Tracheostomy 

tracheostomy

I remember when I started as a new nurse feeling very intimidated by tracheostomies (or as most people call them - trachs, sounds like trakes). I was terrified that it was going to fall out or that I was going to injure the patient while managing it.  I've since worked with them for six years in the ICU and feel very comfortable with them now.  Hopefully this helps you to be at ease that trachs are not bad to manage!

What Is It?

Just like any other type of "ostomy", a tracheostomy is literally a hole in the trachea (windpipe).  Hence, trache (trachea) -ostomy (hole). This is a surgical opening that is made to the trachea by a trained medical professional.  In the ICU, we usually have two doctors at bedside to help with performing a tracheotomy at bedside.  One doctor is performing the actual procedure while the other has a scope down the patient's trachea looking at the procedure from the inside view.

The procedure to create this hole is called a tracheotomy.  When a trach is no longer indicated for a patient, it is either allowed to close on its own or through a surgical procedure depending on the patient.  Some patient may need to have the trach permanently.

Why Do Patients Need One?

The underlying reason that a person needs to have a tracheostomy is due to a lack of air getting to the lungs.  There are a variety of specific reasons for which a patient may need to have a tracheostomy:

An obstruction blocking the normal flow of air from the trachea up through the mouth.  A few examples are tumors or anaphylaxis.  I cared for a patient who had a tumor pressing on her trachea.  As the night went on, her wheezing got worse and worse despite other interventions.  We ended up deciding to perform a tracheotomy at 4:00 AM because we were very concerned that her airway was going to close off completely.  The procedure went smoothly (thankfully considering that there is not as much staff on nights) and the patient was able to instantly breathe without as much distress.

Need for long-term use of a ventilator for breathing.  This is the main reason that I have seen tracheotomies performed.  It is very uncomfortable for patients to have an endotracheal tube in their mouths for extended amounts of time.  It can also cause a great deal of breakdown within the mouth.

Tracheostomies are much easier to manage for the staff and the patient as well.  It is great for weaning patients off of the ventilator.  When the patient is ready to not have as much support as the ventilator gives, the patient can take breaks from the ventilator using different methods of oxygenation allowing them to breathe on their own. If they tire out, the ventilator tubing is simply reattached to the trach and they can get the support that they need. For these patients, I always compare this to normal working out.  You don't just run a marathon overnight! It takes running a mile, then two, then ten, etc.  For these patients, it may take being off the ventilator for one hour, then two, then eight, etc. It can be extremely exhausting for them.

Trauma to the face and neck causing swelling or damage.  This could be due to direct physical damage to the trachea or due to airway burns from smoke, steam, or corrosive materials.

Tracheotomy Procedure

The following video is slightly graphic, but I think that it does a great job of showing how the tracheotomy is performed.  In my ICU there were usually two doctors, a respiratory therapist, and one nurse dedicated to this procedure all in sterile gowns, sterile gloves, masks, etc.  The bedside nurse was in charge of giving initial medications for sedation and pain, and then in charge of monitoring vital signs. 

Managing Tracheostomies

The main intervention that you will be doing as a bedside nurse is deep suctioning a patient's lungs through their tracheostomy. If the patient has a closed (in-line) suction set up then suctioning is the same as normal endotracheal suctioning. If they do not have this in place then it is a bit more of a process to perform suctioning.  Johns Hopkins Medicine lists the following steps for deep suctioning via a tracheostomy: 

Equipment
Clean suction catheter (Make sure you have the correct size)
Distilled or sterile water
Normal saline
Suction machine in working order
Suction connection tubing
Jar to soak inner cannula (if applicable)
Tracheostomy brushes (to clean tracheostomy tube)
Extra tracheostomy tube

