An artificial airway is a tube inserted in the trachea either through the mouth or nose or by a surgical incision. Artificial airways have been known to medical science for 3000 years. George Washington ultimately died of upper airway obstruction because his physicians could not agree on the use of tracheostomy. It was not until 1909, when Chevalier Jackson published his classic paper on tracheotomy,¹ that this procedure gained some acceptance. The procedure did not become a highly specialized technique in patient care until the invention of modern tracheostomy tubes and the development of intermittent positive-pressure ventilators. In today’s clinical practice, artificial airways have the following four basic purposes: to bypass upper airway obstruction, to assist or control respirations over prolonged periods, to facilitate the care of chronic respiratory tract infections, and to prevent aspiration of oral and gastric secretions. Multiple disease processes and traumatic problems can require an artificial airway, but each situation, simple or complex, can fit into one or several of these categories (Box 44-1).

Box 44-1

Disease Processes That Could Require an Artificial Airway Because of Respiratory Insufficiency

Primary lung disease (e.g., emphysema, chronic bronchitis, pulmonary fibrosis, cystic fibrosis, severe pneumonia, burned lung, and toxic inhalation)

Systemic disease with secondary lung involvement (e.g., cardiac failure, renal failure [fluid overload], and multiorgan system failure)

Neuromuscular disease (e.g., polio, Guillain-Barré syndrome, myasthenia gravis, use of muscle relaxants, and tetanus)

Central nervous system depression (e.g., drugs, postanesthesia, metabolic coma, cerebrovascular accident, meningitis, and central nervous system tumors)

Trauma (e.g., head/neck/chest surgery or injuries)

Diseases complicated by extremes of age (e.g., premature infant or older adult)

Mechanical obstruction (e.g., upper airway infection, laryngeal paralysis, tumor, edema, bleeding, foreign body, and thyroid malignancy)

Recurrent aspiration (e.g., glottic incompetence, occlusive diseases of the esophagus, and swallowing disorders of various causes)

From Selecky PA: Tracheostomy—a review of present-day indications, complications, and care, Heart Lung 3:272-283, 1974.

Indications of Need

The respiratory care team can play a vital role in recognizing patient need for a tracheostomy by noting physiological changes that indicate respiratory distress.² Cardinal signs of dangerous airway obstruction are stridor and chest wall retractions. Early clinical signs may include restlessness, agitation, tachycardia, confusion, motor dysfunction, and decreased oxygen saturation on pulse oximetry. These signs may be accompanied by headache, flapping tremor, audible wheezing, congestion, and diaphoresis. Cyanosis from impaired oxygenation of the blood is a late, ominous sign.

In children, restlessness is due to the lack of oxygen unless another factor (e.g., thirst) is clearly evident. Extreme fatigue and an inability to sleep indicate impending danger. Apprehension, restlessness, and mental confusion at any age may be taken as early signs of hypoxemia.

Complications of Tracheostomy

Depending on the patient’s impairment, selection of the appropriate airway is made by considering the following factors: What is the best means of accomplishing the goal? Is it an emergency or a controlled, determined situation? Will the airway be needed for long-term care? In general, oral endotracheal tubes are inserted in emergencies. They are the quickest and easiest tubes to insert, even for relatively untrained personnel. A nasotracheal tube will generally replace the oral endotracheal tube for a long-term intubation. The nasal tube is more efficient in that it is better secured, allows the patient to eat, is easier to suction, and is generally more comfortable for the patient.

There are certain complications with nasotracheal tubes. Among these are sinus blockage and pain, vocal cord damage, and pressure necrosis to the cartilaginous structure of the nose. To reduce these complications, the airway should be evaluated daily. The tube should be removed as quickly as possible when the indication for intubation is reversed. If there appears to be a need for a more long-term airway, however, a tracheostomy should be considered. The procedure should not be taken lightly because many additional complications may occur.

Complications of tracheostomy can be surgical, postoperative, or physiological. Complications that occur at the time of the operation are more frequently direct results of the surgical procedure itself. Delayed complications may result directly or indirectly from surgery, postoperative care, or the abrupt physiological changes resulting from tracheostomy. Objectives of caring for the patient after a tracheostomy are to maintain patency of the tube, cleanliness of the wound site, and good aeration of the lungs, as well as to observe any changes in the patient’s vital signs and oxygenation by pulse oximetry.

