RESOURCES
OBJECTIVES & QUESTIONS
Overview of Routine Care
Which aspects should be considered as part of the routine care of a patient with a tracheostomy?
Cleaning of the Tube
- Inner cannula must be removed and checked at least once per nursing shift (every 8-12 hours)
- The outer part of the tube can be cleaned simply with saline solution
- A spare inner cannula should be kept at the bedside to minimise time of disconnection
- Whole tracheostomy tube should be changed regularly, typically, every 28 days:
- Changes should be planned
- Unplanned changes should be reported as a critical incident
Stoma Care
- Stomas needs to be kept clean and dry
- Specific absorbent dressing should be used around the tube
- Stomas should be inspected at least once per day
Cuff Deflation and Management
- Cuff pressure should be maintained as low as possible to prevent air leaks
- Ideally a pressure below 25cmH2O should be used
- Clearance of subglottic secretions from above the cuff should occur before cuff deflation
Secretion Management
- Inspired gases must be warmed and humidified
- Use of a closed system is preferred for invasively ventilated patients and reduces the frequency of breaking the breathing circuit
Monitoring
- Capnography is mandatory for invasively ventilated patients.
Location
- Patients must be manages on safe locations within the hospital:
- Critical care units with staff trained, equipped and supported in providing safe, high quality care
- Alternative predetermined wards within the hospital with sufficient experience and training to manage tracheostomies
- Out-of-hours discharge from critical care of patients recently weaned from ventilation, or with newly formed tracheostomies, is not recommended
Equipment
- Patients should have a small portable box of essential equipment that is kept with them at all times
- A difficult airway trolley and fibreoptic scope should be rapidly accessible on the critical care unit
Team Members
- A multidisciplinary team-based model of care should be used to manage patients with a tracheostomy including:
- Intensivist or Anaesthetist with an interest in tracheostomy care
- Head and Neck Surgeon
- Speech & language Therapist
- Respiratory Physiotherapist
- Dietician
- All staff caring for a patient with a tracheostomy should be appropriately trained
- Whilst on the ICU, the intensive care team take primary responsibility for the care of tracheostomies
Documentation
- All tracheostomies should be recorded as a surgical procedure
- Each patient should have a passport containing pertinent information including:
- Grade of intubation
- Tracheostomy tube type and size
- Insertion date and complications
- Details of all subsequent tracheostomy changes
- A daily review and a clear weaning plan documented in the notes
What equipment should be available with a patient that has a tracheostomy?
Should be available with the patient at all times – usually in a ‘tracheostomy box’ that goes with the patient from critical care to the ward:
- Non-powdered latex-free gloves, aprons and eye protection
- Spare tracheostomy tubes of the same type as inserted:
- One the same size
- One a size smaller
- Tracheal dilators
- Catheter mount or connection
- Tracheostomy disconnection wedge
- Tracheostomy tube holder and dressing
- 10ml syringe (if tube cuffed)
- Tracheal hook
- Scissors or stitch cutter if tracheostomy tube is sutured)
- Water-soluble lubricating jelly
- Sterile dressing pack
- Clean pot for spare inner cannula
Other equipment that should be available on critical care includes:
- Resuscitation equipment
- Rebreathing bag and tubing
- Operational suction unit and yankeur sucker
- Appropriately sized suction catheters
- Humidification equipment
- Nurse call bell: the patient may be unable to call for help verbally
Humidification
What are the recommendations regarding humidification for patients with tracheostomies?
All patient with tracheostomies must have, inspired gases warmed and humidified to reduce the chance of blockage
Why is humidification required for patients with tracheostomies?
- Tracheostomies bypass the normal humidification mechanisms of the upper airway
- As a result, patients are prone to:
- Life-threatening blockage with tenacious sputum
- Keratinisation and ulceration of the tracheal mucosa
- Sputum retention
- Atelectasis and secondary infection
- Adequate humidification is vital to prevent these complications
What methods of humidification should be used for patients with a tracheostomy?
- Recommended method of humidification depends upon the clinical status of the patient:
HME (Buchanan bib, Swedish nose)
- Self ventilating patients (no oxygen)
Cold water bath
- Self ventilating patient (on oxygen)
HME for breathing circuit
- Ventilated patient with minimal secretions (replace every 24hr)
Heated water bath (active humidification)
- Ventilated patient with thick secretions
- Self-ventilating patient (on oxygen) with thick secretions
Oral Intake
Why do patients with a tracheostomy experience risk with oral intake?
- Tracheostomy tube can cause problems with swallowing:
- May prevent the vertical movement of the larynx intrinsic to swallowing.
- Presence of an inflated cuff compresses the oesophagus increasing the risk of aspiration
- May be underlying co-morbidities increasing risk of dysphagia:
- Associated neurological or mechanical causes of dysphagia
- Significant ongoing respiratory failure
How should oral intake be initiated in the patient with a tracheostomy?
