What would the critical care nurse recognize as a condition that may indicate a patients need to have a tracheostomy?
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Safety considerations are important when caring for a patient with a temporary tracheostomy. Early detection and resolution of problems in tracheostomy management are important to prevent serious incidents arising. Nurses working outside critical care areas need to be competent and confident in the management or detection of potential problems with tracheostomies. This article summarises the essential care of a patient with a temporary tracheostomy with reference to best practice guidelines, emphasising the importance of prompt intervention and response, if a potential problem is identified. Nursing Standard. 29, 26, 42-49. doi: 10.7748/ns.29.26.42.e9742 Correspondence
Peer review This article has been subject to double blind peer review Received: 05 November 2014 Accepted: 01 December 2014 Want to read more?Already subscribed? Log inORUnlock full access to RCNi Plus todaySave over 50% on your first 3 monthsYour subscription package includes:
Subscribe RCN student member? Try Nursing Standard StudentAlternatively, you can purchase access to this article for the next seven days. Buy now Or Overview BackgroundTracheostomy is an operative procedure that creates a surgical airway in the cervical trachea. [1, 2] It is most often performed in patients who have had difficulty weaning off a ventilator, followed by those who have suffered trauma or a catastrophic neurologic insult. [3] Infectious and neoplastic processes are less common in diseases that require a surgical airway. Tracheostomy is a utilitarian surgical procedure of access; therefore, it should be discussed in light of the problem it addresses: access to the tracheobronchial tree. The trachea is a conduit between the upper airway and the lungs that delivers moist warm air and expels carbon dioxide and sputum. Failure or blockage at any point along that conduit can be most readily corrected with the provision of access for mechanical ventilators and suction equipment. In the case of upper airway obstruction, tracheostomy provides a path of low resistance for air exchange. The traditional semantic difference between tracheostomy and tracheotomy is now blurred because the hole is variably permanent. If a cannula is in place, an unsutured opening heals into a patent stoma within a week. If decannulation is performed (ie, the tracheostomy cannula is removed), the hole usually closes in a similar amount of time. The cut edges of the tracheal opening can be sutured to the skin with a few absorbable sutures to facilitate cannulation and, if necessary, recannulation can be performed. Alternatively, a permanent stoma can be created with circumferential sutures. The term tracheostomy is used, by convention, for all these procedures and is considered to be synonymous with tracheotomy. The trachea is nearly but not quite cylindrical but is flattened posteriorly. In cross-section, it is D-shaped, with incomplete cartilaginous rings anteriorly and laterally, and a straight membranous wall posteriorly. The trachea measures about 11 cm in length and is chondromembranous. This structure starts from the inferior part of the larynx (cricoid cartilage) in the neck, opposite the 6th cervical vertebra, to the intervertebral disc between T4-5 vertebrae in the thorax, where it divides at the carina into the right and left main stem bronchi. For more information about the relevant anatomy, see Trachea Anatomy. IndicationsThe advent of the antibiotic era and advances in anesthesia have made tracheostomy a commonly performed elective procedure. Important to note, however, is that there are situations when tracheostomy is quite urgent or emergent. This typically involves patient who is immediate need of a surgical airway because of impending airway obstruction. General indications include the following:
Tracheostomy may also be performed to provide a long-term route for mechanical ventilation in cases of respiratory failure or to provide pulmonary toilet in the following cases:
The cuffed tube allows the trachea to be sealed off from the esophagus and its refluxing contents. Thus, this intervention can prevent aspiration and provide for the removal of any aspirated substances. However, some investigators argue that the risk of aspiration is not actually lessened, as secretions can leak around the cuffed tube and reach the lower airway. The Council on Critical Care of the American College of Chest Physicians recommends tracheostomy in patients who are expected to require mechanical ventilation for longer than 7 days. [4] However, the final decision is made on an individual basis based on comorbidities and the patient’s current condition. A retrospective population-based study from Taiwan compared the long-term mortality between patients on prolonged mechanical ventilation with tracheostomy with those without tracheostomy and found no differences in long-term