ELL ME ABOUT A TRACHEOSTOMY BEFORE I N EED T ELL MEABOUT A TRACHEOSTOMY ... – To comply with tube manufacturers guidelines ... • Use care with gauze padding –can become an obstruction

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“TELL ME ABOUT A TRACHEOSTOMY

BEFORE I NEED ONE”

PEDIATRIC VENTILATOR APPLICATION OF PASSYPEDIATRIC VENTILATOR APPLICATION OF PASSY--MUIRMUIR® ® VALVEVALVE

Linda Dean, RRT

Clinical SpecialistPassy-Muir Inc.

[email protected](949) 833-8255

Disclosure: Financial — Employee of Passy-Muir Inc.Nonfinancial — No relevant nonfinancial relationship exists.

Is There Anything I Can Do To Postpone A Tracheostomy?

• Noninvasive Ventilation

• Airway Clearance



There are many forms of non-invasive ventilation


Today’s options are much smaller


There are multiple mask types

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Sip and Puff Ventilation


Airway Clearance Devices



Left: PEP Valve

Right: Bronchial Hygiene acapella® Vibratory PEP Therapy System-Portex



The Vest-Airway Clearance System http://www.thevest.com/

Why Do Some People Need A Tracheostomy?

• Prolonged mechanical ventilation

• NIV no longer meets your needs

• Upper airway obstruction (temporary or permanent)

• Secretion management (neuromuscular disease)

• Improved patient comfort

What Are The Advantages of a Tracheostomy?

• Can save your life

• Quality of life can be great

• Frees up face/hands for eating, etc.

• May decrease need for continuous ventilation

• Provides direct access to your lungs for:

– Secretion removal

– Mechanical ventilation

– Medication delivery

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What Are The Disadvantages of a Tracheostomy?

• Increased risk of infection, bleeding, scar tissue

• Requires a surgical procedure

• Emotional and psycho-social issues – altered body image

• Communicating and swallowing may be altered

• Sense of taste and smell can be lost

• The natural warming, humidification and filtering of air that usually takes place in the upper airway is lost

• Need for home health services/skilled caregivers

• Increased equipment needs• Cost of care can be a burden

***MOST IMPORTANT: you decide

Upper Respiratory Tract

• Nasal Cavity

• Oral Cavity

• Pharynx

• Larynx

Nasal Cavity

Oral Cavity

Pharynx

Larynx

Lower Respiratory Tract

• Trachea

• Bronchi

– right and left mainstem

• Bronchioles

• Alveoli - air sacks

– lined with surfactant,

filled with air to prevent

collapse/ atelectasis

Tracheostomy or Tracheotomy?

Which One Is It?

• Tracheotomy is defined

as the surgical opening

of the trachea.

Tracheostomy or Tracheotomy?Which One Is It?

• Tracheostomy also refers

to a surgical procedure:

the creation of a stoma

at the skin surface, but

most often is referring to

the tube that is inserted

How Is A Tracheotomy Performed?

• Percutaneous – at the

bedside (usually while

the patient is in critical

care)

• Open – in an operating

room

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Open Tracheotomy

• The oldest surgical

procedure

• The patient goes to the

operating room

• Vertical incision is made

between 3-4 or 4-5

cartilage rings

• Tube is inserted and

sutured in place for

safety

What Does The Tube Look Like, And Where Does It Go?

There are many choices of tubes!!!!! Parts of a tracheostomy tube - ISO STANDARDS

Neck flange

Pilot balloon

15 mm connector-hubTube shaft

CuffInflation line

Pilot port with one way valve

Tracheostomy Tubes

• Single Lumen/Cannula • Double Lumen/Cannula

Fenestrated Tracheostomy Tube

Image used by permission from Covidien

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Extra Length Tubes

distal proximal

Increased skin-to-tracheal-wall distanceTracheal Malacia or Stenosis

Image used by permission from Nellcor Puritan Bennett LLC, Boulder, Colorado, doing business as Covidien.

