EN4.44 | Tracheostomy and Tracheostomy Care — Summary & Reflection

KEY TAKEAWAYS

Tracheostomy is the surgical creation of an opening in the trachea at the 2nd-3rd ring (not the 1st, which risks subglottic stenosis; not too low, which risks the innominate artery). Four indications: airway obstruction, prolonged ventilation, pulmonary toilet, prophylactic. The critical distinction: tracheostomy = ELECTIVE (planned, OT, 2nd-3rd ring); cricothyroidotomy = EMERGENCY (cricothyroid membrane, converted to formal tracheostomy within 24-48 hours). Tube components: outer tube, inner tube (removable for cleaning — the key safety feature), obturator (introducer — MUST be removed immediately after insertion). Cuffed tubes require cuff pressure 20-25 mmHg; above this = tracheal ischaemia. Speaking valve (Passy-Muir): cuff MUST be deflated. Tracheostomy care: inner tube cleaning every 4-8 hours, humidification, sterile suction, first tube change at 5-7 days. Complications: tube blockage (clean inner tube), dislodgement (re-insert with obturator), tracheo-innominate fistula (late, massive haemorrhage, surgical emergency), subglottic stenosis (cuff over-pressure). Decannulation: requires resolution of indication, tolerance of progressive capping trials, adequate swallow and cough.

REFLECT

Think about a patient who has just undergone a total laryngectomy for laryngeal carcinoma — he will have a permanent tracheostomy for the rest of his life. Before surgery, his voice was his identity: he was a retired schoolteacher who spent his days conversing with his grandchildren. Reflect on what it means for a patient to lose their natural voice and breathe through a hole in their neck. How would you counsel this patient pre-operatively? What voice rehabilitation options would you explain? Now consider the nursing and junior doctor's role in this patient's post-operative recovery: what would you need to know to manage his tracheostomy safely on the ward, respond to complications, and recognise when he is ready for discharge? How does the competency you have studied in this SDL prepare you for that role?