Update on Tracheostomy Care

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This course expires on December 21, 2015.

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First Published: December 1, 2004 Updated: December 1, 2006 Updated: December 1, 2009 Updated: December 21, 2012

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Acknowledgements
RN.com acknowledges the valuable contributions of .Nadine Salmon, MSN, BSN, IBCLC, the Clinical Content Manager for RN.com. She is a South African trained Registered Nurse, Midwife and International Board Certified Lactation Consultant. Nadine obtained an MSN at Grand Canyon University, with an emphasis on Nursing Leadership. Her clinical background is in Labor & Delivery and Postpartum nursing, and she has also worked in Medical Surgical Nursing and Home Health. Nadine has work experience in three countries, including the United States, the United Kingdom and South Africa. She worked for the international nurse division of American Mobile Healthcare, prior to joining the Education Team at RN.com. Nadine is the Lead Nurse Planner for RN.com and is responsible for all clinical aspects of course development. She updates course content to current standards and develops new course materials for RN.com. Susan Herzberger, RN, MSN, the original course author. Susan is a medical-surgical nurse who has experience with burn and ED nursing before moving into nursing education.

Purpose and Objectives

The purpose of Update on Tracheostomy Care is to present an overview of the nursing care of patients who have tracheostomies. This course will also review general guidelines for suctioning and suggest preventive strategies that will lower the risk of complications due to the presence of a tracheostomy tube. After successful completion of this course, you will be able to: 1. Describe the reasons for tracheostomy 2. Define the risks associated with the different tracheostomy procedures 3. List the most common complications likely to arise from temporary and long-term tracheostomies 4. Identify tracheostomy tube types currently in use 5. Describe components of a care plan for a patient with a tracheostomy

Introduction
Providing care for a patient with a tracheostomy (trach) requires you to be familiar with natural and artificial airway anatomy. As a caregiver, you should also recognize potential signs and symptoms of hypoxia and have the ability to perform appropriate nursing actions if the patients trach tube accidentally comes out. This course will focus on how to skillfully adapt your care to the patient with a tracheostomy.

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Courtesy of the National Cancer Institute, 2007. www.nci.gov

Tracheostomy Facts
Tracheotomy is the surgical procedure that creates an opening in the cervical trachea. It is rarely done as an emergency because oral or nasal intubation or cricothyrotomy is much faster and less complicated when managing respiratory arrest. Tracheostomy is usually performed for the following reasons: To bypass an obstruction To maintain an open airway To remove secretions more easily To oxygenate and/or provide mechanical ventilation on a long-term basis

Tracheostomy care and tracheal suctioning are high-risk procedures, and nurses performing these procedures must adhere to the latest evidence-based practice guidelines (Nance-Floyd, 2011). Always check the policy and procedures for tracheostomy care in the facility and unit on which you are working.

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Image provided courtesy of Smiths-Medical BDA, Inc. (2012).

Types of Patients Requiring Tracheostomies

Sometime during your nursing career, you may be responsible to provide care for various types of patients who have tracheostomies. Examples of these patients may include: A comatose patient A patient with cancer of the larynx A burn patient with inhalation damage A COPD patient on mechanical ventilation A pediatric patient with a congenital airway obstruction

Reasons for Performing Tracheostomies

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Inherent abnormality of larynx or trachea Blockage of the airway by a tumor, foreign object, soft tissue swelling or collapse of throat structure Severe throat, neck or mouth injuries Inability to swallow or cough Ineffective expulsion of respiratory secretions Long term coma / unconsciousness Need for long term mechanical ventilation

Tracheostomy tube placement

Tracheostomy Procedures
Tracheostomy in the operating room (surgical tracheostomy) is usually performed under general anesthesia, but can be done under regional anesthesia. The tracheostomy is usually formed between the second and third or third and fourth tracheal cartilages (Freeman, 2011). Retention sutures are often placed in the cartilage with the ends taped to the patients skin. Percutaneous dilatational tracheostomy (PCT or PDT) is done at the patients bedside, usually in the ICU. The patient is sedated with a narcotic and/or tranquilizer. Under local anesthesia, a large bore needle is inserted into the trachea. A guide wire is placed in the opening and a series of dilators placed over the guide wire to create a stoma into which a trach tube is inserted. This procedure takes approximately 15 minutes. This procedure takes less time than surgery and causes less scarring (Freeman, 2011).

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Image provided courtesy of the National Blood Heart Lung Institute (2012).

