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The removable inner tube of the tracheostomy tube.
Inner cannula
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A device inserted into the tracheostomy tube that closes the end of the tube. This allows the tracheostomy tube to be inserted into the tracheostomy. Once inserted, the obturator is removed.
Obturator
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A balloon at the end of a tracheostomy tube that, when inflated, creates a seal between the lungs and the upper airway. Also known as a soft cuff, and as a high-volume, low-pressure cuff.
Tracheal cuff
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A narrowing of the trachea caused by fiber scaring, or the growth of granulation tissue replacing damaged cartilage as a result of over-inflation of a tracheal cuff.
Tracheal stenosis (tracheostenosis)
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Communication between the trachea and the esophagus as a result of erosion of the tracheal wall related to over-inflation of a tracheal cuff.
Tracheoesophageal fistula
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Communication between the trachea and the innominate artery as a result of erosion of the tracheal wall related to over-inflation of a tracheal cuff.
Tracheoinnominate artery fistula
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Exposure of the cartilaginous tracheal rings as a result of erosion of the tracheal wall related to over-inflation of a tracheal cuff.
Tracheomalacia
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A surgically created opening through the neck into the trachea, or windpipe, usually at the level of the second or third tracheal ring.
Tracheostomy
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Fabric tethers used to hold the tracheostomy tube in place.
Tracheostomy tie
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An artificial airway placed directly into the trachea through the tracheostomy.
Tracheostomy Tube
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The patient with a tracheostomy has had a surgically created opening through the neck into the trachea, or windpipe, usually at the level of the second or third tracheal ring. The tracheostomy tube is placed through this opening directly into the trachea.
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When a tracheostomy tube is inserted, the upper airway system is bypassed as are the functions of the upper airway system. These include warming, humidifying, and filtering inspired air. Mucus clearance is performed through the tracheostomy. In addition, the trachea is compromised by the surgical incision and the tracheostomy tube.
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The presence of a tracheostomy tube and a surgical incision can predispose the patient to respiratory tract and wound infections. Therefore you should perform effective hand hygiene before and after providing patient care.
Observe Standard Precautions to avoid contact with blood or potentially infected body fluids. Protective equipment, such as gloves, gowns, masks, and protective eyewear should be used when there is a risk of bleeding or when secretions are present and there is an effective cough. Performing tracheostomy care requires the use of aseptic technique.
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Cleaning the inner cannula is generally performed every 8 hours. The inner cannula may be changed every 24 to 48 hours according to hospital policy. However, more frequent care may be necessary depending on the characteristics of the patient's secretions and/or the size of the tracheostomy tube.
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In most cases the inner cannula is disposable. It is simply removed, discarded and replaced with a new inner cannula. In other instances, the inner cannula may need to be removed and cleaned. Follow your institution's policy and the orders of the physician.
Before beginning, inform the patient about the procedure. Gaining his or her cooperation will enhance the effectiveness of the procedure. In case of emergency, be sure a handheld resuscitation bag with mask is near the patient when providing any kind of tracheostomy care.
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Prior to cleaning or changing the inner cannula, decontaminate your hands and don appropriate personal protective equipment (PPE). Because tracheostomy care procedures may stimulate the cough reflex, personal protective equipment typically includes eye protection, a facemask and gloves. A gown may also be required in some instances. Follow your facility's policies and procedures.
- After donning PPE, hyperoxygenate the patient and suction the airway to remove any secretions. Once suctioning is complete and the patient has fully recovered, you can prepare the necessary supplies.
- Tracheostomy Tube Cleaning Supplies
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Many of the supplies needed are available in pre-packaged sterile kits. They should be organized on a clean work surface at the bedside. Use the cleaning solution recommended by the policies and procedures of your institution. Often this will be a 50/50 solution of saline and hydrogen peroxide. Record the date and time you open the bottles of the cleaning solution that will be used for cleaning and rinsing the inner cannula, faceplate, and stoma. These solutions are discarded within 12 to 24 hours after opening or whenever sterility is in question.
