A lot of people will never see a person with a tracheostomy and if they do, they will wonder “why” that person has to live with a hole in their neck.
A tracheotomy is a procedure that makes an airway patent. If a person has had a traumatic event or injury, disease or if the airway is obstructed to the point of not being able to breathe properly, a bypass in the airway is made via a tracheotomy. This allows the person to breathe properly and not have an obstruction impeding their breathing.. A tracheostomy is a surgical procedure and will be done either in a hospital or via an ENT physician. The procedure takes about 45 minutes. The size of the tracheostomy tube that is put into the neck space depends on the patient and the crowding in the airway.
A trach tube is inserted into a sterile space. That means that the hole in the neck leads directly to the trachea and the lungs and is an open route for infection. The normal humidifier for the body, the nose, is bypassed when someone is trached. The nose also warms and filters the air we breathe. So, it is important to protect this sterile route. A tracheostomy also impedes the patient's ability to speak properly. It is inserted below the level of the vocal cords therefore the ability to get air up to the cords to make vocalizations is impeded. Many trached patients will cover the opening of the trach with their fingers to speak. A trach may be in place to preserve the airway or to give a route for administering mechanical ventilation. It may be permanent or temporary. Either way, there are a lot of considerations and supplies that are needed when a person is “trashed”.
First, the trach tube itself. It can be manufactured by various manufacturers such as Portex, Shiley, Bavona or Jackson. The surgeon or hospital that is performing the surgical procedure will use what is best for the patient. Most tubes are made of PVC or silicone with the exception of the Jackson tube, which is made of stainless steel.
The tube will stay in the “stoma”, which is the hole in the neck that was surgically made, until it is changed for a replacement tube (for routine hygiene) or to a different size tube or removed from the neck entirely. The size of the tube is determined by the size of the patient and how much tissue must be overcome to make a patent airway. If a patient is on mechanical ventilation, they may have a certain type of trach tube that has a “cuff” or balloon on the inside. This balloon seals around the tube and against the airway, so there is only breathing via the tube itself when on the ventilator. This type of tube will have a small “pilot balloon” hanging on the outside that will have a port to fill or empty the interior balloon. The cuff will be deflated during the day or when not on mechanical ventilation so that the patient can breathe more easily through the tube as well as around it. How, if and when to inflate or deflate the cuff is usually outlined by the physician or respiratory therapist prior to the patient being discharged to home.
Most people who have a tracheostomy, do not have a “cuffed” tube. They may have a standard tube or they may have a tube that has a small hole in it at the distal end that is called a fenestration. This allows patients to vocalize more easily by allowing more air flow out to the vocal cords. Again, the doctor determines what type of tube and what features it should or should not have. Patients who have too many secretions may not be candidates for a fenestrated tube. All of the newer style tubes now have disposable inner cannulas. This makes cleaning and infection control much easier to accomplish. The patient simply has to throw out the inner cannula (daily or several times a day) and replace with a new sterile one. If you run out of inner cannulas or have forgotten to reorder them, simply use the one currently in your neck and soak it daily in peroxide for 15 minutes, rinse with sterile water, shake off excess and reinsert.
The tube will be held in place by a trach tube holder also known as a “trach tie”. On both sides of the flange that sits on the outside against the neck are slots. These slots are where the trach tube holder will attach (usually via Velcro) and keep the tube securely in the neck. The trach tube holder, although a very simplistic item, is vital. Even a forceful cough can push the trach tube out of the neck, the holder will keep that from happening. The general rule of thumb is that if you can fit one finger under the holder, it is not too tight or too loose. If a trach tube should come out of the neck, the stoma starts to close up immediately. It may be difficult to nearly impossible to reinsert the tube. You NEVER want to force it back into the neck. If the tube comes out, it is called “accidental decannulation” and is an emergency. You will need to get the patient to the ED to have it reinserted or to have the surgical site re-opened. Remember, for most patients, the trach is their only way of breathing. Some trached patients will have a trach tube on hand that is one size smaller than what is in their neck. This is in case of accidental decannulation. If there is someone capable of inserting the smaller tube EASILY into the neck, it can buy some time as you prepare to get to the hospital. It is still an emergency as the smaller tube may impede the patient's ability to breathe comfortably or properly, but in essence, the airway and the stoma have been preserved and it will be easier and less traumatic to get the proper size back in.
