Está en la página 1de 17

TRACHEOSTOMY I.INTRODUCTION The use of tracheostomy has increased over recent years.

Traditionally, it was confined to the emergency management of upper airway obstruction; more recently, indications have extended to include prolonged mechanical ventilation, chronic respiratory insufficiency, failure of airway protective reflexes,

management of excessive secretions, and obstructive sleep apnoea. Percutaneous tracheostomy at the bedside in intensive care is increasingly popular. II.DEFINITION Tracheostomy is a procedure in which an opening is made into the trachea and an indwelling tube is inserted into the trachea. III.HISTORY

Prior to 16th century Tracheotomy was first depicted on Egyptian artifacts in 3600 BCE. Homerus of Byzantium is said to have written of Alexander the Great saving a soldier from

suffocation by making an incision with the tip of his sword in the man's trachea. 16th-18th centuries The European Renaissance brought with it significant advances in all scientific fields, particularly surgery. During this period, many surgeons attempted to perform tracheotomies, for various reasons and with various methods. Many suggestions were put forward, but little actual progress was made toward making the procedure more successful. The tracheotomy remained a dangerous operation with a very low success rate, and many surgeons still considered the tracheotomy to be a useless and dangerous procedure. The high mortality rate for this operation, which had not improved, supports their position. 19th century In 1869, the German surgeon Friedrich Trendelenburg reported the first successful elective human tracheotomy to be performed for the purpose of administration of general anesthesia. 20th century In the early 20th century, physicians began to use the tracheotomy in the treatment of patients afflicted with paralytic poliomyelitis who required mechanical ventilation. However, surgeons continued to debate various aspects of the tracheotomy well into the 20th century. Many techniques were described and employed, along with many different surgical instruments and tracheal tubes. IV.INDICATIONS 1. To relieve obstruction of the upper air passages caused by: Impaction of foreign body

Acute infections such as laryngotracheobronchitis of children, acute epiglottis of influenza or viral origin, laryngeal diphtheria Edema of the glottis Bilateral abductor paralysis of the vocal folds following injury to the recurrent laryngeal nerves during thyroidectomy Tumours,particularly carcinoma of the larynx Chronic stenosis following tuberculosis or scalding Congenital atresia severe facial trauma 2. To improve respiratory function By reducing anatomical dead space, and also enabling effective respiration of bronchial secretions to be done in Fulminating bronchopneumonia Chronic bronchitis with severe emphysema Chest injury ,particularly flail chest 3. Respiratoty paralysis It allows assisted or positive pressure ventilation to be performed. Secretions Inhaled foreign material due to Unconsciousness associated with head or faciomaxillary injuries Coma from other causes persisting more than a few hours where there is difficulty in maintaining a free airway Tetanus

4. As a preliminary to certain operations on the upper airway and surgery involving the head and neck 5. In the context of failed orotracheal or nasotracheal intubation 6. In the chronic setting, indications for tracheotomy include the long- term mechanical ventilation and tracheal toilet, Comatose patients.

V.ARTICLES NEEDED FOR TRACHEOSTOMY PROCEDURE Tracheostomy set containing Toothed dissecting forceps-1 Curved mosquito forceps-2 Straight mosquito forceps-2 Artery forceps-2 Allis forceps-2 Needle holder Double hook retractors-2 Blunt hook Cricoid hook Sharp scissors Tracheal dilator Cutting edge suture needle with cotton thread Dressing forceps Vaseline gauze

A clean tray containing Suction catheter with connection Hand towel Kidney basin Scalpel blade-No:11 Gloves Mask Apron Antiseptic solution Local anesthetics (Xylocaine 2%) Syringes Needles Spotlight Trachesotomy tube Suction machine O2 supply Ambubag

VI.PROCEDURE The procedure is usually performed in the operation theatre or in intensive care unit, where the patients ventilator can be well controlled and optimal aseptic technique is maintained .An opening is made in the second and third tracheal rings. After the trachea is exposed, a cuffed tracheostomy tube with appropriate size is inserted. This cuff will occlude the space between the tracheal walls and the tube to permit effective mechanical ventilation.

VII.NURSING RESPONSIBILITIES Nursing action Rationale

Explain the procedure to the patient if Allays anxiety and facilitates patient coconscious and get informed consent. operation. visualization of site of

Place patient in supine position with full Promotes extension of neck and head. Remove gown and expose the neck Keep suction and oxygen ready for use

insertion for the procedure.

