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SEWCCN Tracheostomy Guidelines May 2009 1

Tracheostomy Guidelines South East Wales Critical Care Network


Contents

1. Introduction

2. Types of tracheostomy

3. Features of tracheostomy tubes

4. Types of tracheostomy tubes

5. Care of a patient with a tracheostomy

Essential equipment

Humidification

Cleaning inner tubes

6. Care of stoma site

7. Suctioning

8. Weaning

9. Speaking valve

10. Decannulation

11.Changing a tube

12. Swallow

13. Communication

14. Emergencies

Appendices

1. Patient information

2. Tracheostomy tube information

3. Emergency algorithms

4. Integrated Care pathway example

5. Tracheostomy observation chart example


Acknowledgements

This work has been informed by all the Trusts within the South

East Wales Critical Care Network and based on the Intensive Care

Society and NPSA guidelines (with their kind permission)


1. Introduction

This document focuses on the care of adult patients with temporary tracheostomies

within the acute in-patient setting. It sets out general guidelines which are intended to

support and inform all staff involved in the management of patients with both surgical

and percutaneous tracheostomies.

These guidelines set out core principles and aim to ensure that there is a consistent

approach to the management of tracheostomy patients but the authors acknowledge that

there is limited evidence for many of the recommendations. However, this document is

for the most part based on the Intensive Care Society (ICS) and National Patient Safety

Association (NPSA) guidelines with their kind permission to reproduce.

1.2 Definition A tracheostomy is the formation of an opening through the skin into the trachea. A

tracheotomy is the opening created in the trachea itself.

2. Types of tracheostomy

2.1 Surgical tracheostomy

The surgical tracheostomy (i.e. the cut into the trachea) may be a vertical slit,

fenestration, or may utilise an inferiorly based Bjork flap. The skin edges may then be

sutured to the tracheal edge. The operation may be carried out in the operating theatre,

on the ward, or in the intensive care unit. It may be carried out under general or local

anaesthesia. The tracheostomy may be temporary or long term, and may be formed

electively or as an emergency procedure.

A temporary tracheostomy can be formed when patients require long term respiratory

support or are unable to protect their own airways. A tracheostomy tube will be inserted

to maintain the patency of the airway. This can be removed when the patient recovers.

In some circumstances the procedure is elective and patients can be prepared for the

potential difficulties. However unconscious patients will not receive preparation and need

careful psychological support when they begin to recover. This may also be carried out as

an emergency procedure when a patient has an obstructed airway. Among the more

common conditions causing obstruction are trauma to the airway or neck, inhalation of

foreign objects, poisoning, infections or neoplasms.

A temporary tracheostomy may become long term if the patient’s condition requires this.

2.2 Percutaneous Tracheostomy

Most patients within critical care will have tracheostomies performed using a

percutaneous, dilatational technique. This procedure may require a general anaesthetic,

but is usually performed in the intensive care unit by the intensivists. Any patient leaving

critical care with this type of tracheostomy will be followed up by the intensivist and the

critical care outreach education team.

2.3 Laryngectomy

A permanent tracheostomy is created following a total laryngectomy. This involves

creating a permanent stoma where the top of the trachea is brought to the surface of the

skin and sutured to the neck skin. This stoma is kept open by the rigidity of the tracheal

cartilage. The patient will breathe through this stoma for the remainder of his/her life.

There is no connection between the oral airway (the mouth and nose) and the trachea,

and there may be no connection between the pharynx and the trachea unless one has

been specially created. Any ventilation or oxygen support must be via this stoma.


This procedure is elective and the patients need to be carefully prepared for the

consequences of the procedure.

3. Features of Tracheostomy Tubes

• Single lumen tubes – do not have an inner cannula e.g. some Portex tubes.

• Tubes with inner cannula (also called dual lumen or twin lumen tubes) – these

have an outer tube, which is intended to remain in the patient. The inner cannula

can be removed for cleaning, and can be changed to a different type to facilitate

weaning.

Tracheostomy tubes require different features depending on their intended use. There

are a large variety of tubes available which provide some or all of these features.

3.1 Introducers

All tracheostomy tubes should be inserted using an introducer (obturator) to prevent

damaging the trachea during insertion of the tube. Once the tracheostomy tube has been

inserted the introducer should be disposed of. The clear plastic universal cap should also

be stored in a safe place and caerfully labelled to ensure it is not disposed of.

3.2 Cuffs

Some tracheostomy tubes have a cuff which, when inflated, provides an airtight seal

which facilitates artificial ventilation including CPAP. It also prevents aspiration of oral

secretions, vomit and blood from the upper airways.

3.3 Inner tubes

Dual lumen tracheostomy tubes consist of an outer tube, which remains insitu, through

which a smaller, inner tube is inserted. The inner tube has an extension at its upper

aspect which can be connected to other equipment. It can be removed for cleaning but

must be replaced immediately with a spare inner tube which should be at the bedspace.

3.4 Fenestrations

Fenestrated tracheostomy tubes are dual lumen tubes which have a fenestration window

in the middle of the upper aspect of both of the tubes. If the tracheostomy tube is

occluded, this will allow the passage of air and secretions into the mouth and nose in the

normal way rather than directing them out via the tracheostomy tube. These tubes will

always have an optional non-fenestrated inner tube which must be inserted if the patient

requires further respiratory support. A non-fenestrated inner tube should always be

inserted prior to performing tracheal suction to ensure the suction catheter does not pass

through the fenestration and damage the back wall of the trachea.


4 Tracheostomy tube types and choice There are a variety of different tubes on the market and clinicians must choose the most

appropriate tube for their patient.

The ICS advise that ‘tracheostomy tubes should be chosen taking account of

patient and tube characteristics and not just the ease of insertion’.

Factors influencing selection of a temporary tracheostomy tube: from ICS

Guidelines July 2008

Factor Notes

Respiratory function Most temporary tracheostomies will be inserted whilst

a patient is in an intensive care unit and still requiring

some degree of positive pressure ventilation. As a

standard, this will require the use of a cuffed

tracheostomy tube (although it is recognised that

long term mechanical ventilation can be delivered

through an uncuffed tube).

Abnormal airway

anatomy

Upper airway endoscopy following percutaneous

insertion suggests that a standard tracheostomy tube

may be anatomically unsuitable in as many as a third

of adult patients. Obese patients may require a tube

with an extended proximal length, whilst patients with

fixed flexion abnormalities may not easily

accommodate tubes with a fixed angulation.

Airway pathology Localised airway pathology such as tracheomalacia,

granuloma formation etc may on occasion necessitate

the use of a tracheostomy tube that has a longer

distal length than standard.

Compromised airway

protection and weaning

problems

Many patients can be weaned to decannulation

without any need to change from the cuffed

tracheostomy tube that was initially

inserted. In problematic cases however, it may be

useful to consider options such as downsizing, to an

uncuffed or fenestrated tube, or a tube with the

option for sub-glottic aspiration of airway secretions.

The introduction of a speaking valve may also aid

swallowing and secretion control.

Obstructed / absent

upper airway

Patients with an obstructed or absent upper airway

are at particular risk should a tracheostomy become

obstructed or misplaced. This has implications for

both the choice of tracheostomy tube as well as the

method by which the stoma is fashioned.

Clinical environment

Obstruction of a cuffed tracheostomy tube is a

potentially life threatening emergency. Wherever

possible a dual cannula tube (i.e. a tube with an inner

cannula) should be used, particularly for patients in

HDU or ward environments who may not have

immediate access to clinicians with emergency airway

skills. Ward staff can change inner tubes easily and quickly to relieve obstruction with secretions.


4.1 Characteristics of tubes

The characteristics of the tube to be considered when selecting a tracheostomy tube for

temporary use include:

• construction

• dimensions

o internal and outer diameter (ID and OD respectively)

o proximal and distal length (i.e. the length of the tube proximal and distal to its

angulation)

o shape and angulation

• compatibility with percutaneous insertion kit

• presence and nature of tube cuff

• presence of inner cannula (dual cannula tracheostomy)

• fixed versus adjustable flange

• presence of fenestration

• specialist features, e.g. low contour on deflation tight to shaft cuffs, subglottic secretion

control systems, voice enhancement tubes etc

It is essential that the staff caring for a patient with a tracheostomy know the

type of tube in place at any time, and this should be clearly documented in the

patient’s notes

4.2 Construction

• Material

Tracheostomy tubes can be constructed of either metal or plastic, and thereby vary

considerably in rigidity, durability and kink resistance. This may be clinically relevant.

Metal tracheostomy tubes are constructed of either silver or stainless steel, but are

seldom used in the critical care environment, and will not be discussed further.

Temporary tracheostomies are constructed of polyurethane, polyvinyl chloride or silicone.

Products made of polyurethane are more rigid than those constructed of silicone, whilst

those of polyvinyl chloride construction are of an intermediate stiffness (although some

become softer at body temperature).

• Shape

Many tubes have an inherent curvature or angulation; others are completely flexible and

only assume a correct anatomical alignment through appropriate stabilisation at the

stoma and the level of the cuff. Some flexible tubes are reinforced with a spiral wire in

order to avoid kinking and airway obstruction. Whilst the design of some tracheostomy

tubes has been modified to facilitate percutaneous introduction, others are only

appropriate for insertion once a formal track has been formed (either surgically or

through the prior placement of an alternative tube). Various aspects of the construction

of some commonly used tracheostomy tubes are described in appendix 2.

• Dimensions

In most circumstances a tracheostomy tube is both described and selected on the basis

of its size, or more specifically its diameter. This is simple in theory but may easily be

confusing in practice.

Most tracheostomy tubes are sized by internal diameter in millimetres, but this

may not take account of inner cannula in all cases.

See Appendix 1 for dimensions of commonly used tubes

Tracheostomy tubes with the same internal diameter (‘size’) may have quite

different external diameters and length.

4.3 Choosing the correct size

• Diameter

When selecting the size of tube for a patient, there is an unavoidable compromise to be

made between a desire to maximise the functional internal diameter (and thereby reduce

airway resistance and the work of breathing during weaning) and a need to limit the OD

to approximately three-quarters of the internal diameter of the trachea (in order to


facilitate airflow through the upper airway when the cuff is deflated). Furthermore,

selection of a tube that is too small may result in the

need to over-inflate the cuff, thereby increasing the risk of mucosal pressure necrosis,

which in turn increases the risk of complications such as tracheal stenosis and tracheo-

oesophageal fistula. A need to exceed the quoted nominal cuff volume is often an early

indicator that too small a tube has been selected. As a general rule, most adult females

can accommodate a tube with an OD of 10mm, whilst a tube with an OD of 11mm is

suitable for most adult males.

Need for excessive cuff volume or pressure suggests that the tube size may be

too small or it may be misplaced.

• Length and shape

Although a temporary tracheostomy is most commonly selected on the basis of its

diameter, there may be situations where the length, angulation or curvature of a tube is

of relevance. Thus, whilst many tracheostomy tubes are smoothly curved, others are

clearly angulated, thereby allowing a distinction to be made between the proximal (or

horizontal) length of a tube (i.e. the distance between the neckplate and the mid-point of

the angulation) and the distal length (i.e. the distance from the mid-point of the

angulation and the tip). It should be appreciated that these respective lengths are quite

short in standard tubes and may be too short even in the patient with apparently normal

anatomy.

There may be occasions where the proximal length of a standard tube is inadequate (e.g.

in the obese, or when cellulitis around a tracheostomy site increases the depth of the

anterior cervical tissues after insertion), and leads to the tube tip then abutting against

the posterior tracheal wall.

This can result in:

• obstruction of the tube, and consequent difficulties with ventilation and weaning

• injury to the posterior tracheal wall, thereby increasing the risk of tracheo-oesophageal

fistula formation

• suboptimal positioning of the tube cuff, with the associated risk of aspiration,

inadequate ventilation and high cuff pressures

There may also be occasions where the proximal length is too long, with the result that

the knuckle of the tube abuts against the posterior tracheal wall, whilst the tip is pivoted

towards the anterior tracheal wall (the latter increasing the risk of granuloma formation

and the development of a tracheal – innominate artery fistula). Less commonly, there

may be a need to review the distal length of a temporary tracheostomy. For instance,

there may be occasions where there is a need for additional distal length in order to

bypass fistulae or obstructing lesions such as tracheomalacia, tracheal stenosis or

excessive granuloma formation or tumour.

Clinically significant anatomical and pathological variances such as these can be

circumvented by using either extended length tracheostomy tubes with an adjustable

flange or pre-formed extended tubes which are offered with a range of extended

proximal or distal lengths.

Extended length adjustable flange tubes are suitable for short term situations but are

often difficult to introduce percutaneously and are not currently supplied with an inner

cannula. However, the new uniperc is now available and is easy to insert and has an

inner cannula.

Whilst adjustable flange devices are considered suitable for short terms problems,

patients who are likely to need airway access for a considerable length of time may be

better served with pre-formed non standard products such as the Shiley® Tracheosoft

XLT range or the Portex® Blue Line® Extra Horizontal and Vertical length products.

Some manufacturers offer a bespoke service should none of their stock items be suitable.

4.4 Inner cannula (dual cannula tracheostomies)

Many tracheostomies are now manufactured with an inner cannula. The design of some

makes the use of this optional (e.g. Portex® Blue Line Ultra®), whilst for others it is

mandatory, as it is the inner cannulae that has a standard 15mm attachment to connect


to the breathing circuit of a mechanical ventilator (e.g. Shiley®, Kapitex Tracoetwist®).

Whilst some inner cannulae are disposable and designed for single use, others can be

cleaned and re-used.

