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Tracheostomy care guidelines

St. James’s Hospital / Royal Victoria Eye and Ear Hospital

Tracheostomy Care Working Group
October 2000 These guidelines have been produced as an educational support and guide for health care professionals caring for tracheostomy patients in the clinical setting. Advice on the care of a specific patient should always be sought from a suitably qualified professional. The guidelines have been ratified by the Head and Neck Nurses Association of Ireland (HANNA) and are recommended for use by its members.

GUIDELINES WRITTEN BY: TRACHEOSTOMY CARE WORKING GROUP of
ST. JAMES’S / ROYAL VICTORIA EYE AND EAR HOSPITALS

Ms. Margaret Codd, RGN, BNS (St. James’s Hospital) - Chairperson Ms. Yvonne Sheridan, RGN (St. James’s Hospital) Ms. Hilary Collins, RGN (St. James’s Hospital) Ms. Janine Ryan, RGN (St. James’s Hospital) Ms. Maria Creggy, RGN (St. James’s Hospital) Ms. Michelle Royale, RGN (St. James’s Hospital) Ms. Kathleen Canavan, RN, BNS (St. James’s Hospital) Ms. Mildred Grubb, RN, RM, Dip.Nsg.Ed., Dip.Med.Ed., M.Med. Ed (St. James’s Hospital) Ms. Caroline Murphy RGN (Royal Victoria Eye and Ear Hospital)
GUIDELINES REVIEWED BY:

Prof. C. Timon, Ms. D. Hyland, Mr. C. Huet, Mr. C. Beirne Dr. J. Moriarty, Dr. F. O’ Connell, Ms. A. O’Brien, Ms. O.J. Power, Ms. S. James, Ms. S. Brady, Ms. A. M. O’Grady,

Consultant Otolaryngologist, (SJH / RVEEH) Acting Nurse Manager, St. John’s Ward,(St. James’s Hospital) Nurse Tutor, (RVEEH) Consultant Maxillofacial Surgeon, (St. James’s Hospital) Consultant Anaesthetist, (St. James’s Hospital) Consultant Physician, (St. James’s Hospital) Infection Control Sister, (St. James’s Hospital) Clinical Facilitator, ICU, (St. James’s Hospital) Senior Speech and Language Therapist, (St. James’s Hospital) Senior Clinical Nutritionist, (St. James’s Hospital) Senior Physiotherapist, (St. James’s Hospital)

GUIDELINES INCLUDED • • • • • • • • • • • Overview of tracheostomies Bedside equipment. Care of the inner cannula, stoma site and tracheostomy ties. Suctioning via a tracheostomy tube. Humidification of inspired gases. Care of cuffed tracheostomy tube Care of fenestrated tracheostomy tube Care of Passy Muir speaking valves. Decannulation: removal of tracheostomy tube. Dealing with emergencies. Resuscitation via a tracheostomy tube.

OVERVIEW OF TRACHEOSTOMY TUBES
DEFINITIONS
TRACHEOTOMY: Incision

INDICATIONS FOR TRACHEOSTOMY

made below the cricoid cartilage through the 2nd-4th tracheal rings TRACHEOSTOMY: The opening or stoma made by this incision. TRACHEOSTOMY TUBE: Artificial airway inserted into the trachea during tracheotomy

• • • • •

Bypass acute upper airway obstruction. Chronic upper airway obstruction. Facilitate weaning from mechanical ventilation by decreasing anatomical deadspace. Prevention / treatment of retained tracheobronchial secretions. Prevention of pulmonary aspiration.

Figure 1.

TRACHEOSTOMY TUBE IN SITU

Figure 2. TRACHEOSTOMY TUBE COMPONANTS

COMPONANTS OF TRACHEOSTOMY TUBE (See Figure 2) 1. Outer tube 2. Inner tube: Fits snugly into outer tube, can be easily removed for cleaning. 3. Flange: Flat plastic plate attached to outer tube - lies flush against the patient’s neck. 4. 15mm outer diameter termination: Fits all ventilator and respiratory equipment. All remaining features are optional 5. Cuff: Inflatable air reservoir (high volume, low pressure) - helps anchor the tracheostomy tube in place and provides maximum airway sealing with the least amount of local compression. To inflate, air is injected via the... 6. Air inlet valve: One way valve that prevents spontaneous escape of the injected air. 7. Air inlet line: Route for air from air inlet valve to cuff. 8. Pilot cuff: Serves as an indicator of the amount of air in the cuff 9. Fenestration: Hole situated on the curve of the outer tube - used to enhance airflow in and out of the trachea. Single or multiple fenestrations are available. 10. Speaking valve / tracheostomy button or cap: Used to occlude the tracheostomy tube opening (a) former - during expiration to facilitate speech and swallow, (b) latter - during both inspiration and expiration prior to decannulation.

