TRACHEOSTOMY

CARE
TRACHEOSTOMY
is an opening into the trachea through
the neck just below the larynx through
which an indwelling tube is placed and
thus an artificial airway is created.
 TRACHEOSTOMY TUBE
 A curved hollow tube of rubber or plastic inserted into
the tracheostomy stoma (the hole made in the neck
and windpipe (Trachea)) to relieve airway obstruction,
facilitate mechanical ventilation or the removal of
tracheal secretions.
PARTS OF TRACHEOSTOMY TUBE
PURPOSES
• To maintain airway patency by removing mucus and
encrusted secretions.
• To maintain cleanliness and prevent infection at the
tracheostomy site
• To facilitate healing and prevent skin excoriation around
the tracheostomy incision
• To promote comfort
• To prevent displacement
ASSESSMENT
• Respiratory status (ease of breathing, rate, rhythm, depth,
lung sounds, and oxygen saturation level)
• Pulse rate
• Secretions from the tracheostomy site (character and
amount)
• Presence of drainage on tracheostomy dressing or ties
• Appearance of incision (redness, swelling, purulent
discharge, or odor)
EQUIPMENTS
• Sterile disposable tracheostomy cleaning kit or supplies (sterile containers,
sterile nylon brush or pipe cleaners, sterile applicators, gauze squares)
• Sterile suction catheter kit (suction catheter and sterile container for solution)
• Sterile normal saline (Check agency protocol for soaking solution)
• Sterile gloves (2 pairs)
• Clean gloves
• Towel or drape to protect bed linens
• Moisture-proof bag
• Commercially available tracheostomy dressing or sterile 4-in. x -in. gauze
dressing
• Cotton twill ties
• Clean scissors
 PROCEDURE
1. Introduce self and verify the client’s identity using agency protocol. Explain to the client
everything that you need to do, why it is necessary, and how can he cooperate. Eye
blinking, raising a finger can be a means of communication to indicate pain or distress.

2. Observe appropriate infection control procedures such as hand hygiene.

3. Provide for client privacy.

4. Prepare the client and the equipment.

• To promote lung expansion, assist the client to semi-Fowler’s or Fowler’s position.
• Open the tracheostomy kit or sterile basins. Pour the soaking solution and sterile normal
saline into separate containers.
• Establish the sterile field.
• Open other sterile supplies as needed including sterile applicators, suction kit, and
tracheostomy dressing.
5. Suction the tracheostomy tube, if necessary.

• Put a clean glove on your nondominant hand and a sterile glove on your
dominant hand (or put on a pair of sterile gloves).
• Suction the full length of the tracheostomy tube to remove secretions and
ensure a patent airway.
• Rinse the suction catheter and wrap the catheter around your hand, and peel
the glove off so that it turns inside out over the catheter.
• Unlock the inner cannula with the gloved hand. Remove it by gently pulling it
out toward you in line with its curvature. Place it in the soaking solution.
Rationale: This moistens and loosens secretions.
• Remove the soiled tracheostomy dressing. Place the soiled dressing in your
gloved hand and peel the glove off so that it turns inside out over the
dressing. Discard the glove and the dressing.
• Put on sterile gloves. Keep your dominant hand sterile during the procedure.
6. Clean the inner cannula.
• Remove the inner cannula from the soaking solution.
• Clean the lumen and entire inner cannula thoroughly using the brush
or pipe cleaners moistened with sterile normal saline. Inspect the
cannula for cleanliness by holding it at eye level and looking through it
into the light.
• Rinse the inner cannula thoroughly in the sterile normal saline.
• After rinsing, gently tap the cannula against the inside edge of the
sterile saline container. Use a pipe cleaner folded in half to dry only
the inside of the cannula; do not dry the outside. Rationale: This
removes excess liquid from the cannula and prevents possible
aspiration by the client, while leaving a film of moisture on the outer
surface to lubricate the cannula for reinsertion.
7. Replace the inner cannula, securing it in place.

• Insert the inner cannula by grasping the outer

flange and inserting the cannula in the direction of
its curvature.
• Lock the cannula in place by turning the lock (if
present) into position to secure the flange of the
inner cannula to the outer cannula.
8. Clean the incision site and tube flange.