In patients with artificial airways, the normal physiological mechanism for adding moisture to the air via the nasal mucosa is bypassed. Therefore supplemental humidification is extremely important to protect the mucosa from drying and crusting, which results in obstruction.

The dressing under the tracheostomy tube and tracheostomy ties should be changed when they become soiled because dried blood and other secretions near the incision can encourage bacterial growth. The incision should be checked frequently for bleeding. The skin may be cleaned with half-strength hydrogen peroxide and sterile saline when a new dressing is applied. The dressing should be folded into place, never cut. This eliminates the possibility of lint or frayed threads being aspirated. Commercially prepared dressings best meet these criteria.

When changing the tapes that hold the tube in place, it is best to have one nurse hold the tube in place while another replaces the old tapes. An angle is cut at the end of the tape to facilitate its placement through the flange of one side of the tube. The tape is then threaded through the back of the tracheostomy tube and through the other flanged opening and tied securely with a square knot placed on one side of the patient’s neck. One finger should be placed under the twill tape while tying it; this will prevent the tape from being tied too tight.

Pneumothorax can occur immediately after tracheostomy because of laceration of the mediastinal pleura at the time of or within 24 hours of surgery (this arises often in children and patients with chronic obstructive lung disease). Other problems include air embolism, aspiration, and subcutaneous and mediastinal emphysema. Recurrent laryngeal nerve damage or posterior tracheal penetration may occur but is uncommon.

Postoperative Physiological Complications

Attentive nursing care is the single most essential factor in postoperative tracheostomy management. Vigilant monitoring and observation by the entire respiratory care team is of vital importance.

Patients with an artificial airway are understandably apprehensive and have special communication needs. They should be reminded that their inability to speak is only temporary. These patients must be reassured that they will be monitored frequently and can trust and depend fully on the health care team to attend to their needs. If alert, patients must be equipped with a signal light or bell, paper and pencil, magic slate, or picture board for communication.

Airway obstruction is the foremost complication that exists postoperatively for the patient who has undergone tracheostomy. Tracheal secretions are the major source of obstruction, particularly if they are excessive or viscous. When using a cuffed tube, acute obstruction might occur from overinflating the cuff, which allows it to balloon over the end of the tube. Other causes of obstruction are dislodgement of the tube into a false tract anterior to the tube tracheal opening, and kinking of softened plastic cannula.

Tracheobronchitis, inflammation of the trachea and bronchus, is a complication resulting primarily from irritation due to incorrect suctioning technique and the presence of a foreign body in the trachea.

Crusting is a common and complex problem that may result from inadequate humidification of inspired air or patient dehydration. In many instances, ulceration of the tracheal mucosa results from irritation by the airway or incorrect suctioning. This ulcerated area becomes infected with various organisms and is virtually covered by crust. Further suctioning removes the crust, causing discharge of serum and bleeding. The discharge produces a wet eschar that is covered with mucus. Because of the drying effect of air passing over this mass, a hard crust can form. The development of this crust in the trachea might eventually produce a mass large enough to completely plug the tracheal cannula and almost completely obstruct the trachea. Cases have been cited in which an entire cast of the tracheobronchial tree has been removed.

Other physiological complications may be related to the following: hypoxemia developing before or during the procedure and resulting in an uncontrollable patient, cardiac arrest, and increased myocardial sensitivity to adrenalin; alkalosis developing from rapid carbon dioxide washout after establishment of the airway, resulting in myocardial fibrillation and apnea; and cardiac failure, resulting in profuse bronchorrhea caused by pulmonary edema and shock.

A less commonly known physiological complication is related to lack of good oral care. This means the patient with an artificial airway should have his or her teeth brushed at least twice a day (if this is not possible, the green disposable oral swabs can be used) to decrease potential pathogens as Staphylococcus aureus or gram-negative rods.

Chronic complications cited by Dailey and colleagues (1992)³ include the following: infection at the surgical site, aspiration, aerophagia, persistent stoma, and tracheal stenosis.