  1.  Wash your hands.
  2.  Turn on the suction machine and connect the suction connection tubing to the machine.
  3.  Use a clean suction catheter when suctioning the patient. Whenever the suction catheter is to be reused, place the catheter in a container of distilled/sterile water and apply suction for approximately 30 seconds to clear secretions from the inside. Next, rinse the catheter with running water for a few minutes then soak in a solution of one part vinegar and one part distilled/sterile water for 15 minutes. Stir the solution frequently. Rinse the catheters in cool water and air-dry. Allow the catheters to dry in a clear container. Do not reuse catheters if they become stiff or cracked. (I've always used sterile catheters while wearing sterile gloves for deep suctioning.  Maybe the practice varies?)
  4.  Connect the catheter to the suction connection tubing.
  5.  Lay the patient flat on his/her back with a small towel/blanket rolled under the shoulders. Some patients may prefer a sitting position which can also be tried.
  6.  Wet the catheter with sterile/distilled water for lubrication and to test the suction machine and circuit.
  7.  Remove the inner cannula from the tracheostomy tube (if applicable). The patient may not have an inner cannula. If that is the case, skip this step and go to number 8.
    a.  There are different types of inner cannulas, so caregivers will need to learn the specific manner to remove their patient's. Usually rotating the inner cannula in a specific direction will remove it.
    b.  Be careful not to accidentally remove the entire tracheostomy tube while removing the inner cannula. Often by securing one hand on the tracheostomy tube?s flange (neck plate) one can/ will prevent?accidental removal.
    c.  Place the inner cannula in a jar for soaking (if it is disposable, then throw it out).
  8.  Carefully insert the catheter into the tracheostomy tube. Allow the catheter to follow the natural curvature of the tracheostomy tube. The distance to the location of catheter becomes easier to determine with experience. The least traumatic technique is to pre-measure the length of the tracheostomy tube then introduce the catheter only to that length. For example if the patient's tracheostomy tube is 4 cm long, place the catheter 4 cm into the tracheostomy tube. Often, there will be instances when this technique of suctioning (called tip suctioning) will not clear the patient's secretions. For those situations, the catheter may need to be inserted several mm beyond the end of the tracheostomy tube (called deep suctioning). With experience, caregivers will be able to judge the distance to insert the tracheostomy tube without measuring.
  9.  Place your thumb over the suction vent (side of the catheter) intermittently while you remove the catheter. Do not leave the catheter in the tracheostomy tube for more than 5-10 seconds since the patient will not be able to breathe well with the catheter in place.
  10.  Allow the patient to recover from the suctioning and to catch his/her breath. Wait for at least 10 seconds.
  11.  Suction a small amount of distilled/sterile water with the suction catheter to clear any residual debris/secretions.
  12. Insert the inner cannula from extra tracheostomy tube (if applicable).
  13. Turn off suction machine and discard catheter (clean according to step 3 if to be reused).
  14. Clean inner cannula (if applicable).

What To Do If A Tracheostomy Tube Comes Out

If a patient's tracheostomy tube comes out, don't panic!  Just remember that you can always use your bag-valve-mask (BVM) to ventilate the patient.  Immediately get extra help in the room with you.  Don't manage this alone.  Have someone page the patient's healthcare provider.  Use the BVM to oxygenate while waiting.  Place the mask over the patient's mouth and then have an occlusive dressing over the old stoma site to push air to the lungs rather than out the old tracheostomy.  Make sure that there is proper chest rise as you perform these breaths. 

It takes about a week for a trach to mature and have a scarred stoma.  If it has been less than a week, the best recommendation is to use the BVM and orally intubate the patient.  The whole reason for having a trach in place is to ensure that the patient receives the oxygen that they need.  Focus on oxygenation!  

If you are trained to replace a dislodged trach, here are the steps for doing so according to trachs.com

1) Remove the inner cannula from the outer cannula. If you have a cuff, deflate it. If you can, rinse the tube with water, and put water-soluble lubricant on the cannula tip. Insert the obturator into the outer cannula.

2) Lean your head back and use your fingers to spread your stoma open. Using the obturator, slide the outer cannula back into your stoma. Stay as relaxed as possible.

 3) Holding the neck place firmly, remove the obturator as soon as the tube is in place. Tie the trach ties. Do not let go of the neck plate until the ties are secure.

 4) Put the inner cannula back into the outer cannula. Turn the neck of the inner cannula so it locks. Have your doctor check the tube as soon as possible.

References

Mayo Clinic

Johns Hopkins Medicine

AHC Media

Trachs.com

Posted
AuthorCourtney Tracy