The principal (and very major) advantage of an inner cannula is that it allows the

immediate relief of life-threatening airway obstruction in the event of blockage of a

tracheostomy tube with blood clot or encrusted secretions. Whilst traditionally, this has

been seen to be particularly advantageous for patients once they have been discharged

to a ward environment, it is now recognised that tube obstruction can occur even while

the patient is in a critical care facility, and that in such circumstances removal of an

obstructed inner cannula may be preferable to removal and repeat tracheal intubation.

The principal disadvantage of dual cannula tubes is that the inner cannula may

significantly reduce the effective inner diameter of the tracheostomy tube and thereby

increase the work of breathing and impair weaning. Failure to properly lock the inner

tube in place may also result in disconnection of the breathing circuit in circumstances

where it is connected to this rather than the

outer cannula.

Tracheostomy tubes with an inner cannula are inherently safer and are normally

preferred.

4.5 Fenestrated tracheostomy tubes

Many tracheostomy tubes come with the option of a fenestration in the posterior wall of

the intratracheal component of shaft above the cuff. Manufacturers do not recommend

the use of such tubes at the time of percutaneous tracheostomy, and generally they

should not be used whilst a patient still requires mechanical ventilation because of

significant risk of surgical emphysema (even when a non-fenestrated inner cannula is in

place). Although a correctly sited fenestrated tube may aid both phonation and weaning

(by facilitating the flow of air both through as well as around the tracheostomy tube), in

practice the fenestrations are frequently poorly positioned within the trachea, and when

abutting against the posterior tracheal wall may increase airway resistance

and as well as promote the development of granulation tissue in the tracheal mucosa.

The design of the fenestrations varies between manufacturers, with some clinicians

favouring tubes with multiple smaller openings to a single large one, although both

patterns are at risk of blockage by encrusted secretions. If a fenestrated tube is used, it

is vital that the position and on-going potency of the fenestration(s) are checked

regularly if the patient is to benefit from this option. In practice down sizing or switching

to an uncuffed tracheostomy tube is enough to improve flow of air through the upper

airway in most patients.

Fenestrated tracheostomy tubes should be used with caution in mechanically

ventilated patients, and only with patients who are weaning from ventilation.

4.6 Cuffed tracheostomy tubes

In the ICU setting, most patients will require an air-filled cuffed tracheostomy tube

initially, both to facilitate effective mechanical ventilation and also to protect the lower

respiratory tract against aspiration. The cuff should be of a “high volume / low pressure”

design, and should effectively seal the trachea at a pressure of no more than 20 – 25

cmH2O in order to minimise the risk of tracheal mucosal ischaemia and subsequent

tracheal stenosis. Although many manufacturers offer tracheostomy tubes with suitable

cuffs, there is considerable variation between them in the length of the cuff and its

precise shape when inflated. Furthermore, there is now considerable evidence to suggest

that the current high volume / low pressure design is unable to guarantee isolation of the

lower respiratory tract.

The intra-cuff pressure should be monitored regularly


Causes of excessive cuff pressures include:

• the use of a tube that is too small (an indication for which would be a need to inflate

with more than the nominal cuff volume in order to achieve an effective seal)

• poor tube positioning in the trachea

• tracheal dilatation

• over inflation of the cuff

One proposed solution to the problem of cuff-related tracheal mucosal ischaemia is the

use of a foam rather than air-filled cuff (Bivona® Adult Fome-Cuf® tracheostomy tube).

The cuff is constructed of air-filled polyurethane foam within a silicone envelope that is

deflated prior to insertion and then allowed to expand once sited by opening the pilot

port to atmosphere. Correct sizing and placement is crucial to their use, which tends to

be limited to patients with existing tuberelated tracheal injury. The prevention of

phonation is a further significant drawback to the device.

Most patients can wean to decannulation by simply deflating the existing cuff (even

though the residual profile of the deflated cuff can still significantly restrict airflow around

the tube), or alternatively by changing to a smaller or uncuffed tube. In circumstances

where a patient still requires periods of airway protection, but is unable to satisfactorily

breathe past a deflated cuff, it may be advantageous to switch to a so-called “tight to

shaft” tube in which the deflated cuff makes no distinguishable contribution to the

external profile of the tracheostomy tube.

4.7 Percutaneous tracheostomy tubes / kits

Several manufacturers have modified aspects of the construction of their standard

tracheostomy tubes such as cuff and distal tube profiles in order that they are more

easily introduced as part of a percutaneous dilatational technique (e.g. Portex® Per-Fit

and Shiley® PERC). Such changes frequently go unnoticed when the tube comes as a

component of a percutaneous tracheostomy kit and may have unpredictable functional

consequences. Clinicians are advised to carefully evaluate situations where such product

consolidation occurs.

Specialist functionality

Some specialist tracheostomy tubes incorporate a facility for aspiration of sub-glottic

secretions (e.g. Portex® Blue Line Ultra® “Suctionaid” tracheostomy tube, Tracoetwist®

306). Initially advocated in the prevention of ventilator-associated pneumonia, they may

also benefit patients with poor bulbar function who are unable to effectively clear

secretions that accumulate above the tracheostomy tube, although they carry a high risk

of significant laryngeal injury if suction is applied continuously. When considering

changing to one of these devices clinicians are also advised that in order to accommodate

the additional suction channel these tubes may have a wider OD than the standard

device that it is replacing.

Other options include features that enhance phonation such as the Portex® “Vocalaid”

cuffed Blue Line® tracheostomy, in which an external air source is used to deliver gas via

a separate pilot channel to the sub-glottic area, or the introduction one-way speaking

valves such as the Passy- Muir® valve, the latter also improving swallowing and

secretion control.

Summary recommendations

1. Critical care clinicians need to be aware of the wide variability in the construction,

design and functionality of the tracheostomy tubes that are currently available, and

recognise that the anatomical variation of their patients limits the universal applicability

of a single tube type.

2. Most adult patients who require a temporary tracheostomy as part of their critical

illness will initially need a non-fenestrated semi-soft tube with an air-filled cuff. As a

standard, a dual cannula tube (i.e. a tube with an inner cannula) should be used from the


outset unless there is a requirement to insert an extended adjustable flange

tracheostomy (which currently do not have inner tubes available).

3. Patients with single cannula adjustable flange tracheostomies should not be discharged

from a level 3 critical care environment without review of their on-going need for a

device that puts them at particular risk of the consequences of tube obstruction. A

change to a pre-formed extended tracheostomy with an inner cannula should be

considered as soon as the patient is actively weaning from mechanical ventilation and

certainly before discharge from critical care.

4. When considering changing an existing tracheostomy to that of another type or

manufacturer, clinicians should compare the relative lengths and external diameters of

the two tubes, particularly if the proposed new tracheostomy has a wider OD (because

the existing stoma may not accommodate it), shorter length (in case cuff related

granulation tissue obstructs the tube) or different curvature / angulation.

5. Specialist features such as fenestrations, foam or tight to shaft cuffs or a sub-glottic

suction facility may be useful in specific circumstances, although are not recommended

as a routine.

5 Caring for a patient with a temporary tracheostomy tube

Patients immediately post tracheostomy placement usually return either to a critical care

area or a specialist ward environment used to dealing with tracheostomies. Routine care

of an established tracheostomy is a basic ward skill, but unfamiliarity with

tracheostomies and the simple rules governing their routine care often leads to anxiety

for both patient and carer. Good routine care is not difficult and will avoid almost all

emergencies, but patients with tracheotomies should only be cared for in areas

where staff are competent in such care. Regular review and good communication are

the keys to both avoidance of problems, and effective treatment. Consideration should be

given to a pathway such as in appendix 4 to ensure that staff are always aware of all

relevant information.

5.1 Essential Equipment for ward based patient

The following equipment should be immediately available at all times for a patient with a

tracheostomy:

• Operational suction unit, which should be checked at least daily, with suction tubing

attached and Yankeur sucker (by patient bedside)

• Appropriately sized suction catheters (by patient bedside).To calculate size use the

following formula:

o size of tracheostomy tube x 3/2

• Appropriate PPE

o Non-powdered latex free gloves, aprons and eye protection (by patient

bedside)

o Disposagloves or equivalent

• Spare tracheostomy tubes of the same type as inserted: one the same size and one a

size smaller (by patient bedside)

• Spare inner cannula (by patient bedside)

• 2 bottles of sterile water and receptacle for flushing through tubing and cleaning inner

tubes

• Inner cannula cleaning equipment

• Tracheal dilators for new surgical tracheostomies only and to be used only by those

competent in doing so

• O2 therapy – wall flow meter and tracheostomy mask


• Rebreathing/ambu bag and tubing (available for emergency use)

• Catheter mount or connection Tracheostomy disconnection wedge

• Tracheostomy tube holder and dressing

• 10ml syringe (if tube cuffed) (by patient bedside)

One approach is to ensure that all these are in a ‘tracheostomy box’ that goes with the

patient from critical care to the ward.

Intervention Rationale

The equipment listed above should be

at the patients bedside at all times.

Each shift the nurse responsible for the

patient should check the equipment is present and in working order.

This equipment is the minimum

required to care for a patient with a

tracheostomy including emergency situations.

For cuffed tracheostomy tubes: assess

cuff pressure once each shift as follows:

First clear any secretions from the

upper airways i.e. above the cuff of the

tracheostomy tube. Deflate the amount

of air in the cuff by 1-2 mls until air

leakage can be heard. Gently reinflate the cuff until the leak stops.

Record procedure on patients observation chart.

To ensure the cuff is not over inflated

which may cause damage to the

trachea but is creating a seal.

The tracheostomy site should be

assessed at least each 24 hours and

redressed as appropriate - see section 6 on stoma site care

To check for signs of infection. If the

site is inflamed take a swab and send

to microbiology for MC&S.

Ensure the tube remains patent by

regular tracheal suction and cleaning

the inner tube if present - see section

5.5 on inner tube care

Maintain adequate airway

Humidification must be maintained at

all times – see section 5.2 - 5.4 on humidification of a tracheostomy

Replace lost natural function of upper

airway

Ensure patients have call bell and aids

for communication

Patients with cuffed tracheostomies

may be unable to speak

Air entry should be assessed on a

regular basis - by observing chest

movements and listening to air entry.

This is especially important for patients

with a new tracheostomy or a reduced level of consciousness.

To ensure the tube is patent and in the

correct position

Assess the need for mouth care and

deliver as necessary

Patients with tracheostomy have

altered upper airway function and may

have increased mouth care requirements.

Patients may only eat and drink if they

have been assessed as able by the

Speech and Language Therapist (SLT).

Ensures they are able to swallow safely

which will prevent aspiration


5.2 HUMIDIFICATION

After a tracheostomy the patient needs additional humidification, as that provided

by the upper respiratory tract is no longer available. Additional humidification aims

to prevent secretions becoming viscous and dry leading to consolidation and

pneumonia. In turn effective humidification will aid expectoration and suction of

secretions, and prevent crust formation. For thick tenacious secretions, heated

humidification may be required.

Humidification is essential for patients with temporary tracheostomies

Humidification can be given via:

• Cold water humidification system if receiving oxygen therapy

• Saline nebulisers, every 4 hours or prn. Liaise daily with physio and medical staff

• Heated humidification systems such as Fisher Paykell, and Flowgen

Natural humidification can be conserved by:

• A Swedish nose/thermovent over end of

tracheostomy tube. Such devices must

be assessed during 2 hourly checks and

changed when soiled, or at least every

24 hours.

To prevent clogging up the

Swedish nose and therefore

interfering with respiration.

• Tracheostomy protectors (Buchanon

Protector) may be used for patients who

are not oxygen dependent

This acts as a heat moisture

exchanger

Humidification and Speaking Valves

• Speaking valves may reduce the effectiveness of humidification.

• The valve should be removed for brief periods during the day.

• All speaking valves should be removed at night!

• When not in use valves should be kept in a dry clean container ready for

further use.

• Speaking valves should not be used when nebulisers are in situ as they

reduce efficacy


Indications for humidification

(Hough 1994)

Rationale

Bypassing of mucus membranes

Long-term use of medical gases

Tenacious secretions

Infants and children

Humidification systems are

removed or compromised and

thus need support

Problems with humidification

Rain out

Tubing may become clogged with water. Use large bore tubing

to minimise this

Tracheitis Due to lack of humidity the trachea may become irritated

Over saturation

If the periciliary layer is too deep, the tips of the cilia will not

reach the mucus layer and thus will be ineffective

Infection

This was generally a problem with old-fashioned water baths.

However to minimise risk regular replacement of disposables

as per manufacturers guidelines and infection control advice is

recommended.

High gas flow An efficient humidification system is required to cope with an

increased flow rate

Bronchoconstriction

Inhalation of cold mist or water may cause

bronchoconstriction in patients with hyper reactive airways

5.3 To set up cold water humidification

Equipment needed

• Air or oxygen supply

• Gas flow meter

• Elephant tubing

• Humidification set – e.g. aquapak / inspiron

• Tracheostomy mask

Action Rationale

Explain the procedure to the patient To gain co-operation and consent

Assemble equipment and label with

date set up

Provides information about when to

change equipment – see local policy

Turn on oxygen/air flow to

prescribed concentration. Ensure

flow to mask

Provide appropriate gas delivery

Check at least 2 hourly that there is

adequate water supply and that the

humidification is working and empty

water that may have collected in

the tubing and water traps

To ensure gas supply is maintained

and water supply replaced when

necessary

Secure tracheostomy mask over the

tracheostomy

To humidify the airway

Change the mask and tubing at

least weekly or if they become

soiled

To prevent the introduction of

infection – local policy

Document all interventions in

patient notes

For ongoing evaluation


5.4 To set up heated humidification

Equipment needed

• As above

• Replace humidification set with heated

humidification set.

