The increasing demand for prolonged ventilation and therefore tracheostomies has lead to the increase number of patients being nursed on the wards with tracheostomies, Russell & Harkin (2001)
The ENT ward may be required to care for, not only, the ENT patients but patients from other specialities where the ward team are insufficiently equipped to care for this group of patient. However, with the evolving role of the tracheostomy practitioner the 'general' wards are being formally trained and supported in the care delivery and management of their patients with tracheostomies.

This care guide will cover the main issues surrounding the care of a patient with a tracheostomy.

• Indications for a tracheostomy
  
• Anatomy and physiology
• Airway options
• Formation of a tracheostomy
• Pre-operative care
• Peri-operative care
• Post-operative care
• Complications
• Humidification
• Suctioning
• Wound Care
• Speech and Language Assessment and Management
• Weaning
• Long term tracheostomy care and management
• Tube changes
• Tube types
• Paediatrics

Indications for a tracheostomy

• Upper airway obstruction (actual/potential)
  
• Prolonged artificial ventilation
• Facilitate bronchial toilet
• Head injuries
• Aspiration caused by Laryngeal nerve damage

Anatomy and Physiology Diagram needed to show:

larynx, pharynx, epiglottis, glottis, cricothyroid membrane, vocal cords, trachea, oesophagus, thyroid cartilage, blood and nerve supply.

Upper Respiratory Tract

• Warms inspired gases to body temperature
  
• Humidification of inspired gases to 100% humidity at 37degrees centigrade.
• Protects the bronchial tree from infection

Consists of:

• Nasal cavities
  
• Pharynx
• Larynx
• Trachea
• Carina

Percutaneous Dilatational Tracheostomy

The patient eligible for this procedure will have easily identified anatomical landmarks to allow the tracheostomy to be placed between the 1st / 2nd or 2nd/3rd tracheal cartilages.
This procedure has the potential to increase safety for the patient who can have the procedure carried out in the intensive care setting at the appropriate time for the health care team and the patient, whilst reducing the wait for the surgical team and/ or theatres to become available.
N.B: The post-operative care should be identical but it should be made aware that if accidental decannulation occurs within the first 5 days the replacement of the tube may de more difficult due to the snug fit of the skin around the shaft of the tube.

Surgical Tracheostomy

This is by far the most common technique used within the ENT unit due to the patient's conditions. This procedure requires regular pre-operative work-up due to the use of a general anaesthetic.
The skin incision will allow visualisation of the thyroid lying above the trachea. The thyoid isthmus will then be dissected to expose the trachea. A window or flap (bjork) will be made into the trachea and the endotracheal tube will be raised and the appropriate tracheostomy tube inserted and where appropriate the cuff will be inflated.
The skin is then closed and to help prevent accidental tube displacement/misplacement the tracheostomy tube itself is also sutured into place. Care is taken to prevent surgical emphysema by too tight sutures.
In an emergency situation a local anaesthetic can be used prior to the tracheostomy being performed. The patient will then be likely to receive a general anaesthetic only when the airway has been secured.

Minitracheostomy (cricothyroidotomy)

This airway option is performed for patients who require bronchial toilet or where time and facilities do not allow for a more formal tracheostomy. The minitrach tube is inserted between the thyroid and cricoid cartilage (adams apple). The tube is uncuffed and has an inner diameter of 4.0mm which allows a size 10fg catheter to pass down it.
This form of airway is an emergency option which should be converted to a formal tracheostomy if the patient still requires airway support after 24 hours.

Pre-operative care

Patient preparation should include a realistic explanation of what to expect.
The patients should be prepared about the altered breathing sensation and the care that this will require i.e: humidified oxygen therapy and suctioning.
Due to the absence of airflow for phonation the patient must be given alternative methods of communication. The literacy of the patient must be considered to ensure the appropriate aides to be supplied i.e: pen and paper, picture charts and call system.

