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- •Contents
- •Contributors
- •Preface
- •Acknowledgments
- •The Upper Airway
- •The Lower Airway
- •Indications for Tracheotomy
- •Timing of Tracheotomy
- •Preoperative Management
- •Anesthesia Management
- •Comparative Anatomy of the Adult and Infant Airways
- •Conclusion
- •Key Points
- •Surgical Technique
- •Postoperative Care
- •Summary
- •Key Points
- •Parts of a Tracheostomy Tube
- •General Types of Tracheostomy Tubes
- •Special Use Tracheostomy Tubes
- •Tracheostomy Accessories and Appliances
- •Summary
- •Key Points
- •Considerations When Fitting a Tracheostomy Tube
- •Tracheostomy Tube Changes
- •Fitting a Tracheostomy Button
- •Summary
- •Key Points
- •The Critically Ill Patient on Mechanical Ventilation
- •Retained Secretions
- •Cuff Leaks
- •Pistoning
- •Cuff Changes at Altitude
- •Cuff Changes With Anesthesia
- •The Complex Tracheostomy Wound
- •Tracheostomy as a Lived Experience
- •Defective Tracheostomy Tubes
- •Missing Parts
- •Summary
- •Key Points
- •General Principles of Voice Restoration
- •Patients Who Do Not Require Mechanical Ventilation
- •Patients Who Require Intermittent Positive-Pressure Ventilation
- •Patients Who Require Continuous Mechanical Ventilation
- •Summary
- •Key Points
- •Maintenance of the Tracheostomy Tube
- •Mobilization of Secretions
- •Oral Care
- •Other Tracheal Appliances
- •Nutrition
- •Care of the Patient at Home
- •Summary
- •Key Points
- •Indications for Tracheostomy in Children
- •Outcome of Children With Tracheostomies
- •Procedural Steps in the Care of the Child With a Tracheostomy
- •Management of the Child With a Tracheostomy in the Community
- •Developmental Issues
- •Summary
- •Key Points
- •Types of Laryngectomy
- •Swallowing After Laryngectomy
- •Speech After Laryngectomy
- •Ventilator-Dependent Tracheostomized Patients
- •Quality of Life
- •Summary
- •Key Points
- •Intraoperative Complications
- •Early Postoperative Complications
- •Late Postoperative Complications
- •Summary
- •Key Points
- •Factors to Consider Prior to Decannulation
- •Determining Readiness for Decannulation
- •Decannulation Protocol
- •After Decannulation
- •Summary
- •Key Points
- •Discharge Disposition of Patients With Tracheostomies
- •Tracheostomy in Acute Rehabilitation
- •Adapting Choice of Tracheostomy Tube and Care Plans to Clinical Settings
- •Providing Phonation for Patients Who Require Positive-Pressure Ventilation
- •Evaluating the Need for Relief of Upper Airway Obstruction
- •Considerations for Transitioning Tracheostomy Tubes
- •Discharge to Home
- •Care for Patients at Home
- •Clinical Follow-Up
- •Summary
- •Key Points
- •Index


Tracheostomies
The Complete Guide

Linda L. Morris, PhD, APN, CCNS, FCCM, is the clinical nurse specialist for re-
spiratory care and tracheostomy specialist at Northwestern Memorial Hospital
in Chicago, Illinois. She is also assistant professor of clinical anesthesiology
at Northwestern University Feinberg School of Medicine. With many years of
experience in critical care, Dr. Morris has also held positions in clinical education and academia. Current research interests include quality of life and body
image perception with tracheostomy patients, outcomes of an exercise program
with newly tracheostomized patients, and awareness during resuscitation from
cardiac arrest.
M. Sherif Afifi, MD, FCCM, FCCP, is an associate professor of anesthesiology
and surgery, and Chief of the Anesthesiology Critical Care Division at Northwestern University Feinberg School of Medicine, Chicago, Illinois. The scope
of his clinical practice is centered on the perioperative care of cardiac, thoracic, and transplant patients. His postgraduate medical training started with
a research fellowship in respiratory physiology and drug safety and efficacy
at the Duke University Hyperbaric Center and completed with clinical residency and fellowship training at the Cleveland Clinic Foundation. He served
on the faculty at the Cleveland Clinic, Yale University School of Medicine, and
was interim residency program director at the Advocate Masonic Medical Center in Chicago, Illinois. He has mentored and consulted in the United States
and internationally, and is the recipient of awards from national societies and
specialty international medical centers.

Tracheostomies
The Complete Guide
Linda L. Morris, PhD, APN, CCNS, FCCM
M. Sherif Afifi, MD, FCCM, FCCP
Editors
New York