BEDSIDE EQUIPMENT
Every patient with a tracheostomy tube should have the following equipment available at the bedside: • • • Spare tracheostomy tubes Tracheal dilator. Suctioning equipment Suction machine fitted with filter; suction tubing; suction catheters (see suctioning page for sizes); gloves (as below); bottle of sterile water to rinse tubing - change daily. Ensure equipment is assembled and working properly. • Humidification equipment Equipment depends on method used - see humidification page. Ensure equipment is assembled and working properly. • Gloves Non-sterile ** Sterile gloves (for suctioning) Same size and type as patient is wearing. Smaller size

• •

Infectious waste bag

Dry clean container for holding the speaking valve, occlusive cap/button or spare inner cannula when not in use. (Get from theatre)

**Natural rubber latex gloves to be used by all except those who have latex allergy.
Nitrile gloves to be used by those with latex allergy.

CARE OF THE INNER CANNULA, STOMA SITE AND TRACHEOSTOMY TIES
AIM: 1. To maintain a patent airway. 2. To maintain skin integrity. 3. To prevent infection. 4. To prevent tube displacement

FREQUENCY OF CLEANING Inner Cannula: Check every shift -see box below. Clean PRN Stoma: PRN to keep clean and dry Ties: PRN to keep clean and dry

EQUIPMENT FOR STOMA CARE Dressing trolley Dressing pack Pair of sterile gloves Unsterile gloves Normal saline solution Scissors Lyofoam dressing Suctioning equipment New trach. ties Infectious waste bag (Sterile pipe cleaners - single use only)

To check inner cannula: Wash hands. Wearing a non-sterile glove, remove inner cannula. Handle only the outer portion of the cannula. If clean, reinsert and lock into place. If soiled continue with step (d) below.

(a) (b) (c) (d) (e) (f) (g) (h) (i) (j)

Wash hands. Wearing unsterile gloves remove and dispose of the soiled dressing. Wash hands. Put on sterile gloves. First, remove and clean the inner cannula using sterile pipe cleaners and normal saline. Dry. Reinsert. Secondly, clean the stoma site using gauze and normal saline. Pat dry. Apply lyofoam / keyhole dressing if necessary. Lastly, if ties are soiled and need changing, have a second nurse hold the tracheostomy tube securely in place, remove and replace tracheostomy ties. (Leave 1 finger space between ties and the patient’s neck.) Ensure patient comfort. Discard of used equipment as per hospital policy. Wash Hands. Document procedure in the patient’s notes.

Note: Leave first dressing intact for 24hrs if possible as the tracheostomy is a fresh wound.

SUCTIONING VIA A TRACHEOSTOMY TUBE
AIM: To maintain a patent airway by removing endotracheal secretions.

FREQUENCY OF SUCTIONING Suctioning is performed only as needed, NOT to a pre-set schedule (Knipper ’84, Carroll ’89, Stone and Turner ’89) Be aware that suctioning will be needed more frequently in the immediate post-operative period

WORKING OUT SUCTION CATHETER SIZE

Size of trach. tube (mm) x 3 2 E.g. 8x3 2 = size 12 suction catheter

This ensures that suction catheter is </= ½ the internal diameter of tracheostomy tube.

(a) Explain the procedure to the patient - wash hands, put on gloves. Put on apron and fluid shield mask if necessary for standard (universal) precautions). Turn on suction apparatus and test that vacuum pressure is < -150mmHg. (b) Open / expose only the vacuum control segment of the suction catheter and attach to the suction tubing. (c) Put on disposable sterile gloves over the non-sterile gloves and withdraw the sterile catheter from the protective sleeve. (d) Maintaining sterility, insert the suction catheter with NO suction applied until resistance is met, then pull back about 1-2 cms before applying continuous suction as the catheter is smoothly withdrawn from airway. NOTE: Recommended suction time (i.e. from insertion to removal of suction catheter) = <15secs Use a new sterile catheter for each suction pass. (Stone et al ’91, Young ’84, Carroll ’88, Link et al ’76). No more than 3 passes recommended per treatment. (e) On completing procedure, ensure patient comfort, discard of equipment as per hospital policy, wash hands and document procedure in the patient’s notes.

