What are the key components of immediate post-operative care for a patient who has undergone a tracheostomy?

Post-Tracheostomy Care

Immediate post-tracheostomy care requires trained personnel to verify tube position (4-6 cm from carina), secure the tube properly, monitor for hemorrhage every 3 hours for the first 4 days, and maintain emergency reintubation equipment at bedside at all times. 1

Immediate Post-Operative Care (First Hours)

Initial Verification and Securing

• Verify tube position using anatomical landmarks with the tube tip 4-6 cm from the carina in the tracheal lumen 1
• Secure the tube with skin sutures, ties, or Velcro, ensuring it is neither too tight nor too loose (movement limited to 1 finger width) 1
• Confirm airway patency by performing easy tracheal suction, monitoring end-tidal CO2 (comparing with pre-tracheostomy values), and verifying absence of subcutaneous emphysema in cervical or thoracic regions 1
• Obtain chest X-ray to confirm proper tube position 1
• Check cuff pressure maintaining it below 30 cmH2O (typically 25-35 cmH2O depending on institutional protocol) 1

Hemodynamic Monitoring

• Verify hemodynamic stability and absence of cardiac rhythm disorders immediately post-procedure 1
• Monitor vital signs including level of consciousness, respiratory rate, heart rate, blood pressure, oxygen saturation, temperature, and pain score 1

Emergency Preparedness

• Keep reintubation and tracheostomy equipment in the room or immediately accessible in case of early accidental dislodgement 1
• Ensure waveform capnography is immediately available and functional 1
• Have tracheal dilators available (institutional preference varies, but particularly important for percutaneous tracheostomies) 1

Care During Days 0-4 (Critical Early Period)

Hemorrhage Surveillance

• Monitor for hemorrhagic signs (visible at stoma site or during tracheal suction) every 3 hours postoperatively 1
• This is the highest-risk period for major bleeding complications 2, 3

Stoma Care

• Change dressings with physiological saline 3 times every 24 hours to prevent accumulation of secretions and moisture at the stoma 1
• Examine the stoma and check for signs of local infection 1

Airway Management

• Perform tracheal suction according to usual practice (defined frequency or on request), but measure maximum depth (down to carina, up one centimeter, and document the distance) 1
• Provide airway humidification using heated humidifier if necessary 1
• Care for inner cannula if present with cuffed tube 1

Positioning and Mechanical Considerations

• Elevate head of bed by 30° in median position, preserving head and trunk axis during mobilization and position changes 1
• Ensure ventilator tubing is not pressing on the tracheostomy stoma 1

Ongoing Care (After Day 4)

Daily Maintenance

• Change fixation daily or more frequently if oozing (hemorrhage or pus) occurs 1
• Inspect stoma daily and cleanse with isotonic saline 1

Tube Changes

• Avoid routine tube changes in the ICU setting; changes should be guided by clinical indications only 1
• Do not change tubes before 4 days after surgical tracheostomy or 7-10 days after percutaneous tracheostomy due to risk of tube displacement and respiratory arrest 1
• Consider tube change for suspected local infection, bleeding, or to reduce tube caliber to facilitate speech 1

Staffing and Communication Requirements

Personnel

• Assign trained staff in tracheostomy management to care for the patient 1
• Maintain one-to-one nursing ratio during the immediate post-operative period 1
• Ensure appropriately skilled anesthesiologist is immediately available 1

Communication Protocol

• Provide clear verbal handover and written instructions for recovery and ward/HDU staff 1
• Brief on-call team about high-risk patients with written airway management plan 1
• Display bed-head sign with local emergency contact details specific to the patient 1

Critical Warning Signs

Early Complications (Hours to Days)

• Stridor, obstructed breathing pattern, or agitation indicate airway compromise requiring immediate intervention 1
• Hemorrhage visible at stoma or during suctioning 1, 2
• Subcutaneous emphysema in cervical or thoracic regions 1
• Tube displacement or obstruction - the greatest life threats to tracheostomy patients 2, 3

Late Complications

• Mediastinitis signs: severe sore throat, deep cervical pain, chest pain, dysphagia, painful swallowing, fever, and crepitus 1
• Tracheoesophageal fistula, tracheal stenosis, or infection 2, 3

Common Pitfalls to Avoid

• Never rely solely on pulse oximetry for monitoring ventilation - it is not designed as a ventilation monitor and can give incorrect readings 1
• Never ignore an agitated patient or one complaining of breathing difficulty, even if objective signs are absent 1
• Do not perform early tube changes within the first 4-7 days as the tract is not mature and carries significant risk 1
• Remove any obstructing devices (decannulation caps, obturators, speaking valves with inflated cuff, blocked humidifying devices) in an emergency 1
• Ensure oxygen is administered to both face and tracheostomy during emergencies, requiring two oxygen sources 1