• Using sterile applicators or gauze dressings moistened with normal saline,

clean the incision site. Handle the sterile supplies with your dominant hand.
Use each applicator or gauze dressing only once and then discard. Rationale:
This avoids contaminating a clean area with a soiled gauze dressing or
applicator.
• Hydrogen peroxide may be used (usually in a half-strength solution mixed
with sterile normal saline; use a separate sterile container if this is
necessary) to remove crusty secretions. Check agency policy. Thoroughly
rinse the cleaned area using gauze squares moistened with sterile normal
saline. Rationale: Hydrogen peroxide can be irritating to the skin and inhibit
healing if not thoroughly removed.
• Clean the flange of the tube in the same manner.
• Thoroughly dry the client’s skin and tube flanges with dry gauze squares.
9. Apply a sterile dressing

• Use a commercially prepared tracheostomy dressing of non-

raveling material or open and refold a 4-in. x 4-in. gauze dressing
into a V shape. Avoid using cotton-filled gauze squares or cutting
the 4-in. x 4-in. gauze. Rationale: Cotton lint or gauze fibers can
be aspirated by the client, potentially creating a tracheal abscess.
• Place the dressing under the flange of the tracheostomy tube.
• While applying the dressing, ensure that the tracheostomy tube
is securely supported. Rationale: Excessive movement of the
tracheostomy tube irritates the trachea.
10. Change the tracheostomy ties.

• Change as needed to keep the skin clean and dry.

• Twill tape and specially manufactured Velcro ties are
available. Twill tape is inexpensive and readily available;
however, it is easily soiled and can trap moisture that
leads to irritation of the skin of the neck. Velcro ties are
becoming more commonly used. They are wider, more
comfortable, and cause less skin abrasion.
• Tracheal Suctioning
 A means of clearing thick mucus and secretions from the
trachea and lower airway through the application of
negative pressure via a suction catheter.
Tracheostomy care video
Tracheostomy Tube
Cuff
PURPOSE
• The purpose of the inflated tracheostomy tube cuff is to
direct airflow through the tracheostomy tube. This is
typically during mechanical ventilation when the ventilator
circuit must be closed to control and monitor ventilation for
the ventilator patient, who frequently has a more seriously
compromised system than patients not on a ventilator.

• The inflated cuff also may be important in cases of gross

emesis or reflux when gross aspiration is present, to limit
the penetration of aspirated material into the lower airway.
Inflated Cuff Considerations
The inflated cuff should be avoided whenever possible
because it has the potential to cause multiple complications,
such as:
1. Increased risk of tracheal injury, including mucosal
injury, stenosis, granulomas, and more;
2. Diminished ability to use the upper airway, leading to
disuse atrophy over time; and
3. Restriction of laryngeal movement (laryngeal tethering)
which may impact swallowing negatively.
Cuff Deflation
Deflating the tracheostomy tube cuff, when appropriate, has
been shown to have multiple patient benefits, including:

1.Reducing the risk of potential tracheal mucosal damage;

2.Returning the patient to a more normal physiology, including
closing the system through the use of a bias-closed position, no-
leak Valve;
3.Restoring speech and improving communication;
4.Allowing for the possible improvement of the swallow;
5.Potentially lowering the risk of aspiration;
6.Allowing rehabilitation to begin as early as possible; and
7.Decreasing the time to decannulation.
• Decannulation
 The process whereby a tracheostomy tube is removed once patient
no longer needs it.

• Humidification
 The mechanical process of increasing the water vapour content of an
inspired gas.

• Stoma
 An opening, either natural or surgically created, which connects a
portion of the body cavity to the outside environment (in this case,
between the trachea and the anterior surface of the neck).
OROPHARYGEAL and
NASOPHARYNGEAL
SUCTIONING
• OROPHARYGEAL SUCTIONING
Extends from the lips to the pharynx.
Requires the insertion of a suction catheter through the
mouth to the pharynx.