Action

As per cold water humidification plus:

Rationale

Set up heater unit according to

manufacturers guidelines

Safe and comfortable system

Check at least 2 hourly that there is

adequate water supply and that the

humidification is working and is not too hot

and empty water that may have collected in

the tubing and water traps

To ensure gas supply and

temperature are maintained

and water supply replaced

when necessary

Secure tracheostomy mask over the

tracheostomy

To humidify the airway

Change the mask and tubing at least weekly

or if they become soiled

To prevent the introduction of

infection – local policy

Document all interventions in patient notes For ongoing evaluation

5.5 CLEANING TRACHEOSTOMY INNER TUBES

The inner tube should be checked every two hours and cleaned as required,

minimally once per nursing shift ie.3 times in 24 hours. Within critical care,

ventilated patients may have a longer period between inner tube checks as

recurrent disconnection from ventilation may be detrimental to overall

management of the patient. Do we comment on the longer term pateint may also

have longer periods without an inner check?

Remember! An inner tube narrows the lumen of the tracheostomy tube. The

lumen may therefore become easily blocked by secretions within the internal

diameter of the inner cannula

EQUIPMENT

I bowl / disposable kidney dish

Protective clothing

A clean inner tube

Sterile water –. The bottle should be dated, labelled and renewed

every 24 hours.

Tracheostomy cleaning swabs

Gauze squares


Action Rationale

Explain the procedure to the patient and sit

patient up to 45-70 degrees, as their condition

allows.

To gain informed consent and allow

easy access to tracheostomy.

Wash hands, put on non-sterile gloves. Reduces risk of infection

Hold tracheostomy flange with one hand; hold

inner tube with the other.

To secure the outer tracheostomy

tube

Shiley tubes – Turn the inner tube anti-

clockwise to unlock it and remove it from the

outer tracheostomy tube, placing it in a bowl

ready for cleaning at end of procedure.

Portex ultraline tubes – hold ring pull of

inner tube and pull out and down to remove.

Place inner cannula in a bowl ready for cleaning

at end of procedure.

Replace immediately with clean inner tube

(Docherty and Bench 2002).

Shiley tubes – Twist new inner tube clockwise

until it clicks into place (when 2 blue dots are in

line), continuing to stabilise the tracheostomy

flange.

Portex ultraline tubes – slide inner tube into

place until a gentle click is felt. The

tracheostomy phlange should be stabilised

throughout procedure

Reduces risk of outer tube blocking

To ensure inner tube secure and

prevent displacement

Place soiled inner tube in bowl of sterile water

(Choate and Barbetti 2003)

To loosen secretions which may be

attached to it. Tap water is an

infection risk and has been shown to

increase incidence of nosocomial

pneumonia (US Centres for Disease

Control 1997). Due to infection

control risks, do not leave inner

tubes to soak in water.

Clean soiled inner tube with tracheostomy

cleaning swabs – see ordering information

Tracheostomy cleaning swabs will not

affect the surface of the inner tube.

Due to infection control risks, do

not use brushes supplied with

tracheostomy tubes.

Shake off all excess water, dry with gauze

squares and store in a dry container with a lid

at the patient’s bedside.

A clean inner tube should always be

available to use urgently (Docherty

and Bench 2002)


Clear away equipment as per the clinical waste

disposal guidelines; remove gloves and wash

hands.

For infection control purposes.

Document care Professional responsibility and to

ensure effective multi-disciplinary

communication

Never leave a double lumen tracheostomy tube without an inner tube in

situ.

6 CHANGING TRACHEOSTOMY TIES & DRESSING and CARE OF TRACHEOSTOMY SITE: ASEPTIC PROCEDURE

This procedure should be carried out at least daily and more frequently if required with

two staff present.

Equipment Needed:

Sterile dressing pack (including gloves), trolley and yellow clinical waste bag

Protection – apron and visor

Tracheostomy dressing – for example Kapitex trachi-dress (See ordering

information)

Vaseline or Cavilon lollipop sticks as appropriate

Cleaning solution, 0.9% sodium chloride

Tracheostomy velcro tracheostomy holder

CHECK ALL EMERGENCY EQUIPMENT IS IN WORKING ORDER AND WITHIN EASY

REACH

Action Rationale

Explain and discuss procedure with patient Allows for co-operation, patient

reassurance and to gain informed

consent from patient.

Two person procedure, one of whom must be

qualified (lead) and an assisting member of

staff (who may be unqualified).

To maintain safety and limit cross

infection.

Screen area and assist patient to

comfortable position, with neck extended (if

patients condition allows)

Ensures privacy, patient comfort and

allows easy access to stoma.

Lead person – assess if suction is required.

(Refer to suction guidelines)

To clear secretions and minimise

patient coughing and potential tube

displacement during procedure.

Promote patient comfort.

Assistant – prepare the dressing trolley

items with the lead.

For ready use

Both staff wash hands and put on gloves Reduces risk of infection


(lead should wear sterile gloves) Aseptic technique

Assistant – loosen tracheostomy velcro neck

tapes and hold the tracheostomy tube

securely in place, preferably by the outer

tube.

To stabilise the tracheostomy tube

and reduce the risk of displacement.

Lead - remove soiled dressing and clean

around the tracheostomy site with normal

saline and sterile gauze, using an aseptic

technique Dry thoroughly.

Removes secretions and prevents

infection from any crusting which may

have formed. Normal saline is non-

irritant (Harkin 1998, Serra 2000,

NHS Quality Improvement Scotland

2003).

Lead - observe tracheostomy site for

Infection

Pressure damage

Bleeding

Overgranulation

Apply skin protection if excessive secretions

or if the stoma site is red/inflamed.

Early detection and prompt treatment

of complications

Barrier cream can protect skin from

tracheal secretions and encourage

wound healing as appropriate (NHS

Quality Improvement Scotland 2003)

Cardiff and Vale Trust recommend

Cavilon lollipop sticks

If the stoma is not intact or the area is

becoming excoriated, the senior nurse and

medical staff on the ward should be notified

Communication if there is a change in

site status is important as a

photograph may be necessary to

monitor progress

Apply clean tracheostomy keyhole dressing,

starting from below the tracheostomy tube.

A member of the tracheostomy team, a Head

and Neck Consultant or an experienced

nurse on a specialist unit will identify

patients who do not require a dressing.

To absorb any discharge from around

tracheostomy site and to avoid

pressure from the tube, promoting

patient comfort.

Refer to manufacturers advice for

individual dressings

Secure the tracheostomy tube in position

with a Velcro tracheostomy tube holder.

Ensure that it is possible to allowing two

fingers to pass between the tracheostomy

holder and the neck

To prevent displacement and pressure

damage to skin (Tamburri 2000, NHS

Quality Improvement Scotland 2003)

Clear away equipment as per the clinical

waste disposal guidelines, remove gloves

and wash hands

Adhering to Health and Safety and

Infection Control Policies

Document Professional responsibility and to

ensure effective multi-disciplinary

communication


7 SUCTIONING A TRACHEOSTOMY

7.1 Introduction

Suction should not be routinely carried out on a patient with a tracheostomy.

Suctioning should only be carried out following an assessment of need (Glass and

Grap 1995, Day 2000, HEYH 2001).

Clearing secretions with suction will: -

• Maintain a patent airway

• Prevent lung collapse due to small airways blocked by secretions

The frequency of suction varies widely between patients. Each must be

individually assessed. Factors which should be considered are;

• Patients ability to cough and clear own secretions

• Amount and consistency of secretions

• Oxygen saturation/arterial blood gases

• Presence of infection

As with all techniques, you should only carry out suctioning if it is within

your own scope of practice.

7.2 Equipment Needed

Catheters

• Suction catheters with porthole suction

• Size 10 FG-12 FG (French gauge), depending on the size of the

tracheostomy tube – the catheters should be < 50% diameter of

the tube

• Generally the equation tube size x 3/2 is used to select a catheter

of the correct size.

Suction Machine

Vacuum 100-150 mmHg or up to 20 KPa

Use the lowest pressure possible to remove secretions

Eye Protector and apron

Should be worn by operator at all times during the procedure

Gloves

1 Pair of non-sterile disposable gloves to be worn throughout

procedure

Over these place clean disposal glove on dominant hand - this hand

should only touch the catheter (see below)

Oxygen

To preoxygenate patient as necessary to prevent adverse effects

(Brooks et al 2000, HEYH 2001)

Yankeur – for oral and external use.

Sputum specimen trap – if required for sample

Yellow bag for waste disposal

One litre bottle of sterile water – to clean suction tubing. The bottle

should be dated, labelled and renewed every 24 hours.


7.3 Procedure

Action Rationale

Explain procedure to patient To reassure patient

Wash hands, put on gloves, apron and

visor and change inner cannula if

necessary as directed above.

To prevent cross-infection and

protect against contact with

body substances.

If patient is receiving oxygen therapy

preoxygenation may be required by

increasing oxygen to 100% for 1

minute prior to suctioning

Suctioning may frequently

lead to hypoxaemia. In order

to prevent this,

preoxygenation is

recommended prior to

suctioning. Pre oxygenation

will also reduce the likelihood

of any cardiac arrhythmias

(Adam and Osbourne 1997,

Day 2000, Brooks et al 2000,

HEHY 2001, NHNN 2003).

Check suction pressure is within

previously stated parameters and

that you have the correct size of

suction catheter

To ensure appropriate

pressure is applied for the

procedure and that the

catheter is of an appropriate

size for the patient.

Open outer package of sterile catheter

and peel back the adapter end of the

catheter package. With catheter in

package, attach adapter to suction

tubing. Do not touch the body of

catheter.

To keep the catheter as clean

as possible allowing for a clean

technique

Put clean glove on dominant hand

without touching its outer surface.

Gloves minimise the risk of

infection transfer to the

catheter.

Take package off the catheter. With

the dominant hand hold the catheter,

ensuring the glove only touches the

catheter and nothing else. Insert the

catheter gently into the tracheostomy

tube without applying suction.

Gentleness is essential:

damage to the tracheal

mucosa can lead to trauma

and respiratory infection.

Saline bolus prior to suctioning

is not recommended – it has

been shown to increase rate of

nosocomial infection (McKelvie

1998, NHNN 2003)

Insert catheter gently until resistance

is felt, withdraw catheter 1 cm, then

apply continuous suction withdrawing

the catheter smoothly at all times.

OR Insert catheter until cough is

stimulated; stop and apply continuous

suction withdrawing the catheter

smoothly at all times. There is no

need to rotate catheter.

To prevent the catheter from

adhering to the tracheal

mucosa, negative pressure

should only be applied during

withdrawal (McKelvie 1998).


If resistance is present continue

procedure and check inner tube

patency.

Check that you are using the

correct catheter size.

Resistance may indicate that

the inner cannula is blocked

with secretions and needs to

be changed and cleaned. If

problems persist after

cleaning, inform nurse in

charge and Physio during the

day, overnight contact the

Hospital at Night Team.

Suction should not exceed 10 seconds

at a time

Prolonged suction will result in

hypoxaemia and trauma

(HEHY 2001, NHNN 2003)

Replace tracheostomy mask and

return oxygen supply to prescribed

percentage. If further suctioning is

indicated pre-oxygenate as per 3.

In order to minimise the risk

of hypoxaemia (Adam and

Osbourne 1997, Day 2000)

Dispose of catheter and glove as per

Trust infection control policy

Infection control

Repeat suction process as necessary

(but no more than 3 suction passes

should be made during any one

suction episode) using a new catheter

and sterile/clean gloves each time.

Catheters are used only once

to reduce the risk of

introducing infection. The

number of suction passes may

contribute to the occurrence of

complications (NHNN 2003)

Assess the patients respiratory status

following suctioning. This should

include assessing the rate, depth and

pattern of respiration and by using a

pulse oximeter.

To reassess efficacy of suction

(Glass and Grap 1995, NHNN

2003)

After the final suction, flush through

suction tubing with sterile water.

To loosen secretions that have

adhered to the inside of the

tube.

Note colour, quantity and tenacity of

secretions. Record in patient’s

tracheostomy record.

For effective communication of

information.

Clean suction equipment should be

replaced every 24 hours or as

necessary.

Infection control

7.4 Closed Suction Technique

This technique is only suitable for ventilated patients. The inner cannula should

not be fenestrated for ventilation and therefore will not need to be changed for

suctioning purposes. It will still require a 2 hourly check as per guidelines on

tracheostomy tube care.

Indications for a closed suction system include

• PEEP dependence

• Oxygen dependence


• Immunosuppressed patients

• Patients that are a potential infection risk to staff

• Blood on suction

• High Frequency Oscillator Ventilation (HFOV)

As with all techniques, you should only carry out closed system

suctioning if it is within your own scope of practice.

Action Rationale

Explain procedure to patient To reassure patient

Wash hands, put on gloves and

apron and change

To prevent cross-infection and

protect against contact with

body substances (Glass and

Grap 1995, Wood 1998)

If patient is receiving oxygen

therapy ensure preoxygenation by

increasing % of oxygen to 100%

for 1 minute prior to suctioning

Suctioning may frequently lead

to hypoxaemia. In order to

prevent this, preoxygenation is

recommended prior to

suctioning (Adam and

Osbourne 1997, Day 2000)

Check suction pressure is within

previously stated parameters and

that you have the correct size of

catheter attached to endotracheal

tube

To ensure appropriate pressure

is applied for the procedure

and that the catheter is of an

appropriate size for the patient.

Insert catheter gently until

resistance is felt, withdraw

catheter 2 cm, then apply

continuous suction withdrawing

the catheter smoothly at all times.