Tracheostomy Procedures
A third procedural choice is surgical tracheostomy (mini-tracheostomy) done at the bedside (Imperatore et al., 2004). This is a compromise solution that reduces the number of patients having to go to the OR. Percutaneous dilatational tracheostomy is contraindicated in a quarter of patients requiring tracheostomy, mostly due to anatomical irregularities or coagulation problems. Bedside tracheostomy can be preferable because it allows for continuity of monitoring, causes less upheaval for the patient, and costs less than a tracheostomy in the operating room.

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1: Vocal cords 2: Thyroid cartilage 3: Cricoid cartilage 4: Tracheal cartilage 5: Balloon cuff Image provide courtesy of Wikipedia (2007.

Temporary Tracheostomy Versus Permanent Laryngectomy

A tracheostomy may be a temporary or permanent measure. Although the outward appearance of the two may look alike, there are significant anatomical differences that may have implications for patient safety, if the tracheostomy tube were to be dislodged (Freeman, 2011). When a temporary tracheostomy is inserted, the upper airway will remain patent if the tracheostomy tube were to be dislodged. However, in a permanent laryngectomy, the larynx is removed and an artificial tracheostomy is created, so that there is no connection between the patient's upper airway and the trachea itself (Wright, 2005 in Freeman, 2011).

Risks Associated with Tracheostomies

The risks involved during each of these procedures are similar and are related to: Reactions to medication and anesthesia Uncontrollable bleeding Respiratory problems Possibility of cardiac arrest

Generally, 6% of patients have post-procedural complications such as abnormal bleeding or wound infection (et al., 2004). In one study comparing surgical tracheostomy patients with PCT patients, PCT patients show a lower incidence of these complications (SIMS Portex, 1998; Caulfield & Astle, 2003).

Post Procedural Tracheostomy Care

The first two days following tracheostomy are especially uncomfortable for the patient. Your patient is
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adjusting to the trauma of surgery, the pain of a fresh incision, the presence of a foreign object in the trachea, and the inability to communicate through speech. Patients commonly report choking sensations (Robinson, 2000) and generally take one to three days to adapt to breathing through a tracheostomy tube (Medline Plus, 2003). If your patient had a PCT, it is standard procedure to check vital signs every fifteen minutes for one hour, every half an hour for the next hour, then hourly for four hours (Caulfield & Astle, 2003). Follow your organization's guidelines for the care of patients returning from the operating room.

Anticipated Side Effects of Tracheostomies

Respiratory secretions will often temporarily increase in your patient after a tracheostomy. Observe for signs and symptoms of impaired gas exchange that can be created by mucus plugs. Encourage your patient to breathe deep and cough. Ensure adequate humidification and fluid intake to keep secretions thinned. A small amount of bleeding from the stoma is expected for a few days after a tracheostomy but constant oozing is abnormal and requires intervention. A blood vessel may need surgical litigation or the patients physician may direct you to pack the wound around the tube to stop the bleeding. Slight inflammation commonly occurs at the surgical site too. There may also be redness, pain, and a small amount of drainage. Lower respiratory infection requires more frequent assessment and most likely antibiotic intervention. Air sometimes escapes into the tracheostomy incision creating subcutaneous emphysema around the stoma. This is generally of no clinical consequence but can be palpated around the stoma site. Excessive manipulation of the trach tube during coughing and suctioning can break improperly secured ties and dislodge the tube. Within the first 48 hours the freshly created stoma has a potential to close shut, constituting a medical emergency. To minimize this risk, trach ties are not usually changed for 24 hours. The first tube change is generally done by a physician after approximately one week (Lewis, Heitkemper & Dirksen, 2000). Each organization will have emergency policies and procedures to follow in the case of a dislodged fresh tracheostomy tube. Test Yourself: Adequate humidification and fluid intake will help keep secretions: A. Copious B. Thinned C. Tenacious D. Free from infection The correct answer is: Thinned

Types of Tracheostomy Tubes

A variety of tracheostomy tubes are available, depending on the patient's specific needs. Tracheostomy tubes vary in size, composition, number of parts, and shape.
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Tracheostomy tubes may be made of metal, PVC material, or silicone and will differ accordingly in the degree of flexibility they provide. They are disposable or reusable. You will encounter different kinds of trach tubes selected for individual patient needs.

