Daily checks

There should be a detailed plan of care for all patients with a tracheostomy. A suggested care plan is provided in this manual, but local policies may already be in place. The care plan should be reviewed on a daily basis and updated if there is any change.

The patient with a tracheostomy needs diligent observation and assessment. The nurse caring for the patient is responsible for this, seeking advice from other professionals as appropriate.

Patient assessment

At the start of each shift, the staff nurse caring for the patient with a tracheostomy should carry out a full assessment of the patient, which should include:

• why did the patient have a tracheostomy?
  
• when was the tracheostomy performed?
  
• was it surgical or percutaneous (may have implications for ease of reinsertion) and does the patient have a larynx? (i.e. does the patient have a communication between the oral airway and the lungs?); bedhead signs at the patients’ bed space to quickly and easily communicate this information
  
• type and size of tracheostomy tube and availability of spare and emergency equipment
  
• cough effort
  
• ability to swallow, including any SALT assessments
  
• sputum characteristics (colour, volume, consistency, odour)
  
• check and change inner cannula for any build-up of secretions (see later)
  
• check tracheostomy holder is secure and clean
  
• check stoma dressing is clean
  
• routine observations.

This assessment should be documented on the care plan at the start of every shift.

Humidification

Heated humidification operates actively by increasing the heat and water vapour content of inspired gas. Gas can be delivered fully saturated at core temperature, depending on the system employed. A heater and water bath system is shown in Figure 5.1. These systems are indicated for tracheostomy patients requiring mechanical ventilation or oxygen therapy for ≥ 96 h. This type of humidification is more effective than heat moisture exchanger (HME) filters for those patients receiving artificial ventilation and should be used if the HME is not adequate.

Figure 5.1 A heater and water bath humidification system.

Cold humidification

Cold humidification bubbles gas through cold water, but only delivers a relative humidity of around 50% at ambient temperatures. For tracheostomy patients on high inspiratory flow rates of oxygen with tenacious secretions or patients complaining of subjective dryness, a heated device is indicated.Note: Condensation from heated or cold humidification should be considered infectious waste and disposed of according to hospital policy using strict universal precautions. Because condensate is infectious waste, it should never be drained back into the humidifier reservoir.

Saline nebulisation

The nebuliser unit converts saline into a supersaturated aerosol of liquid droplets which penetrate the lung, moistening the airways. It may be indicated in tracheostomy patients who are mechanically ventilated, receiving oxygen therapy or self-ventilating on air (Figure 5.2).

Figure 5.2 Saline nebulisation.

Saline nebulisers help to reduce the viscosity of secretions, which makes them easier to remove by suction or cough. Saline nebulisation involves administration of 5–10 ml 0.9% sterile normal saline into the nebuliser unit 2–4 hourly or as required. Nebulisers must be connected to a gas source with a flow rate of 6–8 l/min (or follow manufacturer’s guidelines). Remember that if the patient requires supplemental oxygen, then the gas driving the nebuliser should be oxygen and not air. Ensure that nebulisation is given via the tracheostomy (not the face mask!). A nebuliser can be attached to a tracheostomy mask or a T-piece circuit.

Heat moisture exchanger (HME)

HMEs consist of rolls of metal gauze or a condenser element like propylene sponge/fibre sheet/corrugated paper. These products are placed either directly onto the end of the tracheostomy tube or can be placed into a breathing circuit. They conserve heat and moisture on expiration via the tube. They need to be checked regularly to ensure they are not occluded by secretions, which may obstruct the airway. They require checking regularly and must be changed at least every 24 h. Some product ranges also offer oxygen delivery inlets, suction ports. Heat moisture devices are available as small cylinders or nozzles that attach directly to tracheostomy tubes, allowing for patient mobility and may have speaking valves incorporated in them (Figure 5.3).

Figure 5.3 Different types of HME: (a) thermovent, (b) for anaesthetic circuits and (c) ‘Swedish nose’.

Stoma filters or bibs

This group of humidification devices contains a foam layer that absorbs moisture from the patient’s expired gases. They are predominantly used for established tracheostomy patients and are often favoured by patients as they are less bulky and conspicuous and are able to completely obscure the tube from sight.

Figure 5.4 shows a ‘Buchanan bib’. These can be used by tracheostomy or laryngectomy patients and come in a variety of styles and designs. Some can disguise the stoma completely and the patient just appears to be wearing a scarf or cravat (see Figure 5.5).

Figure 5.4 A Buchanan bib.

Figure 5.5 Patients wearing stoma filters.

