return to: Tracheotomy - Tracheostomy

see also: Tracheostomy Home Care Booklet

see also: Tracheotomy stoma care with betadine Tracheostomal care with povidone iodine Tracheostomy stomal care

UIHC OTOLARYNGOLOGY & HEAD AND NECK SURGERY

TRACHEOSTOMY OUTPATIENT CLINIC: Examination of the patient

PROTOCOL - TRACHEOSTOMY CHANGE & FLEXIBLE FIBEROPTIC BRONCHOSCOPY AND LARYNGOSCOPY

*Ensure (verbal consent) that the patient desires spray (describe substance and process) and procedure

1. Spray nostril(s) prior to FFL (lidocaine 4%/phenylephrine 1%)
2. Spray through tracheotomy tube prior to change
   1. Apply finger to tracheotomy tube immediately after spraying and have patient cough (ideally delivering material through vocal cords to taste in mouth; serves the purpose of anesthetizing larynx and trachea)

-- Before Trach Change --

*Ensure the following sites are imaged with continuously running video (taken through fiberoptic scope) to permit single images to be selected from video for printing and storage in EPIC:

1. Face (confirms it is the patient – addresses potential error in typing into computer)
2. Tracheotomy appliance (before change)
   1. External exam - show tracheotomy type and size
   2. Internal exam - inspects relationship between tracheotomy tube tip and trachea for possible irritation / erosion / crusting / anatomic obstruction
   3. Tracheobronchial tree to include carina for malacia / scar / crusts
3. Oral Cavity – teeth, soft palate (prepare for microDL – estimate Mallampati)
4. Nasal Cavity, Nasopharynx, Oropharynx, Hypopharynx (possible OSAS risk)
5. Larynx – reiterate verbal consent to place scope between now-anesthetized vocal cords to view subglottis and trachea from above (especially useful with Montgomery cannulas, subglottic stenosis, granulation tissue extending in from tracheostome)

-- Prepare to Remove Trach by --

1. Having multiple back-up plans to re-establish airway
   1. May warrant having the ‘crash cart’ with ambu bag and multiple endotracheal tubes (useful to cannulate tracheostomy in difficult cases)
   2. Have nurse in room during tracheotomy change for assistance and materials
   3. Have suction out and working with Frasier tip; nasal speculum, bayonet forceps
   4. Have replacement Trach ready (lubricated with K-Y gel and with obturator in place)

-- Remove Trach --

1. Image stoma after Trach removed with fiberoptic scope
   1. Inspect stoma
   2. Inspect trachea mucosa
   3. Inspect Carina

-- Place new Trach --

1. Insert Trach with obturator into stoma with patient during expiration
2. Remove obturator quickly
3. Wrap neck straps around patient and secure
4. Insert inner cannula and twist into place
5. Imaging Trach placement (after change)
   1. Inspect tracheobronchial tree to include carina

Possible post-Trach change discussion with patient:

1. Decannulation – factors prohibiting or in favor of it
2. Montgomery canula / Passey-Muir valve – pros/cons show videos:
3. Tracheostomal revision – potential need to enlarge stoma, remove granulation tissue
4. Follow up appointment / followup intervention
5. Tracheostomal hygiene
   1. Frequency of changes
   2. Potential application of tracheotomy sponges with dilute betadine application (usual: 10 minute applications twice a day)

see: Tracheotomy stoma care Tracheostomal care Tracheostomy stomal care