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These Guidelines replace previous Guidelines issued in May 2018
Prepared by the All Wales Tracheostomy Advisory Group, chaired by
Duncan Ingrams, Assistant Medical Director Aneurin Bevan University
Health Board.
Febuary 2019
Tracheostomy Guidelines for NHS
Wales
Adults and Children
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Introduction
Formulating one set of guidelines to cover all of the different indications for all types of tracheostomy in adults and children, in hospital and the community is a difficult task but it is hoped that this attempt will be useful in providing a reference document. It was decided to try and look particularly at those points in the management of tracheostomy patients that are associated with the greatest risk and to see how these risks can be reduced. The guidelines are aimed at all healthcare professionals involved in the management of patients with a tracheostomy. In November 2018 a new chapter on management of paediatric tracheostomies was added.
Tracheostomy is the placement of an opening into the trachea to allow for unobstructed breathing. It can be done in an emergency or as an elective procedure, in an operating theatre, critical care setting, ward or street and under general, local or no anaesthetic. Patients may then undergo mechanical ventilation for a short period or for the rest of their lives or they may breathe for themselves. They may be discharged from a hospital to live at home or be cared for in a community care setting. The tracheostomy itself may be a temporary opening for a few hours or permanent. The opening is usually held open by a plastic or metal tube but some types may be formed by suturing the skin to the wall of the trachea to create a stable stoma. These guidelines were commissioned by Dr Chris Jones, Deputy Chief Medical Officer for Wales, to create a single document that will allow all members of the multi-disciplinary teams that manage tracheostomies in Wales rapid access to information. The aim is to reduce adverse incidents that may occur when correct procedures are not known or are not followed. Several Health Boards already have their own guidelines and this document has been prepared with reference to those and to the National Tracheostomy Safety Project, the NCEPOD document of 2014, “On the Right Trach?”, and the Intensive Care Society Standards of 2014, amongst other publications.
Acknowledgment is given to the help of Professor Brendan McGrath and Professor Tony Narula and to my co-authors Sandeep Berry, Marileze Du Preez, Campbell Edmondson, Karen James, Vijay Kumar, Chris Roberts, Anthony Turley, and Jonathan Whelan. Graham Roblin, Alun Tomkinson, Val Willmott and Julie Bickel from the Noah’s Ark Children’s Hospital for Wales prepared the paediatric chapter. I am also grateful to Anne Llewellyn-Edwards and John Gorst for their comments.
Duncan Ingrams, Assistant Medical Director ABUHB
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Contents
Executive summary
1
Pre-treatment, technique and tube selection
2
Tube Changing
3
Decannulation
4
Movement between units, wards and theatres – communication needs.
5
Transfer to the community.
6
Emergency Management
7
Paediatric tracheostomy
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All Health Boards and Trusts in Wales should have a multidisciplinary tracheostomy team (MDT) to monitor adherence to these guidelines via appropriate audit. The team may formulate their own operational policy.
Staff caring for patients who have had a tracheostomy need to be appropriately trained. Patients should be managed by the MDT. Discharge planning should start as soon as possible after the tube has been placed.
Ultrasound examination of the neck should be used in all patients who have had previous neck surgery, including a previous tracheostomy and in those where altered anatomy is suspected.
An appropriate tracheostomy tube should usually be selected in advance of the procedure.
For safety reasons a dual lumen tube should always be used in adults. Paediatric anatomy in younger children will not accommodate a double lumen tube and a single lumen tube will be needed.
Accessory equipment may be specific to the type of tube used. Care must be taken to ensure that incompatible equipment is not used. Reducing the range of tubes available in a Health Board should be considered.
Tubes need to be changed regularly, either when they are becoming obstructed or cannot be cleaned or within 30 days of placement.
Attention to detail is important during tube changing. The checklist should be completed.
Decannulation must be carried out in a controlled fashion by appropriately trained staff. Facilities for recannulation must always be available. For that reason decannulation in the community is rarely appropriate.
Movement of a patient with a tracheostomy increases risk, particularly tube displacement. Good communication between teams is essential and the transfer form should be used. Additional equipment must go with the patient. Children crawl run play, attend school etc. and this all needs to be supervised.
Transfer to the community is a particular time of risk and involvement of all appropriate staff, including the Welsh Ambulance service is mandatory.
Management of emergencies should start with assessment of the patient. If the tube is blocked and cannot be cleared it must be removed to allow breathing through the mouth or neck, or pulmonary resuscitation.
Laryngectomy patients have no airway via the mouth and nose. If it is not clear if a patient has had a laryngectomy or a simple tracheostomy, resuscitation with oxygen and ventilation must be given via the neck stoma, even if additional measures are duplicated via the mouth. It must be made clear on a ward if a patient has a laryngectomy or other tracheostomy.
Executive Summary
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Definition
A tracheostomy is the creation of an opening into the trachea (wind pipe) through the neck skin, which can be temporary or permanent.
Tracheostomy is an invasive procedure and as such is covered by NatSSIPs (National Safety Standards for Invasive Procedures). The NatSSIP guidelines outline the key elements for the development of LocSSIPs (Local Safety Standards for Invasive Procedures) including governance, documentation, handovers, briefing, procedural verification, and sign in and out. National Safety Standards for Safety Procedures was issued by Welsh Government in September 2016 along with a Patient Safety Notice (PSN034) supporting the introduction of the standards.
http://www.patientsafety.wales.nhs.uk/sitesplus/documents/1104/NatSSIPs%20WALES%20%28FINAL%29%20September%2020161.pdf (http://www.patientsafety.wales.nhs.uk/sitesplus/documents/1104/PSN034%20Supporting%20introduction%20of%20NSSIPs.pdf
Indications Emergency airway - Oral or nasal intubation impossible
Trauma - Facial fractures
Airway oedema (swelling) - Burns - Drug sensitivities - After upper airway surgery
Need for prolonged artificial ventilation - Reduces anatomical dead space - Aids weaning from ventilation
Upper airway obstruction - Foreign body - Tumour
Prolonged absence laryngeal reflexes or an inability to swallow safely
Airway access for mucus suctioning
1. Pre-treatment, technique and tube
selection
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Types of tracheostomy
Percutaneous Tracheostomy The majority of tracheostomies are now carried out in a critical care unit. Most patients within critical care will have tracheostomies performed using a percutaneous, dilatational technique. This procedure may require a general anaesthetic, but can also be done with increased sedation and a local anaesthetic.
Surgical tracheotomy
Surgical procedures are carried out in an operating theatre in most cases. The surgical tracheotomy (i.e. the cut into the trachea) may be a vertical slit, a window (fenestration), or may utilise an inferiorly based Björk flap. The skin edges may be sutured to the tracheal edge to create a semi permanent opening. This is almost always the case in children. In emergencies the operation may be performed elsewhere, such as on a ward. It can be performed under general or local anaesthetic. The term tracheostomy relates to the finished operation, which can be temporary or long term, and can be formed either electively or as an emergency procedure. Any patient who requires a tracheostomy with a history of the following may need to be taken to theatre for a surgical tracheostomy as opposed to a percutaneous tracheostomy. 1. Surgery to the neck. 2. A previous tracheostomy. 3. Difficult cases due to spinal injury, bariatric problems and known altered anatomy
including blood supply.
Laryngectomy Patients who have had a total laryngectomy have a permanent tracheostomy. This involves creating a stoma where the top of the trachea is brought to the surface and sutured to the neck skin. This stoma is kept open by the rigidity of the tracheal cartilage. This is the patient’s only airway as there is no connection between the mouth and nose and the trachea, and there may be no connection between the pharynx and the trachea unless one has been specially created. Any ventilation or oxygen support must be via this stoma.
