Flashcards in O13 Tracheotomy, Tracheostomy EXAM 3 Deck (44):
What is a tracheotomy?
Opening the trachea at any level/any point in order to create an airway.
T/F: a tracheotomy is almost always an emergency procedure to open the airway.
What is the difference between a tracheotomy and tracheostomy?
A TRACHEOTOMY is a temporary emergency procedure to create an airway for someone who can't breathe.
A TRACHEOSTOMY is a long-term option - cutting a flap off of the tracheal cartilage below the larynx and inserting a tube (the stoma will be closed at a later date unless it is a laryngectomy patient, in which case it is permanent).
What are the two major criteria for deciding whether to do a tracheotomy or tracheostomy?
1. Pump failure - diaphragm or intercostal muscle failure.
-Flail chest: cibcage will get smaller upon muscle contraction of inhaling, so rather than air coming in, it goes out.
-Injury to brain, brainstem, or spinal cord at the cervical level; results in paralysis or paresis.
2. Blockage that won't resolve quickly enough to maintain an airway.
- Crushed larynx or stenosis of larynx
-may require mechanical assistance to breathe until the pump or lungs can function correctly
What is stenosis of the larynx?
Broken or swollen larynx - needs tracheostomy
What is a ventilator and what is it used for?
It is a tube to maintain the airway that breathes for the patient, allowing more oxygen to get through the lungs, because you can raise the oxygen content of the air going into the lungs.
-Air pressure can also be raised.
Where does the ventilator tube go?
It is pushed through the mouth, up through the vocal folds, and into the trachea.
Having a ventilator placed between the vocal folds long-term is damaging to them as well as damaging to ________.
CN X - Vagus
a) What is the maximum amount of time you want to a patient to use a ventilator for?
b) If needed longer than this amount of time, what should you consider doing?
c) What are some side-effects of being ventilated longer than this amount of time?
-If needed longer than 5-7 days, consider a tracheostomy.
-Can cause vocal fold edema (swelling) and dental abscesses, which can be fatal in a hospital-setting because the mouth is close to the brain.
What are 4 indications that a tracheostomy is needed?
a) Length of time on ventilator
b) Difficulty mobilizing secretions
c) Airway trauma that won't resolve quickly
d) Surgical indications
Talk about why difficulty mobilizing secretions is an indication of needing a tracheostomy.
Because if you cannot clear the mucous that your body is constantly creating, it will build up and you will develop pneumonia.
A tracheostomy will allow the mucous to be cleared out easier through suctioning, etc...
What are the 4 surgical indications of a tracheostomy being necessary?
1. Skull or dural surgeries (outermost layer of meninges)
2. Head and neck cancers causing:
- Pressure on brainstem;
- tumor interfering with the larynx or airway;
3. TBI - tracheostomy instead of intubation
4. A patient who is going to start going downhill needs a tracheostomy BEFORE they become highly medically fragile and close to death.
Managing secretions: what is suctioning?
Removal of secretions from the airway; keeping the airway patient (open)
What do you need to remember when suctioning a patient?
1. Suctioning is not sterile but you must use a clean technique.
2. WASH YOUR HANDS BEFORE AND AFTER SUCTIONING!
3. Suctioning is not a painful or distressing procedure, so if your patient is in distress, you are sticking the suctioning tube farther than the canula/suction catheter and touching the trachea (ouch).
T/F: suctioning can be performed outside of an acute setting (at home).
Why do you need to be aware of the size of the suction catheter?
Because you need to not stick the suction catheter deeper than the length of the tube - you will poke them in the trachea.
During suctioning, observe the secretions... Be aware of/watch out for:
o Be aware of what normal-looking mucous looks like
o Should be clear, runny, without many bubbles
o Yellow, thick snot is not healthy; GREEN is INFECTION – go to doctor!
o Note if you are having to suction more often than usual.
o Be aware of how it smells – should not have a smell
o Check sight, thickness, smell, and whether there is any blood.
After looking at the fluid that you are suctioning, what do you need to do?
• Always chart what you do, saw, noticed, who you told, etc...
• Tell someone if the mucous is not healthy-looking, and then chart that you told someone (name the person you told, and give the time you told them).
What are the equipment you need/may need before suctioning?
1. suction unit
2. suction catheters
3. suction unit connecting tubes
4. bowl or bottle of tap water to flush the suction tube
What are the 10 instructions for suctioning?
