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Tracheostomy
Upper and Lower Respiratory System
What is a tracheotomy?


  it’s involves surgical creation of an external
opening through the 2nd and 3rd or 3rd and 4th
ring of the trachea
Trachy
A Tracheostomy can be


- Temporary,
- Permanent or
- placed during Emergency.
Cricothyrotomy

is an emergency tracheotomy that may
also be performed when endotracheal
        intubation is impossible
Indications for Tracheostomy :

   1. Airway Obstruction
Congenital
Ex: larynx hemangioma    Ex: Sub glottic or tracheal
                         stenosis,
Foreign body aspiration


  Ex: Swallowed or inhaled
object lodged in upper airway
Infection

Ex: Acute epiglottitis,

It is an infection of the
epiglottis and
supraglottic
structures.
2. Airway Clearance:




clears the secretions that cannot be cleared due to
weakness and conditions requiring long term airway
support, like progressive neurological conditions such as:
Severe brain injury ….ect
3.Long Term Intubation:
What is considered Long Term
Intubation for an adult and pediatric
patient???

  Adult: Intubated more than two weeks.

 Pediatric: Intubated more than 3-4 weeks.
4. Elective/Prophylactic


1- During major head and neck surgery
        2- Radiation treatment
What physiological changes occur
   with a tracheostomy???
temporary voice loss.
       loss of the airborne particle
filtration, warming and humidification
            action of the nose.
 potential impairment of swallowing.
    Mucociliary transport and cough
        mechanisms are impaired.
How is a Tracheostomy performed?
IN 2 WAYS :

1-SURGICAL               {OPEN (ST)}
(ENT) SURGEON, OR A THORACIC SURGEON.

2- PERCUTANEOUS                    PERCUTANEOUS DILATATION

TRACHEOSTOMY   (PDT) IS DONE USING PERCUTANEOUS DILATATION
TECHNIQUE.
Surgical tracheostomy performed in
            patients with:
1. Tumors of the upper airway
2. Previously failed/difficult percutaneous procedure
3. Major vascular structures at risk
4. Anatomical abnormality (e.g. goiters)
5. Short neck
6. Morbid obesity
7. Emergency airway
Goiters   is a swelling of the thyroid gland, which can lead to a swelling of the neck or larynx (voice box)
Nursing Considerations

In (ST), the pt may come back with stay sutures
around the tube - to hold or manipulate the operating area.

In ST sutures are removed after the first
tracheostomy tube change - 5-7 days of the
insertion, while the stoma is forming or as
ordered by the operating surgeon.
stay sutures done:
to prevint accedint accidentally
           dislodged.
Percutaneous
        insertion:

 The first tube change should
  not be performed before 2
weeks of the initial insertion??
because the stoma is very tight
and the risk of the tracheotomy
      collapsing is high.
Holistic Nursing Considerations

    During the first 2-3 days…the patient is
             uncomfortable due to
       trauma of surgery, pain of a fresh
incision, choking, presence of a foreign object
 in his trachea and inability to communicate
               through speech.
keep in mind .. the
patient is more than a
    “trach tube!”

1- pain management.
   2- reassurance.
     3- education
What are the risks involved in
       tracheostomy?

1-Reactions to medication and
anesthesia.
2-Uncontrollable bleeding.
3-Respiratory problems.
4-Possibility of cardiac arrest.
What are the complications of a
            Tracheostomy?
Early ( Life-threatening )                          Late
                                                  Infection :
 Accidental tube displacement      1- stoma site
                                   2- chest-
                                   50-60% of tracheostomy patients may
                                   develop nosocomial pneumonia
  Blocked tracheostomy tube
                                               Skin breakdown
Damage during surgery - possible
       hemorrhage.                             Tracheal stenosis

        Sx emphysema                      Tracheo-esophageal fistula :
                                   1- Abdominal distention
            Trauma                 2- Liquid food suctioned through
                                   tracheostomy tube.
        Pneumothorax
What are the parts of the
 tracheostomy tube?
Parts of Tracheostomy Tube
        Part                               Main features
    Outer canula                       Main body of the tube
        cuff              A balloon at the distal end of the tube, provide
                                  seal between the rachea & tube