Mini Tracheostomy This is for sputum clearance and not for ventilation. An uncuffed small bore tube is inserted through the cricothyroid membrane or tracheostome after decannulation.
Important tip: If there is any suggestion of altered anatomy an ultrasound
scan of the neck must be undertaken prior to the operation.
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Tracheostomy Tubes
There is a wide range of tubes available, with differing characteristics. Clinicians need to recognise that the requirements of a tracheostomy tube may vary with time and changing clinical circumstances. Clinical staff must therefore make an informed choice of which to tubes to stock, and which to use for a particular patient.
Single lumen tubes have been associated with Serious Incidents and should not be used in adults. For younger children a single lumen tube is required. If an adult patient is transferred with a single lumen tube it should be changed to a dual lumen tube as soon as it is safe to do so. The incident should be reported back to the referring team.
Dual lumen tubes (with an outer tube intended to remain in the patient and an inner cannula which is removed for cleaning), are inherently safer and should always be used in adults.
Adjustable flange tubes may be needed in those patients with large necks, significant swelling or other changed anatomy. They may have additional ports to clear subglottic secretions with suction.
Tracheostomy tubes require different features depending on their intended use. There are a large variety of tubes available which provide some or all of these features.
Introducers
All tracheostomy tubes should be inserted using an introducer to prevent damaging the trachea during insertion of the tube. Once the tracheostomy tube has been inserted the introducer should be disposed of. When changing tubes, a bougie or similar can be used to ensure placement, in which case the introducer is not needed.
Cuffs Some tracheostomy tubes have a cuff which when inflated provides a seal to facilitate artificial ventilation. It also reduces the risk of aspiration of oral secretions, vomit and blood from the upper airways.
Inner tubes Dual lumen tracheostomy tubes consist of an outer tube, which remains in situ, through which a smaller inner tube is inserted. The inner tube can be connected directly to other equipment. It can be removed for cleaning but must be replaced immediately afterwards.
Fenestrations Fenestrated tracheostomy tubes are dual lumen tubes which have a window in the middle of the upper aspect of both tubes. If the tracheostomy tube is then occluded digitally, with a cap, speaking valve etc., then air and secretions can pass into the mouth and nose in the normal way rather than directing them out via the tracheostomy tube. These tubes will always have an optional non-fenestrated inner tube which may be inserted if the patient requires further respiratory support. A non-fenestrated inner tube should always be inserted prior to performing tracheal suction to ensure the suction catheter does not pass through the fenestration and into the larynx instead of into the trachea. A non-fenestrated inner tube is also recommended overnight to help reduce the drying out, or swelling, of the mucous membrane through the fenestrated area.
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Characteristics of tubes The characteristics of the tube to be considered when selecting a tracheostomy tube for temporary use include:
Construction
dimensions internal and outer diameter (ID and OD respectively) proximal and distal length (i.e. the length of the tube proximal and distal to
its angulation) shape and angulation
compatibility with percutaneous insertion kit
presence and nature of tube cuff
presence of inner cannula
fixed versus adjustable flange
presence of fenestration
specialist features, e.g. low contour on deflation tight to shaft cuffs, subglottic secretion control systems, voice enhancement tubes etc.
Important tip: It is essential that the staff caring for a patient with a tracheostomy know the type of tube in place at any time. This should be clearly documented in the patient’s notes
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Structural Construction
Material Tracheostomy tubes can be constructed of either metal or plastic, and thereby vary considerably in rigidity, durability and kink resistance. This may be clinically relevant.
Metal tracheostomy tubes are constructed of either silver or stainless steel and are seldom used. They do provide a cost effective management choice for permanent, lifelong tracheostomies.
Temporary tracheostomies are constructed of polyurethane, polyvinyl chloride or silicone. Products made of polyurethane are more rigid than those constructed of silicone, whilst those of polyvinyl chloride construction are of an intermediate stiffness (although some become softer at body temperature).
Shape Many tubes have an inherent curvature or angulation; others are completely flexible and only assume a correct anatomical alignment through appropriate stabilisation at the stoma and the level of the cuff. Some flexible tubes are reinforced with a spiral wire in order to avoid kinking and airway obstruction. Whilst the design of some tracheostomy tubes has been modified to facilitate percutaneous introduction, others are only appropriate for insertion once a formal track has been formed (either surgically or through the prior placement of an alternative tube).
Dimensions In most circumstances a tracheostomy tube is both described and selected on the basis of its size, or more specifically its diameter. This is simple in theory but may easily be confusing in practice.
Important tip: Tracheostomy tubes with the same internal diameter (‘size’) may have quite different external diameters and length.
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Choosing the correct size
Diameter
When selecting the size of tube for a patient there is an unavoidable compromise to be made between a desire to maximise the functional internal diameter (and thereby reduce airway resistance and the work of breathing during weaning) and a need to limit the outer diameter (OD) to approximately three-quarters of the internal diameter of the trachea (in order to facilitate airflow through the upper airway when the cuff is deflated). Furthermore, selection of a tube that is too small may result in the need to over-inflate the cuff, thereby increasing the risk of mucosal pressure necrosis, which in turn increases the risk of complications such as tracheal stenosis and tracheo-oesophageal fistula. A need to exceed the quoted nominal cuff volume is often an early indicator that too small a tube has been selected. As a general rule, most adult females can accommodate a tube with an OD of 10mm, whilst a tube with an OD of 11mm is suitable for most adult males.
Length and shape
Although a temporary tracheostomy is most commonly selected on the basis of its diameter, there may be situations where the length, angulation or curvature of a tube is of relevance. Thus, whilst many tracheostomy tubes are smoothly curved, others are clearly angulated, thereby allowing a distinction to be made between the proximal (or horizontal) length of a tube (i.e. the distance between the neckplate and the mid-point of the angulation) and the distal length (i.e. the distance from the mid-point of the angulation and the tip). It should be appreciated that these respective lengths are quite short in standard tubes and may be too short even in the patient with apparently normal anatomy. There may be occasions where the proximal length of a standard tube is inadequate (e.g. in the obese, or when cellulitis around a tracheostomy site increases the depth of the anterior cervical tissues after insertion), and leads to the tube tip then abutting against the posterior tracheal wall.
This can result in:
Obstruction of the tube, and consequent difficulties with ventilation and weaning
Injury to the posterior tracheal wall, thereby increasing the risk of tracheo-oesophageal fistula formation
Suboptimal positioning of the tube cuff, with the associated risk of aspiration, inadequate ventilation and high cuff pressures
There may also be occasions where the proximal length is too long, with the result that the knuckle of the tube abuts against the posterior tracheal wall, whilst the tip is pivoted towards the anterior tracheal wall (the latter increasing the risk of granuloma formation and the development of a tracheal – innominate arterial fistula). Less commonly, there may be a need to review the distal length of a temporary tracheostomy. For instance, there may be occasions where there is a need for additional distal length in order to bypass fistulae or obstructing lesions such as tracheomalacia, tracheal stenosis or excessive granuloma formation.
Clinically significant anatomical and pathological variances such as these can be circumvented by using either extended length tracheostomy tubes with an adjustable flange or pre-formed extended tubes which are offered with a range of extended
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proximal or distal lengths. Extended length adjustable flange tubes are suitable for short term situations but are often difficult to introduce percutaneously and may not be supplied with an inner cannula. These should only be used if no alternative is available in an emergency.
