Tracheostomy Care

Lindsay Gambit, Sara Lum, & Brian Palmer N Nevada d State St t College C ll School of Nursing 2010

What is a tracheostomy?
S Surgical i l incision i i i in the trachea Opening O i i is called ll d a stoma Tube T b is i i inserted d to allow air to flow in and out of lungs
Tracheostomy tube acts as airway Tracheostomy tube must be clear of secretions Tracheostomy tube is approximately size of individuals little finger

Reasons for Tracheostomy

St Structural/muscular t l/ l abnormalities in airway Apnea A ( (no b breathing) thi ) or pauses in breathing Abnormal Ab l growth hi in airway i that h interferes with breathing Injury or burn to the head/neck that cause airway to swell

Types of Tracheostomy Tubes

Uncuffed, Uncuffed single cannula (most common) Uncuffed double cannula Uncuffed,

Cuffed, single cannula

Cuffed, double cannula

Additional Pieces to Trach

An artificial nose helps: Hold your childs own warmth and moisture in the airway. Filter small objects from the airway.

OBTURATOR:A guide placed inside the tube when the tube is being inserted. The obturator is removed immediately after the tube is placed.

Passy Muir Valve (PMV): Passy-Muir increases speech production & improves swallowing

Safety Measures
Do not use powders or aerosols around child Keep small particles such as sand, glitter, lint, chalk away g y from students tracheostomy Keep small pieces of food or water away from tracheostomy Keep glue or chemicals with strong fumes away from child
Tracheostomies bypass the bodys body s normal filtering process:

Responsibilities of Unlicensed Personnel

1. S 1 Suctioning ti i 2. Removal and insertion of t tracheostomy h t tube t b Only in cases of emergency signs g of respiratory p y distress (see next slide)

Suctioning
Purpose
Students with tracheostomies are often unable to cough in order to clear mucous If tracheostomy y is plugged, p gg , student cannot properly breathe A plugged tracheostomy tube can be life-threatening Suctioning almost always clears tracheostomy tube of secretions A catheter that fits into the tracheostomy tube is attached t suction to ti machine hi to t perform f suctioning

Signs & symptoms of respiratory distress

Grunting, noisy breathing Difficulty breathing Increased rate of breathing very fast or very slow Pale, blue color around the lips, nails, & eyes Flaring nostrils (move in and out t when h breathing) b thi ) Restlessness Sweating or clammy skin Anxious, frightened look P d ti Production of f large l amounts t of f secretions that are not removed from the trachea by coughing

Suctioning Equipment
Portable Suction machine Suction connection tubing Sterile suction catheter Gloves Water/Saline BVM (resuscitation bag)

Position for suctioning, tube removal, & insertion

Steps for suctioning

Wash hands Put on gloves Use one gloved hand to hold suction end of catheter & protect catheter from touching anything Attach catheter to suction machine If child has artificial nose or Passy Muir, hold outer cannula and remove artificial nose/Passy Muir Gently insert catheter into tracheostomy to specified depth indicated Cover thumbhole on catheter to apply suction Gently twist the catheter as it is being removed Remember child is not getting oxygen during suctioning. Complete procedure should be < 5 seconds! Discard d suction catheter h & gloves l Wash hands

Suctioning

Suction depth
Pre-measured Pre measured technique for routine suctioning based on school nurse assessment Pre-marked catheters Deep technique increases risk of epithelial damage Only twist catheter during removal. Never twist catheter during insertion. insertion Do not insert suction catheter beyond the tip of the tracheostomy tube.

Emergency Trach Tube Removal

If suctioning fails to remove plug in tube call 911 Roll a towel or blanket under childs shoulders so head is tilted slightly back or position per careplan Put on gloves Open new tube & insert obturator into new tube Lubricate the end of the new tube with water water-soluble soluble lubricant/sterile water if provided A partner may have to restrain childs arms while tube is removed Gently remove old tube (deflate cuff if applicable)

Emergency Trach Tube Insertion

Gently insert new tracheostomy tube Quickly remove obturator, while holding outer edges of tube wings to prevent decannulation (inflate cuff if applicable) Suction if indicated Continue to monitor childs breathing Secure tracheostomy tube with tracheostomy ties or hold tube in place until 911 arrives Remove gloves

CPR with Tracheostomy: Unconscious Student

Call 911 Put on gloves Begin with Chest Compressions (30:2) Remove tracheostomy tube Pulmonary resuscitation with mouth to mouth
Pinch nose, nose cover stoma with gloved finger and proceed to ventilate using a barrier device

Pulmonary resuscitation with mouth to stoma

Close mouth, pinch nose, and then proceed to ventilate using a barrier device

BVM (licensed nurse only); if unable to ventilate follow above protocol p

References
Berman, , A., , Snyder, y , S., , Kozier, , B. & Erb., , G. (2008) ( ) Fundamentals of nursing: Concepts, process, and practice, 8th Edition. Upper Saddle River, NJ: Pearson Education Inc. Components of tracheostomy care. Retrieved September 8, 2009 from http://www.thoracic.org/sctions/education/care-of-the-child-with-achronic-trahceostomy/components-of-tracheostomy-care/index chronic trahceostomy/components of tracheostomy care/index.html html Godson, R. (2009). Our children deserve a better deal on school nurses. Nursing Times. Higgins, D. (2009). Basic nursing principles of caring for patients with tracheostomy: The basic principles of nursing care and monitoring for patients ti t with ith t tracheostomies. h t i N Nursing i Ti Times, 105(3), 105(3) 14-15 14 15 Individuals with disabilities education act (IDEA): Management of children in least restrictive environment. (2008). Retrieved on September 22, 2009 from http://www.nasn.org/Default.aspx?tabid=149 Koziol Cindy Koziol, Cindy. Personal interview on September 21, 21 2009 Lipe, S. & Beasley, S. (2004). Critical thinking in nursing: A cognitive skills workbook. Philadelphia: Lippincott Williams & Wilkins

References
Myers, S. & Sharp, D. (2005). Emergency ventilation of the tracheostomy patient, part I: A story of tracheostomy history and patient management: Advocating education for emergency resuscitation. Otorhinolaryngology Journal, 23(1) , J., , Williams, , J., , & Gibbin, , K. (2003). ( ) Children with tracheostomy: y Smith, Experience of their carers in school. Child: Care, Health, & Development, 29(4), 291-296 Tracheostomy, Retrieved September 12, 2009 from http://www.nlm.nih.gov/medlineplus/ency/article/002955.html Tracheostomy Care, Retrieved September 8, 2009 from http://my.clevelandclinic.org/head_neck/patients/head_neck_cancer/tr acheostomy_care.aspx Tracheostomy care handbook: A guide for the health care provider. R t i Retrieved d on S September t b 12 12, 2009 from f http://www.nbngroup.com/manuals/machine/tracheostomy-carehandbook.pdf