TRACHEOSTOMY It is an operation in which the windpipe is opened from the front of neck or Surgical creation of an opening into the trachea Indications for tracheostomy 1. Upper airway obstruction: to relieve upper airway obstruction  Infection : laryngeal infection  Neoplasm: carcinoma of larynx and pharynx  Trauma: laryngo-tracheal injuries  Foreign body in larynx  Neurological : B/L vocal cord palsy 2. Respiratory insufficiency : who needs prolong ventilation  Comatose patient without cough reflex: head and chest injuries, poisoning  Neurological condition: myasthenia garvis, poliomyelitis  COPD  Pneumonia 3. Tracheobronchial toileting  Accumulation of secretion in lower respiratory tract prevent proper gas diffusion at alveoli  Tracheostomy allows frequent and adequate pulmonary aspiration  Pulmonary edema  Congestive heart failure  Chronic lung disease and infections Types of Tracheostomy  Depending upon the urgency  Emergency  acute laryngeal obstruction demanding urgent relief.  Elective  Temporary  Permanent Technique  Position / Anaesthesia Tracheostomy Tubes  Metal tubes  Non-metal tubes Types of Tracheostomy Tubes  Portex tube (with cuff)  prevent aspiration  can be used in ventilator  May get blocked- has to be removed  Metal tubes  2 tubes - inner and outer tubes  Advantage - can be used for long period and has and less chance of blockade (if inner tube is blocked, it can be removed and patient breathes through the outer tube) Metallic tube Non metallic tube It has set of outer tube, inner tube and introducer Outer tube is fastened to neck with ribbon strap Inner tube is slipped into outer tube and fused to it by locking device Made of silastic Consists of single tube Advantage Main advantage of metal tube is that , if crusts or mucous plug blocks the inner tube and patient has difficulty in breathing, inner tube can be removed while outer tube remains in trachea and maintains patency of airway allowing the patient to breathe Advantage : Have inflatable cuff and can be connected to ventilator Disadvantage Do not have cuff and cannot produce an airtight seal needed for ventilator If lower end of metal tube do not fit properly, it can cause injury and even erosion of tracheal wall Disadvantage Inflatable cuff itself can cause excess cuff pressure leading to subglottic stenosis if used more than 2-3 weeks Has single tube, so that tube can get blocked due to mucous plug or crust leading to respiratory obstruction Nursing Care of Tracheostomy  Meticulous postoperative care of tracheostomy is necessary to avoid complication  Bed should be close to nursing station  Bedside items - suction machine with sterile suction catheters, 1 extra tracheostomy tube, paper and pen for the patient to communicate  Suction: regular tracheal suction after putting 1-2 ml of sterile saline into trachea to prevent crusting  Humidification : regular humidification( done by inhalation of steam or alternately by electric humidification unit ; nebulizer)  Chest physiotherapy: regular chest physiotherapy  First change of tube The first change of tracheostomy tube is done after 72 hours of surgery . after 72 hours a tract usually form and remains patent . if removed earlier than there is likelihood of soft tissue around tracheostomy collapsing and obstructing the airway Subsequent change of tube  When a metal tube is used –inner tube is removed, cleaned and reinserted without disturbing outer tube, 2 times a day  Outer tube is similarly removed and cleaned and reinserted once a day  When single lumen silastic tube is used – this tube should be removed cleaned and reinserted everyday Deflation of cuffed tube  When a cuffed silastic tube is used, cuff should be deflated every 2 hours for a few seconds or min in order to prevent tracheal injuries- necrosis and subglottic stenosis Principles of Decanulation  Tube size reduced before decanulation  Tube is corked off for increasing periods  Self-ventilating for at least one full night  No further need for tracheal suction  Remove the tube; plug the tracheostomy site