• NASOPHARYNGEAL SUCTIONING
Extends from the tip of the nose to the pharynx.
 The suction catheter is inserted through the nostrils in
to the pharynx.
INDICATIONS
• Suction is indicated for visible or audible airway
secretions, signs of airway obstruction or signs
of oxygen deficit that persist in spite of the
patient's best cough effort.
INDICATIONS
• Patient feels/ indicates the presence of secretions in his /
her airway
• Deteriorating arterial blood gas values
• Altered chest movements
• Restlessness
• Decreased oxygen saturation levels
• Diminished air entry
• Change of colour
• Tachypnoea
CAUTION
 Suspected epiglottitis
 Occluded nasal passages
 Nasal Bleeding
 Acute head, facial, or neck injury(nasopharyngeal suctioning
not advisable with basal skull fractures
 Coagulopathy or bleeding disorder
 Laryngospasm
 Irritable airway
 Tracheal surgery
 Gastric surgery with high anastomosis
COMPLICATIONS
Suctioning is not a benign procedure and adverse physiological
effects directly attributed to oral or
nasopharyngeal suctioning are well documented e.g.:

 Hypoxia Discomfort/pain
 Atelectasis  Hypo/hypertension
 Cardiovascular changes  Overstimulation of secretions
 Laryngospasm
 Intra cranial pressure alterations
 Sepsis
 Pneumothorax  Gagging/vomiting
 Bacterial infection  Nosocomial infection
SAFETY CONSIDERATIONS
 Hand hygiene
 Review all safety considerations for oral suctioning.
 The mouth and pharynx contain bacteria that can potentially contaminate the
trachea. If necessary, suction the mouth with a different suction catheter /
yankauer prior to beginning this procedure. Perform regular good mouth
care.
 Monitor the client throughout the procedure, and stop suctioning if the client
experiences rapid changes in status.
 Suctioning can cause increased intracranial pressure in patients with head
injury. The nurse can reduce this risk by hyper-oxygenating the patient before
suctioning and/or limit the number of times a suction catheter is inserted into
the trachea.
 Use sterile technique for oropharyngeal suctioning.
 PROCEDURE
STEPS ADDITIONAL INFORMATION

1. Assess the need for suctioning including respiratory Perform baseline respiratory assessment including
assessment, signs of hypoxia, inability to clear own SpO2.
secretions adequately, alterations in oxygenation levels
Assess for additional factors that might influence
procedure, i.e., recent surgery; head, chest, or neck
tumors; facial or nasal trauma; and neuromuscular
diseases.

Determine if the patient is on any medications that

increase risk of bleeding

2. Explain the procedure in calm reassuring manner Procedure can cause patient anxiety. This is part of the
explaining the benefits to remove secretions to make consent procedure. Allow the patient an opportunity to
breathing easier. ask questions.

3. Position the patient in semi to high Fowler’s – unless Promotes lung expansion and promotes secretion
contraindicated. Drape chest with towel or disposable clearance.
pad.
 STEPS ADDITIONAL INFORMATION
4. Perform hand hygiene. Gather equipment. Suction machine (portable or wall); canister &
Ensure suction set up is working liner; connective tubing (2), suction catheter,
lubricant, sterile saline or water (acts as
lubricant), PPE (sterile gloves, face shield and / or
gown), pulse oximeter.

5. Administer oxygen if needed Hyper-oxygenating might be necessary if the

patient is hypoxic or at risk of hypoxia during
procedure.
6. Estimate the appropriate suctioning depth by This is done with the suction catheter still in the
measuring the catheter from the tip of the sterile package. Ensures that the catheter
patient’s nose to the angle of the mandible or to remains sterile and at minimum reaches the
the earlobe pharynx.
 STEPS ADDITIONAL INFORMATION
7. Turn the suction device on, and set the It is the tip of the catheter that you try to
vacuum regulator to the appropriate keep sterile.
negative pressure. Set suction levels to
medium / moderate. Suction setting:
Attach the suction catheter to the tubing
whilst remaining in the sterile package. Adult 80 to 100 mmHg
Children 60 to 80 mmHg
Open the sterile water / saline. *Not to exceed 150 mmgHg (AARC 2004)

If using lubricant, squeeze water soluble

lubricant onto sterile surface.

8. Hand hygiene & Donne PPE At minimum PPE should include: sterile
gloves & face shield.
Sterile gloves reduce risk of transmitting
microorganisms into the lungs.
 STEPS ADDITIONAL INFORMATION
9. Apply sterile gloves. With the non-dominant hand, You can also apply a non sterile glove to the non
pick up the packaged connecting tubing. dominant hand and a sterile glove to the dominant
Expose the suction catheter enough to allow the hand.
dominant hand to grab the sterile catheter. There is more than one way to remove the sterile
suction catheter from the package: the principle is keep
Wrap the sterile catheter around the dominant hand. the dominant hand & the suction catheter tip sterile.

