CARING FOR THE TRACHEOSTOMISED PATIENT: WHAT TO LOOK OUT FOR DR MOHD NAZRI ALI Anaesthesiologist & Intensivist HRPZ II, Kota Bharu, Kelantan
Tracheostomy The Enabling Disability
Tracheostomy Are becoming increasingly common place both within the acute setting and community As a result of this there is an expectation of increased knowledge and more advanced nursing and healthcare skills in ward staff caring for this patient.
Tracheostomy is commonly performed procedure in ICU Estimated 15,000 insertion procedures in the UK annually Local data (NCEPOD UK 2014) ( MRIC 2015 )
Types of Tracheostomy Surgical tracheostomy : Performed in the OR or at bedside under moderate sedation / GA
Percutaneous dilatational tracheostomy is done at the patient s bedside, usually in the ICU setting. Contraindicated in anatomical irregularities or coagulation problems
Why does your patient have a tracheostomy? To maintain a patent airway when the ability to do this is temporarily or permanently compromised -Bypass obstructed airway Tumour Foreign body obstruction Facilitate removal of secretion Facilitate weaning of ventilator Optimize sedation Decreased work of breathing ( severe COAD)
Tracheostomy.. Is not without
Complications Haemorrhage Wound infection Sub-cutaneous emphysema Tube obstruction Fausse route Tube displacement Early Recognizing complications will allow early intervention and prevent negative outcomes Late Swallowing problems Tracheoesophageal fistula Tracheal stenosis Granuloma formation Tracheo-innomate artery fistula
The essential principles when caring for patient with a tracheostomy are based on Maintaining patient safety Airway patency Facilitating communication Preventing complication associated with procedures
Care of the tracheostomy Major factors must be considered in the care of tracheostomy patient Basic nursing care Cuff pressure Humidification of inspired air Airway patency and secretion clearance Speech Nutrition
Basic nursing care Some general measures are advocated for immediate post tracheostomy care : Tracheostomy cannula is secured in place Left to heal for 5-7 days Kept clean and dry Inner cannula is changed daily or more frequent if necessary Avoids angulation
Wound assessment General Offensive odour Pain during dressing change Allergic reaction to product Surgical incision Bleeding Infection Wound breakdown Tracheostomy stoma site Increase in size Appearances of stoma edges Appearance of peri-stoma tissue (maceration,cellulitis) Nature &quality of exudates Presence of granuloma tissue
Cuff pressure Tracheostomy tube cuffs require monitoring to maintain pressure in a range of 20-25mmHg High cuff pressure exceed 25-35 mmhg exceed capillary perfusion pressure will result compression of mucosal capillaries Mucosal ischemia Tracheal stenosis Low cuff pressure below 18 mmhg may caused the cuff to develop longitudinal folds Micro aspiration VAP
Cuff pressure should be monitored with calibrated devices
Humidification The importance of humidification can t be overemphasized Nasopharynx : provide natural humidification mechanism for the airway Keep airway moist Bypass by the tracheostomy
Strategies Properly hydrated with oral, IV fluids ( mucosal surface to remain moist and to ensure the viscid secretions remain atop the cilia) Instillation sterile saline directly into tracheostomy during suctioning (not too much) Conserved patient s own moisture ( HME) Saline nebuliser moist the airway
Airway patency and secretion clearances Many of the nursing skills employed are aimed at the mobilization of pulmonary secretions Strategies Frequent turning Encouragement of deep breathing and ambulation Chest physiotherapy and postural drainage Saline nebulizer Suctioning
1.Suctioning a patient never be considered routine Suction when : Clinically in distress Increase airway pressures Increase patient apprehension Auscultation ronchi Other-request by the patient
Size of suction catheter Less than half of internal diameter tracheostomy Divide the internal diameter of trachy by two AND multiply the answer by three French gauge suction catheter Suctioning should be done PRN, after chest physiotherapy,nebulisation Use the lowest pressure needed ( usually < 120 mmhg, definitely not beyond 200 mmhg Suctioning performed less than 10 seconds Insert the catheter : length of trachy + ¼ inch
