Tracheostomy | Definition, Types of Tube, Procedures in Cleaning

Tracheostomy | Definition, Types of Tube, Procedures in Cleaning

WHAT IS TRACHEOSTOMY?

TRACHEOSTOMY is a surgical opening in the anterior wall of the trachea to facilitate breathing. The tube enables airflow to enter the trachea and lungs directly, thus bypassing the pharynx and larynx. Depending on the person’s condition, the tracheostomy may be temporary or permanent.

TYPES OF TRACHEOSTOMY TUBES:

1. SINGLE LUMEN TUBES

It maximizes the inner lumen of the tracheostomy tube decreasing airway resistance.

Disadvantages – Short term use

2. DOUBLE LUMEN TUBE

It has a removable inner lumen.  Secretions can adhere to the internal lumen of a tracheostomy tube and severely reduce the inner lumen diameter increasing the work of breathing and/or obstructing the patient’s airway. The inner lumen in double-lumen tracheostomy tubes reduces the internal diameter by 1-1.5 mm. This may increase the patient’s effort to breathing.

Disadvantages:

• A double lumen tracheostomy tube can remain in place for a maximum of 29 Days
• The inner lumen can be changed/cleaned frequently reducing the risk of occlusion

3. UNCUFFED TUBES

should be used with caution in patients who have an incompetent cough reflex. And it is suitable for a patient in the recovery phase of critical illness who has returned from intensive care and may still require chest physiotherapy, suction via the trachea and airway support.

Disadvantages:

• Patients who require artificial ventilation
• The patient requiring greater than 40% oxygen therapy
• Protection against gross aspiration

4. CUFFED TUBES

are only used for mechanical ventilation. This type of tracheostomy tube has a cuff that can be inflated inside the trachea to form a seal with the surrounding tissues of the tracheal wall. When the cuff is inflated, inspiration and expiration is via the tracheostomy tube.

Disadvantages:

• In patients requiring ventilation, an inflated cuff forms a seal to facilitate positive pressure ventilation
• In patients with poor or absent swallowing reflexes, an inflated cuff will assist in minimizing the risk of gross aspiration.

5. FENESTRATED TUBES

refer to the holes in the lumen of the tracheostomy tube. There can be several small holes or one large hole. Airflow can be directed either via the tracheostomy tube or partially via the upper airway and tracheostomy tube.

Disadvantages:

• May create an opportunity for oral and stomach contents to enter the lungs through the fenestration increasing the risk of aspiration in patients with an incompetent cough reflex
• Patients requiring intermittent positive pressure ventilation (IPPV) should have a non-fenestrated tracheostomy tube inserted at the earliest opportunity, a non-fenestrated inner lumen can be used as an interim measure to allow IPPV in the short term.

6. ADJUSTABLE FLANGE TUBES 

It means that the tracheostomy tube can be adjusted to the desired length. Patients who have deep-set tracheas are those, for example, who are obese or have distorted anatomy within the neck due to inflammation, tumor. Patients with spinal abnormalities such as kyphosis may also benefit from this type of tube.

Disadvantages:

• Movement of the flange is not recommended as a routine procedure because of the high risk of accidental decannulation.

3 parts of Tracheostomy Tubes:

1. Inner Cannula
2. Outer Cannula
3. Obturator

HOME SUPPLIES FOR TRACHEOSTOMY:

1. Sterile saline solution
2. 5 cc syringes for instilling saline solution
3. Sterile container for saline solution
4. Gauze squares to use when coughing (soft paper towels can be used)
5. An extra tracheostomy tube
6. Dressing
7. Ties and/or Velcro tube holder
8. Tracheostomy brushes/pipe cleaners
9. A plastic basin for cleaning the inner cannula/tracheostomy tube
10. Suction catheters
11. Tubing for the suction machine
12. Clean scissors

Procedures for Cleaning the Tracheostomy Tubes:

HAND WASHING

You must wash your hands before and after the all cares because your hands may spread germs.

HUMIDITY

Extra humidity is required because the nose and mouth, which filter, warm, and moisten the air you breathe, are bypassed. More moisture is needed whenever secretions become thick, dry, or form plugs.

MAKING SALINE SOLUTION 

Saline solution is a salt solution that can be made by boiling water for 5 minutes, then adding 1 1/2 level teaspoons of non-iodized salt per quart of water. Cool to room temperature prior to use. Because germs may grow in the solution, discard unused saline solution after 24 hours.

INSTILLING SALINE SOLUTION 

The purpose of instilling saline solution into your airway is to stimulate cough and clear secretions. Pour a small amount of saline solution into a clean cup.

