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Monday, December 12, 2016

Tracheostomy Care at home 3

Management of Tracheotomy Care 3


Physiotherapy Care for Tracheotomy.
  • Must conduct a thorough assessment of patient at the start of visit
  • Observe for signs of hypoxia, infection, excessive secretions, pain, etc
  • Examine trach tube, any attached tubing and equipment, as well as stoma site
  • Observe for redness, purulent drainage, and abnormal bleeding around the stoma – note the amount, color, consistency, and odor of secretions
  • Auscultate breath sounds
  • Ensure that appropriate emergency trach supplies and CPR equipment is at bedside
  • Be aware of when and why the trach was inserted , how it was performed, the type and size of tube inserted
  • Please note:  When a trach is inserted, the natural warming, humidification and filtering of inhaled air (from nares / mouth) is lost.  Therefor it is essential to provide an alternate form of humidification.
Tracheostomy Humidification
As mentioned previously, the nose and mouth provide warmth, moisture and filtration for the air we breath.  Having a tracheostomy tube, however, by-passes these mechanisms so humidification must be provided to keep secretions thin and to avoid mucus plugs

Types of tracheostomy humidification systems
  1. Heated humidification (increased heat and water vapor inhaled) –
  2. Ambient or cold water humidification
  3. Heat and moisture exchangers
  4. Stoma protectors
  5. Heat moisture exchanger (attached to the outside of a trach tube for long-term trach patients) – looks like a t-tube attachment
Humidification examples

Mobilizing Secretions under Physio Care
  • Many trach patients have acute or chronic disease that predispose to stagnation of secretions
  • Frequent repositioning, deep breathing and coughing, chest physiotherapy, postural drainage, oral and parenteral hydration and supplemental humidification all help to thin and mobilize secretions
  • Tubing from an external moisture source accumulates moisture and will need frequent draining – ensure the tubing is positioned LOWER than the patient to avoid aspiration risk!
Suctioning Care

  • Necessary for all trach patients to remove secretions and assess for airway patency
  • Acute care patients need to be assessed every two hours (teach family members)
  • Routinely done 2x / day, but more often if needed – particularly a newly placed tracheostomy or when there is infection present
  • Suctioning activates psychological and physiological reflexes that make the experience both uncomfortable and frightening
  • Precaution– severe hypoxia, cardiac arrhythmias, and even cardiac arrest when the airway is occluded by the catheter and air is simultaneously sucked out the lungs.

Indications for Suctioning
  1. Dyspnea:  Flared nostrils, chest retractions and/or prolonged wheezing
  2. Noisy breathing
  3. Cyanosis and clammy skin
  4. Restlessness and agitation
  5. Copious secretions; moist cough
  6. Low oxygen saturation
  7. Increased peak inspiratory pressure on mechanical ventilator
Procedure for suctioning
  1. Place patient in semi-fowler’s position
  2. Select appropriate sized suction catheter
  3. Hyper oxygenate BEFORE each suction pass (exceptions to hyper oxygenation are children and patients with long-term tracheostomies)
  4. Insert catheter to a pre-measured depth or (to point of resistance if deep suctioning)
  5. Apply suction on withdrawal while slowly removing suction catheter
  6. Limit suctioning to 5 seconds for pre-measured depth and 10-15 seconds for deep suctioning
  7. Use suction pressure between 80 – 120 mmHg
  8. Limit suctioning to 3 passes and discontinue if HR drops by 20; increases by 40, produces arrhythmias, or decreases 02 < 90%
  9. It’s important to note:  suction mouth AFTER trach suctioning to remove secretions ABOVE CUFF.  DO NOT CONTAMINATE the trach be going from mouth back to trach
  10. Reassess the patient’s condition after suctioning and recommence oxygen therapy as soon as possible, ideally within 10 seconds of completing suctioning.  

Tracheostomy Ties
  • To lower the risk of a new trach tube accidentally dislodging, ties are usually not changed within the first 24 HOURS FOLLOWING INSERTION; thereafter, ties are generally changed daily
  •  To lower the risk of accidental decannulation (the trach tube coming out) the tie changes should be performed by two people or with new ties secured BEFORE old ties are removed.
  • Various ties are available on the market today such as velcro tape and twill tape.  Maintain two finger breaths between patient neck and ties for ease and comfort.

