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These guidelines have been produced as an educational support and guide for health
care professionals caring for tracheostomy patients in the clinical setting. Advice on
the care of a specific patient should always be sought from a suitably qualified
professional.
The guidelines have been ratified by the Head and Neck Nurses Association of
Ireland (HANNA) and are recommended for use by its members.
• Overview of tracheostomies
• Bedside equipment.
• Care of the inner cannula, stoma site and tracheostomy ties.
• Suctioning via a tracheostomy tube.
• Humidification of inspired gases.
• Care of cuffed tracheostomy tube
• Care of fenestrated tracheostomy tube
• Care of Passy Muir speaking valves.
• Decannulation: removal of tracheostomy tube.
• Dealing with emergencies.
• Resuscitation via a tracheostomy tube.
OVERVIEW OF TRACHEOSTOMY TUBES
1. Outer tube
2. Inner tube: Fits snugly into outer tube, can be easily removed for cleaning.
3. Flange: Flat plastic plate attached to outer tube - lies flush against the patient’s
neck.
4. 15mm outer diameter termination: Fits all ventilator and respiratory equipment.
Every patient with a tracheostomy tube should have the following equipment available at the
bedside:
• Gloves Non-sterile **
Sterile gloves (for suctioning)
• Dry clean container for holding the speaking valve, occlusive cap/button or spare inner
cannula when not in use. (Get from theatre)
**Natural rubber latex gloves to be used by all except those who have latex allergy.
Nitrile gloves to be used by those with latex allergy.
CARE OF THE INNER CANNULA, STOMA SITE AND
TRACHEOSTOMY TIES
To check inner cannula: Wash hands. Wearing a non-sterile glove, remove inner cannula.
Handle only the outer portion of the cannula. If clean, reinsert and lock into place. If soiled -
continue with step (d) below.
Note:
Leave first dressing intact for 24hrs if possible as the tracheostomy is a fresh wound.
SUCTIONING VIA A TRACHEOSTOMY TUBE
(a) Explain the procedure to the patient - wash hands, put on gloves. Put on apron and
fluid shield mask if necessary for standard (universal) precautions). Turn on
suction apparatus and test that vacuum pressure is < -150mmHg.
(b) Open / expose only the vacuum control segment of the suction catheter and attach
to the suction tubing.
(c) Put on disposable sterile gloves over the non-sterile gloves and withdraw the
sterile catheter from the protective sleeve.
(d) Maintaining sterility, insert the suction catheter with NO suction applied until
resistance is met, then pull back about 1-2 cms before applying continuous suction
as the catheter is smoothly withdrawn from airway.
NOTE: Recommended suction time (i.e. from insertion to removal of suction
catheter) = <15secs
Use a new sterile catheter for each suction pass. (Stone et al ’91,
Young ’84, Carroll ’88, Link et al ’76).
No more than 3 passes recommended per treatment.
(e) On completing procedure, ensure patient comfort, discard of equipment as per
hospital policy, wash hands and document procedure in the patient’s notes.
HUMIDIFICATIONOF INSPIRED GASES
NOTE: All patients with tracheostomy tubes require humidification of inspired gases.
• The method used for humidification can be altered as the patient’s condition changes
• Do not combine methods - use one at a time.
.
NURSING MANAGEMENT
HEATED HUMIDIFERS
• Set up as per operators manual.
• Monitor temperature of inspired gases. This is easily achieved if the system used
has a digital temperature display. If it does not, then test the temperature by
holding the oxygen tubing against a clean bared inner arm. Gas flow should feel
at body temperature.
• Monitor water level and change bottles PRN.
• If condensation collects in tubing, - drain tubing into a sterile jug and dispose of
into sluice.
• Using clean technique, change all tubing weekly. (Date tubing when changed)
NEBULIZERS
• Administer as prescribed.
• Wash in warm soapy water, rinse and dry thoroughly after each treatment.
CARE OF CUFFED TRACHEOSTOMY TUBE
• Immediately post-operatively - to
prevent aspiration of blood or serous
fluid from the wound
• To seal the trachea during mechanical
ventilation
• To seal the trachea during swimming!
• To prevent aspiration of leakage from
tracheo-oesophageal fistula
• To prevent aspiration due to laryngeal
incompetence
NURSING MANAGEMENT
• Tracheostomy cuff is inflated only - (a) if the patient is being mechanically ventilated,
(b) if inflation is specifically ordered by doctor.
• Check with doctor that it is OK to do so , and then proceed with cuff deflation......
• Patients can be extremely sensitive to changes in cuff pressure. A little coughing is not
unusual during manipulation. Take care to explain the procedure to the patient and to
inflate / deflate the cuff slowly.
• To deflate cuff: First, suction the oropharynx to remove any secretions that may have
pooled on top of the inflated cuff. Then, using a syringe, slowly aspirate air from the air
inlet port. Once deflated, expiratory noises may be heard as air passes up around the
tracheostomy tube. Reassure the patient that these are normal and will settle.
