A tracheostomy is a surgical procedure in which an opening is made in the trachea to enable the patient to breath. This artificial airway may be used in emergency situations, may be an elective procedure or may be combined with mechanical ventilation.
Indications
- Need for prolonged ventilation
- Laryngotracheobronchitis
- Epiglottitis with edema or laryngeal spasm
- Foreign bodies that cannot be removed via larynx
- Congenital anomalies or acquired stenosis of the larynx or upper trachea
- Central nervous system disorders
- Subglottic stenosis
- Tracheomalacia
- Vocal cord paralysis
Equipment Needed
A sterile tray containing:
- Tracheostomy tube (silastic, polyvinyl chloride, or plastic tubes)
- Extra tracheostomy tube in the case of
accidental dislodgement - Obturator and extra inner cannula (Pig.8.8)
- Tracheostomy ties
- Small curved scissors
- Blunt hemostat
- Cotton-tipped applicators
- Water
- 3% hydrogen peroxide
- Betadine swabs
- Uncut dressing pads
- Oxygen
- Self-inflating resuscitation bag
- Lubricating jelly
- Call bell within child’s/parents’ reach
- Suction equipment:
- A pair of sterile gloves
- Suction apparatus with good negative pressure
- Sterile suction catheter
- No 6 Fr catheters for infants and young children, no. 8-10 for old children
- – Sterile saline
Preparation of the Child and Family
- Explain to the parents about surgical procedure.
- Explain the indications.
- Use all the possible means to reduce the anxiety.
Procedure
- Position the infant/child supine with a blanket or towel roll to extend the neck.
- Open all packaging and cut tracheostomy ties to appropriate length if necessary.
- Clean around the tracheostomy site with prescribed solution (half-strength hydrogen peroxide or acetic acid, normal saline (NS), Betadine or soap and water] and cotton-tipped applicators working from just around the tracheostomy tube outward.
- Rinse with sterile water and cotton-tipped applicator in a similar fashion.
- Place the pre-cut sterile gauze under the tracheostomy tube.
- With the assistant holding the tube in place, cut the ties, and remove from the tube.
- Attach the clean ties to the tube and secure in the place.
Nurse’s Responsibility
- Nursing care is indispensable to the survival of the patient because blockage of the tube by mucus or other secretions can lead to suffocation.
- Usually after the procedure, the child is placed in intensive care unit because this is the critical period requiring frequent suctioning and very close observation.
When the condition stabilizes, the child is transferred to the regular unit. - The child with tracheostomy is placed in an area of high visibility.
- Infants and children normally communicate their needs by crying but the tracheostomy prohibits vocalization.
- Whenever possible, one person is assigned to the child and to work with the parents. Reinforce preoperative teaching.
- Explain what has happened in an age-appropriate manner.
- For example, “You are having a lot of trouble breathing. The operation called tracheostomy helps you breathe easier. A small opening has been made in your neck. A hallow tube is inserted to keep the area open. It is frightening not able to speak. When you are better, the hole will close by itself, and your voice will return.”
- An explanation of suction might be we have to keep the area in your neck open. This tube goes into the airway and clears it. Demonstrate the use of suction in a glass of water.
- Prepare the child for unfamiliar sound. You might feel like gagging, but afterward you will feel better. I know this is difficult for you. And I am sorry there is no easier way.
- Added moisture and humidity are provided using a special tracheostomy collar, or direct attachment to a mechanical ventilator. This is necessary because the nose and the mouth no longer warm and moisten the inspired air.
- The anatomical difference between a child and adult is the small child’s inability to communicate through writing, which increases the need for close observation.
- Maintaining patency of the tracheostomy tube is of utmost important. Plastic or silastic tubes are generally used because they are flexible and reduce crust formation. They are lightweight and disposable, and most do not have inner cannula. Cuffed tubes are not usually necessary in infants and in small children because their air passages are small, and the tracheostomy tube provides a sufficient seal.
Suction Depths
- Shallow suctioning: Suction secretions at the opening of the trach tube that the child has coughed up.
- Premeasured suctioning: Suction the length of the trach tube. Suction depth varies depending on the size of the trach tube. The obturator can be used as a measuring guide.
- Deep suctioning: Insert the catheter until resistance is felt. (Deep suctioning is usually not necessary. Be careful to avoid vigorous suctioning, as this may injure the lining of the airway.)
Signs that a Child Needs Suctioning
- Rattling mucus sounds from the trach.
- Fast breathing.
- Bubbles of mucus in trach opening.
- Dry raspy breathing or a whistling noise from trach.
- Older children may vocalize or signal a need to be suctioned.
- Signs of respiratory distress.