Suction a small amount of sterile NS / water. Suctioning sterile NS/ water ensures properly
functioning equipment.
Apply lubricant if necessary (to 10 cm of catheter tip)

10. Insert suction catheter via route of choice (oral / The route chosen will depend on the urgency of the
nasal) until you feel that you are in the pharynx or until situation and presence of tubes and the skill level of the
you feel resistance: nurse. Each route comes with inherit risks:
Oral (last resort) Oral (increases risk of respiratory infection by
Nasal introduction of oral bacteria to the trachea). This route
should be used as a last resort
Nasal (increases risk of nasal trauma – chose a nare
with least resistance). Can also be done through a nasal
airway
All: increased risk of vasovagal response laryngospasm
( which could lead to airway obstruction / hypoxia)
 STEPS ADDITIONAL INFORMATION
Important for this patient population is frequent and
adequate mouth care and collaboration with
respiratory therapy and physiotherapy

Introduction of the catheter sometimes stimulates a

cough response.

Suction applied during insertion increases risk of

mucosal damage and increases risk of hypoxia

11. Apply intermittent suction as the catheter is Do not apply suction for longer than 10 to 15
withdrawn. This means occluding and releasing the seconds. Suction removes oxygen and increases
catheter vent with the non-dominant thumb. Some risk of hypoxia as oxygen is sucked out.
sources suggest twisting catheter back and forth The need to rotate the catheter is questioned in the
as the catheter is withdrawn. Always encourage literature because modern suction catheters have
the patient to cough. multiple eyes / holes (Moore, 2003).

Encourage patient to cough to promote secretion

clearance.
 STEPS ADDITIONAL INFORMATION

12. Replace the oxygen delivery device, if Reapply oxygen delivery device, if applicable
applicable, and instruct the patient to take deep
breaths to encourage oxygenation.

13. Clear secretions from the suction catheter by Clears tubing of secretions to maintain patency
suctioning sterile water / saline to clear tubing of
secretions.
 STEPS ADDITIONAL INFORMATION
14. Assess the need to repeat the procedure. Observe for changes to cardiopulmonary status.
Can often be done through observation of
breathing pattern including HR and SpO2.

If stethoscope is needed, hand hygiene and

reapplication of sterile gloves is necessary if you
are going to repeat the procedure.

When possible, provide recovery time (at least 1

minute) between suction passes to allow for
ventilation and oxygenation to occur.

15. Discard suction catheter, sterile saline / water, Open suctioning method requires new suction
lubricant, sterile gloves. Turn off suction. Remove catheter after each round of suctioning. Reuse
gloves. Perform hand hygiene. Ensure the patient may introduce microorganisms into the patient’s
is comfortable and the call bell within reach. respiratory tract increasing risk of infection

16. Document the procedure in the patient’s

record.
Oropharyngeal Suctioning Video
Nasotracheal Suctioning Video
OXYGEN
SATURATION
OXYGEN SATURATION
measures the percentage of oxyhemoglobin
(oxygen bound hemoglobin) in the blood, and
it is represented as arterial oxygen saturation
(SaO2) and venous oxygen saturation (SvO2).
is a vital parameter to define blood oxygen
content and oxygen delivery.
• Normal arterial oxygen is approximately
75 to 100 millimeters of mercury (mm Hg).

• Values under 60 mm Hg usually indicate the need for

supplemental oxygen.

• Normal pulse oximeter readings usually range from 95

to 100 percent.

• Values under 90 percent are considered low

METHODS FOR MEASURING OXYGEN SATURATION LEVEL
• PULSE OXIMETER
 is a small clip that is often put on a finger, although it can also be used on the
ear or toe. It measures blood oxygen indirectly by light absorption through a
person’s pulse.
 is a device intended for the non-invasive measurement of arterial blood oxygen
saturation and pulse rate. Typically it uses two LEDs (light-emitting diodes)
generating red and infrared lights through a translucent part of the body. Bone,
tissue, pigmentation, and venous vessels normally absorb a constant amount
of light over time. Oxy-hemoglobin and its deoxygenated form have
significantly different absorption pattern. The arteriolar bed normally pulsates
and absorbs variable amounts of light during systole and diastole, as blood
volume increases and decreases. The ratio of light absorbed at systole and
diastole is translated into an oxygen saturation measurement.
PULSE OXIMETER
• ARTERIAL BLOOD GAS ANALYSIS (ABG)
 This is a blood test using samples extracted from an
artery. The test determines the pH of the blood, the partial
pressure of carbon dioxide and oxygen, and the
bicarbonate level. Many blood gas analyzers will also
report concentrations of lactate, hemoglobin, several
electrolytes, oxy-hemoglobin, carboxyhemoglobin and
methemoglobin. The arterial blood gas analysis
determines gas exchange levels in the blood related to
lung function.
SYMPTOMS OF LOW BLOOD OXYGEN LEVEL

