A guide to tracheostoma reintubation.

Introduction

An RN was making rounds on the rehab unit of the extended-care facility. John X., a 19-year-old head injury of four months ago, was restless. He had a #8 Shiley trach with the cuff deflated. Upon the RN's visit to John's room, it was discovered that he accidentally extubated himself. If this had happened two months previously, John would have had to have gone to the nearest hospital ER to have a sterile trach placed by a doctor. That, however, was not necessary-because of the new skill training achieved by the RNs at the Maria Joseph Living Care Center in Dayton, Ohio.

The Ohio Board of Nursing Education and Nurse Registration issued a statement concerning tracheostomy tubes.' In the statement on catheter maintenance, effective June 26, 1986, it was indicated that RNs may "routinely position and reinsert in well-established stomas or in a new stoma in an emergency." A program was designed to give RNs one hour of background material on tracheostomas, which includes assessing the resident and troubleshooting the trach followed by one half-hour of demonstrations and questions. A return demonstration was required before certification was awarded.

Back to basics

A tracheostomy is an external opening made into the trachea. The reasons for the opening are many. It can include "relief of upper airway obstruction, improved pulmonary hygiene, tracheal access for longterm positive pressure ventilation, and decreased airway resistance to assist weaning from mechanical ventilator support."(2)

Complications can arise, even in an established stoma. The skin around the stoma can become irritated, the cuff can malfunction and need replacement, and infection can occur at any time. "Pneumonia is a consequence of changes in airway bacterial colonization after tracheostomy. Sixty to 100 percent of residents with long-term tracheostomies colonize their tracheobronchial tree with Pseudomonas or EGNB (enteric Gram-negative bacilli)."(3) To add to that, the resident may accidentally, or purposefully, become extubated.

The procedure