Guidelines for Nursing Care of the Tracheostomy Patient

Three major factors must be considered in the care of the tracheostomy patient:

1. Humidification

2. Mobilization of secretions

3. Airway patency.

Humidity

The importance of humidification can not be overemphasized. The nasopharynx, which provides the natural humidification mechanism for the airway, has been bypassed by tracheostomy. It is absolutely essential that adequate humidity be provided to keep the airway moist.

In the immediate postoperative period, humidity is usually supplied via a heated gas vapor generator on a mechanical ventilator or via a heated aerosol supplied to the patient utilizing a T-piece attached directly to the tracheostomy tube, or a tracheostomy mask.

The patient must be properly hydrated with oral or I.V. fluids to permit the mucosal surface to remain moist and to ensure that the viscid secretions remain atop the cilia. This will make the secretions thinner and more mobile.

Instillation of sterile saline directly into the tracheostomy tube at intervals, usually before and during suctioning, may aid in loosening and keeping secretions moist.

 

The patient's own moisture may be conserved by the use of a simple condenser humidifier. As the patient exhales water vapor, it condenses on a pleated paper filter and is revaporized on inhalation. SIMS Portex Inc. has a heat and moisture device (Thermovent® T) available for the tracheostomy patient. Supplemental oxygen can be added to the inspired air with a special adapter (Thermovent 02).

Mobilization of Secretions

Many of the nursing skills employed are aimed at the mobilization of pulmonary secretions. Frequent turning, encouragement of deep breathing, and ambulation are important in the prevention of pulmonary complications.

Regular chest physiotherapy and postural drainage are both very effective in the mobilization of secretions and should be used routinely during the postoperative period. Manual ventilation jbagging) along with tracheal instillation of normal saline may also aid in the mobilization of secretions.

Suctioning

Suctioning is at best an uncomfortable procedure and is usually a frightening one for the patient. It is a procedure where both psychological and physiological defensive reflexes will come into play for the protection of the airway. It is essential to remember several things when suctioning a patient:

1. A tracheostomy is an open surgical wound and strict asepsis and universal precautions should be observed.

2. A clear explanation of the procedure with reassurance will help to decrease the patient's anxiety and fears.

3. Partial occlusion of the airway by the suction catheter, combined with aspiration of air from the lung while using an open suction system, can result in severe hypoxia, cardiac arrhythmia, and even cardiac arrest. Suctioning procedures must NEVER exceed 15 seconds even if no visible signs of stress are noted. The O.D. of the suction catheter should not exceed 50% of the I.D. of the lumen being suctioned.

4. The upper airway is lined with delicate tissue and care must be taken to avoid damage to these tissues during suctioning. For this reason, suction is applied only intermittently and with catheter rotation to avoid trauma to the mucosal walls of the trachea and bronchi.

5. Suction is applied ONLY during withdrawal in order to decrease the volume of air removed from the lungs and decrease the hypoxic effect and trauma to the airway.

6. The outer diameter of the suction catheter should be, at a maximum, one half \Vi) the inner diameter of the tracheostomy tube. A suction catheter of greater diameter could lead to obstruction to the air flow around the catheter during the procedure. When a closed suction system is used, this atmosphere will be oxygen enriched or will be supplied by the ventilator (see figure 1).

The following chart is included for reference. It relates the approximate size suction catheter to be used in conjunction with tracheostomy and endotracheal tubes.

Suction Catheter Sizing to Tracheostomy Tabes

 

Suction Catheters

SIMS Portex Inc. offers suction catheters in several styles and in various kit forms. The following is a guide for the practitioner to the various features of each of these styles:

Maxi-Flo9 Suction Catheter Kits

The Maxi-Flo suction catheters feature a catheter tip design which maximizes suction efficiency and minimizes trauma to the airway. The soft leading edge of the catheter reduces the possibility of damage to the carina associated with repeated suctioning. The large opening of the distal tip provides for easy and efficient removal of secretions. The lateral eyes are soft and close to the tip which increases suction efficiency. This catheter is available in several kit configurations as well as a single catheter package. The Maxi-Flo suction catheter maximizes efficiency and minimizes airway trauma.

Cathmark® Suction Catheter Kits

Cathmark suction catheters offer a method for safer neonatal and pediatric suctioning, as the chart on each package guides the clinician in determining the proper distance for catheter insertion. The graduations (every 2 cm) enable the clinician to advance the catheter accordingly, providing a margin of safety and potentially reducing the incidence of pneumothorax.

No Pour Pok® Suction Catheter Kits

No Pour Pak suction catheter kits are available in two different forms: the No Pour Pak II and the Economy No Pour Pak II.

The No Pour suction catheter kits all help to minimize the risk of nosocomial infections, protecting the patient and clinician from exposure to contaminated material when the suction procedure is completed. No Pour Pak n features a snap-on lid and resealable water basin allowing for total containment of the catheter, gloves, and solution for safe disposal at the completion of the suction procedure. The Economy No Pour Pak II contains many of the features of the No Pour Pak II yet is more economical because it has vinyl gloves and does not include a containment lid.

Coude Suction Catheter Kit

Clinical studies have shown that angled coude catheters ensure almost 100% entrance into the right main stem bronchus and approximately 45% entrance into the left main stem bronchus. Straight catheters enter the left main bronchus less than 10% of the time, regardless of the head position (see figure 2). For ease and accuracy of entering and suctioning the left bronchus, coude (angled) catheters are advocated (see figure 3).

Irri-Cath* Suction System

Figure 3.

The exclusive Irri-Cath suction system combines continuous irrigation and suction to significantly increase efficiency and effectiveness of secretion removal. It provides an alternative to the fiberoptic bronchoscopy for bronchial alveolar lavage as a diagnostic aid.

Irri-Cath allows for continuous irrigation to the exact suction site which reduces the viscosity of secretions, permitting immediate removal. More efficient removal of secretions with Irri-Cath decreases the frequency of necessary suctioning.

Steri-Catif Closed Ventilation Suction System

The Steri-Cath closed ventilation suction system catheter allows the clinician to maintain mechanical ventilation during the suction procedures. Suctioning without disconnecting the patient from the ventilator reduces many of the problems associated with open suction systems. This system reduces the possibility of cross-contamination, protecting both the patient and clinician with an enclosed catheter and thumb valve. The dual lumen system offers ease of instilling saline for lavage and irrigation as well as for the administration of intratracheal medications through a separate inner lumen. The lightweight T-connector and swivel eliminates torque associated with connecting closed suction systems directly to endotracheal or tracheostomy tubes. A closed ventilation suction system has been designed for the tracheostomy patient. It contains all the features of the standard closed ventilation system but features a 14fr catheter 30 cm in length.

 

Psychological Care

Many tracheostomy patients are totally dependent upon the caregivers and can do little for themselves. The alert patient will initially be apprehensive and frightened. Since the patient, especially with an inflated cuffed tube, will be unable to speak, every word and action of the staff is carefully observed. It is imperative that an atmosphere of calmness and confidence be created for the patient since emotional status will influence breathing pattern and acceptance of mechanical ventilation.

Most patients should be continually reminded that their inability to speak is only temporary. It is difficult, frustrating, tiring, and disheartening for a tracheostomized patient to attempt to talk. Other forms of communication such as a pad and pencil, a communication board, or the use of a specialty tracheostomy tube (Trach-Talk™) should be considered. The ability to communicate becomes imperative.

Caregivers should also provide encouragement and reassurance to the patient during attempts to swallow or eat, since the patient may be afraid of choking.

The apprehensive family may be reassured by pointing out to them such things as the call bell that is easily accessible, and the close proximity of a trained professional medical staff.