Continuing Education Module: Tracheostomy Care for All Ages

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Continuing Education ModuleTracheostomy Care
for All Ages
Maryland Institute for Emergency Medical
Services Systems Emergency Medical Services for
Children
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Acknowledgments
Contributors

• Linda Arapian, MSN, RNC, CEN, EMTB
• Liz Berg, RN, BSN, CCRN, EMT-B
• Craig Engler, RRT
• Terry Satchell, NREMT-P, RN
• Mary Alice Vanhoy, RN, BSN, NREMT-P, CEN
• Allen Walker, MD, MBA
• Cynthia Wright-Johnson, RN, MSN

This module/training program is part of the
Maryland CSHN Program developed under a Maryland
EMSC Partnership Grant. The Pediatric Education
Subcommittee of PEMAC participated in the
development of the instructional component of
this presentation.
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Tracheostomy Module Objectives

• To become familiarwith the different
  tracheostomy tubes
• To identify common tracheostomy emergencies
• To review EMS management of tracheostomy
  emergencies
• To demonstrate suctioning and changing a
  tracheostomy tube

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Tracheostomy Care for All Ages

• II. General Patient Care
• D. Initial Assessment
• 2. Airway
• a) Open and establish airway using
• appropriate adjunct
• b) Place patient in appropriate position
• c) Suction airway as needed, including
  tracheostomy
  tubes (New 04)

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A is for AIRWAY
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Pediatric AIRWAY Review of AP

• The tongue is large
• Vocal cords are fragile
• Trachea is short and narrow

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Pediatrics Positioning the Airway
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Adult Airway

• Larynx at the 4-5th vertebrae
• Vocal cords are narrowest part of the airway

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Tracheostomy

• A surgical opening in the trachea into which a
  special tube is placed

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Tracheostomy

• Patient may have a tracheostomy because of
• Vocal cord paralysis
• Inability to handle secretions
• Head and neck anatomical differences
• High Spinal Cord Injuries
• Unable to maintain functional airway
• Laryngeal cancer
• Long-term mechanical ventilation

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Laryngectomy vs. Tracheostomy
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Pre-Packaged Tracheostomy Tube
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Single Cannula with Obturatorfor infants young
children
Inner and Outer Diameter
Trach Size
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Assessment and Interventions
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Common Problems with Trachs
D

• Dislodged
• Obstructed
• Pneumothorax
• Equipment

O
P
E
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D is for Dislodged / Decannulation
D
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Dislodged
D

• Trachs may become dislodged
• Improper airway positioning
• When the trach ties are too loose
• When younger children can reach and untie the
  ties
• Vigorous coughing or sudden moves
• Significant weight changes
• Cuffed trach problems ?

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RULES for Inserting a Tracheostomy Tube
D
BLS

• Preparation
• Proper positioning of the patient
• Ready to go trach set includes
• Trach with obturator and ties attached
• ( ideal)
• Suction equipment
• Normal saline/sterile water

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RULES for Inserting a Tracheostomy Tube
D
BLS

• When possible, lubricate the new tube before
  insertion
• If lubricant not available, use saline or water

• Prepare the trach tube with lubricant

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Inserting a Tracheostomy Tube
ALWAYS TWO PEOPLE
D
BLS
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D
Insertion of a Tracheostomy Tube
BLS
If you meet resistance STOP !
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D
Insertion of a Tracheostomy Tube
BLS
Obturator Being Removed
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D
Insertion of a Tracheostomy Tube
BLS
Inserting Inner Cannula
Inner Cannula In Place
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D
Insertion of a Tracheostomy Tube
BLS
Trach Held in Place, BV to Tracheostomy
Ventilations While Listening to Breath Sounds
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D
Securing the Tracheostomy Tube
BLS

• Cuff Inflated, Syringe Empty

• Syringe Full, No Air In Cuff

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D
Securing the Tracheostomy Tube
BLS
Baby with One Fingertip
One Fingertip Fits Under the Adult Ties
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If BLS Is Unable to Re-Insert the Tracheostomy
Tube
D
BLS