Types of Tracheostomy Care Techniques
- Sterile technique: Sterile catheters and sterile gloves
- Modified sterile technique: Sterile catheters and clean gloves
- Clean technique: Clean catheter and clean
Procedure
- Explain the procedure in a way appropriate for the child’s age and understanding.
- Wash hands
- Set up equipment and connect suction catheter to machine tubing.
- Pour NS into cup
- Put on gloves
- Turn on suction machine
- Place tip of catheter into saline cup to moisten and test to see that suction is working.
- Instill sterile NS with plastic squeeze ampoule into the trach tube if needed for thick or dry secretions. Excessive use of saline is not recommended. Use saline only if the mucus is very thick, hard to cough up or difficult to suction. Saline may also be instilled via a syringe or eye dropper, which is less expensive than single dose units. Recommended amount per instillation is approximately 1 cm.
- Gently insert catheter into the trach tube without applying suction. (Suction only length of trach tube premeasured suctioning. Deeper insertion may be needed if the child has an ineffective cough.)
- Put thumb over opening in catheter to create suction and use a circular motion (twirl catheter between thumb and index finger) while withdrawing the catheter so that the mucus is removed well from all areas. Avoid suctioning longer than 10 seconds because of oxygen loss.
Note: Research findings had shown that by applying suction both going in and then out of the tube takes less time and therefore results in less hypoxia. Also, there are now holes on all sides of the suction catheters, so twirling is not necessary. - Draw saline from cup through catheter to clear catheter.
- For trach tubes with cuffs, it may be necessary to deflate the cuff periodically for suctioning to prevent pooling of secretions above trach cuff.
- Let the child rest and breathe, then repeat suction if needed until clear (allow at least 30 seconds between suctioning).
- Oxygenate as ordered (extra oxygen may be given before and after suction to prevent hypoxia).
- Some children need extra breaths with an Ambu bag (approximately 3-5 breaths).
- Purposes of bagging: Hyperoxygenation, hyperinflation, and hyperventilation of the lungs. However, this is usually not needed for stable children with no additional respiratory problems.
Nurse’s Responsibility
- Withdraw the catheter while rotating and applying suction by covering the part on the catheter with the thumb.
- Hold the suction for no >5 seconds.
- The child should be allowed to rest for about a minute and take 2 or 3 breaths between suctioning.
- Hyperventilate the child with 100% oxygen between suctioning to prevent hypoxia.
- The use of pulse oximeter can provide a measure of the child’s oxygenation during and after the procedure.
Additional Measures
- Frequent change of position, the use of arm restraints, oral feeding unless contra-indicated.
- Careful bathing to prevent water entering the tube.
- Range of motion exercise is a must for long-term patients and in acute cases, arm restraints are removed one at a time to allow for passive exercises.
- Although the patients, initially may have nothing by mouth, as their condition improves, they progress to a soft or normal diet.
- Fowler’s position is preferred during feeding.
- Older children can cooperate by holding their head flexed with chin down. This decreases swallowing difficulties because when the esophagus opens and the airway narrows.
- Monitor feeding of an infant closely so that no food particles aspirated through the tracheostomy.
- Some patients are discharged with the tracheostomy. This should be anticipated, and instruction and demonstration for patients should begin early.
- Parents who are comfortable with the procedure during hospitalization feel more secure when the child returns home.
- It is advisable for the parents to be
“demonstrated” on tracheostomy procedure before discharging and most hospitals now require this. - Trach ties: Children often may develop, rashes or skin breakdown under the trach ties because of leaking secretions, perspiration, and the short length of the child’s neck or any skeletal deformities.
Treatment of these conditions includes antibiotic or antifungal creams, powders more frequent tie changes, changing the type of ties, using pads to bridge the damaged area. Occasionally, it is necessary to reposition the patient to reduce the pressure on the area.
If all these have been failed, ENT specialists may need to suture the trach in the place and thus temporarily eliminate the need for any type of trach ties.
Suction Pressure
Infant: 60-100 mm Hg
Children: 100-110 mm Hg
Adult: 110-150 mm Hg
Chest physiotherapy can be given to remove the secretions.
Complications
Intraoperative: Hemorrhage, tracheoesophageal fistula, pneumothorax, pneumomediastinum, cricoid cartilage injury, cardiopulmonary injury, tube obstruction or displacement, posterior tracheal wall disruption, or death.
Immediate postoperative: Hemorrhage, wound infection, subcutaneous emphysema, pneumothorax, pulmonary edema, dysphagia, pneumonia, sepsis, atelectasis, death.
Late postoperative: Suprasternal collapse, suprasternal/distal tracheal granuloma, tracheoesophageal fistula, tracheocutaneous fistula, laryngotracheal stenosis, tracheal wall erosion, hemorrhage, inability to decannulate, mucus plug, bronchospasm, death.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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