Image of tracheostomy tube showing outer cannula with inflatable cuff (top), inner cannula (middle) and obturator (bottom). Klaus D. Peter (2008). Image provided under the Creative Commons Attribution License. Retrieved from: http://en.wikipedia.org/wiki/File:Tracheostomy_tube.jpg

Cuffless & Pediatric Tubes

Cuffless tracheostomy tubes are rarely used in acute care, but are more suitable for use in long term ventilation. The cuffless tube usually has a double-lumen, and the patient must have effective cough and gag reflexes to prevent aspiration. Cuffless models often have disposable inner cannulas that need to be frequently replaced. Refer to your unit's policy & procedure to identify how often the inner cannula should be changed. For the acute care patient, a pilot tube allows the cuff to be inflated with air, foam, or water, providing a closed airway for mechanical ventilation and preventing aspiration of gastric or oral secretions. For infants and small children, single cannula, soft plastic trach tubes are usually used (Bissell, 2004). These are generally without cuffs but still adaptable for mechanical ventilation equipment. Single cannula tubes may require additional humidification to prevent the accumulation of secretions. Disposable and reusable trach tubes are both available, and tubes can be custom made.

Courtesy of Smiths Medical ASD,Inc. (2012)

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Courtesy of Smiths Medical ASD,Inc. (2012)

Cuffed Tubes
Also known as the Universal / Double Lumen Tube, the cuffed tracheostomy tube is the most common type of tracheostomy tube. It consists of three parts: An outer cannula with an inflatable cuff and pilot tube An inner cannula An obturator The outer cannula has an inflated cuff that keeps the airway open. When inflated, this tube seals the airway and prevents the aspiration of oral or gastric secretions. The cuff directs air through but not around the tube. It is commonly used when mechanical ventilation is required, to provide a closed airway system. The inner cannula of the cuffed tube has a universal adaptor for use with a ventilator and other respiratory equipment. The inner cannulas must be removed, cleaned, and reinserted, unless it is disposable. The obturator has a rounded tip for smoothly inserting the outer tube and avoiding trauma to the tracheal wall. It is important to keep the obturator near the bedside in case of an emergency. For the acute care patient, a pilot tube allows the cuff to be inflated with air, foam, or water, providing a closed airway for mechanical ventilation and preventing aspiration of gastric or oral secretions.

Image of a cuffed tracheostomy tube showing the inflated balloon, which forms a seal between the traheostomy tube and the trachea. This prevents air leakage. Image courtesy of Smiths-Medical ASD, Inc. (2012).

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Fenestrated Tubes
These tubes have an opening on the posterior wall of the outer cannula, which allows air to flow through the upper airway and tracheostomy opening. This air movement allows the patient to speak and produce a more effective cough. The fenestrated tube is often used during weaning to ensure that patients can tolerate breathing through the natural airway before tube removal.

Courtesy of Smiths Medical ASD, Inc. (2012).

More info: Some clinicians believe fenestrated tubes aid in the clearance of secretions. Others feel these tubes promote the development of granulation tissue. There is little scientific data to support either of the latter two opinions (American Thoracic Society, 2009).

Communication and Tracheostomies

Some trach tubes are designed to allow patients to speak. Patients being weaned off trach tubes may have either a cuffless, fenestrated tube with an opening that allows air to flow across the larynx, or a tracheostomy button that does not extend into the trachea enough to restrict airflow past the larynx. For long-term tracheostomy patients, speaking is possible with these options: A fenestrated inner cannula inside a cuffed outer cannula allows speech when the cuff is deflated. Some tubes have cuffs that expand on inspiration and deflate on expiration allowing speech as you expire. Others have cuffs that have to be manually deflated. A tracheostomy speaking valve is a device that attaches to the trach tube. The Passy-Muir Valve is a commonly used speaking valve that contains a diaphragm that opens on inspiration and closes on expiration so that air is exhaled through the vocal cords and upper airwary. The cuff of the tracheostomy tube must be completely deflated during speaking valve use to allow for exhalation through the upper airway.

A speaking trach tube forces air or oxygen from an outside source to flow across the vocal cords, independent of the airflow within a closed system created by a cuffed trach tube. The patient has control over this air line with a thumb port.

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Image of the Passy-Muir Speaking Valve, placed on the hub of the tracheostomy tube, it redirects air flow through the vocal folds, mouth and nose enabling voice and improved communication. Image courtesy of Passy-Muir, Inc., Irvine, CA.