Low blood oxygen levels can result in abnormal circulation

and cause the following symptoms:

high blood pressure shortness of breath

lack of coordination headache
visual disorders restlessness
sense of euphoria dizziness
rapid heartbeat rapid breathing
chest pain
confusion
 CAUSES
Hypoxemia, or oxygen levels below the normal values, may
be caused by:

not enough oxygen in the air

inability of the lungs to inhale and send oxygen to all
cells and tissues
inability of the bloodstream to circulate to the lungs,
collect oxygen, and transport it around the body
Several medical conditions and situations can contribute to the
above factors, including:
• asthma
• heart diseases, including congenital heart disease
• high altitude
• anemia
• chronic obstructive pulmonary disease or COPD
• interstitial lung disease
• emphysema
• acute respiratory distress syndrome or ARDS
• pneumonia
• obstruction of an artery in the lung, for instance, due to a blood clot
• pulmonary fibrosis or scarring and damage to the lungs
• presence of air or gas in the chest that makes the lungs collapse
• excess fluid in the lungs
• sleep apnea where breathing is interrupted during sleep
• certain medications, including some narcotics and painkillers
NEBULIZATION
THERAPY
NEBULIZATION
is the process of medication administration
via inhalation. It utilizes a nebulizer which
transports medications to the lungs by
means of mist inhalation.
INDICATION
Nebulization therapy is used to deliver medications along the
respiratory tract and is indicated to various respiratory
problems and diseases such as:
Bronchospasms
Chest tightness
Excessive and thick mucus secretions
Respiratory congestions
Pneumonia
Atelectasis
Asthma
CONTRAINDICATION
In some cases, nebulization is restricted or avoided due to possible
untoward results or rather decreased effectiveness such as:

 Patients with unstable and increased blood pressure

 Individuals with cardiac irritability (may result to dysrhythmias)
 Persons with increased pulses
 Unconscious patients (inhalation may be done via mask but the
therapeutic effect may be significantly low)
EQUIPMENTS:
Nebulizer and nebulizer connecting tubes
Compressor oxygen tank
Mouthpiece/mask
Respiratory medication to be administered
Normal saline solution
NEBULIZER
MASK

MOUTH PIE
CE
PROCEDURE
1. Position the patient appropriately, allowing optimal
ventilation.
2. Assess and record breath sounds, respiratory status,
pulse rate and other significant respiratory functions.
3. Teach patient the proper way of inhalation:
 Slow inhalation through the mouth via the mouthpiece
 Short pause after the inspiration
 Slow and complete exhalation
 Some resting breaths before another deep inhalatio n
4. Prepare equipments at hand
5. Check doctor’s orders for the medication, prepare
thereafter
6. Place the medication in the nebulizer while adding the
amount of saline solution ordered.
7. Attach the nebulizer to the compressed gas source
8. Attach the connecting tubes and mouthpiece to the nebulizer
9. Turn the machine on (notice the mist produced by the
nebulizer)
10. Offer the nebulizer to the patient, offer assistance until he
is able to perform proper inhalation (if unable to hold the
nebulizer [pediatric/geriatric/special cases], replace the
mouthpiece with mask
11. Continue until medication is consumed
12. Reassess patient status from breath sounds, respiratory
status, pulse rate and other significant respiratory functions
needed. Compare and record significant changes and
improvement. Refer if necessary
13.Attend to possible side effects and inhalation reactions
NURSING RESPONSIBILITY
• As nurses, it is important that we teach the patients
the proper way of doing the therapy to facilitate
effective results and prevent complications
(demonstration is very useful). Emphasize
compliance to therapy and to report untoward
symptoms immediately for apposite intervention.
Nebulization Therapy Video
THANK YOU