Mucolytics

This group of medications reduce the ‘thickness’ of secretions by breaking down some of the bonds that exist between the mucus. They are indicated when the patient has excessively thick secretions that are difficult to expectorate. Examples include hypertonic saline or acetylcysteine (via nebuliser), carbocysteine (via mouth) or DNAases such as dornase alfa (used in conditions such as cyctic fibrosis).

Hydration

Ensuring that the patient is adequately hydrated is essential in managing the secretion load of a patient. This can be enteral, intravenous or even subcutaneous.

Documentation

Given here is a list of practices that should be recorded.

• The method of humidification in use in the patient’s care plan or clinical record as per local procedure
  
• Evidence of evaluation and instigation of action taken in the patient’s care plan or clinical record as per local procedure
  
• A signature for accountability of care for each shift as per local procedure
  
• The date and time that devices are changed and/or are due to be changed.

Humidification ladder

The level of humidification required by patients will change depending on their clinical state, level of respiratory support required and their degree of hydration. If the current degree of humidification is not adequate enough, then the patient should be ‘stepped up’ to the next level. Patients with tracheostomies and laryngectomies are incredibly vulnerable to complications as a result of inadequate humidification, and the importance of preventing tracheostomy-related complications cannot be emphasised enough. This becomes even more important if the patient is unwell, dehydrated or has purulent secretions.

The humidification ladder

Heated water bath (active humidification)

• Ventilated patient with thick secretions
  
• Self-ventilating patient (on oxygen) with thick secretions

HME for breathing circuit

• Ventilated patient with minimal secretions (replace every 24 h)
  
• Monitor effectiveness (less likely to be effective if required for more than 5 days)

Cold water bath

• Self-ventilating patient (on oxygen)

HME (Buchanan bib, Swedish nose)

• Self-ventilating patients (no oxygen).

Add saline nebulisers or mucolytics and ensure adequate hydration if secretions aren’t improving.

Other methods of improving secretions

Mobilisation

There is good evidence, borne out by expert opinion and commentary, that mobilising patients will help improve the clearance of secretions. Mobilisation should be encouraged for all patients with an airway stoma. The assistance of physiotherapists is essential for patients who cannot mobilise independently, or who are sedated and/or ventilated. These interventions can be combined with aggressive chest physiotherapy.

There is evidence that patient movements and interventions can be associated with an increased risk of tracheostomy tube displacement, but others have clearly shown that careful mobilisation of even the most dependant patients can be achieved safely, without increasing the risks of tube displacement, while reducing the risks of pneumonia and shortening time receiving invasive ventilation.

Instilled saline

This practice is advocated by some when secretions prove difficult to manage. There is no clear evidence for benefit or harm. Saline is probably most effective when directed using a bronchoalveolar lavage, which is appropriate for discrete areas of mucus plugging, especially if associated with distal collapse or consolidation. Bronchoscopy may require sedation, but is technically straightforward via a tracheostomy in experienced hands.

Suctioning

Figure 5.6 shows a selection of ‘open’ suction catheters and a ‘closed’ suction system, as described earlier. Note the inverted red saline ampule.

Figure 5.6 Suction: (a) ‘open’ catheters and (b) a ‘closed’ system.

Patient assessment

In order for the practitioner to assess whether the patient requires suctioning, with an awake, cooperative patient, it may be possible to first encourage them to cough up the secretions, thereby reducing excessive suctioning. Support the patient in a position that will aid coughing (unless contraindicated) and address any factors that may reduce the effectiveness of coughing, such as pain or hydration status.

Indications that the patient may require suctioning include:

• noisy and or moist respirations
  
• increased respiratory effort
  
• prolonged expiratory breath sounds
  
• restlessness
  
• reduced oxygen saturation levels
  
• increased or ineffective coughing
  
• increased use of intercostal muscles
  
• patient request
  
• more sinister signs of airway obstruction such as hypoxia and cardiovascular changes.

Sedated or ventilated patients may have deep secretions, which may not lead to some of the signs described. These secretions may need to be mobilised by physiotherapy and attention to humidification before suctioning becomes effective.

Suction catheter selection

Tracheal damage and hypoxia may be caused during tracheal suction. This can be minimised by using the appropriate sized suction catheter. If the catheter is too large, the suction it creates can cause damage. A large catheter will also occlude the tracheal tube, which may cause hypoxia. It has been recommended that the diameter of the catheter should be no more than half the internal diameter of the tracheal tube. If the catheter is too small, it will not be adequate to remove secretions, so repeated attempts will be necessary. This has also been shown to damage the trachea. A rough guide to choosing the correct size of catheter was proposed by Odell and others (1993):

Table 5.1 illustrates this.