    Pilot balloon       External balloon connected to the inflation line to
                                  the internal cuff ( vice versa)

 Flange/ neck plate              Support the main tube structure.
                                     Tube type, size & coude

Introducer/ obturator     Bevel, smooth rounded dilating tip tipped placed
                        inside the inner canula of the tube during insertion.
                           ( reduce the risk of trauma ) removed once the
                                      tube in correct placement

   15 mm adaptor        Allow attachment to ventilation equipment/ ambu-
                                              bag
Types of tracheostomy tubes

Single lumen:
- Larger inner diameter than double lumen
tube.
- Absence of removable inner cannula.
Double lumen:
- Removable inner cannula (twist-lock
connection ) prevent build up of secretion.
Cuffed t.t
         indication                       contraindication


     Risk of aspiration                  Child < 12 years old


Newly formed stoma ( adult )   Risk of tracheal tissue damage from cuff


            PPV


    Unstable condition
Indication
                cuff                             cuffless


        Minemiz aspiration                No risk for aspiration


    Allow PPV ( one way valve )          Pt no longer need PPV


Close system ( upper & lower airway )   Pt still need airway access
        Minemiz emphysema
Indication Close Suction System:


- Pt regyuireing Highy PEEP, Fio2

- TB, ARDS

- To Avoiding dramatic drop in oxygen.
Fenestration:

Single or multiple holes in the superior
curvature of the shaft of outer and inner
cannula.

Indication:
- Improve speech & swallowing function.
Occlusion cap:

Soolid piece of plasticc can be placed
on the end of a 15mm hub.
Indication :
Blocks all air flow via tracheostomy
(end stage weaning )
Humidification:
1- pt requiring oxygen with excessive
secretion/bedridden ( continuous  ATM ) with need
to be labeled, dated and changed as per PP.
2- alert mobiles pt with minimal secretion ( HME )
change Q 24hr.
3- buchannan bib ( contains a special foam
(hydrolox) which act as filter & HME. Shoud by
Change/washed up to 3 use’s only.
Nursing Considerations..
Condition of tracheostomy dressing wet/dry


Stoma site should be observed for:
- Bleeding
- Increase stoma size
- Appearance of stoma edges and tissue
( e.g. maceration, cellulites)
- Evidence of infection (purulent discharge, pain,
offensive odor, tenderness
- Allergic reaction to dressing product
- Tube secured to skin, ties are appropriately tight
Patient on oxygen: TM T-piece, humidification -
method.
Suctioning
                         Indications for Suctioning
if pt have one or more of the following :
Excessive secretions
Decreased oxygen saturations
Tachypnea , bradypnea or tachycardia
Restlessness, increased use of intercostal
        muscles, or sweating
Noisy breath sounds/decreased breath
sound
Poor ineffective cough
Change in skin color from baseline
Reduced expired air flow from tube
during expiration
Collection of sputum specimens
Trachy
Prior to section:
- hyperventelation
   - hyperoxygenation
 to Reduse Hypoxemia.
Caution:
COPD: patients should
only have 20% increase
of oxygenation.


Hyperventelation , will
be used for non-
spontaneous breather,
as it may have significant
adverse effects .

Ex: Reduced venous
return and barotraumas
Potential Complications of
             Suctioning:
- Hypoxemia
- Hypotension
- Increased intracranial pressure
- Hyper/Hypoventilation
- Cardiac arrhythmias
- Increased work of breathing
- Bronchospasm
- Infection
- Accidental extubation/decannulation
- Cardiac Arrest
Famous People who was
  tracheostomies
King Fahd bin Abdul Aziz Al Saud
                                   John Fitzgerald Kennedy (U.S. President)
(king of SA)
Thank you


done by :
Marwah M.Ibrahim
Any Question

References

- American Journal of Critical Care.
- Tracheostomy multiprofessional handbook (1ed
addition ).
- Critical Care Nurse.