To ensure the patient is nursed in a safe environment the immediate bed environment must include

• Spare tracheostomy tubes (one same size /one size smaller)
  
• Tracheal dilators
• Scissors/stitch cutters
• Syringe
• Re-breath bag and tubing
• Suction equipment with appropriate size cathters
• Gloves

Peri-operative care

(For all types of tracheostomy)

1. Place a pillow under shoulders to permit full extension of head and neck.
2. Control patient respiration with ventilator and sedation, as necessary.
3. Endotracheal tube cuff to be deflated and tapes loosened (but not removed).
4. Prep and drape the anterior neck area.
5. Local anaesthesia may be required to surrounding area.
6. Endo-tracheal tube will be withdrawn to prevent damage to tube during stoma formation.
7. Procedure carried out either by formation of surgical window or dilatation.
8. Position will be checked by positive air presence and by endoscopy.
9. Endotracheal tube will be removed once tracheostomy tube has been successfully inserted and cuff inflated.
10. Suction via tracheostomy tube to remove blood and secretions.
11. Skin incision closed.
12. Tracheostomy tube is secured by the use of sutures through neck plate to skin and velcro tapes (unless contra-indicated).

Complications

Immediate

• Haemorrhage
• Tube misplacement/displacement
• Pneumothorax

Immediate

• Tube occlusion by secretions and/or blood
• Infection -chest/local skin
• Cuff under/over inflation
• Surgical emphysema

Late

• Tracheal ulceration
• Tracheo-oesophageal fistula
• Tracheo-cutaneous fistula
• Granulation tissue (skin/tracheal)
• Tracheal stenosis (at incision or cuff site)
• Scar formation

Post -operative Care

The following paragraphs are related to the care required to ensure a safe airway and an appropriate approach to patient rehabilitation.

Humidification

The 'normal' function of the upper respiratory tract is an effective method at reducing infection and maintaining effective gas exchange.
Over humidification

• Poor gas exchange
• Increased secretions due to decreased evaporation
• Degeneration and adhesion of cilia
• Condensation of water droplets causing atelectesis
• Mucosal cooling/burning

Under humidification

• Heat loss
• Dehydration of respiratory tract
• Epithelial damage
• Impaired function of mucocilary elevator
• Sputum retention
• Atelectasis
• Bronchospasm from dry gases/ cold water

Options

Ultrasonic delivery system
Water delivery system	- kendall aerodyne
	- Fisher Packell
Saline nebulisers
Heat and moisture exchange filters (swedish noses)
Buchanan Bibs

Suctioning

Why?
To help clear secretions and maintain a patent airway.

Patient assessment.
Are there audible secretions which the patient is unable to clear themselves.
Is the patient coughing?
Is there a decreased oxygenation saturation.
Is the patient more anxious?
Has the patients respiration rate and/or pattern changed?
Has the patients pallor changed?

Equipment needed.
Gloves and eyeshield
Appropriate size of suction catheter (max. of half of inner lumen diameter)
Suction collection container and tubing (cleaned every 24hours)
Non-sterile gloves
Has the patients pallor changed?

How?
Prepare the patient-position and explanation of procedure
Connect appropriate catheter to suction tubing
Suction pressure not to exceed 150mmHg/20kPa (adult levels)
Pre-oxygenate patient if necessary
Put on clean gloves
Withdraw catheter from sleeve
Insert catheter to the level of distal end of tracheostomy tube (to reduce tracheal ulceration)
Apply suction only on withdrawal of catheter
Dispose of glove and catheter each time
Rinse tubing by suctioning clean water through tubing
Assess for need for further suctioning
Record viscosity and quantity of secretions.
Reassess effectiveness of humidification

Complications

There are complications by the ineffective or inappropriate use of suctioning, therefore it should only be carried out when necessary.
The complications are:

• Cardiovascular instability (vagal stimulation)
• Hypoxaemia (cardiac arrhythmias)
• Pneumothorax (neo-nates)
• Bronchospasm
• Aspiration of stomach contents
• Infection
• Mucosal Irritation
• Tracheal necrosis
• Pain
• Anxiety

