Best practice statement : caring for the patient with a tracheostomy

Best Practice Statement ~ March 2007

Caring for the patient with a tracheostomy

© NHS Quality Improvement Scotland 2007

ISBN 1-84404-453-X

First published January 2003Reviewed April 2007

You can copy or reproduce the information in this document for use within NHS Scotland and foreducational purposes. You must not make a profit using information in this document.Commercial organisations must get our written permission before reproducing this document.

www.nhshealthquality.org

Contents

Introduction i

Key stages in the development of best practice statements ii

Best practice statement: Caring for the patient with a tracheostomy iii

Section 1: Education and training 1

Section 2: Communication 3

Section 3: Swallowing and nutrition 5

Section 4: Stoma care 7

Section 5: Tracheostomy tube management 9

Section 6: Suctioning 14

Section 7: Humidification 15

Appendix 1: Volume of tracheostomies in Scotland 18

Appendix 2: Factors that affect communication 19

Appendix 3: Factors that may affect swallowing 20

Appendix 4: Types of tracheostomy tube 21

Appendix 5: Illustrations 22

Appendix 6: Audit tool 26

Glossary 28

References 30

Who was involved in developing the statement? 35


i

Introduction

NHS Quality Improvement Scotland (NHS QIS) was set up by the Scottish

Parliament in 2003 to take the lead in improving the quality of care and

treatment delivered by NHSScotland.

The purpose of NHS QIS is to improve the quality of healthcare in

Scotland by setting standards and monitoring performance, and by

providing NHS Scotland with advice, guidance and support on effective

clinical practice and service improvements.

A series of best practice statements has been produced within the

Practice Development Unit of NHS QIS, designed to offer guidance on

best and achievable practice in a specific area of care. These statements

reflect the current emphasis on delivering care that is patient-centred,

cost-effective and fair. They reflect the commitment of NHS QIS to

sharing local excellence at a national level.

Best practice statements are produced by a systematic process, outlined

overleaf, and underpinned by a number of key principles.

• They are intended to guide practice and promote a consistent,

cohesive and achievable approach to care. Their aims are realistic but

challenging.

• They are primarily intended for use by registered nurses, midwives,

allied health professionals, and the staff who support them.

• They are developed where variation in practice exists and seek to

establish an agreed approach for practitioners.

• Responsibility for implementation of these statements rests at local

level.

Best practice statements are reviewed, and, if necessary, updated after 3

years in order to ensure the statements continue to reflect current thinking

with regard to best practice.

ii

Topic selection and Scoping Process.

Establish working group. Establish reference group to

advise on consultation drafts.

Review literature on topic.

Source grey literature.

Ascertain current policy and legislation.

Seek information from manufacturers,

voluntary groups and other relevant

sources. Determine focus and content

of statement.

Review evidence for

relevance to practice.

Determine how patients’

views will be incorporated.

Draft document sent to

reference group.

Wide consultation process.

Review and revise statement

in light of consultation

comments.

Publish and disseminate

statement.

Review and update process.

Identify new research/findings

affecting topic.

Consider challenges of using statement

in practice.

Feedback on impact

of statement is

sought/ impact

evaluation.

Key stages in the development of best practice statements


iii

Best practice statement: Caring for the patient with atracheostomy

A tracheostomy is an opening in the front of the trachea that can be

temporary or permanent. Temporary ones usually have a tracheostomy

tube in place to keep them open. Indications for the formation of a

tracheostomy will include protection from aspiration in cases of

swallowing impairment, to facilitate breathing and weaning from artificial

ventilation and to facilitate clearance of secretions. Examples of patients

who may have a tracheostomy are those with neuromuscular disorders

who have impaired swallowing and coughing, those who have a poor

cough or gag reflex after a head injury or a protracted critical illness and

patients who have had their larynx removed surgically. As with the

original, this revised statement does not refer to care of patients with a

laryngectomy.

The different nature of the situations in which a tracheostomy could be

employed means that it is difficult to track the epidemiology of this

procedure. Due to the increasing sophistication of medical technology

and higher survival rates from diseases such as motor neurone disease,

the incidence of tracheostomy in general wards and in the community is

increasing. In Scotland, the volume of tracheostomy operations over the

last decade has increased (Appendix 1). In 2002, the Ear, Nose and Throat

(ENT) Nursing network from the Nursing and Midwifery Practice

Development Unit, which subsequently merged with other organisations

to become NHS QIS, identified this topic as one where guidance and

support in the form of professional consensus would help promote

consistent practice across Scotland.

This statement was originally designed for healthcare professionals,

especially nurses, who may not necessarily work in a specialist

environment and where there is access only to professional support

available as ‘outreach’ from specialist clinical areas. The management of a

tracheostomy involves other professionals such as dietitians,

physiotherapists, specialist nurses, and speech and language therapists.

The membership of the working groups convened first to develop the

statement and then to review it reflects this.

iv

In reviewing the statement, it was agreed that little new formal evidence

with the potential to change practice had been published since the

statement had been first developed. Information gathered from users of

the statement as part of the review process suggested that the revised

statement should refer only to adults.

The working group identified several significant principles to consider

when caring for the patient with a tracheostomy. Firstly, there is a need to

acknowledge that there will be differences between the practices and

procedures involved in caring for a patient with a tracheostomy who lives

in the community, and where the stoma is established, to those which are

typical of intensive care units (ICUs) and specialist wards, eg thoracic

wards, where the stoma is relatively new.

Secondly, the working group, recognised that in addition to the

continuum of management requirements, there is a continuum of factors

which come into play in the patient journey. There is a requirement, for

example, to cater for the psychological, nutritional and communication

needs of the patient which may also vary along the care pathway as the

balance of risks changes.

This statement is designed primarily for the non-specialist practitioner, as

an introductory statement and as a guide to best practice and what

support should be available locally. The working group acknowledges,

however, that some specialist units have used the statement. It is not

designed as a ‘how to’ document, since the group envisage that local

protocols and agreements will determine this, but where professional

consensus exists on particular procedures, this is recorded in the

statement. The statement will support local policies and procedures. It is

the hope of the Practice Development Unit that, in time, the best practice

statements will stimulate research and the development of a more formal

evidence base; the statements are targeted at areas of clinical practice

where the formal evidence base is still in the process of being developed

and where there is a variation in practice across Scotland.

Since the statement was first published, the concept of risk management

has become more familiar to healthcare practitioners, and the working

group reviewing the statement was keen to stress that any consideration

of the patient with a tracheostomy should be within such a risk

management framework. Examples of this could include consideration of


v

the risk of occlusion, the risk of infection and the realistic management of

cuff pressure testing in the community. Similarly, the working group

discussed suctioning pressures, aware that this is a high risk procedure,

and emphasised that the lowest possible pressure should be used,

recognising that, as in all situations, the professional practitioner will be

responsive to the context and address relative risks accordingly. In

addition to acknowledging risk, the group recognised that all healthcare

workers have a professional responsibility to ensure they have the

knowledge and skills necessary to care for the patient with a

tracheostomy. A separate section on education and training in the revised

statement highlights the importance of this.

Since the publication of the original statement, the group acknowledged

that an increased awareness of the special resuscitation requirements of

patients with a tracheostomy is necessary and patient safety information

from the National Patient Safety Agency (2005) has drawn attention to

this. If the number of people with a tracheostomy in Scotland is

increasing, as the data from ISD would suggest (Appendix 1), there is a

need for enhanced awareness-raising in resuscitation training.

In addition to keeping technical skills at a suitable level, which is

mandatory for professionals, good communication skills are very

significant; not only in relieving anxiety in the patient, but also in

involving the carer and educating both to undertake confident self-care in

the community. This is particularly important where there are additional

factors affecting the patient’s capacity to communicate such as visual

impairment, a learning disability, or the patient’s use of English as a

second language.

The statement focuses on the physical care of the patient, but the

working group recognises that psychological support may well be

necessary if the patient with a tracheostomy is to be integrated

successfully into the community and that the best care will go beyond the

recognition and addressing of physical need.

Responding to requests from users of the original statements, this revised

version contains an audit tool. This could be used for the individual

healthcare practitioner to monitor his or her own practice with an

individual patient, or by a ward or larger service unit.

vi


1

Sect

ion

1:

Ed

ucat

ion

an

d t

rain

ing

Key

Po

ints

~

1 Th

ere

is a

n i

ncr

easi

ng

inci

den

ce o

f pa

tien

ts w

ith

a tr

ach

eost

omy

both

in

hos

pita

l an

d in

the

com

mu

nit

y. N

HS

boa

rds

have

a r

espo

nsi

bili

tyto

wa

rds

thes

e pa

tien

ts a

nd

als

o fo

r pr

epa

rin

g he

alth

care

sta

ff to

ca

re fo

r th

em.

2

A pa

tien

t-cen

tred

app

roa

ch, g

ood

com

mu

nic

ati

on s

kills

, an

d te

chn

ica

l com

pete

nce

are

req

uir

ed to

ca

re fo

r, a

ssu

re a

nd

ass

ist p

ati

ents

in

ada

ptin

g to

an

d m

an

agi

ng

a tr

ach

eost

omy.

3Pa

tien

ts a

nd

thei

r ca

rers

req

uir

e ed

uca

tion

an

d su

ppor

t in

ada

ptin

g to

an

d li

vin

g w

ith

a tr

ach

eost

omy.

Hea

lthca

re p

ract

ition

ers

carin

g fo

r a

pat

ient

with

atr

ache

osto

my

have

acc

ess

to:

•ed

ucat

ion

and

trai

ning

to

mee

t lo

cal n

eed,

and

•st

anda

rdis

ed lo

cal p

roto

cols

or

guid

elin

es d

evel

oped

by

loca

l sp

ecia

lists

.

Hea

lthca

re p

ract

ition

ers

who

com

e in

to c

onta

ct w

ith a

pat

ient

with

a t

rach

eost

omy

(no

mat

ter

how

infr

eque

ntly

)un

ders

tand

:

•th

e p

artic

ular

indi

catio

ns f

or t

rach

eost

omy

•ris

ks a

ssoc

iate

d w

ith a

tra

cheo

stom

y•

pot

entia

l com

plic

atio

ns

•th

e ty

pes

of

tube

s an

d eq

uip

men

t in

volv

ed in

eac

h ca

se,

and

•th

e im

por

tanc

e of

Sta

ndar

d In

fect

ion

Con

trol

Pr

ecau

tions

(SI

CPs

).

Hea

lthca

re p

rofe

ssio

nals

and

car

ers

who

are

in c

onta

ctw

ith t

rach

eost

omy

pat

ient

s ha

ve a

cces

s to

and

rec

eive

trai

ning

on:

•ai

rway

, an

d•

vent

ilatio

n m

anag

emen

t of

pat

ient

s w

ith a

tra

cheo

stom

y.

Hea

lthca

re p

rofe

ssio

nals

nee

d to

be

equi

pp

ed w

ith t

heap

pro

pria

te k

now

ledg

e an

d sk

ills

to m

eet

the

uniq

uene

eds

of t

hese

pat

ient

s co

mp

eten

tly a

nd e

ffect

ivel

y.

It is

a p

rofe

ssio

nal r

esp

onsi

bilit

y to

be

able

to

addr

ess

pat

ient

nee

ds c

omp

eten

tly.

It is

the

pro

fess

iona

l res

pon

sibi

lity

of h

ealth

care

sta

ff to

be p

rep

ared

and

com

pet

ent

to d

eal w

ith e

mer

genc

ysi

tuat

ions

.

Ther

e ar

e lo

cal t

rain

ing

and

educ

atio

n op

por

tuni

ties

for

heal

thca

re p

rofe

ssio

nals

to

mee

t lo

cal n

eed.

Ther

e ar

e lo

cal p

roto

cols

or

guid

elin

es t

o su

pp

ort

staf

fca

ring

for

the

pat

ient

with

a t

rach

eost

omy.

Educ

atio

n is

pro

vide

d to

dev

elop

and

up

date

kno

wle

dge

ofhe

alth

care

pro

fess

iona

ls w

orki

ng w

ith p

atie

nts

with

atr

ache

osto

my.

Resu

scita

tion

trai

ning

sp

ecifi

c to

pat

ient

s w

ith a

trac

heos

tom

y is

aud

ited,

and

tai

lore

d to

loca

l nee

d.

Staf

f p

erso

nal d

evel

opm

ent

pla

ns id

entif

y re

susc

itatio

ntr

aini

ng r

equi

rem

ents

for

rel

evan

t p

rofe

ssio

nals

.

Key

staf

f id

entif

ied

as c

omp

eten

t ar

e re

adily

ava

ilabl

e to

atte

nd t

o em

erge

ncie

s.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

2

Hea

lthca

re p

rofe

ssio

nals

kno

w w

hen

to s

eek,

and

hav

eac

cess

to,

pro

fess

iona

l adv

ice

and

assi

stan

ce f

rom

the

rele

vant

sp

ecia

lists

on

the:

•co

mp

lex

nutr

ition

•

ches

t p

hysi

othe

rap

y•

infe

ctio

n co

ntro

l•

com

mun

icat

ion

•re

susc

itatio

n, a

nd

•sp

ecia

list

equi

pm

ent

req

uire

men

ts o

f p

atie

nts

with

a

trac

heos

tom

y.