http://www.aurorahealthcare.org/yourhealth/health-
gate/getcontent.asp?URLhealthgate=%2214874.html
%22

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Trachy

  • 2. Upper and Lower Respiratory System
  • 3. What is a tracheotomy? it’s involves surgical creation of an external opening through the 2nd and 3rd or 3rd and 4th ring of the trachea
  • 5. A Tracheostomy can be - Temporary, - Permanent or - placed during Emergency.
  • 6. Cricothyrotomy is an emergency tracheotomy that may also be performed when endotracheal intubation is impossible
  • 7. Indications for Tracheostomy : 1. Airway Obstruction
  • 8. Congenital Ex: larynx hemangioma Ex: Sub glottic or tracheal stenosis,
  • 9. Foreign body aspiration Ex: Swallowed or inhaled object lodged in upper airway
  • 10. Infection Ex: Acute epiglottitis, It is an infection of the epiglottis and supraglottic structures.
  • 11. 2. Airway Clearance: clears the secretions that cannot be cleared due to weakness and conditions requiring long term airway support, like progressive neurological conditions such as: Severe brain injury ….ect
  • 13. What is considered Long Term Intubation for an adult and pediatric patient??? Adult: Intubated more than two weeks. Pediatric: Intubated more than 3-4 weeks.
  • 14. 4. Elective/Prophylactic 1- During major head and neck surgery 2- Radiation treatment
  • 15. What physiological changes occur with a tracheostomy???
  • 16. temporary voice loss. loss of the airborne particle filtration, warming and humidification action of the nose. potential impairment of swallowing. Mucociliary transport and cough mechanisms are impaired.
  • 17. How is a Tracheostomy performed? IN 2 WAYS : 1-SURGICAL {OPEN (ST)} (ENT) SURGEON, OR A THORACIC SURGEON. 2- PERCUTANEOUS PERCUTANEOUS DILATATION TRACHEOSTOMY (PDT) IS DONE USING PERCUTANEOUS DILATATION TECHNIQUE.
  • 18. Surgical tracheostomy performed in patients with: 1. Tumors of the upper airway 2. Previously failed/difficult percutaneous procedure 3. Major vascular structures at risk 4. Anatomical abnormality (e.g. goiters) 5. Short neck 6. Morbid obesity 7. Emergency airway
  • 19. Goiters is a swelling of the thyroid gland, which can lead to a swelling of the neck or larynx (voice box)
  • 20. Nursing Considerations In (ST), the pt may come back with stay sutures around the tube - to hold or manipulate the operating area. In ST sutures are removed after the first tracheostomy tube change - 5-7 days of the insertion, while the stoma is forming or as ordered by the operating surgeon.
  • 21. stay sutures done: to prevint accedint accidentally dislodged.
  • 22. Percutaneous insertion: The first tube change should not be performed before 2 weeks of the initial insertion?? because the stoma is very tight and the risk of the tracheotomy collapsing is high.
  • 23. Holistic Nursing Considerations During the first 2-3 days…the patient is uncomfortable due to trauma of surgery, pain of a fresh incision, choking, presence of a foreign object in his trachea and inability to communicate through speech.
  • 24. keep in mind .. the patient is more than a “trach tube!” 1- pain management. 2- reassurance. 3- education
  • 25. What are the risks involved in tracheostomy? 1-Reactions to medication and anesthesia. 2-Uncontrollable bleeding. 3-Respiratory problems. 4-Possibility of cardiac arrest.
  • 26. What are the complications of a Tracheostomy? Early ( Life-threatening ) Late Infection : Accidental tube displacement 1- stoma site 2- chest- 50-60% of tracheostomy patients may develop nosocomial pneumonia Blocked tracheostomy tube Skin breakdown Damage during surgery - possible hemorrhage. Tracheal stenosis Sx emphysema Tracheo-esophageal fistula : 1- Abdominal distention Trauma 2- Liquid food suctioned through tracheostomy tube. Pneumothorax
  • 27. What are the parts of the tracheostomy tube?
