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The earliest tracheostomy tubes were made of silver and consisted of only the three basic components. Later models came with an adaptor on the inner cannula to allow connection with a ventilator. The plastic tracheostomy tubes that are popular today may or may not have an inner cannula, but most have an inflatable cuff attached. The inflatable cuff may be built on the outer cannula, or it may be applied as needed. The cuff that is to be applied must be the proper size in order to be effective. The purpose of the cuff is to hold the tube in place and prevent the flow of air around the outside of the outer cannula. This allows for more effective ventilation of the patient and prevents the aspiration of liquids into the trachea. The cuffs may maintain a constant high or low pressure. Some cuffs are attached to a balloon to allow the pressure to vary in response to conditions within the trachea, for example, when a patient coughs or changes position.
Accidental expulsion of the outer cannula due to violent coughing or improperly tied tapes is rare; should it happen, however, a dilator or hemostat must be used to hold open the incision while another tube is inserted. A dilator, obturator, and tracheostomy tube of the same size as that in the patient are kept at the bedside at all times.
The mucus will be slightly blood-tinged immediately after the tracheostomy is performed, but it should gradually assume a normal color. If there is evidence of persistent bleeding, this should be reported, as it may indicate internal hemorrhage. The mucus is suctioned as necessary with an electric or wall suction apparatus. The size of the catheter to be used for suctioning will depend on the size of the tracheostomy tube. The catheter should be small enough to move freely into and out of the tube and large enough to aspirate secretions effectively. Air inhaled through a tracheostomy tube is moisturized to prevent drying and caking of secretions. The instillation of sterile saline to loosen secretions was formerly done but is no longer recommended.
Tracheostomy care is usually a sterile procedure. Selected patients in home care settings may use clean techniques. Special care must be taken to prevent introduction of infectious organisms into either the surgical wound or the respiratory tract. Standard tracheostomy kits are available and usually include gauze sponges, twill tape, disposable containers for hydrogen peroxide, a small brush, pipe cleaners, and a tracheostomy dressing that is slit so that it fits around the tube. If additional dressings are needed, gauze squares without fillers are used and loose strings must be avoided so that fibers and threads are not aspirated through the tube.
Patients with a permanent tracheostomy must be taught self-care before leaving the hospital. As they become accustomed to breathing through the tube, suctioning it as necessary and replacing the dressings, they will become less apprehensive. Patients must be cautioned against swimming, and should be warned to use care when taking a shower or bath that water is not aspirated through the tracheostomy. Newer models of tracheostomy tubes allow the patient to speak without manually closing off the opening through which air passes into the trachea.
See also: tracheotomy.
tracheostomySurgery The incision in the anterior wall of the trachea to establish an airway Indications Upper airway obstruction–due to congenital lesions or acute events-eg foreign body, diphtheria, bilateral voal cord paralysis, laryngeal neoplasms, regional trauma, edema, or anaphylactic reactions, or inability to handle upper or lower respiratory secretions Pros Relieves obstruction, ↓ dead air space, therefore the work required for effective ventilation; facilitates lavage Cons Loss of effective cough; ↑ susceptibility to infection, especially with Pseudomonas spp.
tracheostomy(tra?ke-os'to-me) [? + stoma, mouth]
CAUTION!To avoid injury to the structures of the neck, tracheostomy should be performed only by skilled or well-trained health care professionals.
Vital signs are monitored frequently after surgery. Warm, humidified oxygen is administered. The patient is placed in the semi-Fowler position to promote ease of breathing. A restful environment is provided. Communication is established by questions with simple yes and no answers, hand signals, and simple sign language and with use of a slate or an alphabet board for writing. (Written communication requires vision, hand strength, and dexterity and is often difficult or impossible for acutely ill patients.) Later, the patient is taught how to cover the tracheostomy with the cuff deflated to facilitate speech, or is provided with a speaking valve and taught how to use it. Before the patient is able to speak, the nurse should be alert to the patient's unmet needs and assist to prevent increased anxiety. Chest physiotherapy promotes aeration of the lung. Suctioning of secretions with prehyperoxygenation and posthyperoxygenation and tracheostomy care are provided as necessary, using aseptic technique throughout. Dressing is changed frequently during the first 24 hr postoperatively, and the surgical site is observed for excessive bleeding. Coughing and deep breathing are encouraged at regular intervals. A teaching plan should cover stoma care, which includes cleansing, removing crusts, and filtering air with a suitable filter. The patient and his or her health care team should watch for signs of infection, such as reddening of the skin or drainage of pus from the surgical site. Aspiration is a risk for all tracheostomized patients, but may be reduced when a speaking valve is used. The patient is assessed for signs and symptoms of aspiration, including changes in secretion production, fever, and mental status changes. The patient should not smoke and should avoid secondhand smoke. Activities may be gradually increased to include noncontact sports but should not include swimming. Showering may be permitted if the patient wears a protective plastic bib or uses a hand to cover the stoma. The patient should be reassured that secretions will decrease and that taste and smell will gradually return. If a speaking valve is used, the patient is taught to clean it daily with water and mild, fragrance-free soap, to rinse it thoroughly and allow it to air dry, and to place it in its storage container when not in use. The importance of follow-up care with an ear, nose, and throat specialist is stressed.
tracheostomyAn operation to make an artificial opening through the front of the neck into the windpipe (trachea). A tube is then inserted to maintain the opening and allow breathing. Tracheostomy is necessary when life is threatened by obstruction to the airway or when breathing must be maintained artificially for long periods by an air pump.