Tracheotomy is one of the commonly used techniques not only for upper and lower airway obstruction, but also for obstruction of lower airway secretions and respiratory disturbances due to inadequate alveolar ventilation.
The objectives of tracheotomy are to.
(1) reduce the resistance of the airway: 1/3 – 1/2 of the resistance of the normal airway comes from the upper airway, and tracheotomy reduces the resistance of the airway and facilitates ventilation.
(2)Reduce the dead space of airway: about 100 ml of dead space of airway is in the upper airway, and tracheotomy increases the effective ventilation volume.
(3)Tracheotomy facilitates sputum aspiration and respiratory humidification, and prevents pulmonary infection caused by aspiration of pharyngeal secretions and vomitus into the lungs.
(4) It facilitates intermittent positive pressure breathing with the ventilator.
(5) To buy time to treat the primary disease.
Indications for tracheotomy.
(1) dyspnea, cyanosis of the lips and finger (toe) nails, labored breathing, trigeminal signs, adult respiratory rate > 35 times/min, lung volume < 500 ml, tidal volume < 250 ml.
(2) The patient is irritable, sweating profusely, heart rate >120 beats/min, blood pressure is elevated, cough is weak, and respiratory secretions are numerous and sticky.
(3) partial pressure of oxygen < 8 kPa (60 ml Hg), partial pressure of carbon dioxide > 6.67 kPa (50 mm Hg), PH < 7.35.
Tracheotomy care.
Post-tracheotomy care is very important, and improper care can produce many complications and can even make the patient’s life dangerous.
(1) Keep the room temperature and humidity appropriate: Place the patient in a single patient room with fresh air, quiet, clean and dust-free, keep the room temperature at 21 degrees Celsius and the relative humidity at 60%. Cover the mouth of the tracheal cannula with 2-4 layers of wet gauze, sprinkle water on the ground frequently, or use a humidifier, and disinfect indoor air with UV light at regular intervals.
(2) Prevent blockage of tracheal tube: Blockage of the catheter due to air sac slippage is a common emergency, and patients often have sudden respiratory distress, cyanosis, and irritability. When encountering this situation, the trocar balloon should be taken out immediately along with the examination. Blockage of the catheter by secretions is also a common cause. Due to the adhesion of secretion, it accumulates into a lump and causes blockage of the tracheal tube, resulting in breathing difficulty for the patient, so it should be cleared in time. In addition, when replacing the catheter for cleaning and disinfection, the gauze should be prevented from being left in the catheter.
(3) Timely aspiration: In tracheotomy patients, coughing and sputum excretion are difficult because the epiglottis loses its function and the cough reflex is weakened. If sputum is not sucked out in time, it will block the catheter. When aspirating sputum, pay attention to the rotation of the aspiration tube from the deep left and right and raise it upward, and the aspiration tube must be changed every time.
(4), fully carry out wetting: under normal circumstances, the air inhaled into the respiratory tract is wetted by the mucous membrane of the nasal cavity, oral cavity and upper respiratory tract. Tracheotomy patients lose the above wetting function, which tends to make secretions dry and produce tracheal blockage, pulmonary atelectasis and secondary infection.
Therefore, the following methods of humidification should be used.
①Intermittent wetting: 500 ml of saline plus 160,000 units of gentamicin and 5 mg of chymotrypsin should be injected into the trachea after each sputum aspiration for a total of 2-5 ml per day, and ultrasonic nebulized inhalation can also be used intermittently.
②Continuous wetting method: slowly drip the wetting solution into the trachea through the scalp needle with a drip rate of 4-6 drops/min. by infusion. Not less than 200 ml per day and night, antibiotics or other drugs can be added to the humidified solution as needed.
(5) Prevention of local infection: strict aseptic operation to prevent infection. The tracheal cannula is cleaned and disinfected 2-3 times daily, and the gauze pad of the tracheal tube is kept dry and changed daily. The catheter is first soaked in 0.5% Neosporin, then boiled and disinfected, and then rinsed with water and then boiled and disinfected again to be reused.
