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Tracheostomy
tubes are inserted through an incision (stoma) made between the
second and third tracheal rings.
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The obturator
should always be inserted into the outer cannula when the tube is
being advanced into the stoma.
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Once the tube is
properly positioned, the obturator should be removed and the inner
cannula inserted.
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The cuff is then
inflated and tracheostomy ties are used to secure the tube.
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Some tubes use
foam cuffs such as the Bivona Foam Cuff, which are deflated during
insertion; when the tube is in place, the cuff is allowed to resume
its normal foam shape, which provides an effective seal against the
tracheal wall. (This type of cuff exerts about 20 mm Hg pressure on
the tracheal wall.
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Indications for
tracheostomies
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To bypass
upper airway obstruction
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To prevent
problems posed by oral or nasal ET tubes
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To allow
patient to swallow and receive nourishment
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For long term
airway care (ET tubes should be left in no longer than 3 to 4
wks)
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Immediate
complications of tracheostomy tubes occurring within the first 24
hrs and associated with the tracheotomy procedure:
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Pneumothorax
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Bleeding
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Air embolism
from tearing of pleural vein
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Subcutaneous
emphysema
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Late
complications of tracheotomy tubes occurring more than 2 days after
the tracheotomy:
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Hemorrhage
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Infection
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Airway
obstruction
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Tracheoesophageal fistula
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Interference
with swallowing
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Rupture of
innominate artery
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Stomal
stenosis
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Tracheitis
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Changing a
tracheostomy tube within 48 hrs of the tracheotomy is not
advisable and should only be done by a surgeon, if it is done at
all, because the tracheal rings may recede when the tube is
removed, making reintubation difficult. |
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Tracheal stoma
care
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Stoma care
involves both the cleaning of the stoma site and the application
of clean tracheostomy ties and dressing. This is a sterile
procedure, so care must be taken to wear sterile gloves and
perform the task as aseptically as possible.
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The
tracheostomy tube should be stabilized with one hand while the
old dressing is removed. The old ties should be cut and then
removed. Continuing to stabilize the tube at this point is
essential to prevent accidental decannulation caused by coughing
or sudden movement. Always have a spare tracheostomy tube at the
bedside during this procedure.
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The stoma
area may be cleaned with 4x4 inch gauze pads soaked with
hydrogen peroxide. After cleaning, discard the pads in a dirty
area away from the sterile field. The stoma should be assessed
for swelling, redness, or pulsation of the tube.
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Cotton-tipped
applicators may be dipped in peroxide to do more detailed
cleaning around the stoma site and flanges of the trach tube.
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After the
stoma site is cleansed, rinse the site using gauze pads dipped
in sterile water. Gently dry the area by patting with sterile
gauze pads.
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Apply a
sterile 4x4 inch gauze pad dressing supplied with the trach care
kit. Never make a dressing by cutting the gauze pad to the
proper size. Cotton filaments from the gauze pad may be absorbed
into the stoma and may result in an abscess.
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The new ties
may then be applied. The ties should be cut to the proper size
before beginning stoma care so the tube may be stabilized
throughout the procedure. Use a square knot to secure the tube.
Never use a bow, which can be easily untied.
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The chest
should be auscultated immediately following the procedure to
ensure that the tube has been maintained in the proper position.
If the patient exhibits respiratory distress, determine whether
ventilation is adequate. If there is doubt about proper tube
placement, remove the tube, cover the stoma with a sterile 4x4
inch gauze, and ventilate the patient by mouth or with bag-mask
ventilation.
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If after
changing a tracheostomy tube subcutaneous emphysema and
respiratory distress is observed with little or no air movement
auscultated, the tube is malpositioned and must be removed
immediately; the patient must then be ventilated by bag-mask. |
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Special
tracheostomy tubes
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Fenestrated
tracheostomy tube
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This tube
is used to aid in weaning the patient from a tracheostomy
tube and to allow the patient to talk.
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With the
inner cannula removed, air may pass through the hole
(fenestration) in the outer cannula, allowing for weaning
from the tracheostomy tube and enabling speech.
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The outer
cannula may be plugged with the cap on the proximal end of
the tube. With the cuff deflated, air flows through the
tube, out the fenestration, and through the patient’s upper
airway.
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If
ventilation is necessary, the inner cannula may be
reinserted and the cuff reinflated.
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Tracheostomy
button
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This
airway consists of a short, hollow tube, which is used to
replace the tracheostomy tube but still maintain the stoma
patent, in case problems arise.
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The
patient has complete use of the upper airway.
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Kistner
tracheostomy tube
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This
airway is used to wean patients from tracheostomy tubes
while maintaining a patent stoma.
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Kistner
tubes are much like tracheostomy buttons, except they have a
one way valve on the proximal end of the tube.
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Air
enters through the one way valve and the tube during
inspiration. As the patient exhales, the valve closes and
the air flows up through the vocal cords and out the nose
and mouth.
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Speaking
tracheostomy tubes
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A
constant gas flow is available above the cuff and around the
vocal cords to allow speech.
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The cuff
remains inflated.
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Passy-Muir
speaking valve
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The
Passy-Muir valve (PMV) is the most commonly used
tracheostomy and ventilator speaking valve. It fits onto the
15 mm adaptor of the trach tube.
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Before
placement of the PMV, the patient’s trach tube cuff should
be deflated and the airway suctioned so that any secretions
present in the trach tube and those that have pooled above
the cuff will not be aspirated into the airway.
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The trach
tube cuff must always be completely deflated when using the
PMV. The PMV opens on inspiration and closes at the end of
inspiration so that the patient’s exhaled air is redirected
around the deflated cuff and trach tube, through the vocal
cords, and out the mouth and nose, allowing the patient to
vocalize. The PMV restores natural airflow and pressures
necessary for improved communication, improved swallow and
decreased aspiration, improved secretion management,
improved oxygenation, and expedited weaning and
decannulation.
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PMV’s may
be used on tracheostomized and ventilator-dependent
patients. When using the PMV inline on a ventilator, the
tidal volume may need to be increased to compensate for gas
loss through the upper airway. The tidal volume should be
increased to meet the peak inspiratory pressures (PIP)
before deflating the cuff and placing the PMV.
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