OR Insert catheter until cough is

stimulated; stop and apply

continuous suction withdrawing

the catheter smoothly at all times

There is no need to rotate

catheter

To prevent the catheter from

adhering to the tracheal

mucosa, negative pressure

should only be applied during

withdrawal (McKelvie 1998,

NHNN 2003)

If resistance is present continue

procedure and check inner tube

patency.

Check that you are using the

correct catheter size.

Resistance may indicate that

the inner cannula is blocked

with secretions and needs to be

changed and cleaned. If

problems persist after cleaning,

inform nurse in charge and

liaise with medical colleagues

Suction should not exceed 10

seconds at a time

Prolonged suction will result in

hypoxaemia and trauma (HEHY

2001, NHNN 2003)


Return oxygen supply to

prescribed percentage. If further

suctioning is indicated

preoxygenate as per 3.

In order to minimise the risk of

hypoxaemia (Adam and

Osbourne 1997, Day 2000

Brooks et al 2000, HEHY 2001)

Repeat suction process as

necessary (but no more than 3

suction passes should be made

during any one suction episode)

using a new catheter and

sterile/clean gloves each time.

Catheters are used only once

to reduce the risk of

introducing infection. The

number of suction passes may

contribute to the occurrence of

complications (NHNN 2003)

Assess the patients respiratory

status following suctioning. This

should include using a pulse

oximeter.

To reassess efficacy of suction

(Glass and Grap 1995, NHNN

2003)

Note colour, quantity and tenacity

of secretions. Record in patient’s

tracheostomy record.

For effective communication of

information.

Clean suction equipment should be

replaced every 24 hours or as

necessary.

Infection control

8 WEANING AND DECANNULATION FROM A TRACHEOSTOMY

It is important that each individual case is carefully discussed and a clear plan

made prior to the weaning process commencing. This must be continuously

evaluated. These guidelines are intended to assist in the decision making and

timing of each stage of the weaning process. There is evidence from the

literature, which highlights that although tracheostomy weaning needs to be

individualised, a standard procedure is essential to decrease anxiety and facilitate

success (Doerkson, 1994, Heffner, 1995, Ladyshewsky and Gousseau, 1996).

8.1 Preparation for Weaning

The decision to wean a patient should be taken by the multidisciplinary team. The

patient must be involved in this discussion if possible (Ladyshewsky and Gousseau

1996, Harkin and Russell 2001, Choate and Barbetti 2003). The process usually

consists of the following stages.

� Tracheostomy

� Cuff deflation

� Fenestrated tube

� Swallow assessment

� Speaking valve

� Downsizing of tube

� Capping off

� Decannulation


Patients may not be appropriate to proceed to full decannulation and the process

may take a number of weeks or longer and vary at different stages. It should also

be noted that this is not a linear process and that patients may go backwards as

well as forwards. In some instances some steps in the process may be omitted.

Any decisions should always be dictated by patient needs.

8.2 Pre-Weaning Criteria

(Godwin and Heffner 1991, Doerksen et al 1994, Heffner 1995, Dikeman and

Kazandjian 1995, Ladyshewsky and Gousseau 1996, Choate and Barbetti 2003)

� Original indication for tracheostomy is resolving

� Spontaneously breathing with a regular respiratory

pattern and rate less than 30 breaths per minute

� On oxygen dependency less than 35% with adequate

saturations

� Strong cough – able to clear to the top of the

tracheostomy tube

� Clear chest

� Adequate nutrition

� Patient needs to be seen to be coping with their own

saliva and where appropriate assessed by a Speech and

Language Therapist or a competent Healthcare

Practitioner.

� Multidisciplinary team in agreement

8.3 Contraindications to weaning

� Tumour

� Upper airway oedema

� Absent or inadequate cough or gag reflex

� Persistent dysphagia and compromised airway

protection

� Reduced ability to clear secretions

8.3.1 Considerations for Cuff Deflation

To maximise success, cuff deflation should be considered only if the pre-weaning

criteria are met.

8.4 Cuff Deflation Assessment

(Dikeman and Kazandjian 1995, Royal Free 2002, National Hospital 2003)

Action Rationale

Explain procedure to the

patient

To gain patient consent and

minimise anxiety

Sit patient upright To optimise lung expansion

Assess patients’ respiratory

status i.e. rate, depth and

pattern

Ensures that the patient remains

stable

Suction on deflation of cuff or To clear any loose secretions that


encourage active cough

may have pooled above the cuff

and may be colonised by bacteria

(Dikeman and Kazandjian 1995)

Deflate cuff slowly and note

reaction to cuff deflation

Allows the patient to adjust to

changes in airflow (Dikeman and

Kazandjian 1995)

Monitor

Respiratory rate and effort

Any spontaneous swallow

attempts

Additional wheezes/stridor

Any voicing

Monitor oxygen saturation

Observe for signs of fatigue

Ability to deal with oral

secretions

To assess patients ability to

tolerate cuff deflation and detect

any difficulties

8.4.1 Indications that a patient is coping safely with cuff deflation are:

• If spontaneous swallows are noted

• If manages to swallow oral secretions

• If maintains O2 saturations

• If able to cough at least into tracheostomy tube

• If respiratory/cardiovascular systems are stable

8.4.2 Do not continue with cuff deflation if any of the following occur:

• Constant oral drooling

• No swallows observed

• Respiratory or cardiovascular distress

• Fatigues quickly

• Fails to protect airway e.g. audible pooled “wet” pharyngeal secretions

• Desaturation

• REINFLATE the cuff and reassess when appropriate

The multidisciplinary team should agree and determine the length of time the patient is

able to tolerate cuff deflation. This may vary from a few minutes to permanent cuff

deflation and depends on the individual patients’ abilities. Careful respiratory monitoring

during the process of weaning and decannulation is essential. Many patients will require

the cuff deflated in incremental periods (Dikeman and Kazandjian 1995, SLT 2003)

8.5 Cuffless Tubes

If a patient tolerates cuff deflation well but is likely to require a tracheostomy for a

further period a cuffless tube should be considered at the earliest opportunity. Even a

deflated cuff in the airway has been shown to increase work of breathing (Hussey and

Bishop 1996).

8.6 Cuff Management

The tracheostomy cuff provides a seal to enable positive pressure ventilation and also

provides some protection against aspiration of secretions. Cuff pressure should be

monitored at least once a shift using a cuff manometer with pressure between 16-

24mmHg. Constant unchecked high pressure in a cuff may lead to mucosal necrosis,

stenosis or fistula formation between the trachea and oesophagus (Tamburri 2000,

Choate and Barbetti 2003, SLT 2003).

• Cuff pressure should not exceed 25 cm H2O.

• If an air leak occurs with the cuff pressure at the maximum recommended,

the tracheostomy may have become displaced or may require changing:

medical or other professionals who are competent in tracheostomy

management should review the patient.


Finger tip pressure on the external pilot balloon is not an accurate method of measuring

cuff pressure!

The cuff should be deflated to remove the tube, to allow the patient to eat or drink and

when a speaking valve or decannulation cap is secured to the tube.

• Failure to deflate the cuff when the speaking valve or decannulation cap is

secured to the tube will result in a total occlusion of the patient’s airway and

potentially catastrophic results.

8.7 Fenestrated Tubes

Tracheostomy tubes can also be fenestrated: i.e. a window in the outer tube, which is

patent if an inner fenestrated tube is also sited. This allows for use of the native airway.

With a fenestrated inner tube in situ using digital occlusion or a speaking valve, a voice

may be elicited – see assessment of phonation using a speaking valve.

There is little literature as to when they should be used and generally this is left to

clinical judgement. Fenestrated tubes are often used when there is an extended weaning

period. They have been shown to reduce the work of breathing (Hussey and Bishop

1996).

Fenestrated tubes always come with a non-fenestrated inner cannula that can be inserted

for suctioning or respiratory support. Suction should never be performed with a

fenestrated inner tube in situ – this will cause damage to the trachea (Harkin 1998, Royal

Free 2002, National Hospital 2003)

9 Speaking valve Patients who are able to take oral nutrition should be assessed as safe to do so by a

Speech and Language Therapist or a competent Healthcare Practitioner (Dikeman and

Kazandjian 1995, Pannunzio 1996, Higgins and MacLean 1997, Schonhofer et al 1999,

Thompson-Ward et al 1999, Tamburri 2000, Choate and Barbetti 2003, SLT 2003). This

is particularly important as tracheostomised patients have a high incidence of aspiration

(Dikeman and Kazandjian 1995, Pannunzio 1996, Higgins and MacLean 1997, Schonhofer

et a, 1999, Elpern et al 2000, Chew et al 2002, SLT 2003). (See Swallow Assessment

Procedure)

9.1 Assessment of Phonation and Use of a Speaking Valve

The speaking valve can be used as an aid to communication. It may also improve the

biomechanics of swallow (Elpern, 2000, Suiter, 2000).

See also Communication Issues

THE CUFF MUST BE FULLY DEFLATED IN

ORDER TO USE A SPEAKING VALVE!

(OTHERWISE THE PATIENT WILL BE

UNABLE TO EXHALE)

9.2 Contraindications to the use of a speaking valve

(ref Dikeman and Kazandjian 1995, St Georges 2000)

� Severe tracheal/laryngeal stenosis

� Airway obstruction

� Inability to tolerate cuff deflation

� End stage pulmonary disease

� Unstable medical/pulmonary status

� Anarthria

� Laryngectomy

� Severe anxiety or severe cognitive dysfunction


9.3 Use of Speaking Valve - Procedure

(Dikeman and Kazandjian 1995, St Georges 2000, SLT 2003, Swansea

2003)

Action Rationale

Explain procedure to the

patient

Gain consent and reduce anxiety

Ensure cuff is fully deflated To ensure that the patient is able to

exhale

If the outer tube is fenestrated,

insert the fenestrated inner

tube

This allows passage of air through

the native airway.

On expiration, lightly occlude

the tracheostomy with your

finger and ask the patient to

breathe on to your

forearm/hand to assess for

expiration from mouth

This is a simple assessment of

whether the patient will tolerate

tube occlusion

Ask the patient to say “aah”

and listen to the quality and

ease of voice production

To assess the patients ability to

vocalise

Be aware that a valve is not

suitable for someone who has

no or very minimal tongue

function

These patients should be discussed

with and assessed by the speech

and language therapist

If voice is clear and effortless,

try with a speaking valve

This ensures optimal chance of

success

If this is tolerated set an

individualised speaking valve

regime. The time the speaking

valve is applied should be

clearly documented and a time

for removal stated on the

tracheostomy observation

chart.

Patient regime should be reviewed

daily and adapted as status dictates

[Patient will tire with a speaking

valve insitu so should wear it for a

short time initially and gradually

increase use over time]

If the patient’s voice is gurgly

ask the patient to cough and

clear secretions

To ensure that the patient is able to

clear the airway independently

The patient should be

monitored closely as the patient

may fatigue quickly. They

should have a call bell within

easy reach

To ensure maximum observation of

the patient. The patient is able to

summon help immediately if

distressed

The speaking valve should not

be worn at night

Due to increased resistance

produced the patient may struggle if

secretions build up behind the valve

If voice is consistently hoarse ENT specialist will be able to assess


or weak, a referral to ENT may

be indicated

the larynx directly

9.3.1 Indications that a patient is coping safely with use of the speaking

valve

� If respiratory/cardiovascular systems are stable

� If voice is clear

� If maintains O2 saturations

� If patient is comfortable

Do not continue with the procedure if any of the following occur

� Constant oral drooling

� Increased work of breathing

� Desaturation

� Respiratory or cardiovascular distress

� Fatigues quickly

� Change of facial colour

� Stridor

� Voice is gurgly and wet and unable to be cleared

REMOVE the speaking valve and reassess when appropriate

9.4 Use of a speaking valve with a ventilated Patient

(Bell 1996, Kaut et al 1996)

In this situation only the turquoise Passy Muir valve can be used within a ventilator

circuit.

Only staff competent in its use (or supervised by staff experienced in its use)

should attempt to fit a speaking valve into a ventilator circuit.

Action Rationale

Explain procedure to the patient Gain consent and reduce anxiety

Ensure cuff is fully deflated To ensure that the patient is

able to exhale

If the outer tube is fenestrated,

insert the fenestrated inner tube

This allows passage of air

through the native airway

Adjust the alarm settings on the

ventilator

To allow the speaking valve to

be inserted without continually

setting off alarms

Try the Passy Muir valve in the

ventilator circuit

Fit according to Passy Muir

recommendations

Ask the patient to say “aah” and

listen to the quality and ease of

voice production

To assess the patients ability to

vocalise

If the patient’s voice is gurgly

ask the patient to cough and

clear secretions

To ensure that the patient is

able to clear the airway

independently

The patient should be monitored To ensure maximum observation


closely as the patient may

fatigue quickly. They should not

be left unsupervised

of the patient. The patient is

able to summon help

immediately if distressed

A short trial period is

recommended with time using

the Passy Muir valve increased

according to the patients ability

to tolerate it in the ventilation

circuit

Build up tolerance slowly. This

may be difficult if the

tracheostomy tube is relatively

large and downsizing of the tube

may be required before

speaking valve use is tolerated

9.5 Downsizing of Tubes

It may be necessary to downsize the tracheostomy tube in order to tolerate a

speaking valve and continue the weaning process. In some patients a large

tracheostomy tube will not allow enough airflow around the tube to elicit

phonation (Dikeman and Kazandjian 1995). Larger tubes have also been shown to

increase work of breathing (Hussey and Bishop 1996).

