INFORMATION • atelectasis or lung collapse the airway, respiratory insufficiency, and stasis

A. DESCRIPTIVE TERMS • mucosal damage of secretions.

Tracheotomy: A surgical incision into the trachea for the
purpose of establishing an airway. Performed in the
operating
room. A tube is placed in the trachea just below the 2nd and
3rd
tracheal ring, bypassing the epiglottis. A tracheostomy may
be
emergency, temporary, permanent, or prophylactic.
Tracheostomy: A tracheal stoma or opening that results
from a
tracheotomy.
Trach: A tracheostomy site or tube is often referred to as a
“trach.” This term will be used frequently in the manual.
Inner cannula: A “sleeve” which fits inside the trach tube
and
may be removed for cleaning.
Flange or neck plate: Holds ties, prevents pressure points
and movement.
Obturator: Guides the tube into position without causing
trauma to tissues. Is removed
once the trach tube is in place.
Cuff: Surrounds the outer cannula. Inflated (with air) inside
trachea to prevent
aspiration and to seal the trach wall to allow more efficient
air exchange, especially with
a ventilator.
Fenestration: Hole in trach tube to allow air passage for
speaking (trach tube
is below larynx, making speech with a cuffed non-
fenestrated tube impossible).
Ties: Cotton tie (may or may not have Velcro attachment)
around neck to decrease
movement of trach tube.
Decannulation: The process of weaning patient from trach
use. Considered once a
patient has a patent upper airway. Consists of straight
removal or “corking” (plugging)
the tube for periods of time.
B. TYPES OF TUBES
• Metal (Jackson) or plastic (Shiley, Portex)
• Single cannula or double cannula
• Cuffed or uncuffed
• Fenestrated (for speaking) or non-fenestrated
• Disposable and permanent
• Long-term and short-term
C. INDICATIONS FOR A TRACHEOSTOMY
1. Maintain a patent airway
• bypass upper airway obstruction (foreign bodies, traumatic
injuries, vocal
cord paralysis, surgical edema, tumors, burns)
2. Facilitate removal of secretions
• severe bronchitis in a debilitated patient, neuromuscular
disease, paralysis of
chest muscles and diaphragm
3. Permit long-term positive pressure ventilation
• massive chest wall trauma, respiratory failure, high lesion
spinal cord injury,
prolonged coma, neuromuscular disease
4. Prevent aspiration of gastric contents
• prolonged unconsciousness
5. Lung / airway / breathing centre anomalies secondary to
congenital defect
• broncho spasm
• tracheobronchial bacterial growth
Psychosocial impact
• alteration in body image
• alteration in communication
• risk for unmet needs
E. EMERGENCY EQUIPMENT
These items should be kept at the patient’s bedside at all
times and to be with the patient
when transported off the unit:
Suction equipment
10mL syringe for cuff inflation/deflation
Obturator for tube now in situ
Replacement trach tube in specially marked bag (one size
smaller than in situ)
Scissors (for post-laryngectomy patient)
Ambu bag (manual resuscitation bag)
Oxygen equipment (optional)
Tracheal dilator set (for post-trach patient with new
stoma; in PAR) (optional)
Nasotracheal Suctioning
• Intended to remove accumulated secretions or
other materials that cannot be moved by the
patient's spontaneous cough or less invasive
procedures. Suctioning of the tracheobronchial
tree in a patient without an artificial airway can
be accomplished by inserting a sterile suction
catheter lubricated with water-soluble jelly
through the nares into the nasal passage, down
through the oropharynx, past the glottis, and
into the trachea (see Procedure Guidelines 10-9,
pages 232 to 234).
• Nasotracheal suction is a blind, high-risk
procedure with uncertain outcome.
Complications include mechanical trauma,
hypoxia, dysrhythmias, bradycardia, increased
blood pressure, vomiting, increased intracranial
pressure (ICP), and misdirection of catheter.
• Contraindications include:
○ Bleeding disorders such as
disseminated intravascular
coagulation, thrombocytopenia,
leukemia.
○ Laryngeal edema, laryngeal spasm.
○ Esophageal varices.
○ Tracheal surgery.
○ Gastric surgery with high
anastomosis.
○ Myocardial infarction.
• Assess the need for suctioning at least every 2
hours through auscultation of the chest.
○ Ventilation with a manual
resuscitation bag will facilitate
auscultation and may stimulate
coughing, decreasing the need for
suctioning.
• Maintain sterile technique while suctioning (see
Procedure Guidelines 10-10, pages 234 to 236).
• Administer supplemental 100% oxygen through
the mechanical ventilator or manual
resuscitation bag before, after, and between
suctioning passes to prevent hypoxemia.
• Closed system suctioning may be done with the
suction catheter contained in the mechanical
ventilator tubing. Ventilator disconnection is not
necessary so time is saved, sterility is
maintained, and risk of exposure to body fluids is
eliminated.
Community and Home Care Considerations
• Teach caregivers to suction in the home situation
using clean technique, rather than sterile. Wash
hands well before suctioning.
• Put on fresh examination gloves for suctioning,
and reuse catheter after rinsing it in warm water.
• Be aware that appropriate and aggressive airway
clearance will assist in preventing pulmonary
complications, thus lessening the need for
hospitalization.
For children, nebulization is one of the easiest and
most effective ways to administer asthma medicine.2
Using appropriately sized masks that fit infants, or
mouthpieces for older children and adults, patients
simply breathe normally until all the medicine has
been inhaled. Another advantage of nebulization,
particularly for young children, is that it requires no
special technique to get the medicine into the lungs.
By contrast, MDIs require proper technique that may
be hard for young children to master, and in many
cases a significant portion of the medicine does not
reach the child's lungs.3
Nebulizer – is a respiratory device tat delivers medicine to
the lungs as a fine mist.

○ Occluded nasal passages or nasal

6. Improve patient comfort due to absence of endotracheal bleeding.
(ET) tube
• enables eating, speaking; increased mobility due to tube
security
○ Epiglottitis.

• in general, if extubation (ET) not possible, tracheotomy ○ Head, facial, or neck injury.
performed after 7 to
10 days for long-term ventilation • May cause trauma to the nasal passages.
7. Decrease work of breathing and increase volume entering
the lungs by reducing ○ Do not attempt to force the catheter
anatomical dead space if resistance is met.
• severe COPDhwlo
D. COMPLICATIONS ○ Report if significant bleeding occurs.
Immediate: • Insert a nasal airway if repeated suctioning is
• hemorrhage
necessary to protect the nasal passages from
• pneumothorax
trauma.
• subcutaneous and mediastinal emphysema
• respiratory and cardiovascular collapse • Be alert for signs of laryngeal edema due to
• dislodged tube irritation and trauma.
Late:
• airway obstruction (obstruction with secretions, ○ Stop if suctioning becomes difficult
constriction of airway by ties, or if the patient develops new upper
improper tube or placement, overinflated cuff) airway noise or obstruction.
• infection (nosocomial pulmonary infection rate in patient
with a trach is 50-66%; ○ Duration of the suctioning should be
largely due to natural body defenses being bypassed by the limited to less than 15 seconds.
trach tube; infection can
Suctioning Through an Endotracheal or Tracheostomy Tube
be pulmonary, stomal)
• aspiration (secretions, gastric contents)
• tracheal damage (progressive, fistula) • Ineffective coughing may cause secretion
• dislodged tube collection in the artificial airway or
Complications associated with suctioning: tracheobronchial tree, resulting in narrowing of
• hypoxemia → dysrhythmia, hypotension, cardiac arrest