Tracheostomy: A hole at the base of the neck that communicates with the trachea. Typically a tube is left in this communication to allow for spontaneous or mechanical ventilation as well as access to the airway for irrigation, suctioning or bronchoscopy.
Open Tracheostomy: The tracheostomy is created with incision, dissection through the soft tissues of the neck and creation of a hole in the trachea to accept the tracheostomy tube.
Percutaneous Tracheostomy: An incision is made in the neck skin; wire is fed into the trachea through the incision. The tracheostomy is enlarged with dilation to accept the tracheostomy tube.
Fresh tracheostomy: The first seven days after a tracheostomy is performed the tract is not stable and the soft tissues of this tract may collapse making it difficult to reinsert the tracheostomy tube.
Trach Site: The skin under the tracheostomy tube phalange (face plate).
Tracheal Decannulation: When the tracheostomy tube no longer resides within the trachea. This can occur with the tube still located within the skin of the trach site. In an established tracheostomy, the tube is usually easily reinserted as the fibrous tissue that lines the tract insures the tube will enter the airway. Decannulation can be a planned procedure (such as when the patient has their tracheostomy tube changed by a physician) or it can be an emergency (such as when the patient pulls their tracheostomy out accidentally).
Laryngectomy: A surgical procedure in which the larynx is removed leaving the patient with a laryngectomy stoma at the base of the neck. There is no communication between the mouth and nose and the airway in these patients. They can only be ventilated through the laryngectomy stoma at the base of the neck.
Tracheostomy Precautions (new and old)
1. Place sign at head of bed to read: (Try to ascertain if the patient’s tracheostomy is due to a laryengectomy)
Indication (include all that apply): 1difficult airway 1respiratory failure 1 pulmonary toilet, airway obstruction,
1other_______________________
Tracheostomy tube size: 1 6 18 1 6 xlt proximal 1 other_________________
Service responsible for tracheostomy: 1 ENT 1 Blue Surgery 1 Neurosurgery ICU 1 Pulmonary ICU
1 Critical Care Medicine 1 Other__________________
2. For fresh (new) tracheostomy site:
a. Tracheostomy care should not be started until 24 hours after the tracheostomy is performed and then every 12 hours
and as needed
b. Minimize use of manual bag ventilation; if manual bag ventilation is required ask respiratory therapy for assistance
c. Patients who are mechanically ventilated must have support for the ventilator tubing.
d. If replacing tracheostomy ties within the first 3 days and if ENT patient, notify the service.
Tracheostomy Site Care
1. Aggressive cleaning of a new trach should be avoided. Use of saline to clean under the tracheostomy phalange is
preferred. If peroxide is used it must be rinsed with saline. Cotton tipped applicators should be used every 12 hours
and PRN
2. Monitor the sutures every shift to assess for tightness preventing routine maintenance or increase irritation of the
skin. Please notify physician to assess whether the sutures maybe able to be loosen to assist with skin irritation and
routine tracheostomy care.
3. If increase secretions are noted around the trach site use skin barrier wipes on skin around tracheostomy and polymen
(a foam dressing) underneath tracheostomy may assist with absorption of secretions and decrease pressure ulcer at the
site.
4. Assessment of the skin around the tracheostomy plate, stoma and tracheostomy ties for redness or irritation every 12
hours. If noted nnotify the physician/provider of redness and place WOCN consult.
5. Removal of the tracheostomy sutures should occur on or around day 7. Collaborate with the physician/providers about the removal of the sutures. .
6. Emergency materials should be on hand in case of emergent tracheostomy replacement. Materials should include
replacement tracheostomy, tracheostomy tray, obturator and crash cart per policy NRO8-O5.
7. Never use ™Surgicel or any other material to attempt to stop bleeding at tracheostomy site.
Patient Education
1. Begin patient or caregiver tracheostomy education. Additional education will be provided depending on the
discharge plan
Tracheostomy hand off Nursing SBAR (what all nurses accepting patient with tracheostomy must know!)
1. Information on sign above bed for all tracheostomies
2. If patient is “old tracheostomy”- gather as much information as you can to put on sign above bed, may have to ask family about tracheostomy.
3. Clinical signs of problems with the tracheostomy tube may include:
a. Unable to pass suction catheter easily through the tracheostomy tube and into the trachea
b. Unable to ventilate patient easily
c. Frank bleeding(site bleeding)
d. More than minimal hemoptysis
e. Subcutaneous air in the neck, shoulder or chest wall
f. Evidence of respiratory distress
g. Leakage to air around the tracheostomy cuff when on the ventilator.
h. The phalange of the tracheostomy tube is not lying flush to the neck.
If any of the above clinical signs are noted, notify the service managing the tracheostomy immediately, if service unable to examine patient immediately, escalate calls per policy
Emergency Tracheal Decannulation Response:
1) Decannulation is an emergency requiring acute intervention when the patient has:
a) Respiratory distress
b) Hypoxemia
2) The patient’s nurse should be aware of the location of needed supplies for reinsertion of tube.
a) New tracheostomy tube (should be in the patient’s room)
b) Obturator of existing tracheostomy tube( should be in the patient’s room)
c) Location of emergency tracheostomy tray ( in the code cart)
d) Location of crash cart with intubation supplies( on floor)
3) Response at discovery of decannulation
a) For non-emergent notify team responsible for the tracheostomy and follow their instructions. . Response time should be within 15 minutes.
4) If emergency Call Code Team 3-5200
o Stat page the responsible team who is managing the tracheostomy
o If assistance needed from anesthesia notify the OR desk 3-5631If patient is ventilator dependent:
o Use bag-valve mask to ventilate through the upper airway (mouth and nose) while, gently occluding the stoma with a gloved finger or hand to reduce leaking during positive pressure ventilation, if patient has not had laryengectomy.
o When the emergency team arrives
o Patient’s nurse will inform the team of tracheostomy indications and any past airway issues if known
o Readied equipment and supplies will be provided
o The provider may try to reinsert the tracheostomy tube using the obturator. If this fails he may use the tracheostomy equipment to reestablish the tracheostomy tract and then reintubate as needed.
o If unable to reinsert the tracheostomy tube; or tracheostomy is fresh; or no skilled surgeon is available the provider will attempt oral intubation to re-establish an airway.
o If patient had a LARYNGECTOMY they have an end stoma and CANNOT BE INTUBATED via the mouth. Laryngectomy patients must be oxygenated by stoma. (May use pediatric face mask to neck stoma or bag ventilation) The provider must intubate stoma.