Facilitates timely use of articles

Assist

in

preparing

skin

and Reduce risk of infection and reduce sensation of pain.

administering local anesthetic Assist in and support patient as incision is made and provide suitable

tracheostomy tube for insertion Assist in securing tracheostomy tube to Reduce chance of tube displacement neck by tying a tape Assist while tube is being sutured in Reduce chance of tube displacement place Place Vaseline gauze around the tube Assist patient in comfortable position Replace equipments Document the time, tube size, purpose of tracheostomy and patients condition Minimize bleeding and aids in healing

VII.POST PROCEDURE CARE Connect to ventilator (if needed) Place patient in semi-fowlers position. Check vital signs. Administer analgesics and sedatives as per order. Watch for complications like bleeding, respiratory failure and blockage of tracheostomy tube with secretions. If metal tube is inserted, leave the stillete in a sterile tray at the bedside. Keep suction apparatus and suction ready at bedside. Alleviate the apprehension of the patient and provide an effective means of communication

Reassure the patient

Provide paper or pencil or a communication board to communicate.

VIII.TRACHEOSTOMY CARE Tracheostomy care includes changing a tracheostomy inner tube, cleaning tracheostomy site and changing dressing around the site. Equipments 1. Tracheostomy care kit containing Gallipots-3 Sterile towel Sterile nylon brush/tube brush Sterile gauze squares Cotton twill ties or tracheostomy tie tapes Sterile bowl for solution 2. A clean tray containing Sterile suction catheter Hydrogen peroxide Normal saline Sterile gloves-2 pairs Clean scissors Face mask and eye shield Kidney basin Waterproof pad 3. Suction apparatus

Procedure Nursing action Rationale

Assess condition of stoma(redness, Presence of any of these indicates swelling, character of secretions, infection and culture examination may be warranted.

presence of purulence or bleeding) Examine neck for

subcutaneous Indicates air leak into subcutaneous

emphysema evidenced by crepitus tissue around the ostomy site Explain procedure to the patient and Obtains cooperation from patient teach means of communication such as writing, communication board. Assist patient to a fowlers position and Promotes place waterproof pad on chest. Wash hands thoroughly Assemble equipment lung expansion and

prevention soiling of linen. Prevents cross infection Hydrogen peroxide and saline removes

Open the sterile tracheostomy kit, pour mucus and crust which promote hydrogen peroxide and sterile normal bacterial growth. saline in separate gallipots Open other sterile supplies as needed Enhances including sterile applicators,suction kit procedure and tracheostomy care kit(dressing Protects the nurse kit). Put on facemaskand eye shield Put sterile gloves.place sterile towel Maintain aseptic technique on patients chest Suction the full length of tracheostomy Removes secretions performance phase of

tube and pharynx thoroughly Rinse the suction catheter and discard it Unlock the inner cannula (if present) Hydrogen peroxide moistens and

and remove it by gently pulling it out loosens dried secretion towards you in line with its curvature .place the inner cannula in the bowl with hydrogen peroxide

solution(applicable for tubes having inner and outer cannula) Remove the soiled tracheostomy

dressing ,discard dressing and gloves Put sterile gloves Clean the flange of the tube using Using the applicator or gauze once sterile applicators only, avoid contaminating a clean area with soiled gauze. Clean the stoma area with a Hydrogen peroxide helps to loosen dry

gauze(make only a single sweep with crusted secretions. each gauze sponge before discarding) Hydrogen peroxide is irritating to the Half strength hydrogen peroxide skin and inhibits healing if not (mixed with normal saline) may removed thoroughly. be used. Thoroughly rinse the cleaned area using gauze squires

moistened with sterile normal saline.

Dry the stoma tube with dry sterile gauze. An infected wound may be cleansed with gauze saturated with an aseptic solution, then dried. A thin layer of antibiotic ointment may be applied to the stoma with a cotton swab. Cleaning the inner cannula Remove the inner cannula from soaking solution. Clean the lumen and entire cannula thoroughly using the brush. Rinse the cleaned cannula by rinsing it with sterile normal saline (agitating the cannula in the container with saline cleans it well). Gently tap the cannula against the inside of the sterile saline container after rinsing. Replace the inner cannula and secure it in place Insert the inner cannula by grasping the outer flange and This secures the flange of the Thorough rinsing is important to remove hydrogen peroxide from the inner cannula. Removes solution adhering on the cannula. May help to clear the wound infection.

pushing in the direction of its curvature. Lock the cannula in place by turning the lock into position. Apply sterile dressing Open and refold a 4x4 gauze dressing into a v shape and place under the flange of the tracheostomy tube. Do not cut gauze pieces Ensure that the tracheostomy tube is securely supported while applying dressing. Change the tracheostomy tie Leave the soiled tape in place until the new one is applied. Cut a piece of tape that is twice the neck circumference plus 10 cm. Cut the ends of tape diagonally. Apply new tape Grasp slit end of clean tape and pull it through opening on one side of the tracheostomy tube. Pull the other end of the tape and pull it through opening on

inner cannula to the outer cannula.

