Some tracheostomy tubes have an inner cannula that should be removed during cleaning. If the inner cannula is disposable, it should be replaced with a new one. If it is non-disposable, the inner cannula is cleaned at least every 8 hours. Cleaning the inner cannula helps remove mucous accumulation inside the tube.
The area around the stoma should be cleaned every 8 hours. Frequent cleaning helps prevent skin breakdown and subsequent infection. If there is a tracheostomy dressing, do not cut the dressing or any 4 x 4s, as small bits of gauze could be aspirated through the tracheostomy tube.
The tracheostomy ties should be changed as needed. During changes, the two person technique is recommended to prevent tracheostomy dislodgement. One person stabilizes the tracheostomy while the second person changes the ties. Afterwards, a pinkie finger is placed underneath the ties to ensure a snug fig. Tight ties can cause damage to the skin or external tracheostomy tube, and loose ties can lead to tube dislodgement or internal damage to the trachea or stoma
Tracheostomies with inflated cuffs prevent patients from speaking. If patients are able to breathe spontaneously, deflating the cuff of the tracheostomy tube will allow exhaled air to flow over the vocal cords and facilitate the ability to talk. Occluding the tube will help facilitate speech. However, since this method may introduce bacteria from the fingers and cause infection, specialized tracheostomy tubes and speaking valves are encouraged to help with speech.
After tracheostomy insertion, the patient may experience difficulty swallowing. Have the patient in an upright position while eating and if possible, partially (or completely) deflate the cuff during meals. Patient should eat slowly and tuck their chin down and move the forehead forward while swallowing. Small volumes of liquid should be consumed, possibly using a spoon to control the volume. Sometimes, the patient may require a referral with a speech therapist to regain the ability to swallow.
A replacement tube of equal or smaller size should be kept at the bedside in case of emergency reinsertion. If the tube is dislodged, immediately try to replace it with a new tube. Each tube has an obturator used to help ease insertion of the tube. Immediately after insertion, the obturator is removed to allow air flow and should be placed in an easily accessible location at the bedside for quick use in case the cannula is accidentally removed.
Since it takes 5-7 days for the stoma to fully heal, the tube may be easily dislodged and require a replacement tube. Use a curved Kelly clamp or a hemostat to spread the opening. Lubricate the tip of the replacement tube with saline and insert the tube into the stoma at a 45-degree angle to the neck. If the tube cannot be replaced, place the patient in the semi-Fowler's position and assess the patient's respiratory effort, ventilate the patient with manual resuscitation bag or bag valve mask (BVM or Ambu bag), and call the Rapid Response Team.
Since it takes 5-7 days for the stoma to fully heal, the first tube change is completed after at least one week following tracheostomy insertion. The physician is responsible to completing the first tube change in order to assess the status of the stoma. Afterwards, the tracheostomy tube should be changed one month after the first tube change.
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