Adjustable Flange Tube

Air Filled Cuffs

• Cuff Deflated• Cuff Inflated

Water Filled Cuffs TTS

• Cuff Up • Cuff Deflated

Day to Day Needs Of A TracheostomyPatient

• Patient Information – “Neck Breather Alert”

– Reason for tracheotomy/date of initial tracheotomy

– Brand, type, size tube – spare tubes at bedside

– Local fire and rescue, police, and your electric company

should be alerted to your needs

• Assessment:

– Sputum characteristics – signs of infection

– Cough strength, mucus production

– Check security of tube holder/ties

Day to Day Needs Of A Tracheostomy Patient –Swallowing

• Presence of a tracheostomytube may:– Make swallowing more

difficult

– May increase the risk of aspiration (as high as 85%)

Assessment, evaluation, and therapy by a Speech Language Pathologist may make oral intake possible

If oral intake is not an option, alternative feeding options should be discussed

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Day to Day Needs Of A Tracheostomy Patient Humidification

HME – artificial nose Trach Collar – used with

aerosol generating device


• Drink plenty of fluids, eat

sensibly, and avoid

people who have colds

and flu

• Take care nothing enters

the tracheostomy(leaves, bugs, hairs, shaving cream, cotton swabs,

powders, dust, fumes, etc)


• NaCl Nebulizer therapy

• NaCl instillation

• Bibs that heat and filter

Day to Day Needs Of A Tracheostomy Patient Trach Care

• Bronchiol-pulmonary Hygiene

– Suctioning

– Assistive coughing and breathing techniques

– Devices

• Acapella/PEP/Therapy Vest

• Cough Assist

• Inner Cannula Change Cleaning

– Disposable inner cannula is changed daily and PRN

– Non-disposable inner cannula is cleaned 2 X day and PRN

STOMA CARESTOMA CARE

Day to Day Needs Of A Tracheostomy Patient Oral Care

• Give special care to nose and mouth

• Unable to sense mouth odor

• Good mouth care stimulates salivation and taste buds

Day to Day Needs Of A Tracheostomy Patient Stoma Care

• Trach site must be cleaned daily– After the trach stoma has healed, plain soap and water can be

used to clean the skin around the trach

• NEVER USE: powders, lotions

• Antibiotic ointment may be used for redness

• Moleskin can be wrapped around ties to prevent

rubbing

• Change/wash fabric tube ties daily – can use twill

tape, Velcro fasteners

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Day to Day Needs Of A Tracheostomy PatientRoutine Tracheostomy Tube Changes

• First tube change is done by a surgeon (preference)– To assure stoma and tract established

• Routine change of tube - physician will advise:• Change monthly if double lumen tube• Change weekly if single lumen tube

– To reduce complication of granulation tissue

– To decrease risk of infection– To comply with tube manufacturers guidelines

NOTE*** There is no current consensus/guideline for adults (local practices)

Day to Day Needs Of A Tracheostomy PatientPersonal Hygiene

When showering:

• Cover tracheostomy with HME or shower guard

• Angle spray away from stoma

How Will I Communicate?Airflow With A Tracheostomy Tube

Alternative Communication Devices

• Intercom system

• Bells on ankles/shoes to hear a child

• Tricycle horn, squeaker toy, bell• Finger occlusion

• Call system, light or bell (adapted as necessary)

• Picture, word and/or alphabet communication board• Facial expression or eye gaze board (limited mobility)

• Magic slate writing board

• Pencil and paper• Simple gesture

• Signing

• Lip reading• Speaking Valves

Leak Speech For Ventilator Patients

• Cuff is deflated to allow airflow through the mouth

• May be some loss of ventilation, adjust volumes to compensate

– to much volume can be harmful to the lungs!

• Vocalize during inspiration – why is this unnatural?


The Passy-Muir® Tracheostomy & Ventilator

Swallowing and Speaking Valve

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Passy-Muir® Valve Placement


Physiologic Benefits of Passy-Muir ® valve

• Restores Voice/Communication

• Improves Swallowing

• Restores Physiologic PEEP

• Improves Secretion Management

• Improves Oxygenation

• Promotes Weaning and Decannulation

• May Decrease Risk of Aspiration

• Improves Smell & Taste

Other Resources:

• www.passy-muir.com

• www.hopkinsmedicine.org/tracheostomy/living

• www.Tracheostomy.com

• http://www.ventusers.org

• http://www.upmc.com/patients-

visitors/education/documents/tracheostomycare.pdf

• http://www.kchealthcare.com/media/67088/product%

20information%20and%20tool_trach%20care_home%20

care%20guide.pdf


Linda Dean, RRT

Clinical SpecialistPassy-Muir Inc.

[email protected](949) 833-8255

Disclosure: Financial — Employee of Passy-Muir Inc.Nonfinancial — No relevant nonfinancial relationship exists.