Nursing Care: Assessment

When caring for a patient with a tracheostomy, a thorough assessment should be completed at the start of every shift (Freeman, 2011). Dont allow tracheostomy equipment to distract you from your first priority, which is assessement of the patient. Observe your patient for signs of hypoxia, infection, and pain. Examine the trach tube, any tubing and equipment connected to it, as well as the stoma site. Observe for redness, purulent drainage, and abnormal bleeding around the stoma. Note the amount, color, consistency, and odor of secretions. Auscultate to breath sounds with a stethoscope. Before beginning any care, ensure that the appropriate emergency trach replacement tubes and CPR equipment is at the bedside. Be sure to clarify why the tracheostomy was initially performed, how it was performed and the type and size of tube inserted (Russell 2005 in Freedman, 2011).

Image provided courtesy of Smiths-Medical ABD, Inc. (2012.

True or False: In addition to listening to lung sounds, you should observe your patient for signs of hypoxia. The correct answer is: True.

Nursing Care: Providing Humidification

When a tracheostomy is inserted, the natural warming, humidification and filtering of inhaled air is lost
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(Freeman, 2011). Therefore, it is essential to provide an alternate form of humidification. There are various humidification methods available, including: Heated humidification (Increases heat and water vapor inhaled) Ambient or cold water humidification Heat and moisture exchangers Stoma protectors

(Freeman, 2011) Ensure that you are familiar with the method used in your organization. Note! Humidifiers and nebulizers may be used with, or independent of, mechanical ventilation. A moisture conservation device, called a heat moisture exchanger, can also be attached to the outside of a trach tube for long-term trach patients (Bissell, 2004).

Thermovent Heat & Moisture Exchanger Image provided by Smiths-Medical ABD, Inc. (2012).

Nursing Care: Mobilizing Secretions

Trach patients often experience a temporary increase in the production of secretions, and usually require assistance to mobilize these secretions. Their artificial airway bypasses natural humidification and imposes a foreign object that the body reacts to. In addition, many patients have acute and/or chronic diseases 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.

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Nursing Care: Suctioning

Suctioning is necessary for all trach patients to remove secretions and assess airway patency. Acute care patients need to be assessed every two hours for the need for suctioning. Suctioning is routinely done twice a day but more often if needed, particularly following tracheostomy or when there is an infection present. Suctioning activates psychological and physiological reflexes that make the experience both uncomfortable and frightening for your patient (SIMS Portex, 1998). They may have severe hypoxia, cardiac arrhythmias, and even cardiac arrest when the airway is occluded by the catheter and air is simultaneously sucked out of the lungs. Always explain the procedure beforehand. Test Yourself Acute care patients need to be assessed every ____hours for the need for suctioning. A. One B. Two C. Three D. Four The correct answer is B: Two.

Nursing Care: Suctioning

Indications for suctioning include: Dyspnea: Flared nostrils, chest retractions and / or prolonged wheezing Noisy breathing Cyanosis and clammy skin Restlessness and agitation Copious secretions; moist cough Low oxygen saturation Increased peak inspiratory pressure on mechanical ventilator (Bissell, 2004) Copy and paste the following link into your Internet browser to watch a video demonstrating aseptic suctioning technique: http://www.youtube.com/watch?v=UVuPzhOWxRs

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Image provided courtesy of Smiths-Medical ASD, Inc. (2012).

Selecting A Suction Catheter

Selection of the appropriate size suction catheter is vital in reducing the risk of trauma during suctioning. The following formula can be used to determine the correct size suction catheter to use: Divide the internal diameter of the tracheostomy by two, and multiply the answer by three, to obtain the French gauge of the correct suction catheter (Billau, 2004 in Feeman, 2011). For example: When a size 8 tracheostomy tube is used, the internal diameter of the tracheostomy will be (8mm/2) X 3 = 12. Therefore, a size 12 French gauge catheter is suitable for use (Freeman, 2011).

Procedure for Suctioning

The risks involved with suctioning can be minimized by following technical parameters agreed upon by clinicians and researchers: Position patient in semi-Fowlers. Time the suctioning procedure to occur prior to eating. Select the appropriate size suction catheter, based on the size on the tracheostomy tube used. Hyperoxygenate before each pass with the catheter, although some initial suctioning should be done if using bag ventilation, so as not to drive secretions deeper toward the lungs. (Exceptions to hyperoxygenation are children and those with long-term tracheostomies.) Insert the catheter to a pre-measured depth matching the length of the tube and only to a point of resistance, if deeper suctioning is necessary. Supply suction intermittently while rotating unless the catheter has side holes. (Controversy exists on whether to apply suction on withdrawal only or on both insertion and withdrawal.) Limit suctioning to 5 seconds for pre-measured depth and 10-15 seconds for deep suctioning (Freeman, 2011). Use suction pressure between 80 and 120 mmHg. Limit suctioning to 3 passes and discontinue if heart rate drops by 20, increases by 40, produces arrhythmias, or decreases oxygen saturation to less than 90%.