Size chart

Wound Care

The surrounding skin is at risk of breakdown due to the presence of chest secretions leaking from the stoma site.
The purpose of a dressing is to absorb wound exudate and remove from skin surface, prevent skin breakdown from the tube and to offer patient comfort.
A tracheostomy dressing must be pre-cut to reduce the risk of loose fibres becoming dislodged from the dressing and tracking into the trachea.
A popular method of skin protection is the application to intact skin of a barrier film e.g: Cavilon foam applicators, (3M).

Dressing Options

• Metalline
• Lyofoam T
• Trachi-dress (Kapitex)
• Cavilon (3M)

Tapes

To reduce the risk or accidental tube misplacement /displacement the tube will require some form of device to maintain position.
There are several questions that should be asked prior to choosing a device:

• Is the surrounding skin intact and able to withstand the pressure/abrasion from a tape/ribbon?
• Is the patient at risk of dislodging the tube? (age, agitation, neurological status, risk of falls?)
• Has the patient had a flap formation on the neck area which would be damaged by tapes?

Options
Sutures
Ribbon tape (non-elastic)
Velcro tapes

Speech and Language Assessment

Due to the positioning of the tracheostomy tube, in particular the cuffed tube used as the first tube for the adult patient, the patient will experience an absence and/or difficulty with both swallowing and phonation.
The early involvement of the speech and language therapist will ensure the timely and appropriate introduction of swallowing and phonation trials post-operatively.
The swallowing assessment will consider the following criteria:

• Indication for the tracheostomy
• Upper airway obstruction
• Oral mobility
• Signs of aspiration
• Blue dye test
• Laryngeal elevation

The formation of a tracheostomy will bypass the 'normal ' upper respiratory tract. This eliminates the vital functions of the upper airway in effective gas exchange (see anatomy and physiology).
To reduce the risk of poor gas exchange, sputum retention and tube/airway occlusion it is essential to deliver supplementary humidification.

Tube types (table with uses/benefits/limitations/costs/manufacturers)
Routine use
Cuffed
Uncuffed
Fenestrated

Single lumen (paediatric)
Double lumen (replacable/disposable)
Specials
Extendable neck flange
Length variables (distal/proximal)
Materials(silver/plastic/silastic)

Tube changes
First tube change
Ventilated/cuffed tube change
Patient self care

Paediatrics
Indications
Special considerations:

• Safety/tube ties
• Play objects bathing/sand/small objects
• Acceptance of tube-play therapist
• Inner tube
• Uncuffed tube

Weaning
From article
Weaning chart

Long term tracheostomy
Ventilation
Self care
Preparation
Equipment required
Multi-disciplinary involvement/training
Tube changes
Support/troubleshooting
Emergency kit

Patient advice and leaflet and supplies details
Shiley (Tyco)
Portex
Kapitex

References

Day,T.	(2000) Tracheal suctioning: when, why and how. Nursing Times:96:20, 13-15
Harkin, H.	(1998) Tracheostomy management. Nursing Times; 94:21. 56-58
Heafield, S et al	(1999) Tracheostomy management in ordinary wards. Hospital Medicine; 60: 4, 261-262
Laws-Chapman, C.	(1998) Tracheostomy tube management. Care of the critically ill: How to guides; 14: 5S
Russell, CA & Harkin H, Serra, A	(2000) Tracheostomy Care. Tracheostomy Standard; 14: 42, 45-52

 

 

 

 

 

 

 

 

Claudia Russell

Aid for Children with Tracheostomies is a national self help group operating as a registered charity. It was founded in May 1983 and is run by parents of children with a tracheostomy and by people who sympathise with the needs of such families. ACT as an organisation is non profit making, it links groups and individual members throughout Great Britain and Northern Ireland. For further information visit: www.actfortrachykids.com