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13 Tracheostomy Cuff and Tube Care 91 PROCEDURE Tracheostomy Cuff and 13 Tube Care Renee Johnson PURPOSE: Tracheostomy tube care includes care of the tracheal tube cuff, the inner and outer cannulas of the tracheal tube, and the tracheal dressing and ties. Proper care of the tracheostomy tube maintains an adequate airway seal and tracheal tube patency. Proper cuff infl ation may decrease the risk of aspiration of some particles. The tracheal dressing and ties are changed to maintain skin integrity and decrease the risk of infection. Additionally, the tracheal ties help maintain stability of the tracheal tube and prevent tube dislodgement. PREREQUISITE NURSING identifi ed by the surgeon, and an incision is made below KNOWLEDGE the cricoid cartilage. The isthmus of the thyroid gland is exposed, cross-clamped, and ligated. A Bjork fl ap may be • Tracheotomy refers to the surgical procedure in which an created. The fl ap is created when a small portion of the incision is made below the cricoid cartilage through the tracheal cartilage is pulled down and sutured to the skin. second to fourth tracheal rings ( Fig. 13-1 ). Tracheostomy The fl ap helps facilitate reinsertion of the tracheostomy refers to the opening, or the stoma, made by the incision. tube if it is dislodged, especially in patients who may be The tracheostomy tube is the artifi cial airway inserted into obese or have diffi cult anatomy. 14 Percutaneous tracheot- the trachea during the tracheotomy ( Fig. 13-2 ). omy has been proven to be a safe alternative to surgical • A tracheotomy is performed as either an elective or emer- tracheostomy on mechanically ventilated patients.8,13 gent procedure for a variety of reasons ( Box 13-1 ). There Unlike surgical tracheotomy, percutaneous tracheotomy is no standard time when a tracheotomy should be per- can be performed without direct visualization of the formed. The decision is based on the projected length of trachea. 14 A bronchoscope may or may not be used to time that mechanical ventilation or an artifi cial airway is assist with visualization during the procedure. A needle is required to remain in place. A tracheostomy tube is the passed into the trachea. A J-tipped guidewire is placed into preferred method of airway maintenance in patients who the trachea, the incision is then the dilated, and the trache- may require mechanical ventilation for more than 14 to ostomy tube is placed. 21 days. 4-6,20,23,25 Further studies need to be done to help • Tracheostomies are not without complications. Common predict which mechanically ventilated patients may benefi t complications include infection, bleeding, tracheomala- from early tracheostomy. 2,3,11-13 cia, skin breakdown, and transesophageal fi stula. Common • Compared with endotracheal tubes, tracheostomy tubes postoperative tracheostomy emergencies are hemorrhage, provide added benefi ts to patients, including the follow- tube obstruction, and dislodgement. Hemorrhage can ing: prevention of further laryngeal injury from the trans- occur at the stoma site or into the trachea. A small amount laryngeal tube; improved patient comfort, acceptance, and of bleeding is expected postprocedure and is limited to a tolerance; ease of oral care; decreased work of breathing short period of time. Bleeding that continues or is moder- due to decreased airfl ow resistance; facilitation of weaning ate to large in volume could be due to a bleeding vessel from mechanical ventilation; decreased requirements or a tracheoinnominate artery fi stula. Bleeding vessels for sedation; provision of a speech mechanism which may need to be ligated by a physician. enhances communication; increased patient mobility; • Tracheoinnominate artery fi stula is a rare complication facilitation of removal of secretions; and reduced risk for with high mortality indices. In this complication the unintentional airway loss. innominate artery has eroded into the trachea, which can • Elective tracheotomy is generally performed in the operat- result in exsanguination and is more common when a ing room but may be performed at the bedside; percutane- tracheostomy tube is subject to traction to one side or the ous tracheotomy is commonly performed at the bedside other, away from the midline. Any concerns over bleeding on ventilated patients. Emergent surgical cricothyrotomy should be reported to the physician immediately. Tube may occur before the patient arrives in the critical care obstruction can occur from occlusion due to secretions or unit or at the bedside (for additional information on from the tracheostomy tube being displaced into the ante- cricothyrotomy refer to Procedure 11 ). rior portion of the trachea within a false passage. If the • Surgical placement is performed under general anesthesia. tube is obstructed from secretions, it should be suctioned. Using an open surgical technique, a stoma is created. The If the tube is felt to be dislodged into a false passage, trachea is visualized by the surgeon. Landmarks are treatment depends on how mature the stoma is. If the 89 90 Unit I Pulmonary System Thyroid stoma is mature the tube should be replaced. If the stoma cartilage is immature—that is, the stoma is less than a week old— mask ventilation should be employed with the cuff defl ated Cricothyroid and an orotracheal tube should be inserted. Once the Cricothyroi- membrane airway is secure the tracheostomy can be revised. 