9.6 Capping off Tracheostomy Tube

THE CUFF MUST BE FULLY DEFLATED WHEN

CAPPING OFF (OTHERWISE THE PATIENT

WILL BE UNABLE TO BREATHE)

9.6.1 Procedure for Capping Off

Action Rationale

Discuss aims and explain

procedure to the patient

Gain consent and reduce anxiety

Ensure cuff is fully deflated To ensure that the patient is able

to exhale

The patient must be able to

swallow his or her own secretions

safely

To ensure that the patient is able

to protect their airway

Place cap over end of

tracheostomy tube

To stop air entering the

tracheostomy and thus making

the patient breathe via upper

airway

Apply facial oxygen if required via

a face mask and encourage the

patient to take deep breaths

Provide supplementary oxygen

and to help them begin to feel the

change in breathing

Ensure that the patient is able to

obtain adequate breath via upper

airway

Tracheostomy tube may be too

large to allow the patient to

breathe around it. (Remove cap

and discuss need for smaller tube

with tracheostomy team)

Stay with the patient until they

are settled and feel comfortable

The patient may become anxious

or is genuinely unable to breathe

requiring immediate assistance

Agree with the multi-disciplinary

team or the tracheostomy team

the period for capping off

This should be an individualised

regime that is reviewed daily

Do not continue with the procedure if any of the following occur:


� Increased work of breathing

� Oxygen desaturation

� Respiratory or cardiovascular distress

� Fatigues quickly

� Change of facial colour

� Stridor

9.6.1 Indications that the patient is coping safely with use of the cap are:

� If respiratory/cardiovascular systems are stable

� If voice remains clear

� If maintains O2 saturations

� If patient is comfortable

Within current literature, time for capping off varies from 6 – 48 hours. There is

the greatest consensus that a patient should be able to tolerate at least 24 hours

capped off prior to decannulation. However, this should be based on individual

assessment (Heffner 1995, Ladyshewsky and Gousseau 1996, Harkin 1998).

10 Decannulation

The decision to decannulate should be agreed by the multidisciplinary team. The

capping off period having been individually determined based on patient status.

The patient should be aware of the procedure and be able to get help immediately

if distressed (St Georges 2000). The planned decannulation of a tracheostomy

tube should be carried out during normal weekday working hours (St Georges

2000, Royal Alexandra 2003). During these times, there is greater staff

availability should a patient develop problems.


10.1 Procedure for Decannulation

Action Rationale

Discuss aims and explain

procedure to the patient

To gain consent and avoid undue

anxiety

Check that all emergency

equipment is at the bedside

To ensure appropriate equipment

is available if the patient has

difficulties post decannulation

(Choate and Barbetti 2003)

Ensure that the patient is sitting

in an upright position

To optimise lung expansion

Universal precautions should be

adhered to

To reduce the risk of infection

Ensure the cuff is deflated;

remove the tracheostomy tapes

and dressing. Remove the

tracheostomy tube in a gentle

outward and downward

movement

The tracheostomy tube will follow

the anatomical formation of the

tract. Rapid jerking or pulling the

tube upwards will cause trauma to

the trachea and acute discomfort

to the patient (St Georges 2000)

Following decannulation the

stoma should be cleaned; dried;

dressed and covered with an

occlusive dressing (Harkin 1998,

Serra 2000, Harkin and Russell

2001, Choate and Barbetti 2003).

This will absorb any bronchial

secretions whilst occluding the

stoma opening to aid healing and

communication. Although most

UK papers recommend an

occlusive dressing, there is no

consensus on which type is most

appropriate

Assess the dressing at least once

a shift and change as indicated.

Dressings should be changed at

least daily. Observe stoma for

signs of infection on dressing

changes

This is to reduce the risk of pooled

secretions that may delay wound

healing and cause maceration

increasing risk of infection

The patient should be encouraged

to apply overpressure on the

stoma dressing on speech and

coughing

It is suggested that this will

minimise any leak from the stoma

site, produce a more effective

cough and encourage stoma

closure (ORL 1994, St James

2000, Harkin and Russell 2001,

Choate and Barbetti 2003).


10.2 Following decannulation, the following signs may indicate that an

immediate anaesthetic or ENT opinion is required:

Problems Actions in all circumstances

� Stridor

� Persistently decreased

oxygenation

� Increased respiratory rate

� Increased heart rate

� Sweatiness

� Agitation

� Cyanosis

� Loss of consciousness

• Position patient in a

sitting/high side lying

• Check tracheostomy dressing

for leakage

• Encourage deep breathing

• Clear secretions via active

cough / suction if necessary

• Give oxygen via face mask

• Ready emergency trolley

• Monitor oxygen saturations via

pulse oximeter continuously

If you have any queries with regard to the weaning process or any difficulties with

tracheostomy care please contact the relevant multidisciplinary team member. If

urgent assistance is needed contact a member of the tracheostomy team, the

head and neck ward or critical care unit.

There should be clear guidance to staff to observe for complications, clear criteria for

review and point of contact to obtain urgent review by tracheostomy team, anaesthetic,

intensive care or surgical staff.

A tracheostomy should be removed as soon as it is no longer required.

Care of patients with tracheostomies will be multidisciplinary, but it must be clear who is

responsible, particularly when patients are not under the direct care of the critical care

team. Every Trust should have an explicit policy on this.

It must be clear which person or team is responsible for management of the

tracheostomy, especially if it is not the specialty with primary responsibility for

the patient’s care.

11 CHANGING A TRACHEOSTOMY TUBE

Changing a tracheostomy tube is potentially hazardous, but so is failure to do so.

Unfortunately, recommendations for the frequency of changing tracheostomy tubes are

inconsistent and unsupported by evidence. Basic principles guiding replacement of a

tracheostomy tube are listed in the box below.


Tracheostomy tubes should only be changed by staff who are competent to do

so. Most will be doctors, but there are specialist non-medical practitioners who

have the necessary skills.

Doctors who have not had relevant training will not have competency in this

area, and should not undertake the procedure unsupervised.

11.1 The first tube change

Changes within the first 72 hours should be avoided unless absolutely essential and

should only be performed in an environment in which trans-laryngeal intubation can

immediately be established.

Although the risk of stomal closure lessens somewhat thereafter, the first change

remains hazardous, particularly following a percutaneous procedure, and exchange over

a bougie or an airway exchange catheter that allows the continued insufflation of oxygen

such as the Frova catheter or Cook TM airway exchange catheter should be considered.

Whilst problems can occur in any patient, they are particularly likely in the obese, those

with a deep trachea, other anatomical difficulties.

11.2 Second and subsequent changes

A standard procedure for subsequent changes of a tracheostomy tube is described in

Basic principles for changing a tracheostomy tube

• Tracheostomy tubes without an inner cannula should be changed every 7-

14 days, the frequency then decreasing once the patient is free of

pulmonary secretions and has a well formed clean stoma

• A European Economic Community Directive (1993) states that

tracheostomy tubes with an inner cannula can remain in place for a

maximum of thirty days.

• The first tracheostomy tube change:

o Should not be performed within 72 hours following a surgical

tracheostomy and not before 3 – 5 (and ideally 7 – 10) days

after a percutaneous tracheostomy to allow the stoma to

become established.

o The decision to change the tube must be made in conjunction

with a medical practitioner competent in the care of

tracheostomies.

o Must be carried out by either:

� a medical practitioner with appropriate, advanced airway

skills, or

� Another suitably skilled practitioner.

• Subsequent changes can be made by experienced personnel trained in

tracheostomy tube changes (e.g. specialist tracheostomy nurse)

• In practice, the frequency with which the tube needs to be changed will be

affected by the individual patient’s condition and the type of tube used.

Elective changes are inherently safer than those done in a crisis.


appendix 4. It is reasonable to expect that two skilled practitioners should be present

when changing the tube, particularly when a previous change has been difficult.

Resuscitation equipment must be readily available, as should a smaller tube.

If a patient has a smooth long term stoma and has regular tracheostomy changes, it is

reasonable to introduce the new tube using the tracheostomy introducer rather than an

airway exchange device.

The practitioner must however be aware of the risk of paratracheal tube placement with

any blind technique and be able to recognise the clinical features of failure to re-

cannulate the trachea.

It is essential that if the new tube cannot be inserted or is misplaced, there is

an agreed procedure for handling the situation.

Following tracheostomy tube change patients should be monitored for difficulties

11.3 Signs that a patient may have difficulties

Respiratory or cardiovascular distress

Cyanosis

Desaturation

Increased work of breathing

Stridor

Change of facial colour

Sweatiness

Agitation

Loss of consciousness

IF REINSERTION OF THE TRACHEOSTOMY TUBE FAILS, CALL THE ARREST TEAM

AND BE FAMILIAR WITH THE EMERGENCY ALGORITHMS

12 SWALLOWING

The presence of a tracheostomy tube can adversely affect swallowing in patients who

previously had no swallowing difficulties.

Swallowing assessment should only be undertaken by an appropriately trained

professional (Dikeman and Kazandjian 1995, Pannunzio 1996, Higgins and MacLean

1997, Schonhofer et al 1999, Thompson-Ward et al 1999, Tamburri 2000, Choate and

Barbetti 2003, SLT 2003). The speech and language therapist is most commonly and

appropriately the team member who carries out dysphagia (swallowing) assessment and

intervention. As in other aspects of care a team approach is optimal and assessment and

management decisions should be shared.

12.1 Indications for a swallowing assessment - (St Georges Hospital 2000).

1. Patients with neurological involvement e.g. CVA, Head Injury, post neurosurgery,

Guillian Barre, progressive neurology and A.I.D.S.

2. Patients post oral or head and neck surgery/radiotherapy, oesophageal or pharyngeal stricture, voice problems and acute/chronic chest difficulties.

3. Patients with evidence of aspiration of food/ fluid/ oral secretions on tracheal suctioning.

4. Patients who present with persistent wet or weak voice when cuff is deflated and speaking valve or decannulation cap in place.

12.2 Procedure for oral intake in Tracheostomised Patients.

Action Rationale


The patient should meet pre-weaning

criteria and tolerate cuff deflation.

To optimise success in weaning

(Dikeman and Kazandjian 1995,

Ladyshewsky and Goussau 1996,

Choate and Barbetti 2003)

Discuss aims with patient and explain

procedure to patient

To gain consent and minimise

anxiety

Sit the patient upright in the bed or a

chair with the chin flexed slightly towards

the chest.

This position may improve reduced

laryngeal closure and delays in the

swallowing reflex. (Logemann

1993)

Suction via the tracheostomy tube and

oropharynx after cuff deflation.

Secretions may pool above the inflated

cuff. When cuff is deflated these

secretions may enter the lungs

(Dykeman and Kazandjian 1995).

Deflate the cuff fully for ALL ORAL

INTAKE, if it is agreed that the patient

can tolerate this. However, in special

circumstances e.g. quality of life issues, a

team decision for small amounts of oral

intake, with partial cuff deflation may be

indicated.

Tracheostomy tube cuffs only reduce the

risk of aspiration not prevent it

(Dikeman and Kazandjian 1995).

An inflated cuff may contribute to silent

aspiration and reduce effectiveness of a

cough (Tippett and Siebens 1991).

It can contribute to swallowing problems

and loss of protective reflexes.

(Logemann 1983, Bonanno 1971, Nash

1981 cited in Higgins and Maclean 1997).

A deflated cuff it better for oral

communication and swallowing as it

allows laryngeal and upper airway

resistance (Tippett and Siebens 1991).

Oral intake should be deferred until at

least partial cuff deflation is achieved

(Dikeman and Kazandjian 1995).

If the team will not permit cuff deflation

it is up to the individual SLT to explain

the risks of a swallowing assessment in

the presence of an inflated cuff and a

team discussion on the management of

the individual case should follow.

If the patient is aspirating, it is vital to

know immediately so that suctioning can

be carried out and management planned.

With an inflated cuff such information is

delayed (Groher 1992).

If neurogenic dysphagia is suspected or

patient has undergone head and neck

surgery, a full bedside evaluation of

swallowing should be undertaken by a

proficient SLT.

For full swallowing assessment, see

South Wales Speech and Language

Therapy Tracheostomy Working Group

document March 2002.

Eye protection should be worn by staff

working with these patients and universal

precautions adhered to.

Infection control

Regular suctioning should be available

throughout the swallowing assessment

by nursing or physiotherapy staff. They

must therefore remain in attendance at

all times. Ensure unfenestrated inner

cannula is replaced prior to suctioning.

To ensure a clear airway. The SLT in

Cardiff and Vale NHS Trust does not

undertake this procedure


If the patient has a fenestrated

tracheostomy tube, ensure the inner

cannula is replaced by a fenestrated

inner cannula if available. Finger

occlusion or speaking valves can be used

at this stage if tolerated.

This allows laryngeal examination e.g.

voice quality and cough and helps

normalise the pressures thus improving

the swallow function (Gross et al 1992).

Occlusion of the tracheostomy tube may

reduce or eliminate aspiration. (Muz et al

1989, Dettelbach et al 1995, Ebling and

Gross 1996, Stachler et al 1996 all cited

in Leder 2001)

However Logemann (1998) argues that

an individual assessment is necessary. A

Passy-Muir speaking valve may help to

reduce, though not eliminate aspiration

(Elpern 2000).

Encourage the patient to clear the throat

and expectorate secretions.

Intermittently check the voice quality and

cough by occluding the tracheostomy

tube (with a gloved finger) or by using a

speaking valve and ask the patients to

say 'ah' or count aloud. If voice quality

deteriorates and sounds wet, encourage

the patient to clear any secretions by

coughing and re-swallowing.

The competent practitioner/SLT will

progress the patient to trial swallows if

indicated.

A gurgly/wet voice may indicate

laryngeal penetration. A weak cough may

increase the risk of aspiration (Dikeman

and Kazandjian1995).