HUMIDIFICATIONOF INSPIRED GASES
Aims: 1. To prevent drying of pulmonary secretions. 2..To preserve muco-ciliary function. NOTE: All patients with tracheostomy tubes require humidification of inspired gases. CHOOSING METHOD
A) HEATED HUMIDIFIERS - Recommended for:

EQUIPMENT NEEDED A) * Heating unit, * Sterile water , * Oxygen tubing, * Tracheostomy mask. B) * Heat moisture exchange filter * Oxygen tubing to fit filter if O2 therapy requested
C) * Nebulizer

• • • •

patients with new tracheostomy tubes dehydrated patients immobile patients patients with tenacious secretions Recommended for: patients that are adequately hydrated mobile patients Not suitable for patients with copious secretions in helping to loosen secretions and soothing irritable airways.

B) HEAT MOISTURE EXCHANGE FILTERS -

• • •

C) NEBULIZERS - nebulized normal saline is effective

* Oxygen tubing * Sterile saline

• •

The method used for humidification can be altered as the patient’s condition changes Do not combine methods - use one at a time.

.
NURSING MANAGEMENT HEATED HUMIDIFERS • Set up as per operators manual. • Monitor temperature of inspired gases. This is easily achieved if the system used has a digital temperature display. If it does not, then test the temperature by holding the oxygen tubing against a clean bared inner arm. Gas flow should feel at body temperature. • Monitor water level and change bottles PRN. • If condensation collects in tubing, - drain tubing into a sterile jug and dispose of into sluice. • Using clean technique, change all tubing weekly. (Date tubing when changed) HEAT MOISTURE EXCHANGERS • Change daily and PRN to keep clean and dry. (Swedish noses/thermovents can be easily “coughed off” - apply new Swedish nose each time this happens). • Discard of soiled Swedish noses in infectious waste. NEBULIZERS • Administer as prescribed. • Wash in warm soapy water, rinse and dry thoroughly after each treatment.

CARE OF CUFFED TRACHEOSTOMY TUBE

INDICATIONS FOR CUFFED TUBE • • • • • Immediately post-operatively - to prevent aspiration of blood or serous fluid from the wound To seal the trachea during mechanical ventilation To seal the trachea during swimming! To prevent aspiration of leakage from tracheo-oesophageal fistula To prevent aspiration due to laryngeal incompetence

NURSING MANAGEMENT • • • • It is unusual for ward patients to need their cuff inflated. Tracheostomy cuff is inflated only - (a) if the patient is being mechanically ventilated, (b) if inflation is specifically ordered by doctor. Check with doctor that it is OK to do so , and then proceed with cuff deflation...... Patients can be extremely sensitive to changes in cuff pressure. A little coughing is not unusual during manipulation. Take care to explain the procedure to the patient and to inflate / deflate the cuff slowly. To deflate cuff: First, suction the oropharynx to remove any secretions that may have pooled on top of the inflated cuff. Then, using a syringe, slowly aspirate air from the air inlet port. Once deflated, expiratory noises may be heard as air passes up around the tracheostomy tube. Reassure the patient that these are normal and will settle. To inflate cuff: Inject approximately 5-7mls of air via the air inlet port to achieve airway seal. A one-way valve system prevents injected air from escaping.

• •

NOTE: If used correctly, there is no need for low pressure cuffs to be deflated ever hour. (Powaser et al 1976, Bryant et al 1971) Cuff pressures can be measured by using a spirometer attached to the air inlet port of the tracheostomy tube. Recommended cuff pressure is <25mmHg. This is presently no policy regarding this practice in this hospital.

CARE OF FENESTRATED TRACHEOSTOMY TUBE

USES OF FENESTRATED TUBES

1. To facilitate / improve speech - The
fenestration (hole) allows increased volumes of air to be forced up through the larynx during exhalation.