Whilst adjustable flange devices are considered suitable for short terms problems, patients who are likely to need airway access for a considerable length of time may be better served with pre-formed non standard products such as the Shiley® Tracheosoft XLT range or the Portex® Blue Line® Extra Horizontal and Vertical length products. Some manufacturers offer a bespoke service should none of their stock items be suitable.
Inner cannula (dual cannula tracheostomies) for adult use
Many tracheostomies are now manufactured with an inner cannula. The design of some makes the use of this optional (e.g. Portex® Blue Line Ultra®), whilst for others it is mandatory, as it is the inner cannula that has a standard 15mm attachment to connect to the breathing circuit of a mechanical ventilator (e.g. Shiley®, Kapitex Tracoetwist®). Whilst some inner cannulae are disposable and designed for single use, others can be cleaned and re-used. The principal (and very major) advantage of an inner cannula is that it allows the immediate relief of life-threatening airway obstruction in the event of blockage of a tracheostomy tube with blood clot or encrusted secretions. Whilst traditionally, this has been seen to be particularly advantageous for patients once they have been discharged to a ward environment, it is now recognised that tube obstruction can occur even while the patient is in a critical care facility, and that in such circumstances removal of an obstructed inner cannula may be preferable to removal and repeat tracheal intubation.
The principal disadvantage of dual cannula tubes is that the inner cannula may significantly reduce the effective inner diameter of the tracheostomy tube, and thereby increase the work of breathing and impair weaning. Failure to properly lock the inner tube in place may also result in disconnection of the breathing circuit in circumstances where it is connected to this rather than the outer cannula.
Fenestrated tracheostomy tubes
Tracheostomy tubes may come with the option of a fenestration in the posterior wall of the shaft above the cuff, in both inner and outer tube. Manufacturers do not recommend the use of such tubes at the time of percutaneous tracheostomy, and generally they should not be used whilst a patient still requires mechanical ventilation because of significant risk of surgical emphysema (even when a non-fenestrated inner cannula is in place). Although a correctly sited fenestrated tube may aid both phonation and weaning (by facilitating the flow of air both through as well as around the tracheostomy tube), in practice the fenestrations are frequently poorly positioned within the trachea, and when abutting against the posterior tracheal wall may increase airway resistance and as well as promote the development of granulation
Important tip: Dual lumen tracheostomy tubes with an inner cannula are inherently safer should be used in adults. Children need single lumen tubes.
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tissue in the tracheal mucosa. The design of the fenestrations varies between manufacturers, with some clinicians favouring tubes with multiple smaller openings to a single large one, although both patterns are at risk of blockage by encrusted secretions. If a fenestrated tube is used, it is important that the position and on-going potency of the fenestration(s) are checked regularly if the patient is to benefit from this option. In practice down sizing or switching to an uncuffed tracheostomy tube may be enough to improve flow of air through the upper airway.
Cuffed tracheostomy tubes
In a critical care setting, most patients will require an air filled cuffed tracheostomy tube initially, both to facilitate effective mechanical ventilation and also to protect the lower respiratory tract against aspiration. The cuff should be of a “high volume / low pressure” design, and should effectively seal the trachea at a pressure of no more than 20 – 25 cmH2O in order to minimise the risk of tracheal mucosal ischaemia and subsequent tracheal stenosis. Although many manufacturers offer tracheostomy tubes with suitable cuffs, there is considerable variation between them in the length of the cuff and its precise shape when inflated. Furthermore, there is now considerable evidence to suggest that the current high volume / low pressure design is unable to guarantee isolation of the lower respiratory tract.
The intra-cuff pressure should be monitored regularly
Causes of excessive cuff pressures include:
the use of a tube that is too small (an indication for which would be a need to
inflate with more than the nominal cuff volume in order to achieve an effective
seal)
poor tube positioning in the trachea
tracheal dilatation
over inflation of the cuff
One proposed solution to the problem of cuff-related tracheal mucosal ischaemia is
the use of a foam rather than air-filled cuff (Bivona® Adult Fome-Cuf® tracheostomy
tube). The cuff is constructed of air-filled polyurethane foam within a silicone
envelope that is deflated prior to insertion and then allowed to expand once sited by
opening the pilot port to atmosphere. Correct sizing and placement is crucial to their
use, which tends to be limited to patients with existing tube related tracheal injury.
The prevention of phonation is a further significant drawback to the device.
Important tip: Fenestrated tracheostomy tubes should be used with caution in mechanically ventilated patients, and only with patients who are weaning from ventilation.
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Weaning
Most patients can wean to decannulation by simply deflating the existing cuff or
alternatively by down sizing to a smaller or uncuffed tube. In circumstances where a
patient still requires periods of airway protection, but is unable to satisfactorily
breathe past a deflated cuff, it may be advantageous to switch to a so-called “tight to
shaft” tube in which the deflated cuff makes no distinguishable contribution to the
external profile of the tracheostomy tube.
Percutaneous tracheostomy tubes / kits
Several manufacturers have modified aspects of the construction of their standard
tracheostomy tubes such as cuff and distal tube profiles in order that they are more
easily introduced as part of a percutaneous dilatational technique (e.g. Portex® Per-
Fit and Shiley® PERC). Such changes frequently go unnoticed when the tube comes
as a component of a percutaneous tracheostomy kit and may have unpredictable
functional consequences. Clinicians are advised to carefully evaluate situations
where such product consolidation occurs.
Specialist functionality
Some specialist tracheostomy tubes incorporate a facility for aspiration of sub-glottic
secretions (e.g. Portex® Blue Line Ultra® “Suctionaid” tracheostomy tube,
Tracoetwist® 306). Initially advocated in the prevention of ventilator-associated
pneumonia, they may also benefit patients with poor bulbar function who are unable
to effectively clear secretions that accumulate above the tracheostomy tube,
although they carry a high risk of significant laryngeal injury if suction is applied
continuously. When considering changing to one of these devices clinicians are also
advised that in order to accommodate the additional suction channel these tubes
may have a wider OD than the standard device that it is replacing.
Other options include features that enhance phonation such as the Portex®
“Vocalaid” cuffed Blue Line® tracheostomy, in which an external air source is used to
deliver gas via a separate pilot channel to the sub-glottic area, or the introduction
one-way speaking valves such as the Passy- Muir® valve, the latter also improving
swallowing and secretion control.
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1. All staff involved in the placement and management of tracheotomy tubes need to be aware of the wide variability in the construction, design and functionality of the tubes that are currently available, and recognise that the anatomical variation of their patients limits the universal applicability of a single tube type. 2. Most adult patients who require a temporary tracheostomy as part of their critical illness will initially need a non-fenestrated semi-soft tube with an air-filled cuff. As a standard, a dual cannula tube (i.e. a tube with an inner cannula) should be used from the outset in all adults unless there is a requirement to insert an extended adjustable flange tracheostomy. Dual lumen versions of adjustable flange tubes are available but may best be ordered as a customized order for an individual patient. Children will usually have a single lumen tube. See Chapter 7 for more information about paediatric tracheostomy. 3. Patients with single cannula adjustable flange tracheostomies should not be discharged from a critical care environment without review of their on-going need for a device that puts them at particular risk of the consequences of tube obstruction. A change to a pre-formed extended tracheostomy with an inner cannula should be considered as soon as the patient is actively weaning from mechanical ventilation and certainly before discharge from critical care. 4. When considering changing an existing tracheostomy to that of another type or manufacturer, clinicians should compare the relative lengths and external diameters of the two tubes, particularly if the proposed new tracheostomy has a wider OD (because the existing stoma may not accommodate it), shorter length (in case cuff related granulation tissue obstructs the tube) or different curvature / angulation. 5. Specialist features such as fenestrations, foam or tight to shaft cuffs or a sub-glottic suction facility may be useful in specific circumstances, although are not recommended as a routine.