Definitions:• Airway: The passage that allows air (oxygen) to get to the lungs

• Ashen: A word that describes a pale, gray color to the skin

• Bactroban: An antibiotic ointment used for redness or irritation around the

tracheostomy

• Breathing: The process of taking air through the airway and into the lungs,

supplying the body with oxygen vital for survival

• Canister: A collection device for secretions and saline, attached to the

suction machine

• Cannula: The part of the trach tube that is inside the airway

• Catheter: A thin tube used to suction secretions out of the tracheostomy.

Catheters come in different sizes (example, 6 French)

• Circulation: The process of blood being pumped by the heart and traveling

through the body via blood vessels, arteries and veins

• Dusky: A blue color to the skin, lips or nail beds that signifies a decrease of

oxygen in the body

Definitions:• Flanges: Flat plastic/silicone front of the tube with holes on each side. These

holes are where the trach ties are inserted and secured.

• Humidification: The process of putting moisture in the air, done by a

humidifier. Humidification keeps secretions in the tracheostomy from becoming dried out and plugging the tracheostomy tube

• Humidifier: A device that puts water in the air via a machine

• Moleskin: A soft material with a sticky backing that can be applied to the

trach ties to prevent or decrease irritation from rubbing trach ties

• Mucus: Thick secretions from the tracheostomy. These need to be suctioned

from the trach in order to keep the airway clear and patent

• Mummy Restraint: A sheet or blanket, wrapped securely around the child to

hold his arms down and prevent excessive movement during a procedure

• Obturator: The stiff piece of plastic shaped like the trach tube with a

rounded end that guides the flexible trach tube into place during a trach

tube insertion. The obturator must be removed immediately after the trach is

in place because it obstructs the airway.

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Definitions:

• Resusitation Bag: A device that allows you to push oxygen into the lungs via the airway. The resusitation bag may be connected to an oxygen tank.

• Rescue Breathing: The process of delivering one breath every 5-10 seconds into the tracheostomy because he/she is unable to breathe independently

• Respiratory Distress : A condition demonstrated by difficulty breathing, retractions, dusky or ashen color, fast breathing

• Retractions: Sucking in of the neck and/or chest between the ribs (a sign of respiratory distress)

• Shiley, Bivona, Portex, Tracoe: Brands of tracheostomy tubes • Sterile Water : Tap water that is boiled and stored in sterile container. It

may also be purchased.• Stoma : The opening in the neck where the trach tube is inserted• Suctioning : The process of removing secretions from the tracheostomy

by applying suction through a catheter

Definitions:• Ties: Twill tape, Velcro® fasteners, or shoelaces that are

threaded through the flanges on each side of the tracheostomy to keep the trach in place

• Trach: Short for tracheostomy• Trach Nose: (HME) A special piece of equipment with a filter

to collect heated/humidified air on exhalation, to heat/humidify inspiration on the next breath into the tracheostomy

• Trach Size: The particular diameter and length of the trachtube (varies with the age and size of the patient)

• Trach Tube : The piece of the tracheostomy providing the artificial airway that goes into the patient’s body

• Tracheotomy : A procedure that creates an opening for an artificial airway to maintain your patient’s ability to breathe

• Twill Tape: Cotton strings used to tie the tracheostomy in place

• Velcro Ties: Trach ties commercially available that use velcroto secure around the neck

Trach Safety:

• Use caution around water – shower guards

• Foreign objects small enough to inhale• Avoid turtle necks shirts and plastic bibs

• Use care with gauze padding – can become an obstruction• Environmental Control: dust, lint, mold , pet hair, and smoke in

the home• Systemic hydration – drink plenty of water• Avoid aerosol sprays

• Transport with care on windy, cold days• Practice infection control: vaccines, hand washing, crowds,

screen visitors• Watch for change in secretions – signs of infection

• Disinfect toys – dishwasher• Disinfect respiratory equipment – white vinegar

Equipment Recommended For Home:

• Spare Trach Tubes (same size and smaller sizes)• Suction Catheters

• Suction Machines (-80 to -100mmHg)• Sterile Water• Resusitation Bag and face mask – proper sized• Bulb Syringes• HME’s (artificial noses)• Compressor for Humidification• Trach Collar and Tubing• Q-Tips• Hydrogen Peroxide

• Gloves• Oxygen• Apnea Monitor• Pulse Oximeter

Documents

ELL ME ABOUT A TRACHEOSTOMY BEFORE I N EED T ELL MEABOUT A TRACHEOSTOMY ... – To comply with tube manufacturers guidelines ... • Use care with gauze padding –can become an obstruction