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Suction mouth after trach suctioning to remove secretions above a cuffed tube. Do not contaminate the trach by going from mouth back to trach. Reassess the patient's condition after suctioning and recommence oxygen therapy as soon as possible, ideally within 10 seconds of completing suctioning (Freeman, 2011).

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 of a new tracheostomy tube. Thereafter, ties are generally changed daily after the first 24 hours. 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 (McConnell, 2002; Bissell, 2004). Twill tapes, Velcro tapes, metal chains, and plastic IV tubing are some of the options available. You should be able to easily slip one or two fingers between the ties and the neck for a proper fit. Do not use Velcro if there is a possibility the patient will try to pull them apart.

Image provided courtesy of Marpac (2012).

Maintenance of The Inner Cannula

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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 half-strength hydrogen peroxide and normal saline solution, or normal saline. Reinsert and lock in place within a fifteen minute time frame.

Nursing Care: Cuff Pressure

Cuff pressure should be maintained in a range from 20 mmHg to 25 mmHg (Freeman, 2011). Cuff pressures are measured with a manometer and should be measured every shift (Intensive Care Society 2008 in Freeman, 2011). If your patient has a cuffed trach, check cuff pressure every four to eight hours. Complications can arise quickly from excessive pressure that can inhibit capillary perfusion. Record the pressure reading and report your findings to the physician if you notice it takes increasing volumes to inflate the tracheostomy cuff. The need to increase the volume to inflate the cuff may indicate that the valve may be faulty or tracheal changes may have occurred. Deflating and inflating the cuff is a way to: Assess how the cuff is working. Periodically relieve pressure on the trachea.

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Let secretions above the cuff to drain down so you can suction them.

The frequency of this procedure should be coordinated with suctioning and the routine care schedule. There are two ways to determine the best cuff pressure: The occlusive technique is used when the cuff has a pressure relief valve for self-adjustment. The minimal leak technique is used to provide some pressure slack by releasing a small amount of pressure after inflating the cuff to a point indicating a tight seal. 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 hiss returns.

Test Yourself: If your patient has a cuffed trach, check cuff pressure every: A. One to two hours B. Two to four hours C. Four to eight hours D. Twenty four hours The correct answer is C: Four to eight hours.

Nursing Care: Changing The Trach Tube

Trach tubes, (both the single cannula type and the outer cannula of a universal type), are changed every one to four weeks. Metal tubes can eventually develop cracks at the soldered joints. Silicon tubes can crack or tear. Soft PVC tubes stiffen with age. When a patient has had a tracheostomy for several months, the stoma is well formed and tube changes can be safely done on a monthly basis, even at home, using a clean technique. In the hospital however, safety requires two people using sterile technique for inserting a new tube. The initial tube change is usually performed by a physician (SIMS Portex, 1998). Ensure that your patient has not eaten or received a tube feeding at least an hour before this procedure. For cuffed tubes, test the cuff by inflating and deflating before inserting it. Always use the tracheostomy obturator for a smooth guide to insertion. Test Yourself: In the hospital, safety requires ____people using sterile technique to insert a new tube. A. Two B. Three C. Four D. None of the above The correct answer is A: Two.

Nursing Care: Trach Site Care & Dressing Changes

Begin by assessing the stoma for infection and skin breakdown. Clean the stoma with a Q-tip or gauze square moistened with normal saline solution (NSS). Avoid using hydrogen peroxide unless the site is
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infected, as it can impair healing (Nance-Floyd, 2011). If there are signs of infection, the skin around the stoma can be cleaned with swabs soaked in half-strength hydrogen peroxide, rinsed with normal saline solution (NSS) and patted dry. Occasional redness and purulent drainage may be expected. Topical treatment can be used for minor infections. Dressings around the stoma are only changed for excessive exudate. If necessary, dressings should be uncut gauze or sponges and changed frequently enough to keep the area clean and dry. Tracheostomy dressing changes promote skin integrity and help prevent infection (Nance-Floyd, 2011). Follow your unit's Policies and Procedures regarding dressing changes. At least once per shift, apply a new dressing to the stoma site to absorb secretions and insulate the skin. After applying a skin barrier, apply a split-drain or foam dressing (Nance-Floyd, 2011). Change wet dressings immediately.