Summary recommendations
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Introduction
Changing a tracheostomy tube is potentially hazardous. Unfortunately, recommendations for the frequency of changing tracheostomy tubes are inconsistent and unsupported by evidence.
Basic principles guiding replacement of a tracheostomy tube are listed in the box below. A more detailed example is given in appendix.
Basic principles for changing a tracheostomy tube
Single lumen tubes should not be used in adults, but if present they should be changed every 7-14 days. See Chapter 7 for Paediatric care. Subsequent frequency may decrease once the patient has reduced the amount of pulmonary secretions and has a well formed clean stoma. .
A European Economic Community Directive (1993) states that tracheostomy tubes with an inner cannula can remain in place for a maximum of 30 days to help prevent infection, maintain a healthy stoma, and prevent degradation of the composition material. Individual manufacturers have recommendations for maximum use of their devices. This assumes the inner cannula is changed or cleaned according the manufacturer’s instructions at least daily. In patients with very productive chests the inner cannula may need reviewing and cleaning every few hours.
The first routine tracheostomy tube change:
Should not be performed within 4 days following a surgical tracheostomy and 7-10 days after a percutaneous tracheostomy, unless in an emergency, to allow the stoma to become established.
The decision to change the tube is usually a multi-disciplinary one, considering weaning, swallowing, ventilation, speaking and the ongoing need for a cuff.
Must be carried out by a person competent to do so and with advanced airway expertise and equipment immediately available.
Techniques involving exchange over a bougie or airway exchange catheter may be safer for the first change.
Technique used and ease should be recorded, along with recommendations for future exchanges.
Subsequent changes can be made by relevant staff who are competent to do so, e.g. specialist tracheostomy nurses or therapists. In practice, the frequency with which the tube needs to be changed will be affected by the individual patient’s condition and the type of tube used. Elective changes are inherently safer than those done in an emergency.
2. Tube changing
Important tip: Tracheostomy tubes should only be changed by staff who
are competent to do so. This includes trained doctors as well as specialist
non-medical practitioners who have been assessed to have the necessary
skills.
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Although problems can occur in any patient they are particularly likely in the obese, those with a deep trachea, and other anatomical difficulties. In these circumstances the patient should be pre-oxygenated and monitored appropriately, which could include pulse oximetry and the availability of capnography or bronchoscopy to confirm placement. Whilst the same principles apply to subsequent changes, the first change is usually the most difficult and technically challenging. Significant numbers of patients in NCEPOD report experienced unplanned early tube changes at less than 7 days.
Prior to tube exchange, consideration should be given to equipment, personnel, procedure and the environment required should problems arise when inserting the new tube.
Subsequent changes in the community are possible without monitoring if the tracheostomy is well established and the staff are competent.
The procedure for changing a tube
When planning a tracheostomy tube change always consider:
Is this the best time to be doing this?
Am I the best person to do this?
Is the patient adequately/appropriately prepared?
Have I got all the essential/appropriate equipment?
Is there adequate support?
The type of tracheostomy tube used should be tailored to the patients’ condition and will depend on various factors such as length of weaning time, original reason for tracheostomy and type of secretions.
This is a two person technique, with one person supporting the tube and the patient and the other performing the change. In patients who are at risk of aspiration it is recommended that any enteral feed be stopped 3-4 hours prior to the procedure and the enteral tube aspirated immediately prior to the procedure. The procedure used for changing any tracheostomy tube will depend on the circumstances of that change. There are two commonly used methods:
Guided exchange using a tube exchange device -usually required for early changes and for patients with a high risk of airway loss
Blind exchange using an obturator – for patients with formed stomas and a low risk of airway loss
Important tip: It is essential that if the new tube cannot be inserted or is
misplaced there is an agreed procedure for responding to the situation.
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Equipment
Dressing pack
Suture cutter
Appropriately sized tracheostomy tube and one a size smaller
Adjustable tracheostomy tube holder. Ties have been associated with problems
and should be avoided if possible.
10ml syringe for cuffed tubes
Water-soluble lubricant
Sterile normal saline
Pre-cut slim line key hole dressing e.g. Metalline™ or if large secretions use a
more absorbent dressing such as Allevyn™ or Lyofoam™
Gloves, apron and protective eye wear
Tracheal dilators
Functioning suction unit and appropriate sized suction catheters (tracheostomy
tube size x3, divide by 2)
Stethoscope
Airway exchange catheter
Resuscitation equipment
Microbiological swab
Blind exchange using an obturator/bougie
Check emergency equipment
Explain procedure to patient and gain patient consent
Position patient in semi-recumbent position
Where required pre-oxygenate
Ensure assistant is clear regarding what is expected of them
Check and lubricate tube
Insert obturator into the tracheostomy tube
Ask assistant to suction if required, remove old dressing, inner cannula and tapes
and support tube
(Deflate cuff with suction applied)
Remove tube on expiration
If patient not oxygen dependent and stoma well formed, observe site, swab if site
looks infected and clean stoma
Insert tube on expiration, remove obturator (inflate cuff)
Check for airflow through tube. If possible, identify presence of CO2 using a
CO2 detector
Ask assistant to support the new tube
Dress and apply holder – allowing 2 finger clearance for comfort and safety.
Replace inner cannula where used
Check patient is stable (and cuff pressure)
Document procedure in the case notes using printed label where available and
check patient again. If using a fenestrated tube, place spare inner cannula in
emergency pack and clearly label tube
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Guided exchange using an airway exchange device
Check emergency equipment
Explain procedure to patient and gain patient consent
Position patient in semi-recumbent position
Where required pre-oxygenate
Ensure assistant is clear regarding what is expected of them
Check and lubricate tube
Ask assistant to suction if required, remove old dressing, inner cannula (if
required) and tapes and support the tube
Insert exchange device to length of tube
Ask assistant to deflate the cuff
Remove old tube over exchange device
Insert new tube over exchange device
Check for airflow through tube. Inflate cuff.
Remove exchange device. Identify presence of CO2 using a CO2detector
Observe site, swab if required and clean while assistant support the tube
Dress and apply holder allowing 2 finger clearance for comfort and safety
Replace inner cannula (if removed)
Check patient is stable (and cuff pressure)
Document procedure in the case notes using printed label where available and
check patient again. If using a fenestrated tube, place spare inner cannula in
emergency pack and clearly label tube
If unable to re-insert tube successfully or the patient become compromised:
Call the on-call anaesthetist/ENT/Resus team immediately and as appropriate to
the situation, to assist and/or orally intubate where appropriate
Maintain oxygenation via stoma and nose and mouth with a facemask
Use tracheal dilator and attempt to re-insert tube
Reposition patients neck and attempt to re-insert tube
Consider using a smaller size tube
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Tracheostomy Tube Change Checklist
Indications for Change
□ Tube >30 days for those with inner tube
□ Downsizing
□ Convert to cuffless tube
□ Convert to fenestrated tube
Appropriate for tracheostomy Tube Change: YES / NO
Team Briefing - Roles established
Operator - ___________________
Assistant - ___________________
Type of tube change: Blind obturator / Over airway catheter
Confirm new tube to be sited: YES / NO
Pre- tube change Checklist
Safety equipment check Tube Change Tray
□ Oxygen □ Dressing pack
□ Suction □ Saline
□ Suction catheters □ Tracheostomy dressing and tapes
□ Gloves □ Bougie / Airway catheter (if required)
□ Yankauer sucker □ Stitch cutter (if sutures present)
□ Tube available in smaller size □ Syringe (if cuffed tube)
□ End tidal CO2 monitor □ Tracheal dilators
□ Resuscitation equipment □ Appropriate sized tracheostomy
□ Aqua gel
Cautions / Considerations
Feed stopped YES / NO
Anaesthetic cover needed YES / NO
Tube change process as per ICS Guidelines YES / NO
Airway stable throughout YES / NO
Documentation in medical notes □ Signed
Date
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Tracheostomy Decannulation
Background
Decannulation describes the process of tracheostomy tube removal once the need for the tube has resolved. There are many advantages to decannulation, including improved vocal cord function, swallowing, patient comfort and communication. As such decannulation should be considered as soon as clinically safe and possible after the need for a tracheostomy tube has reversed. In assessing the patient for decannulation it is important firstly to consider the reason for insertion. As mentioned above this might vary from planned head and neck surgical procedures, weaning from prolonged mechanical ventilation, inability to protect the airway due to impaired neurological status or an emergency upper airway obstruction. In all these situations however there are some common features and steps that need to be considered during the decannulation process.
