Procedure, Types and Complication of Tracheostomy

Subject: Medical and Surgical Nursing II (Theory)

Overview

A tracheostomy is a surgical technique that involves creating a hole through the neck into the trachea (windpipe). Typically, a tube is inserted into this incision to establish an airway and remove secretions from the lungs. This tube is referred to as a tracheostomy tube, or trach tube. The goal of tracheostomy is to keep the airways open to allow for therapeutic gas exchanges, to allow for Bronchial toilet: to eliminate tracheal bronchial secretion, to maintain optimal physical comfort, and to prevent aspiration and transmission of harmful microorganisms. Early complications that may occur during or shortly after the tracheostomy procedure include bleeding, air trapped in the lungs (pneumothorax), pneumomediastinum, subcutaneous emphysema, swallowing tube injury, and so on. Many of these early issues can be prevented or dealt with effectively in a hospital setting by our expert surgeons. Later complications that may develop while the tracheostomy tube is in situ include the tracheostomy tube being accidentally removed, infection in the trachea and surrounding the tracheostomy tube, and so on. Tracheostomy tube suctioning is done only when necessary. The sterile technique must be followed. Nurses should be aware that suctioning is frequently required during the initial postoperative period.

Procedure

The surgery is usually conducted in the intensive care unit or the operating room. In either location, the patient's pulse oximeter (oxygen saturation) and heart rhythm are continuously monitored (EKG). To make the procedure more comfortable for the patient, anesthesiologists typically use a combination of intravenous medication and a local anesthetic. The surgeon makes a low neck incision. The trachea is located in the center, and an opening is made to allow the new breathing path (tracheostomy tube) to be introduced below the voice box (larynx). Newer approaches involving specific tools have enabled this treatment to be performed percutaneously (a less invasive approach using a piercing method rather than an open surgical incision).

Types of tracheostomy tubes:

Temporary
Permanent

Care of Tracheostomy Patients

Preoperative nursing measures: In addition to standard pre-operative preparation of the patient unit, the following measures should be scheduled ahead of time.

For at least the first 48 hours, the patient will require close supervision.
The nursing staff must remember two things: the patient's survival depends on a clear airway, and the patient will experience a temporary loss of speech. As a result, the patient must be continuously monitored for airway patency, and any unpleasant signs or symptoms must be addressed immediately.
The patient will be concerned about his inability to communicate through his voice. Always keep a call bell near the patient. Create a temporary communication method, such as writing notes or using flash cards, so that the patient can communicate his needs to the nursing staff.
The patient should be kept in a room where the temperature and humidity can be controlled at optimal levels for the first several days after surgery. Increased warmth and humidity will assist to minimize tracheal irritation caused by the natural warming and moisturizing of the nasopharyngeal airways.
The patient's room should be outfitted with all of the equipment required for the patient's treatment. Suction equipment, a backup tracheostomy tube set, and sterile dressing material are examples of such items.

Post- operative measures: The following nursing actions should be noted in addition to routine post-operative nursing care:

When caring for the wound and the airway, always use fundamental aseptic principles. Use separate suction sets for pharyngeal and tracheostomy suctioning.
Always keep an eye out for indicators of respiratory obstruction, such as restlessness, cyanosis, an elevated pulse, or gurgling noises during respiration.
When suctioning, look for blood in the aspirated secretion and watch for bleeding in an incision.
When the patient swallows, keep an eye out for choking and coughing. This could imply esophageal injury with tracheal leaking of ingested substances.
Post-operative care:
- Every 12 hours, suction with no 8fr catheters.
- Boiling water in a kettle in front of the pt will humidify the air.
- Clean the inner tube as often as needed.
- Regularly clean the tube.
- Prophylactic antibiotics should be given.

Complication

Early Complications that may arise during the tracheostomy procedure or soon thereafter include:

Bleeding
Trapped air in the lungs (pneumothorax)
Air trapped in the chest's deeper levels (pneumomediastinum)
Air is trapped beneath the skin near the tracheostomy (subcutaneous emphysema)
The swallowing tube has been damaged (esophagus)
Damage to the nerve that controls the vocal chords (recurrent laryngeal nerve)
Blood clots, mucus, or airway wall pressure can all clog the tracheostomy tube. Suctioning, humidifying the air, and using the proper tracheostomy tube can all help to prevent blockages.

Many of these early complications can be avoided or dealt with appropriately in a hospital setting by our experienced surgeons. Other complications from the surgery may arise over time.

Later Complications that may occur while the tracheostomy tube is in place include:

The tracheostomy tube was accidentally removed (accidental decannulation)
Infection of the trachea and the area surrounding the tracheostomy tube
The windpipe itself can be damaged for a variety of reasons, including tube pressure, bacteria that cause infections and scar tissue, and friction from a tube that moves too much.

These complications can usually be prevented or quickly dealt with if the caregiver has proper knowledge of how to care for the tracheostomy site.

Delayed Complications that may result from a longer-term presence of a tracheostomy includes:

Tracheal thinning (erosion) caused by the tube pushing against it (tracheomalacia)
A tracheoesophageal fistula is the formation of a small connection between the trachea (windpipe) and the esophagus (swallowing tube).
Bump formation (granulation tissue) that may require surgical removal before decannulation (trach tube removal) can occur.
Narrowing or collapse of the airway above the tracheostomy site, which may necessitate an additional surgical procedure to repair.
The opening may not shut on its own when the tracheostomy tube is withdrawn. Tubes that have been in situ for 16 weeks or more are more likely to require surgical closure.
A clean tracheostomy site, proper tracheostomy tube maintenance, and regular airway assessment by an otolaryngologist should help to reduce the recurrence of any of these issues.