Cleaning the stoma. Image provided courtesy of Smiths Medical ABD, Inc. (2012).

Nursing Care: Nutrition & Communication

A tracheostomy will not prevent a patient from eating although some patients may have concurrent swallowing problems that need evaluation by an otolaryngologist or speech pathologist. Patients may have poor appetite because of disease or in reaction to copious respiratory secretions. Suctioning prior to meals is helpful. Inability to speak is anxiety-provoking for most patients and you will need to devise alternative methods of communication for your patient until long-term speaking solutions are initiated. Patients require an extra measure of sensitivity in the first few days post-tracheostomy while they are coping with choking sensations and pain. The patient should always have a call bell within reach at all times. A writing pad or a yes/no system to communicate will assist with communication.

Complications
Complications from a tracheostomy can arise in the first few days or within several weeks. Initially, the most common complications are: Inflammation and edema of the trachea. Infection and abscess of the stoma and/or pulmonary tree.

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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 tracheostomy tube are due to tracheal scarring and erosion. Stenosis, the narrowing of the trachea from scar tissue, occurs in 5 to 15% of patients (Fenstermacher & Hong, 2004). This development escalates with a history of endotracheal intubation and/or excessive tracheostomy tube cuff pressure. Scarring can occur at the stoma, the tube cuff site, or at the point where the distal end of the tube presses on the tracheal wall. It may cover a large area extending beyond the trachea, in weblike fashion, or appear as a localized granuloma. True or False: Long-term complications from the presence of a trach tube are due to coughing. The correct answer is: False. Long-term complications from the presence of a trach tube are due to tracheal scarring and erosion. Complications Common Tracheal irritation Long-term Stenosis

Infection + abscesses Webbing + granulomas Mucosal bleeding Fistulas

Stenosis: Is a fairly common complication of tracheostomies, but are usually not significant enough for surgical intervention unless it narrows the airway more than 50% (Fenstermacher & Hong, 2004). Thus, a patient will usually not be scoped to assess tracheal stenosis until after the trach tube is taken out. Ulceration and scarring: May occur with prolonged exposure to a tracheostomy tube. Treatment options for scarring may include: Serial dilation Endoscopic excision Anterior cricoid split or laryngotracheoplasty (Bissell, 2004)

Fistula Formation: Fistulas may take months to develop. The constant pressure from a poorly fitted tracheostomy tube, excessive cuff volume, and/or a 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
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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
Tracheostomy 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 it for 24 hours. During these times, the patient should be closely observed for respiratory distress (Freeman, 2011). Systematic downsizing of the tube may also be used for the weaning process. Assess your patients risk of aspiration before removing the tube. It is advisable to keep the patient nil by mouth for at least four hours beforehand and / or have their nasogastric tube aspirated (Feeman, 2011). Once the tube is removed, an occlusive dressing should be placed over the remaining stoma to form a seal so that the patient can breathe normally through the nose and mouth (Woodrow, 2002 in Freeman, 2011). Once the tube is taken out, the stoma usually gradually closes by itself. If not, minor surgery will be required. The patient should be instructed to apply gentle pressure over the stoma dressing when coughing or speaking to aid the closure of the stoma (Intensive Care Society, 2008 in Freeman, 2011). Dressings need to be kept dry and may require frequent changes.

Image provided courtesy of Smiths-Medical ASD, Inc. (2012).

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Home Care
A patient discharged home with a tracheostomy usually requires home nursing services, however, patient and family education should start in the hospital. Two adult caregivers should be trained so that at least one individual is available to the patient at all times (American Thoracic Society, 2012). Care of a tracheostomy tube at home depends on whether the tube is temporary or permanent. A temporary tube will be removed and the area allowed to heal when the tube is no longer needed. With a permanent tube, the tracheostomy will need to remain open. Some tubes may have an inner cannula that will require cleaning several times a day or whenever it becomes clogged with secretions. Initial care of a tracheostomy at home might include: Warm compress to the incision site to help relieve discomfort Humidified air (to keep the site from drying out) Wearing a scarf over the tracheostomy opening to keep the area clean and dry Following up with your physician with any concerns or changes