14 The dotomy physician should be notifi ed if the tube becomes obstructed Cricoid and aggressive measures other than routine suctioning are cartilage needed to clear the cannula or secretions of debris. • An initial tracheotomy tube change varies depending Percutaneous Subcricoid on whether the trach was placed via standard surgical dilational space procedure or via percutaneous approach. Currently there tracheostomy is no evidence to justify when the initial or subsequent First tracheal cartilage tracheotomy tubes should be changed; it typically occurs by physician preference. The fi rst tube change most Standard lracheoslomy Second tracheal commonly occurs around day 5 postoperatively. Some sile cartilage reports state that for a percutaneous tracheotomy the initial change should not occur until postoperative day 10 to allow the stoma to mature. After the initial change, the tracheotomy should be changed approximately every 14 days thereafter. The fi rst change is usually done by the Figure 13-1 Sites for tracheostomy insertion. (From Serra A: physician. 12,14 Tracheostomy care, Nurs Stand 14:42,45–52, 2000.) • In all instances, caution should be used to ensure that the tracheostomy tube is not accidentally dislodged or decan- nulated. The stoma takes approximately 1 week to heal posttracheotomy. Dislodgment of the tube in the fi rst week is considered an emergency; the tissue may collapse, and it may not be possible to replace the tracheal tube. Predis- Oral pharynx posing factors to tube dislodgement or decannulation include an underinfl ated cuff, loose ties, neck or airway edema, excessive coughing, agitation or undersedation, Epiglottis morbid obesity, downward traction caused by the weight of the ventilator circuit, and an improperly sized trache- Larynx ostomy tube. Trach ties should be secure. Weight or trac- Vocal cords tion from the ventilator circuit should be minimized; when Thyroid cartilage transporting or mobilizing the patient the tube should Trachea Cricothyroid membrane remain in a neutral midline position. Tube position should be noted before and after the patient is moved to ensure Cricoid cartilage Esophagus safety. Individual institutions usually use protocols to manage new tracheostomy tubes and accidental dislodg- ment to ensure patient safety. 7,12,14,17,31,33 • A tracheostomy tube is shorter than but similar in diameter to an endotracheal tube. Some tracheostomy tubes have both outer and inner cannulas. The outer cannula forms the body of the tracheostomy tube with a cuff. The neck Figure 13-2 A tracheostomy (sometimes called a tracheotomy) fl ange, attached to the outer cannula, assists in stabilizing is created surgically by making an opening through the skin of the the tube in the trachea and provides the small holes neces- neck into the trachea. (From Serra A: Tracheostomy care, Nurs sary for properly securing the tube. Some tracheostomy Stand 14:42,45–52, 2000.) tubes have an inner cannula inserted into the outer cannula. The inner cannula is removable for easy cleaning without airway compromise and may be disposable. The tracheal tube cuff is an infl atable balloon that surrounds the shaft BOX 13-1 Indications for Tracheostomy of the tracheal tube near its distal end. When infl ated, the • Bypass acute upper airway obstruction cuff presses against the tracheal wall to prevent air leakage • Prolonged need for artifi cial airway and pressure loss from the lungs during positive pressure • Prophylaxis for anticipated airway problems ventilation. The tracheal tube cuff is infl ated by injecting • Reduction of anatomical dead space air through a pilot balloon with a one-way infl ation valve. • Prevention of pulmonary aspiration The air in the pilot balloon is used to assess of the amount • Retained tracheobronchial secretions of pressure in the tracheal tube cuff ( Fig. 13-3 ). • Chronic upper airway obstruction • Tracheostomy tubes are available in various materials, sizes, and styles from several manufacturers. It is important 13 Tracheostomy Cuff and Tube Care 91 the inner cannula is removed, the cuff defl ated, and the Outer cannula tracheostomy tube occluded with the plastic plug, the patient can breathe through the fenestration(s)
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