Trach and Chest Tube Care Keith R. Bailey RN, MSN, CCRN

• “High Risk-Low Incidence “ Skill (Paul 2010) • Individual Nurse Only Has Trached Patient Infrequently • Many Risk Factors: Imply Need For Know How • Pt Population Present In All Areas Of Hospital • This Presentation: To Reduce Anxiety Level And Increase Knowledge Base Of Nurses

Reasons For Tracheostomy

 Airway Obstruction : Tumors Or Other Cause  Failure To Wean From Mechanical Ventilator  Inability To Control Secretions  Pulmonary Toileting  Trauma  Obstructive Sleep Apnea

Risks To Tracheostomy Patients

 Hypoxia  Bleeding  Respiratory Arrest  Airway Occlusion  Infection  Aspiration  Tube Displacement Types Of Trachs

 Cuffed  Cuffless  Disposable Inner Cannula  Non Disposable Inner Cannula  Non Removable Tube Source: Lippincott’s nursing procedures (5th ed.). (2009). Tracheostomy care (p.555). Philadelphia, PA: Lippincott, Williams & Wilkins. Cuffed Vs Cuffless

 Cuffed Trach: Usually For Less Stable Pt.  Cuff Is Inflated To Seal Trachea Opening  Less Risk Of Aspiration  Required For Mechanical Ventilation  Greater Risk Of Necrosis D/T Cuff Pressure  Cuffless Trach: Usually For Stable Patients  Long Term: Able To Eat, Speak Cannulas

 Different Designs, Manufacturers  Disposable Cannulas: Disgard and Replace  Non Disposable Cannulas: Clean & Replace  Non Removable Tubes:  Metal: Old Trachs With Stainless Steel  Plastic: Formulated To Repel Secretions Source: Lippincott’s nursing procedures (5th ed.). (2009). Tracheostomy care (p.556-557). Philadelphia, PA: Lippincott, Williams & Wilkins. Trach Care

 Clean Outer Stoma And Flange  Replace Gauze Dressing (If Present)  Replace Or Clean Inner Cannula (If Present)  Check Cuff Pressure (If Cuffed)  18 – 25 mmHg Pressure Recommended  Respiratory Therapy Has Pressure Gages  Trach Tie Change: 2 People Needed S O U R C E : LIPPINCOTT’S NURSING PROCEDURES (5TH ED.). (2009). T R A C H E A L CUFF - PRESSURE MEASUREMENTS (P.551). PHILADELPHIA, PA: LIPPINCOTT, WILLIAMS & WILKINS. Speaking Valves

 Enable Patient To Speak Through Vocal Cords  Enable Patient To Undergo Swallow Test  Cuffed Trach Must Be Deflated  Assess Patient For Distress: Remove Valve If:  Decreasing SAO2, Changes In Heart Rate  Dyspnea, Tachypnea, Coughing  Anxiety, Coughing, Diaphoresis

Source: Lippincott’s nursing procedures (5th ed.). (2009). Tracheal suction (p.560-561). Philadelphia, PA: Lippincott, Williams & Wilkins. Suctioning: Best Practice Pederson Et Al (2008)

• Only When Necessary: Combine With Q Shift Assessment, Ascultation, Repositioning, Etc. • Catheter < 50% Of Internal Airway Diameter • Use Lowest Possible Suction 80-120 mmHg If Possible, Up To 200 mmHg • Limit Depth To Length Of Tube Or To Carina • Continuous, Not Intermittent • Less Than 15 Sec For Suction Pass

Suctioning Best Practice, Cont’d

 Saline NOT Routinely Recommended  Oxygenate With 100% O2 For 30 Seconds Prior To And After Suctioning  Hyperinflation NOT Recommended Increased Risk Of Barotrauma  Use Sterile Catheter For Each Insertion  Open Or Closed System: No Preference Chest Tube Care

 “High Risk-Low Incidence” Skill  Similar Patient Population  Many Patients Have Both At Times  Patients Present In All Areas Of Hospital Reasons For Chest tubes

• Pneumothorax • Hemothorax • Postop Drainage • Serous, Infected, Malignant Fluid Drainage • Trauma • May Be Inserted In OR, IR, ICU • Thoracentesis Catheter May Be Pulled After Draining, Prior To Arrival On Floor Risks To Chest Tube Patients

 Pneumothorax  Bleeding  Infection  Pain  Tube Displacement Source: Hanson, C.W. (2009). Procedures in critical care (p. 90). New York, NY: McGraw Hill. Source: Nutbeam, T., & Daniels, R. (Eds.). (2010). ABC of practical procedures. (p. 90). Hoboken, NJ: Wiley-Blackwell.

Source: Nutbeam, T., & Daniels, R. (Eds.). (2010). ABC of practical procedures. (p. 89). Hoboken, NJ: Wiley-Blackwell. Collection Device

 3 Elements To Collection Device:  Water Seal (Blue Liquid In Left Chamber)  Suction Control (Dial in Upper Left Section)  Collection Chamber (Filling From R To Left)

 -20 Cm Suction Most Common  Orange Pop Up Window= Suction On Source: Lippincott’s nursing procedures (5th ed.). (2009). Thoracic drainage (p.560). Philadelphia, PA: Lippincott, Williams & Wilkins. To Connect Chest Tube

 Check MD Order For Suction Vs Water Seal  Dial In Suction Level (-20 Cm Most Common)  Connect Wall Suction To Collection Device  Orange Pop Up Window Shows With Suction  Blue Water Chamber 0-7 Air Leak Scale  Assess Drainage, Record Q Shift in I&O

Patient Assessment

 Absent Or Diminished Lung Sounds  Dyspnea, Tachypnea  Chest Pain  Tracheal Shift  Sucking Sound At Site  Diaphoresis  Notify MD If Patient Is In Distress Thank You

• References • Hanson,W. (2009) Procedures in critical care. McGraw Hill Medical. • Lippincott’s Nursing Procedures 5th Ed. (2009). Wolters Kluwer/ Lippincott Williams & Wilkins • Nutbeam,T. and Daniels,R. Eds (2010). ABC of practical procedures. Wiley-Blackwell BMJ Books, a John Wiley & Sons, Ltd. Publication. • Paul,F. (2010). Tracheostomy care and management in general hospital and community settings: Literature review. British Association of Critical care Nurses. Nursing in Critical Care 2010. Vol.15,No.2. 76-85. Pederson,C., Rosendahl-Nielson,M.,Hjermind,J., and Egerod,I. (2009). Endotracheal suctioning of the adult intubated patient-What is the evidence? Intensive and Critical Care Nursing 2009, 25, 21-30. www.elsvier.com/iccn

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