Tracheostomies become necessary surgery for many reasons. If a patient has had obstruction of the airway, due to an allergic reaction or injury that causes edema, a tracheostomy can be required. Tracheostomy is also often performed when ventilator support will be permanent.
How is tracheostomy surgery performed?
The surgeon palpates the superior thyroid notch, cricoid and suprasternal notch through the skin, and finds the cricothyroid space just below the thyroid cartilage's interior edge. The patient's neck is extended over one shoulder unless contraindicated, with bronchoscopy used for proper positioning. A 3-4 cm incision is made either horizontally or vertically. An introducer needle is placed using a bronchoscopy to determine best placement for it.
The needle is then withdrawn with the cannula kept in place. A guide wire is used to place the stylet with the safety ridge toward the wire; the tract is dilated and the tracheostomy tube is placed by loading it onto the dilator, with the dilator loaded onto the safety ridge of the stylet.
The tracheostomy tube is placed with confirmation by bronchoscope and then the bronchoscope is directed through the tracheostomy tube to ensure correct placement. The tube is secured with two sutures on each side, in addition to tracheostomy tape, and connected to the ventilator via an extension to so that the tube is immobilized until postsurgical healing has taken place.
Performing proper tracheostomy care
Tracheostomy care will generally be done once a day (or more) after the patient goes home.
To perform proper care:
- Hands should be washed thoroughly with soap and water.
- If the patient can do his/her own care, the procedure should be done sitting or standing in front of a mirror.
- The person performing the tracheostomy care should put on nonsterile gloves.
- The tracheostomy tube is suctioned; the inner cannula is removed if it's present.
- Hydrogen peroxide is poured over and into the inner cannula until it has been thoroughly cleaned.
- Pipe cleaners or a small brush used just for that purpose are used to clean the cannula thoroughly.
- The cannula is then rinsed with normal saline, distilled water, or tap water (as long as there is no septic tank and the tap water is not well water but has been properly treated).
- Gauze pads are used to dry the inside and outside of the cannula and then the cannula is reinserted and locked into place.
- Soiled gauze dressing around the stoma is removed and thrown away.
- Once the neck has been inspected and found free of drainage, infection, redness, hardness, etc., the exposed parts of the outer cannula and the skin around the stoma are cleaned with cotton swabs dipped in a 50-50 solution of water and hydrogen peroxide.
- A clean washcloth should then be saturated with tap water (if appropriate), normal saline, or distilled water, and used to wipe the skin clean of hydrogen peroxide solution.
- A clean, dry washcloth/towel is used to dry the skin around the stoma and the exposed outer cannula.
- The tracheostomy tubes are also changed, replacing the tracheostomy ties with fresh ones, placing a fine mesh gauze that's had a slit cut in it or folded in half under the tracheostomy and tie.
Once finished, gloves should be thrown away, hands should be washed again with soap and water, and the basin and brush should also be washed and dried before being put away. The towel and washcloth should be laundered (not reused), and hands washed a third time with soap and water after the process is complete.