Welcome to the Specialized Medical Services respiratory training webinar series!

SMS is your LTC facility single source for oxygen, medical equipment,

respiratory care services and supplies nationwide.

This respiratory module is for reference purposes and designed to provide a basic understanding of Tracheostomy Tubes commonly used in

Long Term Care. It is still important to consult your local respiratory professional and

follow physician orders when applying respiratory treatment.

At the completion of each training module, a short post test will be offered, and with successful completion,

a training certificate recognizing your participation for your records.

TRACHEOSTOMY TUBES Webinar Training Session

Training Objectives

• What is a tracheostomy and tube

• Understand different types of tracheostomy tubes

– How they work

– When to use them

– Basic treatment and care recommendations

• Where to resource product information

Anatomy and a Tracheostomy Tube

Larynx (Vocal Cords)

Esophagus (Behind Trachea)

Trachea (Wind Pipe)

Tracheostomy Tube

Thyroid Gland

Tongue

Epiglottis (Flap)

Sinus Cavity

What is a Tracheostomy & Tube?

• Tracheotomy

• Medical procedure to establish access to the trachea via a neck incision

• Surgical procedure done in the OR or ICU bedside.

• Tracheostomy

• Actual opening (hole in neck)

• A trach tube is placed in the neck of the patient to keep the hole open

• Tracheosotmy Tube

Disposable or reusable prosthetic device inserted in to the tracheostomy opening

to create an artificial airway

Made of plastic, silicone, or metal

3 main varieties:

Cuffless, cuffed , or fenestrated

Tube selection based on:

Individual patient’s clinical condition

Physician preference

Tracheostomy Indications

• Acute trauma

• Prolonged intubation

• Respiratory failure (long term)

• Sleep apnea

• Congenital abnormality of the larynx or trachea

• Severe neck or mouth injuries or cancer

• Inhalation injuries

• Large foreign body in airway

• Vocal cord paralysis

• Inability to clear secretions

• Tracheal stenosis or malacia

Risk or Complications

• Bleeding

– Post surgical

– Excessive suctioning

• Pneumothorax

• Infection risk

• Aspiration risk

• Subcutaneous emphysema

• Tracheal stenosis

• Tracheal-esophageal fistula

Tracheostomy Tube Types: Cuffless

• May be plastic, silicone or metal (reusable)

• Allows air to flow freely

• Reduces risk of tracheal tissue damage

• Stable patient’s with minimal secretions or no aspiration

Tracheostomy Tube Types: Cuffed

• Made of plastic or silicone, disposable

• A cuff is a balloon-like device around distal end

• Can be inflated with air to create a tight fit

• Patients at risk for aspirating will have a cuff inflated to protect airway

• Low pressure, low volume to minimize risk of tracheal tissue damage

• Some cuffs may also be constructed of foam and inflate when pilot line is opened to room air

Tracheostomy Tube Types: Fenestrated

•Can be cuffless or cuffed,

•Fenestration: A window cut into the outer cannula

•To open: • The inner cannula is removed or fenestrated • The tube is capped or plugged

•Used when: •Cuff inflation is not required •A speaking valve is in use •The tube is capped for wearing

•When the fenestration is open, patient can • Breathe spontaneously • Cough • Speak

Cuffless (plastic or metal)

Plastic Cuffed (low pressure and low

volume)

Fenestrated

Advantages Advantages Advantages

•Lightweight, comfortable, inexpensive for patient (plastic) •Reduced risk of tracheal damage (plastic) •Reusable and inexpensive (metal)

•Disposable •Conforms to anatomy •More confortable than metal •Prevents aspiration of fluid or secretions

•Speech possible through upper airway when external opening is plugged and the cuff is deflated

Disadvantages Disadvantages Disadvantages

• Increased risk of aspiration in adults due to absence of cuff (plastic & metal) •Rigid and uncomfortable (metal) • 15 mm respiratory adapter lacking for ventilation, or to adapt communication device (metal)