Open the kit and spread the sterile waterproof drape with the waterproof side next to the table surface. Place a sterile drape on the patient's chest near the tracheostomy.
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While wearing a sterile glove on your dominant hand, arrange the sterile supplies. These typically include:
- Cotton-tipped applicators
- A cleaning brush
- Tracheostomy dressings
- Gauze pads
- A tracheostomy tie
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Cleaning the Tracheostomy Tube:
With the ungloved hand, pour the sterile saline into the empty sterile containers and onto 4 of the gauze pads. Then pour the cleaning solution into the containers holding the cleaning brush, cotton-tipped applicators, and gauze pads. Leave 4 of the gauze pads dry.
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Pre-oxygenate the patient by adjusting the oxygen concentration, or by instructing the patient to take several deep breaths before removing the tracheostomy collar.
- Put on the other sterile glove, and remove the tracheostomy collar. Carefully unlock the inner cannula and remove it. Do not allow encrustations or other matter to fall into the outer tube. Replace the tracheostomy collar before proceeding.
- Place the inner cannula in the cleaning solution.
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Remove the tracheostomy collar and gently remove the dressing from beneath the faceplate, and discard it using appropriate technique. Remember to replace the tracheostomy collar.
Decontaminate your hands and reglove. Then, remove the inner cannula from the cleaning solution and clean it with a sterile tracheostomy cleaning brush. Carefully clean both the inside and the outside of the tube, then rinse it in the sterile saline, agitating it for 10 seconds to rinse it thoroughly.
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Inspect the cannula carefully, looking for any dried secretions and bristles from the brush. Repeat the cleaning process if necessary.
- If clean, tap the cannula against the inside edge of the saline container to remove excess liquid. Do not dry the cannula. Leaving a thin film of moisture acts as a lubricant that facilitates reinsertion.
- Reinsert the inner cannula, lock it in place, and replace the tracheostomy collar. If it is necessary to change the inner cannula, use a new sterile inner cannula.
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Once the inner cannula has been reinserted, use one of the cotton-tipped applicators saturated with cleaning solution to clean the faceplate of the tracheostomy tube. Do not allow any of the solution to enter the patient's airway, as the solution may be irritating to the mucous membranes.
If the patient cannot breathe spontaneously, or there is difficulty maintaining oxygen saturation levels, insert a spare inner cannula or adapt the tracheostomy tube while the inner cannula is being cleaned. The patient can then be reconnected to the ventilator, or hand ventilated.
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Caring for the stoma itself is another essential of patient care. As with all airway procedures, decontaminate your hands, put on sterile gloves and follow Standard Precautions.
Begin by inspecting the stoma and surrounding skin. The area should be pink and free of irritation, swelling, or other abnormalities, such as purulent discharge from the stoma. Be sure to report any signs of bleeding or discharge or swelling.
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To cleanse the stoma and surrounding skin, use a 4x4 gauze pad saturated with the cleaning solution used by your facility. Wring out any excess solution. Cotton-tipped swabs may also be used to clean the stoma. Follow your facility's policy and procedures.
Clean from the stoma toward the periphery using a clean gauze pad each time. Be sure to gently and meticulously clean the skin beneath the faceplate while avoiding unnecessary manipulation of the tracheostomy tube. Note the presence of blood, aspirant material or changes in the color of discharge.
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Then use gauze pads saturated with normal saline to rinse the area. Follow the same technique used to clean the site. Thoroughly blot the area dry and then prepare to apply a sterile tracheostomy dressing.
Carefully position the new dressing under the ties and slip it gently beneath the faceplate. The edges of the tracheostomy dressing are sewed together to prevent threads from entering the trachea. Never use gauze with cotton filling, since lint can enter the patient's airway.
