TRACHEOSTOMY TUBE INSERTION

INTRODUCTION-
The terms "tracheotomy" and "tracheostomy" are used interchangeably. Derived from
the Greek word tracheia arteria (rough artery) and tome means (incision),tracheotomy
refers to operation that open trachea, where as tracheostomy results in the formation of
a tracheostoma or opening itself. A tracheotomy tube is inserted in the opening to keep
it open. Emergency tracheostomy is performed as a lifesaving procedure.
Tracheostomy in early days was considered slashing of the neck to save a life. It was in
1718 that Lorenz Heister coined the term tracheotomy. In 1921 Chevalier Jackson
described the indications and techniques for modern tracheostomy.
DEFINITION –
Tracheostomy is a surgical opening in the trachea (windpipe) that forms a temporary or
permanent opening to make breathing easier.(www. medindia.net/)

Acc. To. Annamma Jacob – A surgical opening into anterior wall of trachea and
inserting a tube to maintain patent airway.

Acc. To Sr. Nancy – A tracheostomy is an artificial opening made in the trachea into
which a tube is inserted to established and, maintain a patent air way.

CLASSIFICATION OF TRACHEOSTOMY –
1. According to the situation under which the tracheostomy is done it can be
classified into emergency and prophylactic’
In Emergency, a tracheostomy is done to relieve the respiratory distress
In prophylactic the need is anticipated and tracheostomy is done.
2. According to duration – it can be temporary and permanent.
3. According to the place of incision – tracheostomy can be classified into high and
low’ in high tracheostomy. The incision is above the so called isthmus of the
thyroid.
In low tracheostomy, the incision is made below the so called isthmus of the
thyroid at the level of 3rd and 4th of the trachea.

INDICATION-
Now days, tracheostomy is done only in those cases in which intubation by a mouth or
nasal tube are not a feasible option. There are broadly four groups of patients on whom
tracheostomy needs to be performed:
1.To relieve breathing difficulties by any blockage in the airway passages for
example-
Foreign body Impactation in the airways.
  ·Acute infection of the airways
  ·Edema of the airways
  ·Paralysis of vocal cords following injury
  ·Tumors of the vocal cords
Burn
  ·Trauma in the region
 2.To improve respiratory functions by reducing the length of the airway, which may
be required in special lung conditions like- Bronchopneumonia
Bronchitis with Emphysema
  · Chest injury
In these conditions the tracheostomy tube also helps in aspiration of excessive
secretion that may be caused due to infection or injury
3. Respiratory nerve damage temporary or permanent causing paralysis of chest
muscles that assist in breathing. In these situations performing assisted or positive
pressure respirations may be required in conditions like-
  · Unconsciousness associated with head injuries
  · Barbiturate poisoning
  · Poliomyelitis
  · Tetanus
These patients may also aspirate their gastric content into the lungs and
a tracheostomy tube may be helpful for aspiration these secretions.
4. As a preliminary step in certain surgeries on the upper airway.

TYPES OF TRACHEOSTOMY TUBES

TRACHEOSTOMY TUBES –
A tracheostomy (trach) tube is a curved tube that is inserted into a tracheostomy stoma
(the hole made in the neck and windpipe). There are several different brands of
tracheostomy tubes, but all have similar parts.
In double-cannula tubes, The main parts of a double cannula tracheostomy tube are
 the outer tube (or cannula),
 the inner tube (or cannula)
 and the obturator.

The inner cannula is inserted and locked in place after the obturator is removed; it acts
as a removable liner for the more permanent, outer tube. The inner cannula can be
withdrawn for brief periods to be cleaned.
The obturator is used only to guide the outer tube during insertion and is removed
immediately after the outer tube is in place.
The outer tube has ties to secure it in place around the child’s neck.
Many of the smaller plastic tracheostomy tubes do not have an inner tube. They are
called single-cannula tubes. For infants and small children, the trach tube is usually a
single-cannula plastic tube and is generally not cuffed (even if mechanical ventilation is
required). The tube size and type is determined by the doctor depending on the reason
for the trach tube as well as the size, age and medical needs of the child.
Tracheostomy tubes can be made of metal, plastic or silicone. Plastic and silicone tubes
are increasingly popular because they are lightweight and there is less crusting of
secretions.
Tracheostomy tubes come in many varieties, including cuffed, uncuffed and
fenestrated. A cuff is a soft balloon around the distal (far) end of the tube that can be
inflated to allow for mechanical ventilation in patients with respiratory failure. The
cuffs are inflated with air, foam or sterile water. There are several types of cuffs. The
low volume cuff is similar to a balloon, a high volume cuff is barrel-shaped. The high
volume cuff may be better to avoid complications such as stenosis, because it spreads the pressure out,
rather than pushing on one spot in the airway. Tight to shaft (TTS) balloons by Bivona are instilled
with sterile water. These work well for children who can be off the ventilator at times. When the
balloon is deflated, the tube allows air around tube for vocalization. In small children, cuffed tubes
may not be needed, however, in older children a low-pressure cuff may be needed to achieve an
adequate seal.
For children who are not ventilator dependant, the tracheostomy tube should allow
some airflow around the tube to avoid damage to the tracheal wall and to permit speech.
Fenestrated tubes have an opening in the tube that permits speech through the upper
airway when the external opening is blocked, even if the tube is too big to allow airflow
around the outer cannula. Fenestrated tubes are not recommended for small children,
because they can obstruct the opening with granulation tissue. The opening of the hole
must be at a correct angle to prevent problems. Also, in an emergency, a solid inner
cannula must be inserted in order to ventilate the child through the trach.
 