• Generally more expensive than other tubes • Excessive or long term cuff

inflation can cause tracheal stenosis

• Possible occlusion of fenestration • Cap/plug removal necessary before inflating cuff

Tracheosotmy Tube Design and Sizes

• Tubes differ in rigidity, internal/external diameter, and cuff design – Metal, stainless steel tubes are very rigid and inflexible. (greater risk of tracheal tissue irritation) – Plastic and silicone tubes are soft and flexible, and conform to the patient’s anatomy – Refer to each manufacturers’ reference material for exact specifications

• Sizing varies among manufacturers (sizing and type usually found on tube flange) • Sizing will refer to

– Internal Diameter (ID) – Outer Diameter (OD) – Jackson size - a number between the two – Length

• Outer cannula: main shaft of tube

• Obturator: smooth, round tip device, placed inside tracheostomy tube to facilitate insertion

• Inner cannula: is disposable or non-disposable, and can be removed for periodic cleaning to prevent airway obstruction from accumulated secretions

• Trach Tube flange: stabilizes the tube in the trachea and provides holes for securing the tube to the neck with a trach tie or holder

• Manufacturers’ tracheostomy tube replacement parts are not interchangeable with other brands

Refer to the manufacturers’ Product Reference Guide, or your Respiratory Therapist for correct item order #s.

Tracheostomy Tube Types Jackson (Metal)

Reusable Inner Cannula w/ 15 mm Adapter

Outer Cannula w/Flange

Obturator Reusable Inner Cannula Tracheostomy Plug

Tracheostomy Tube Types Shiley-Disposable

Cuffless, Reusable Inner Cannula Cuffed, Reusable Inner Cannula

Fenestrated (FEN) Non Fenestrated (LPC)

Non Fenestrated (CFS) Fenestrated (CFN)

Laryngectomy (LGT)

Tracheostomy Tube Types Shiley-Disposable

Cuffed, Disposable Inner Cannula Cuffless, Disposable Inner Cannula

Non Fenestrated (DCFS) Fenestrated (DCFN)

Fenestrated (DFEN) Non Fenestrated (DCT)

Percutaneous (PERC)

Tracheostomy Tube Types Shiley-Disposable

Extended Length-Distal or Proximal,

Cuffed or Cuffless, Disposable Inner Cannula Disposable Inner Cannula (DIC) Fenestrated DIC (DIC-FEN)

Spare Inner Cannula (SIC)

Cap-Fenestrated DIC (CAP) Disp Decannulation Plug (DDCP)

Decannulation Plug (DCP)

Single Cannula Cuffed (SCT)

Tracheostomy Tube Types Portex-Disposable

Disposable Inner Cannula Series

Uncuffed, Uncuffed Fenestrated, Cuffed, Cuffed Fenestrated

Blue Line Series-Single Cannula Cuffed and Uncuffed

Tracheostomy Tube Types Bivona-Disposable

Aire-Cuf

Uncuffed Fome-Cuff

TTS

Laryngectomy

Minimal Occluding Volume(MOV) or Minimal Leak Technique

• Reduces pressure between tube cuff and tracheal wall

• The cuff-to-tracheal wall pressure should be low as possible

• Prevents tissue necrosis

Minimal Occlusive Volume Minimal Leak Technique

1. Inject air into the cuff until no airflow is auscultated over the trachea during peak inflation of a positive pressure breath (use ambu bag)

1. Inject air into the cuff until the air leak around the cuff is eliminated

2. Cuff pressures may be monitored with a monometer when available

2. Remove a small amount of air from the cuff until a slight leak occurs during the peak inflation of a positive pressure breath

3. Cuff pressures may be monitored with a monometer when available

Tracheostomy Tube Accessories: Holders

• Twill Tape/Ties – Cloth/Woven – Comes in roll – Cut to length desired – Uncomfortable when

soiled or moist

• Velcro Holders – Foam and cloth – Individually

prepackaged – Varying sizes – Soft, comfortable – Easy to apply

Changing Holder or Twill Ties

• Wash hands and wear gloves

• Assist the patient into a semi-Fowler’s position

• Guard against accidental tube expulsion

– Patient movement or coughing can dislodge the tube

– Have an assistant available

• If using scissors, take caution not to cut the tube of the pilot line on a cuffed tube