The Modified Evans Blue Dye Test

(MBDT) should be carried out by the SLT

or other competent practitioner.

For competencies regarding MEBDT see

Tippett 2000 p168-171.

This test should be used by professionals

trained in the assessment of dysphagia

(Tippett and Siebens 1991, Gilardeau et

al 1995, Thompson-Ward et al 1999,

Choate and Barbetti 2003).THIS TEST

SHOULD BE INTERPRETED

CONSERVATIVELY and monitored very

carefully (Meyers 1995, Perusi 2001)

The test is initially carried out with sterile

water and the blue dye. If a different

consistency is needed to be trialled, the

blue dye can be mixed with pudding or

thickened fluids.

The appropriate consistency is dependent

on the underlying impairment/aspiration

risk

Nursing and physiotherapy staff are

asked to monitor the tracheostomy

secretions using a tracking chart.

Blue dye on suctioning indicates

aspiration. This needs to be monitored as

secretions can be discoloured for up to

72 hours (Dikeman and Kazandjian

1995). See Blue dye tracking sheet

(Appendix 2)

The SLT's recommendations such as

patient positioning, swallowing

manoeuvres and modified textured diets

will be clearly documented in the medical

notes and discussed with the relevant

staff.

The Dietitian will also be notified.

Professional responsibility to ensure

effective multidisciplinary communication


13 COMMUNICATION

The ability to communicate is affected by the presence of a tracheostomy tube. The

patient will be unable to talk and produce voice in the normal way since no air will pass

through the vocal cords unless the patient is able to benefit from a fenestrated tube, a

speaking valve or in some cases leakage of air around the tube. [N.B. This will not be the

case where the patient has undergone a laryngectomy.] All other systems required to

enable the patient to communicate will be intact unless there is a co-existing neurological

impairment with possible muscular weakness, impaired sensory function, language and

cognitive deficits. The patient’s general medical condition may result in fatigue, reduced

alertness, behavioural influences, reduced motivation all of which may impede

communication.

13.1 Process for establishing good communication with the patient

Action

Rationale

If possible ascertain whether the patient

had communication or literacy difficulties

pre-tracheostomy.

To obtain a baseline of the patients ability.

Explain to the patient /relative why they

are having communication problems [when

appropriate the patient/family should be

warned pre-tracheostomy placement

regarding the effect on communication.]

To provide reassurance.

Check if the patient can see, hear,

understand, use facial expression such as

smile/ blink, write.

To review available options

When appropriate provide the patient with

a means of attracting attention e.g.

buzzer/call button.

To facilitate basic communication.

Establish a method for the patient to

indicate YES /NO. Ensure everyone who

comes in contact with the patient

is aware of what method is being used.

Enables the patient to respond to simple

questions.

If a coded eye blink is the only means

available instruct the patient to blink once

for yes and twice for no in response to a

question.

Ensures the same system is always used.

If the patient can mouth then to aid lip

reading ask the patient to exaggerate their

lip movement and to speak in short but

complete sentences.

To facilitate oral communication.

If a patient is able to have an uncuffed or

deflated cuff tube then trial of a speaking

valve may be appropriate. [Please refer to

the section on speaking valves.]

To facilitate oral communication.

Where more specific communication

problems exist please refer to the Speech &

Language Therapy department who will

To reduce frustration and enable the

patient to express his/her needs more fully.

South Wales Speech and Language


assess and provide other options for

alternative communication e.g. picture/

word boards, electronic communication

aids etc.

Therapy Tracheostomy Working Group

2002

14 Emergencies, Common Complications and their Management

The main life threatening complications associated with a tracheostomy are blockage,

dislodgement and bleeding.

14.1 Blockage and displacement

A blocked or displaced tracheostomy tube generally presents with respiratory difficulty.

The nature of the problem will often be obvious, but if not, it is important to adopt a

systematic approach and be aware that acutely ill patients may have other cardio-

respiratory reasons for difficulty in breathing.

Every hospital must have a procedure for managing patients whose

tracheostomy is blocked or displaced. Staff must be aware of this and receive

appropriate training to manage the problem.

Tracheostomy tubes may become dislodged or displaced for a number of reasons. This

can be a stressful event for both patients and staff, and prevention is better than cure. It

is important to ensure that the tracheostomy tube holder is adjusted regularly so that the

tube is fixed in a secure, comfortable position all times. Tracheostomy tubes may become

dislodged when a ventilated patient is turned, or moved from their bed to a trolley.

Restless or agitated patients may pull at their tracheostomy tubes, or ventilator tubing

attached to the tracheostomy.

A partly dislodged tracheostomy tube is just as dangerous, if not more dangerous, as a

completely removed tracheostomy tube.

Airway: is the airway (at least partially) patent?

• If the tube is displaced, the patient may be breathing through their nose or mouth.

The patient may be safe in the short term, requiring urgent but not emergency

action. Only experienced staff should try to replace the tube under such

circumstances. If in doubt it will usually be safer to remove a partly dislodged tube,

although a suction catheter or airway exchange catheter may be first advanced

through it to allow oxygen administration. The airway should be maintained by other

methods until experienced help arrives.

• If tube is partially occluded, the patient may still be able to breathe through it, but

with difficulty. If the tube has an inner cannula, this should be removed and changed.

If the tube does not have an inner cannula, but a suction catheter can be passed

down the tracheostomy tube, then it must be at least partially patent. It may be

possible to change the tube over a catheter or other airway exchange device.

Staff treating patients with a tracheostomy in an emergency situation need to

be aware that ‘bag and mask’ ventilation via the mouth is not possible with a

cuffed tracheostomy tube in situ.

Individual hospitals are advised to develop their own specific guidelines with bleep

numbers, taking account of available staff and recognising this may happen day or night.

Chest X rays do not give useful information about the position of the tube in this

situation. Fibreoptic bronchoscopy may be useful if it is immediately available, but this

should not delay treatment.


Displaced tracheostomy tube

This guidance is appropriate for patients capable of spontaneous respiration. In

a patient who is fully ventilated, critically ventilator dependent or paralysed,

prompt replacement or removal and replacement by a tracheal tube will be

required. Such a situation is only likely to arise in a level 3 area, but can also

occur in a cardio-respiratory arrest elsewhere. Remember tube displacement as

a possible cause of cardio-respiratory arrest.

DON’T PANIC!

1. Call for help – senior medical and nursing staff, other AHPs with

tracheostomy care skills (e.g. physiotherapist). If in doubt, call for

anaesthetic assistance

2. Reassure patient. 3. Assess patency of airway (A) and patient’s breathing (B). Is air passing

through the tracheostomy tube or stoma? Is the patient breathing via mouth

or nose? Check oxygen saturation with a pulse oximeter.

4. If airway is not patent, it must be cleared immediately.

• ONLY SENIOR STAFF WITH APPROPRIATE EXPERIENCE OF

TRACHEOSTOMY MANAGEMENT SHOULD ATTEMPT TO RE-INSERT

DISLODGED OR DISPLACED TRACHEOSTOMY.

• ANY SUCH ATTEMPT SHOULD BE QUICKLY ABANDONED IF

UNSUCCESSFUL.

• MULTIPLE ATTEMPTS SHOULD NOT BE MADE.

• IF IN ANY DOUBT, REMOVE TRACHEOSTOMY TUBE AND ALLOW

BREATHING THROUGH THE STOMA OR THE MOUTH/NOSE.

• APPLY OXYGEN MASK OVER ONE OR BOTH SITES OF AIR ENTRY.

Appropriately experienced staff may attempt to re-insert a tracheostomy tube in

a patient with a well-formed track from skin to the tracheal stoma. Typically, this

would be more than 72 hours following surgical tracheostomy or more than 7

days after percutaneous tracheostomy. It is advisable to attempt any such re-

insertion using a gum elastic bougie or, if time permits, a fibre-optic

bronchoscope.

5. Re-establish the airway in the usual fashion – tilt the head back to extend the head on the neck, perform a jaw thrust. If necessary insert an oral airway

(Guedel). Note that if ‘bag and mask’ ventilation is attempted, air will escape

through the stoma. In this situation, get a colleague to occlude the stoma by

applying pressure over it with gauze swabs or a pad.

6. Tracheal intubation may be needed – this should only be performed by a

doctor competent in tracheal intubation. This is not the time to “have a go”.

It may be necessary to push the tracheal tube distal to the stoma. (Use an

‘uncut’ tube.)

7. If the patient is breathing adequately at this point, there may be no need to

artificially assist ventilation. Check the oxygen saturation with a pulse

oximeter and administer oxygen as equired via a facemask or resuscitation

bag with an oxygen reservoir.

8. If artificial ventilation is needed, use a resuscitation bag and mask in the

standard fashion. aintain occlusion of the stoma as above to prevent an air

leak. If the patient has been intubated, the person controlling the airway

(usually an anaesthetist or intensivist) will ventilate with the resuscitation

bag. Measurement of oxygen saturation with a pulse oximeter will confirm

adequacy of oxygenation.


14.2 BLOCKED TRACHEOSTOMY TUBE

A tracheostomy tube may become blocked with thick tracheal secretions, blood or foreign

bodies. The patient may present with increasing respiratory distress over a few hours, or

with a much more rapid deterioration. In either case, a blocked tracheostomy tube is an

emergency situation in which the patient’s life is at risk if it is not rapidly resolved.

Prevention is better than cure:

• Patients with tracheostomies must always receive adequate humidification of their

inspired gas to lessen the risk of tube blockage.

• The risk of tube blockage is reduced by the use of a tracheostomy tube with an inner

cannula. Such tubes should have their inner cannula cleaned regularly to prevent the

buildup of secretions. The precise frequency will depend on individual risk assessment.

• Certain specialist tracheostomy tubes (e.g. adjustable length or custom-made long

tubes) may not have an inner cannula. Extra vigilance is needed in these patients to

minimise the risk of tube blockage.

If a blocked tracheostomy tube is suspected, rapid diagnosis will enable prompt

treatment.

YOU NEED TO KNOW IF THE TRACHEOSTOMY TUBE HAS AN INNER CANNULA

9. At this point the patient is safe, with a patent airway and adequate respiration. Do not panic or rush. Take time to think about what the patient

needs at this time.

10. A decision must now be reached about re-insertion of the tracheostomy tube.

This decision should only be made an experienced anaesthetist, intensivist, or

ENT surgeon. The ecision will be depend on the ability of the patient to

maintain a patent airway without the racheostomy tube, and to maintain

oxygenation, cough and clear respiratory tract secretions without artificial

assistance. If there is any doubt, the correct decision is to reinsert the

tracheostomy tube.

11. Re-insertion of the tracheostomy tube can now take place in a controlled

manner. It may be possible to do this in the ward, providing the stoma has a

well-established track (at least 7 days old). Relevant equipment should be

available at the bedside in the patient’s tracheostomy box or from the cardiac

arrest trolley (e.g. tracheal dilator forceps). If in doubt arrange to move the

patient to a critical care area, ENT ward, or operating theatre. Another option

for an experienced practitioner is to pass a tracheal tube via the tracheostomy stoma, which may be easier to advance than a tracheotomy tube.


14.3 BLEEDING FROM A TRACHEOSTOMY

Bleeding is the most common complication of tracheostomy. Bleeding may occur early

(within 48 hours of formation of the tracheostomy) or late (several days afterwards). It

may be minor (settles with simple conservative management) or major (requiring

transfusion of blood and/or blood products) and surgical exploration may be needed to

identify and deal with the source of bleeding.

The management of bleeding from a tracheostomy therefore depends upon the context in

which the bleeding occurs.

14.4 Early minor bleeding

Oozing from the stoma site is the most common type of bleeding seen following

formation of a tracheostomy. Most commonly, this is the result of the effects of the

vasoconstrictor used to infiltrate the incision site wearing off. Blood staining of the

dressings may be noted, or there may be blood staining of tracheal secretions. Large

volumes of fresh blood represent significant bleeding, which

may require surgical exploration.

DON’T PANIC!

1. Call for help: senior medical and nursing staff, other AHPs with

tracheostomy care skills (e.g. physiotherapist).

2. Reassure patient. 3. Assess patency of airway (A) and patient’s breathing (B). Is air passing

through the tracheostomy tube or stoma? Is the patient breathing via the

mouth or nose? Check the oxygen saturation with a pulse oximeter.

4. If the airway is not patent, this must be dealt with first.

5. If the patient is awake, breathing spontaneously and co-operative, encourage the patient to give a vigorous cough – this may be sufficient to

relieve the obstruction by shifting a plug of thick secretions.

6. If the tracheostomy tube has an inner cannula, remove it.

7. Attempt tracheal suction with a suction catheter – this alone may be

sufficient to remove a thick plug of secretions.

8. If the obstruction is not relieved, then deflate the tracheostomy tube cuff.

Administer oxygen via a facemask if the patient is breathing

spontaneously. If the patient is not breathing spontaneously, it will be

necessary to ventilate the patient with a resuscitation bag and mask – an

oral airway (Guedel) may be necessary. Monitor the oxygen saturation

with a pulse oximeter.

9. If it is not possible to achieve adequate oxygenation, then remove the

tracheostomy tube and suction and proceed as per dislodged tracheostomy

tube protocol. Consider passing Yankeur or other large bore suction

catheters directly into the trachea via stoma to remove thick secretions or

blood clot. Suction applied directly via the tracheostomy tube or

translaryngeal tube may also be required to remove big clots, or large

mucus plugs (as in neonates for meconium aspiration).

10. If the patient is now adequately oxygenated, then it is now safe to consider changing the tracheostomy tube. This is not necessary if removal of the inner cannula has relieved the obstruction.


