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 Describe difference with a laryngectomy – e.g. Laryngeal cancer or deficit in swallow or laryngeal function in neurological disease. Separates lungs and trachea from mouth.

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 Active treatment- Don’t panic Call for help ( Senior H & N Surgeon) Reassure patient Bleeding may temporarily be reduced by applying finger pressure to the root of the neck in the sternal notch. If cuffed tube in situ inflate cuff. Await senior medical assistance for urgent intervention. Let theatre know.

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 Don’t panic Call for help ( Senior Medical / Nursing Staff / Other AHP’s / Physio. Reassure the patient Assess patency of airway / breathing. If patient breathing spontaneously and co-operative encourage to give vigorous cough- this may relive the obstruction. Remove inner cannula and replace with a clean one. If blockage still present attempt tracheal suction this may relieve the obstruction The full tracheostomy tube may need removing ideally by competent practitioners, but may be neccassary in life threatening situation , when above have not worked.

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. Don’t panic Call for help ( Senior H & N reg or above ) Reassure the patient If tube is partially dislodged check tube patency the patient may still be able to breathe through it with difficulty. Remove inner cannula to increase tube airway capacity. Check oxygen sat administer oxygen if necessary Senior medical staff may re insert a new tube. If the tube is completely removed within 72 hrs , tracheal dilators may be used to keep stoma open. If tube is completely removed after 72 hrs administer oxygen and await senior medical intervention for tube re insertion.

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 Check patient sats, consider hyperoxygenation. Can make deterioration quicker in COPD Change suction tubing / walled suction collection bottle at least every 2 hours Sterile water bottle (date and discard and replace at least every 24 hours) Position patient as upright as possible with head in neutral alignment Always suction with non fenestrated inner tube Suction unit 100-120mmHg / 13-16kPa (ICS, 2008) to minimise risk of atelectasis collapsed lung tissue Insert tubing no more than a 1/3 of catheter advanced Suction for no longer than 10 seconds Catheter size = (Trachy size -2) x 2 e.g. Size 8 trachy would be size 12Fg suction catheter Check O2 sats Suction can make pt cough, this is ok

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 Long term water humidification can increase risk of respiratory infections and make the stoma wet / sore.

NORMAL MECHANISM OF HUMIDIFICATION Temp 37°C, Rel. Humidity 100% 5cm below carina Ciliated Epithelial Cells Many hair-like structures on each cell beat within an aqueous layer Aqueous Layer Low viscosity fluid- cilia protrude upwards through the aqueous layer on forward stroke to engage mucuc. Curling back within the fluid on backwards stroke releasing mucus. Action moves mucus upwards. Depth of layer is critical for effective movement Gel Layer Floats on top of aqueous layer to trap contaminants and moved from the airways by cilia. The moisture content of mucus is important as dry mucus cannot be moved

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

Leak due to deflation cuff

Partial withdrawal 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. Voice Tube extending from stoma De-saturation Pallor Absent or reduced expired air Unable to pass Suction catheter Respiratory distress 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?