• To inflate cuff: Inject approximately 5-7mls of air via the air inlet port to achieve airway
seal. A one-way valve system prevents injected air from escaping.
NOTE:
• If used correctly, there is no need for low pressure cuffs to be deflated ever hour. (Powaser et
al 1976, Bryant et al 1971)
• Cuff pressures can be measured by using a spirometer attached to the air inlet port of the
tracheostomy tube. Recommended cuff pressure is <25mmHg. This is presently no policy
regarding this practice in this hospital.
CARE OF FENESTRATED TRACHEOSTOMY TUBE
• A fenestrated tracheostomy tube can only function as such if both the outer and inner
cannulas contain a fenestration (hole)!
• The fenestration allows secretions as well as air to pass up and down the patient’s airway.
If needed, give the patient a sputum container or tissues and bag for secretions.
• Speaking: Speech is facilitated by inserting the fenestrated inner cannula, and occluding
the tracheostomy tube opening by using one of the following: (CUFF SHOULD BE
DEFLATED) a) the patients finger
b) a speaking valve
c) a decannulation plug / cap / button.
• Eating: While using a fenestrated tube restores some of the normal swallow protection
mechanisms, nurses should be aware of and observe for signs of aspiration. Swallowing is
further improved by having the cuff deflated and the tracheostomy opening occluded at
the moment of swallow - methods outlined above.
• Store cleaned speaking valve, cap and spare inner cannula in a sealed, clean, dry
container at the patient’s bedside (specimen containers available from theatre).
CARE OF PASSY MUIR SPEAKING VALVE
The speaking valve contains a movable Clean daily - as per inner cannula
plastic disc that opens on inspiration but or
closes on expiration. This means that Wash in soapy water.
during expiration no air can escape Rinse thoroughly in cool-tepid water (not hot).
through the tracheostomy tube opening. It Air dry.
is redirected up through the larynx instead.
• To use the valve the tracheostomy cuff should be deflated (see page on cuff care)
• To use the valve patients should also be medically stable, and have enough pulmonary
compliance to exhale around the tracheostomy tube, and out through the nose and mouth.
• Stay with the patient during first wearing. (i.e.5-10mins or until patient is confident
wearing valve).
• Increase wear-time as tolerated.
• Ensure patient has a sputum container or tissues and bag for orally expectorated
secretions.
• Increased mouthcare is necessary if the patient experiences dry mouth.
• Assess the patient’s work of breathing. Observe for adequate exhalation - so that stacking
of breaths is avoided.
• Observe secretions. Thick unmanageable secretions require a medical review by the
patient’s team so that they are carefully evaluated and treated.
• If the patient complains of difficulty exhaling, downsizing of the tracheostomy tube
usually allows enough airflow to enable valve use.
• DO NOT WEAR SPEAKING VALVE WHILE SLEEPING - this is to avoid the risk
of the disc becoming clogged with sputum and preventing the patient breathing while
he/she is sleeping.
• DO NOT THROW AWAY -speaking valves are not disposable, (they are single patient
use).
DECANNULATION : REMOVAL OF TRACHEOSTOMY TUBE
Once the need for tracheostomy tube has resolved the doctor will decide to proceed with steps
towards decannulation.
Encouragement and support are particularly important throughout this phase of patient care.
STEP 3
Decannulation • Encourage patient to press on the stoma dressing
• The tracheostomy tube is removed, stoma when coughing to prevent it being “coughed off”, and
edges are approximated, and an occlusive to prevent secretions escaping via the stoma.
gauze + sleek dressing is applied • Change dressing if loose or soiled.
• It takes approximately 10 days for the
tracheotomy to heal.
DEALING WITH EMERGENCIES
NOTE: Tracheostomies are usually sutured in place for the first week after insertion and so
are unlikely to be displaced.
ACUTE DYSPNOEA
..is most commonly caused by partial or complete blockage of the tracheostomy tube by
retained secretions. To unblock the tracheostomy tube.....
1. ASK THE PATIENT TO COUGH: A strong cough may be all that is needed to expel
secretions.
2. REMOVE THE INNER CANNULA: If there are secretions stuck in the tube, they will
automatically be removed when you take out the inner cannula. The outer tube - which
does not have secretions in it - will allow the patient to breath freely.
Clean and replace the inner cannula.
3. SUCTION: If coughing or removing the inner cannula do not work, it may be that the
secretions are lower down the patients airway. Use the suction machine to remove the
secretions.
4. If these measures fail - commence low concentration oxygen therapy via a tracheostomy
mask, and call for medical assistance.
It is possible that the tracheostomy may have become displaced. Stay with
the patient until assistance arrives. Prepare for change of tracheostomy tube.
RESUSCITATION VIA A TRACHEOSTOMY TUBE
...... PLUS.....
STEP 1
STEP 2
STEP 3
VENTILATE -
IF UNABLE TO VENTILATE: