upper airway functions bypassed when patient has tracheotomy performed

TRACHEOSTOMY CARE

BILL WOJCIECHOWSKI, MS, RRTDEPARTMENT OF CARDIORESPIRATORY CAREUNIVERSITY OF SOUTH ALABAMAMOBILE, ALABAMA

TRACHEOSTOMY CARE

Upper airway functionsbypassed whenpatient hastracheotomyperformed.

UPPER AIRWAY FUNCTIONS

Heat/moisture exchange

Thermoregulation Gustation (taste) Olfaction (smell) Filtration

CLINICAL COMPLICATIONS

Altered or loss of voice Speech & language delays (young

children) Loss of smell & taste Compromised nutritional status Impaired swallowing/increased risk

of aspiration Secretion control issues/infection Psychological distress Loss of physiologic PEEP


Absence of airflow often creates Frustration Anxiety Psychological distress

For children: delayed speech & language development


Absence of airflow decreases sensations Smell Taste Poor appetite Skin health Supplemental

feeding Difficulty swallowing Risk of aspiration


Cuffed trach tubes anchor larynx & sometimes interfere with: Laryngeal elevation Epiglottic inversion Airway protection

Cuffed trach tubes secure larynx,Deflated cuff: more freedom.

Three phases of normal swallowing:1) Oral phase2) Pharyngeal phase3) Esophageal phase


Normal swallowing (pharyngeal phase): Oral & nasal cavities sealed Vocal cords close Positive pressure generated below

cords Air prevented from entering larynx Larynx elevates & moves forward Acts as a lever (mechanical event) Epiglottis seals larynx Food/liquid directed into esophagus


Swallowing with Trach Tube Inserted: Vocal cords close Air flows through trach tube No subglottic

positive pressure Reduced sensations in

larynx & pharynx Pooling of airway secretions Increase risk of aspirationMost patients OK!!


Absence of upper airway airflow (inability to nose-breathe) compromises: Heat/moisture exchange Increased secretion viscosity Increased secretion volume Frequent suctioning Increase risk of airway

trauma/infection Presence of trach tube stimulates

secretions

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With cuff inflated: No physiologic PEEP Possible

micro-atelectasis Decreased

alveolar ventilation Compromised

oxygenation

Cuff deflated

Cuff inflated

Physiologic PEEPPresent

Physiologic PEEPAbsent

TRACHEOSTOMY CARE

Inspect stoma daily: irritation/inflammation.

Tracheostomy care is done every 8 to 12 hours and PRN.

Avoid dressings trapping moisture. Check secretions: white & clear;

greenish-yellow Odor often indicates infection. Assess need for suctioning q2h.

TRACHEOSTOMY CARE Signs of Infection:

Yellow or green secretions (pink or blood-tinged)

Thicker mucus Greater volume of mucus Stoma site bleeding Foul odor from stoma Febrile patient Pulmonary congestion Increased RR Listlessness Discomfort with trach/tender stoma site

CLEANING INNER CANNULA

PROCEDURE

CLEAN INNER CANNULA

1. Loosen inner cannula.

2. Hold outer cannula with one hand. Turninner cannula to right with other hand tounlock.

CLEAN INNER CANNULA

3. Remove the inner cannula bysteadily pulling it down and towardyour chest until it is out.

CLEAN INNER CANNULA

4. Place inner cannula in the solution of hydrogenperoxide & normal saline, and don sterile gloves.

CLEAN INNER CANNULA

5. Use trach brush, or pipe cleaner, to clean inner cannula of mucus and dried secretions.

CLEAN INNER CANNULA

6. Place it in bowl of normal saline (NS).

7. Shake off excess NS. Moisture will act as lubricant during inner cannula reinsertion.

CLEAN INNER CANNULA

8. Reinsert inner cannula, keeping curved portion facing downward.

CLEAN INNER CANNULA

9. Lock inner cannula into position.

10. Wash bowls thoroughly and allow to air dry. Soak trach brush soak in hydrogen peroxide-NS solution &, rinse with NS. Air to dry. Discard pipe cleaners.

CUFF PRESSURE

Goal: maintain cuff pressure below tracheal mucosal capillary perfusion pressure which is: 25 to 30 mm Hg.

Cuff pressure maintained: 20 to 25 mm Hg, or 25 to 35 cm H2O

Higher cuff pressures Cut off tracheal mucosal blood flow Tracheal wall damage

(necrosis/tracheomalcia)

CPR - TRACHEOSTOMY

Caregivers must receive CPR training. Suction if indicated. Change trach tube if clogged.

Spare tubes (cuffless &/or cuffed): same size & 1 size smaller

Pinch nose & mouth (cuffless trach). 2 breaths with manual

resuscitator/mouth-to-trach/mouth-to-stoma: STOMA LEAK

Mouth-to-mouth/bag-mask with finger over stoma: STOMA LEAK

TRACHEOSTOMY & SPEECH

Fenestrated: Weaning Speech

Granuloma formation

Increased risk of aspiration


Some space around tube

Snug fit: tube too large non-fenestrated:

poor or no speech


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TRACHEOSTOMY TUBE PRECAUTIONS

Use extreme caution with baths and water

No swimming Avoid powder, talc, chlorine

bleach, ammonia, aerosol sprays, or colognes and perfumes

Prevent foreign objects from entering trach tube


TRACHEOSTOMY TUBE PRECAUTIONS

Avoid dust Avoid sand and beach Watch play with other children to

assure toys, fingers or other foreign bodies are not put into trach and trach is not pulled

No contact sports Frequent hand washing


EDUCATION

Teach airway anatomy Teach about equipment Teach CPR Teach infection control Teach humidification Teach suctioning Teach about speaking

valves/fenestrated trach tubes Teach communication through speech

therapy


upper airway functions bypassed when patient has tracheotomy performed

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