Tracheostomy Care

TRACHEOSTOMY TUBE
Firm, curved artificial airway inserted
directly into the trachea at the level
of the second or third tracheal ring
through surgically made incision.

Principles of a
Tracheostomy
A patient with a tracheostomy has had a
surgically created opening made in the
lower airway, usually at the level of the 2nd
or 3rd tracheal ring
When a tracheostomy is inserted, the
upper airway is bypassed- this also
includes bypassing the following normal
functions:
humidifying
warming
filtering of air

Principles of a
Tracheostomy
Maintenance of airway patency
is very important.

Parts of a Tracheostomy
Outer cannula
with cuffs
Inner
cannula
Obturator (to
blunt end)
Trach tie/
trach
collar (oxygen)

Tracheostomy Care:
Cleaning of the inner cannula is generally performed
every 8 hours, & changing the cannula (sterile
procedure) every 24-48 hours (or per facility policy)
Prior to cleansing the inner cannula, hyperinflate &
hyperoxygenate the patient, & suction the airway to
remove secretions
The area around the trach stoma should be
intact/pink, free of irritation, swelling, & purulent
drainage

Tracheostomy Care:
Always assess the integrity of the new
trach tube & obturator to be inserted by
inflating the cuff to check for a leak
Prior to changing the tube, hyperoxygenate the patient
& hyperextend the neck
The cuff on an artificial airway creates a
seal between the wall of the trachea & the
outside of the tube, allowing positive
pressure ventilation & preventing
aspiration of foreign material into the
airway & lungs

Complications of overinflation of
the trach cuff include (due to
excess
pressure on tracheal
Tracheitis
wall):
Bleeding
Tracheal erosion/necrosis
Tracheomalacia
Tracheal stenosis
Tracheoesophageal fistula

Tracheostomy Care
Equipment:

Hydrogen peroxide
Sterile saline
Sterile gloves
Disposable tracheostomy kit
Clean scissors (if ties must be
replaced

Tracheostomy Care Kit:

Sterile gloves
Gauze sponges
Drain sponge
Cotton swabs
Pipe cleaners
Forceps
Trach tie
Brush
3 containers
Sterile sodium
chloride &
hydrogen peroxide

Tracheostomy Care
Procedure:
Wash hands
Explain procedure
Place patient in high fowlers position
Open sterile pack
Loosen caps on peroxide & saline bottles
Remove & discard neck dressing with clean gloves
Open/don sterile gloves
Set up sterile field & separate sterile basins
Check labels/dates on bottles- if previously used, lip the
bottles
Place sterile drape over patient
Using non-dominant hand (now the clean hand), pour
solutions into basins (1 NACL & 1 H2O2/NACL mix)
Remove the inner cannula using clean hand & drop into
the NaCl/peroxide mix)

Tracheostomy Care
Procedure:
Dip sterile applicators & gauze in NaCl/peroxide mix,

& clean around trach site

Next, rinse trach site using sterile applicators & gauze
Pick up inner cannula with clean hand on clean
end & scrub interior & exterior with brush
Rinse inner cannula in NaCl
Dry inner cannula with pipe cleaner, leaving small
amount of saline on cannula to decrease friction for
reinsertion
Reinsert cannula with clean hand/lock into place
Apply a sterile drain sponge to trach site with forceps
or sterile hand
Thread clean ties through flange holes & tie
securely/carefully cut & remove soiled ties

Tracheostomy Care
Documentation:
Condition of tracheal site
Size/type of trach
Patient tolerance- be specific (vital
signs, O2 saturation, etc.)
Color, volume, consistency of sputum
Improvement in breath sounds

A horizontal skin incision is marked midway between the

cricoid cartilage and the sternal notch. The skin is infiltrated
with Xylocaine-Epinephrine to decrease the bleeding.
The skin incision is made with a Colorado Needle mounted
on an electric knife (Bovie). A steel blade scalpel is as good
and is preferred by many surgeons.

After incising the subcutaneous tissue and platysma, the strap

muscles are separated in the midline.
The strap muscles is a name given to the four infrahyoid muscles
that lie in front of the larynx. They are the sternohyoid,
sternothyroid, thyrohyoid and the omohyoid.

The isthmus of the thyroid gland is either retracted or divided in the

midline. (In this picture, the isthmus has been divided and retracted
laterally, along with the strap muscles.) The anterior tracheal wall is
divided between the third and fourth tracheal rings. A clamp is used to
widen the tracheal opening. The endotracheal tube is seen inside the
tracheal lumen.

The tracheal wall incision is extended downward, bilaterally

to form a "trapdoor" flap. The flap is everted with an Allis
clamp.
A silk suture is used to retract the trapdoor flap, making it
easier to insert the tracheostomy cannula, and preventing it
from going through a false passage into the mediastinum.

While pulling on the silk suture to retract the trapdoor flap, the tracheotomy
cannula, with its cuff deflated, is inserted into the lumen of the trachea.
The cannula is sutured to the skin. An "accordeon" Racine adaptor is placed on the
cannula and connected to the anesthesia circuit.
A piece of Xeroform gauze is slit and placed around the tracheostomy cannula.
Other tracheostomy dressigs are available and would do just as well.
Umbilical tape is inserted into the slots of the cannula and tied.
Side view of the "accordeon" adapter that connects to the anesthesia circuit. (The
patient's head is to the right side of the picture)
To prevent a tight fit around the neck, the umbilical tape is tied over a finger, while
the neck is flexed.

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