• BVM, Dressing to Stoma for Adult Manikin

• Same, with Baby Manikin

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Decannulation
D
ALS

• ALS Interventions
• Attempt BLS interventions FIRST
• Then consider
• Insert endotracheal tube into trach stoma
• OR
• As last resort - orally intubate (if
  appropriate) while maintaining occlusive
  dressing over the stoma

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ALS Intervention Inserting an ETT
D
ALS

• Inserting ETT -- DO NOT CUT the ETT
• Guide to inserting the ETT
• Cuffed vs. uncuffed tubes
• Someone MUST be assigned to constantly maintain
  the ETT placement in the stoma
• Secure the ETT

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ALS Intervention Inserting an ETT
D
ALS

• Measuring with Adult Trach Tube

• Baby Trach Measure

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ALS Intervention Inserting an ETT
D
ALS

• Adult Holding ETT, Ventilating through ETT, And
  Listening to Breath Sounds

• Baby Holding ETT in Place, Ventilating through
  ETT, and Listening to Breath Sounds

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Confirmation of Tracheostomy or ET Tube
Placement
D
ALS

• No resistance while inserting tube
• Equal chest rise and fall
• Equal breath sounds
• Improved skin color and vital signs
• End-tidal CO2 detection/capnography
• Pulse oximetry

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Dislodged Trach Algorithm
DECANNULATION (a)
REPLACE TRACH TUBE (b)
UNABLE
ACCEPTED
BVM STOMA (c)()
OBSTRUCTED (d)
CHEST RISE?
SUCTION (e)
ALS
YES
NO
CHANGE TRACH TUBE (f)
ALS
INSERT ETT (g)
O2 / POSITION
ALS
ORALLY INTUBATE (h)
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O is for OBSTRUCTION
O

• Trachs may become obstructed
• Improper positioning of the patient
• Secretions
• Bleeding
• Foreign objects
• Trach nose clogged
• Edema in the trachea (rare)

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Signs of Tracheostomy Tube Obstruction
O

• Respiratory distress
• Increased work of breathing/retractions
• Copious secretions
• Decreased breath sounds/chest rise
• Altered mental status
• Changes in vital signs
• Cyanosis
• Ventilator high pressure alarms

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O
Obstruction Suction
BLS

• Adult, Measure Using an Adult Obturator

• Measure Using a Ped Obturator

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Trach/Suction Catheter Sizing
O
Trach Size Catheter Size
00 3.5 trach tube 5-6 French catheter
4.0 4.5 trach tube 8-10 French catheter
5.0 5.5 Trach tube 10-12 French catheter
6.0 7.0 Trach Tube 14 French catheter
7.0 8.0 Trach Tube 16 French catheter
8.0 9.0 Trach Tube 18 French catheter
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Obstruction Single Cannula
O
BLS

• If unable to insert to the measured depth
• Obstruction is IN the tube itself
• Remove the tracheostomy tube

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Obstruction Inner Cannula
O
BLS

• If a double lumen trach, remove the inner cannula
• Replace with new inner cannula
• If new inner cannula not available, rinse
  original inner cannula with water and reinsert
• Reassess the patient

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Obstruction Remove Trach
O
BLS

• If you have not been able to
• ventilate the patient, or
• insert a suction catheter to the measured depth
• You need to REMOVE the trach as the obstruction
  is IN the tracheostomy tube

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Removing a Tracheostomy Tube Step 1
O
BLS

• ALWAYS TWO PEOPLE
• Proper patient positioning

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Removing a Tracheostomy Tube Step 2
O
BLS

• Remove old trach tube
• 1st person holds patient
• 2nd person removes trach tube

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Removing a Cuffed Tracheostomy Tube Step 1
O
BLS

• Empty Syringe Attached, Balloon Full

• Syringe Full, Balloon Empty

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Removing a Cuffed Tracheostomy Tube Step 2
O
BLS

• Cutting the Ties

• Removing the Trach, Ties Dangling

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Inserting a Tracheostomy Tube
BLS
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O is for Obstruction Type II
O

• You have been able to insert a suction catheter
  to the measured depth and suctioned
• Assessments reveal NO improvement in patient
  condition
• Obstruction is below the tracheostomy tube

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Obstruction IIBelow the Tracheostomy Tube
O
BLS