Common complications after tracheotomy.
Tracheotomy complications are related to the operator’s proficiency, the condition of the primary disease and the quality of care.
The following complications frequently occur.
(1) Detubation: Detubation is mainly caused by poor fixation. Detubation is a serious and urgent situation, and asphyxia will occur if not treated in time. Patients show respiratory distress, red and purple face, irritability, sweating, etc. If the catheter is completely dislodged, the patient can stop breathing instantly.
(2) Bleeding: It can be caused by incomplete hemostasis during tracheotomy or damage to the tracheal wall due to catheter compression, irritation, rough suction action, etc. The patient feels pain in the sternal stalk or blood in the sputum, and once hemorrhage occurs, tracheal intubation should be performed immediately to stop the bleeding by pressure.
(3) Subcutaneous emphysema: It is a relatively common complication after tracheotomy, which mostly occurs in the neck and may occasionally extend to the chest and head. There is a twisting sensation or grip of snow when the emphysema is palpated by hand, and there is violent bubble sound on auscultation.
(4) Mediastinal emphysema and pneumothorax: it is easy to occur in those with subcutaneous emphysema, and the patient may have chest pain. The presence of mediastinal emphysema and pneumothorax can be detected on examination and chest X-ray, and should be treated quickly.
(5) Infection: It is the most common complication of tracheotomy. It is related to room air pollution, aseptic operation is not strict and the original condition. After infection, the airway sputum volume increases dyspnea and fever, which can aggravate the original disease.
(6) Tracheal wall ulceration and perforation: Ischemic necrosis of the tracheal mucosa due to inappropriate selection of cannula or too long placement time, deflation of the air sac when it is not set, etc. In mild cases, ulcers are formed, and in severe cases, perforation can be caused, as well as tracheoesophageal fistula.
(7) Subsonic granuloma, scarring and stenosis: local irritation with the tracheal cannula has a tube and is a late complication after tracheotomy.
Post-tracheotomy aspiration maneuvers.
Sucking sputum for tracheotomy patients is a technical operation frequently performed, and the correct operation will directly affect the effect of sucking sputum and the condition.
Therefore, the following matters should be noted.
(1) The suctioning action should be gentle to reduce the damage to the tracheal wall. Choose 12-14 rubber or silicone tubes with moderate hardness, smooth surface and relatively large inner diameter, or special suction tubes.
(2) Strictly aseptic operation: wash hands before operation, use one catheter at a time, and aspirate endotracheal and oral secretions first according to the principle of first inside and then outside.
(3) Take 3-5 deep breaths before aspiration, and for those using ventilators, hyperventilation is required for 2-3 minutes to increase the partial pressure of oxygen in the alveoli, and then aspirate the secretions quickly, accurately and gently. It should be rotated from deep left to right and raised upwards avoiding lifting and inserting up and down. A suction time should not exceed 15 seconds, especially in patients with respiratory failure, longer suction can cause hypoxia, respiratory distress, and even asphyxia. If the secretion is too much and cannot be sucked at once, it can be re-attracted after hyperventilation.
(4)When suctioning sputum, you should reach the depth of trachea and then open the suction device, or fold the suction tube by hand so that it does not leak, and open the suction tube after it is deep into the trachea.
(5) Suction negative pressure should not exceed 6.7 kPa is appropriate.
Pre-extubation care for tracheotomy patients.
Once the cause of tracheotomy is removed and the patient’s condition is relatively stable, extubation should be considered. In this stage, all resuscitation items and instruments should be prepared, and the patient’s respiratory changes and pronunciation should be closely observed. If the patient is found to have difficulty in breathing, cyanosis and irritability, the blockage should be removed immediately, extubation should be suspended, and laryngeal lesions should be examined and treated.
After 24-48 hours of full blockage, if the patient has no respiratory difficulty, good pronunciation and normal sputum discharge, the tube can be removed. The wound is tightened with butterfly tape and covered with sterile gauze.