In attempting to provide some clear indicators as to when decannulation can safely be attempted the literature is of limited value consisting of mainly expert opinions together with international current practice surveys. Not surprisingly given the difficulties in attempting such studies in this patient cohort there is a paucity of clinical trials and no randomised controlled trials. As yet no validated quantitative scoring system has been devised to aid the decision process for decannulation although a quantitative semi quantitative clinical score has been proposed. There can also be disagreement between different groups over the best time to decannulate but seeking the views of all of the multi disciplinary team is clearly important. Chronic co-morbidities and the lack of evidenced-based weaning and decannulation guidelines make it difficult to predict outcomes for individual patients.
Process of decannulation
The most important determinants commonly reported when considering and
assessing readiness for decannulation are:
Availability of suitably trained staff
level of consciousness
tolerance of cuff deflation
resolution of condition that necessitated the tracheostomy tube
ability to tolerate tracheostomy tube capping
cough effectiveness
quantity of secretions and ability to manage secretions
Other relevant factors in reaching a decision include the following:
the patient’s co-morbid disease state
the cause of any respiratory failure
swallowing dysfunction
the respiratory rate
ongoing requirements for supplementary oxygen
3. Decannulation
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Criteria for Decannulation
For any patient the decision to decannulate MUST be a multidisciplinary (MDT) one and the following criteria should be fulfilled:
There should be a person present who is able to recannulate should decannulation prove unsuccessful.
Emergency bedside equipment should be available
The optimal time for decannulation is usually in the morning when the patient has rested overnight and their condition can be observed during the daytime.
In a non-neurologically compromised patient the subject should be able to obey commands.
Respiratory function should be stable. The SpO2 must be over 94% breathing room air or at a suitable level (86-92%) in patients with chronic obstructive pulmonary disease (COPD). Supplementary oxygen may be required but should not exceed FiO2 0.40.
There must be an adequate cough and the ability to clear secretions effectively and independently. The need for mechanical aspiration / suction can be assessed by the number of tracheal aspirations over a 24-hour period (although a cut-off number has not been established). Abundant chest secretiopns (bronchorrhoea), and need for frequent suction should be considered relative contraindications to decannulation. Assessment of protective reflexes is also essential, in particular to evaluate the effectiveness of the cough reflex. The intensity of the cough can be demonstrated either spontaneously or induced by tracheal aspiration. The absence of an effective cough is also a relative contraindication to decannulation. However a Peak Cough Flow over 160 L/min, with adjuvant techniques such as manually or mechanically assisted cough devices has been shown to indicate that decannulation should be successful.
Cardiovascular stability
Tolerates cuff deflation for 24 hours and/ or tolerates speaking valve 12 hours or more (usually during daytime) or decannulation cap for up to four hours (if air flow is present on finger occlusion). In patients following head and neck surgery, the decannulation cap may be left for longer periods at the discretion of the surgeon. Alternatively, if the tracheostomy was placed to allow for surgical oedema it can be removed as soon as the airway is deemed to be safe, sometimes without a period of occlusion. Usually however, airway assessment should be performed clinically by occlusion of the tracheostomy with the cuff deflated or with an uncuffed tracheostomy tube. Airflow over the cords should allow phonation and if the patient is unable to phonate, has stridor or laboured breathing, or manifests any respiratory distress, a thorough endoscopic examination of the airway, including the vocal cords and subglottic space, is recommended. Endoscopic inspection of the airway, although not routinely performed prior to decannulation, can be helpful in revealing tracheal abnormalities or vocal cord dysfunction.
No new lung infiltrates on x-ray (when indicated)
If the criteria for decannualtion are met - explain procedure to patient, ensure cuff is completely deflated (if applicable), cut any holding sutures and remove tracheostomy tube. Cover stoma with a semi-permeable dressing.
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Post Decannulation
Monitor patient closely for 24-48 hours post decannulation.
The emergency tracheostomy equipment tray should be kept by the patient’s bedside for 24-48 hours post decannulation in case of emergency.
Decannulation failure
Currently there is no universally accepted definition for decannulation failure however literature has suggested the need to reinsert an artificial airway within 24h or up to 3 days post decannulation as potential definitions of failure to decannulate.
A variety of reasons may contribute to failure to decannulate. It is therefore essential that any patient who has had their tracheostomy removed should be closely observed in the immediate post decannulation period. Some patients may have an increase in their work of breathing however the changes in work of breathing between individuals are considerable and are closely related to altered airway resistance. Those weaning from prolonged ventilator support in Critical Care being particularly at risk of fatigue. Inadequate cough reflex may result in an inability to clear secretions and removal of the tracheostomy tube may unmask tracheal damage including stenosis, tracheomalacia and granuloma that may not been previously recognised. These complications may present as stridor, altered quality in vocalization and/or an increase in work of breathing. A patient should be referred to the ENT team if concerned or the emergency team if acute respiratory distress is observed.
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FLOW CHART FOR DECANNULATION
MECHANICAL VENTILATION NO
LONGER REQUIRED
TRACHEOSTOMY OCCLUSION TOLERATED
DECANNULATE
ADEQUATE MENTAL STATUS
EFFECTIVE COUGH
SECRETIONS CONTROLLED
TRACHEOSTOMY TUBE
INSERTION
NO YES
FIBEROPTIC AIRWAY
EVALUATION
AIRWAY PATENTCY
ESTABLISHED / RE-
ESTABLISHED
TRACHEOSTOMY OCCLUSION
TOLERATED
ADEQUATE MENTAL STATUS
EFFECTIVE COUGH
SECRETIONS CONTROLLED
LONG TERM
TRACHEOSTOMY
TUBE
NO
MONITOR PATIENT CLOSELY
FOR 24-48 HOURS
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Transferring tracheostomy patients
Patients with tracheostomies often need to be moved. From an operating theatre to a ward or critical care unit, between wards or unit and between hospitals. Transfers from hospital to home or back again are covered in the next section. This is a potential time of risk to the patient as movement from bed to trolley or wheelchair increases the risk of tube displacement. The precise circumstances of the transfer will determine the personnel and equipment needed, but communication is key.
The initial decision must be agreed by the team looking after the patient and the team, family etc. who will receive them. Particular care must be given to patients being discharged home on their own that the communication with community teams is functional.
Planning the transfer must include an assessment of the times when the patient is at risk. This is usually at the point of transfer from a bed into a trolley or chair, and again when the patient is transferred back to a bed.
