UNM COC:  Your Healthcare Primer for Long Term Care

 
Tracheostomy Care

Javier Aceves, M.D. (Pediatrician) 

Definition

Tracheotomy is the surgical procedure to place an artificial opening on the trachea or breathing pipe, and Tracheostomy is the stoma or skin opening on the trachea on the front of the neck just below "Adam’s apple". Sometimes healthcare personnel refer to the tube and opening as the "trache". These terms are frequently used interchangeably.

Introduction

Individuals with an artificial airway on their necks or trache usually have them because they have either a problem with:

1. Airway obstruction, (the mouth, throat and or wind pipe is or becomes obstructed or blocked) either because of epiglotitis (infection), swelling, tumor, cystic hygroma (a cyst), Stenosis (narrowing), burns, trauma, and or congenital anomalies (deformities) of the airway.

2. Chronic lung disease, chest wall instability, diaphragm dysfunction and or the person needs prolonged pulmonary support (can’t breath on their own)

3. Neuro-muscular conditions that cause weakness or paralysis, neurosensory problems of the airway (for example, trouble swallowing saliva, so that is gets stuck in the airway), unconsciousness, central hypoventilation syndrome/central apnea (weak breathing effort).

Individuals with a tracheostomy may or may not be able to care for themselves because they are debilitated, can not move, or at times their cognitive level does not allow them to safely follow the care procedures or protocols. Some may feel intimidated by the procedure. Very frequently where there is a need for a trache there is also need for mechanical ventilation.

Tracheostomy tubes by-pass the vocal cords and therefore most patients with a trache are not able to talk. Some tracheostomy tubes allow air to go through the vocal cords (they are fenestrated- have holes) and patients are capable of making sounds.

Artificial airways can be life saving and appropriate care of them is extremely important. These airways need daily care by licensed personnel such as nurses and or family members who have been properly trained by them. Individuals who have a trache are frequently followed by a Pulmonary Team. These teams are formed by doctors, nurses and technical professionals like respiratory therapists who assess the integrity of the airway, check for infections, bleeding, make modifications when necessary for the mechanical ventilator when there is one in place, and write-up recommendations for the daily care of these artificial airways.

Diagnosis

It is very important to become familiar with the signs of potential complications when there is a trache in place. Symptoms of acute respiratory distress or difficulty breathing are the most important complications. You may observe the person:

• appear frightened, restless, anxious

• the skin and mucosa (lips and gums) may get dusky or bluish (cyanosis), or there may be paleness and flared nostrils,

• muscles around the neck may be retracting and you may not see the chest move much.

• If you have a stethoscope and listen to the lung fields there may not be much air flow. You need to act promptly! Your patient may stop breathing at any time!

• If the patient has an oxymeter, check oxygen saturation ("02 SAT’s"); the value may be lower than normal (<92%) and the heart rate can be too fast or too slow.

• Fast breathing or none at all,

• grunting, stridor (gasping for breath), whistling

• there may be eating/feeding difficulties

Prevention and Treatment

Most complications can be prevented by appropriately cleaning and caring for the tube and skin around it. A series of routines can make an enormous difference.

• Clean stoma (skin opening) daily; soapy water is OK.

• Change periodically (once a week is recommended)

• Maintain supplies at home: 2 trache tubes (one their usually size and one smaller), trache ties, sterile water, blunt ended scissors, suction machine)

• When changing it, have a second person assist you.

Trache tubes come out from time to time and being prepared can avoid serious emergencies. Here are some recommendations:

• Stay calm

• Re-insert tube immediately (if a spare is not available use the one that came out)

• Observe if the person can breath through the stoma

• DO NOT FORCE the tube in! Try the smaller tube if available. If you can’t get it in, call 911 for assistance

There are some other practical issues to consider when taking care of individuals with a tracheostomy.

Do's and Don'ts

Do’s:

• Practice extreme caution with baths

• avoid exposures to respiratory illness as much as possible

• follow appropriate hair washing protocols

• yearly Flu shot recommended

Don’ts:

• No swimming

• No showering

• No play at the beach or with sand or chalk

• No baby powder

• No aerosol sprays

• No plastic bibs

Emergency Situations – What can go wrong?

Mucus plugs and accidental displacement of the tube are the most common complications leading to respiratory distress. Infections are also common and can become very rapidly an emergency because of mucus plug formation and swelling. Complications can be acute or develop over a longer period of time:

• Acute: Bleeding, infection, fistula (extra hole), decannulation (tube coming out)

• Chronic: fistulas, granuloma (scar tissue), pressure sores, stenosis (narrowing/tightening of the opening)

Conclusion

Tracheostomy tubes are a form of artificial airway. They can be life saving on acute situations and they may be needed for long term care too. There are many reasons for which it is medically necessary too have a trache. Simple protocols for daily care can prevent major complications. It is important to have a plan to care for them and a plan in case there are complications.

Javier Aceves, M.D. (Pediatrician)