Then seek surgical haemostasis in theatres with appropriate senior surgeon. Junior

surgeons should not explore such wounds alone as major vessel bleeding and a

compromised airway will require senior ENT, cardiothoracic or vascular expertise.

14.5 Major early bleeding

Proceed as minor bleeding guideline. Note that large volumes of blood in the trachea may

cause respiratory embarrassment – the patient may need further respiratory support in a

critical care area. Beware of the risk of the tracheostomy tube becoming occluded by

blood clot. If this occurs, proceed as per blocked tracheostomy tube guideline. If airway

obstruction occurs due to blood clot

in the airway (look with a laryngoscope) then direct suction on the tracheal tube with

suction tubing may be required to remove it. Large clots will not pass through a suction

catheter or a fibreoptic bronchoscope suction channel.

DON’T PANIC!

1. Call for help– senior medical and nursing staff, other AHPs with


2. Reassure patient. 3. Whilst maintaining control of the tracheostomy tube, remove the

tracheostomy tube holder and dressing.

4. Clean stoma site with sterile saline.

5. Inspect stoma site, looking for any obvious bleeding point.

6. Apply manual pressure to any obvious bleeding point – this may be

sufficient to stop minor oozing. Suturing locally may also be effective.

7. If still bleeding, infiltrate any obvious bleeding point with dilute

adrenaline (1:80,000 to 1:200,000). If no obvious bleeding point,

infiltrate the stoma margins with dilute adrenaline.

8. If still oozing, apply Kaltostat packing to stoma to promote local clot

formation. The Kaltostat may also be soaked in dilute adrenaline.

9. 1Check full blood count and a coagulation screen. Correct any

abnormalities in the standard fashion.

10. If bleeding is not stopped by these measures, refer to ENT or other

appropriate surgeon for surgical exploration.

DON’T PANIC!

1. In most situations of significant bleeding, secure the airway by

translaryngeal intubation with the cuff below the stoma so the airway is

protected from blood entering the trachea from the stoma. Then

temporary haemostasis of the stoma can be achieved by digital

pressure, packing the wound with gauze or deep tension sutures.

2. Early referral to an appropriate SENIOR surgeon (e.g. ENT,

cardiothoracic, vascular expertise) for urgent surgical exploration is

necessary.

3. Ensure that cross-matched blood is made available.

4. Check full blood count and a coagulation screen. Correct any

abnormalities in the standard fashion.


14.6 Late bleeding

Late bleeding may occur because of erosion of blood vessels in and around the stoma

site. This is more likely if there has been infection of the stoma site. Such bleeding may

settle with conservative management, as described in the early bleed guideline. More

worryingly, however, is the prospect of such bleeding being the result of erosion of a

major artery in the root of the neck where there has

been pressure from the tracheostomy tube itself or the cuff tube (another reason why it

is important to ensure that the tracheostomy tube cuff pressure is monitored to avoid

over-inflation). Most commonly, this erosion occurs into the right brachio-cephalic artery

(also known as the innominate artery), resulting in a tracheo-innominate artery fistula.

This situation may be heralded in the preceding hours by a small, apparently

insignificant, sentinel bleed. Bleeding from such a fistula will be massive. THIS IS A LIFE-

THREATENING EMERGENCY and so decisions need to be rapidly made. It is well

recognised that fatalities occur in this situation, and that this may be the mode of death

for some patients with head and neck cancers. The appropriate management may,

therefore, be palliation. Such a decision should, ideally, have been made in advance and

in discussion with the patient and family, clearly documented in the patient’s medical

notes and communicated to the nursing staff (who will undoubtedly have to deal with this

situation). If active treatment is still the plan, proceed as below:

DON’T PANIC!

1. Call for help– senior medical and nursing staff, other AHPs with


2. Reassure the patient. 3. Proceed as described in the major early bleeding guideline.

4. Bleeding may be temporarily reduced or stopped by applying finger

pressure to the root of the neck in the sternal notch, or by inflating the

tracheostomy tube cuff (if present) with a 50ml syringe of air. This

inflation should be done slowly and steadily to inflate the balloon to a

maximum volume without bursting it. Depending on the type and size of

the tracheostomy tube this may be anywhere between 10 and 35 ml.

5. Urgent referral for surgical exploration must now be made, if not already

done so. In addition to an ENT or maxillofacial surgeon, it may be

necessary to get help from a vascular surgeon. Sometimes, the damage

can only be repaired utilising cardio-pulmonary bypass, and so a

cardiothoracic surgeon may also be needed to help. The operating

theatres must be informed that this is an NCEPOD Category One

emergency, as any delay will increase the risk of death significantly.


Appendices

1. Patient information

2. Tracheostomy tube information

3. Emergency algorithms

4. Integrated Care pathway example

5. Tracheostomy observation chart example


Appendix 1

Tracheostomy on the Intensive Care Unit

Information for patients and their relatives

Many patients on the Intensive Care Unit (ICU) need help with their breathing as a result

of their illness. This may be achieved by attaching the patient to a ventilator (breathing

machine). In order to attach the patient to the ventilator, they need a plastic tube that

goes through the patient's mouth (or, occasionally, nose) into the trachea (windpipe).

When the patient has recovered from their illness and no longer requires the ventilator,

this tube will be removed. It is perfectly safe to leave the tube in place for several days.

If a patient needs a breathing machine for a long period of time a tube in the mouth or

nose can be very uncomfortable and medicines may be needed to allow the patient to put

up with the tube. A tracheostomy can help reduce this discomfort and in some cases will

allow us to wake the patient up and get them off a breathing machine faster.

What is a Tracheostomy?

A tracheostomy is a hole in the front of the neck into the trachea (windpipe). A tube can

then be inserted through this hole into the trachea in order to allow the patient to be

connected to a ventilator and to allow access for suction (clearing phlegm off the lungs).

The pictures below show where the tube is placed and some of the commonly seen

tracheostomy tubes that are used in Wales:

Figure 1 - The position of the

tracheostomy tube in the trachea.

Figure 2 – Some common tracheostomy

tubes

Benefits of a tracheostomy

• A tracheostomy is more comfortable than a breathing tube in the mouth.

• It allows us to clean the mouth and lip read more easily.

• A tube in the mouth or nose can damage the delicate tissues in the mouth and throat.

A tracheostomy reduces this risk.

• If a patient has lots of phlegm (sputum / secretions) a tracheostomy allows staff to

suck them out easily even if they do not have a very strong cough.


Is it safe? Are there any risks?

A tracheostomy is generally a very safe procedure. However, like any procedure there

are some risks and complications associated with it. A tracheostomy is only performed

when the benefits are greater than the risks.

Most of the complications are minor and of no great significance. However, very

occasionally, a severe complication may arise which may call for intervention.

The risks associated with the procedure are: -

• Bleeding

• Infection

• Damage to other structures in the neck

Fortunately, complications are extremely rare. These are the most serious risks from

having a tracheostomy, as the patient may experience severe difficulty with breathing.

There have very rarely been deaths recorded in the medical literature due to this

procedure.

How is a Tracheostomy done?

A tracheostomy can be done in the intensive care unit by the intensive care senior

doctors and consultants (this is called a percutaneous tracheostomy) OR by an Ear Nose

and Throat (ENT) surgeon in theatre (this is a surgical tracheostomy).

Which ever way it is done the patient is put to sleep (has an anaesthetic) which means

they will not be aware of what is happening and will not feel any pain. The procedure

itself takes less than half an hour.

How long does a tracheostomy stay in place?

It is perfectly safe to leave a tracheostomy tube in place for a prolonged period of time.

However, in the type of patient we most commonly see on the ICU, we would expect to

be able to remove the tracheostomy tube when the patient is judged as no longer

requiring it. This time period will vary depending on the needs of the individual - for

some this may be a few days for others it could be a few weeks.

Tracheostomies may be removed on ICU but patients can also go to the ward with one in

place. Before a tracheostomy is taken out patients have to undergo a weaning process to

assess that it is safe to remove. This is broken down into stages which allow staff to see

how a person is coping. This process is different for each person and staff will be able to

discuss with you how you / your relative is doing.

When the tube does come out a dressing pad is applied to the hole and secured with

tape. The hole usually closes fairly quickly within a week to ten days after removal, the

hole will have sealed off, leaving only a small scar. The scar from a percutaneous

tracheostomy is less than a centimetre (1/2 inch), with a surgical tracheostomy it is 11/2

centimetres (3/4 inch).

Communication

A tracheostomy tube it bypasses the larynx (voicebox) and therefore you will not be able

to speak. However staff can be very good at lip reading and can provide pen and paper,

symbols charts or communication aids to help. You may also be referred to a speech and

language therapist to help you.

As part of the weaning process a speaking valve can sometimes be attached, allowing a

patient to speak with the tracheostomy tube still in place. Staff will be able to advise you

if and when this may be appropriate.

Eating and Drinking

A tracheostomy tube can make it more effortful to swallow and some patients have

problems with aspiration (food / drink going down the wrong way). This can be assessed

by staff and if possible you will be allowed to eat and drink. If you have continued

problems with aspiration you will be seen by a speech and language therapist.

Are there any long-term problems?

Occasionally patients may develop narrowing of the trachea. This is called stenosis. Often

this is not problematic but if this narrowing causes noisy breathing your General

Practitioner (GP) is advised to refer you to an ENT surgeon for investigation and

treatment. In our experience, it is very rare for this to occur.

Some useful websites


The links below you may find of some use: -

http://www.tracheostomy-uk.com

http://www.tracheostomy.com although this site is about children it has some useful

information

http://www.ics.ac.uk/patrel/patrel.asp provides general information on critical care

Acknowledgements

Thanks to the Intensive Care Society (ICS) for use of their resources.


Appendix 2

Tracheostomy Tubes The table below gives the dimensions of dual cannula Portex® Blue Line Ultra®

tracheostomy tube (ICS guidelines 2008)

Equivalent

Jackson size

(approx.)

ID without

inner cannula

(mm)

ID with inner

cannula (mm)

OD (mm) Length (mm)

5 6.0 5.0 9.2 64.5

6 7.0 5.5 10.5 70.0

7 7.5 6.0 11.3 73.0

8 8.0 6.5 11.9 75.5

- 8.5 7.0 12.6 78.0

- 9.0 7.5 13.3 81.0

10 10.0 8.5 14.0 87.5

The table below gives dimensions of dual cannula Shiley® tracheostomy tubes

Jackson size ID without

inner cannula

(mm)

ID with inner

cannula (mm)

OD (mm) Length (mm)*

4 6.7 5.0 9.4 62-65

6 8.1 6.4 10.8 74-76

8 9.1 7.6 12.2 79-81

10 10.7 8.9 13.8 79-81

* varying according to precise model selected

The table below is a comparison of ID and OD tracheostomy tubes with and without inner

cannulae

Portex® Blue Line® Portex® Blue Line

Ultra®

Shiley® Dual Cannula

Tube

Kapitex®

Tracoetwist® ID with (mm)

ID without (mm)

OD (mm)

ID with (mm)

ID without (mm)

OD (mm)

ID with (mm)

ID without (mm)

OD (mm)

ID with (mm)

ID without (mm)

OD (mm)

4.0 5.8 7.2

5.0 7.0 8.6

n/a 6.0 8.3 5.0 6.0 9.2 5.0 6.7 9.4 6.0 8.1 9.2

5.0 7.0 9.7 5.5 7.0 10.5 7.0 8.9 10.4

6.0 7.5 11.3

8.0 11.0 6.5 8.0 11.9 6.4 8.1 10.8 8.0 10.1 11.4

7.0 8.5 12.6

7.0 9.0 12.4 7.5 9.0 13.3 7.6 9.1 12.2 9.0 10.8 12.5

n/a 10.0 13.8 8.5 10.0 14.0 8.9 10.7 13.8 10.0 11.9 13.8

Bold type indicates the dimension used to describe the tube commercially. Data for the Shiley® dual cannula tube refers to Jackson sizes 4,6,8 & 10 respectively


Physical characteristics of some tracheostomy tubes Tube Material Stiffness Curvature

or

angulation

Angle°°°° Notes

Mallinckrodt

armoured

adjustable

flange

Soft 100 Spiral wire

reinforced

wall

Shiley Semi-rigid Curved 90

Shiley®

Tracheosoft

XLT

Angulated 90

Mallinckrodt

PERC

Designed for

se with the

Cook®

percutaneous

tracheostomy

kit

Portex® Blue

Line®

PVC Medium Curved 90 ?105

Portex® Blue

Line Ultra®

PVC Medium Curved 90 ?105

Portex®

adjustable

flange

PVC Medium Angulated 110

Portex® Per-

Fit®

PVC Medium Curved

Portex ®

Blue

Line Ultra®

Suctionaid

PVC Medium Curved 105

Thermo labile

PVC allows

tube to

soften in

vivo.

Portex® Blue

Line®, Blue

Line Ultra®

and PERC®

are

compatible

with a

customised

percutaneous

tracheostomy

kit.

Bivona®

Aire-

Cuf®

adjustable

flange

Silicone Soft n/a n/a Wire

reinforced for

kink

resistance

Bivona®

Aire-

Cuf®

adjustable

flange

Silicone Medium Curved 90

Kapitex®

Tracoetwist®

Polyurethane Semi-rigid 90

Kapitex®

Tracoevario®

Soft Option for

spiral wire

reinforcement

available


Extended length adjustable flange tracheostomy tubes

ID

(mm)

OD

(mm)

Length

(mm)

Portex®

adjustable

flange

6.0 8.2

7.0 9.6 91

8.0 10.9 104

9.0 12.3 119

10.0 13.7

Semi-rigid pre-formed tube

with total length of 100 mm.