• One-way valve directs airflow past vocal cords • Allows patient to speak without finger occlusion • Airflow through oral and nasal chambers:

• Decreases secretions • Increases smelling ability • Improves swallowing. • Reduces hygiene and infection concerns • Design minimizes Work of Breathing

• Lightweight valve minimizes pressure on stoma site • Connector adapts to most tubes, including pediatric • Convenient hinged cap allows easy cleaning • Optional oxygen supplement port and cap

Tracheostomy Tube Accessories: Speaking Valves

• Always use a fenestrated tube

• Make sure cuff is deflated

• Never use with foam cuff tubes

• Never leave in place at night or during naps

• Check for secretion build up and clean as needed

• Valves are non-disposable – store in clean with lid when not in use

• Clean daily with mild soap and warm water

Care Precautions: Speaking Valves

Tracheostomy Tubes Order Features

Refer to PORTEX and SHILEY web-sites for Product Reference Guide • Standard Disposable ( Single Lumen, Reusable, or Disposable Inner Cannula)

• Extended Length

Contact SMS or your Distributor for Item Order #s • Metal (Reusable, Cuffless Only) • Specialty/Extended Use (Foam Cuff, Adjustable Flange) • Custom Order

ALWAYS HAVE A BACK-UP TRACHEOSTOMY TUBE AVAILABLE IN THE FACILITY!

Tracheostomy Tube Site Care

• Care goals: • Ensure airway patency by keeping tube free of secretions and buildup

• Maintain mucous membrane and skin integrity

• Prevent infection

• Use aseptic technique until stoma has healed • Use sterile gloves for recently performed tracheotomies

• On healed stomas, clean gloves may be substituted based on facility policy

• Preparation for Care • Assemble all equipment and supplies in the patient’s room

• Use a waterproof trash bag to discard soiled items

• Establish a sterile field on the over-bed or bedside table

• Prepare solutions in containers

• Obtain or prepare new tracheostomy ties if indicated

• If replacing the disposable inner cannula, open package, maintaining sterile technique

Tracheostomy Tube Care

• Implementation • Assess patient to determine need for care

• Explain procedure to the patient

• Place patient in semi-Fowler’s position

• Remove humidification or ventilation device

• Suction patient to clear secretions

• Reconnect patient to humidifier and oxygen

• Proceed with cleaning of stoma and cannula care • Use sterile or clean gloves

• Complete stoma site care and reusable cannula cleaning

• Change disposable inner cannula and trach ties/holder as ordered and PRN ( refer to Facility procedure for cleaning and inner cannula replacement)

Tracheostomy Tube Care

• Always have experienced caregiver when administering tracheostomy tube care

• Emergency Tube Replacement • Maintain sterile tracheal dilator or hemostat

• Sterile obturator that fits the tracheostomy tube in use

• Spare tracheostomy tube and obturator

• Suction equipment and supplies

• Resuscitation bag

CALL 911 IF UNABLE TO REESTABLISH AIRWAY

Tracheostomy Suctioning

• Determine Need: • Assess breath sounds

• If patient can cough up secretions on their own,

allow them the opportunity to

• Suction only when clinically necessary

• Risks include: hypoxia, dysrhythmias, and atelectasis • Dysrhythmias can be caused by myocardial hypoxia and

stimulation of the vagus nerve

• If the patient is cardiac monitored, observe heart rate and rhythm for changes. If the patient is not monitored, check the pulse periodically.

• Atelectasis can occur as a result of high negative pressure during suctioning, which can cause alveolar collapse.

• Suction pressure should be set at 80 to 120 mmHg.