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Most facilities change tracheostomy tubes on a routine basis as a preventive care measure. However, this is a controversial issue and generally, if the airway is functioning properly and an infectious process is not present, it may not be necessary to change the tracheostomy tube. Be sure to know and follow your institution's policy on changing tracheostomy tubes.
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Tracheostomy Tube Changing Supplies
sterile supplies. This includes:
- A source of suction
- A catheter kit
- Drain sponges
- A tracheostomy tube with an inner cannula and obturator
- Water soluble lubricant
- A syringe
- A pair of sterile gloves
- A basin, sterile water
- A tracheostomy care kit
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Changing the Tracheostomy Tube: Preparation
Changing the tracheostomy tube requires the use of sterile technique. Begin by opening the sterile supplies and prepare a sterile work area. You will need the help of an assistant to safely change the tracheostomy tube.
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After decontaminating your hands and donning appropriate personal protective equipment, including sterile gloves, remove the inner cannula from the new tracheostomy tube and insert the obturator.
Check the integrity of the tracheal cuff by fully inflating the cuff. Observe the cuff for symmetry. If the cuff inflates unevenly or is abnormally shaped when inflated, it may be defective and should not be used. In this event, deflate the cuff discard the tracheostomy tube, and obtain a new one. Check the integrity of the new cuff in the same manner.
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To further assess the integrity of the cuff, immerse the entire tracheostomy tube, including the connection between the syringe and pilot balloon line, in the basin of sterile water. As the cuff is inflated, watch for any air leaks. None should be apparent.
After you have tested the cuff's integrity, lubricate the tracheostomy tube with water-soluble lubricant, then reshape the cuff by tapering it back and away from the distal end of the outer cannula to facilitate insertion.
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While you are preparing the supplies, the assistant can suction the oropharynx to remove any secretions that may have collected above the cuff.
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Changing the Tracheostomy Tube: Procedure:
- To begin changing the tracheostomy tube, first preoxygenate the patient and hyperextend the patient's neck. Attach the syringe to the pilot balloon line. Ask the assistant to insert a sterile catheter into the trachea to suction the patient as you deflate the cuff. When resistance is felt, continue to pull back on the plunger to ensure complete deflation of the cuff.
- Then have the assistant remove the tie and swiftly remove the tracheostomy tube by pulling it downward toward the chest following the curve of the tube. The tube should never be pulled straight out.
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Place the new tracheostomy tube perpendicular to the trachea and gently insert it. Turn the tube so that it is positioned correctly in the trachea. Remove the obturator and feel for the movement of air. Then insert the inner cannula and reconnect the oxygen source.
Auscultate the chest for the presence of bilateral breath sounds. Observe for bilateral chest expansion. A bronchoscopy may be ordered to verify correct tube placement.
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Once correct placement is determined, inflate the cuff and secure the airway with the tie.
Observe the patient for any signs of respiratory distress. Then discard all the used supplies and disposable equipment, and remember to discard your gloves and wash your hands before leaving the room.
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Document the care provided and the patient's condition before, during, and after the procedure. Remember to include the size of the tube and the amount of air used to inflate the cuff.
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Considerations With Obese Patients:
Obese patients are at risk of complications related to tube insertion. There is an increased chance that misalignment of the exterior and interior openings of the tracheotomy may lead to misplacement of the tracheostomy tube. This can result in misplacement of the tube within the neck wall. In these cases, patients should be placed in the same position they were in when the tracheostomy tubes was initially placed to realign the entrance and exit holes.
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There is also the risk that the tracheostomy tube will not extend fully into the trachea, but can become trapped within the pre-tracheal space before reaching the trachea. Ensuring the tracheostomy tube is the correct length can prevent this from occurring.
Maintaining adequate cuff pressure is another important aspect of care for the patient with an artificial airway. The cuff on an artificial airway creates a seal between the lungs and the upper airway. This seal permits positive pressure ventilation and can prevent aspiration of foreign material into the lungs. A soft cuff, also called a high-volume, low-pressure cuff, should be used. When inflated properly, the soft cuff requires a markedly lower intracuff pressure to function effectively.