Personnel trained in recannulation must accompany the patient as if the tube is displaced it may need to be replaced during the journey.
It is completely unacceptable for a tracheostomy patient to be moved from one area of the hospital to another (or from one hospital to another) until both areas have agreed that a bed and trained personnel are available,
Particular care must be taken with ventilated patients who may have to be transferred onto a portable system for the transfer itself. Adequate oxygen and power must be assured before the move commences. An emergency drug box must also accompany the patient under these circumstances.
Although sometimes unavoidable for logistical reasons, it is poor practice to transfer a patient with a tracheostomy during the night.
4. Movement between units, wards and
theatres – communication needs.
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ALL WALES TRANSFER INFORMATION FOR PATIENTS WITH
TRACHEOSTOMIES
Between wards, units and hospitals
1. Primary Reason for Tracheostomy:
Assist weaning from ventilation
Maintain an airway
Post facial surgery
Secretion clearance
Risk of aspiration
Other____________________________________________
2. Type of Tracheostomy: Percutaneous Surgical
3. Date of Tracheostomy procedure:
4. Advised tube change date (max 30 days):
5. Sutures present? Yes / No Date for removal:
Brand of Tracheostomy
Size
Type of Tube
Cuff present? Y / N
Inner tube present? Y / N
Fenestrated? Y / N
Adjustable flange? Y / N
6. Current Requirements:
Humidification
Oxygen
Suction Catheter
Size
Secretion
Heated
Cold Water
Swedish Nose
Buchanan Bib
Regular Saline
Nebulisers
%_______ Quantity
Type
Name:
Hospital Number:
DOB:
Address
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Date of transfer:______________________________________
Professional completing form:
Name: Designation: Sign:
Professional receiving form:
Name: Designation: Sign:
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ALL WALES TRANSFER INFORMATION FOR PATIENTS WITH
TRACHEOSTOMIES
From Theatre to ITU/Ward
1. Primary Reason for Tracheostomy:
To assist weaning from the ventilator
Maintain an airway
Post Maxillofacial/ENT surgery
Secretion clearance
Risk of aspiration
Other____________________________________________
2. Type of Tracheostomy: Percutaneous Surgical
3. Date of Tracheostomy procedure:
4. Advised tube change date (max 30 days):
5. Sutures present? Yes / No Date for removal:
Brand of Tracheostomy
Size
Type of Tube
Cuff present? Y / N
Inner tube present? Y / N
New inner tube included Y/N
Fenestrated? Y / N
Adjustable flange? Y / N
6. Current Requirements:
Humidification
Oxygen
Suction Catheter
Size
Secretion
Heated
Cold Water
Swedish Nose
Buchanan Bib
Regular Saline
Nebulisers
%_______ Quantity
Type
Name:
Hospital Number:
DOB:
Address
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Date of transfer:______________________________________
Professional completing form:
Name: Designation: Sign:
Professional receiving form:
Name: Designation: Sign:
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ALL WALES TRANSFER INFORMATION FOR PATIENTS WITH
TRACHEOSTOMIES
From ITU to Ward
1. Primary Reason for Tracheostomy:
To assist weaning from the ventilator
Maintain an airway
Post Maxillofacial/ENT surgery
Secretion clearance
Risk of aspiration
Other____________________________________________
2. Type of Tracheostomy: Percutaneous Surgical
3. Date of Tracheostomy procedure:
4. Advised tube change date (max 30 days):
5. Sutures present? Yes / No Date for removal:
Brand of Tracheostomy
Size
Type of Tube
Cuff present? Y / N
Inner tube present? Y / N
New inner tube included Y/N
Fenestrated? Y / N
Adjustable flange? Y / N
6. Current Requirements:
Humidification
Oxygen
Suction Catheter
Size
Secretion
Heated
Cold Water
Swedish Nose
Buchanan Bib
Regular Saline
Nebulisers
%_______ Quantity
Type
Name:
Hospital Number:
DOB:
Address
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Microbiology: Sputum
Swallow/Nutritional
status
Weaning to date
Date of Culture
Sputum culture
results
Secretion
type 24 hrs
prior to
transfer
Assessed by SALT:
Assessed by Dietetics:
NBM?
If not NBM, please
describe current oral
intake:
Cuff deflation and
current cuff status:
Finger
occlusion/capping:
Speaking Valve:
Suggested tube change date________________________________
Date of transfer:
Professional completing form:
Name: Designation: Sign:
Professional receiving form
Name: Designation: Sign:
Name: Designation: Sign:
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INTRODUCTION
Regardless of the reason for tracheostomy, the impact on the patient may be physically and psychologically profound and despite the increase in their numbers, suitably trained and experienced healthcare professionals who care for and train the tracheostomised patient remain in short supply. The tracheostomy may have been performed urgently to relieve acute or chronic upper airway obstruction or as a planned procedure to facilitate effective weaning from ventilation, but the impact of possible complete voice loss, reduced subglottic pressure and the mere presence of a tracheostomy tube in the trachea is disturbing.
There should be a partnership between the patient and the multidisciplinary healthcare team to prepare for discharge ensuring all members of the clinical team are adequately trained and prepared to support the patient and their ability to self manage the tracheostomy.
Procurement of a portable suction unit – a clinical necessity, can take considerable time, rendering the patient hospitalised when clinically fit for discharge so early recognition of the need is important, unless the patient is an existing tracheostomy patient who has been previously self-caring and does not require suction.
Many care facilities will not accept tracheostomised patients so those few who do need regular support and intervention. Many tracheostomised patients have significant co-morbidities which may impede their ability to self care –hypoxic brain injury, arthritic hands, visual impairment etc, so astute clinical assessment prior to discharge is important.
There should be a point of contact for the patient and scheduled tracheostomy tube changes arranged prior to discharge.
The aim of any discharging MDT would be a patient educated to manage their tracheostomy at home with appropriate equipment and support network thus minimizing the risk of adverse clinical event requiring emergency hospitalization.
5. Transfer to the Community.
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All Wales transfer requirements for tracheostomy patients on
discharge from hospital to community
Early referral to tracheostomy CNS or equivalent trained nursing team.
MDT approach to advance discharge planning.
Assessment of the patient’s physical and psychological ability to manage their tracheostomy.
Prompt start for training of the tracheostomised patient and others if appropriate, e.g. a relative or significant other, in inner tube care and suction technique prior to discharge.
Printed learning objectives with point by point instructions to support learning.
Discussion on emergency situations e.g. displaced tube, bleeding from tracheostomy or tubal occlusion and the appropriate course of action.
Emergency contact number preferably a mobile number with text facility ( the patient may not have a voice )
Inform local ambulance service who will highlight the patient status in advance as a “neck breather”.
Early referral to community nurses concerning their potential need for tracheostomy management training and future input particularly the provision of suction catheters (not on prescription, but available through community supplier).
Early provision of portable suction unit and nebuliser. The patient should be trained on their home equipment and mechanical integrity should be checked prior to discharge.
Provision of appropriate equipment and regular prescription from the general practitioner for tracheostomy consumables. There are commercial companies supporting the provision of consumables e.g. Countrywide Supplies.
Provision of a hospital pack i.e. a spare tracheostomy tube with printed information on type of tube, reason for tracheostomy and any pertinent information regarding the airway. The patients are asked to bring this to hospital in the event of emergency admission.
Advance arrangements for complete tube changes either on community or within the hospital setting dependant on local services. A checklist is included. Pdf versions are available and are to be completed for transfers.
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Checklist for transfer of tracheostomy patients from hospital to the
community.