Suctioning Tips

• Use good aseptic technique

• Reassure the patient

• Suction quickly – only 10-12 seconds

• Oxygenate before and after suctioning

• Don't suction too deep – can cause trauma and bleeding

• Keep secretions thin by keeping the patient well hydrated

• Suction only when withdrawing catheter

• Check patient oxygen saturation level as needed

Suction Catheter Size and Hydration • Diameter of suction catheter should be approximately half the

diameter of tracheostomy tube • Most adult patients: size 10-14 Fr • Thick secretions: size 14Fr

• Normal saline may be instilled into the patient's tracheostomy

tube when the secretions are thick. Consult your physician or respiratory therapist.

• A mucolytic agent may also be considered to help break up the thick secretions.

Tracheostomy Tube Internal Diameter Suction Catheter Size 5.0 mm 10 Fr. 5.5 mm 10 Fr. 6.0 mm 12 Fr. 6.5 mm 12 Fr. 7.0 mm 14 Fr. 8.0 mm 14 Fr. 9.0 mm 14 Fr.

Tracheostomy Tube Removal

• Decannulation of tracheostomy tube (removal of tube) – No longer ventilator dependent

– Successful swallow evaluation

– No aspiration problems

– Stable lungs and airway

– Successful ‘plugging’ or ‘capping’ trials

• Decannulation procedure – Confirm MD order to remove tracheostomy tube

– Communicate with patient/family on decannulation

– Suction airway to remove excess secretions

– Remove tracheostomy tube and tape sterile gauze to neck over stoma site

– Stoma site will usually close within a couple of weeks

Monitoring the Tube & Care

Monitor:

• Airway patency, breath sounds and swallowing ability.

• Ability to cough and clear secretions

• Sputum: color, odor, amount, thickness.

• Oral and fluid intake

• Patient’s work of breathing and oxygen saturation

• Need for supplemental humidification and/or oxygen

• If patient is taking oral fluids or food, assess ability to swallow without coughing.

• If patient is an aspiration risk, physician should request a speech therapy consult order for swallowing assessment and possible swallowing studies.

Steps to Follow • Identify patient need, develop plan of care

• Verify MD prescription

– Type of tracheostomy tube

– Care requirements: suctioning, tracheotomy care, humidification, oxygen, and other respiratory treatments

• Use appropriate equipment and treatment delivery devices

• Monitor patient for benefit & continued need

• Document all treatments

• Follow best practice and safety guidelines

• Monitor supply par levels

• Routinely change tracheostomy tube and ancillary supplies

ALWAYS HAVE A BACK-UP TRACHEOSTOMY TUBE AVAILABLE IN THE FACILITY!

Tracheostomy Tube Care Instructions

Note: It is extremely important to know the Brand (Shiley, Portex), Size (4, 6), Type (Cuffless, Fenestrated, etc.), Inner Cannula (Disposable, Reusable, Single) being used.

• Change tracheostomy tube every 30-45 days

• Change DIC (disposable inner cannula) daily

• Tracheostomy tube site care BID

• Cuff MUST be deflated when using Speaking Valve

• Suction every shift as needed

CONSULT YOUR PHYSICIAN AND LOCAL RESPIRATORY THERAPIST

FOR TRACHEOSTOMY TUBE VERIFICATION & TREATMENT PROTOCOLS

Session Review

• What is a tracheostomy and tube

• Understand different types of tracheostomy tubes

– How they work

–When to use them

– Basic treatment and care recommendations

• Where to resource product information

Other Tracheostomy Tube Resources

• AARC Clinical / Technical References

• www.aarc.org

• Manufacturers’ product material Boston Medical www.bosmed.com

Covidien (Shiley) www.nellcor.com (For Shiley Product Quick Reference Guide call 1-800-635-5267)

Dale Medical www.dalemed.com

Passy-Muir www.passy-muir.com

SMITHS Medical (Bivona) www.smiths-medical.com/catalog/bivona-tracheostomy-tube

SMITHS Medical (Portex) www.smiths-medical.com/catalog/portextracheostomy-tube

(For Bivona & Portex Product Reference Guide call 1-800-258-5361)

1-800-786-3656

Thank You!

Take our post-session quiz and print your certificate of completion