Metallic tracheostomy tube Single Cannular Shiley

Pediatric Tracheostomy Tube Obturator at Right

ADVANTAGES OF TRACHEOSTOMY-
Tracheostomy has certain advantageous over the temporary tube called endotracheal
tube because it-
Reduces patient discomfort
  · Reduces need for sedation
  · Improves ability to maintain oral and bronchial hygiene
  · Reduces risk of trauma to the windpipe and trachea
  · Makes breathing easier with less effort for a sick patient
  · Easier to move off assisted breathing using a ventilator.

NURSES RESPONSIBILITY IN HELPING THE DOCTOR IN

TRACHEOSTOMY

 Check the patient’s name & identification data.

 Assess the need for tracheostomy by watching the signs and symptoms of
respiration distress such as chest wall retraction, stridor, increasing tachycardia
accompanied by decreasing rate of respiration, restlessness, apprehension,
confusion, exhaustion, diaphoresis etc.A period of respiratory distress leads to
cyanosis due to impaired oxygenation of blood.
 Assess the possibility of intubation of trachea when doubt exists about the need
for tracheostomy .remember, the time lost makes the desparate.

PREPARATION OF THE ARTICLES

COVERED STERILE TRAY  Right angle retractor – 2

CONTAINING small sizes
 Tracheostomy tubes 3  Tissue cutting scissor
sizes (large, medium,and  Suture cutting scissors
small size  hole sheet
 Tracheal dilator -1  Suture roll
 Sponge holder  Fine thumb forceps
 Small needle holder toothed -1
 B.P handle with Blade no.  Fine thumb forceps non
11 toothed – 1
 Curved artery clamp -4  syringes and needle for
small, 4 medium local anesthesia
 Sharp scissors curved and  Dressing towels with towel
straight – 2 small clips.
  gown, gloves and masks
 cotton pads, gauze pieces
and cotton balls

UNSTERILE TRAY CONTAINING

 Mackintosh and towel
 Local anesthesia e.g.
lignocaine 2%
 Sterile Vaseline gauze in
container
 Kidney tray and paper bag
 Spot light
 electric suction
 spirit, iodine and cleaning
lotion to clean the skin
 Linen
PREPARATION OF THE PATIENT AND THE ENVIRONMENT

 Explain the procedure to the patient and his relatives to win their
confidence and cooperation. Explain to them that is a life saving
measure. Get the written consent from relatives.
 Provide privacy with screen and curtains.
 Cover the patient with a bath blanket or a sheet and fanfold the top linen
to the foot end of the bed.
 Remove the upper garments and put on a gown.
 Adjust position of the bed to a comfortable working of the doctor.
 Move the patient to the edge of the bed to prevent over reaching.
 Place the mackintosh and towel under the head and neck of the patient.

PROCEDURE –
S.NO NURSING ACTION RATIONALE
1. Place patient in supine position with the neck & Promotes visualization
head extended by keeping a pillow under the of site of insertion for
shoulder and neck. the procedure.
2. Remove gown and expose neck.
3. Keep suction and oxygen ready for use
4. Assisting in preparing skin and local anesthesia or Reduces risk of
general anesthesia is used for the procedure. Infection Reduce
sensation of pain
5. A horizontal cut is made across the neck above the
'sternal notch' using a blade.
6. The skin is separated and surrounding tissues are
dissected to expose the trachea.
7 The 2nd or 3rd of the tracheal ring is incised for the
tracheostomy tube to be placed.
8 A suitable size tracheostomy tube is then introduced
inside. While choosing the tube, the smallest
feasible tube should be used.
9 A general rule is that the tube should be three It is held in place by
fourths of the diameter of the trachea. using a necktie.
The cuff of the tube is inflated by using 2-5 ml of
air.
10 The incision is closed using skin sutures by the side Reduce the chance of
of the tracheostomy tube. displacement
11 place Vaseline gauze around tube Dressing is applied for
 the wound to heal
12. Document time, tube size, purpose of tracheostomy
and patient’s condition