Patients are not to be transferred until all boxes are ticked.
Please place list in patient’s notes or scan to digital file.
Action Required Tick when complete
Refer to tracheostomy CNS or equivalent specialist nursing service and plan discharge with MDT
Assess patient’s physical and psychological ability to manage tracheostomy.
Training for patient and or relatives/carers on tube management including nebulisers and suction as appropriate.
Emergency situations discussed e.g. displaced tube, bleeding from tracheostomy or tubal occlusion
Emergency contact number given to patient/carers. Facility for text (the patient may not have a voice).
Inform local ambulance service who will highlight the patient status in advance as a “neck breather”.
Refer to GP and community nurses for possible tracheostomy management training and future input. E.g. provision of suction catheters.
Suction unit and nebuliser provided.
Consumable equipment given and ongoing prescription from GP assured.
Hospital pack including spare tracheostomy tube with printed information on type of tube, reason for tracheostomy and any pertinent information regarding the airway. Advise patient to bring pack with them if they need to reattend hospital.
Arrangements made for future tube changes. In community or within the hospital
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ALL WALES DOCUMENT FOR THE TRACHEOSTOMISED PATIENT ON
DISCHARGE FROM HOSPITAL TO THE COMMUNITY.
Prompt referral to the
tracheostomy MDT for
advance discharge
planning
Refer to community nurses for the
provision of a portable suction unit
for home use and any training
requirements pre- patient
discharge.
Printed learning objectives with point by
point instructions to support learning.
Discussion on emergency situations e.g.
displaced tube, bleeding, tubal occlusion
and the appropriate course of action.
Refer to a commercial company
supporting the provision of
tracheostomy consumables via
prescription e.g. countrywide
supplies.
Assessment of the patient’s physical
and psychological ability to manage
their tracheostomy.
Early start for training for the patient and a
significant other in tracheostomy
management and suction technique.
Provision of an emergency pack – spare
tube. Printed information re: type of tube,
reason for intubation and any specific details
pertaining to the tracheostomy. The patient is
advised to bring this with them, in the event
of emergency admission to hospital.
Provision of a nebuliser for
discharge. Ensure any inhalers have
been converted into nebules. The
patient should be trained on their
home equipment and its mechanical
integrity checked pre-discharge.
Advance arrangements for regular
complete tube changes either in
community or in hospital (dependant on
local services.
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Emergency management in the community
There are always concerns when patients with a tracheostomy are managed in the community, and yet a number of patients will be managed outside of hospital at some point in their care. The following flow charts have been prepared to assist non specialist teams when managing emergencies. Most tracheostomies will be managed without removing them, but if the airway is blocked with no airflow, no ability to pass a suction catheter (if available) and no movement of the chest if air is blown into the end of the tube, the tracheostomy must be removed. It is likely that the tube itself is blocked with mucus or blood clot. The patient may then be able to breathe on their own, but if not check for a pulse and start cardiopulmonary resuscitation if required. Pulmonary resuscitation should then proceed using either the mouth and blocking the stoma in the neck, or via the stoma and closing the mouth.
It is important to try and differentiate between a patient in the community with a tracheostomy (who should therefore have a potentially patent upper airway) and a laryngectomy (who by definition will have an end-stoma and no airway via the mouth or nose). If in doubt, please follow the guidance for tracheostomy emergencies, but always ensure that oxygen and ventilation are given via the neck stoma, even if this is duplicated via the mouth. However if you are confident a patient has a laryngectomy then the laryngectomy guidance should be followed as attempts at managing the airway from the mouth or nose will be unsuccessful.
Please note that a patient who has had a laryngectomy is called a “laryngectomee”. You may see this term on cards carried by the patient, or on stickers on car and house windows.
6. Emergency Management.
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Emergency Management of a tracheostomy patient
37
Emergency management of a laryngectomy patient
38
Introduction Paediatric tracheostomies are managed differently from adults. The aim is for the child to be safely discharged home with full healthcare support. The parents or main carers will be fully trained and competent in tracheostomy care before the child is discharged, with the community team providing support. Parents and carers are also made aware of the risks involved with children crawling, playing and pulling on their tube. Whilst managed differently paediatric tracheostomies are also covered by NatSSIPs (National Safety Standards for Invasive Procedures). The NatSSIP guidelines outline the key elements for the development of LocSSIPs (Local Safety Standards for Invasive Procedures) including governance, documentation, handovers, briefing, procedural verification, and sign in and out. National Safety Standards for Safety Procedures was issued by Welsh Government in September 2016 along with a Patient Safety Notice (PSN034) supporting the introduction of the standards.
www.patientsafety.wales.nhs.uk/sitesplus/documents/1104/NatSSIPs%20WALES%20%28FINAL%29%20September%2020161.pdf www.patientsafety.wales.nhs.uk/sitesplus/documents/1104/PSN034%20Supporting%20introduction%20of%20NSSIPs.pdf Why a tracheostomy? There are numerous reasons for a tracheostomy to be performed. Every child has a different reason, the priority being to maintain a clear accessible airway. In all children a tracheostomy is performed by an open approach and never via a percutaneous approach. . Procedure
A horizontal incision is made between the suprasternal notch and the cricoid cartilage, the tissue, including thyroid tissue, between the skin and the trachea is divided. The trachea is dissected out in the midline and a vertical incision is made through the 2nd and 3rd tracheal rings and the tracheostomy tube is placed through the incision.
7. Paediatric tracheostomy
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Stay sutures During surgery the child may have sutures inserted into each side of the trachea and brought out through the skin incision and taped to the chest. These are not removed until after the first tracheostomy change. They are removed by the surgeon who performed the surgery. If the tube is dislodged the sutures are pulled upwards and away from each other bringing the trachea closer to the skin surface and opening the hole into the trachea aiding insertion of a new tube. In other circumstances the trachea may be sutured to the skin edges to aid tracheal changes and no tracheal sutures will be present. Types of tubes used in children The type and size of the tube is again a decision made by the surgeon. There are numerous tracheostomy tubes. Every child should be treated as an individual regarding their care and needs as this can vary considerably. The size of the child rather than the age defines the type and size of tracheostomy tube the patient has. Some children will have an adult size tube by the time they transition to adult care, whereas many other children will have some form of disability and will continue with a paediatric size tube after transitioning. The age at which children transition will depend on the co-morbidities and needs of the child. As a result, before they are moved to adult care there should be joint discussion between the paediatric and adult teams involved in both the hospital and the community settings to ensure a smooth as possible transition. As ENT departments look after both the paediatric and adult population then care from an ENT perspective should be seamless and continuous. Uncuffed single lumen tubes
Uncuffed single lumen tubes are invariably used for children. The most common are the Shiley and Bivona tubes which come in sizes ranging from size 2.5 Neo to 5.5 Paeds. The neo tubes are shorter and with a different curve compared to the paediatric tubes. The majority of babies will have a neonatal tube. These tubes are not fenestrated and do not have an inner tube owing to the very small inner diameter of the tracheostomy tube. Tracheostomy tubes have a V flange or straight flange and either can be used depending on the shape of the child’s neck.
Rigid tubes, like Shiley, are radiopaque biocompatible polyvinyl chloride tubes and are compatible with X ray and MRI scanners and should be changed on average once a week and are single use. More flexible tubes like Bivona’s Flextend tubes are radiopaque wire reinforced silicone tubes but they are not always compatible with some MRI scanners. These can be changed monthly. These can be cleaned and reused up to 5 times each. The manufacturer’s booklet describes a few different cleaning techniques Tracheostomy tubes vary in length diameter angle and shape depending on the manufacturer. Always check the type and dimensions of the tube insitu and whether you need a paediatric or neonatal tube before changing the tube.
