T

Tracheostomy

Description

A tracheostomy is a surgically created stoma (opening) in the trachea to establish an airway. It is used to (1) bypass an upper airway obstruction, (2) facilitate removal of secretions, or (3) permit long-term mechanical ventilation.

Most surgical tracheostomies are done in the operating room using general anesthesia. These are typically done electively on patients already intubated who require prolonged mechanical ventilation. When swelling, trauma, or upper airway obstruction prevents endotracheal intubation, an emergent surgical tracheostomy may be performed at the bedside.

A minimally invasive percutaneous tracheostomy can also be performed at the bedside using local anesthesia and sedation and analgesia. A needle is placed into the trachea, followed by a guide wire. The opening is progressively dilated until it is large enough for insertion of a tracheostomy tube.

■ A tracheostomy provides a more secure airway, is less likely to be displaced, and allows more freedom of movement than an endotracheal tube. There is less risk of long-term damage to the vocal cords. Airway resistance and work of breathing are decreased, facilitating independent breathing. Patient comfort may be increased because no tube is present in the mouth.

■ The patient can eat with a tracheostomy because the tube enters lower in the airway (Fig. 24). Speaking is also permitted once the tracheostomy cuff can be deflated.

Fig. 24. Tracheostomy tube. A, Parts of a tracheostomy tube. B, Tracheostomy tube inserted in airway with inflated cuff.

When the patient can adequately exchange air and expectorate secretions, the tracheostomy tube can be removed. Close the stoma with tape strips and cover it with an occlusive dressing. Instruct the patient to splint the stoma with the fingers when coughing, swallowing, or speaking.

■ Epithelial tissue begins to form in 24 to 48 hours, and the opening closes in several days. Surgical intervention to close a tracheostomy is not required.

Nursing management

Before the tracheotomy, explain to the patient and family the purpose of the procedure and inform them that the patient will not be able to speak if an inflated cuff is used. A variety of tubes are available to meet patient needs (see Fig. 25). Characteristics and nursing management of tracheostomies are described in Table 27-5, Lewis et al.: Medical-Surgical Nursing, ed. 9, p. 508.

Care should be taken not to dislodge the tracheostomy tube during the first 5 to 7 days when the stoma is not mature (healed).

■ Retention sutures may be placed in the tracheal cartilage when the tracheotomy is performed. Tape the free ends of the sutures to the skin in a place and manner that leaves them accessible if the tube is dislodged.

■ Because tube replacement is difficult, several precautions are required: (1) keep a replacement tube of equal or smaller size at the bedside, readily available for emergency reinsertion, (2) do not change tracheostomy tapes for at least 24 hours after the insertion procedure, and (3) let a physician perform the first tube change, usually no sooner than 7 days after the tracheotomy.

■ If the tube is accidentally dislodged, immediately attempt to replace it. See the discussion of tube replacement techniques on p. 510 of Lewis et al.: Medical-Surgical Nursing, ed. 9.

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