Hea

lthca

re p

rofe

ssio

nals

mai

ntai

n co

mp

eten

cy in

car

ing

for

a p

atie

nt w

ith a

tra

cheo

stom

y.

Educ

atio

n an

d re

assu

ranc

e of

the

pat

ient

and

car

er s

tart

sp

rior

to a

tra

cheo

stom

y be

ing

per

form

ed a

nd c

ontin

ues

thro

ugh

the

pat

ient

jour

ney.

The

educ

atio

n of

pat

ient

s an

d th

eir

care

rs,

and

acce

ss t

oad

vice

and

sup

por

t is

nec

essa

ry if

pat

ient

s ar

e to

live

succ

essf

ully

in t

he h

ome

envi

ronm

ent.

Prof

essi

onal

dis

crim

inat

ion

is r

equi

red

to id

entif

y th

e p

oint

at w

hich

it is

ap

pro

pria

te t

o se

ek s

pec

ialis

t ad

vice

, eg

fro

mp

hysi

othe

rap

ists

, di

etiti

ans,

and

sp

eech

and

lang

uage

ther

apis

ts.

It is

a p

rofe

ssio

nal o

blig

atio

n to

mai

ntai

n co

mp

eten

cy.

In a

dditi

on t

o ca

re,

heal

thca

re p

rofe

ssio

nals

are

inst

rum

enta

l in

insp

iring

con

fiden

ce a

nd o

fferin

g su

pp

ort

to p

atie

nts

with

a t

rach

eost

omy.

Patie

nts

with

a t

rach

eost

omy

who

rec

eive

ade

qua

teed

ucat

ion

and

sup

por

t ca

n be

saf

ely

tran

sfer

red

out

ofho

spita

l to

live

in t

he c

omm

unity

.

Ther

e ar

e cl

ear

lines

of

com

mun

icat

ion

and

agre

edar

rang

emen

ts b

etw

een

the

diffe

rent

hea

lthca

rep

rofe

ssio

nals

who

may

be

req

uire

d to

pro

vide

car

efo

r th

e p

atie

nt w

ith a

tra

cheo

stom

y.

Ther

e is

evi

denc

e of

com

pet

ency

bas

ed t

rain

ing

and

educ

atio

n p

rovi

sion

for

rel

evan

t he

alth

care

sta

ff.

Pers

onal

Dev

elop

men

t Pl

ans

refle

ct t

he le

vel o

f co

mp

eten

cyac

hiev

ed o

r re

qui

red.

Reco

rds

or a

udits

of

info

rmat

ion

give

n to

pat

ient

san

d ca

rers

at

par

ticul

ar s

tage

s of

the

pat

ient

jour

ney

dem

onst

rate

tha

t ap

pro

pria

te in

form

atio

n is

conv

eyed

effe

ctiv

ely.

Patie

nts

and

care

rs in

the

com

mun

ity h

ave

cont

act

deta

ils o

f sp

ecia

list

help

, eg

a h

ome

vent

ilatio

n te

amor

tra

cheo

stom

y nu

rse

spec

ialis

t.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

Key

Ch

alle

ng

es ~

1Id

enti

fyin

g th

e ed

uca

tion

an

d tr

ain

ing

nee

ds o

f a d

iver

se g

rou

p of

sta

ff a

nd

add

ress

ing

thes

e n

eeds

wit

hin

res

ourc

e co

nst

rain

ts.

2Ra

isin

g a

wa

ren

ess

of th

e sp

ecif

ic r

esu

scit

ati

on r

equ

irem

ents

of p

ati

ents

wit

h a

tra

cheo

stom

y.


3

Sect

ion

2:

Co

mm

unic

atio

n

Key

Po

ints

~

1Th

e im

pact

of t

he lo

ss o

f nor

ma

l voi

ce fo

llow

ing

tra

cheo

stom

y sh

ould

not

be

un

der-

esti

ma

ted

an

d, w

hen

ever

pos

sibl

e, p

ati

ents

an

d th

eir

fam

ilie

ssh

ould

be

prep

are

d fo

r th

is. D

evel

opin

g a

ltern

ati

ve m

ean

s of

com

mu

nic

ati

on, i

ncl

udi

ng

the

use

of a

spe

aki

ng

valv

e, i

s a

vit

al p

art

of c

are

.

2Th

e sp

eech

an

d la

ngu

age

ther

api

st h

as

a k

ey r

ole

in th

e ca

re o

f pa

tien

ts w

ith

a tr

ach

eost

omy

whe

n th

ere

are

com

mu

nic

ati

on d

iffi

culti

es.

3

Ven

tila

tor-

depe

nde

nt p

ati

ents

, wit

h re

spir

ato

ry s

tabi

lity

an

d th

e a

bili

ty to

voc

ali

se, c

an

ach

ieve

spe

ech

an

d sh

ould

be

con

side

red

for

spec

iali

stsp

eaki

ng

valv

es (

Dik

ema

n &

Ka

zan

djia

n 1

995,

Ma

na

nzo

et a

l 199

3, T

ippe

ts &

Sie

ben

s 19

91).

Com

pute

rise

d sp

eech

ou

tpu

t sys

tem

s sh

ould

be

con

side

red

for

pati

ents

wit

h lo

ng-

term

com

mu

nic

ati

on p

robl

ems

(Dik

ema

n &

Ka

zan

djia

n 1

995)

.

Hea

lthca

re p

rofe

ssio

nals

are

kno

wle

dgea

ble

abou

tco

mm

unic

atio

n p

robl

ems

asso

ciat

ed w

ith p

atie

nts

with

atr

ache

osto

my

and

fact

ors

that

affe

ct c

omm

unic

atio

n(A

pp

endi

x 2)

.

The

heal

thca

re p

ract

ition

er s

houl

d be

aw

are

ofco

mm

unic

atio

n di

fficu

lties

and

rec

ogni

se w

hen

to in

volv

eth

e sp

eech

and

lang

uage

the

rap

ist.

A c

omm

unic

atio

n as

sess

men

t st

arts

pre

-op

erat

ivel

y fo

r an

elec

tive

trac

heos

tom

y.

Spec

ialis

t co

mm

unic

atio

n as

sess

men

t by

the

sp

eech

and

lang

uage

the

rap

ist

incl

udes

a h

isto

ry a

nd p

hysi

cal

exam

inat

ion.

Initi

al a

sses

smen

t in

clud

es t

he p

atie

nt’s

abi

lity

to s

ee,

hear

, to

uch,

writ

e, u

nder

stan

d, o

r us

e fa

cial

exp

ress

ions

suc

h as

sm

iling

or

code

d bl

inki

ng.

Follo

win

g as

sess

men

t, a

com

mun

icat

ion

care

pla

n,re

cogn

isin

g th

e in

volv

emen

t of

fam

ilies

and

car

ers,

incl

udin

g co

nsid

erat

ion

of a

sp

eaki

ng v

alve

, an

d sp

ecifi

c to

indi

vidu

al n

eeds

, is

dra

wn

up.

Patie

nts

with

a t

rach

eost

omy

may

hav

e co

mm

unic

atio

np

robl

ems

that

affe

ct t

heir

abili

ty t

o in

tera

ct a

nd b

ein

volv

ed in

the

ir ow

n ca

re.

Att

entio

n is

giv

en t

o th

e p

sych

olog

ical

imp

act

of t

he lo

ss o

fvo

ice.

Ass

essm

ent

allo

ws

pro

blem

s w

ith c

omm

unic

atio

n to

be

qui

ckly

iden

tifie

d an

d im

med

iate

act

ion

can

be t

aken

to

min

imis

e th

e co

nseq

uenc

es o

f th

ese

pro

blem

s.

Patie

nts

with

a t

rach

eost

omy

may

hav

e co

mp

lex

com

mun

icat

ion

need

s an

d re

qui

re a

com

bina

tion

ofap

pro

ache

s to

min

imis

e p

robl

ems

(act

ual o

r p

oten

tial).

Succ

essf

ul m

anag

emen

t of

com

mun

icat

ion

pro

blem

s an

dth

e us

e of

sp

eaki

ng v

alve

s ar

e on

ly p

ossi

ble

thro

ugh

invo

lvem

ent

and

educ

atio

n of

fam

ilies

and

car

ers.

In-s

ervi

ce e

duca

tion

to d

evel

op a

nd u

pda

te k

now

ledg

e of

nurs

es w

orki

ng w

ith p

atie

nts

with

a t

rach

eost

omy,

incl

udin

gco

mm

unic

atio

n, is

pro

vide

d.

Ther

e ar

e w

ritte

n cr

iteria

for

ref

erra

l to

the

spee

ch a

ndla

ngua

ge t

hera

pis

t.

Com

mun

icat

ion

asse

ssm

ent

is d

ocum

ente

d in

the

pat

ient

reco

rd.

Whe

re d

ysfu

nctio

n is

iden

tifie

d, a

pp

rop

riate

reco

mm

enda

tions

for

alte

rnat

ive

met

hods

of

com

mun

icat

ion

are

mad

e.

Ther

e is

an

agre

ed p

roto

col o

n th

e m

anag

emen

t of

com

mun

icat

ion

issu

es,

incl

udin

g th

e us

e of

sp

eaki

ng v

alve

san

d p

oten

tial i

nvol

vem

ent

of t

he s

pee

ch a

nd la

ngua

geth

erap

ist

to e

ncou

rage

voc

alis

ing

tech

niq

ues.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

4

Hea

lthca

re p

rofe

ssio

nals

pla

n, im

ple

men

t an

d ev

alua

te t

heco

mm

unic

atio

n ca

re p

lan

spec

ific

to t

he p

atie

nt’s

nee

dsan

d re

view

thi

s at

pre

-det

erm

ined

inte

rval

s or

whe

n he

alth

need

s ch

ange

.

The

com

mun

icat

ion

care

pla

n re

qui

res

an in

terd

isci

plin

ary

app

roac

h an

d a

pro

toco

l tha

t is

agr

eed

and

adhe

red

to.

Hea

lthca

re p

rofe

ssio

nals

are

aw

are

of t

he p

artic

ular

com

mun

icat

ion

need

s of

ven

tilat

or-d

epen

dent

pat

ient

sw

ho h

ave

a tr

ache

osto

my.

Vent

ilato

r-de

pen

dent

pat

ient

s w

ith a

tra

cheo

stom

y ar

egi

ven

the

opp

ortu

nity

to

spea

k an

d co

mm

unic

ate

with

min

imal

ass

ista

nce.

Patie

nts

have

a m

eans

of

sum

mon

ing

sup

por

t an

d ad

vice

par

ticul

arly

dur

ing

emer

genc

y si

tuat

ions

.

Nee

ds c

hang

e w

ith a

ltera

tions

in h

ealth

sta

tus.

Man

y di

ffere

nt h

ealth

care

pro

fess

iona

ls a

re in

volv

ed in

sup

por

ting

the

pat

ient

and

a r

ecog

nise

d p

roce

dure

sho

uld

faci

litat

e co

mm

unic

atio

n.

Pass

y-M

uir

valv

es a

re a

t p

rese

nt t

he o

nly

valv

es d

esig

ned

for

use

with

a v

entil

ator

. N

ot a

ll p

atie

nts

are

suffi

cien

tlyst

able

to

use

a va

lve.

In a

dditi

on t

o th

e re

stor

atio

n of

sp

eech

, sp

ecia

lised

spea

king

val

ves

for

use

with

pat

ient

s on

a v

entil

ator

may

be b

enef

icia

l in

the

wea

ning

pro

cess

and

dec

reas

ese

cret

ions

effe

ctin

g co

nsid

erab

le im

pro

vem

ent

in w

ellb

eing

(Dik

eman

& K

azan

djia

n 19

95).

Patie

nts

with

res

pira

tory

sta

bilit

y w

ho h

ave

an u

ncuf

fed

tube

in s

itu s

omet

imes

evo

lve

voca

lisin

g te

chni

que

s us

ing

the

vent

ilato

r ai

rflo

w,

eg ‘l

eak

spee

ch’.

Thes

e te

chni

que

sca

n be

enc

oura

ged

by t

he s

pee

ch a

nd la

ngua

ge t

hera

pis

t.

Patie

nts

are

at r

isk

if th

ey a

re u

nabl

e to

sum

mon

hel

pbe

caus

e of

com

mun

icat

ion

diffi

culti

es.

Ther

e is

a r

ecor

d of

whe

n re

-ass

essm

ent

is d

ue.

The

pro

toco

l has

bee

n ag

reed

with

in t

he m

ultid

isci

plin

ary

team

.

An

audi

t of

pat

ient

rec

ords

indi

cate

s ad

here

nce

to t

hep

roto

col.

Fact

ors

that

affe

ct in

divi

dual

com

mun

icat

ion

need

s(A

pp

endi

x 2)

are

doc

umen

ted

in t

he c

are

pla

n.

Ap

pro

pria

te e

qui

pm

ent

is a

vaila

ble

in h

osp

ital a

nd h

ome

to s

umm

on h

elp

, eg

nur

se c

all s

yste

m,

‘car

e ca

ll’,

slee

pap

noea

mon

itor,

text

pho

ne a

nd in

terc

oms.

