Resume Of After-care Of A Tracheotomic Case


Categories: TRACHEOTOMY
Sources: A Manual Of Peroral Endoscopy And Laryngeal Surgery

1. Always bear in mind that tracheotomy is not an ultimate object.

The ultimate object is to pipe air down into the lungs. Tracheotomy is

only a means to that end.

2. Sterile tray beside bed should contain duplicate (exact)

tracheotomy tube, Trousseau dilator, hemostat, thumb forceps, silver

probe, scissors, scalpel, probe-pointed curved bistoury. Sterile

gloves ready.

3. Special nursing necessary for safety.

4. Laxative.

5. Sponge away secretions before they are drawn in.

6. Cover wound with wide large gauze square slit so it fits around

cannula under the tape holder. Pull off ravelings. Keep wet with

1 : 10,000 Bichloride solution.

7. Change dressing every hour or oftener.

8. Abundance of fresh air, temperature preferably about 70 degrees.

9. Nurse should remove inner cannula as often as needed and clean

it with pipe cleaner before boiling.

10. Outer cannula should be changed every day by the surgeon or

long-experienced tracheotomy nurse. A pilot should be used and care

should be taken not to injure the cut ends of the tracheal cartilage.

11. A sterile, bent probe may be inserted downward in the trachea

with both cannulae out to excite cough if necessary to expel

secretions. An aspirating tube should be used, when necessary.

12. A patient with a properly fitted cannula free of secretions

breathes noiselessly. Any sound demands immediate attention.

13. If the respiratory rate increase it is much more likely to be

due to obstruction in, malposition of, or shortness of the cannula

than to lung complications.

14. Be sure that:

(a) The cannula is clear and clean.

(b) The cannula is long enough to reach well down into the

trachea. A cannula that was long enough when the operation was done

may be too short after the cervical tissues swell.

(c) The distal end of the cannula actually is deeply in the

trachea. The only way to be sure is, when inserting the cannula, to

spread the wound and the tracheal incision with a Trousseau dilator,

then see the interior of the tracheal lumen and see the cannula

enter therein.

15. If after attending to the above mentioned details there are

still signs of obstructive dyspnea, a bronchoscopy should be done for

finding and removal of the obstruction in the trachea or main bronchi.

16. If all the pipes, natural and instrumental, are clear there

can be no such thing as obstructive dyspnea.

17. Pneumonia and pulmonary edema may exist before tracheotomy, but

they are rare sequelae.

18. Decannulation, in cases of tracheotomy done for temporary

conditions should not be attempted until the patient has slept at

least 3 nights with his cannula tightly corked. A properly fitted

cannula (i.e. one not larger than half the area of cross section of

the trachea) permits the by-passage of plenty of air. A partial cork

should be worn for a few days first for testing and weaning a child

away from the easier breathing through the neck. In cases of chronic

laryngeal stenosis a prolonged test is necessary before attempting

decannulation.

19. A tracheotomic case may be aphonic, hence unable to call for

help.

20. The foregoing rules apply to the post-operative periods. After

the wound has healed and a fistula is established, the patient, if not

a child, may learn to care for his own cannula.

[298] 21. Do not give cough-sedatives or narcotics. The cough reflex

is the watch dog of the lungs.





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