  • 28. Parts of Tracheostomy Tube Part Main features Outer canula Main body of the tube cuff A balloon at the distal end of the tube, provide seal between the rachea & tube Pilot balloon External balloon connected to the inflation line to the internal cuff ( vice versa) Flange/ neck plate Support the main tube structure. Tube type, size & coude Introducer/ obturator Bevel, smooth rounded dilating tip tipped placed inside the inner canula of the tube during insertion. ( reduce the risk of trauma ) removed once the tube in correct placement 15 mm adaptor Allow attachment to ventilation equipment/ ambu- bag
  • 29. Types of tracheostomy tubes Single lumen: - Larger inner diameter than double lumen tube. - Absence of removable inner cannula. Double lumen: - Removable inner cannula (twist-lock connection ) prevent build up of secretion.
  • 30. Cuffed t.t indication contraindication Risk of aspiration Child < 12 years old Newly formed stoma ( adult ) Risk of tracheal tissue damage from cuff PPV Unstable condition
  • 31. Indication cuff cuffless Minemiz aspiration No risk for aspiration Allow PPV ( one way valve ) Pt no longer need PPV Close system ( upper & lower airway ) Pt still need airway access Minemiz emphysema
  • 32. Indication Close Suction System: - Pt regyuireing Highy PEEP, Fio2 - TB, ARDS - To Avoiding dramatic drop in oxygen.
  • 33. Fenestration: Single or multiple holes in the superior curvature of the shaft of outer and inner cannula. Indication: - Improve speech & swallowing function.
  • 34. Occlusion cap: Soolid piece of plasticc can be placed on the end of a 15mm hub. Indication : Blocks all air flow via tracheostomy (end stage weaning )
  • 35. Humidification: 1- pt requiring oxygen with excessive secretion/bedridden ( continuous ATM ) with need to be labeled, dated and changed as per PP. 2- alert mobiles pt with minimal secretion ( HME ) change Q 24hr. 3- buchannan bib ( contains a special foam (hydrolox) which act as filter & HME. Shoud by Change/washed up to 3 use’s only.
  • 37. Condition of tracheostomy dressing wet/dry Stoma site should be observed for: - Bleeding - Increase stoma size - Appearance of stoma edges and tissue ( e.g. maceration, cellulites) - Evidence of infection (purulent discharge, pain, offensive odor, tenderness - Allergic reaction to dressing product - Tube secured to skin, ties are appropriately tight Patient on oxygen: TM T-piece, humidification - method.
  • 38. Suctioning Indications for Suctioning if pt have one or more of the following : Excessive secretions Decreased oxygen saturations Tachypnea , bradypnea or tachycardia Restlessness, increased use of intercostal muscles, or sweating Noisy breath sounds/decreased breath sound Poor ineffective cough Change in skin color from baseline Reduced expired air flow from tube during expiration Collection of sputum specimens
  • 40. Prior to section: - hyperventelation - hyperoxygenation to Reduse Hypoxemia.
  • 41. Caution: COPD: patients should only have 20% increase of oxygenation. Hyperventelation , will be used for non- spontaneous breather, as it may have significant adverse effects . Ex: Reduced venous return and barotraumas
  • 42. Potential Complications of Suctioning: - Hypoxemia - Hypotension - Increased intracranial pressure - Hyper/Hypoventilation - Cardiac arrhythmias - Increased work of breathing - Bronchospasm - Infection - Accidental extubation/decannulation - Cardiac Arrest
  • 43. Famous People who was tracheostomies
  • 44. King Fahd bin Abdul Aziz Al Saud John Fitzgerald Kennedy (U.S. President) (king of SA)
  • 45. Thank you done by : Marwah M.Ibrahim
  • 46. Any Question References - American Journal of Critical Care. - Tracheostomy multiprofessional handbook (1ed addition ). - Critical Care Nurse. http://www.aurorahealthcare.org/yourhealth/health- gate/getcontent.asp?URLhealthgate=%2214874.html %22