Some patients who have a trach only need to have it open during the night for mechanical ventilation or for when they are short of breath. These types of patients can “close” the trach up with the cap that comes with the trach tube or they may be utilizing a “speaking valve” like a Passy-Muir valve, to cover the tube opening allowing them to speak. If the trach is open for the majority of the time, artificial humidification will be needed. Remember, when you are trached, the nose is not be used for breathing and therefore the air going into the trach to breathe is not humidified and is not warmed. The patient will have equipment at home to compensate for the moisture deficiency. A large volume humidifier will deliver the necessary moisture to the airway so that it helps to thin out secretions and not allow them to dry out. If secretions get dried and you suddenly add moisture, the secretions will swell and may block off a portion of the airway or lung. This is why it is important to keep the lungs consistently moisturized. The patient can also develop “mucus plugs” from too little moisture. These can block off an airway and become an emergency. Heated humidification for trach use is rare in the home and most can use the standard cool humidification to keep things moisturized. The moisture from large volume humidifiers is delivered via a trach mask. The mask fits around the trach area and attaches to the humidifier. The large volume humidifier set up has several replaceable parts such as the water jar (distilled water is recommended), the corrugated tubing that is attached to the water jar and delivers the humidity to the mask and the trach mask itself. It is a standard to change these parts monthly and to wash them daily. It is recommended to administer humidity several hours a day and all night long for any person with an “open trach”. If ventilated, the machine will have a humidifier attached to it. Some patients have what is called an HME, or heat-moisture exchanger. This is a device that fits over the trach opening and has a sponge-like material in it that traps the patient's exhaled air which contains moisture and redelivers that moisture when the patient takes his/her next breath. This is an item that has to be approved to use by a doctor as many patients cannot withstand anything covering the trach opening.
Some patients who are trached have copious secretions. If they are unable to mobilize the secretions out of the lungs or airways themselves (due to ineffective cough, etc), then they will employ a suction machine to assist them. A suction machine will utilize a catheter (size to be determined by a physician) that will be inserted into the trach opening and slid down the airway and used to “suction” up the mucus.
Yankauers There are also tonsil suction devices such as the Yankauer that are used to suction the oral cavity for patients who cannot swallow effectively or who pool secretions in the mouth or upper airway. Suction machines have several replaceable parts. The catheters, the collection cannister (where suctioned secretions go), connecting tubing (which attaches the catheter to the collection cannister) and the machine filter (which allows the motor to function properly). Depending on usage will depend on how often parts are replaced.
Most catheters, connecting tubing, and collection cannisters are replaced monthly. Filter replacement is quarterly or sooner if it gets wet or soiled. I always recommend having extras on hand of all parts in case of a manufacturer's backorder or if you forget to order replacement parts in a timely manner.
Trach care kits are available for patients who have a permanent inner cannula (non-disposable) so that they can clean the inner cannula daily (or several times a day). They contain a small plastic tray for soaking the inner cannula, a brush to scrub the inside of the inner cannula, gloves, dressings, twill to use as a trach tie. Different kits contain different parts, so it is important to order what is necessary for the patient's needs.
A patient with a trach tube will need to have some padding or barrier between the “flange” that sits against the neck and the neck itself. Most use “split 4X4” gauze or gauze sponges that are split. They are used to keep the skin dry, absorb any secretions or discharge from the stoma and keep the flange from rubbing against the skin and causing irritation. It is recommended to change the gauze daily or more frequently if soiled.
Showering with a tracheotomy is easier now than ever. There are products such as stoma shower guards and stoma covers so that a patient can take a shower without having to worry about getting water into the trach opening. Cloth stoma covers can be worn during the day for a patient to cover the area for hygiene or privacy reasons.
One of the most important considerations, when a patient is trached, is not only keeping the airway open but also making sure that the stoma and area around it are kept intact. The patient’s stoma should be checked daily for the breakdown of skin, bleeding, redness, or signs of infection. It can be swabbed with peroxide around the opening where the tube sits to keep the skin healthy. If any signs of infection or breakdown are present, the patient should see their doctor. I have practiced as a respiratory therapist for almost 30 years and have seen many advancements in trach products and trach care. It has never been easier to live home and lead a more normal life than ever. Advancements are still being made and the products are more user-friendly than ever. There are no longer stigmas attached to trach patients as there were in the past. In a local Walmart, there is a trached team member waiting on customers, I see him there all the time. More and more trached patients are discharged to home and there is better equipped to care for them.
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My name is Laura Castricone and I am a Certified Respiratory Therapist. I have been practicing in the state of Connecticut since 1992. I have worked in several aspects of respiratory care ...
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