Table 5.1 Suction catheter sizing.

^a It is more appropriate to use a size 12 catheter because, although slightly larger than ½ diameter, it is more effective for secretion removal.

The frequency of suctioning

There is no clear consensus on how frequently a patient should receive suctioning. This will be dictated by the various patient factors related to the ability to spontaneously clear the secretions. Attempting tracheal suction at least once per 8 h strikes a reasonable practical balance. This should ensure that the tube remains patent. Failure to pass a suction catheter is a ‘Red Flag’ warning that that tube may be blocked or displaced and should prompt assessment by an appropriately trained individual.

The depth of suctioning

Passing a suction catheter to the tip of the tracheostomy tube can be considered ‘shallow’ suctioning. This is often all that is required if the patient has reasonably loose secretions which can be coughed towards the end of the tube. Passing a suction catheter any further than this can be considered as ‘deep’ suctioning and may be required if more shallow suctioning does not clear the secretions adequately. Many authors advocate advancing the suction catheter through the tube until it reaches the carina (where resistance will be encountered). The catheter should then be withdrawn slightly before suction is commenced. Clearly, the length of the tracheostomy tube in situ needs to be known so that the suction catheter is inserted to an appropriate distance. There is no clear message from the literature to guide suction technique, despite a Cochrane review.

The pressures for suctioning

Choosing the correct pressure is a balance of effectiveness of clearing secretions against limiting the potential for damage, either by directly traumatising the tissues or by aspirating oxygen from the trachea and contributing to hypoxia. Pressures used effectively in the literature range from as little as −80 mmHg to −300 mmHg. Most would agree that a pressure of no greater than −150 mmHg (−20 kPa) is appropriate for most patients.

Equipment for suctioning

• ‘Clean’ disposable gloves as per local policy
  
• Protective eyewear
  
• Appropriately sized sterile suction catheters (see selection guide earlier)
  
• Sodium chloride 0.9% ampoules (only for closed circuit units)
  
• Oxygen therapy—wall flow meter and tracheostomy mask—if necessary
  
• Oxygen saturation monitor—where appropriate
  
• Suction equipment (wall or portable unit)
  
• Disposable, sterile ‘double’ gloves can be used to keep the catheter tip sterile from the packet and allow easy disposal

Most closed suction systems allow the suction tubing from the wall-mounted suction unit to be constantly connected to the catheter assembly. To prevent continuous suction being applied, there is a valve to stop the suction being applied [white lock between the green sections in Figure 5.7(a)]. The tip of the catheter should always be in the withdrawn position when not being used, as shown [the visible black marker, as shown in Figure 5.7(b), indicates that the tube is withdrawn].

Figure 5.7 Closed suction systems showing (a) the valve to stop suction and (b) the black marker indicating the tube is withdrawn. (c) Open suction.

Summary

Table 5.2 summarises the key actions related to suctioning and their rationale (adapted from the NPSA expert working group).

Table 5.2 Suction—key actions to be taken and their rationale.

Videos demonstrating open and closed suction techniques can be found in the links given in the footnotes and as part of the e-learning modules available at www.tracheostomy.org.uk.

• Open suction¹
  
• Closed suction²
  
• Assessment of patency of a laryngectomy stoma³

Stoma care and securing the tube

Strict management of these dressings is essential, as wound degradation will occur if wet or soggy dressings remain in contact with the surrounding skin. The tracheostomy wound should be inspected at least daily. Any pus should be swabbed and sent for microbiological culture. Excessive moisture or secretions may be because of an underlying respiratory infection, which should be treated appropriately (Figure 5.8).

Figure 5.8 Tracheostomy dressings.

Inspection of the stoma should also include assessment of where the tapes or ties are in contact with the skin of the neck or face, including the back of the head. Sometimes, the patient’s head position means that the tube will cause pressure areas on the skin of the neck (Figure 5.9) or chest. Specialist advice and consideration of a different tube type may be required.

Figure 5.9 Pressure wound resulting from tube fixation.