mortality between the two groups. [5] It is also important to outline what tracheostomy does not or will not do for the patient. Specifically, tracheostomy does not prevent aspiration of airway or other secretions. Additional diagnoses for which tracheostomy is often considered early in the course include botulism, amyotrophic lateral sclerosis, and cervical spine injury, among others. ContraindicationsNo absolute contraindications exist for tracheostomy. A strong relative contraindication to discrete surgical access to the airway is the anticipation that the blockage is a laryngeal carcinoma. The definitive procedure (usually a laryngectomy) is planned, and prior manipulation of the tumor is avoided because it may lead to increased incidence of stomal recurrence. Temporary tracheostomy may be performed just under the first tracheal ring in anticipation of a laryngectomy at a later time. End-of-life issues may also come to bear on the decision to perform a tracheostomy because it may represent further mechanization of the patient's care to family members. In fact, the performance of a tracheostomy does not affect the decision to extend or to withdraw care. Hygiene is improved, quality of life (speaking and eating, if relevant) is improved, and placement in long-term care is facilitated in some cases; however, dependence on mechanical ventilation may not be changed. Technical ConsiderationsProcedure planningTracheostomies can be performed through with an open or percutaneous technique. Open tracheostomy is one of the oldest procedures described in the literature and is still the procedure of choice for some trauma centers. However, the use of percutaneous tracheostomy has been increasing since its introduction in the 1980s. Studies have supported percutaneous over open tracheostomies. However, the final technique depends on the surgeon’s experience and comfort, in addition to guidelines of the facility where this procedure is to be performed. Patient selection - Percutaneous versus open tracheostomyIn 1969, Toy and Weinstein described a technique of tracheostomy performed percutaneously at the bedside using essentially a Seldinger technique modified with progressive dilation. [6] Its main advantage is that it can be performed at the bedside; therefore, the expense and logistics of transportation and operating room usage are eliminated. These advantages are mitigated because bedside anesthesia is required and bronchoscopic visualization adds to the expense and personnel required. Moreover, preparation for the possibility of an emergent open tracheostomy is important. Its disadvantages stem from the decreased exposure and thus decreased visualization and control. A study of 149 critically ill patients found a greater risk of severe (>50%) suprastomal stenosis developing as a late complication of percutaneous dilational tracheostomy versus surgical tracheostomy. [7] The following patients are commonly recognized to be unfavorable candidates:
Kost reported on the use of this procedure in 500 consecutive intubated adults in the intensive care unit. [8] When this procedure was performed in conjunction with bronchoscopy, the complication rate was acceptably low (9.2%). No serious complications (eg, pneumothorax, pneumomediastinum, death) occurred. The most common complications were oxygen desaturation in 14 patients (defined as a drop, even transient, to less than 90%) and bleeding in 12 patients (when intervention was required to control the bleeding). Complication preventionPotential complications are due to direct injury. Bedside ultrasound is often used to survey the tracheostomy site during the planning stage, especially for percutaneous tracheostomies. This is to identify vessels that may be under the intended incision and to help avoid injury. The cricothyroid muscle, vocal muscles, and the vocal cords are vulnerable to injury during tracheostomy (see the image below).  The innominate artery, or brachiocephalic trunk, crosses from left to right anterior to the trachea at the superior thoracic inlet and lies just beneath the sternum. The trachea is membranous posteriorly and is formed of semicircular cartilaginous rings anteriorly and laterally. The spaces between the rings are membranous. The recurrent laryngeal nerves and inferior thyroid veins that travel in the tracheoesophageal groove are paratracheal structures vulnerable to injury if dissection strays from the midline (see the image below). The recurrent laryngeal nerve is also vulnerable to injury from the cuff of the tracheostomy tube, particularly if the cuff is overinflated. The great vessels (ie, carotid arteries, internal jugular veins) could be damaged should dissection go far afield, which is a real risk in pediatric or obese patients. The thyroid gland lies anteriorly to the trachea with a lobe on both sides and the isthmus, which crosses the trachea at approximately the level of the second and third tracheal rings. This tissue is extremely vascular and must be divided with careful hemostasis.
