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CHAPTER 20 Caring for Clients With Upper Respiratory Disorders

TREATMENT MODALITIES FOR AIRWAY OBSTRUCTION OR AIRWAY MAINTENANCE Clients with serious airway conditions require aggressive treatment to maintain an airway or relieve airway obstruc tion. This section discusses tracheostomy, tracheotomy, en dotracheal intubation, and mechanical ventilation. Tracheotomy andTracheostomy A tracheotomy is a surgical procedure that makes an open ing into the trachea. A tracheostomy is a surgical opening into the trachea into which a tracheostomy or laryngec tomy tube is inserted. A tracheostomy may be temporary or permanent. A permanent opening in the trachea is required for certain disorders, such as a laryngectomy for laryngeal cancer. General Considerations Tracheostomy tubes come in several sizes and differ from laryngectomy tubes in length and diameter. A cuffed trache ostomy tube has a cuff on the lower end inflated with air to provide a snug fit (Fig. 20-6). The cuff prevents aspiration of liquids or escape of air when a mechanical ventilator is used. The primary provider specifies the amount of air to be injected into the cuff, usually to achieve a pressure between 20 and 25 mm H 2 O, to ensure appropriate seating of the cuff in the trachea. The pressure in the cuff requires monitoring with a pressure gauge every 8 hours. A cuffless tracheos tomy tube does not have a cuff at the end of the tube and may be used when the client does not require a ventilator for breathing (Tracheostomy Education, 2021). During the immediate postoperative period, the primary provider may change the tracheostomy tube every 3 to 5 days. An obturator is placed in the tube to facilitate place ment. Once the tracheostomy tube is in place, the obturator is removed. The outer tube is held snugly in place by tapes inserted into the openings on either side and tied at the side of the client’s neck.

The respiratory passages react to the creation of the new opening with inflammation and excessive mucous se cretion. Copious respiratory secretions are life-threatening. The client cannot be left unattended during the immediate postoperative period because the secretions make frequent suctioning necessary. In addition, inspired air passes di rectly into the trachea, bronchi, and lungs without becoming warmed and moistened by passing through the nose. Dry se cretions can subsequently develop, which easily form crusts that can break off and obstruct the lower airway, causing serious respiratory problems. Humidification by a mist col lar is usually necessary to prevent drying and incrustation of the mucous membrane in the trachea and the main bronchus. The long- and short-term complications of tracheostomy include infection, bleeding, airway obstruction resulting from hardened secretions, aspiration, injury to the laryngeal nerve, erosion of the trachea, fistula formation between the esophagus and the trachea, and penetration of the posterior tracheal wall. Nursing Management After surgery, the nurse monitors vital signs, auscultates breath sounds, and assesses skin color, level of conscious ness, and mental status. The nurse monitors for potential complications and checks airway patency frequently. To facilitate breathing during the immediate postopera tive period, the nurse positions the client as ordered. When the client is fully awake and blood pressure is stable, the nurse elevates the head of the bed to about 45 degrees. This position decreases edema and makes breathing easier. The nurse inspects the tracheostomy carefully, ensuring that the tapes are secure. If the tube is not tied securely, the client can cough it out, a serious occurrence if the edges of the trachea have not been sutured to the skin. This may be the case in a temporary tracheostomy. The nurse keeps a tra cheal dilator at the bedside at all times. If the outer tube ac cidentally comes out, the nurse inserts the dilator to hold the edges of the stoma apart until the primary provider arrives to insert another tube. A tracheal tube must never be forced back in place because it may compress the client’s trachea (by pushing the tube alongside and compressing the trachea rather than inserting it into the stoma). Such action could cause respiratory arrest. Secretions can rapidly clog the inner lumen of the tra cheostomy tube, resulting in severe respiratory difficulty or death by asphyxiation. If the airway is obstructed, the client becomes cyanotic, restless, and frightened. The nurse suc tions the client’s tracheostomy tube to remove secretions that can obstruct the airway (Nursing Guidelines 20-2) but avoids unnecessary suctioning to decrease trauma to the air way. When explaining the procedure, the nurse tells the cli ent that the suction catheter will be inserted for only a few seconds. An extra tracheostomy tube of the same size at the bedside is essential because an immediate change may be necessary if the tube becomes blocked with mucus that can not be removed. After suctioning is completed, the nurse pro vides routine tracheostomy care (Nursing Guidelines 20-3)

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Figure 20-6 Cuffed tracheostomy components. (A) Tracheostomy ties. (B) Cuffed tracheostomy tube.The cuff at the lower end of the outer tracheostomy tube is inflated with air to provide a snug fit in the trachea. (C) Obturator is used to guide placement of tracheostomy tube.