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TRACHEOSTOMY TUBES AND CANNULAS
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A tracheostomy is an opening between cartilaginous rings in the trachea and the skin, with a tracheostomy tube placed into the stoma to facilitate ventilation. Tracheostomy is usually performed by an otolaryngologist as an elective or semi-elective procedure and is not an emergency procedure. Most tracheostomies are performed on chronically ill patients requiring prolonged mechanical ventilation.
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There are many types of tracheostomy tubes available, including those made of plastic, silicone, nylon, and metal. Most hospitals stock only a few types of tracheostomy tubes, and one must be familiar with the types available. Tracheostomy tubes vary in diameter, total length, the length before and after the curve, and the presence or absence of a cuff (Figure 247-1). The size of the tracheostomy tube is usually defined by the inner diameter, ranging in adults from 5 to 10 mm and in pediatric patients from 2.5 to 6.5 mm. Most pediatric and adult tracheostomy tubes have a 15-mm standard respiratory connection that may be used with ventilator tubing or a bag-valve device.
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Fenestrated tracheostomy tubes have an opening along the dorsal surface of the body of the tube. The fenestration allows the passage of air through the tracheostomy tube to the vocal cords so the patient can speak. Irritation from the fenestration may promote growth of granulation tissue, which may extend into the fenestration, leading to bleeding, obstruction, and difficulty removing the tracheostomy tube. If any difficulty is encountered removing a fenestrated tracheostomy tube, obtain surgical or ear, nose, and throat consultation.
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Most adult tracheostomy tubes have a removable inner cannula, which allows secretions to be cleared from the lumen without removing the entire tube from the trachea. In assessing an adult tracheostomy patient, remove and examine the inner cannula for crusting or obstruction. Both disposable and reusable inner cannulas may be cleaned by using a small brush dipped in a solution of hydrogen peroxide and then rinsing the cannula with warm tap water. If the correct size of disposable inner cannula is not available in the ED, use the existing inner cannula temporarily, or change the entire tracheostomy tube. Pediatric tracheostomy tubes never have an inner cannula because of the small inner diameter, so the entire tube must be removed for cleaning.
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COMPLICATIONS OF TRACHEOSTOMIES
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Complications due to the surgery are grouped according to the timing since the tracheostomy and the technique. Summed complication rates from randomized controlled trials show 10.0% for percutaneous technique and 8.7% for open tracheostomy.1 Bleeding, obstruction, dislodgement, and infection are all potential early complications, occurring within the first week. Late complications are those that occur after 1 week. Granulation, tracheal stenosis, a fistula (tracheocutaneous, tracheoesophageal, or tracheoinnominate) plus any of the early ...