CRITICAL POINTERS: Tracheostomies

Editor's note: Critical Pointers offers key steps for managing acutely ill adults for nurses who work in all settings.

A tracheostomy is usually a temporary measure to relieve airway obstruction or maintain airway patency. Although there are various tracheostomy tube designs, these essential points can help you protect this critical lifeline.

Assessment

Tracheostomy tube

• Are the trachea and the tube midline? Is the twill tape or self-adhesive device secure? How many fingers can you slip between the tape and the neck?
  
• Tracheal deviation may signal abnormal bleeding. A misaligned tube puts pressure on the tracheal wall increasing risk for wall necrosis and erosion. Palpable tube pulsations suggest impending erosion of an artery.
  
• Palpate around the stoma for subcutaneous emphysema (feels like Rice Krispies), which occurs if air leaks out into muscle planes from tracheal wall erosion or a dislodged trach tube.
  
• An unsecured tube can suddenly be dislodged when a patient coughs.
  
• Check cuff pressures using your facility protocol. Pressures greater then 25 mm Hg inhibit capillary perfusion, increasing risk for tracheal necrosis and erosion.

Stoma

• Is it clean and dry? Is there redness or purulent drainage?
  
• Note that 60% to 100% of long-term tracheostomy sites have colonization of the stoma wound with Pseudomonas or other gram-negative bacteria. Colonization sets the stage for infection.

Secretions

• What is the color, consistency, and amount?
  
• Expect secretions to increase due to tracheal mucosa irritation from the tube's presence.
  
• Bloody secretions beyond the fourth day post-tracheotomy are abnormal.
  
• Dry secretions can signal dehydration; copious secretions can signal fluid volume overload.

Interventions

Maintaining the airway

• When suctioning an adult, use 12-16 French catheter and set wall suction at 120-150 mm Hg or portable machines at 10-15 inches of water.
  
• Hyperoxygenate before and after each pass of the catheter.
  
• Monitor heart rate, cardiac rhythm, skin color and level of consciousness. Stop and oxygenate the patient if adverse changes occur.
  
• Apply suction at less then 5-second intervals, only when you're withdrawing the catheter, and for no more than a total of 15 seconds.
  
• Avoid injecting saline prior to suctioning as research finds this adversely affects oxygenation. Hydration is the best method for thinning secretions. Humidification of oxygen keeps mucosa moist.
  
• Follow your facility trach care protocol. Always have an assistant. The greatest risk for tube dislodgement is when changing the trach ties.
  
• Reintubation in the first 36 hours after tracheotomy is an emergency. The stoma may collapse. If reintubation is unsuccessful, call for emergency personnel and provide assisted ventilation. Use a bag-valve-mask device and oxygen placed over the patient's mouth and nose.

Preventing infection

• Always use a new sterile catheter to suction the trachea. Change the closed system suction catheters at least every 24 hours.
  
• Keep the stoma and its dressing clean and dry.

Preventing tracheal trauma

• Support ventilator or oxygen tubing so that it doesn't put traction on the trach tube.
  
• Secure the outer cannula with twill tape or a self-adhesive device. Only 2 fingers should easily slip beneath the tape.
  
• Keep a replacement tube, which is the same size or one size smaller, at the bedside. A smaller size may be needed if tracheal wall spasm occurs following a traumatic dislodgement.
  
• Inflate the cuff using a minimal technique or pressure manometer.

Promoting comfort

• Give analgesics for pain. Remember that an incision created the tracheostomy.
  
• Be calm and reassuring. Patients with a tracheostomy report sensations of choking.

Finally, make sure to document your assessment, interventions, trach tube size, and communications with other healthcare professionals.