1. TRACHEOSTOMY CARE
Rosie Ratcliffe (Previous Macmillan Head and Neck Clinical Nurse Specialist)
Amended 2012

2. 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

3. 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.

4. 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

5. 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

6. 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

7. 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

8. 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

9. Common complications
Tracheostomy complications are usually divided into 3 categories
Intra-operative
Early post-operative
Late post-operative

10. Intra-operative Bleeding Tube malpostion
Tracheal / trache-oesophageal laceration
Recurrent laryngeal nerve damage
Pneumothorax

11. Early post-operative Bleeding Tube blockage Infection
Subcutaneous surgical emphysema
Tube malpostion
Displacement

12. 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

13. 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.

14. 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.

15. 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.

16. 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

17. 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 mmHg / 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

18. 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.

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. SPEECH

26. 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

27. TROUBLE SHOOTER

28. Leak due to deflation cuff

29. Partial withdrawal
Partial withdrawal

30. Ulceration into oesophagus

31. Leak due to deflation and surgical emphysema

32. Obstruction due to herniation of cuff over end of tube.

33. Obstruction due to kinking

34. 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.

35. Blockage by secretions

36. Dilation of trachea by over inflated cuff.

37. 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

38. Any questions?