1. Draw up 2 to 3 cc into the syringe.
2. While taking a deep breath, instill saline solution through the tracheostomy tube.
3. Cough while covering your tube with a gauze sponge or soft paper towel.
4. Repeat until your airway is clear. If unable to clear your airway with saline solution, use suction.
5. When secretions become thick and dry, the saline solution may need to be instilled as often as every hour.

CLEANING THE HUMIDIFIER

Daily and Weekly Procedure for Cleaning the Humidifier:

• Daily

1. Empty and clean tub with hot, soapy water. Rinse well.
2. Fill with fresh tap water.
3. Never add water to the humidifier without emptying and rinsing the tub.

• Weekly

1. Empty and rinse.
2. Fill the humidifier tub with equal parts of vinegar and water and turn the humidifier on for 1 hour. Due to the strong smell of the vinegar, place the humidifier in a room where no one is present.
3. Empty the humidifier and wash all parts with hot, soapy water. Rinse well.
4. Fill the tub with clean water and turn on the humidifier for another hour.
5. Empty and air dry. The unit is ready for use.

SUCTION

The purpose of suction is to remove secretions that you cannot cough out. The suction will clear your airway and help you breathe better. The correct size suction catheter should be used. The catheter should be half the size of the tracheostomy tube.

1. Connect suction catheter to tubing from the suction machine.
2. Moisten the catheter tip with a saline solution.
3. Take 4 to 5 deep breaths.
4. Gently insert the suction catheter through the tracheostomy tube. Do not cover the suction control vent while you insert the catheter. Pass the catheter as far as you can without force, then withdraw slightly before starting suction.
5. To apply suction, cover the vent with your thumb. Do not apply suction for more than 10 seconds. Release thumb from vent if you feel the catheter grab during suction. Gently rotate the catheter as it is withdrawn
6. Suction saline solution to clean the catheter.
7. Do not insert the catheter more than 3 times during a suction period. If more suction is needed, allow yourself a 5- or 10-minute rest.
8. Breathe deeply after the catheter is removed.

CLEANING THE INNER CANNULA

To ensure that the inner cannula does not become plugged, it must be cleaned.

• To unlock and remove the inner cannula, turn it until the notch area is reached and slide it out.
• Use a small brush or pipe cleaners to clean the inner cannula under cool running water.
• Look through the inner cannula to make sure it is clean. Shake the inner cannula to remove excess moisture.
• Reinsert the inner cannula and lock in place.

USE OF A TRACHEOSTOMY CORK 

• Secure the cork string to the tube tie.
• The cork should be removed for shortness of breath or to cough out secretions that you cannot handle through the nose or mouth.
• Continue to clean your inner cannula. Remove cork when cleaning and replace.

SKIN CARE

• Q-tips or a damp washcloth may be used to gently clean around the neck opening.
• Gauze may be placed under the ties next to the skin. Hold the tube while changing the gauze.
• Change the gauze if it becomes wet, dirty, or frayed.
• Look for redness or skin breakdown.
• Use of dilute betadine soaked drain sponges for 10-minute applications followed by placement of dry drain sponge may be recommended.

CHANGING THE TRACHEOSTOMY TIE

1. Different ties can be used, such as twill tape, bias tape, or Velcro tube holders.
2. Change the tie when wet, dirty, or frayed. Plan to do this when you have someone to help you.
3. The clean tie should be in place before the soiled tie is removed.
4. If using twill tape or bias tape, cut a piece of tape approximately 30 inches long.

• Insert tie through an opening in the neck plate and bring it around to the other side of the neck.
• Insert this same end through the other side in the neck plate and pull it through. Secure the tie in a triple knot at the side of the neck.
• Make sure the new tie is not too tight or too loose. You should be able to slip 1 finger under the tie.
• Remove the old tie.
• If the tie stretches with wear, retie it.

5. If using a Velcro tube holder.

• Thread narrow Velcro tabs through an opening in the neck plate.
• Adhere tabs to soft material on the band.
• Adjust and secure to fit your neck.
• Cut off the excess band.

The recommended maximum time a tube on whether it is a single or double-lumen tube.

• Inner lumen bay become blocked with secretions
• The tube requires replacement every 5-7 days

CHANGING/REPLACING THE TRACHEOSTOMY TUBE

If you have been instructed to change your tube, this is done about once a week.

1. Prepare the clean tube:

a. Insert the tie into the opening of the neck plate.

b. Place the obturator inside the outer cannula

c. Moisten the lower portion of the tube with saline solution.