Test Yourself: Home care teaching for a tracheostomy patient includes instructing them that a _____ compress to the incision site to help relieve discomfort. A. hot B. cold C. warm D. roxanol The correct answer is C: warm. Individualize your care plan to accommodate the patient and their environment. Instruct the tracheostomy patient to avoid: Deep bathing water Fine particles such as powders, chalk, sand, dust, mold, and smoke Loose fibers and hair found on fuzzy toys and pets Persons with contagious illnesses Cold air and wind

Portable suction equipment is available for travel and should be tested before depending on it. You may direct patients and families to go online to a nurse-created website designed for pediatric trach patients but applicable to adults as well. This award-winning site contains both educational and support resources (copy and paste the following link into your Internet browser): http://www.tracheostomy.com

Conclusion
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Tracheostomy care requires specific equipment and planning to provide individualized patient care. Early and ongoing preventive strategies for tracheostomy care will be essential to meet the needs of your patients. Many of the tracheostomy patients you care for will only require a tracheostomy temporarily during an acute phase of critical care. Other patients may be trached for life. You must be prepared to care effectively for all patients with tracheostomies. To achieve positive outcomes in patients with tracheostomies, nurses must keep abreast of best practices and develop and maintain skills necessary to manage tracheostomies.

References
American Thoracic Society. (2012). Care of the child with a chronic tracheostomy. Retrieved September 10, 2004 from http://www.thoracic.org Bissell, Cyntia. (2004). Aarons tracheostomy page. Retrieved September 11, 2004 and November 19, 2009 from http://www.tracheostomy.com Caulfield, E. & Astle, S. (2003). Bedside tracheostomy: A step-by-step guide. RN Magazine, 66:41. Retrieved September 11, 2004 from http://www.rnweb.com Dixon, L. (2003). Tracheostomy: Postoperative recovery. Retrieved September 10, 2004 from http://www.perspectivesinnursing.org . Fenstermacher, D. & Hong, D. (2004). Mechanical ventilation: What have we learned? Critical Care Nursing Quarterly, 27(3): 258-294. Freeman, S. (2011). Care of adult patients with a temporary tracheostomy. Nursing Standard, 26 (2), p. 49-56. Imperatore, F.; Diurno, F.; Passannanti, T.; Liguori, G.; dIgnazio, N.; Marsilia, P.; Munciello, F. & Occhiochiuso, L. (2004). Early and late complications after elective bedside surgical tracheostomy: Our experience. Medscape General Medicine, 6(2). Retrieved September 11, 2004 from http://www.medscape.com Lewis, S.; Heitkemper, M. & Dirksen, S. (2000). Medical-Surgical Nursing: Assessment and management of clinical problems. Fifth edition. St. Louis, Missouri: Mosby, Inc. McConnell, E. (2002). Providing tracheostomy care. Nursing 2002, 32(1): 17. Medline Plus. (2003). Medical Encyclopedia: Tracheostomy. Retrieved September 10, 2004 from http://www.nlm.nih.gov/medlineplus/ency/article/002955.htm Nance-Floyd, B. (2011). Tracheostomy Care: An evidence-based guide to suctioning & dressing changes. American Nurse Today, 6 (7), p. 14-16. National Cancer Institute. (2007). NCI Visuals Online. Larynx and Nearby Structures. Image retrieved November 26, 2012 from: http://visualsonline.cancer.gov/details.cfm?imageid=4357
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National Heart, Lung & Blood Institute (2012). Tracheostomy Care Image. Retrieved Nov 14, 2012 from: http://www.nhlbi.nih.gov/health//dci/Diseases/trach/trach_during.html Peter, K. (2008). Tracheostomy Tube Image. Retrieved from:http://en.wikipedia.org/wiki/File:Tracheostomy_tube.jpg Robinson, E. (2000). Critical pointers: Tracheostomies. Retrieved September 10, 2004 from http://tracheostomy.com Schreiber, D. (2001). Trach care at home: A how-to guide. RN Magazine, 7:43. Retrieved September 11, 2004 from http://www.rnweb.com SIMS Portex, Inc. (1998). Tracheostomy care handbook: A guide for the health care provider. Retrieved September 11, 2004 from http://www.trachestomy.com Smith-Medical, INC. (2009).Tracheostomy Images. Reproduced with permission from Smiths-Medical.
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