Tracheostomy care

[billy bow legs]

Hello to all,

I have a question, or should I say many questions regarding the care of a pediatric pt with a tracheostomy. I have read my nursing textbooks, and online articles, but still quite confused. My book stated that the trachea tube consists of two parts, the outer tube, and the obturator. Am I to understand that not all tubes have an inner cannula? What exactly does a trach change consist of? Is the whole thing removed, leaving an empty stoma(how often/where is this performed/by who?) How do you suction a trach? Do you have to remove any pieces to suction? Does every trach have a cap/artificial nose(and when are they to be removed, besides to bvm a pt)? If a pt accidenty decannulates themselves, what comes in the trach boxes at the bedside, is it the outer cannula(is the outer cannula the piece with the flanges for the ribbons), the inner cannula, and the obturator(which I know is removed) I would greatly appreciate a very detailed answer. Thank you so much.

[nicolel1182]

sounds to me like you need to do lots of google research

are you taking a trach case?

[jadu1106]

hello~

i am not a rn yet, therefore i cannot give a good detailed explanation myself, but i do know where you can get the information. i have to read the info several times and many times need some sort of visual before handling something such as trach care with real hands-on experience.

so here is an excellent website i got from allnurses.com:

www.icufaqs.org

also while researching this topic many months ago, i came across a pdf file that is all about tracheostomy care, so i am attaching that also in hopes it helps you.

i hope this information is helpful to you.

jadu1106 :heartbeat

trach stuff.pdf

[PICNICRN, BSN, RN]

OK............ I seem to remember adults having an inner and outer cannula- I wouldn't know about that.

Pediatric trachs are one cannula with an opturator. You place the trach and pull out the opturator- now you have an airway!

An extra trach in the pt's size along with a size smaller is kept at the bedside for an emergency.

To change the trach, you simply take out the old(you will see the stoma) and replace it with the new- usually done weekly- unless it's brand new.

To suction, you pass a suction cath through the trach(you will bag as needed with suctioning) there is nothing to remove to suction(unless they are on a vent, then you remove them from the circuit).

Sometimes, if it is an old trach, the pt will have a PM valve(cap) on the end of the trach, otherwise, you will just see it "open".

Trach boxes contain only the trach and opturator. The ties come seperately and need to be cut to fit the kid.

Hope this helps!!

[Pedi-Gree, BSN, RN]

my book stated that the trachea tube consists of two parts, the outer tube, and the obturator. am i to understand that not all tubes have an inner cannula?

pediatric and neonatal trach tubes at the smaller end of the scale don't have inner cannulae. they are just too small to want to take up any of that internal diameter with extra plastic. the obturator helps keep the trach tube rigid for ease of insertion and is removed once the trach is in situ, because it is a solid piece and totally obstructs the airway.

what exactly does a trach change consist of? is the whole thing removed, leaving an empty stoma(how often/where is this performed/by who?)

a trach change is simply removing the one that's in place and putting a new one in its place. the frequency is decided upon initially by the surgeon and if the patient is a long term trach patient there is usually a protocol in place for routine changes. of course, the trach can be changed at any time if it becomes obstructed, if the flange tears and the ties can't be secured and so on. the mature stoma (more than a week or so post tracheostomy) won't close in the few minutes it takes to place a new tube. the trach change can be done in the patient's room by a nurse or an rt, or the physician; the first trach change will usually be done by the surgeon or np. most policies have some provision for physician presence on the floor, or having a second person in the room in case of problems. it's a simple procedure. you get your new trach out of the box, attach the ties to one end of the flange, lubricate the tip with sterile water and set aside. you then clean the stoma, suction the patient if needed, preoxygenate by handventilating if needed, cut or undo the ties then with the new trach in your dominant hand, you remove the old one with your nondominant hand. as the old trach comes out, have the new trach ready to slip into the stoma. when it's in, stabilize it against the patient's neck and remove the obturator. then secure the ties. it's a good idea to have a second person help the first few times you do it, until you have the confidence and quickness to do it smoothly.

how do you suction a trach? do you have to remove any pieces to suction?

if the patient is ventilated and does not have an inline suction catheter, you will have to disconnect the ventilator tubing to suction. an artificial nose will also have to be removed. some will tell you to pass the suction catheter without suction until you feel resistance, then pull back 1-2 cm before applying the suction as you withdraw the catheter. others prefer to determine the distance from the point of insertion of the catheter to the distal end of the trach tube and use that as a depth guide. where i work, we have a paper measuring tape with the depth marked on it taped to the vent or the siderail of the bed so that we know how far to go.

does every trach have a cap/artificial nose(and when are they to be removed, besides to bvm a pt)?

artificial noses are used to humidify and filter air when a patient is breathing spontaneously and doesn't need supplemental oxygen. they come in a variety of designs and sizes and some can have supplemental o2 as well; they're not included in the package with the trach tube.

if a pt accidenty decannulates themselves, what comes in the trach boxes at the bedside, is it the outer cannula(is the outer cannula the piece with the flanges for the ribbons), the inner cannula, and the obturator(which i know is removed).

if the trach the patient is using has an inner cannula, then the spares in the room or the travel bag should also. the package should contain the trach tube, the inner cannula (unless a pedi/neo), the obturator (which will be inside the inner cannula which will be inside the trach tube) and some twill tape. i don't recommend using the twill tape unless it's all you have. the velcro ties are much kinder to the skin on the neck.

does that help?

[mondkmondk]

I don't know about peds, just old folks' nursing...but in my experience, the actual trach always stayed in, then there was an inner canula that either came out to be cleaned and then put back in or towards the end of my trach experience, they were making disposable inner cannulas; we would just throw them away and insert a new one. The ties we used had a pad for the back of the neck and then little shoestring like things that were run through the holes of the stationary trach, then looped back around and were held on by velcro.

To suction the trach, you need a glass of saline and a suction catheter. You thread the catheter in slowly and apply gentle suction, sometimes the patient will gag and I stop threading but still apply gentle suction in case some secretions are brought up. Then I rinse the catheter by sucking up the saline.

Some of the really old trachs had balloons...anytime they ate or were suctioned, these balloons had to be inflated with 5 cc air. I haven't seen a trach with a balloon in years though.

Blessings, Michelle

P.S. Sometimes when the secretions are really thick and difficult to suction, I would put a few drops of normal saline directly into the trach, just a few drops, to better liquefy the secretions, then rinse the catheter with saline, then gently suction again.

Hope this helps!

[Pedi-Gree, BSN, RN]

Trachs with cuffs are still used regularly. We use them on our older peds patients whose airways are more anatomically adult-like, kids for whom any amount of leak around the tube is detrimental and those who will have a lot of oral secretions that could be aspirated. And of course for anyone who is permitted to eat and drink!

[NRSKarenRN, BSN, RN]

peds info:

aaron's tracheostomy page: trach care

ce article: pediatric tracheostomy and ventilator care

great links in our pulmonary forum: tracheostomy and vent information

many pictures too