Distinct angulation limiting

maximum proximal length to

40mm. Constructed using

thermosensitive

polyvinylchloride that softens

at body temperature. No

inner cannula. Not

specifically designed for

compatibility with

percutaneous introducer kits.

Bivona® Mid-

range Aire-

Cuf®

6.0 8.7 110

7.0 10.0 120

8.0 11.0 130

9.0 12.3 140

Flexible spiral wire-reinforced

silicone shaft. No angulation

and seamless variability in

position of flange and the

resulting proximal and distal

lengths. No inner cannula.

Not specifically designed for

compatibility with

percutaneous introducer kits.

Rusch®

UltrTracheoflx®

7.0 10.8 82 Siliconised PVC construction

with kink resistant spiral

steel wire reinforcement.

Preformed angulation with

distal length ranging from 45

to 62mm. Long low pressure

high volume cuff. No inner

cannula. Not specifically

designed for compatibility

with percutaneous introducer

kits

Extra-length pre-formed Portex® Blue Line® tracheostomy tubes

Extra Horizontal Length

ID (mm) OD (mm) Horizontal length

(mm)

Total length

(mm)

7.0 9.7 18 84

8.0 11.0 22 95

9.0 12.4 28 106

Currently only

available in North

America.

Thermosensitive

siliconised PVC

construction.

No inner cannula

Extra Vertical Length with Double Cuff

ID (mm) OD (mm) Vertical length

(mm)

Total length

(mm)

7.0 9.7 41 83

8.0 11.0 45 93

9.0 12.4 48 103

10.0 13.8 52 113

Thermosensitive

siliconised PVC

construction. No inner

cannula. Constructed

with two

independently

inflatable cuffs.

Shiley® TracheoSoft® XLT Extended Length tracheostomy tubes Proximal extension

ID (mm) OD (mm) Total length Proximal Radial Distal length


(mm) length

(mm)

length

(mm)

(mm)

5.0 9.6 90 20 37 33

6.0 11.0 95 23 38 34

7.0 12.3 100 27 39 34

8.0 13.3 105 30 40 35

Distal extension

5.0 9.6 90 5.0 37 48

6.0 11.0 95 8.0 38 48

7.0 12.3 100 12.0 39 49

8.0 13.3 105 15.0 40 50

Provided with disposable inner cannula with integral 15mm twist lock connector.

Available with or without high volume/low pressure cuff.


YES

NO

NO YES

NO

YES

DISLODGED/DISPLACED TRACHEOSTOMY TUBE

General Ward Setting

DON’T PANIC!

Call for help

Assess Airway Patency (A) and Breathing (B).

Is the airway patent?

Reassure Patient

Patient is safe.

Re-establish airway. Tilt head back. Use jaw thrust. Insert oral (Guedel) airway. Occlude stoma site with pad. Consider endotracheal intubation (anaesthetist or intensivist only ).

Is the patient breathing or can the patient be ventilated?

Administer oxygen by available route. Monitor oxygen saturation (pulse

oximeter).

Only senior staff with appropriate experience of tracheostomy management (e.g. ENT surgeon or Intensivist) should ever attempt to re-insert a dislodged or displaced tracheostomy. Any such attempt should be quickly abandoned if unsuccessful. Multiple attempts should not be made. If in any doubt, remove tracheostomy tube.

Does the patient need the tracheostomy tube to be replaced? Decision to be made by experienced ENT or Intensive Care doctor (usually in discussion with physiotherapist).

Proceed to Re-insertion

flowchart

Apply dressing. Monitor for signs of breathing difficulties. If in doubt, obtain chest X-ray.

Appendix 3


YES

NO

YES

YES

DISLODGED/DISPLACED TRACHEOSTOMY TUBE – Critical Care Setting

NO YES

DON’T PANIC!

Call for help



Reassure Patient

Re-establish airway. Tilt head back. Use jaw thrust. Insert oral (Guedel) airway. Occlude stoma site with pad. Consider endotrach eal intubation.


Identify if percutaneous or surgical tracheostomy?

Percutaneous more than 7 days old? OR

Surgical more than 72 hours old?

Consider attempting re-insertion using gum-elastic bougie and/or fibre-optic bronchoscope.

Patient is safe .

Only senior staff with appropriate experie nce of tracheostomy management (e.g. ENT surgeon or Intensivist) should ever attempt to re-insert a dislodged or displaced tracheostomy. Any s uch attempt should be quickly abandoned if unsuccessful. Multiple atte mpts should not be made. If in any doubt, remove tracheostomy tube.

Administer oxygen by available route. Monitor oxygen saturation (pulse

oximeter).

Proceed to Re-insertion

flowchart Does the patient need the tracheostomy tube to be replaced? Decision to be made by experienced ENT or Intensive Care doctor (usually in discussion with physiotherapist).

Apply dressing. Monitor for signs of breathing difficulties. If in doubt, obtain chest X-ray.

YES

NO


NO

NO

NO

YES

RE - INSERTION OF TRACHEOSTOMY TUBE

Patient has continuing need for trach eostomy tube? (Decision made by experienced Intensive Care doctor or by experienced ENT surgeon)

YES

Apply dressing. Monitor for signs of

breathing difficulties. If in doubt , obtain chest X- ray.

Is the tracheostomy stoma well - formed? (More than 7 d ays for a percutaneous tracheostomy or more than 72 hours for a surgical tracheostomy)

Consider moving patient to a critical care area, ENT ward or an operating theatre area. If in doubt, refer to experienced Intensive Care doctor or ENT surgeon

Assemble necessary equipment. Must include tracheostomy tube of same size as previously and one size smaller. Open sterile dressing pack onto trolley. Check tracheostomy tube cuff (if present).

Position patient sitting up at 30 – 45 degrees. Remove pillo w to extend neck. Consider placing pillow or sandbag behind shoulders to optimise position

Check tracheostomy tube. Clean stoma site with sterile saline. Lubricate tracheostomy tube with water - based jelly (e.g. K - Y jelly or aqua gel )

Insert new tracheos tomy tube. Remove obturator. Inflate cuff (if present)


Remove tracheostomy tube.

If in doubt, return to dislodged /displaced tracheostomy tube flowchart

YES


NO

YES

YES

NO

NO

YES

YES

NO

NO YES

NO

YES

YES

NO

NO

NO

BLOCKED TRACHEOSTOMY TUBE

Patient with tracheostomy in s itu develops respiratory embarrassment or distress

DON’T PANIC!

Call for help



Re - establish airway. Deflate tracheostomy tube cuff (if present). Remove tracheostomy inner cannula and rep lace with clean inner . Tilt head back. Use jaw thrust. Insert oral (Guedel) airway if n eeded.

Is the patient awake and able to co - operate?

Remove tracheostomy inner cannula (if present). Encourage patient to give a strong

Obstruction r elieved?

Attempt tracheal suction (NO MORE

THAN TWICE)

Is the patient breathing?

Ensure inner tube is completely clean before replacing. Depending on type of tube, a new inner cannula may be indicated, or a new tracheostomy tube may b e needed. Decision should be made by experienced Intensive Care or ENT doctor.

Remove tracheostomy tube. Proceed as per dislodged/ displaced tracheostomy tube flowchart

Can the patient be ventilated by hand?

Obstruction relieved?

New tracheostomy tube needed?

Apply new dressing and tube holder

Proceed as per re - insertion of

tracheostomy tube flowchart


NO YES

YES NO

NO

YES

BLEEDING TRACHEOSTOMY Blood oozing from stoma site, staining dressings an d/or blood

found on tracheal suctioning

Is the tracheostomy less than 7 days old?

Consider possibility of tracheo-innominate artery fistula

A SMALL BLEED MAY HERALD THE ONSET OF MAJOR

HAEMORRHAGE. SEEK URGENT EXPERT HELP.

Remove dressing and tracheostomy tube holder.

Clean site with sterile saline

DON’T PANIC!

Call for help

Check observations – pulse, BP, respiratory rate. Establish IV

access

Look for obvious bleeding point. Apply pressure if

seen.

Is the bleeding controlled by pressure?

If still bleeding when pressure removed, infiltrate bleeding point and/or stoma edges with dilute adrenaline. Apply Kaltostat dressing if necessary

Is the bleeding now controlled?

MAJOR BLEED LIKELY! Check observations. Take blood for FBC, coagulation screen and cross-match 4 units of blood.

Apply dressing. Monitor for further bleeding.

Refer to ENT surgeon for urgent exploration

Apply finger pressure to sternal notch. Using 50ml

syringe, carefully hyper-inflate tube cuff (if present).


INTEGRATED CARE PATHWAY For patients with percutaneous tracheostomies

CONSULTANT: ____________________________________________

DATE PATHWAY COMMENCED: _____________________________

DATE PATHWAY COMPLETED: ______________________________

• This Integrated Care Pathway (ICP) is a multidisciplinary document and replaces all other documentation relating to this episode of care; it thus forms the patient’s sole record of care.

• It is intended as a guide to good practice and is evidence based. • The ICP is not a rigid document and clinicians are free to use their own professional judgement as

appropriate, recording as a Variance any alterations to the practice outlined, or any deviation from the expected plan of treatment. It is set out in chronological order to enable the patient's progress to be monitored.

• All sections should be fully completed. Please follow all instructions. • It is essential that all entries are signed and dated as indicated. Sign only for care that YOU have carried out. • Use black ink only. Any variation from the expected plan of care: anything that happens that is not expected is recorded as a VARIANCE. In recording variances, please give as much information as possible. Please ensure your details are included in the initials box below –

• This pathway should be commenced when patients with a percutaneous

tracheostomy no longer require mechanical ventilation

Guidelines for completing the pathway

Initials

Print Name

Signature

Designation

Tracheostomy Study Day Completed

Post Study Day Competencies Completed

Patient Addressograph

Appendix 4


�Met this indicates that an activity has been completed, you tick the appropriate box and initial the corresponding shift �Unmet this indicates that you have been unable to complete a specific activity and you need to complete the variance table for that day writing the activity code, a description of why the activity could not be completed and the action taken � Not Applicable only to be used if the activity is not required for the patient Date of discharge to ward_______________ Time ________________ Ward________________________________ � Contents of blue box checked and correct Signature ____________________ Print name____________________ Rationale for percutanous tracheostomy insertion � Prolonged airway protection � Prolonged ventilator requirements � To aid weaning Details __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


TRACHEOSTOMY OBSERVATION CHART

Tube type: ________________________________ Tube size: _________________________________

Suction catheter size required: _______________

X3 size of tracheostomy tube divided by 2 e.g. size 7 tracheostomy = 7X3=21 divided by 2=10.5 so use a size 10 suction catheter. The catheters should be <50 % diameter of the tube (Glass and Grap 1995, Wood 1998)

Date of initial tracheostomy: _______________________ Date of last tracheostomy change: __________________ Date of next recommended change: _________________

Date of decannulation: ___________________

Ward:

SALT ASSEMENT (refer to page 25) Date ____________________ Details

Tracheostomy size=suction catheter Size 6 tube=suction catheter size 8 often a 10 is used and this fits with the alternate equation of double and minus 2 personally would not recommend an 8 for a size 6 tube as does not clear and not readily stocked on the weards Size 7 tube=suction catheter size 10

Aim of the integrated care Pathway Anticipated outcomes To care appropriately for tracheostomy. To support weaning from tracheostomy as tolerated and safe To prevent secondary complications.

Appendix 5

SEWCCN Tracheostomy Group

May 09

60

Day 1 Date______________ Bedside equipment check Early Late Night Blue box and contents checked � � � Suction working effectively � � �

Does Suction liner requires changing � � �

Appropriate sized suction catheters � � �

Oxygen working if required � � �

Spare inner tube available � � �

Please initial appropriate shift

ACTIVITY CODE

DAY 1 - ACTIVITY TIME (2 HOURLY)

Clinical Assessments

1.0 Competent Health care professional to check oxygen percentage 2 hourly

� � � � � � � � � � � �

1.1

Competent Health care professional to check adequate humidification 2 hourly � Aquapak � Swedish nose � Other

� � � � � � � � � � � �

1.2

Competent Health care professional to record S =speaking valve attached N= speaking valve not attached ensure cuff deflation if speaking valve is attached

� � � � � � � � � � � �

1.3 Please remove speaking valve when patient is asleep if appropriate

� � � � � � � � � � � �

1.4

Competent Health care professional to assess need for suction 2 hourly If suction is required pre oxygenate patient to 100 % oxygen for 1 minute prior to commencing procedure and return to prior oxygen setting on completion of suction.

� � � � � � � � � � � �

1.5

Competent Health care professional to record quantity and type of secretions when tracheal suction has been performed 1=scanty, 2= moderate, 3=profuse

M=mucoid B=blood stained, P=purulent

� � � � � � � � � � � �

1.6

Competent Health care professional to clean inner tube 2 hourly With sterile water and Kapitex swabs (refer to guidelines p 26 )

� � � � � � � � � � � �

1.7 2 health care professionals to change dressing and tapes as required or at least every 24 hours

� � � � � � � � � � � �

1.8

Competent Health care professional to check tracheal cuff pressure with cuff pressure manometer and adjust to 16-24 cms h20

� � � � � � � � � � � �

�Met �Unmet � Not Applicable

SEWCCN Tracheostomy Group

May 09

61

ACTIVITY CODE

DAY 1 - ACTIVITY TIME (2 HOURLY)

record cuff pressure if cuff inflated

1.9 Competent Health care professional to check if tapes are secure and stoma site condition

� � � � � � � � � � � �

1.91 Record I if cuff inflated and D if cuff deflated

� � � � � � � � � � � �

Please initial appropriate Time Day 1 variance table Activity code

description of variance action taken initials

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