Copyright © 2010 Springer Publishing Company, LLC
All rights reserved.
No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or
otherwise, without the prior permission of Springer Publishing Company, LLC, or authorization through payment of the appropriate fees to the Copyright Clearance Center,
Inc., 222 Rosewood Drive, Danvers, MA 01923, 978–750–8400, fax 978–646–8600,
info@copyright.com or on the web at www.copyright.com.
Springer Publishing Company, LLC
11 West 42nd Street
New York, NY 10036
www.springerpub.com
Acquisitions Editor: Allan Graubard
Project Manager: Julia Rosen
Cover Design: Mimi Flow
Composition: Apex CoVantage, LLC
E-book ISBN: 978-08261-0518-9
09 10 11 12/5 4 3 2 1
The author and the publisher of this Work have made every effort to use sources
believed to be reliable to provide information that is accurate and compatible with
the standards generally accepted at the time of publication. Because medical science
is continually advancing, our knowledge base continues to expand. Therefore, as
new information becomes available, changes in procedures become necessary. We
recommend that the reader always consult current research and specific institutional
policies before performing any clinical procedure. The author and publisher shall not
be liable for any special, consequential, or exemplary damages resulting, in whole or in
part, from the readers’ use of, or reliance on, the information contained in this book. The
publisher has no responsibility for the persistence or accuracy of URLs for external or
third-party Internet Web sites referred to in this publication and does not guarantee
that any content on such Web sites is, or will remain, accurate or appropriate.
Library of Congress Cataloging-in-Publication Data
Morris, Linda, 1954 –
Tracheostomies : the complete guide / Linda Morris, M. Sherif Afifi.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-8261-0517-2 (alk. paper)
1. Tracheotomy. I. Afifi, M. Sherif. II. Title.
[DNLM: 1. Tracheostomy. 2. Tracheotomy. WF 490 M877t 2009]
RF517.M67 2009
617.5'33—dc22 2009043752
Printed in the United States of America by Hamilton Printing Company.

To my parents, Louise Hostert Morris and the late Bernard Franklin Morris,
who have inspired my inquisitive nature and supported all of my endeavors. . . .
L.L.M.

This page intentionally left blank

Contents
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
Chapter 1
Functional Anatomy of the Airway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
M. Sherif Afifi
The Upper Airway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
The Lower Airway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Comparative Anatomy of the Adult and Infant Airways . . . . . . . . . . . . . . 13
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Chapter 2 Tracheotomy Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Michiel J. Bové and M. Sherif Afifi
Indications for Tracheotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Timing of Tracheotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Preoperative Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Anesthesia Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Chapter 3 Types of Tracheostomy Tubes and Related Appliances . . . . . . . . . . . . . . 41
Linda L. Morris
Parts of a Tracheostomy Tube . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
General Types of Tracheostomy Tubes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Special Use Tracheostomy Tubes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Tracheostomy Accessories and Appliances . . . . . . . . . . . . . . . . . . . . . . . 103
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
vii

Contents
viii
Chapter 4 Fitting and Changing a Tracheostomy Tube . . . . . . . . . . . . . . . . . . . . . . . 115
Linda L. Morris
Considerations When Fitting a Tracheostomy Tube . . . . . . . . . . . . . . . . 115
Tracheostomy Tube Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Fitting a Tracheostomy Button . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Chapter 5 Special Considerations for the Tracheostomy Patient . . . . . . . . . . . . . . 159
Linda L. Morris
The Critically Ill Patient on Mechanical Ventilation . . . . . . . . . . . . . . . . 160
Retained Secretions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Cuff Leaks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Pistoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Cuff Changes at Altitude . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Cuff Changes With Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
The Complex Tracheostomy Wound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Tracheostomy as a Lived Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Defective Tracheostomy Tubes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
Missing Parts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
Chapter 6 Phonation With a Tracheostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Linda L. Morris
General Principles of Voice Restoration . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Patients Who Do Not Require Mechanical Ventilation . . . . . . . . . . . . . . 183
Patients Who Require Intermittent Positive-Pressure Ventilation . . . . 196
Patients Who Require Continuous Mechanical Ventilation . . . . . . . . . . 197
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
Chapter 7 Care of the Tracheostomy Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Linda L. Morris
Maintenance of the Tracheostomy Tube . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Mobilization of Secretions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Oral Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
Other Tracheal Appliances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
Care of the Patient at Home . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
Chapter 8 Special Considerations for the Child With a Tracheostomy . . . . . . . . . . 243
Linda Sue Van Roeyen
Indications for Tracheostomy in Children . . . . . . . . . . . . . . . . . . . . . . . . 244

Contents
Outcome of Children With Tracheostomies . . . . . . . . . . . . . . . . . . . . . . . 244
Procedural Steps in the Care of the Child
With a Tracheostomy
Management of the Child With a Tracheostomy
in the Community
Developmental Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
ix
Chapter 9 Special Considerations for the Patient With a Laryngectomy . . . . . . . . 265
Jeri A. Logemann
Types of Laryngectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266
Swallowing After Laryngectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
Speech After Laryngectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270
Ventilator-Dependent Tracheostomized Patients . . . . . . . . . . . . . . . . . . 272
Quality of Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
Chapter 10 Complications and Emergency Procedures . . . . . . . . . . . . . . . . . . . . . . . 277
Michiel J. Bové and Linda L. Morris
Intraoperative Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280
Early Postoperative Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
Late Postoperative Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
Chapter 11 Downsizing and Decannulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
Linda L. Morris
Factors to Consider Prior to Decannulation . . . . . . . . . . . . . . . . . . . . . . . 304
Determining Readiness for Decannulation . . . . . . . . . . . . . . . . . . . . . . . 309
Decannulation Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
After Decannulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319
Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319
Chapter 12 Rehabilitation and Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
John Parson and Linda L. Morris
Discharge Disposition of Patients With Tracheostomies . . . . . . . . . . . . 323
Tracheostomy in Acute Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . 324
Adapting Choice of Tracheostomy Tube and
Care Plans to Clinical Settings
Providing Phonation for Patients Who Require
Positive-Pressure Ventilation
Evaluating the Need for Relief of Upper Airway Obstruction . . . . . . . . 335
Considerations for Transitioning Tracheostomy Tubes . . . . . . . . . . . . . . 337
Discharge to Home . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
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