Tra

inin

gin

the

ir us

e is

giv

en b

efor

e di

scha

rge

from

hos

pita

l.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

Key

Ch

alle

ng

es ~

1Pr

ovis

ion

of i

n-s

ervi

ce e

duca

tion

wit

h th

e su

ppor

t of s

peci

ali

st s

peec

h a

nd

lan

gua

ge th

era

pist

s to

dev

elop

kn

owle

dge

of tr

ach

eost

omy

com

mu

nic

ati

on i

ssu

es.

2D

evel

opm

ent o

f gu

idel

ines

an

d pr

otoc

ols

rela

tin

g to

com

mu

nic

ati

on o

f pa

tien

ts w

ith

a tr

ach

eost

omy.

3Ef

fect

ive

disc

harg

e pl

an

nin

g to

faci

lita

te a

sm

ooth

tra

nsi

tion

in

to th

e co

mm

un

ity.

4En

suri

ng

tha

t acc

ess

to s

peci

ali

st a

dvic

e a

nd

supp

ort i

s a

vail

abl

e pa

rtic

ula

rly

for

thos

e pa

tien

ts w

ith

com

plex

com

mu

nic

ati

on n

eeds

.

5Pr

ovid

ing

add

itio

na

l res

ourc

es fo

r eq

uip

men

t an

d ed

uca

tion

for

pati

ents

an

d th

eir

fam

ilie

s in

thei

r ow

n h

ome.


5

Sect

ion

3:

Sw

allo

win

g a

nd

nut

riti

on

Key

Po

ints

~

1Sw

allo

win

g di

fficu

lties

ma

y be

ca

use

d by

ma

ny

fact

ors

(App

endi

x 3)

.

2Th

e pr

esen

ce o

f a tr

ach

eost

omy

tube

ma

y im

pair

sw

allo

win

g a

nd

can

com

prom

ise

pati

ents

’ nu

trit

ion

al s

tatu

s. A

ll he

alth

care

pra

ctit

ion

ers,

an

d

regi

ster

ed n

urs

es, a

nd

diet

itia

ns

in p

art

icu

lar,

ha

ve a

n i

mpo

rta

nt r

ole

in e

nsu

rin

g th

e pr

ovis

ion

of g

ood

nu

trit

ion

al c

are

for

the

pati

ent w

ith

a

tra

cheo

stom

y.

3Pa

tien

ts w

ith

a tr

ach

eost

omy

ma

y ex

peri

ence

loss

of a

ppet

ite

due

to th

e a

ltere

d a

irw

ay,

whi

ch c

au

ses

redu

ctio

n i

n th

e a

bili

ty to

sm

ell.

4Pa

tien

ts u

nde

rgoi

ng

radi

othe

rapy

ma

y ex

peri

ence

alte

red

tast

e se

nsa

tion

s a

nd/

or a

pa

infu

l, u

lcer

ate

d m

outh

.

5Pa

tien

ts s

hou

ld n

ot

be fe

d w

hen

they

ha

ve a

n i

nfla

ted

cuff.

By

defla

tin

g th

e cu

ff, th

e ef

fect

s of

the

tra

cheo

stom

y m

ay

be r

edu

ced

(App

endi

x 3)

.

Hea

lthca

re p

rofe

ssio

ns a

re k

now

ledg

eabl

e ab

out

nutr

ition

alp

robl

ems

asso

ciat

ed w

ith p

atie

nts

with

a t

rach

eost

omy.

An

app

rop

riate

ly t

rain

ed n

urse

will

und

erta

ke a

n in

itial

asse

ssm

ent

of s

wal

low

ing

func

tion

and

reco

gnis

e w

hen

toin

volv

e th

e di

etiti

an,

spee

ch a

nd la

ngua

ge t

hera

pis

t/sp

ecia

list

help

, an

d do

so

with

out

dela

y.

Spec

ialis

t sw

allo

win

g as

sess

men

t by

the

sp

eech

and

lang

uage

the

rap

ist

incl

udes

a h

isto

ry a

nd p

hysi

cal

exam

inat

ion

of s

wal

low

ing

func

tion.

Die

titia

ns u

nder

take

ass

essm

ent

of n

utrit

iona

l nee

ds.

Patie

nts

with

a t

rach

eost

omy

may

hav

e sw

allo

win

gp

robl

ems

and

be a

t ris

k fr

om a

spira

tion

and

inad

equa

tenu

triti

on.

Ther

e ar

e m

any

fact

ors

that

can

affe

ct s

wal

low

ing

(Ap

pen

dix

3).

If p

robl

ems

with

sw

allo

win

g an

d nu

triti

on a

re id

entif

ied

qui

ckly

, ac

tion

can

be t

aken

to

min

imis

e th

e p

oten

tial

cons

eque

nces

of

thes

e p

robl

ems,

eg

the

risk

of a

spira

tion.

If sw

allo

win

g is

ful

ly a

sses

sed,

pro

blem

s ar

e th

en id

entif

ied

and

actio

n ta

ken

to m

inim

ise

thei

r p

oten

tial c

onse

que

nces

eg t

he r

isk

of a

spira

tion,

or

of in

adeq

uate

nut

ritio

n.

A c

lear

pre

scrip

tion

of n

utrit

iona

l req

uire

men

ts s

pec

ific

toth

e in

divi

dual

pat

ient

is r

equi

red

to e

nsur

e th

at a

deq

uate

nutr

ition

is r

ecei

ved

safe

ly.

Patie

nts

with

a t

rach

eost

omy

may

exp

erie

nce

loss

of

app

etite

bec

ause

of

redu

ctio

n in

sen

se o

f sm

ell.

Patie

nts

unde

rgoi

ng r

adio

ther

apy

may

exp

erie

nce

alte

red

tast

ese

nsat

ions

and

/or

a p

ainf

ul,

ulce

rate

d m

outh

/thr

oat.

Educ

atio

n an

d tr

aini

ng o

n nu

triti

onal

issu

es is

pro

vide

d to

deve

lop

and

up

date

the

kno

wle

dge

of n

urse

s w

orki

ng w

ithp

atie

nts

with

a t

rach

eost

omy.

Ther

e ar

e ag

reed

crit

eria

for

ref

erra

l to

the

spee

ch a

ndla

ngua

ge t

hera

pis

t, t

he d

ietit

ian

and

othe

r sp

ecia

list

help

.

Ther

e is

a r

ecor

d of

ass

essm

ent

and

refe

rral

in t

he p

atie

nt’s

reco

rd.

Whe

re d

ysfu

nctio

n is

iden

tifie

d, a

pp

rop

riate

inve

stig

atio

nsar

e un

dert

aken

und

er t

he g

uida

nce

and

pro

fess

iona

l ris

kas

sess

men

t of

the

sp

eech

and

lang

uage

the

rap

ist,

eg

Mod

ified

Eva

ns B

lue

Dye

tes

ts,

fibre

optic

eva

luat

ion

ofsw

allo

win

g (F

EES)

and

vid

eoflu

oros

cop

y of

sw

allo

w.

Ther

e ar

e gu

idel

ines

rel

atin

g to

the

nut

ritio

n of

pat

ient

sw

ith a

tra

cheo

stom

y, in

clud

ing

the

adm

inis

trat

ion

of

naso

-gas

tric

and

gas

tros

tom

y fe

edin

g.

Fact

ors

that

affe

ct in

divi

dual

die

tary

inta

ke a

re d

ocum

ente

din

the

car

e p

lan.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

6

For

oral

fee

ding

, th

e p

atie

nt s

houl

d:

•be

con

side

red

at r

isk

of a

spira

tion

•N

OT

have

the

cuf

f in

flate

d•

be in

the

up

right

pos

ition

, un

less

con

trai

ndic

ated

•be

giv

en t

he c

orre

ct f

ood

cons

iste

ncy

and,

whe

re

app

rop

riate

, ha

ve c

omp

ensa

tory

str

ateg

ies

as id

entif

ied

by t

he s

pee

ch a

nd la

ngua

ge t

hera

pis

t.

Con

side

ratio

n sh

ould

be

give

n to

:

•th

e sp

eaki

ng v

alve

, an

d •

effe

ctiv

e an

alge

sic

for

mou

th p

ain.

Ora

l hyg

iene

sho

uld

be m

aint

aine

d th

roug

h re

gula

r or

alca

re.

For

naso

gast

ric a

nd g

astr

osto

my

feed

ing,

bes

t p

ract

ice

guid

elin

es s

houl

d be

fol

low

ed.

Follo

win

g as

sess

men

t, h

ealth

care

pro

fess

iona

ls p

lan,

imp

lem

ent

and

eval

uate

a n

utrit

iona

l car

e p

lan

spec

ific

toth

e p

atie

nt’s

nee

ds a

nd r

evie

w t

his

at p

re-d

eter

min

edin

terv

als

or w

hen

heal

th n

eeds

cha

nge.

Unl

ess

asse

ssed

oth

erw

ise,

pat

ient

s ar

e at

ris

k of

asp

iratio

n.

Infla

ted

cuffs

will

not

pre

vent

asp

iratio

n of

foo

d (L

eder

and

Ross

200

0) (

Ap

pen

dix

3).

The

spea

king

val

ve m

ay n

ot h

ave

to b

e re

mov

ed f

or o

ral

feed

ing.

Goo

d or

al h

ealth

will

ass

ist

effe

ctiv

e nu

triti

on (

Serr

a 20

00,

Dik

eman

& K

azan

djia

n 19

95,

St G

eorg

e’s

Hea

lthca

re N

HS

Trus

t 20

06).

(NH

S Q

IS 2

003)

.

The

asse

ssm

ent

and

deve

lop

men

t of

a n

utrit

iona

l car

ep

lan

whi

ch is

imp

lem

ente

d an

d ev

alua

ted

is a

clin

ical

stan

dard

. (N

HS

QIS

200

3).

Nut

ritio

nal n

eeds

cha

nge

with

alte

ratio

ns in

hea

lth s

tatu

s.

The

nutr

ition

car

e p

lan

iden

tifie

s fa

ctor

s to

be

cons

ider

edfo

r th

e in

divi

dual

.

Indi

vidu

al c

are

pla

ns in

clud

e ag

reem

ent

on r

epea

t sc

reen

ing

inte

rval

s.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

Key

Ch

alle

ng

es ~

1Pr

ovis

ion

of i

n-s

ervi

ce e

duca

tion

wit

h th

e su

ppor

t of t

he s

peec

h a

nd

lan

gua

ge th

era

py a

nd

diet

etic

s de

part

men

ts to

dev

elop

kn

owle

dge

oftr

ach

eost

omy

swa

llow

ing

an

d n

utr

itio

n i

ssu

es.

2D

evel

opm

ent o

f gu

idel

ines

an

d pr

otoc

ols

rela

tin

g to

nu

trit

ion

of p

ati

ents

wit

h a

tra

cheo

stom

y a

nd

mu

ltidi

scip

lin

ary

ref

erra

ls.

3En

suri

ng

acc

ess

to s

peci

ali

st a

dvic

e a

nd

supp

ort p

art

icu

larl

y fo

r th

ose

pati

ents

wit

h co

mpl

ex n

utr

itio

na

l nee

ds.

4Av

ail

abi

lity

of s

wa

llow

ing

ass

essm

ent s

ervi

ces,

eg

app

ropr

iate

acc

ess

to v

ideo

fluor

osco

py.

5Ef

fect

ive

disc

harg

e pl

an

nin

g to

faci

lita

te a

sm

ooth

tra

nsi

tion

from

hos

pita

l to

the

com

mu

nit

y.


7

Sect

ion

4:

Sto

ma

care

Key

Po

ints

~

1Pa

tien

ts w

ith

a tr

ach

eost

omy

are

at i

ncr

ease

d ri

sk o

f in

fect

ion

.

2Ef

fect

ive

ma

na

gem

ent o

f the

sto

ma

wil

l aid

the

prev

enti

on o

f per

isto

ma

l in

fect

ion

an

d ir

rita

tion

.

3A

wel

l-for

med

tra

chea

l tra

ct w

ill u

sua

lly b

e ev

iden

t abo

ut 5

–7 d

ays

pos

t-ope

rati

vely

; su

ture

s, i

f pre

sen

t, ca

n u

sua

lly b

e re

mov

ed 7

–10

days

aft

erth

e pr

oced

ure

dep

endi

ng

on th

e n

atu

re o

f the

pro

cedu

re.

4Th

e m

an

age

men

t req

uir

emen

ts o

f a n

ew s

tom

a in

the

acu

te c

are

en

viro

nm

ent a

nd

subs

equ

ently

, whe

n th

e pa

tien

t is

in th

e co

mm

un

ity,

are

diff

eren

t.

5If

the

pati

ent i

s u

nde

rgoi

ng

radi

othe

rapy

thei

r sk

in i

nte

grit

y w

ill b

e gr

eatly

com

prom

ised

, req

uir

ing

furt

her

ass

essm

ent a

nd

eva

lua

tion

of s

tom

a

ma

na

gem

ent.

Adv

ice

from

spe

cia

list

cen

tres

reg

ard

ing

stom

a c

are

sho

uld

be

sou

ght d

uri

ng

this

tim

e.

