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Full text of "Diseases Of The Nose Throat And Ear"

TRACHEOSTOMY                                    171

are tied with the head extended the tube may become loose on flexion
when the muscles relax. The safest way is to stitch it to the skin with
2/0 silk.

3. Removal of Secretions. Excess secretions occur after a tracheostomy since
the trachea is exposed to^gajk^^r^aj^and tne tube acts as a foreign body and
stimulates the formation of secretions. During the first 48 hours secretions
should be removed half-hourly and thereafter ever^l jorJLhours. The nurse
should wear sterile gloves. A sterile rubber catheter is attached to one limb of
the Y-shaped plastic connector from the suction apparatus and the sterile
catheter is inserted into the tracheostomy tube by means of sterile artery
forceps. She then places her thumb over the open limb of the Y-shaped
connection to close the air entry into the suction apparatus and withdraws the
catheter. This manoeuvre should not take more than 10 seconds or else the
patient will be rendered hypoxic. This is repeated until no further secretions
remain.

4. Humidification. This is necessary to prevent crusting of the secretions and
is done most simply by instilling normal saline down the tracheostomy tube.
Before suction 5 ml of normal saline are dripped down the tube, suction is
then performed and afterwards 5 ml of normal saline are dripped down the
tube and left in the tracheobronchial tree.

5.  Changing the Tube. Tracheostomy tubes should not be disturbed for the
first 48-72 hours, but thereafter the tube is changed daily and cleaned at
regular intervals. On inserting the tube it is essential to check that it is in the
trachea and not lying anterior to it in the mediastinum. If this happens
respiration will not be heard through the tube and respiratory embarrassment
may recur.

6. Care of the Inflatable Cuff. When a cuff is blown up to occlude any leaks in
the airway the pressure must be higher than the systolic blood pressure. This
means that the area of tracheal wall with which it is in contact is liable to
ischaemic necrosis if the cuff is inflated for more than a few hours. It should
therefore be let down every half hour- when the nurse attends the patient for
suction.

7.  Dressings. Waterproof squares are made which protect the surrounding
skin from maceration from secretions and the movement of the tube edges.

8. Removal of the Tube. This presents no problem in the adult—the tube is
removed once the patient can sleep for a night with the tube corked. The
wound should then be freshened and sutured to prevent ugly scar formation.
In children it is very much more difficult to remove a tracheostomy tube that
has been present for more than a few days. It was thought at one time that this
difficulty was psychological, but it is now thought that the subglottic region
above the trachea acts as a sump and that subglottic oedema occurs. This is
avoidable by using the Rees-Pracy tracheostomy tube which is fenestrated
and valved so that when the patient exhales, air goes up through the larynx
thus blowing out any secretions which are stagnating in the subglottis.

COMPLICATIONS

Ofrf Surgical Emphysema, This is occasionally found in the immediate post-
operative period and presents as a swollen area around the root of the neck
and upper chest which displays crepitus on palpation. It is due to overtight