- Confirm that patient can tolerate cuff deflation
- Start with sips of water, fluids and then soft diet providing the patient shows no signs of respiratory distress (coughing, desaturation, increased tracheal secretions, increased respiratory rate etc)
- In problematic cases consider referral to Speech and Language therapy for swallowing assessment. The more complex patient longer term may benefit from more formal endoscopic or radiological assessment of swallowing
When should oral intake be allowed with an inflated cuff?
- Made on an individual patient basis after a swallowing assessment
- Should be regularly reviewed for evidence of aspiration
- Sips of sterile water are initially given and if tolerated without coughing, desaturation, fatigue or signs of aspiration on tracheal suctioning, then the patient may eat and drink, noting that a soft diet may be more easily managed
- Should the patient fail to swallow effectively, then assessment by a speech and language professional is recommended
Overview of Tracheostomy Exchange
Why are routine tracheostomy changes required?
- Prevent infection
- Maintain a healthy stoma
- Prevent degradation of the composition material
When should routine tracheostomy changes be performed?
Type
Initial Change
Subsequent Changes
Single Lumen Tracheostomy
- Surgical tracheostomy - not within 4 days
- Percutaneous tracheostomy not within 7-10 days
- Every 7-14 days.
Double Lumen Tracheostomy
- Surgical tracheostomy - not within 4 days
- Percutaneous tracheostomy not within 7-10 days
- Inner cannula:
- At least every day
- Review every couple of hours if heavy secretions
- Outer tube:
- At least every 30 days (European Economic Community Directive)
What are the contraindications to tracheostomy change?
- Unstable clinical condition (balancing risks/benefits)
- High levels of ventilatory support or oxygen
- High risk of losing the airway:
- Tracheostomy was performed within the last 7 days (especially if percutaneously formed)
- Undergoing radiotherapy to the neck region (or completed course in last 2 weeks)
- In palliative care patients where quality of life will not be improved
- Patient refusal
Exchange Procedure
What techniques can be used for performing a tracheostomy change?
There are two commonly used methods:
- Guided exchange using a tube exchange device (gum elastic bougie or airway exchange Catheter):
- Recommended technique for first tube change
- May be advisable for subsequent changes for patients with a high risk of airway loss
- Blind exchange using an obturator:
- For patients with formed stomas and a low risk of airway loss
How should you perform a routine tracheostomy change?
- Dressing pack
- Suture cutter
- Pen torch
- Appropriately sized tracheostomy tube and one a size smaller
- Tracheostomy tube holder
- 10ml syringe for cuffed tubes
- Water-soluble lubricant
- Sterile normal saline
- Pre-cut slim line keyhole dressing
- Gloves, apron and protective eyewear
- Tracheal dilators
- Functioning suction unit and appropriate sized suction catheters
- Stethoscope
- Mapleson’s C Circuit
- Capnograph
- Airway exchange catheter, wire or bougie
- Resuscitation equipment
- Ensure appropriate assistance – 2 person procedure
- Consider availability of equipment:
- Airway expertise, specialist airway equipment and anaesthetic medication.
- The immediacy of such support (bedside, on the unit, in the hospital) should be dictated by the clinical circumstances, location and personnel involved
- Explain procedure and obtain consent from the patient
- Check previous laryngoscopy grade
- Ensure nil by mouth and/or aspirate NG tube
- Pre-oxygenate the patient
- Ensure appropriate monitoring – saturations should be monitored in all patients
- Position the patient:
- Semi-recumbent position
- Neck extended (brings the trachea anteriorly)
- Prepare the new tracheostomy tube:
- Check the cuff for leaks
- Ensure obturator easy to remove
- Lubricate well
- Carefully suction the trachea and pharynx
- Remove the old tracheostomy dressing and clean around the stoma site.
- Deflate the tube cuff using the synchronized cuff deflation and suction technique.
- If using an introducer obturator:
- Remove the old tube in an ‘out then down’ movement on expiration
- Insert the new tube into the stoma with the introducer in the tracheostomy tube lumen
- Ensure that the first movement is 90 to the cervical axis, then gently rotate down to allow passage into the trachea.
- Remove the obturator immediately.
- If using an airway exchange device:
- After the patient has stopped coughing pass the exchange catheter through the tracheostomy to just beyond the tip of the tracheostomy tube
- Remove the tube leaving the exchange catheter in place, and railroad the new tracheostomy over it during expiration
- Remove the exchange catheter, inflate the cuff and administer oxygen
- Where appropriate, insert the inner cannula and check the cuff pressure
- Confirm positioning:
- Identify the presence of CO2 using a capnograph
- Confirm normal chest movement, air entry and oxygen saturation
- Clean the stoma site as necessary, change the dressing and secure the tracheostomy tube with a tube holder
- Record tube change in the medical notes:
- Time, date, size, type of tube and any complications