All

pat

ient

s w

ith a

tra

cheo

stom

y st

oma

shou

ld h

ave

freq

uenc

y of

sto

ma

care

ass

esse

d in

acc

orda

nce

with

indi

vidu

al p

atie

nt n

eed.

All

pat

ient

s sh

ould

hav

e an

eva

luat

ion

of s

tom

al c

ondi

tion

docu

men

ted

in t

he p

atie

nt r

ecor

d an

d an

ap

pro

pria

te p

lan

of c

are

initi

ated

.

The

stom

a sh

ould

be

clea

ned

with

nor

mal

sal

ine

and

aba

rrie

r fil

m m

ay h

elp

to

pro

tect

the

sur

roun

ding

ski

n.C

otto

n w

ool s

houl

d n

ot

be u

sed

to c

lean

se a

roun

d th

est

oma.

Use

of

dres

sing

s ar

ound

the

sto

ma

site

is n

ot a

lway

sne

cess

ary

but

can

help

to

abso

rb s

ecre

tions

and

aid

com

fort

for

silv

er t

ubes

.

Trac

heos

tom

y st

omas

are

a p

oten

tial a

venu

e fo

r re

spira

tory

trac

t in

fect

ion

and

pot

entia

l site

of

per

isto

mal

infe

ctio

n.

Cle

an t

echn

ique

is a

dvoc

ated

as

the

skin

is c

olon

ised

with

orga

nism

s.

To a

llow

ong

oing

ass

essm

ent

of t

he s

tom

a.

To p

rote

ct t

he s

kin

from

tra

chea

l sec

retio

ns a

nden

cour

agem

ent

of w

ound

hea

ling.

Nor

mal

sal

ine

is n

on-ir

ritan

t to

the

ski

n an

d tr

ache

alm

ucos

a. A

bar

rier

film

may

hel

p t

o p

rote

ct t

he s

urro

undi

ngsk

in f

ollo

win

g an

ass

essm

ent

of p

atie

nt n

eed.

Ther

e is

a r

isk

of in

hala

tion

of f

ibre

s fr

om c

otto

n w

ool.

Trac

heos

tom

y tu

bes

have

sof

t fla

nges

(ex

cep

t si

lver

tub

es)

that

do

not

alw

ays

req

uire

a d

ress

ing

betw

een

the

tube

and

the

skin

.

Dre

ssin

gs c

an p

rovi

de a

n id

eal e

nviro

nmen

t fo

r ba

cter

ial

mul

tiplic

atio

n.

Hea

lthca

re p

rofe

ssio

nals

are

abl

e to

dem

onst

rate

ap

plic

atio

nof

the

fun

dam

enta

l prin

cip

les

of in

fect

ion

cont

rol i

nclu

ding

clea

n st

oma

care

.

Inci

denc

e of

per

isto

mal

infe

ctio

n in

pat

ient

s w

ith a

trac

heos

tom

y is

kep

t to

a m

inim

um.

Ther

e is

doc

umen

ted

evid

ence

of

stom

al c

ondi

tion

in t

hep

atie

nt r

ecor

d an

d lo

cal p

olic

ies/

guid

elin

es a

re a

vaila

ble.

Hea

lthca

re p

rofe

ssio

nals

are

aw

are

of t

he r

isks

and

ben

efits

of a

pp

lyin

g ba

rrie

r fil

m a

nd m

etho

ds t

o en

cour

age

wou

ndhe

alin

g.

Hea

lthca

re p

rofe

ssio

nals

are

kno

wle

dgea

ble

in t

he t

ypes

of

dres

sing

s av

aila

ble

and

able

to

sele

ct t

he m

ost

app

rop

riate

one

base

d on

an

asse

ssm

ent

of p

atie

nt n

eed.

Loca

l pol

icie

s an

d gu

idel

ines

are

ava

ilabl

e on

wou

nd c

are

pro

duct

s.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

8

If dr

essi

ngs

are

indi

cate

d, b

ased

on

clin

ical

nee

d, g

auze

swab

s sh

ould

no

tbe

use

d. A

man

ufac

ture

d tr

ache

osto

my

dres

sing

is r

ecom

men

ded,

pre

fera

bly

slim

-line

to

caus

em

inim

al d

isp

lace

men

t of

the

tub

e.

Ties

sec

urin

g th

e tr

ache

osto

my

tube

sho

uld

be c

heck

ed f

orse

curit

y p

rior

to u

nder

taki

ng a

ny p

roce

dure

esp

ecia

llyfo

llow

ing

rem

oval

of

the

flang

e su

ture

s.

Patie

nts

and/

or c

arer

s ar

e ta

ught

to

man

age

thei

r ow

nst

oma

care

prio

r to

dis

char

ge.

Fibr

es m

ay b

reak

off

the

gauz

e sw

abs

and

ente

r th

ere

spira

tory

tra

ct.

To r

educ

e th

e in

cide

nce

of a

ccid

enta

l tub

e di

slod

gem

ent

To e

ncou

rage

inde

pen

denc

e in

pat

ient

s w

ith a

trac

heos

tom

y.

The

typ

e of

dre

ssin

g is

doc

umen

ted

in t

he p

atie

nt r

ecor

d.

Trac

heos

tom

y tu

bes

rem

ain

secu

re.

Ther

e is

doc

umen

ted

evid

ence

tha

t th

e p

atie

nt a

nd c

arer

have

bee

n ta

ught

to

care

for

sto

ma.

Patie

nts

and

care

rs a

re a

war

e of

the

imp

orta

nce

of k

eep

ing

the

stom

a cl

ean

and

avoi

ding

use

of

aero

sols

and

tal

car

ound

the

sto

ma

site

.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

Key

Ch

alle

ng

es ~

1D

evel

opm

ent o

f loc

al p

olic

ies/

guid

elin

es r

ela

tin

g to

tra

cheo

stom

y st

oma

ca

re.

2D

evel

opm

ent o

f evi

den

ce to

su

ppor

t cu

rren

t pra

ctic

e.

3En

suri

ng

pati

ents

wit

h a

tra

cheo

stom

y a

nd

thei

r ca

rers

are

con

fide

nt a

nd

com

pete

nt i

n s

tom

a c

are

pri

or to

dis

cha

rge.

4Pr

ovid

ing

pati

ents

an

d th

eir

fam

ilie

s w

ith

info

rma

tion

on

ca

rin

g fo

r th

eir

stom

a.


9

Sect

ion

5:

Tra

cheo

sto

my

tub

e m

anag

emen

t

Key

Po

ints

~ G

ener

al t

ube

man

agem

ent

1Th

ere

is a

va

riet

y of

tra

cheo

stom

y tu

bes

ava

ila

ble.

Tra

cheo

stom

y tu

bes

are

ma

de fr

om e

ithe

r pl

ast

ic o

r si

lver

. All

fit i

nto

the

follo

win

g ca

tego

ries

:cu

ffed/

un

cuffe

d; fe

nes

tra

ted/

un

fen

estr

ate

d; d

oubl

e/si

ngl

e ca

nn

ula

; min

itra

cheo

stom

y; a

nd

thos

e w

ith

an

adj

ust

abl

e fla

nge

. Ea

ch tu

be ty

pere

quir

es s

peci

fic

ma

na

gem

ent*

.

2St

aff

invo

lved

in

tra

cheo

stom

y m

an

age

men

t sho

uld

be

aw

are

of t

he s

urg

ica

l tec

hniq

ue

use

d to

form

the

tra

cheo

stom

y, i

e op

en o

r pe

rcu

tan

eou

s,

as

tube

ma

na

gem

ent w

ill v

ary

acc

ordi

ngl

y.

3M

an

y tr

ach

eost

omy

tube

s ha

ve i

nn

er c

an

nu

lae;

som

e a

re d

ispo

sabl

e, b

ut s

ome

are

des

ign

ed to

be

clea

ned

an

d re

use

d fo

r th

e sa

me

pati

ent.

4Ef

fect

ive

tube

ma

na

gem

ent c

ombi

ned

wit

h su

ctio

n a

nd

hum

idif

ica

tion

ca

n r

edu

ce th

e in

cide

nce

of c

ompl

ica

tion

s in

the

tra

cheo

stom

y pa

tien

ta

nd

is i

nte

gra

l to

the

redu

ctio

n o

f cli

nic

al r

isk.

5Th

e pa

tien

t an

d a

ca

rer

or r

ela

tive

sho

uld

be

con

fide

nt a

nd

com

pete

nt i

n tu

be m

an

age

men

t pri

or to

dis

cha

rge

from

hos

pita

l.

Indi

vidu

al a

sses

smen

t of

the

mos

t ap

pro

pria

te t

ube

shou

ldbe

mad

e by

the

mul

tidis

cip

linar

y te

am t

akin

g in

to a

ccou

ntth

e p

atie

nt’s

pre

fere

nce.

All

pat

ient

s, w

hene

ver

pos

sibl

e, w

ill h

ave

a do

uble

cann

ulat

ed t

ube

in s

itu.

Exce

ptio

ns in

clud

e p

atie

nts

with

am

initr

ache

osto

my

and

pae

diat

rics.

It is

goo

d p

ract

ice

for

the

pat

ient

to

have

ano

ther

tub

eav

aila

ble.

If th

e p

atie

nt is

usi

ng a

silv

er t

ube

(whi

ch d

oes

not

have

an

inne

r ca

nnul

a) it

sho

uld

be c

hang

ed e

very

5–7

day

s. T

his

shou

ld b

e as

sess

ed o

n an

indi

vidu

al b

asis

as

pat

ient

s w

ithex

cess

ive

secr

etio

ns m

ay r

equi

re m

ore

freq

uent

cha

nges

.

Con

side

ratio

n ne

eds

to b

e gi

ven

to:

•th

e cl

inic

al n

eed/

reas

on f

or t

rach

eost

omy

•th

e am

ount

of

secr

etio

ns•

whe

ther

the

pat

ient

will

be

taug

ht s

elf-

care

with

a v

iew

to

hom

e tr

ache

osto

my

care

, an

d•

whe

ther

rad

ioth

erap

y is

req

uire

d.

Tube

blo

ckag

e ca

n be

red

uced

by

the

use

of a

n in

ner

cann

ula

that

can

be

easi

ly r

emov

ed in

an

emer

genc

y.

Usu

ally

tra

cheo

stom

y tu

bes

with

inne

r ca

nnul

ae d

o no

tne

ed t

o be

rem

oved

or

chan

ged

and

can

be u

sed

up t

o 30

days

in s

itu.

This

min

imis

es r

isk.

This

pre

vent

s in

fect

ion

and

the

tube

bec

omin

g bl

ocke

dw

ith s

ecre

tions

.

Ther

e ar

e lo

cal a

sses

smen

t p

rogr

amm

es r

elev

ant

to c

linic

alne

ed a

nd in

divi

dual

req

uire

men

ts.

Hea

lthca

re p

rofe

ssio

nals

hav

e kn

owle

dge

of t

he t

ubes

avai

labl

e an

d in

dica

tions

for

use

and

are

abl

e to

pro

vide

app

rop

riate

adv

ice

on t

ube

usag

e.

Hea

lthca

re p

rofe

ssio

nals

are

kno

wle

dgea

ble

in r

isk

man

agem

ent

issu

es a

nd h

ow t

o p

reve

nt t

ube

obst

ruct

ion.

Trac

heos

tom

y tu

be c

are

is e

ffect

ivel

y m

anag

ed in

the

clin

ical

are

a.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

* Tr

ache

osto

my

tube

s ar

e co

mm

only

ref

erre

d to

by

the

nam

e of

the

man

ufac

ture

r, eg

Shi

ley,

Por

tex

or K

apite

x.

Illus

trat

ions

of

avai

labl

e tu

bes

are

pro

vide

d in

Ap

pen

dix

5.

10

The

firs

t tu

be

chan

ge

is a

hig

h r

isk

pro

ced

ure

and

shou

ld b

e un

dert

aken

und

er m

edic

al d

irect

ion.

Thi

s ta

kes

pla

ce 3

–7 d

ays

afte

r th

e su

rgic

al p

roce

dure

(on

ly if

atr

ache

osto

my

tube

with

no

inne

r ca

nnul

a is

use

d).

Inp

atie

nts

with

a p

ercu

tane

ous

trac

heos

tom

y, a

t le

ast

7 da

yssh

ould

pas

s be

fore

the

firs

t tu

be c

hang

e.

A n

ote

shou

ld b

e m

ade

of t

he t

echn

ique

use

d to

for

m t

hetr

ache

osto

my

and

in p

artic

ular

whe

ther

the

tra

chea

isst

itche

d up

to

the

skin

.

Loca

l gui

delin

es a

re a

vaila

ble

for

staf

f co

mp

eten

t to

unde

rtak

e a

first

tub

e ch

ange

.

Tube

s w

ith in

ner

cann

ulae

can

rem

ain

in p

lace

for

29–

31da

ys d

epen

ding

on

the

man

ufac

ture

r.