2. To

improve swallow function Restoring more normal airflow restores some of the protective mechanisms of normal swallow.
Figure 4. Fenestrated tracheostomy tube

NURSING CONSIDERATIONS WHEN USING FENESTRATED TUBES. • • • A fenestrated tracheostomy tube can only function as such if both the outer and inner cannulas contain a fenestration (hole)! The fenestration allows secretions as well as air to pass up and down the patient’s airway. If needed, give the patient a sputum container or tissues and bag for secretions. Speaking: Speech is facilitated by inserting the fenestrated inner cannula, and occluding the tracheostomy tube opening by using one of the following: (CUFF SHOULD BE DEFLATED) a) the patients finger b) a speaking valve c) a decannulation plug / cap / button. Suctioning: If suctioning is required, change to a non-fenestrated inner cannula. This is to prevent the suction catheter passing through the fenestration and traumatising the delicate lining of the posterior tracheal wall. Eating: While using a fenestrated tube restores some of the normal swallow protection mechanisms, nurses should be aware of and observe for signs of aspiration. Swallowing is further improved by having the cuff deflated and the tracheostomy opening occluded at the moment of swallow - methods outlined above. Cleaning of a fenestrated inner cannula is the same as for non-fenestrated tube. Store cleaned speaking valve, cap and spare inner cannula in a sealed, clean, container at the patient’s bedside (specimen containers available from theatre). dry

• •

CARE OF PASSY MUIR SPEAKING VALVE

HOW IT WORKS The speaking valve contains a movable plastic disc that opens on inspiration but closes on expiration. This means that during expiration no air can escape through the tracheostomy tube opening. It is redirected up through the larynx instead.

CLEANING INSTRUCTIONS. Clean daily - as per inner cannula or Wash in soapy water. Rinse thoroughly in cool-tepid water (not hot). Air dry.

WHILE WEARING THE VALVE, THE PATIENT WILL NOTICE........ • Air exhaling via the nose and mouth. • Expectoration returns to the normal route, i.e. the oral cavity. • Speech is improved, full sentences are possible. • Patients are able to blow their nose/sneeze • Oral + nasal secretions lessen because of • Occassional dryness of mucosa may occur. evaporation of secretions as air is exhaled. • Lung backpressure - normal feeling of restored volume - may take getting used to. • Energy levels may increase. • Strong coughing may blow off valve.

NURSING CONSDERATIONS WITH THE PASSY MUIR VALVE. • • • • • • • • • • • To use the valve the tracheostomy cuff should be deflated (see page on cuff care) To use the valve patients should also be medically stable, and have enough pulmonary compliance to exhale around the tracheostomy tube, and out through the nose and mouth. Stay with the patient during first wearing. (i.e.5-10mins or until patient is confident wearing valve). Increase wear-time as tolerated. Ensure patient has a sputum container or tissues and bag for orally expectorated secretions. Increased mouthcare is necessary if the patient experiences dry mouth. Assess the patient’s work of breathing. Observe for adequate exhalation - so that stacking of breaths is avoided. Observe secretions. Thick unmanageable secretions require a medical review by the patient’s team so that they are carefully evaluated and treated. If the patient complains of difficulty exhaling, downsizing of the tracheostomy tube usually allows enough airflow to enable valve use. DO NOT WEAR SPEAKING VALVE WHILE SLEEPING - this is to avoid the risk of the disc becoming clogged with sputum and preventing the patient breathing while he/she is sleeping. DO NOT THROW AWAY -speaking valves are not disposable, (they are single patient use).

DECANNULATION : REMOVAL OF TRACHEOSTOMY TUBE
Once the need for tracheostomy tube has resolved the doctor will decide to proceed with steps towards decannulation. Encouragement and support are particularly important throughout this phase of patient care.

STEPS OF DECANNULATION STEP 1 Downsizing of the tracheostomy tube • (at least 5-7 days after original tube insertion) • means changing to smaller size, cuffless, tube. (Check with doctor if fenestrated tube to be inserted at this time.) • This first tube change is ALWAYS carried out by a doctor. • Sometimes a second downsizing is necessary, before proceeding to....

