What are the basics of tracheostomy indications and management? 

I think that the most helpful literature for understanding trachs comes from the nursing literature, since nurses have to deal with daily trach care. I remember the first time I had a trached patient on the wards, and being asked what size his trach was and blankly staring back at the nurse asking me. Hopefully, with this overview, you will be able to take care of your trached patients more confidently!

Indications for a trach:

  1. on ventilator for chronic hypoxic or hypercapnic failure for >21 days
  2. obstructive process such as tumors within the airway, paralyzed vocal cords, swelling, stricture, or unusual airway anatomy (tracheobronchomalacia is a common one).
  3. obesity or hypoventilation
  4. Neurological problems that impair ability to clear secretions

Details to know about your patient: 

  1. Do they have a cuff?
  2. Is their cannula fenestrated (allowing speech) or unfenestrated?
  3. What is the gauge (diameter/size) of the trach?
  4. When was it last changed?

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Aspects of trach care include:

  • Suctioning: a patient needs suctioning if they have increased work of breathing, increased respiratory rate, desats, wheezing, copious secretions, or are unable to clear secretions on their own. For open-system suctioning, catheter size shouldn’t exceed half the inner diameter of the internal trach tube. To determine the appropriate-size French catheter, divide the internal trach tube size by two and multiply this number by three. A #12 French catheter is routinely used for closed suctioning.
  • Cleaning: Clean the stoma with a gauze square or other nonfraying material moistened with normal saline solution. Start at the 12 o’clock position of the stoma and wipe toward the 3 o’clock position. Begin again with a new gauze square at 12 o’clock and clean toward 9 o’clock. To clean the lower half of the site, start at the 3 o’clock position and clean toward 6 o’clock; then wipe from 9 o’clock to 6 o’clock, using a clean moistened gauze square for each wipe. Continue this pattern on the surrounding skin and tube flange. Avoid using a hydrogen peroxide mixture unless the site is infected, as it can impair healing.
  • At least once per shift, apply a new dressing to the stoma site to absorb secretions and insulate the skin. After applying a skin barrier, apply either a split-drain or a foam dressing. Change a wet dressing immediately.
  • Use cotton string ties or a Velcro holder to secure the trach tube. Velcro tends to be more comfortable than ties, which may cut into the patient’s neck; also, it’s easier to apply. To avoid inadvertent dislodgement of the tracheostomy tube, one person should hold the tube in place while a second person performs the tie exchange.

Pearls relevant to interns: 

  • A patient with a newly placed trach should have their first tube changed before leaving the hospital. In general a trach should be replaced about every 2 weeks (“expert consensus”) because crap builds up on every and any type of trach within 1 month.
  • Your contingencies for freshly trached patients overnight should include massive hemorrhage (tamponade with the cuff), trach obstruction (usually a mucus plug, secretions, or false tract) or tube falling out (intubate and don’t replace the trach).
  • Cuff leak: The purpose of the cuff is to provide a closed system. Cuff pressure should be 20 to 25 cm H2O with most tracheostomy tubes. Underinflation promotes leakage and VAP, while overinflation may cause tracheomalacia, ulcerations, fistulas, and stenosis.
    A persistent leak will be manifested by audible noises around the tracheostomy tube and loss of returned volumes with ventilation. For example, if the tidal volume is set at 700 mL, and the returned volumes are only 500 mL, the patient is not getting the
    benefit of the entire tidal volume.
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