CARING FOR THE

TRACHEOSTOMISED PATIENT: WHAT TO LOOK OUT FOR

DR MOHD NAZRI ALI

Anaesthesiologist & Intensivist

HRPZ II, Kota Bharu,

Kelantan

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Tracheostomy The Enabling Disability

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Tracheostomy

• Are becoming increasingly common place both within the

acute setting and community

• As a result of this there is an expectation of increased

knowledge and more advanced nursing and

healthcare skills in ward staff caring for this patient.

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• Tracheostomy is commonly performed procedure in ICU

• Estimated 15,000 insertion procedures in the UK annually (NCEPOD UK 2014)

• Local data

( MRIC 2015 )

Types of Tracheostomy

Surgical tracheostomy : Performed in the OR or at bedside

under moderate sedation / GA

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• Percutaneous dilatational tracheostomy is done at the

patient’s bedside, usually in the ICU setting.

• Contraindicated in anatomical irregularities or coagulation

problems

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Why does your patient have a tracheostomy ?

• To maintain a patent airway when the ability to do this is

temporarily or permanently compromised

-Bypass obstructed airway

Tumour

Foreign body obstruction

• Facilitate removal of secretion

• Facilitate weaning of ventilator

• Optimize sedation

• Decreased work of breathing ( severe COAD)

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Is not without

Tracheostomy..

Complications

Early

Late

• Haemorrhage

• Wound infection

• Sub-cutaneous

emphysema

• Tube obstruction

• Fausse route

• Tube displacement

• Swallowing problems

• Tracheoesophageal

fistula

• Tracheal stenosis

• Granuloma formation

• Tracheo-innomate artery

fistula

Recognizing complications will allow early intervention and

prevent negative outcomes

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The essential principles when caring for

patient with a tracheostomy are based on

• Maintaining patient safety

• Airway patency

• Facilitating communication

• Preventing complication associated with procedures

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Care of the tracheostomy

• Major factors must be considered in the

care of tracheostomy patient Basic nursing care

Cuff pressure

Humidification of inspired air

Airway patency and secretion clearance

Speech

Nutrition

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Basic nursing care

• Some general measures are advocated for immediate

post tracheostomy care :

Tracheostomy cannula is secured in place

Left to heal for 5-7 days

Kept clean and dry

Inner cannula is changed daily or more frequent if necessary

Avoids angulation

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Wound assessment

General

• Offensive odour

• Pain during dressing change

• Allergic reaction to product

Surgical incision

Bleeding

Infection

Wound breakdown

Tracheostomy stoma site

• Increase in size

• Appearances of stoma

edges

• Appearance of peri-stoma

tissue

(maceration,cellulitis)

• Nature &quality of

exudates

• Presence of granuloma

tissue

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Cuff pressure

• Tracheostomy tube cuffs require monitoring to maintain

pressure in a range of 20-25mmHg

• High cuff pressure exceed 25-35 mmHg exceed capillary

perfusion pressure will result compression of mucosal

capillaries

Mucosal ischemia

Tracheal stenosis

• Low cuff pressure below 18 mmHg may caused the cuff to

develop longitudinal folds

Micro aspiration

VAP

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Cuff pressure should be monitored

with calibrated devices

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Humidification

• The importance of humidification can’t be over-

emphasized

• Nasopharynx :

provide natural humidification mechanism for the airway

Keep airway moist

• Bypass by the tracheostomy

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Strategies

Properly hydrated with oral, IV fluids ( mucosal surface

to remain moist and to ensure the viscid secretions

remain atop the cilia)

Instillation sterile saline directly into tracheostomy

during suctioning

(not too much)

Conserved patient’s own moisture ( HME)

Saline nebuliser – moist the airway

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Airway patency and secretion clearances

• Many of the nursing skills employed are aimed at the

mobilization of pulmonary secretions

• Strategies

• Frequent turning

• Encouragement of deep breathing and ambulation

• Chest physiotherapy and postural drainage

• Saline nebulizer

• Suctioning

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1.Suctioning a patient never be considered routine

• Suction when :