All

pat

ient

s w

ith a

tra

cheo

stom

y ha

ve t

ubes

cle

aned

or

rep

lace

d as

ap

pro

pria

te f

ollo

win

g th

e m

anuf

actu

rer’s

guid

elin

es a

nd in

line

with

infe

ctio

n co

ntro

l pol

icie

s.

Brus

hes

are

not

used

on

pla

stic

tub

es u

nles

s sp

ecifi

cally

reco

mm

ende

d by

the

man

ufac

ture

r.

All

pat

ient

s w

ith a

tra

cheo

stom

y ha

ve t

ubes

rep

lace

dfo

llow

ing

the

man

ufac

ture

r’s g

uide

lines

(A

pp

endi

ces

4an

d 5)

.

The

time

dela

y al

low

s a

trac

t to

bec

ome

esta

blis

hed

with

inth

e tr

ache

a th

eref

ore

min

imis

ing

the

risk

of s

tom

al c

losu

reon

tub

e re

mov

al.

Stitc

hes

and

typ

e of

sut

urin

g w

ill a

ffect

car

e.

Exp

erie

nced

sta

ff ar

e re

qui

red

to u

nder

take

firs

t ch

ange

of

the

trac

heos

tom

y tu

be.

The

inne

r ca

nnul

a is

fre

que

ntly

cha

nged

the

refo

re t

heou

ter

tube

pat

ency

is m

aint

aine

d (E

urop

ean

Uni

on 1

993)

.

Tube

s in

situ

are

a p

oten

tial r

eser

voir

for

path

ogen

ic b

acte

ria

Brus

hes

may

cau

se d

amag

e to

the

lini

ng o

f th

e tu

be.

To c

omp

ly w

ith s

afet

y re

gula

tions

and

pre

vent

tub

eda

mag

e w

ith in

app

rop

riate

cle

anin

g.

Ther

e ar

e lo

cal g

uide

lines

and

pol

icie

s on

man

agem

ent

ofth

e tu

be in

clud

ing

info

rmat

ion

on t

he f

req

uenc

y of

tub

ech

angi

ng.

The

pat

ient

rec

ord

will

con

tain

thi

s in

form

atio

n.

Gui

delin

es a

re a

vaila

ble

in t

he c

linic

al a

rea,

and

com

pet

ency

of s

taff

to u

nder

take

the

rol

e is

ass

esse

d.

Ther

e is

doc

umen

ted

evid

ence

of t

he d

ate

and

ease

of c

hang

e.

A r

ecor

d of

out

er t

ube

chan

ges

is a

vaila

ble

in t

he p

atie

nt’s

reco

rds

with

ap

pro

pria

te d

ates

.

Loca

l pol

icie

s/gu

idel

ines

are

ava

ilabl

e on

how

tra

cheo

stom

ytu

bes

are

clea

ned.

The

se a

re in

line

with

the

man

ufac

ture

r’sgu

idel

ines

, lo

cal i

nfec

tion

cont

rol a

nd d

econ

tam

inat

ion

pol

icie

s.

Loca

l pol

icie

s/gu

idel

ines

are

ava

ilabl

e on

tra

cheo

stom

y tu

bere

pla

cem

ent

in li

ne w

ith t

he m

anuf

actu

rer’s

gui

delin

es a

nd a

writ

ten

reco

rd o

f se

rial n

umbe

rs a

nd d

ates

rep

lace

d.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d


11

In a

dditi

on t

o st

anda

rd r

esus

cita

tion

equi

pm

ent,

all

pat

ient

s w

ith a

tra

cheo

stom

y in

hos

pita

l req

uire

the

follo

win

g eq

uip

men

t to

be

read

ily a

cces

sibl

e fo

rem

erge

ncy

pro

cedu

res:

•tr

ache

al d

ilato

rs•

a cu

ffed

trac

heos

tom

y tu

be a

nd a

n un

cuffe

dtr

ache

osto

my

tube

the

sam

e si

ze a

s th

e pa

tient

is w

earin

g•

a tr

ache

osto

my

tube

sm

alle

r th

an t

he s

ize

the

pat

ient

is

wea

ring

•st

itch

cutt

ers,

and

•10

ml s

yrin

ge.

All

pat

ient

s fo

r w

hom

dec

annu

latio

n is

con

side

red

shou

ldbe

indi

vidu

ally

ass

esse

d by

the

mul

tidis

cip

linar

y te

am.

Mon

itorin

g an

d ob

serv

atio

n of

the

pat

ient

tak

es p

lace

durin

g de

cann

ulat

ion.

Trac

heal

dila

tors

and

a s

mal

ler

size

d tr

ache

osto

my

tube

are

avai

labl

e at

the

pat

ient

’s b

edsi

de d

urin

g th

e de

cann

ulat

ion

pro

cess

.

Follo

win

g tu

be r

emov

al,

an a

irtig

ht d

ress

ing

is p

lace

d ov

erth

e st

oma.

To c

omp

ly w

ith s

afet

y re

gula

tions

.

To e

nsur

e ap

pro

pria

te e

qui

pm

ent

is a

vaila

ble

in a

nem

erge

ncy.

Use

of

a 20

ml s

yrin

ge a

s p

art

of t

he r

esus

cita

tion

equi

pm

ent

may

pos

e a

risk

of o

verin

flatio

n of

a c

uffe

dtr

ache

osto

my

tube

and

sub

sequ

ent

dam

age

to t

he t

rach

ea.

This

will

fac

ilita

te s

afe

and

effe

ctiv

e de

cann

ulat

ion

and

avoi

d re

-inse

rtio

n of

tra

cheo

stom

y.

To a

llow

ear

ly d

etec

tion

of a

ny d

iffic

ultie

s du

ring/

afte

rth

e p

roce

ss.

Emer

genc

y eq

uip

men

t is

ava

ilabl

e to

man

age

any

resp

irato

ry d

iffic

ultie

s.

To e

ncou

rage

the

sto

ma

to c

lose

as

qui

ckly

as

pos

sibl

ew

ith m

inim

al d

amag

e to

ski

n in

tegr

ity.

Loca

tion

of e

mer

genc

y eq

uip

men

t is

cle

arly

sta

ted

inlo

cal p

roto

cols

.

Hea

lthca

re p

rofe

ssio

nals

are

aw

are

of h

ow t

o re

susc

itate

a p

atie

nt w

ith a

tra

cheo

stom

y.

Ther

e ar

e lo

cal p

olic

ies

and

guid

elin

es o

n th

ede

cann

ulat

ion

pro

cedu

re.

The

stom

a cl

oses

with

min

imal

ski

n da

mag

e fr

omth

e dr

essi

ng.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

Key

Po

ints

~ I

nn

er c

ann

ula

man

agem

ent

1In

ner

ca

nn

ula

e re

duce

the

lum

en o

f the

ou

ter

tra

cheo

stom

y tu

be i

ncr

easi

ng

resp

ira

tory

effo

rt.

2In

ner

ca

nn

ula

e a

re d

esig

ned

to a

llow

ea

sy r

emov

al f

or c

lea

nin

g w

itho

ut h

avi

ng

to r

emov

e th

e ou

ter

tube

.

All

pat

ient

s w

ith a

tra

cheo

stom

y tu

be w

ith a

n in

ner

cann

ula

req

uire

indi

vidu

al a

sses

smen

t of

the

fre

que

ncy

ofin

ner

cann

ula

care

.

To e

nsur

e th

e in

ner

cann

ula

rem

ains

fre

e fr

om s

ecre

tions

.D

ocum

enta

tion

iden

tifie

s th

e:

•ty

pe

of t

ube

in s

itu•

amou

nt o

f se

cret

ions

the

pat

ient

pro

duce

s, a

nd

•fr

eque

ncy

of c

lean

ing.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

12

Key

Po

ints

~ C

uffe

d t

rach

eost

om

y tu

bes

1C

uffe

d tr

ach

eost

omy

tube

s a

re u

sed

to p

rote

ct th

e a

irw

ay.

2Pa

tien

ts w

ho a

re v

enti

late

d of

ten

ha

ve a

cu

ffed

tra

cheo

stom

y tu

be; e

xcep

tion

s m

ay

be h

ome-

ven

tila

ted

pati

ents

.

3Ap

prop

ria

te m

an

age

men

t of a

cu

ffed

tube

ca

n p

reve

nt d

am

age

to th

e tr

ach

eal m

uco

sa.

4Tr

ach

eost

omy

tube

s ha

ve a

low

-pre

ssu

re c

uff

tha

t rem

oves

the

nee

d to

def

late

the

cuff

on a

reg

ula

r ba

sis.

5M

an

omet

ers

to m

easu

re c

uff

pres

sure

, wit

h st

aff

com

pete

nt i

n th

eir

use

, sho

uld

be

ava

ila

ble.

6If

a tr

ach

eost

omy

ma

sk i

s to

be

use

d in

com

bin

ati

on w

ith

a c

uffe

d tr

ach

eost

omy

tube

, use

rs m

ay

wis

h to

con

side

r em

ploy

ing

a m

ask

ma

nn

ufa

ctu

red

from

a r

igid

ma

teri

al,

whi

ch i

s le

ss li

kely

to o

cclu

de th

e co

nn

ecto

r on

the

tra

cheo

stom

y tu

be e

ven

if d

ispl

ace

d (S

cott

ish

Hea

lthca

re S

upp

lies

200

1).

All

cuffe

d tr

ache

osto

my

tube

s ha

ve c

uff

pre

ssur

e ch

ecke

dtw

ice

daily

mai

ntai

ning

pre

ssur

e be

twee

n 15

–30

cmH

2 Ous

ing

a m

anom

eter

.

Man

omet

ers

req

uire

car

eful

man

agem

ent.

Min

imal

occl

usio

n vo

lum

e te

chni

que

s th

at d

o no

t re

qui

re t

he u

se o

fa

man

omet

er m

ay h

ave

to b

e em

plo

yed

as a

n al

tern

ativ

e.

Cuf

f p

ress

ure

abov

e 30

cm

H2 O

may

cau

se d

amag

e to

the

trac

heal

muc

osa.

If t

he p

ress

ure

is b

elow

thi

s, a

spira

tion

may

occ

ur.

Man

omet

ers

may

bre

ak,

or b

ecom

e da

mag

ed,

and

ther

efor

e, le

ss r

elia

ble.

Alte

rnat

ive

volu

me

man

agem

ent

tech

niq

ues

may

be

deve

lop

ed b

y th

e ex

per

ienc

edhe

alth

care

pro

fess

iona

l, p

atie

nt a

nd c

arer

.

Loca

l pro

toco

ls o

r gu

idel

ines

on

reco

rdin

g of

cuf

f p

ress

ure

are

avai

labl

e.

Pres

sure

is d

ocum

ente

d w

ithin

the

nur

sing

rec

ords

.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

The

inne

r ca

nnul

a is

cle

aned

with

war

m w

ater

and

ai

r-dr

ied

in a

ccor

danc

e w

ith in

fect

ion

cont

rol

req

uire

men

ts p

rior

to r

e-in

sert

ion.

Tube

s in

situ

are

a p

oten

tial r

eser

voir

for

pat

hoge

nic

bact

eria

.It

is d

ocum

ente

d th

at t

rach

eost

omy

inne

r ca

nnul

ae a

recl

eane

d an

d st

ored

in li

ne w

ith t

he m

anuf

actu

rer’s

guid

elin

es,

loca

l inf

ectio

n co

ntro

l and

dec

onta

min

atio

np

olic

ies.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d


13

Key

Po

ints

~ F

enes

trat

ed t

ubes

1Fe

nes

tra

ted

tube

s m

ay

be c

uffe

d or

un

cuffe

d.

2Fe

nes

tra

ted

tube

s a

re u

sed

to e

nco

ura

ge w

ean

ing

from

the

tra

cheo

stom

y a

nd

als

o fo

r vo

icin

g.

3Fe

nes

tra

ted

tube

s a

re s

upp

lied

wit

h tw

o in

ner

ca

nn

ula

e; o

ne

is fe

nes

tra

ted

an

d on

e is

not

.

All

pat

ient

s w

ith a

fen

estr

ated

tra

cheo

stom

y tu

be h

ave

the

fene

stra

ted

inne

r ca

nnul

a re

mov

ed p

rior

to t

rach

eal

suct

ion

and

rep

lace

d w

ith a

n un

fene

stra

ted

inne

r ca

nnul

a.

All

pat

ient

s w

ith a

fen

estr

ated

tub

e re

qui

re a

nun

fene

stra

ted

tube

to

be r

eadi

ly a

cces

sibl

e fo

r us

ein

an

emer

genc

y.

It is

pos

sibl

e to

inse

rt t

he s

uctio

n ca

thet

er t

hrou

gh t

hefe

nest

ratio

n ca

usin

g da

mag

e to

the

tra

chea

l wal

l.

To a

llow

ven

tilat

ion

with

em

erge

ncy

equi

pm

ent

as a

ir w

ill e

xit

via

the

fene

stra

tion.

Hea

lthca

re p

rofe

ssio

nals

rec

eive

tra

inin

g in

the

use

of

fene

stra

ted

trac

heos

tom

y tu

bes.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

Key

Ch

alle

ng

es ~

1D

evel

opm

ent o

f loc

al p

olic

ies/

guid

elin

es r

ela

tin

g to

all

asp

ects

of t

rach

eost

omy

tube

ca

re.