• Suction Catheter Inserted To Measured Depth
  Adult

• Suction Catheter Inserted To The Measured Depth
  Baby

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Suction Is Available Step 1
O
BLS

• Instilling Saline into Adult Trach

• Instilling Saline into Baby Trach

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Suction Is Available Supplemental OxygenStep 2
O
BLS

• BV to trach
• pre-suction

• BV to trach
• pre-suction

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Suction Inserting Suction CatheterStep 3
O
BLS

• Keep fingers at the measured depth to insert the
  catheter
• Insert suction catheter without applying suction

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Suction Step 4
O
BLS

• Apply suction
• Cover the opening on catheter
• For NO MORE than 5-10 seconds (hold your breath
  comfortably)

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Suction Step 5
O
BLS

• Twisting

• Twisting the Catheter Between Fingers as Withdraw

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Re-oxygenate the Patient
O
BLS

• Re-oxygenate the patient between suctioning
  attempts

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Obstructed Trach Algorithm
OBSTRUCTION (a)
SUCTION (b)()
OBSTRUCTION RELIEVED?
YES
NO
O2 / POSITION
SUCTION
CHANGE TRACH TUBE (c)
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P is for Pneumothorax
P

• Pneumothorax can occur from
• High Peak Inspiratory Pressures
• High Positive-End-Expiratory Pressures
• Vigorous BV to tracheostomy or BVM ventilations
• From their underlying disease process (COPD)
• Trauma (fragile patients)

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Signs and Symptoms for Pneumothorax
P

• Shortness of Breath
• Decreased breath sounds
• Potential tachepnea (if spont. breath)
• Cyanosis
• Low pulse ox (lower than baseline)
• Tracheal deviation
• SQ emphysema

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Assessment/Management for Tension Pneumothorax
P

• ASSESSMENTS
• Dropping BP
• Poor perfusion
• Altered mental status
• Absent lung sounds

• MANAGEMENT
• BLS
• Consult
• Request ALS rendezvous
• ALS
• Needle decompression thoracostomy

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Equipment Problems
E

• Equipment problems may include
• Oxygen issues
• Tubing issues (disconnect, obstructed)
• Trach kit not ready to go
• Home vents
• Power failure/unplugged from outlet
• Home ventilator failure/dead battery

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Equipment
E
BLS
BLS

• FOR ALL EQUIPMENT PROBLEMS
• Take the patient off the equipment
• Attempt to ventilate the patient using BV to
  tracheostomy device with supplemental oxygen
• Assess for effectiveness of ventilations
• Take the equipment with the patient to the
  hospital

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SummarySteps to Change a Tracheostomy Tube
BLS

• Gather equipment
• Lay the person flat and midline
• Hyperextend the neck (towel roll)
• Lubricate new trach tube
• Deflate old cuff, if appropriate, WITH syringe
• Untie/cut old ties, pull out old trach
• Put in new trach, remove obturator
• Attempt to ventilate
• Secure the new tracheostomy tube

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GT Button
BLS

• Patients who have a tracheostomy tube may also
  have a gastrostomy tube
• Gastric distention can increase respiratory
  distress due to impingement of the diaphragm
• Important to STOP any feedings and decompress the
  gastrostomy tube

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GastrostomyTube
GastrostomyButton
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Emergency Information Form (EIF) by AAP ACEP

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CONSULTATION is always available
BLS

• Chief complaint
• Current assessment
• PMHx
• Any interventions
• ETA to receiving facility, if not the same as
  consult center

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When and Where to Transport
BLS

• Transport if
• Fever
• Signs and symptoms of infection
• Oxygen saturations lower than usual
• EMS has had to change the tracheostomy tube
• Equipment failure (bring the equipment)
• Family is stressed or distressed

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Remember.

• Assess the PATIENT and the equipment
• Establish A B Cs
• Suction and Oxygen
• Reassess A B Cs
• Change tracheostomy tube, if needed
• Decompress gastric tube, if present
• Bring To-Go Bag equipment
• Take all of the patients lifesaving equipment
• (e.g., ventilator) with him/her to the hospital
• Include a copy of the EIF Form if available
• One family member should accompany the patient

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Thank You ?