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Complications Related to Over-inflation:
If the cuff is over-inflated, the high-volume, low-pressure cuff exerts excess pressure on the tracheal wall, which may decrease capillary perfusion of the affected tissues. Serious complications may result. These complications are primarily related to the intra-arterial capillary perfusion pressure of tracheal tissue, which is estimated to be 30 mm Hg in the adult. At the venous end of the capillary bed, perfusion pressure is 18 mm Hg.
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When intracuff pressure exceeds this perfusion pressure, blood flow is interrupted, resulting in ischemia. If high pressure is maintained and ischemia persists, tracheal bleeding, erosion, and sloughing of the necrotic tissue may occur.
Eventually, as the over-inflated cuff continues to impair the blood supply, the cartilaginous tracheal rings are exposed, causing a condition known as tracheomalacia. This stage is characterized by softening and fragmentation of the cartilage, which weakens the tracheal wall and usually causes the trachea to dilate. Then later, as the tracheal tissue heals, there can be fiber scaring, or the growth of granulation tissue replacing the damaged cartilage, which causes a condition known as tracheal stenosis, or a narrowing of the trachea.
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In addition, tissue erosion can cause communication between the trachea and the esophagus, resulting in tracheoesophageal fistula. Or, the tracheal wall can erode through to the innominate artery to creates a tracheoinnominate artery fistula. At this point frank bleeding and rapid fatal hemorrhage may occur.
Patients at greater risk for these complications include those receiving chemotherapy, taking steroids, and those who are malnourished.
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Finally, in some instances, cuff over-inflation can cause obstruction of the artificial airway by herniation of the cuff over the end of the tube. To avoid over-inflation and prevent these complications, accurate cuff pressure must be maintained.
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Direct Measurement of Intracuff Pressure:
The preferred technique to prevent over-inflation of the cuff is direct measurement of intracuff pressure using a tracheal cuff pressure gauge. Past methods of preventing over-inflation of the cuff required significant deflation of the cuff. However, deflating the cuff may allow contaminated secretions on top of the cuff to migrate into the trachea. This is thought to increase the risk of ventilator-associated pneumonia.
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Assemble the equipment necessary for intracuff pressure measurement. This includes the cuff-pressure manometer, stethoscope, suction equipment and gloves.
- Begin by explaining to the patient what you are going to do. Then decontaminate your hands, don PPE, and suction both the tracheostomy tube and the oropharynx to remove secretions above the cuff.
- Attach the cuff-pressure manometer to the pilot balloon port. If the patient is not on a ventilator, hyperinflate the lungs with an ambu-bag to provide positive pressure for auscultation of an air leak.
- Place the stethoscope over the trachea where the cuff of the tracheostomy tube should be. Listen for an air leak. If an air leak is not heard, slowly deflate the cuff by pressing the red button on the cuff-pressure manometer. When the sound of a leak is heard, release the red button and squeeze the bulb of the cuff-pressure manometer to reinflate the cuff. Add air until you can no longer hear the air leak.
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When you no longer hear the air leak, note the pressure on the manometer dial. This is the minimum pressure required for the tracheal tube cuff to occlude the trachea. This pressure is often between 16 and 24 centimeters of water. Maintaining the lowest possible cuff pressure will help minimize cuff-related problems.
Disconnect the cuff-pressure manometer from the pilot balloon port. Document the cuff pressure you observed, and the method used to measure it.
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When measuring cuff pressure, also be aware of the volume of air required to inflate the cuff. Tracheal dilatation or erosion are indicated by a gradual increase in volume. A sudden increase may indicate a ruptured cuff requiring immediate reintubation.
Also note that if a high cuff pressure is indicated on the manometer but the patient can still speak, the cuff may not be in contact with the walls of the trachea. In this case, the manometer is only measuring the cuff's internal pressure, not the pressure of the cuff against the trachea.
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