POST OPERATIVE PROCEDURE –

 Connect to ventilator (if needed)
 Place patient in semi fowler’s position.
 Check vital signs.
 Many of the patients need 1 to 3 days time to adapt themselves to breathe
through the tracheostomy tube.
 Painkillers and antibiotics are given as per the patients need.
 The patient will have to try and make adjustments to communicate. It would be
very difficult for the patient to initially make any noise or sounds let alone
trying to speak.
 Most patients can learn to speak with a tracheostomy tube after much training
and practice.
 Watch for complication like bleeding, respiratory failure, and blockage of
tracheostomy tube with secretion.
 If metal tube is inserted, leave the stillete in a sterile tray at the bedside.
 Keep suction apparatus and suction tube ready at bedside.
 Once the underlying problem that caused the tracheostomy tube to be placed in
the first place in healed then the tube would be removed.
 A small scar would remain with the hole healing quickly.
 Long term care for tracheostomy tube
 Patients or attendees should learn how to take care of the tracheostomy if they
are to be discharged home after the procedure. This will help them to take care
of the tube at home.
 Normal lifestyles are encouraged and most activities can be resumed.

SUCTIONING OF THE TRACHEA IS DONE AS FOLLOWS

 Wash hands. put on gloves
 Rinse the lumen of the catheter with normal saline and gently insert into the
Trachea.
 Usually catheter is inserted 6 to 8 inches
 Do not apply suction n during the insertion
 Be gentile and slowly withdraw the cathether while rotating it and applying
suction intermittently.
 Suction should not be continued for more 5 to 10 seconds to prevent
hypoxia.
  After the suctioning discard the catheter, the gloves, and the bowl of saline
solution used for raising the catheter.
PROCEDURE OF CLEANING THE INNER CANNULA
 Take out the inner tube after releasing lock
 Wash it under cold water to remove the mucus adhering to it.
 Never wash with hot water as the hot water coagulates the mucus and it
become difficult to remove it.
 Soak it in H2O2 (half strength), Na2Co3 2% or in normal saline to soften the
secretions.
 Then clean it with soap and water using a small brush with fine bristles.
 The rinse it thoroughly under running water.
 Inspect the lumen of the tube to make sure that it is clean.
 Sterilize it by putting it in the boiling water for 3 to 5 minutes.
 Re-insert the inner cannula only after suctioning the outer cannula to remove
the secretion. Be careful not to remove the outer tube.
 After reinserting it, lock the inner cannula securely to the outer tube.
 Keep the skin around the tracheostomy tube clean and dry.
 Skin around the tracheostomy opening is cleaned with a non irritating
cleaning solution.
 Vaseline gauze is helpful to prevent skin excoriation around the tube.
 These dressing may changed every 4 hourly to remove the soilage from
secretions and perspiration.
COMMON COMPLICATIONS WITH TRACHEOSTOMY ARE-
Immediate complication ( 0 – 24 hours)
 Cardiopulmonary arrest
 Major haemorrage
 Tracheolarygeal injury
 Pneumothorax
 Acute surgical emphysema
 Tube displacement
 Hypoxia
 Arrhymias
 Hypotension
Intermediate complication (from day 1 – day 7)
 persisting bleeding
 Tube displacement
 Tube obstruction
 Major atelectasis
 Wound infections.
Late complications (from after 7 days).
 Tracheal ring narrowing or stenosis (usually with high tracheostomy).
 Ulceration of the trachea or main bronchi.
 Tracheomalacia
 Major aspiration
 Chronic speech and swallowing deficits
 Transcutaneous fistula

HEALTH TEACHING OF PATIENT WITH PERMANENT

TRACHEOSTOMY
 How to take care of a tracheostomy tube? Supervise the patient’s self care.
 Teach him what to do if the tube becomes dislodged.
 How to prevent accidental aspiration of fluid, hair, cotton, etc. while taking
bath? Swimming is prohibited.
 They should use a face mirror in front of them when they wash their face to
prevent entry of soap and water into the stoma.
 Special care is necessary when using after shave lotions on neck or any powder
or spray directed towards face, neck and chest.
 The patient should be told to prevent respiratory infections by taking adequate
protections. They should protect themselves from persons who are suffering
from respiratory disease.
 They should use a mirror in front of them when they wash their face to prevent
entry of soap and water into the stoma.
 The patient should be taught how to talk: they should take a deep breath and
then close the tube with a finger and then speak one or two words. Again take a
breath and then do likewise.
 This pt should be encouraged to take a balanced diet to improve their health.
BIBLIOGRAPHY –

1. Annamma Jacob “clinical nursing procedures: the art of nursing practice” first
edition, jaypee brothers medical publisher (p) ltd. page 397 – 398.
2. Sr. Nancy “principles and practice of nursing, senior nursing procedures”4 th
edition volume II, N.R Publishing house, page no 248- 262.
3. http://www.medindia.net/
4. http://www.medline.net/
5. http://www.americanheartassociation.net/