2Pr

ovis

ion

of e

duca

tion

al r

esou

rces

to d

evel

op n

ew s

kills

an

d te

ach

/su

perv

ise

less

exp

erie

nce

d st

aff.

3D

evel

opm

ent o

f evi

den

ce to

su

ppor

t cu

rren

t pra

ctic

e.

4As

sess

ing

the

com

pete

nce

of h

ealth

care

pro

fess

ion

als

to u

nde

rta

ke th

e hi

gh r

isk

proc

edu

re o

f the

firs

t tu

be c

han

ge.

5En

suri

ng

care

rs a

nd

pati

ents

, if a

ble,

are

edu

cate

d in

all

asp

ects

of t

ube

ma

na

gem

ent a

nd

are

con

fide

nt a

nd

com

pete

nt i

n m

an

agi

ng

the

tube

prio

r to

the

pati

ent’s

dis

cha

rge

from

hos

pita

l.

14

Sect

ion

6:

Suc

tio

nin

g

Key

Po

ints

~

1Th

e fr

equ

ency

of t

rach

eal s

uct

ion

ing

shou

ld b

e a

sses

sed

on a

n i

ndi

vidu

al p

ati

ent b

asi

s a

nd

shou

ld o

nly

be

carr

ied

out w

hen

the

pati

ents

are

un

abl

e to

cle

ar

thei

r ow

n a

irw

ay

effe

ctiv

ely.

2Su

ctio

nin

g sh

ould

ma

xim

ise

rem

ova

l of s

ecre

tion

s w

ith

min

ima

l tis

sue

dam

age

an

d hy

poxi

a.

3St

an

dard

in

fect

ion

con

trol

pre

cau

tion

s sh

ould

be

app

lied

, in

clu

din

g go

od h

an

d hy

gien

e a

nd

use

of p

erso

na

l pro

tect

ive

equ

ipm

ent (

PPE)

.

4Su

ctio

n e

quip

men

t sho

uld

be

easi

ly a

cces

sibl

e a

nd

mu

stbe

che

cked

reg

ula

rly.

5Pa

tien

ts w

ho h

ave

dif

ficu

lty c

lea

rin

g se

cret

ion

s m

ay

requ

ire

refe

rra

l to

a p

hysi

othe

rapi

st.

6In

divi

dua

l ass

essm

ent o

f the

pa

tien

t wil

l det

erm

ine

whe

ther

su

ctio

n e

quip

men

t is

requ

ired

at h

ome.

Whe

re p

ossi

ble,

the

low

est

effe

ctiv

e p

ress

ure

shou

ld b

eus

ed.

The

wor

king

gro

up r

ecom

men

ds a

suc

tion

pre

ssur

e be

low

120

mm

Hg,

and

no

mor

e th

an 2

00 m

mH

g (2

6.7

kPa)

as

am

axim

um a

nd o

nly

if ne

cess

ary

in a

dults

.

Suct

ioni

ng s

houl

d la

st n

o lo

nger

tha

n 10

sec

onds

at

a tim

e.

Ap

pro

pria

tely

siz

ed,

sing

le-u

se m

ulti-

eyed

or

clos

ed s

yste

m,

mul

ti-us

e ca

thet

ers

are

used

.

Suct

ioni

ng s

houl

d on

ly b

e ap

plie

d to

the

cat

hete

r as

it is

with

draw

n.

Ther

e is

a r

equi

rem

ent

to s

et s

uctio

n le

vels

whi

ch a

re s

afe

and

effe

ctiv

e (D

onal

d 20

00).

Pres

sure

s in

exc

ess

of 2

6.7k

Pa (

200

mm

Hg)

can

res

ult

ingr

eate

r m

ucos

al t

raum

a (Y

oung

198

4).

Ther

e is

a r

isk

of a

tela

ctas

is if

suc

tion

pre

ssur

e is

too

hig

h(G

lass

& G

rap

199

5, C

arol

l 199

4).

Low

pre

ssur

es a

re le

ss e

ffect

ive

and

pro

long

suc

tion

time

(Lom

holt

1982

).

Prol

onge

d su

ctio

ning

res

ults

in h

ypox

ia.

Trac

heal

suc

tioni

ng c

an c

ause

tra

chea

l muc

osal

dam

age.

Mul

ti-ey

ed c

athe

ters

cau

se le

ast

trau

ma

(Ode

ll et

al 1

993)

.

Ap

ply

ing

suct

ion

to t

he c

athe

ter

whe

n in

sert

ing

can

bedi

fficu

lt an

d da

mag

ing

to t

he t

rach

eal m

ucos

a.

Educ

atio

n p

rogr

amm

es in

form

hea

lthca

re s

taff

on r

isks

asso

ciat

ed w

ith t

rach

eal s

uctio

ning

.

Loca

l pol

icie

s p

rovi

de g

uida

nce

on a

pp

rop

riate

suc

tioni

ngte

chni

que

and

add

ress

the

fol

low

ing

issu

es:

•th

e p

roce

ss f

or s

elec

ting

the

corr

ect

size

of

suct

ion

cath

eter

•

dete

rmin

ing

dep

th o

f su

ctio

ning

, ie

how

far

to

inse

rt

suct

ion

cath

eter

, an

d•

ensu

ring

that

suc

tion

is a

pp

lied

only

on

rem

oval

of t

he s

uctio

n ca

thet

er.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d


15

Hyp

erox

ygen

atio

n ta

kes

pla

ce p

rior

to p

roce

dure

or

in li

new

ith h

osp

ital p

olic

y.

Cau

tion

shou

ld b

e ta

ken

with

pat

ient

s w

ith c

hron

icob

stru

ctiv

e p

ulm

onar

y di

seas

e (C

OPD

).

If a

fene

stra

ted

tube

is in

situ

, a

pla

in in

ner

tube

sho

uld

bein

sert

ed p

rior

to s

uctio

ning

.

Hea

lthca

re s

taff

are

awar

e of

the

psy

chol

ogic

al e

ffect

of

suct

ioni

ng o

n p

atie

nts.

Hea

lthca

re s

taff

are

awar

e of

loca

l inf

ectio

n co

ntro

l pol

icy

and

the

imp

licat

ions

for

tra

chea

l suc

tion.

To m

inim

ise

risk

of h

ypox

ia a

ssoc

iate

d w

ith s

uctio

ning

.

It is

pos

sibl

e to

inse

rt t

he s

uctio

n ca

thet

er t

hrou

gh t

hefe

nest

ratio

n ca

usin

g da

mag

e to

the

tra

chea

l wal

l.

As

pat

ient

s ar

e un

able

to

insp

ire d

urin

g th

e su

ctio

np

roce

dure

anx

iety

leve

ls a

re in

crea

sed.

Ther

e is

a r

isk

of c

onta

min

atio

n of

eq

uip

men

t, c

ross

infe

ctio

n an

d ex

pos

ure

of h

ealth

care

sta

ff to

tra

chea

lse

cret

ions

.

This

is d

ocum

ente

d in

the

pat

ient

’s r

ecor

ds.

This

is d

ocum

ente

d in

the

pat

ient

’s r

ecor

ds.

Info

rmat

ion

is a

vaila

ble

in a

var

iety

of

acce

ssib

le f

orm

ats

to p

rom

ote

pat

ient

und

erst

andi

ng a

nd r

educ

e an

xiet

y.

A lo

cal i

nfec

tion

cont

rol p

olic

y ad

dres

ses

issu

es a

ndp

reca

utio

ns r

equi

red

in r

elat

ion

to t

rach

eal s

uctio

ning

.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

Key

Ch

alle

ng

es ~

1En

suri

ng

app

ropr

iate

equ

ipm

ent i

s re

adi

ly a

vail

abl

e, i

ncl

udi

ng

corr

ect c

ath

eter

siz

e a

nd

type

.

2Pr

ovid

ing

regu

lar

in-s

ervi

ce tr

ain

ing

for

sta

ff w

orki

ng

wit

h pa

tien

ts w

ith

a tr

ach

eost

omy.

3Pr

ovid

ing

supp

ort f

or p

ati

ents

an

d fa

mil

ies.

4En

suri

ng

the

pati

ent u

nde

rsta

nds

the

proc

edu

re.

5Pr

ovid

ing

supp

ort a

nd

tea

chin

g of

su

ctio

nin

g te

chn

iqu

e fo

r pa

tien

ts a

nd

fam

ilie

s.

16

Sect

ion

7:

Hum

idif

icat

ion

Key

Po

ints

~

1Th

e n

orm

al h

um

idif

ica

tion

an

d fi

ltra

tion

sys

tem

is

bypa

ssed

in

pa

tien

ts w

ith

a tr

ach

eost

omy;

hu

mid

ific

ati

on m

ust

be

art

ific

ially

su

pple

men

ted.

2It

is

vita

l tha

t a p

ati

ent w

ith

a tr

ach

eost

omy

rem

ain

s w

ell h

ydra

ted

an

d ha

s so

me

form

of h

um

idif

ica

tion

, as

the

mu

cou

s m

embr

an

es a

re d

rier

in a

deh

ydra

ted

pati

ent,

redu

cin

g m

uco

cilla

ry tr

an

spor

t an

d ca

usi

ng

rete

nti

on a

nd

thic

ken

ing

of s

ecre

tion

s.

3A

ddit

ion

al s

afe

ty c

onsi

dera

tion

s a

re r

equ

ired

whe

n a

cu

ffed

tra

cheo

stom

y tu

be i

s in

sit

u. D

ue

to th

e in

crea

sed

risk

of a

irw

ay

obst

ruct

ion

, a

T- p

iece

sho

uld

be

use

d w

hen

del

iver

ing

neb

uli

sed

dru

gs o

r hu

mid

ifie

d ga

s (S

cott

ish

Hea

lthca

re S

upp

lies

200

1, S

cott

ish

Hea

lthca

re S

upp

lies

200

3).

4H

um

idif

ica

tion

sys

tem

s a

re a

pot

enti

al r

eser

voir

for

infe

ctio

n. I

ndi

vidu

al s

yste

ms

shou

ld b

e ch

osen

app

ropr

iate

ly fo

r ea

ch i

ndi

vidu

al p

ati

ent

follo

win

g ri

sk a

sses

smen

t, a

nd

ma

na

ged

corr

ectly

acc

ordi

ng

to lo

cal p

roto

cols

an

d in

fect

ion

con

trol

pol

icy.

5Th

e n

eed

for

hum

idif

ica

tion

in

pa

tien

ts w

ith

a tr

ach

eost

omy

is o

ngo

ing.

A r

an

ge o

f pro

duct

s is

ava

ila

ble

for

prov

idin

g hu

mid

ific

ati

on i

n

the

pati

ent’s

hom

e en

viro

nm

ent.

Hea

lthca

re s

taff

unde

rtak

e as

sess

men

t of

hum

idifi

catio

nne

eds

in t

rach

eost

omy

pat

ient

s.

Hea

lthca

re p

rofe

ssio

nals

are

aw

are

of p

artic

ular

pro

blem

sas

soci

ated

with

art

ifici

al h

umid

ifica

tion

in t

rach

eost

omy

pat

ient

s.

The

tem

per

atur

e of

hea

ted

hum

idifi

catio

n sh

ould

ran

gebe

twee

n 37

–40o

C

The

‘nor

mal

’ hum

idifi

catio

n an

d fil

trat

ion

syst

em is

byp

asse

d in

pat

ient

s w

ith a

tra

cheo

stom

y.

Exce

ssiv

e ar

tific

ial h

umid

ifica

tion

of in

spire

d ga

ses

may

caus

e as

muc

h ha

rm a

s un

der-

hum

idifi

catio

n.

Hea

ted

syst

ems

are

pro

ne t

o ‘r

ain

out’

whe

n w

ater

vap

our

cool

s an

d co

llect

s in

the

tub

ing.

The

wei

ght

of w

ater

-bas

ed s

yste

ms

can

pul

l on

trac

heos

tom

y m

asks

cau

sing

incr

ease

d ris

k of

air

way

obst

ruct

ion

whe

n a

cuffe

d tu

be is

in s

itu.

A T

-pie

ce s

houl

dal

way

s be

use

d (S

cott

ish H

ealth

care

Sup

plie

s 20

01).

Dis

tille

d w

ater

and

sal

ine

rese

rvoi

rs in

hum

idifi

catio

nsy

stem

s ha

ve b

een

show

n to

be

a p

oten

tial s

ourc

e of

infe

ctio

n (C

ritch

ley

& R

ouls

ten

1993

).

An

insp

ired

gas

tem

per

atur

e of

41o

C o

r m

ore

will

cau

sem

ucos

al d

amag

e (B

rans

on 1

991)

.

Ther

e is

doc

umen

ted

evid

ence

of

hum

idifi

catio

n as

sess

men

tin

the

pat

ient

’s r

ecor

ds.

Trai

ning

and

edu

catio

n p

rogr

amm

es in

form

sta

ff on

the

typ

es o

f hu

mid

ifica

tion

syst

ems

avai

labl

e an

d th

e sa

fe u

se o

fsy

stem

s w

hich

are

em

plo

yed

loca

lly.