Securing the tube in position

Tracheostomy tubes can be secured with cloth or cotton ties, or Velcro holders. A balance must be struck between securing the tube in position and minimising any risks of causing pressure ulceration (see Figure 5.10; with permission). One finger should be able to be inserted between the tape and the patient’s skin to ensure the tube is adequately secured. Tube displacement is more common in the first few days following tracheostomy insertion. Consequently, many centres will suture the tube to the neck skin in addition to the tracheostomy tapes for the first 7–10 days until the tract becomes well established. This may make removing the tube in an emergency more difficult should it become partially displaced and is not mandatory. Suturing also may make cleaning under the tube more difficult. The bedhead sign should make clear what sutures are in situ and how long they should remain for. The sutures pictured here are inflamed and should be removed if the stoma has matured.

Figure 5.10 Tracheostomy tube in situ with inflamed sutures visible (with permission).

Patient assessment

When selecting the most appropriate technique and product for securing the tracheostomy tube, consideration must be given to the risk factors that each patient is exposed to. A tracheostomy tube that becomes displaced is at risk of causing significant respiratory difficulties and/or airway obstruction. It is, therefore, vital to ensure the tracheostomy tube is appropriately secured at all times. Patients at risk of their tube becoming displaced are:

• those who are agitated or confused
  
• those with ventilator circuits attached
  
• those with tapes that are too loose allowing excessive tube movement.

Regular checks of the tapes will help prevent the tube becoming displaced. The patient who has undergone reconstructive surgery to the neck area, which may include a skin and/or muscle flap, may well require the tracheostomy tube to be secured without applying pressure to the delicate flap area. For such a patient, the tube is likely to be secured to the area directly surrounding the tracheostomy, by sutures. Care must be taken to ensure these sutures adequately support the tube in place and prevent tube misplacement.

Equipment in addition to standard bedside equipment

• Dressing trolley
  
• Gloves, disposable apron and protective eye wear
  
• Sterile dressing pack
  
• A 0.9% sterile saline solution (warmed ideally)
  
• Sterile gauze squares
  
• Tracheostomy dressing (pre-cut)
  
• Tracheostomy securing device: either Velcro tube holder or cotton ties (two pieces approximately 50–80 cm each)
  
• Blunt-ended scissors
  
• Barrier cream
  
• Suction unit with appropriate suction catheters.

Procedure

Two people should be present when changing the tapes to help prevent accidental decannulation. It should be clearly communicated throughout the procedure as to which person is responsible for holding the tracheostomy tube. The procedure must be undertaken using an aseptic technique to prevent contamination and risk of infection. Videos of dressing and tube tie changes can be found here, along with the e-learning sessions at www.tracheostomy.org.uk.

• Video of dressing and tube tie change⁴
  
• Dressings and ties captivate presentation here⁵

Documentation

Any dressing or tape change should be documented in the nursing and/or medical notes as appropriate. Any complication identified (e.g. infection and swabs taken) should be considered for further management and this also documented.

Granulation tissue

Overgranulation or hypergranulation at the site of the tracheostomy can be caused by an ill-fitting tube, excessive movement of the tube and/or in response to an infection at the wound site. This tissue can cause bleeding or pain at the wound site and in severe cases make tracheostomy tube changes difficult.

A polyurethane dressing significantly reduces the rate of hypergranulation. Treatment may include local application of silver nitrate. This requires local skin to be protected with petroleum jelly, and may require repeat applications until the overgranulation tissue has shrunken sufficiently. Figure 5.11 shows granulation tissue visible around a tracheo-oesophageal puncture (TEP) valve, which is visible via the laryngectomy stoma.

Figure 5.11 Granulation tissue around a TEP valve.

Patients undergoing radiotherapy to the neck

Carrying out a tracheostomy dressing and tape change for a patient undergoing radiotherapy to the neck must be carried out with caution and particular consideration to the increased discomfort the patient may experience.

Radiotherapy may cause radiotherapy burns, moist or dry desquamation and broken areas of skin. It is advisable to liaise with the radiotherapists to assess skin integrity and to advise on suitable skin treatments. Appropriate analgesia may also be required prior to tapes and dressing changes. It is also the practitioner’s responsibility to identify appropriate timing of tapes and dressing changes and not to be considered simply routine care to avoid unnecessary discomfort or skin damage.

Summary

Table 5.3 summarises key actions related to stoma care and their rationale (adapted from the NPSA expert working group).

Table 5.3 Stoma care—key actions to be taken and their rationale.

Management of the inner cannulae

Most tubes are available with removable, and therefore cleanable, inner cannulae. Designs and materials are improving all of the time and a tube with an inner cannula does not necessarily mean that the internal diameter (and subsequent resistance to air flow) is as compromised as it perhaps used to be with previous designs. Cleaning aims to remove secretions from the inner cannula to reduce the risk of potential obstruction with sputum and subsequent infection. Secretions can adhere to the internal lumen of a tracheostomy tube and severely reduce the inner lumen diameter over time. This potentially can increase the work of breathing and/or obstruct the patient’s airway.

