Tracheostomy

Tracheostomy Tubes. There are many types of tracheostomy tubes available, but the basic structure is the same. All are curved to accommodate the anatomy of the trachea and most consist of an outer cannula to maintain the patency of the airway and an inner cannula that fits snugly inside the outer cannula and can be removed for cleaning and removal of accumulated secretions without disturbing the operative site. An accessory to the tracheostomy tubes is the obturator (pilot), which is an olive-tipped curved rod that is used to guide the outer cannula and prevent scraping of the tracheal walls while the tube is being inserted.



The earliest tracheostomy tubes were made of silver and consisted of only the three basic components. Later models came with an adaptor on the inner cannula to allow connection with a ventilator. The plastic tracheostomy tubes that are popular today may or may not have an inner cannula, but most have an inflatable cuff attached. The inflatable cuff may be built on the outer cannula, or it may be applied as needed. The cuff that is to be applied must be the proper size in order to be effective. The purpose of the cuff is to hold the tube in place and prevent the flow of air around the outside of the outer cannula. This allows for more effective ventilation of the patient and prevents the aspiration of liquids into the trachea. The cuffs may maintain a constant high or low pressure. Some cuffs are attached to a balloon to allow the pressure to vary in response to conditions within the trachea, for example, when a patient coughs or changes position.

Patient Care. The primary concerns of tracheostomy care are maintenance of an adequate airway by keeping the tube free of secretions and prevention of infection. The patient is observed closely for signs of respiratory difficulty. If there is a change in the respiratory rate or a wheezing or crowing sound during inhalation, the tube is probably obstructed. If suctioning does not relieve the situation, emergency assistance should be sought immediately. Restlessness, pallor, and the development of cyanosis are indications of inadequate ventilation of the lungs resulting from obstruction of the airway.



Accidental expulsion of the outer cannula due to violent coughing or improperly tied tapes is rare; should it happen, however, a dilator or hemostat must be used to hold open the incision while another tube is inserted. A dilator, obturator, and tracheostomy tube of the same size as that in the patient are kept at the bedside at all times.

The mucus will be slightly blood-tinged immediately after the tracheostomy is performed, but it should gradually assume a normal color. If there is evidence of persistent bleeding, this should be reported, as it may indicate internal hemorrhage. The mucus is suctioned as necessary with an electric or wall suction apparatus. The size of the catheter to be used for suctioning will depend on the size of the tracheostomy tube. The catheter should be small enough to move freely into and out of the tube and large enough to aspirate secretions effectively. Air inhaled through a tracheostomy tube is moisturized to prevent drying and caking of secretions. The instillation of sterile saline to loosen secretions was formerly done but is no longer recommended.

Tracheostomy care is usually a sterile procedure. Selected patients in home care settings may use clean techniques. Special care must be taken to prevent introduction of infectious organisms into either the surgical wound or the respiratory tract. Standard tracheostomy kits are available and usually include gauze sponges, twill tape, disposable containers for hydrogen peroxide, a small brush, pipe cleaners, and a tracheostomy dressing that is slit so that it fits around the tube. If additional dressings are needed, gauze squares without fillers are used and loose strings must be avoided so that fibers and threads are not aspirated through the tube.

Patients with a permanent tracheostomy must be taught self-care before leaving the hospital. As they become accustomed to breathing through the tube, suctioning it as necessary and replacing the dressings, they will become less apprehensive. Patients must be cautioned against swimming, and should be warned to use care when taking a shower or bath that water is not aspirated through the tracheostomy. Newer models of tracheostomy tubes allow the patient to speak without manually closing off the opening through which air passes into the trachea.