A tracheostomy is a surgical procedure that creates an artificial opening into the trachea, typically at the second or third cartilaginous ring level. This opening allows the insertion of a tracheostomy tube, which can replace an endotracheal tube, provide mechanical ventilation, bypass an upper airway obstruction, or remove accumulated tracheobronchial secretions.

Tracheostomy tubes can be made of semiflexible plastic (polyurethane or silicone), rigid plastic, or metal, and they come in different shapes and sizes. They consist of an outer cannula or main shaft, an inner cannula, and an obturator, which guides the direction of the outer cannula during placement. Many tubes also have an inflated cuff that seals the opening around the tube to prevent air leakage and aspiration, allowing for mechanical ventilation.

Purpose

The primary purpose of a tracheostomy is to establish a patent airway, especially when oral or nasal intubation is not possible. It can also bypass an upper airway obstruction, simplify the removal of secretions, permit long-term mechanical ventilation, and facilitate weaning. Additionally, it can reduce the number of ventilator-dependent days, decrease the length of stay in the hospital, alleviate pain, and improve communication.

Procedure

A tracheostomy is typically carried out in a sterile environment, either in the operating room or intensive care unit, with the administration of local anesthesia and sedation. The procedure begins with creating an incision on the anterior surface of the neck into the trachea, through which the tracheostomy tube is inserted. The tube is secured around the patient's neck with twill tapes or a Velcro strip.

Tracheostomy tubes may be cuffed or cuffless and fenestrated or non-fenestrated. A cuffed tube is used when the patient needs mechanical ventilation, while a cuffless tube is typically used for patients with longer-term tracheostomies when mechanical ventilation is not required. A fenestrated tube has one or more openings allowing the patient to breathe spontaneously and speak with the tracheostomy tube.

Postoperative care involves inflating the tracheostomy cuff immediately and using several methods to confirm correct tracheostomy tube placement. The tracheostomy site is then sutured, and a sterile dressing is applied. Regular checks of cuff pressure and administration of heated, humidified oxygen are necessary to prevent secretions from drying.

Nursing Responsibilities

Nursing care for a patient with tracheostomy includes preparation for emergencies, regular assessment of the tracheostomy site, performing sterile dressing changes every 12 to 24 hours, and ensuring patency of the tracheostomy tube. Nurses must also measure cuff inflation pressure with a cuff manometer at least every 8 hours to prevent tracheal necrosis.

Suctioning and tracheostomy care are complex nursing activities that require knowledge of the agency's scope of practice and policies. Patients should receive humidified air to keep secretions thin and promote comfort. If the inner cannula is disposable, it should be replaced per manufacturer and agency guidelines.

In case of accidental decannulation, nurses should immediately call for help and assess the patient's level of consciousness, ability to breathe, and the presence of any respiratory distress. To facilitate prompt reinsertion, a spare tracheostomy tube—both one of the same size and one size smaller than the patient’s current tube—should always be kept at the bedside. This ensures flexibility if reinsertion with the original size is not possible. Additionally, an obturator should be readily available to guide the new tube safely into place. It’s important to remember to remove the obturator immediately after insertion to keep the airway open.

In conclusion, a tracheostomy is a critical procedure performed for various reasons. The care and management of patients with a tracheostomy require a comprehensive understanding of the procedure and diligent nursing responsibilities.