The inner cannula should be removed and inspected at least once per 8-h shift or if the patient shows any signs of respiratory distress. For a patient undergoing mechanical ventilation, it may not be safe to repeatedly disconnect the ventilator circuit and change the inner tube routinely. Cleaning or changing an inner tube should always represent the best balance of risks to the patient. If an inner tube is not changed, then it should be clearly documented and communicated, along with the rationale.

Figure 5. EXTRA-1 (a) Inner tubes can be removed and cleaned and may have holes (fenestrations) in them. (b) Different manufacturers’ designs may require the inner tube to be in place to connect to a standard anaesthetic or ventilator circuit.

There is debate within the literature on the most appropriate cleaning solution to be used in the context of inner cannula care. A wide variety of solutions are used across healthcare including tap water, sterile water, sterile saline and hydrogen peroxide 10w/v (3%). Evidence to support the use of tap, sterile water or other solutions is equivocal and therefore local policies are highly likely to vary in their recommendations. This is acceptable from a patient safety perspective, but local practice should be influenced by the available water supply and quality, types of tubes used and patient condition. For most obtunded or acutely unwell hospital inpatients, sterile water would seem more appropriate.

It is important to note that the central rationale for cleaning of inner cannula is to mechanically remove debris which may physically obstruct a patient’s airway. A secondary outcome of mechanical cleaning is a reduction in the numbers of microbes present. Inner cannulae can be cleaned at the patient’s bedside.

It should be noted that there can be significant differences between the different manufacturers’ tubes. Kapitex and Shiley tubes commonly require an inner cannula to be in place so that the tubes can be connected to a 15 mm standard anaesthetic breathing circuit. It is therefore essential that patients with these types of tubes in situ have a spare inner tube with them at all times. Videos demonstrating these differences can be accessed by viewing the url present in the footnote.⁶

Disposable inner cannulae are also available from some manufacturers and can improve the ease and subsequent compliance with inner tube care. There is an associated cost and environmental consideration but this may be expected to improve with newer material technologies.

Equipment in addition to standard bedside equipment includes:

• clean, disposable gloves
  
• clean and dry replacement inner cannula
  
• tracheostomy cleaning devices (sponges or brushes)
  
• fragrance-free detergent
  
• cleaning solution: tap water, sterile water or sterile saline (refer to local guidelines from infection control department)
  
• clean and dry covered container for spare inner cannula.

Procedure

Cleaning an inner tube is a relatively straightforward procedure. The inner cannula is removed and inspected. If clean, it can simply be replaced. If it needs to be cleaned, then a spare tube should be inserted at this point. Patients will therefore have one inner tube in situ and one at the bedside being cleaned or drying. Dedicated cleaning packs are commercially available, which makes cleaning quicker and easier (and often more likely to occur).

The tubes should be visibly clean and this can usually be achieved with saline and a foam brush or gauze. Abrasive wire brushes may cause scratch marks on the inside of the tubes and risk colonisation. The tubes are then left to dry in a suitable container. It is essential that the tubes do not sit in water as this may lead to bacterial growth.

Disposable inner tubes are increasingly available and affordable.

Videos demonstrating changing an inner cannula can be accessed in the links given in the footnotes, or by visiting the e-learning section of the website www.tracheostomy.org.uk.

• YouTube video of inner tube changes⁷
  
• narrated e-learning link⁸ (requires flash player)

Documentation

Documentation should include accurate records of inner cannula care in the required format within the patient’s record as per local guidance. Ensure handover of all information, reporting any problems in changing the inner cannula or missing inner cannulae.

Summary

Table 5.4 summarises key actions related to stoma care and their rationale (adapted from the NPSA expert working group).

Table 5.4 Inner cannulae—key actions to be taken and their rationale.

Oral care and swallowing

Figure 5.12 shows an inflated tracheostomy tube. The cuff is pressing on the oesophagus behind the trachea, offering a physical obstruction to swallowing. The tracheostomy tube tethers the anterior structures of the neck and limits the amount of movement of the larynx and upper airways that is required for normal, safe swallowing.

Figure 5.12 The cuff of the tracheostomy tube can be seen to be impinging on the oesophageal lumen.

Reproduced with permission of HEE eLfH.

Related posts:

How the NTSP resources were developed Red flags Courses Human factors Different types of tracheostomy tubes Why and how a tracheostomy is performed

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