TRACHEOSTOMY CARE

Rosie Ratcliffe (Previous Macmillan Head and Neck Clinical Nurse Specialist)

Amended 2012

Aims

To provide basis awareness of caring for patients with tracheostomy tubes

To understand the safety implications when dealing with tracheostomies

To understand complications and emergency procedures with tracheostomy tubes

What is a Tracheostomy?

A tracheostomy is a surgical procedure that is usually performed under a GA or LA (tracheotomy). It is an incision into the trachea (windpipe) that forms a temporary or permanent opening called a stoma

A tube is inserted through the opening to facilitate breathing, protection from aspiration in cases of swallowing impairment and facilitate clearance of secretions

Reasons for a Tracheostomy

Airway obstruction e.g. Upper airway tumours

Lower airways toilet Neurological disease e.g. MND Vocal Cord Paralysis Laryngeal injury or spasms Severe neck / mouth injuries Airway burns from inhalation

smoke/steam Anaphylaxis

Types of Tracheostomy Tubes Double lumen tubes – consist of inner and outer

tubes to aid clearance of secretions without changing the complete tube. Tracoetwist, Tracoecomfort, Shilleys

Fenestrated tubes – these are double lumen with holes built into the shaft to allow air to flow through the vocal cords to facilitate speaking

Both these tubes come either non-cuffed or cuffed

Cuffed tubes - low pressure air filled cuff at the distal end of the tube allows sealing of the airway used to prevent aspiration and facilitate ventilation

Cuffed tubes

Seal the airway to facilitate the delivery of positive ventilation

Prevent airflow through larynx Protect the airway Prevent risk of aspiration External pilot balloons which indicate

when the cuff is inflated or deflated The cuff may impair swallowing due to

pressure on the oesophagus

Un-cuffed tubes

Maintain airway patency Do not protect from aspiration Enable voice around the tube May be used to wean Used for long term tracheostomy

patients Not commonly seen in the acute setting

Cuff pressures

Cuff pressure should be maintained between 15 – 22mmHg

Check pressure by using manometers – every shift, minimum of twice in 24 hours

Minimal occlusion pressures / minimal leak texhnique (auscultation around suprasternal notch) not recommended due to risk of silent aspiration

Voice Syringe

Common complications

Tracheostomy complications are usually divided into 3 categories

Intra-operative Early post-operative Late post-operative

Intra-operative

Bleeding Tube malpostion Tracheal / trache-oesophageal laceration Recurrent laryngeal nerve damage Pneumothorax

Early post-operative

Bleeding Tube blockage Infection Subcutaneous surgical emphysema Tube malpostion Displacement

Late post-operative

Granuloma (growth of inflammatory tissue caused by irritation)

Tracheal stenosis (abnormal narrowing of trachea e.g. from tracheal tumour)

Tracheomalacia (flaccidity of tracheal cartilage causing tracheal collapse e.g. from fistula)

Trachoesophageal fistula Mucosal ulceration

Main life-threatening complications and their management - Bleeding Bleeding – this is the most common complication

of a tracheostomy. It may occur early or late. Minor- settles with conservative management Major- requiring blood transfusion, surgical

exploration / other intervention Management depends on the context in which

the bleeding occurs Palliative management: Dark green towels, crisis

medication, psychological support, suction, external pressure to bleeding site, communication to patient / family debated. Priority - STAY WITH PATIENT

Tube blockage

Tracheostomy tubes can become blocked with thick tracheal secretions, blood or foreign bodies. Presentation may be increasing respiratory distress over a few hours or more rapid deterioration

This can be LIFE THREATENING if not rapidly resolved

Prevention - adequate humidification, regular inner tube changes, suction

Displaced trachesotomy tubes Tubes can become displaced through a

loose or inadequately positioned neck tape, excessive movement of the patient, patient agitation or pulling of equipment that is attached to the tracheostomy tube. A dislodged tube is more dangerous than a completely removed tube

Prevention - regular checks of neck tape, ensure equipment is attached safely, manage agitation, regular observation of patient.

Suctioning

Suctioning can be both uncomfortable

and distressing for the patient, therefore where possible patients should be encouraged to expectorate their own secretions

Patients individual needs need to be assessed frequently

Indications for suctioning - unable to expectorate, blockage in tracheostomy tube

Suctioning Complications

Hypoxia Bradycardia Tracheal mucosal damage Bleeding Infection

Types of humidification

Heat and Moisture Exchanger (HME) Thermovent –T, Inter-surgical HME

common in acute settings Trachi-naze filters, Buchanan bibs

common in long term settings Water humidifiers - Fischer-Paykel

(heated) Respiflow (cool) Saline nebulisers Trachi-spray

20°C 50%

34°C 75%

Temp 37°C, Rel. Humidity 100% 5cm below carina

NORMAL MECHANISM OF HUMIDIFICATION

Tube changes

Tracheostomy tubes should be changed every 28 days as per the European Economic Community Directive (1993)

The first tube change should be carried out by a medical practitioner with appropriate, advanced airway skills

Health professionals who have undergone training and confident / competent

INDICATIONS FOR CHANGING TRACHEOSTOMY TUBE:

Elective:Monthly Assess stoma/ trachea and granulation tissue at stoma

site and / or fenestration Facilitate weaning Speech production Patient comfort

Emergency Blocked tube Misplaced or displaced tube Cuff failure Faulty tube Aspiration Hypoxia Anxiety/Discomfort

Stoma care

Review stoma each shift Assess stoma Clean with NaCl and dry carefully Use barrier cream to protect skin Apply trachi dressing under tube Change neck tapes at least weekly Ensure neck tapes are secure allow 2

fingers to fit between the tapes and neck

Communication

The impact of the loss of normal voice following a tracheostomy should not be under estimated

Loss of voice occurs because no air is passing over the vocal cords

Communication facilitates- expression of feeling, reassurance, patients needs, advice, counselling, social interaction, information giving

Alternative methods of Communication

Non-verbal Lip reading Coded eye blinking Hand gestures Alphabet board / Picture borad Light writer Cuff deflation / fenestrated tubes Intermittent finger occlusion Speaking valves

SPEECH

Teaching patient to live with Tracheostomy

Need lots of reassurance and advice Involve patient in stoma care from an early

stage, changing inner tube frequently Involve SALT with swallowing and speaking Show patient how to clean around stoma

and encourage this on a daily basis Advice re: looking after skin around stoma

site Altered body image

TROUBLE SHOOTER

deflationdeflation

Leak due to deflation cuff.

Partial withdrawal

Ulceration into oesophagus

Leak due to deflation and surgical emphysema

Obstruction due to herniation of cuff over end of tube.

Obstruction due to kinking

Misplacement into pre-tracheal tissues.

Blockage by secretions

Dilation of trachea by over inflated cuff.

Summary

Each shift always check the tracheostomy tube is patent

Know what type / size of tube is in place Know patients normal observations if

appropriate Know if the cuff is inflated / deflated Know emergency procedures Refer to protocol Always know the patients resuscitation

status

Any questions?