2. Inner cannula Inner cannula is one of the most important parts of tracheostomy Keep clear of secretion build-up since can be removed and cleaned Care always requires strict aseptic technique Every 2-3 hours for first 48 H Every 4 hours thereafter
Weaning tracheostomy Increase period of cuff deflated Fenestrated tube Speaking valve Down sizing the tube Capping off tracheostomy tube Decannulation
Decannulation When the patient is being weaned from mechanical ventilation or from tracheostomy tube The use of fenestrated tracheostomy tube may facilitate the decannulation procedure Design of the tube Allows the patient to gradually become used to handling secretions and breathing on his/her own Protection of the cuff if patient should required supportive ventilation
When it is desired to have the patient breath through his/her upper airway Removed inner cannula Cuff deflated Occlude the outer cannula with de-cannulation cap ( monitor for features of airway obstruction / distress )
ALWAYS REMEMBER TO DEFLATE THE CUFF, AS TOTAL AIRWAY OBSTRUCTION WILL OCCUR IF CUFF IS NOT DEFLATED
Speech Ventilator-dependant patient Whispered speech Partially deflation of tracheostomy tube cuff Provided good swallowing Minimal secretion above the cuff Non-ventilator dependant Remove inner cannula Occlude external end of tracheostomy ( cap, one way valve) -Deflated the tube cuff** -Non-cuff tracheostomy Allowing expiratory airflow through the larynx
Fenestrated tube Have an opening on the posterior wall of outer cannula Allowing air to flow through the upper airway Allow patient to speak Often used during weaning
Nutrition Provides opportunities for oral nutrition ( also complicates feeding tube interferences with normal swallowing and airway control ) Tracheostomy Decrease laryngeal elevation during swallowing Inflated cuff may compress oesephagus
Risk factors for for swallowing problems in in patients with with tracheostomy Neurological injury eg. Bulbar palsy Disuse atrophy Head and neck surgery Evidence of aspiration of enteral feed or oral secretion on tracheal suctioning Increase secretion load Coughing and desaturation following oral intake Patient anxiety or distress during oral intake High FiO2
Reduce risk of aspiration by: Confirm that patient can tolerate cuff deflation Sit patient up with head slightly flexed, placed a suction catheter just at the end of tracheostomy deflate the cuff while suctioning.this is to prevent secretion falling into the airway Start with sip of clear fluid then soft diet Observe for respiratory distress, coughing,desaturation,tachypneic For problematic cases consider referral to speech and language therapy for swallowing test / endoscopic or radiological assessment
RED FLAGS Airway A suction catheter not passing easily into the trachea A changing,inadequate or absent capnograph trace Patient with a cuff tracheostomy tube suddenly being able to talk or noise or bubble coming from the upper airway Frequent requirement for (excessive) inflation of the cuff to prevent air leak Pain at the tracheostomy site Visibly displaced tracheostomy tube Bleeding from the tube / stoma
Breathing Increasing ventilator support / O2 requirement Respiratory distress Subcutaneous emphysema Patient complaining that they cannot breath / difficulty in breathing Suspicious of aspiration Circulation An airway emergency may lead to CVS collapse Anxiety, restlessness, agitation and confusion may also due to airway problem
In a nutshell. TRACHE bundle Tapes : keep the tracheostomy tube secure Resus / emergency care : know the resuscitation procedure Airway clear : use the correct suction technique Care of the stoma and neck Humidity : essential to keep the tube clear Emergency equipment : have the box present Tube changes planned
Elizabeth Taylor's Tracheostomy Taylor went to Europe, awaiting production of Cleopatra. In spring of 1961, she developed a case of pneumonia, which led to an emergency tracheotomy and worldwide talk of her impending death. The swelling of sympathy was widely thought to have influenced Academy voters, who awarded Taylor her first Best Actress Oscar Elizabeth later commented, I knew it was a sympathy award, but I was still proud to get it." Meanwhile, Taylor's competitor Shirley MacLaine memorably quipped, "I lost to a tracheotomy!"