REFERENCE

HealthLine. 2005. 2017 http://www.healthline.com/health/tracheostomy

KidsHealth. 1995. 2017 http://www.rch.org.au/kidsinfo/fact_sheets/Tracheostomy_information_for_parents/

Mayo Clinic. 1998. 17 August 2016 http://www.mayoclinic.org/tests-procedures/tracheostomy/home/ovc-20233993

MedicineNet. 1996. 2017 http://www.medicinenet.com/tracheostomy/article.htm

Medline Plus. 05 January 2017 https://medlineplus.gov/ency/article/002955.htm

Medscape. 1994. 2017 http://emedicine.medscape.com/article/865068-overview

Mandal, G.N. Textbook of Adult Nursing. Kathmandu: Makalu Publication House, 2013.

NHS Choice. http://www.nhs.uk/conditions/Tracheostomy/Pages/Introduction.aspx

Web MD. 2005. 2017 http://www.webmd.boots.com/a-to-z-guides/tracheostomy

Things to remember

A tracheostomy is a surgical technique that involves creating a hole through the neck into the trachea (windpipe).
Typically, a tube is inserted into this incision to establish an airway and remove secretions from the lungs.
This tube is referred to as a tracheostomy tube, or trach tube.
The goal of tracheostomy is to keep the airways open to allow for therapeutic gas exchanges, to allow for Bronchial toilet: to remove tracheal bronchial secretion, to maintain optimal physical comfort, and to prevent aspiration and transmission of pathogenic microorganisms.
Early complications that may occur during or shortly after the tracheostomy procedure include bleeding, air trapped in the lungs (pneumothorax), pneumomediastinum, subcutaneous emphysema, swallowing tube injury, and so on.
Many of these early issues can be prevented or dealt with effectively in a hospital setting by our expert surgeons.
Later complications that may develop while the tracheostomy tube is in situ include the tracheostomy tube being accidentally removed, infection in the trachea and surrounding the tracheostomy tube, and so on.
Tracheostomy tube suctioning is done only when necessary. The sterile technique must be followed.
Nurses should be aware that suctioning is frequently required during the initial postoperative period.

Questions and Answers

Write about the care of tracheostomy patients ?

Preoperative nursing measures: In addition to routine preparation of the patient unit for the pre operative care, the following measures should be planned in advance.

The patient will require constant attendance for at least the first 48 hours.
The nursing personnel must remember two important things: the patient’s life depends upon a clear airway, the patient will have a temporary loss of voice. Therefore, the patient must be closely observed for airway patency and immediate action taken when any adverse signs or symptoms are present.
The patient will feel Anxious about his inability to communicate with his voice. Always have a call bell available to the patient. Devise a temporary means of communication such as writing notes or using flash cards so that the patient may communicate his needs to the nursing personnel.
For the first few days postoperatively, the patient should be kept in a room where the temperature and humidity can be maintained at optimum levels. Increased temperature and humidity will help reduce the tracheal irritation that results when inspired air has by passed the natural warming and moisturizing of the nasopharyngeal airways.
The patient’s room should be supplied with a variety of equipment necessary to the care of the patient. Such things include suction equipment, spare tracheostomy tube set, and sterile dressing material.

Post operative measures: in addition to the routine post operative nursing care, the following nursing actions should be noted:

Always apply basic principles of aseptic technic when caring for the incision and the airway. When suctioning use separate set-ups for pharyngeal and tracheostomy suctioning.
Constantly observe the patient for signs for respiratory obstruction such as restlessness, cyanosis, increased pulse, or gurgling noises during respiration.
Watch closely for bleeding in incision, look for blood the aspirated secretion when suctioning.
Be alert when choking and coughing when the patient swallows. This may indicate damage to the esophagus with leakage of swallowed material into the trachea.
Post operative care:
Suction with no 8fr catheters every ½ hrly.
Humidify the air by boiling water in a kettle in front of the pt.
Clean the inner tube as frequently as necessary.
Clean the tube frequently.
Prophylactic antibiotic should be administered.

What are the complication of tracheostomy ?

Early complications that may occur during or shortly after the tracheostomy procedure include:

Bleeding
trapped air in the lungs (pneumothorax)
Air trapped in the chest's deeper layers (pneumomediastinum)
Air is trapped beneath the skin near the tracheostomy (subcutaneousemphysema)
The swallowing tube has been damaged (esophagus)
Damage to the nerve that controls the vocal cords (recurrent laryngeal nerve)
Blood clots, mucus, or airway wall pressure can all block the tracheostomy tube. Suctioning, humidifying the air, and using the proper tracheostomy tube can all help to prevent blockages.
Many of these early complications can be avoided or dealt with appropriately in a hospital setting by our experienced surgeons.

Other complications from the surgery may arise over time.

Complications that may arise later while the tracheostomy tube is in place include:

The tracheostomy tube was accidentally removed (accidental decannulation)
Infection of the trachea and the area surrounding the tracheostomy tube
The windpipe itself can be damaged for a variety of reasons, including tube pressure, bacteria that cause infections and scar tissue, and friction from a tube that moves too much.