Maintenance of the inner cannula
  • The majority of trach tubes have inner cannulas that require cleaning one to three times daily unless they are disposable
  • Use sterile technique to clean the reusable cannula with ½ strength hydrogen peroxide and normal saline or just NS
  • Reinsert and lock back into place within a 15 minute time frame

Trach cuff pressure
  • Cuff pressure (balloon) should be maintained between 20 to 20 mmHg of pressure via a manometer – should be assessed daily;
  • if you don’t have a manometer measuring device – check with the patient/family – to evaluate how many cc’s of cuff pressure they have been utilizing (generally 5-8 cc) depending on trach size
  • With a stethoscope placed on the neck, inflate the cuff until you no longer hear hissing; deflate the cuff in tiny increments until a slight his returns.
Possible Trach Complications
  • Can arise the first few days or within several weeks; initially, the most common complications are:
  • Inflammation and edema of the trachea
  • Infection and abscess of stoma and/or pulmonary tree
  • Bleeding associated with suctioning
  • If humidity is insufficient, mucous membranes dry out and the irritation of an inserted catheter will cause small amounts of bleeding during routine suctioning
  • Long-term complications from the presence of a trach are due to tracheal scarring and erosion
  • Stenosis, the narrowing of the trachea from scar tissue occurs in 5 to 15% of patients
  • Scarring can occur at the stoma, the cuff site, or at the point where the distal end of the tube presses on the tracheal wall – possible granuloma….
  • Stenosis:  fairly common complication of trach patients, but are not usually significant enough for surgical intervention unless it narrows the airway by more than 50% 
  • Ulceration and scarring:  may occur with prolonged exposure to a trach tube; treatment may be:  serial dilation; endoscopic excision; anterior cricoid split or laryngotracheoplasty (balloon open)
  • Fistula formation:  may take months to develop.  The constant pressure from a poorly fitted trach tube, excessive cuff volume, and/or nasogastric feeding tube all contribute to tissue necrosis.  A fistula can develop between the trachea and the esophagus or can grow into the wall containing a major artery
  • Aspiration of gastric contents:  is the consequence for one path of erosion; hemorrhage results from the other.  If your patient is coughing and choking during meals, and trach cuff inflation requires increasing amounts of air, your patient may have a tracheal-esophageal fistula.  A patient with a fistula should be NPO and evaluated for surgery
  • Decannulation:  trach tubes are discontinued surgically or through a transition process of intermittent trials; the trach tube is capped or plugged for lengthening periods of time until the patient can tolerate if for 24 hours; during these times, patient should be closely observed for respiratory distress; systematic downsizing of tube may also be used for the weaning process; always assess your patient’s risk for aspiration BEFORE removing tube; patient should be NPO at least 4 hours prior to removal; once tube is removed, an occlusive dressing should be placed over the remaining stoma to form a seal so that patient can breath normally through the mouth and nose; once removed, the stoma normally closes by itself, if not, minor surgery will be done to close it; patient should be inserted to apply gentle pressure over the stoma dressing when coughing or speaking to aid in the stoma closure; dressings need to be CDI.
Home Trach Care
  1. Patient and family education normally starts in hospital setting
  2. Initial care may consist of:
  3. Warm compress to the incision site to help relieve discomfort
  4. Humidified air
  5. Wearing a scarf over trach opening to keep dry and clean
  6. Follow up with Dr. for any concerns or changes

Patient Instructions
Trach patient’s avoid:
  1. Deep bathing water
  2. Fine particles such as powders, chalk, sand, dust, mold and smoke
  3. Loose fibers and fair found on fuzzy toys and pets
  4. Persons with contagious illnesses
  5. Cold air and wind
  6. Portable suction equipment is available for travel and should be tested PRIOR to use
The sharing of this info is easy for family members and patient to understand how to learn and also understand a Tracheotomy care ,it will give some clear picture to take care and also to prevent any complication after the procedure of Tracheotomy. wallahuaklam.

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