NURSING CONSIDERATIONS Equipment required: Trolley, set with - Dressing pack, sterile gloves, new tube (+ smaller tube), tracheal dilators. stylet or suction catheter (to function as “guide-wire” during tube change), normal saline, KY gel, pencil torch, scissors, clinical waste bag. suctioning equipment, ambubag, ventilatory equipment if patient is ventilated. New dressing and ties. Leakage of air +/- secretions around the new tracheostomy tube may be noticed after smaller tube has been inserted. This is expected and will settle once the stoma reduces in size around the tube. • • • Once capped, the patient must breathe through their nose and mouth again. (Give 02 and nebulizers by face-mask now) CLOSE OBSERVATION is essential in case of respiratory difficulty. While many patients can tolerate continuous wearing of the cap, some find that it may takes getting used to. Therefore wear -time needs to be increased as tolerated. PATIENTS MUST BE TAUGHT TO REMOVE THE CAP THEMSELVES IF THEY EXPERIENCE ANY BREATHING DIFFICULTY. If breathing does not settle with removal of cap inform doctor.

STEP 2 Capping of the tracheostomy tube • This is achieved by applying an occlusive cap to the front of the tracheostomy tube. • Once capping is tolerated for at least 24 consecutive hours the doctor will decide if decannulation can occur.

STEP 3 Decannulation • The tracheostomy tube is removed, stoma edges are approximated, and an occlusive gauze + sleek dressing is applied • It takes approximately 10 days for the tracheotomy to heal.

• •

Encourage patient to press on the stoma dressing when coughing to prevent it being “coughed off”, and to prevent secretions escaping via the stoma. Change dressing if loose or soiled.

DEALING WITH EMERGENCIES
NOTE:

Tracheostomies are usually sutured in place for the first week after insertion and so are unlikely to be displaced.

IF THE TRACHEOSTOMY TUBE FALLS OUT !!...
• • • • • • • • • • DON’T PANIC! Once the tracheostomy tube has been in place for about 5 days the tract is well formed and will not suddenly close. Reassure the patient Call for medical help. Ask the patient to breathe normally via their stoma while waiting for the doctor. The stay suture (if present) or tracheal dilator may be used to help keep the stoma open if necessary. Stay with patient. Prepare for insertion of the new tracheostomy tube Once replaced, tie the tube securely, leaving one finger-space between ties and the patient’s neck. Check tube position by (a) asking the patient to inhale deeply - they should be able to do so easily and comfortably, and (b) hold a piece of tissue in front of the opening - it should be “blown” during patient’s exhalation.

ACUTE DYSPNOEA
..is most commonly caused by partial or complete blockage of the tracheostomy tube by retained secretions. To unblock the tracheostomy tube..... 1. ASK THE PATIENT TO COUGH: A strong cough may be all that is needed to expel secretions. 2. REMOVE THE INNER CANNULA: If there are secretions stuck in the tube, they will automatically be removed when you take out the inner cannula. The outer tube - which does not have secretions in it - will allow the patient to breath freely. Clean and replace the inner cannula. 3. SUCTION: If coughing or removing the inner cannula do not work, it may be that the secretions are lower down the patients airway. Use the suction machine to remove the secretions. 4. If these measures fail - commence low concentration oxygen therapy via a tracheostomy mask, and call for medical assistance. It is possible that the tracheostomy may have become displaced. Stay with the patient until assistance arrives. Prepare for change of tracheostomy tube.

RESUSCITATION VIA A TRACHEOSTOMY TUBE
IN THE EVENT OF A CARDIOPULMONARY ARREST, TREAT TRACHEOSTOMY PATIENTS AS ANY OTHER PATIENTS ...... PLUS..... STEP 1 EXPOSE THE PATIENT’S NECK Remove any clothing covering the tracheostomy tube DO NOT remove tracheostomy

STEP 2 CHECK THAT INNER CANNULA IS PATENT To check inner cannula: Wearing a non-sterile glove, remove inner cannula. If clean, reinsert and lock into place. If soiled replace. Continue resuscitation.

STEP 3 VENTILATE by using ambu-bag attached directly to tracheostomy tube

IF UNABLE TO VENTILATE: ..TRY SUCTIONING: This will clear any secretions blocking the airway below the end of the tracheostomy tube. ..IF STILL UNABLE TO VENTILATE: The tracheostomy tube may have become displaced. Doctor should: 1) Change tracheostomy tube - if unsuccessful...... 2) Orally intubate

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