**Prestep: Make sure you have EVERYTHING necessary! (previous card)
1. have a new suction catheter in case you need to suction in a hurry, and ensure that the pump is ready to use at all times.
2. Wash or gel your hands!
3. Turn on pump and check pressure to make sure pump works!
4. Gently inert catheter into tracheostomy tube (make sure your thumb is off of the catheter port)
5. Apply suction by covering the port with your thumb, and slowly withdraw the catheter (do not rotate or twirl catheter as you remove it)
6. Repeat if patient still needs suction - give patient time to catch breath between suctions
7. Disconnect the catheter from the tubing and dispose of it safely.
8. Clear tube by suctioning a small amount of water through it.
9. Discuss waste management with the ward staff - different arrangements may need to be made when patient is at home.
10. Attach a new catheter for next time.
What does the side port on the catheter do?
Remember, don't plug the tracheostomy tube while suctioning!! If so...
...your patient won't be able to breathe!
How is a patient's suitability for a speaking valve determined?
The SLP evaluates this by judging the patient's ability to maintain reasonable oxygen saturation levels in the blood.
In the hospitals, why do we see tracheostomy patients?
Because they are having issues with speech or swallow! NOT simply because they have a tracheostomy.
What is oxygenation?
refers to the levels of oxygen (O2) in the body (in the case of a speaking valve, it refers to the level of oxygen in a patient's blood)
What color is well-oxygenated blood? Oxygen depleted blood?
well oxygenated blood is red, and oxygen-deprived blood is bluish/dark-purplish
What is the lowest benchmark for O2 stats?
95% is the lowest benchmark for O2 stats; below 95%, people start feeling bad.
How do you measure oxygen saturation level?
From the finger-clips - the tips of the fingers should appear red
T/F: If the patient can’t tolerate a speaking valve, he or she may still be able to achieve a voice because of air leaking around the tube.
True (although voicing will be stronger if they obturate/plug the tracheostomy with their thumb)
o The patient will not be able to voice for as long at a time
o Voice quality without a speaking valve is quieter because there is less air going around the tube
o The patient may be more difficult to understand BUT this is better than having them die from depleted blood-oxygen levels
WHat do you need to consider/remember if the tracheostomy tube is really big?
the patient will not be able to get air around the tube and up to the vocal folds, and thus will not be able to speak (the tube needs to be small enough that it does not occlude the trachea – need to get air around the tube to talk)
What are the five types of tracheostomy tubes discussed in class?
i. Single cannula, cuffed.
ii. Single cannula, non-cuffed.
iii. Double cannula, cuffed: used for longer-term
iv. Metal cannula, non-cuffed.
v. Fenestrated, cuffed - window
What is the fenestrated cuffed tracheostomy tube used for?
Can be used as experimental final step before decannulaiton because this tube can function with normal breathing; patient can speak, cough, etc…
What is a bronchoscopy?
An examination of the inside of the trachea and of the large air passages leading to the lungs.
Usually done as a way of assessing the degree of narrowing of the trachea and the overall general condition of the trachea and the air passageways.
T/F: most babies, children, & adults have no problem eating with a tracheostomy tube in place.
However, some will have difficulty, finding it hard to swallow saliva, cough, and food or fluid can potentially come out of the tracheostomy tube
If a patient does have trouble swallowing with a trach tube in, what are some possible reasons? What should you do to find out the reason?
Leakage or a tear between the trachea and esophagus (AKA tracheal deterioration)
Do a swallow study
Why does the cannula need to be centered in the airway?
It lessens the risk of aspiration and helps to keep the tube from rubbing the airway, which can lead to tracheal deterioration (which will lead to aspiration)
What should you NEVER do with a baby who has a tracheostomy?
Leave them alone with a bottle, because if the baby chokes, the tube can be plugged and the airway will close.
Before feeding (adults or babies), what should you do?
Suction them so that the airway is as patent as possible.
T/F: secretions decrease as we eat.
FALSE - secretions INCREASE as we eat! This is normal.
Why is it important that the tracheostomy patient stays hydrated?
Dehydrated snot production is susceptible to plugging the tube
What is decannulation?
The gradual process of removing the trach tube.
What is the issue with decannulation?
Making sure the patient is maintaining oxygen (O2) stats
T/F: decannulation must happen at the hospital, NOT at the patient's home.
True - must be closely monitored