2. Hold the tube that is in place as you cut the tie.

3. Take a deep breath before removing the tube.

4. Remove the soiled tube and insert the clean tube.

5. Quickly remove the obturator, take a breath, and secure the tie or Velcro tube holder.

6. Insert the inner cannula. If the tube comes out and needs to be replaced

7. Place the obturator inside the outer cannula.

8. Moisten the lower portion of the tube with saline solution.

9. Insert the tube.

10. Remove the obturator.

11. Insert the inner cannula.

CLEANING THE TRACHEOSTOMY TUBE:

1. Clean plastic tubes with mild soap and water or equal parts of hydrogen peroxide and water. Rinse well, air dry, and store in a clean, covered container.
2. Clean metal tubes with mild soap and water. Rinse well, air dry, and store in a clean, covered container.
3. Hydrogen peroxide may be used to clean stainless steel tubes if rinsed well. Do not use with sterling silver tubes.

CLEANING THE SUCTION CATHETERS:

1. Place catheters under cool running tap water to rinse secretions.
2. Wash catheters well in hot soapy water (mild liquid soap) and rinse with tap water. It may be helpful to attach the catheter to suction to remove any remaining soapy water.
3. Soak catheters in equal parts of white vinegar and tap water (1 cup vinegar to 1 cup water) for 1 hour. Rinse catheters with saline solution. Connect catheter to suction to rinse inside of each catheter.
4. Air dry catheters on a clean towel.
5. Store catheters in a clean, covered container.

CARE OF THE SUCTION MACHINE:

1. Empty suction bottle into the toilet.
2. Wash the suction bottle and tubing daily with hot, soapy water.

PRECAUTIONS:

1. When bathing or taking a shower, keep water out of the tube. Do not swim.
2. Avoid powders, aerosol sprays, dust, smoke, and lint from facial tissues.
3. Do not use over-the-counter antihistamines (cold medications), which dry secretions and the airway.

EMERGENCY INFORMATION:

1. Talking on the telephone may be difficult. Plan a way to get help in case of an emergency. Place emergency numbers near the phone, such as the fire department, ambulance, visiting nurse, or doctor.
2. During cardiopulmonary resuscitation (CPR), breathing must be performed mouth to tracheostomy tube not mouth to mouth.

WARNING SIGN 

Please notify your doctor or local emergency room if you feel you are having any of these problems:

• Tracheostomy tube comes out and you are unable to replace it
• Difficulty breathing
• Increased tracheal secretions
• Thick, foul-smelling secretions
• Chest discomfort
• Dry, crusted secretions (mucous plugs) or blood-tinged secretions from the tracheostomy tube
• Fever
• Open skin, sores, or increased redness around the tube

GUIDELINES FOR CARE OF PATIENTS WITH A TRACHEOSTOMY TUBE:

1. Wash your hands thoroughly with soap and water.
2. Stand or sit in a comfortable position in front of a mirror
3. Put on the gloves.
4. Suction the trach tube.
5. If your tube has an inner cannula, remove it.
6. Hold the inner cannula over the basin and pour the hydrogen peroxide over and into it. Use as much hydrogen peroxide as you need to clean the inner cannula thoroughly.
7. Thoroughly rinse the inner cannula with normal saline, tap water, or distilled water
8. Dry the inside and outside of the inner cannula completely with a clean 4 x 4 fine mesh gauze pad.
9. Reinsert the inner cannula and lock it in place.
10. Remove the soiled gauze dressing around your neck and throw it away.
11. Inspect the skin around the stoma for redness, hardness, tenderness, drainage, or a foul smell. If you notice any of these conditions, call your nurse or physician after you finish routine care.

ADDITIONAL GUIDELINES FOR CARE OF PATIENTS WITH A TRACHEOSTOMY TUBE:

1. Soak the cotton-tipped swabs in a solution of half hydrogen peroxide and half water. Use the swabs to clean the exposed parts of the outer cannula and the skin around the stoma.
2. Wet the washcloth with normal saline, tap water, or distilled water. Use the washcloth to wipe away the hydrogen peroxide and clean the skin.
3. Dry the exposed outer cannula and the skin around the stoma with a clean towel.
4. Change the trach tube ties.
5. Place a fine-mesh gauze under the tracheostomy tie and neck-plate by folding it or cutting a slit in it.
6. Remove your gloves and throw them away.
7. Wash your hands with soap and warm water.
8. Wash the basin and small brush with soap and warm water. Dry them and put them away.
9. Put the used washcloth and towel in the laundry.
10. Wash your hands again with soap and warm water.
11. A tracheostomy is performed for several reasons, all involving restricted airways.

Conditions that may require a Tracheostomy include:

• anaphylaxis
• birth defects of the airway
• burns of the airway from inhalation of corrosive material
• cancer in the neck
• chronic lung disease
• coma
• diaphragm dysfunction
• facial burns or surgery
• infection
• injury to the larynx or laryngectomy
• injury to the chest wall
• need for prolonged respiratory or ventilator support
• obstruction of the airway by a foreign body
• obstructive sleep apnea
• paralysis of the muscles used in swallowing
• severe neck or mouth injuries
• tumors
• vocal cord paralysis

References:

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