An

asse

ssm

ent

of t

he n

eed

for

a he

ated

wat

er s

yste

m is

carr

ied

out

afte

r th

e in

itial

nee

d fo

r hu

mid

ified

oxy

gen

ther

apy

has

finis

hed.

Hea

t an

d m

oist

ure

exch

ange

rs a

re u

sed

whe

neve

r in

dica

ted

as a

res

ult

of a

sses

smen

t.

Loca

l pro

toco

ls a

nd d

ocum

enta

tion

in t

he p

atie

nt’s

rec

ord

will

dem

onst

rate

thi

s.

Hum

idifi

catio

n sy

stem

s ar

e m

anag

ed in

acc

orda

nce

with

the

man

ufac

ture

r’s in

stru

ctio

ns,

loca

l gui

delin

es o

r p

roto

cols

,an

d in

fect

ion

cont

rol p

olic

y.

Ther

e is

a s

yste

m t

o m

onito

r in

spire

d ga

s te

mp

erat

ures

.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d


17

Key

Ch

alle

ng

es ~

1Pr

ovis

ion

of t

rain

ing

an

d ed

uca

tion

to d

evel

op k

now

ledg

e of

hea

lthca

re s

taff

cari

ng

for

pati

ents

who

req

uir

e a

rtif

icia

l hu

mid

ific

ati

on.

2D

evel

opm

ent a

nd

impl

emen

tati

on o

f evi

den

ce-b

ase

d pr

otoc

ols

an

d pr

oced

ure

s fo

r he

alth

care

sta

ff.

3Lo

cal p

rovi

sion

an

d a

cces

s to

a r

an

ge o

f hu

mid

ific

ati

on s

yste

ms

an

d eq

uip

men

t.

Patie

nts

and

thei

r ca

rers

are

ful

ly a

war

e of

the

nee

d fo

r,an

d ap

pro

pria

te u

se o

f, he

at a

nd m

oist

ure

exch

ange

rs(S

cott

ish

Hea

lthca

re S

upp

lies

2003

).

Prov

isio

n of

ap

pro

pria

te in

form

atio

n m

ay im

pro

ve p

atie

ntco

mp

lianc

e an

d th

eref

ore

min

imis

e lo

ng-t

erm

pro

blem

s.A

pp

rop

riate

up

-to-

date

info

rmat

ion

is a

vaila

ble

in a

ran

ge

of a

cces

sibl

e fo

rmat

s, e

g w

ritte

n, a

udio

, an

d p

icto

rial t

osu

pp

ort

verb

al d

iscu

ssio

n w

ith p

atie

nts

and

thei

r ca

rers

.

Stat

emen

tR

easo

ns

for

stat

emen

tH

ow

to

dem

on

stra

te s

tate

men

t is

bei

ng

ach

ieve

d

18

Appendix 1: Volume of tracheostomies in Scotland

Volume of tracheostomies (excluding laryngectomies) in ScotlandYears ending 31 December 1996 – 2005

Year of main Volume of

operation Population Tracheostomies1

number rate

1996 5,092,190 507 9.96

1997 5,083,340 682 13.42

1998 5,077,070 795 15.66

1999 5,071,950 839 16.54

2000 5,062,940 909 17.95

2001 5,064,200 874 17.26

2002 5,054,800 938 18.56

2003 5,057,400 823 16.27

2004 5,078,400 903 17.78

2005 5,094,800 983 19.29

Source: Information Services Division (ISD), SMR01 data

1 Based on all operations during the patients’ stay.

ICD10 codes - E42 (excluding E425, E426 and E427)

Appendix 2: Factors that affect communication

An extensive range of speaking valves is available and the majority of

patients can achieve voice (phonation) unless the structures involved in

phonation or articulation are impaired. Best practice is to achieve

communication.

1 Speaking valves are used with uncuffed tracheostomy tubes.

2 Using a speaking valve with a cuffed tracheostomy must be done with

the cuff fully deflated and with extreme caution. Failure to deflate the

cuff would lead to respiratory arrest.

3 To achieve consistent and effortless voicing, the type and size of the

tracheostomy tube may need to be changed. If voicing is not easily

achieved, involvement of a speech and language therapist should be

considered.

4 The individual care plan will record the management of speaking valves,

particularly when the patient sleeps.

5 Some patients may need to speak by finger occlusion of the tube and in

this case, hygiene should be considered.

6 Communication may also be affected by other factors, eg neurological,

mechanical or psychological.

7 A combination of alternative methods of communication may be used

and can support oral communication efforts, eg writing, gesture, coded

eye blinks, picture/word boards, computerised communication aids.

Referral to the speech and language therapist should be made if

problems with communication persist.

Caring for the patient with a trachestomy

19

20

Appendix 3 : Factors that may affect swallowing

There are several causal reasons suggested which predispose patients with

a tracheostomy to aspirate (Leder & Ross 2000, Donizelli et al 2005). By

deflating the cuff, the effect of the tracheostomy on swallowing may be

reduced.

1 Compression of the oesophagus from inflated cuff.

2 Impaired laryngeal elevation as a result of a tethered larynx.

3 Reduction in laryngeal sensitivity as a result of diverted airflow.

4 Disruption of normal co-ordination between breathing and swallowing,

particularly in ventilated patients.

5 Reduced effectiveness of cough to clear secretions from upper airway.

6 Loss of subglottic positive pressure.

7 Neurological or mechanical disorders.

8 Post-operative pain and/or oedema.

9 Radiotherapy pain and/or oedema.

10 Excessively dry mouth (xerostomia) may be due to side effects of

medication.


21

Appendix 4: Types of tracheostomy tube

Tube type Cleaning recommendations Tube replacement

– inaccordance with health

and safety regulations and

manufacturer’s instructions

Single use The tube must not be cleaned and Single use only.

re-used since it is for single use

only.

Single patient use Clean with warm water and air dry Every 29–31 days as required

the tube, and store in accordance by specific manufacturer.

with local policy, ready to be used

by the same patient.

Reusable (silver) Clean with a non-abrasive brush Whenever the patient no

and store dry. longer requires this type

If secretions are particularly sticky, of tube or the tube is

the tube can be soaked in sodium damaged.

bicarbonate solution. (These tubes can be

sterilised and used again

for different patients.)

22

Appendix 5: Illustrations

Anatomy

Single cannulated tube

Epiglottis


23

Uncuffed double cannula tracheostomy tube

Cuffed double cannula tracheostomy tube


24

Uncuffed fenestrated tube

Cuffed fenestrated tube


25

Speaking valve

Mini tracheostomy


26

1 Education and Training Y N Action

Education is provided to fulfil local need, and update knowledge of healthcare professionals

working with patients with a tracheostomy. This includes aspects of tracheostomy management

in the context of patient-centred care, infection control and risk management, and covers

aspects of care listed below.

1a Communication.

1b Swallowing and nutrition.

1c Methods of encouraging wound healing, types of dressings available, and assessment of these in

relation to clinical need.

1d Tubes available and indications for use.

1e Tube use, cuff tube management and management of risk of tube obstruction.

1f The types of humidification systems available and the safe use of systems which are employed

locally.

1g Tracheal suctioning procedures and risks.

1h Resuscitation of a patient with a tracheostomy.

1i Location of emergency equipment.

2 Local protocols, policies or guidelines

There are local written agreements or protocols on all aspects of care of the patient with a

tracheostomy.

2a There are written criteria agreed by the multidisciplinary team, for referral to the:

• speech and language therapist

• physiotherapist

• dietitian, and

• psychologist.

2b There is an agreed protocol on the management of communication issues, including:

• the use of speaking valves, and

• potential involvement of the speech and language therapist to encourage vocalising

techniques.

2c There are guidelines relating to the nutrition of patients with a tracheostomy, including the

administration of naso-gastric and gastrostomy feeding.

2d Local policies/guidelines relate to:

• stomal condition

• wound care products, and

• tube management.

These are in line with the manufacturer’s guidelines and include information on:

• the frequency of tube changing

• a written record of serial numbers and dates replaced

• procedures for tube cleaning in line with infection control guidelines, and

• procedures on cuff management and use of manometer.

2e Guidelines are available in the clinical area and competency of staff to undertake the role of the

first tube change is assessed.

2f Location of emergency equipment is clearly stated in local protocols.

Appendix 6: Audit tool

Audit tool, to identify good practice as outlined in the best practice statement on caring for thepatient with a tracheostomy


27

1 Education and Training Y N Action

2g Local polices provide guidance on appropriate suctioning technique and address the following

issues:

• the process for selecting the correct size of suction catheter

• determining depth of suctioning ie how far to insert suction catheter

• ensuring that suction is applied only on removal of the suction catheter

• hyperoxygenation prior to suctioning, with risk alert for patients with COPD.

2h A local infection control policy addresses issues and precautions required in relation to tracheal

suctioning.

2i Patients and carers are able to summon help in an emergency.

3 Patient care plan/Patient clinical record

3a Stomal condition is documented.

3b The type of dressing is documented.

3c There is documented evidence of the:

• date

• serial number

• ease of tube change, and

• monitoring of the security of tapes holding the tube in situ.

3d There is documented evidence of humidification assessment in the patient’s records.

3e There is a record that an assessment of the need for a heated water system is carried out after

the initial need for humidified oxygen therapy has finished.

3f There is a record of suctioning activity and discussion and the use of information to promote

patient understanding and reduce anxiety about suctioning.

3g There is a record of swallowing assessment and referral.

3h Factors that affect individual dietary intake are documented (Appendix 3).

3i There is a nutritional care plan which includes agreement on repeat nutritional screening

intervals.

3j There is a record of communication assessment and referral.

3k There is a record of when communication re-assessment is due.

3l There is a communication care plan which:

• recognises the involvement of families and carers

• includes consideration of a speaking valve

• is specific to individual needs, and

• is evaluated and reviewed at regular intervals or when health needs change.

4 Patient and carer information

Patient information in a variety of formats is available for all aspects of tracheostomy care, from

preoperative preparation to post-operative management.

4a On discharge to the community, the patient and carer have information in a variety of

accessible formats to promote patient understanding and reduce anxiety around:

• stoma care

• tube management

• humidification

• suctioning

• nutrition

• communication, and

• summoning help in an emergency.


28

Glossary

aspiration The entry of gastric secretions, oropharyngeal secretions or

food and fluid into the tracheobronchial passages (airways)

caused by dysfunction or absence of normal protective

mechanisms.

atelectasis Collapse of lung tissue preventing the exchange of carbon

dioxide and oxygen as part of normal respiration.

barrier film A protective barrier which may look like plastic skin and

protects the skin from becoming red and sore.

‘blue dye’ test Tracheal suctioning at set intervals following the

introduction of blue dye on to the tongue. This may be

modified by mixing foods and liquids with dye (the

Modified Evans Blue Dye Test).

catheter Hollow tube for removing secretions.

cuffed tube A tube with a balloon on the end which can be inflated with

air to hold the tube in position and prevent secretions

entering the respiratory tract.

decannulation Removal of the tracheostomy tube allowing ‘normal’

respiration to occur.

fenestrated tube A tube which has an opening cut into the tube wall to allow

the passage of air.

fibreoptic evaluation A flexible endoscope is placed above the epiglottis and

of swallowing (FEES) laryngeal function is assessed before, during and after

swallowing.

gastrostomy A feeding tube that is inserted surgically through the

abdominal wall into the stomach allowing liquid feed to be

delivered directly into the stomach.

heat and moisture Device to increase moisture content of inspired (breathed

exchanger (HME) in) air.

humidification Equipment for maintaining moisture when giving

system ventilation (not necessarily always oxygen).

hyperoxygenation The use of high concentrations of oxygen before and after

endotracheal suction.

leak speech The patient utilises airflow supplied by the ventilator during

the inspiratory push.

minimal occlusion The gradual inflation of the tracheostomy tube cuff by

volume 0.5 ml increments of air until no air leak is heard - using a

stethoscope held just below the thyroid cartilage.

mucociliary Lining of the respiratory tract.

multi-eyed catheter Catheter with numerous holes around tip.

nasogastric feeding Liquid feed delivered directly into the stomach by a narrow

tube that is passed into the nose and down the oesophagus

(food pipe) into the stomach.

oral feeding Food and drink taken by mouth.

peristomal The area surrounding the stoma.

single use Use once only and then discard.

single patient use Can be used more than once but on one patient only.

sleep apnoea A sleep disorder characterised by periods of absence of

breathing.

speaking valve A valve that has a one way mechanism that allows air to

enter through the tracheostomy tube but closes on

expiration to redirect the airflow past the vocal cords to

give speech.

stoma The artificial opening in the patient’s neck formed by the

tracheostomy.

suctioning The process of removing secretions.

tracheal tract The tract formed by the presence of a tracheostomy tube.

tracheostomy A surgical opening in the anterior wall of the trachea (front

of neck) to facilitate breathing.

T-Tube A device to connect a cuffed tracheostomy tube to a

humidifier.

videofluoroscopy An investigation that provides a comprehensive

examination of swallowing function at different levels.

weaning process Attempt to help patients breathe without the aid of the

tracheostomy tube or ventilator.

ventilator A machine used to assist breathing.


