Tracheostomy

Introduction and Indications for Tracheostomy

A tracheostomy is a surgically created opening in the trachea that provides an alternative airway for patients who cannot breathe normally through the upper respiratory tract. This procedure bypasses the nasal cavity, pharynx, and larynx.

Common reasons for performing a tracheostomy include:

• Upper airway obstruction: Caused by tumors, severe trauma, foreign bodies, or laryngeal edema.
• Prolonged mechanical ventilation: Reduces the risk of laryngeal and tracheal damage from long-term endotracheal intubation.
• Secretions management: Facilitates frequent suctioning in patients with a weak cough or neuromuscular disease.
• Maxillofacial trauma: Prevents airway compromise when facial bones are severely fractured.

Tracheostomy Tubes and Components

Tracheostomy tubes come in various materials, such as plastic, silicone, or metal, and can be cuffed or uncuffed. Understanding the parts of a tracheostomy tube ensures safe bedside nursing care.

• Outer cannula: The main tube that holds the tracheostomy site open.
• Inner cannula: A removable insert that locks inside the outer cannula, allowing regular cleaning or replacement to prevent mucus blockage.
• Obturator: A rounded guide used solely during insertion to prevent the sharp edges of the outer cannula from damaging tracheal tissue; it is removed immediately after placement.
• Cuff: A tiny balloon near the tip that seals the trachea when inflated, preventing aspiration and ensuring proper mechanical ventilation.

Immediate Post-operative Nursing Care

The period immediately following tracheostomy placement carries high risk for airway obstruction and surgical complications. Nurses must maintain strict vigilance.

• Airway Patency: Ensure unobstructed airflow by assessing breath sounds and chest movement.
• Hemorrhage Monitoring: Check the stoma dressing frequently for excessive bleeding or bright red blood.
• Tube Security: Keep replacement tracheostomy tubes of the same size and one size smaller at the bedside, along with an obturator and a functional suction machine.
• Securing Ties: Secure the tracheostomy ties snugly, allowing only one finger to fit underneath to prevent accidental decannulation.

Routine Care and Suctioning Technique

Routine maintenance prevents infection and keeps the airway clear of thick secretions. Suctioning should never be performed routinely on a set schedule; instead, it is done based on clinical need, such as audible secretions, coughing, or decreased oxygen saturation.

Proper suctioning technique protects the delicate tracheal mucosa:

1. Hyperoxygenate the patient before starting.
2. Insert the catheter gently without applying suction.
3. Apply intermittent suction while withdrawing the catheter in a rotating motion.
4. Limit each suction pass to 10 to 15 seconds to prevent severe hypoxia.
5. Allow adequate recovery time between suction passes.

Complications and Emergency Interventions

Tracheostomy tubes can present life-threatening emergencies that require immediate nursing action. Recognizing these issues early saves lives.

• Accidental Decannulation: The tube falls out. If it is a new tracheostomy, this is an extreme emergency because the tract has not matured. Call for help and attempt replacement immediately.
• Tube Obstruction: Caused by thick mucus plugs. The nurse should attempt to suction or clean the inner cannula. If airflow is not restored, the tube must be changed.
• Subcutaneous Emphysema: Air leaks into the surrounding tissue, creating a crackling sensation under the skin around the neck and chest. Report this finding immediately.
• Tracheal-Innominate Artery Fistula: Erosion of the artery by the tube tip, resulting in massive pulsatile bleeding. Immediate management involves over-inflating the cuff and applying direct manual pressure.

Weaning, Decannulation, and Patient Education

When a patient's underlying respiratory condition improves, the tracheostomy tube is gradually removed in a process called weaning and decannulation.

• Weaning Process: The tube size may be downsized, or a fenestrated tube used, or the tube capped to allow the patient to breathe through the upper airway.
• Decannulation Assessment: The patient must be able to cough effectively, protect their own airway, and maintain adequate blood oxygen levels without the tube.
• Stoma Closure: Once the tube is removed, the stoma is covered with an occlusive dressing secured tightly to prevent air leaks while healing by secondary intention.
• Education: Teach patients and caregivers how to perform stoma care, recognize signs of infection, and cover the opening when speaking or coughing.