Avoid using cotton-filled 4x4 gauze .cotton or gauze fiber can be aspirated by the patient potentially creating a tracheal abscess. Excessive movement of the tracheostomy tube irritates the trachea. Leaving tape in place ensures that tube will not be expelled if patient coughs or moves. This action provides a secure attachment with knot. Diagonal cut facilitates insertion of tape into the openings of faceplate.

one side of the tracheostomy tube. Pull the other end of the tape securely through the slit end of the tracheostomy tube on the other side. Tie the tapes at the side of the neck in a square knot. Alternate knot from side to side each time tapes are changed. Ties should be tight enough to keep tube securely in the stoma, and loose enough to permit two fingers to fit between the tape and neck. Remove old tapes carefully. Document all relevant information in the chart Suctioning done Tracheostomy care carried out Dressing change and Observations Prevents irritation and aids in rotation of pressure site Excessive tightness compresses jugular veins, decreases blood circulation to the skin and results in discomfort for patient.

IX.TRACHEAL SUCTIONING When a tracheostomy or an ETT is present, it is usually necessary to suction the patients secretions because the effectiveness of the cough mechanism is

decreased. Tracheal secretion is performed when adventitious breath sounds are detected or whenever secretions are obviously present. Unnecessary suctioning can initiate bronchospasm and cause mechanical trauma to the tracheal mucosa. All equipment that comes into direct contact with the patients lower airway must be sterile to prevent overwhelming pulmonary and systemic infections. Equipments Suction catheters Sterile gloves Goggles for eye protection 5 to 10 ml syringe Sterile normal saline poured in a cup for irrigation Ambu bag with supplemental oxygen Suction machine Procedure Explain the procedure to the patient before beginning and reassurance during suctioning, as the patient may be apprehensive about choking and about an inability to communicate. Wash hands thoroughly Turn on suction source, pressure should not exceed more than 120 mm hg. Open the suction catheter kit. Fill basin with sterile normal saline. Ventilate the patient with manual resuscitation bag and high flow oxygen. Put sterile glove on dominant hand Pick up suction catheter in gloved hand and connect to suction.

Hyper inflate or hyper oxygenate the patients lungs for several deep breaths with ambu bag. Insert catheter at least as far as the end of the tube without applying suction, just enough to stimulate cough reflex. Apply suction while withdrawing the catheter, rotating it gently 360 degrees (no longer than 10 to 15 seconds, because the patient can become hypoxic and develop dysrrhythmias, which can lead to cardiac arrest). Reoxygenate and inflate the patients lungs for several breaths. Instill 3 to 5 ml of normal saline if secretions are so thick. Repeat suction to make airway clear. Rinse catheter in basin with sterile water after the procedure. Suction oropharyngeal cavity after completing tracheal suctioning. Rinse suction tubing. Discard catheter, gloves and basin. Emergency articles to be kept near tracheostomy patient Ambu bag with oxygen supply Suction apparatus and suction catheters Tracheostomy tube of same size and one size lesser than the patients size. Scissors Tracheal dilator If tube become dislodged, and the patient is having difficulty in breathing, the tapes holding the tube is cut and tracheal dilator is inserted and held open to allow entry of air.

X.COMPLICATIONS Complications may be early or late complications. 1.Early complications Early complications immediately after tracheostomy are: Bleeding Pneumothorax Air embolism Aspiration Subcutaneous or mediastinal emphysema Recurrent laryngeal nerve damage Posterior tracheal wall penetration Long term complications It includes Airway obstruction due to accumulation of secretions or protrusion of the cuff over the opening of the tube Infection Rupture of the innominate artery Dysphagia Tracheoesophageal fistula Tracheal dilation Tracheal ischemia Necrosis Tracheal stenosis after the tube is removed.

XI.CONCLUSION Care of tracheostomy patients needs special skill and should be alert in order to prevent complications. A nurse should be tracheostomy patients. XII.REFERANCE 1.Levis [2006] Medical Surgical nursing assessment of measurement of clinical outcomes [6th ed] Mosby. 2.Smeltzer, C.S etal[2004] Brunner and suddarths medical surgical nursing (4 th ed) Philadelphia Lippincoat publishers 3.Mann,V.C,Russell,R.C & Williams,N.S (2000)bailey and Loves short practice of surgery(24th ed),Spain,Chapman & Hall publishers. 4.http:// www. Wikepedia.tracheostomy/htm. 5. http://www.ccmtutorials.com/rs/mv/.htm 6.http:/www.medicinenet.tracheostomy/htm vigilant enough in handling