29

30

References

Anon. 2003. Adult tracheostomy care. Nurs Times, 99(9), 29.

Adult Literacy and Basic Skills Unit (ALBSU). 1994. Making it happen: improving skills

within the health service. London: ALBSU.

Barber L. 2002. Improving airway care. Nurs Stand, 17(5), 22.

Barnett M. 2006. Adapting to living with a tracheostomy. Br J Community Nurs, 20(1), 4-9.

Barnett M. 2005. Tracheostomy management and care. Br J Community Nurs, 19(1), 4-8.

Bell SD. 1996. Use of Passy-Muir tracheostomy speaking valve in mechanically ventilated

neurological patients. Crit Care Nurs, 16(1), 63-68.

Bier J, Hazarian L, McCabe D and Perez Y. 2004. Giving your patient a voice with a

tracheostomy speaking valve. Nursing (US), 34(Suppl: Med/Surg Insider), 16-18.

Borsig A and Steinacker I. 1982. Communication with the patient in the intensive care

unit. Nurs Times, 78(12), 1-11.

Branson R D. 1991 Humidification of inspired gases during mechanical ventilation.

Respir Ther, 3(1), 55-66.

Buglass E. 1999. Tracheostomy care: tracheal suctioning and humidification, Br J Nurs,

8(8), 500-504.

Carroll P. 1994. Safe suctioning. Regist Nurse, 57(5), 32-36.

Choate K and Barbetti J. 2003. Tracheostomy: your questions answered. Aust Nurs J,

10(11), Suppl: Clinical Update 62.

Critchley D and Roulsten J. 1993. Nurses’ knowledge of nebulised therapy. Nurs Stand,

8(10), 37-39.

Dean B. 1997. Evidence-based suction management in accident and emergency: a vital

component of airway care. Accid Emerg Nurs, 5(2), 92-98.

De Carle B. 1985. Tracheostomy care. Nurs Times, 81(40), 50-54.

Denison S. 2004. Decannulation of patients with long-term tracheostomies. Nurs Times,

100(38), 58-59.

Deppe SA, Kelly JW, Thoi LL, Chudy JH, Longfield RN, Ducey JP, Truwit CL and Antopol

MR. 1990. Incidence of Coloniszation, nosocomial pneumonia, and mortality in critically

ill patients using a trach care closed suction system versus an open-suction system:

prospective randomized study. Crit Care Med, 18(12), 1389-1393.

Dikeman KJ and Kazandjian MS. 1995. Communication and swallowing: management of

tracheostomized and ventilator dependant adults. London: Singular Publishing Group.

Donald KJ, Robertson VJ and Tsebelis K 2000. Setting safe and effective suction

pressure. Intensive Care Medicine 26, 15-19.

Donizelli J, Brady S, Wesling M, Craney M 2001. Simultaneous modified Evans blue dye

prodedure and video nasal endoscopic evaluation of the swallow. Laryngoscope

111:1746-1750.

Donizelli J, Brady S, Wesling M, Theisen M. 2005. Effects if the removal of the

tracheotomy tube on swallowing during the fiberoptic endoscopic examination of the

swallow(FEES) Dysphagia 20, 283-289.

Edgtton-Winn M and Wright K. 2005. Tracheostomy: a guide to nursing care. Aust Nurs J,

13(5), 17-20.

European Union. 1993. Council directive concerning medical devices. EU 93/42/EEC.

Brussels: EU.

Feber T. 2006. Tracheostomy care for community nurses: basic principles. Br J

Community Nurs, 11(5), 186-93.

Glass CA and Grap MJ. 1995. Ten tips for safer suctioning. Am J Nurs, 95(5), 51-53.

Griggs A. 1998. Tracheostomy: suctioning and humidification. Nurs Stand, 13(2), 49-53.

Harkin H. 1998. Tracheostomy management. Nurs Times, 94(21), 56-58.

Harkin H and Russell C. 2001. Tracheostomy patient care. Nurs Times, 97(25), 34-36.

Harkin H and Russell C. 2001. Preparing the patient for tracheostomy tube removal.

Nurs Times, 97(26), 34-36.

Harris RB. 1984. National survey of aseptic tracheotomy care techniques in hospitals

with head and neck/ENT surgical departments. Cancer Nurs, 7(1), 23-32.


31


32

Harris RB and Hynman RB. 1984. Clean vs sterile tracheotomy care and level of

pulmonary infection. Nurs Res, 33(2), 80-85.

Hooper M. 1996. Nursing care of the patient with a tracheostomy. Nurs Stand, 10(34),

40-43.

Jackson D and Albamonte S. 1994. Enhancing communication with the Passy-Muir valve.

Paediatr Nurs, 20(2), 149-153.

Kagan C. ed. 1985. Interpersonal skills in nursing research and applications. London:

Croom-Helm.

Kapitex Healthcare. 2001. Making things clearer for tracheostomy patients England:

Kapitex Healthcare.

Laws-Chapman C. 1998. How to guides: tracheostomy tube management. Care of the

Critically Ill, 14(5) S.

Leder SB and Ross DA. 2000 Investigation of the causal relationship between

tracheotomy and aspiration in the acute care setting Largyngoscope 110 641-644.

Lomholt N. 1982 Design and function of tracheal suction catheters. Acta Anaesth.

Scand; 26 (b) 1-3.

McEleney M. 1998. Endotracheal suction. Prof Nurs, 13(6), 373-376.

Mallet J and Dougherty L. eds. 2000. The Royal Marsden manual of clinical nursing

procedures. 5th edition. Oxford: Blackwell Scientific.

Mallinckrodt Medical Inc. 1993. Tracheostomy tube: adult home care guide. California:

Mallinckrodt.

Manzano JL, Lubillo S, Henriquez D, Martin JC, Perez MC and Wilson DJ. 1993. Verbal

communication of ventilator dependent patients. Crit Care Med, 21(4), 512-517.

Marks L and Rainbow D. 2001. Working with Dysphagia. Oxford: Speechmark.

Mirza S and Cameron DS. 2001. The tracheostomy tube change: a review of techniques.

Hosp Med, 62(3), 158-163.

Myers EN, Johnson JT and Murry T. eds. 1998. Tracheotomy: airway management,

communication and swallowing. London: Singular Publishing Group.

National Patient Safety Agency. 2005. Protecting patients who are neck breathers -

Patient safety information 02. London: NHS National Patient Safety Agency.

NHS Quality Improvement Scotland. 2003. Nasogastric and gastrostomy tube feeding

for children being cared for in the community: best practice statement. Edinburgh:

NHS QIS. [under review] www.nhshealthquality.org

NHS Quality Improvement Scotland 2003 Food, fluid and nutritional care in hospitals:

Clinical Standards Edinburgh NHS QIS www.nhshealthquality.org

Odell A, Allder A, Bayne R, Everett C, Scott S, Still B and West S. 1993. Endotracheal

suction for adult, non-head injured, patients: a review of the literature. Intensive Crit

Care Nurs, 9(4), 274-278.

O’Neil-Pirozzi TM, Lisiecki DJ, Jack Momose K, Connors JJ, Milliner MP. 2003

Simultaneous modified barium swallow and blue dye tests; a determination of the

accuracy of blue dye test aspiration findings. Dysphagia 18 32-38.

Passy Muir Inc. 1989. Tracheostomy and ventilator speaking valves. Irvine, USA: Passy

Muir Inc. www.passy-muir.com

Russell C. 2005. Providing the nurse with a guide to tracheostomy care and

management. Br J Nurs, 14(8), 428-33.

Scottish Healthcare Supplies. 1998. Safety Action Notice 98/34. Edinburgh: Scottish

Healthcare Supplies. http://www.show.scot.nhs.uk/shs/

Scottish Healthcare Supplies. 2001. Safety Action Notice (SC) 01/36. Cuffed

endotracheal and cuffed tracheostomy tubes: inappropriate combination with other

breathing system components. Available from Internet:

<www.shs.scot.nhs.uk/hazards_safety/sanpdf/san0136.pdf> [accessed 18 January 2007]

Scottish Healthcare Supplies. 2003. Safety Action Notice (SC) 03/02. Inappropriate use

of breathing filters, HMEs and HMEFs: risk of ineffective patient ventilation. Available

from Internet: <http://www.shs.scot.nhs.uk/hazards_safety/sanpdf/san0302.pdf>

[accessed 18 January 2007]

Sell S, Tasota F. 2004. Tracheostomy mucus plug. Nursing, 34(10), 88.

Serra A. 2000. Tracheostomy care. Nurs Stand, 14(42), 45-52.

Sigler BA and Schuring LT. 1993. Ear, nose and throat disorders. London: Mosby.


33


34

St George’s Healthcare NHS Trust. 2006. Guidelines for the care of patients with

tracheostomy tubes. London: Smiths-Medical Ltd.

Suiter DM, McCullough GH, Powell PW. 2003 Effects of cuff deflation and one-way

speaking valve placement on swallow physiology. Dysphagia 18, 284-292.

Tattersall S. 2005. Choosing a suction machine for use by patients in the community

setting. Prof Nurs, 20(5), 50-51.

Tippetts DC and Siebens AA. 1991. Using ventilators for speaking and swallowing.

Dysphagia, 6(2), 94-99.

Whyte A. 2004. A pioneering role in airways nursing care. Nurs Times, 100(28), 24-25.

Woodrow P. 2002. Managing patients with a tracheostomy in acute care. Nurs Stand,

16(44), 39-46.

Young CS.1984. A review of the adverse effects of airway suction. Physiotherapy 70(3),

104-106.

Young CS. 1984. Recommended guidelines for suction. Physiotherapy 70(3), 106-108.

Useful websites

British Association of Head & Neck Oncology Nurses

www.bahnon.org.uk

ENT information

www.ENTLinx.com

Head and Neck Oncologists’ / Surgeons’ Association

www.bahnon.co.uk

Information on head and neck cancers

www.headandneckcancer.org

Kapitex airway equipment

[email protected]

Mallinckrodt airway equipment

www.mallinckrodt.com

Portex

www.smiths-medical.com


35

Who was involved in developing the statement?

Working Group

Susan Buchanan Staff Nurse

NHS Forth Valley

Lynne Coltart Head & Neck Clinical Nurse Specialist

NHS Dumfries & Galloway

Kathlyn Cowie Clinical Educator, Ventilation Services

NHS Greater Glasgow and Clyde

Rhona Davidson Physiotherapist

NHS Grampian

Catriona Don CCN Team Leader

NHS Tayside

Fiona Elder Staff Nurse

NHS Highland

Penny Gravill Lead Speech and Language Therapist (Neurosurgery)

NHS Grampian

Carolyn Guild Clinical Manager


Lindy Manson Education Co-ordinator

NHS Lothian

Graeme McGibbon ENT & Maxillofacial/Checklist Co-ordinator

NHS Lanarkshire

Anita Nardi Senior Staff Nurse

NHS Grampian

Christine Rait ENT Ward Manager

NHS Grampian

Adam Wood Infection Control Nurse

NHS Borders


36

Reference Group

This group provided first consultation.

Mr Kim Ah-See ENT Consultant

NHS Grampian

Mr N Balaji ENT Consultant

NHS Lanarkshire

Dr S Bennett Consultant Microbiologist

NHS Borders

Dr T Cripps Consultant Anaesthetist

NHS Borders

Mr S Denholm ENT Consultant: Head and Neck Surgeon

NHS Highlands

Dr W T Frame Consultant Anaesthetist


Fiona Grant Project Manager ENT Redesign/Surgical Services

Clinical Co-ordinator

NHS Forth Valley

Angela Griggs Chairperson, RCN ENT and Maxillofacial Nursing

Forum Lecturer Practitioner ENT Nursing, Royal Free

Hampstead

NHS Trust & City University, London

Janis Harvey Physiotherapy Clinical Specialist - Critical Care

NHS Lothian

Lorraine King Clinical Development Nurse

NHS 24

Gregory Hughes Patient Representative

Susan Marr Community Dietitian



37

Mr L McClymont Consultant Surgeon (Head and Neck) and Chairman,

Noscan

NHS Highlands

Linda Prevett Speech and Language Therapist


Aileen Quinn Clinical Change Governance Group

NHS 24

Lesley Sabey Beatson Oncology Centre


Cameron Sellars Senior Speech and Language Therapist


Dr S Stott Consultant Anaesthetist

NHS Grampian

Gillian Thain Respiratory Clinical Specialist

NHS Grampian

Claire Walkington Home Ventilation Team

NHS Lothian

Sheila Wheeler Education Advisor

NHS Grampian

Miss Aileen White Consultant Otolaryngologist


Dr D Williams Consultant Anaesthetist


With NHS QIS support from:

Penny Bond Professional Practice Development Officer

Rosemary Hector Project Co-ordinator

Cliodhna Callanan Project Administrator

NHS Quality Improvement Scotland

Edinburgh Office

Elliott House, 8-10 Hillside Crescent, Edinburgh, EH7 5EA

Phone 0131 623 4300

Glasgow Office

Delta House, 50 West Nile Street, Glasgow G1 2NP

Phone 0141 225 6999

E-mail: [email protected] website: www.nhshealthquality.org

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Best practice statement : caring for the patient with a tracheostomy

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