Author Jonathan P Lindman, MD Otolaryngology-Head and Neck Surgeon, Piedmont Ear, Nose, Throat and Related Allergy Jonathan P Lindman, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, Phi Beta Kappa, American Academy of Sleep Medicine, Triological Society Disclosure: Nothing to disclose. Coauthor(s) Ruben Peralta, MD, FACS, FCCM, FCCP Deputy Trauma Medical Director, Professor and Director of Trauma, Emergency and Critical Care Fellowship Program, Senior Consultant in Surgery, Trauma, Emergency and Critical Care Medicine, Associate Director of Trauma Intensive Care Unit, Hamad General Hospital and Hamad Medical Corporation, Weill Cornell Medical College in Qatar Ruben Peralta, MD, FACS, FCCM, FCCP is a member of the following medical societies: American Association of Blood Banks, American College of Healthcare Executives, American College of Surgeons, American Medical Association, Association for Academic Surgery, Eastern Association for the Surgery of Trauma, Massachusetts Medical Society, Society of Critical Care Medicine, Society of Laparoscopic and Robotic Surgeons Disclosure: Nothing to disclose. Ravindhra G Elluru, MD, PhD Professor, Wright State University, Boonshoft School of Medicine; Pediatric Otolaryngologist, Department of Otolaryngology, Dayton Children's Hospital Medical Center Ravindhra G Elluru, MD, PhD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Bronchoesophagological Association, American College of Surgeons, American Medical Association, Association for Research in Otolaryngology, Society for Ear, Nose and Throat Advances in Children, Triological Society, American Society for Cell Biology Disclosure: Nothing to disclose. Muhammad Kamaal Khan, MBBS, MRCSEd, DOHNS, FRCS(ORL-HNS) Consultant ENT, Department of ENT Head and Neck Surgery, Freeman Hospital, Newcastle upon Tyne, UK Muhammad Kamaal Khan, MBBS, MRCSEd, DOHNS, FRCS(ORL-HNS) is a member of the following medical societies: Royal College of Surgeons of Edinburgh, Royal College of Surgeons of England Disclosure: Nothing to disclose. Specialty Editor Board Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape. Karen H Calhoun, MD, FACS, FAAOA Professor, Department of Otolaryngology-Head and Neck Surgery, Ohio State University College of Medicine Karen H Calhoun, MD, FACS, FAAOA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Head and Neck Society, Association for Research in Otolaryngology, Southern Medical Association, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Rhinologic Society, Society of University Otolaryngologists-Head and Neck Surgeons, Texas Medical Association Disclosure: Nothing to disclose. Chief Editor Guy W Soo Hoo, MD, MPH Professor of Clinical Medicine, University of California, Los Angeles, David Geffen School of Medicine; Director, Medical Intensive Care Unit, Chief, Pulmonary, Critical Care and Sleep Section, West Los Angeles VA Healthcare Center, Veteran Affairs Greater Los Angeles Healthcare System Guy W Soo Hoo, MD, MPH is a member of the following medical societies: American Association for Respiratory Care, American College of Chest Physicians, American College of Physicians, American Thoracic Society, California Thoracic Society, Society of Critical Care Medicine Disclosure: Nothing to disclose. Additional Contributors Charles E Morgan, DMD, MD Assistant Professor, Department of Surgery, Division of Otolaryngology, University of Alabama at Birmingham School of Medicine Charles E Morgan, DMD, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery Disclosure: Nothing to disclose. Acknowledgements The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Susan Dixon, MD, to the development and writing of this article. Medscape Reference also thanks Ravindhra G Elluru, MD, PhD, Associate Professor, Department of Otolaryngology Head and Neck Surgery, University of Cincinnati College of Medicine; Pediatric Otolaryngologist, Department of Otolaryngology, Cincinnati Children's Hospital Medical Center, for assistance with the video contribution to this article.
Which action would the nurse suggest to a patient with a tracheostomy to prevent aspiration?Perform hand hygiene, apply non-sterile gloves. Suction the oropharynx if indicated to remove any pooled secretions before cuff deflation to minimize risk of aspiration.
Which action will the nurse include when doing tracheostomy care quizlet?The nurse is caring for a client with a tracheostomy. Which action would the nurse implement when performing tracheal suctioning? Preoxygenate the client before suctioning.
What assessment method would the nurse use to determine the areas of the lungs that need draining?Auscultate the chest to determine the areas of the chest that need drainage.
Which condition causes subcutaneous emphysema in a patient with a new tracheostomy?Subcutaneous emphysema is the result of air or gas trapped under the skin, typically seen in the chest walls and neck regions. It can develop rapidly, and may be the first clinical sign of a pneumothorax. It can result from trauma during the tracheotomy procedure or tracheal intubation.
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