Tracheostomy Care: Post-op & Maintenance

• 11857 Health Across Lifespan – High Acuity Care Needs discusses intubation and assessing an artificial airway.

Lecture Objectives

• The lecture discusses intubation, including endotracheal tubes (ETT) and tracheostomies.
• Lecture reviews indications for intubation, risks of intubation, and how to verify correct placement.
• Learn how to assesss artificial airways (ETT and Trachy).
• Learn Documentation of an artificial airway.
• Review Nursing responsibilities with artificial airways.
• Review Emergency equipment related to airways.
• Outline how to suction an airway.

When to Intubate

• Intubation is needed for impending cardiorespiratory arrest.
• Intubation is needed for multi-organ failure requiring extensive monitoring
• Intubation is needed for haemodynamic instability with hypotension or unstable cardiac arrhythmia.
• Untreated pneumothorax requires intubation.
• Intubation may be necessary when pneumonia is present in immunocompromised patients.
• Intubation is required when there is a reduced level of consciousness and inability to protect airways.
• Intubation may be required when the patient experiences confusion requiring sedative medications or physical restraints to apply NIV.
• Intubation may be required for vomiting or haematemesis
• Intubation may be required for recent facial/ENT/Upper GI or neurological surgery, trauma, or deformity
• Intubation may be required for an acute burn with possible airway involvement
• Barotrauma may require intubation.
• Allergic reaction to materials of the face/nose mask may call for intubation

Induction Medications

• Sedatives, like Midazolam or propofol, may be administered as induction and infusion.
• Paralytics, like Succinylcholine, Vecuronium, or Rocuronium, are used for induction.
• Paralytics may require infusion thereafter depending on patient condition
• Analgesics, Fentanyl or morphine, may be administered as induction and infusion
• Endotracheal Tube (ETT)

Intubation: ETT

• In orotracheal intubation, the tube is inserted through the mouth
• In nasotracheal intubation, the tube is inserted through the nose
• ETT size ranges from 2.0 to 12.0 mm internal diameter, in 0.5 mm increments.
• An ETT has a radiopaque line that shows on CXR
• Inflated cuff and Pilot tube
• Connector is standard 15mm
• Suction can be performed subglottically.

Risks of Intubation: ETT

• Infection, like pneumonia or ventilator-acquired pneumonia (VAP), is a major risk of intubation.
• Intubation risks tooth dislodgement
• Intubation risks bleeding
• Intubation risks perforation oropharynx
• Oesophageal placement can happen, meaning the tube should be removed immediately and re-placement be attempted in the trachea
• Intubation risks vocal cord damage from prolonged use, extubation without deflating the balloon
• Tracheal mucosa ischaemia can occur due to increased cuff inflation pressures.

Indicators for Tracheostomy

• Tracheostomy is indicated to bypass upper airway obstruction due to subglottic, glottic, or supraglottic issues.
• Tracheostomy helps bypass tumors, foreign bodies, vocal cord paralysis, or following head and neck surgery
• Tracheostomy helps with uncontrolled aspiration, such as decreased conscious state and inability to manage secretions
• Prolonged intubation may warrant tracheostomy
• Tracheostomy is indicated to facilitate long term ventilator support/airway management and help facilitate weaning from ventilator support

Assessing an Artificial Airway

• Assess the type of artificial airway (ETT, NTT or Tracheostomy)
• Assess the size and diameter of the airway
• For an ETT, assess Length at teeth
• Assess Cuff pressure
• Assess securing device adequacy with tapes, anchorfast, or sutures, ensuring it's not too tight or too loose (2 fingers space)
• Suction - frequency and description of secretions, cough reflex present.
• Check for oral/mouth care
• +/- Dressing (trachy) check
• Assess for Pressure areas on lips, mouth, and neck.
• Ventilator settings and circuit/system set up assessment is a function of breathing NOT airway.

Checking Correct Placement

• Airway placement is assessed by auscultating for bilateral breath sounds and checking for bilateral rise and fall of chest.
• Auscultate the epigastrium during insertion.
• End tidal CO2 is the gold standard method for confirming ETT placement during insertion.
• Capnography is even more reliable and is a requirement for continuous monitoring as per anaesthesia and resuscitative guidelines.
• A CXR should be performed daily, and it should be assessed that the tube is 2cm above carina or above biofication of bronchus

Documenting Artificial Airway

• Note the time when you assumed care of patient at 0700hrs.
• Document the airway, including the fact airway is maintained via size 7.5 ETT/ Patient is intubated with size 7.5 ETT
• [choose either], ETT 22cm at teeth, cuff pressure 24cm H2O, ETT secured with anchorfast/tapes [choose], suctioned 2nd hourly with mod amounts thick creamy secretions. Oral cares attended to 2nd hourly APP. Oral mucosa, pink, clean, nil Pressure areas to lips.

Bedside Emergency Equipment Check

• All different sizes of ETT or trachy's are required
• Ensure a Bag valve mask (BVM) without face mask is attached
• Face masks for BVM are required
• Cuff monitor device (manometer) and 10ml syringe
• Trachy dressing equipment should be available
• Securing devices such as spare tapes or anchorfast depending on type of airway are needed
• Tracheal dilators (for tracheostomy patients) are needed.
• Provide Suctioning equipment – circuit + Catheters + Yanker sucker (oral cares)
• Sterile N/Saline for suctioning/gloves
• Make sure you have Oral care equipment such as Lip cream/tooth brush, tooth paste/ mouth swabs

Nursing Responsibilities

• Tracheostomy dressings and strappits cannot be adjusted for 24 hours postoperatively due to risk of dislodgement before a tract forms.
• Airway must be stabilized when moving patient for pressure area cares and other cares (incl: trachy dressing changes), requires a second nurse.
• Daily care must be provided to the patient, including tracheostomy/respiratory needs (e.g. suctioning, dressings, stoma care, respiratory monitoring, monitoring ventilation parameters and liaising with team as required).

Suctioning via ETT or Tracheostomy

• Suctioning is performed when there is a need to remove accumulated pulmonary secretions are evidenced by one or more of the following:
• Include Audible upper respiratory tract noises
• Deterioration of ABGs or SpO2
• Suspected aspiration
• Clinically apparent increased work of breathing
• CXR changes consistent with sputum retention
• Need to obtain a sputum specimen
• Reversible increased peak inspiratory pressures during volume controlled ventilation or decreased tidal volume on pressure controlled ventilation

Explore tracheostomy care including initial post-operative considerations and routine maintenance. Learn about suctioning indications, cuff pressure monitoring, and emergency preparedness. Understand the importance of respiratory assessment and equipment readiness.