Clinically in distress

Increase airway pressures

Increase patient apprehension

Auscultation – ronchi

Other-request by the patient

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Suctioning should be done

PRN, after chest

physiotherapy,nebulisation

Use the lowest pressure

needed ( usually < 120 mmHg,

definitely not beyond 200

mmHg

Suctioning performed less

than 10 seconds

Insert the catheter : length of

trachy + ¼ inch

Size of suction

catheter

Less than half of

internal diameter

tracheostomy

Divide the

internal diameter

of trachy by two

AND multiply the

answer by three

French gauge

suction catheter

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2. Inner cannula

• Inner cannula is one of the most important parts of

tracheostomy

• Keep clear of secretion build-up since can be removed

and cleaned

• Care always requires strict aseptic technique

• Every 2-3 hours for first 48 H

• Every 4 hours thereafter

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Weaning tracheostomy

Increase period of cuff deflated

Fenestrated tube

Speaking valve

Down sizing the tube

Capping off tracheostomy tube

Decannulation

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Decannulation

• When the patient is being weaned from mechanical

ventilation or from tracheostomy tube

• The use of fenestrated tracheostomy tube may facilitate

the decannulation procedure

• Design of the tube

Allows the patient to gradually become used to handling secretions

and breathing on his/her own

Protection of the cuff if patient should required supportive

ventilation

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• When it is desired to have the patient breath through

his/her upper airway

Removed inner cannula

Cuff deflated

Occlude the outer cannula with de-cannulation cap

( monitor for features of airway obstruction / distress )

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ALWAYS REMEMBER TO DEFLATE THE CUFF,

AS TOTAL AIRWAY OBSTRUCTION WILL OCCUR IF

CUFF IS NOT DEFLATED

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Speech

Ventilator-dependant patient

• Whispered speech

• Partially deflation of

tracheostomy tube cuff

• Provided good swallowing

• Minimal secretion above

the cuff

Non-ventilator dependant

• Remove inner cannula

• Occlude external end of

tracheostomy ( cap, one

way valve)

-Deflated the tube cuff**

-Non-cuff tracheostomy

• Allowing expiratory airflow

through the larynx

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Fenestrated tube

Have an opening on the posterior wall of

outer cannula

Allowing air to flow through the upper

airway

Allow patient to speak

Often used during weaning asmic 2017

Nutrition

• Provides opportunities for oral nutrition ( also complicates

feeding –tube interferences with normal swallowing and

airway control )

• Tracheostomy

Decrease laryngeal elevation during swallowing

Inflated cuff may compress oesephagus

• Risk factors for swallowing problems in patients with

tracheostomy

Neurological injury eg. Bulbar palsy

Disuse atrophy

Head and neck surgery

Evidence of aspiration of enteral feed or oral secretion on tracheal

suctioning

Increase secretion load

Coughing and desaturation following oral intake

Patient anxiety or distress during oral intake

High FiO2

Risk factors for swallowing problems in patient with

tracheostomy

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• Reduce risk of aspiration by:

Confirm that patient can tolerate cuff deflation

Sit patient up with head slightly flexed,

placed a suction catheter just at the end of tracheostomy

deflate the cuff while suctioning.This is to prevent secretion falling into the airway

Start with sip of clear fluid then soft diet

Observe for respiratory distress, coughing,desaturation,tachypneic

For problematic cases consider referral to speech and language therapy for swallowing test / endoscopic or radiological assessment

Reduce risk of aspiration by

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RED FLAGS

Airway

• A suction catheter not passing easily into the trachea

• A changing,inadequate or absent capnograph trace

• Patient with a cuff tracheostomy tube suddenly being able to talk or noise or bubble coming from the upper airway

• Frequent requirement for (excessive) inflation of the cuff to prevent air leak

• Pain at the tracheostomy

site

• Visibly displaced

tracheostomy tube

• Bleeding from the tube /

stoma

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Breathing

• Increasing ventilator

support / O2 requirement

• Respiratory distress

• Subcutaneous

emphysema

• Patient complaining that

they cannot breath /

difficulty in breathing

• Suspicious of aspiration

Circulation

• An airway emergency

may lead to CVS collapse

• Anxiety, restlessness,

agitation and confusion

may also due to airway

problem

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In a nutshell….

• Tapes : keep the tracheostomy tube secure

• Resus / emergency care : know the resuscitation

procedure

• Airway clear : use the correct suction technique

• Care of the stoma and neck

• Humidity : essential to keep the tube clear

• Emergency equipment : have the box present

Tube changes planned

TRACHE bundle

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Elizabeth Taylor's Tracheostomy

Taylor went to Europe, awaiting production of Cleopatra. In spring of 1961, she developed a case of pneumonia, which led to an emergency tracheotomy and worldwide talk of her impending death. The swelling of sympathy was widely thought to have influenced Academy voters, who awarded Taylor her first Best Actress Oscar —Elizabeth later commented, I knew it was a sympathy award, but I was still proud to get it." Meanwhile, Taylor's competitor Shirley MacLaine memorably quipped, "I lost to a tracheotomy!"