Postoperative Mechanical Complications

Dislocation of the tube may result from unsatisfactory nursing care, poor attention to the airway during positioning, or ventilator tubing pulling on the airway. If the tracheostomy tube tapes are not kept tight and tied with a square knot or if they become loose as a result of subcutaneous emphysema or edema, the tube may be coughed out of the trachea and become lodged in the tissues of the neck and obstruct the airway. In pediatric patients, stay sutures are frequently used to prevent dislodgement of the tracheostomy tube. These sutures are valuable during recannulization of the tube if it comes dislodged before a tract has been well established. Stay sutures will prevent entry into a false tract. Advantages of this technique include the following: rapid replacement of blocked or displaced tubes, improved exposure of the trachea at surgical intervention, firm anchoring of the trachea at the moment of incision, decreased trauma associated with extubation, and uniform tracheostomy technique for all ages.

Dislodgement of the outer cannula or required removal before a tract has been well established (usually 5 to 10 days) again requires diligence and quick action by the nurse. No attempt at reinsertion should be made without adequate light, satisfactory tissue retraction, tracheal hook, and a Trousseau’s dilator. A Trousseau’s dilator and tracheal hook should be readily available. A spare tracheostomy tube of the correct size should be kept at the patient’s bedside at all times. Should the tube be coughed out, the nurse uses the Trousseau’s dilator to hold the wound apart while summoning the physician. Tragedies have occurred from inserting the tube into the soft tissues of the neck or mediastinum because of a dislodged cannula and the frantic efforts to replace it. Once the tracheostomy tract has been firmly established, the tube can be replaced by the nurse on written order of the physician.

Tracheostomy Tubes

Metal Tubes

Tracheostomy tubes are of two basic types: metal and polyvinyl chloride (hard and soft). Metal tubes are no longer commonly used, but some patients with long-standing metal tracheostomies may prefer not to switch to a polyvinyl chloride tube. Metal tubes can be made of either stainless steel or sterling silver and are composed of the following three parts: an outer cannula that fits into the tracheal incision, an inner cannula that fits into the outer cannula, and an obturator that facilitates insertion of the tube. These three parts constitute a metal tracheostomy set and are not interchangeable with the parts of any other set. Before the outer cannula is inserted into the tracheal incision, the obturator is placed inside. The lower end of the obturator protrudes from the end of the outer cannula and facilitates its insertion into the trachea. This is the only purpose of the obturator. The protruding end of the obturator obstructs the lumen of the outer cannula. When the obturator is removed, it is immediately replaced with the inner cannula. If one part is lost or damaged, the entire set is useless. Therefore each part, including the obturator, must be accounted for carefully. Care should be exercised in handling sterling silver tubes because silver is easily dented.

The inner cannula should always be inspected to be sure it is clean and clear of secretions before it is reinserted. Mucus that has dried inside the inner cannula cannot be cleaned by merely rinsing it with water. The cannula should be soaked in hydrogen peroxide, scrubbed with a tracheostomy brush, and rinsed with saline to be sure all secretions have been removed. If a silver inner cannula becomes discolored, it may be cleaned with silver polish.

To prevent dislodgement, lock the inner cannula into position after reinsertion. The locking mechanism is different with each tube, and the therapist should become familiar with the types used. If the inner cannula is not locked, it may come out if the patient has a forceful exhalation or position change. It is vital that the inner cannula be reinserted quickly if the patient is on mechanical ventilation, especially if the patient is on full support.

Polyvinyl Chloride (Plastic) Disposable Tubes

The development of plastic tracheostomy tubes brought about three major improvements that account for their widespread use: application of silicone to the inner surface of the plastic tube minimizes crusting and adherence of secretions; it is easier to attach a safe, dependable, permanent inflatable cuff to the plastic tube that cannot slip off and occlude the tracheal opening; and lower costs allow the tube to be disposable. Plastic tubes, unlike metal sets, generally have interchangeable parts. The tubes come with and without cuffs.

The cuffed tracheostomy tube is primarily used in conjunction with a positive-pressure ventilator to form a closed system (Figure 44-1). It is also used to reduce the possibility of aspiration because of absent reflexes, protective laryngeal reflexes, or pharyngeal reflexes. The inflatable cuff is located around the lower portion of the tube and, when inflated, seals the trachea from most airflow except through the tube itself (see Figure 44-1

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