed. Philadelphia, PA: Lipincott Williams and Wilkins; 2008:738-741. 2. Zollinger Jr, RM, Zollinger Sr, RM. Zollingers Atlas of Surgical Operations. 8th ed. New York, NY: McGraw-Hill; 2003. 3. Clum S, Rumbak M. Mortality and tracheostomy. Crit Care Med. 2007;35(3):963-964. 4. Angel LF Im S. Timing of tracheotomy and , the comparison of surgical vs. percutaneous dilational tracheotomy. Pulmon Crit Care Update. 2003;13(12). 5. Ernst A, Silvestri CA, Johnstone D. Interventional pulmonary procedures: guidelines from the American College of Chest Physicians. Chest. 2003;123(5):1693-1717.

6. Bhatti N, Mirski M, Tatlipinar A, Koch WM, Goldenberg D. Reduction of complication rate in percutaneous dilation tracheostomies. Laryngoscope. 2007;117(1):172-175. 7. Dixon B, Tasota FJ. Inadvertent tracheal decannulation. Nursing. 2003;33(1):96. 8. Dennis-Rouse MD, Davidson JE. An evidencebased evaluation of tracheostomy care practices. Crit Care Nurs Q. 2008;31(2):150-160. 9. Higgins KM, Punthakee X. Meta-analysis comparison of open versus percutaneous tracheostomy. Laryngoscope. 2007;117(3): 447-454. 10. Joanna Briggs Institute. Tracheal suctioning of adults with an artificial airway. Best Practice. 2000;4(4):1-6. 11. Hess D. Tracheostomy tubes and related appliances. Respir Care. 2005;50(4):497-510. 12. Urden L, Stacy K, Lough M. Thelans Critical Care Nursing Diagnosis and Management. 5th ed. St. Louis, MO: Mosby; 2006:662-670.

Elizabeth Neville Regan is a nursing educator coordinator and Lisa Dallachiesa is a nursing educator at Suburban Hospital in Bethesda, Md. The authors have disclosed that they have no financial relationships related to this article.

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