40
Cuffed tubes Occasionally cuffed tubes are used, but this is rare in babies and children. Cuffed tubes are used when there is a need to provide an airtight seal around the tube for ventilation purposes, and to protect from aspiration. Cuffed tracheostomy tubes have low pressure cuffs and providing they are inflated to the manufacturer’s recommendations they should not cause soft tissue or tracheal stenosis. The TTS (tight to shaft) tubes are the most commonly used as the cuff is water inflated and less traumatic. The TTS cuff is a high pressure low volume cuff and as such the pressure to distend the cuff material will mask the pressure between the cuff and the tracheal wall. Therefore cuff pressure cannot be taken as an indicator of the pressure on the trachea and must not be used to monitor this. Use either minimal leak or minimal occlusive volume techniques to establish the cuff and to ensure correct inflation at regular intervals. The amount of water used should be written on the child’s pathway at the bedside. Introducers
Tracheostomy tubes should always be inserted with an introducer to ensure easy insertion and to prevent damage to the fragile trachea. These are kept in the emergency box once the tube is in situ. Humidification
In normal respiration the function of the upper airway is to moisten, warm and filter the air inhaled. A tracheostomy bypasses the nose and mouth so humidification is added to prevent the mucus drying. Warmed humidification should be constantly applied to the tracheostomy until the first tube change is carried out to prevent crusting or blocking of the tube. Heat and Moisture Exchangers (HMEs, e.g. Swedish noses) are then used unless secretions are very thick. The barrel types are suitable for children/babies over 10kgs and minivent types suitable for under 10kgs. Ties/Tapes
On returning to the ward following surgery the child may have either tapes or Velcro fastening ties and there will be a tracheostomy dressing between the tracheostomy and the skin. The ties need to be changed daily to prevent infection and the neck becoming sore. These need to be secured so that a single finger can fit snuggly between the tapes and the child’s/babies neck. Check the ties a short time after changing them as the tightness can vary slightly with different neck positions. Always check the Velcro ties to ensure that the hard Velcro is under the soft part of the tie to prevent irritation and the neck becoming sore. The dressings need to be changed as often as needed but at least daily.
Important tip: It is essential that the staff caring for a patient with a tracheostomy know the type of tube and size in place at any time. They should also know if the child can be intubated in an emergency and this should be clearly documented in the notes.
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Changing the dressing
1. Loosen one side of tie slightly. 2. Remove dressing carefully. 3. Look at the tracheostomy site and check for any red or irritated area. 4. If the skin is sore, apply a barrier cream to the area. 5. Apply new dressing and secure ties.
Suctioning the tracheostomy There are no set times to use suction. Suction should be used when needed. It is important to identify the reasons for and against using suction. When to use suction
Suction is required when there is ineffective airway clearance
Abnormal breathing sounds
An irregular breathing pattern
A build up of secretions
Increased coughing
Colour and observational changes. Instructions for suctioning Always have all the equipment you will need ready. Check you have the right size suction catheter for the tube. Use a suction catheter that is twice the number of the tube i.e. for a size 4 tube use a size 8 suction catheter. Also check the length prior to inserting the suction catheter, this should be no more than 2mm beyond the tip to prevent suction damaging the trachea wall. Measure against a spare tube. Equipment
Suction
Appropriate suction catheters
Connecting tubes
Water to rinse tube
Gloves.
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Procedure
1. Wash your hands
2. Connect the suction catheter to tubing
3. Turn on the suction and check the pressure
4. Gently insert the catheter into the tracheostomy tube with your thumb off the suction port. The distance it is passed depends on the length on the tube
5. Apply suction by putting your finger /thumb over the port
6. Slowly withdraw the catheter. Multi eyed catheters are more efficient. This
should only take as long as a breath
7. Rinse the tubing and dispose of the catheter. The suction catheter can be reused if suction needs to be repeated straight away providing it has not been contaminated by touching any surrounding area
8. If necessary repeat the procedure after a short time.
IF IT IS THE FIRST CHANGE EMERGENCY BLEEP THE ON CALL SURGICAL TEAM RESPONSIBLE FOR PAEDIATRIC TRACHESTOMY IN YOUR UNIT. Changing the tracheostomy Tube The first tube change should be carried out one week post-operatively. The surgeon who performed the operation usually carries out the first tube change. If present the stay sutures will also be removed at this time. The tube will also need changing if:-
there are crusts around the end due to a build up of secretions
secretions are very thick
there is an obvious problem with secretions. Suction removes most of these secretions but not all and a build up can occur.
For best practice change the tube on a regular basis. Weekly is the usual for biocompatible PVC tubes and monthly for silicone tubes. It is important to check that the replacement tube is the same make and size of the current tube. Any alteration in the type and size of tube should be made by a secondary care team. The child should always have an emergency box at the bedside with the items below inside.
Important tip: The lining of the trachea is very sensitive and can be damaged by suction catheters. To minimize this risk only pass the catheter just to the end of the tracheostomy tube. This can be practiced on a spare tube. IF THE TUBE APPEARS TO REMAIN BLOCKED AND THE CHILD IS HAVING
BREATHING DIFFICULTY, CHANGE THE TUBE.
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N.B. Tracheal dilators are not used with children. Preparation for changing the tube
Acquire all the equipment you will need for the change before you commence. You will need a clean area for the equipment:-
swabs
lubricating gel
clean ties
the new tube and one smaller
normal saline
dressings
emergency box with introducer for tube plus wedge if using a silicone tube to aid the removal of any attachments.
Preparing the child
Before changing the tube put the child/baby in a comfortable position. The neck should be slightly extended and the head straight. One of the easiest ways to obtain this position is putting a rolled up towel or something similar under the child’s shoulders which makes the head tilt backwards slightly. The child’s/ baby’s arms need to be restricted while performing the change. Swaddling can be useful. It is important to keep the child/baby still. The older child will in the beginning need an adult to hold their hands, but as they get accustomed to the change this may not be necessary. Changing the tube. There should be two people for the procedure, one to hold the child and hold the old and new tube in place and one to undo the ties, change the tube and reapply the tapes and dressings. Procedure
1. Wash hands and put on gloves
2. Check the new tube - make sure it is the correct size and make
3. Insert the introducer into the new tracheostomy tube
4. Attach ties making sure the soft part will be against the child’s skin and lubricate the tube
5. Ensure cleaning items and dressings are ready
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6. Position the child on his/her back with the neck extended (to ensure clear view of tube and neck). One person may be needed to hold the child’s hands and hold the tube in place whilst ties are being undone
7. Apply suction only if required
8. Undo the ties and remove the tube
9. Clean the area if needed
10. Insert the new tube with an up and over movement following the natural line of
the trachea. Do not force
11. Remove the introducer. Keep in the emergency box for use in the event of an emergency tube change
12. Check there is airflow from the tube
13. Apply the tracheostomy dressing between the skin and the tracheostomy
whilst the new tube is being held in place by the first person
14. Secure the tracheostomy with the ties around the neck.
Further tube changes Once the first tube change has been completed the subsequent changes should be performed in the beginning by staff qualified in tracheostomy care with the parents. The parents should each prepare for and perform a tracheostomy tube change 3 times (or more if needed in order to be deemed competent) and then if staff feel they are competent and confident they can be signed off by senior tracheostomy trained staff. The parents should also have emergency tracheostomy care and resuscitation demonstrated to them. The nursing staff on the wards should all be trained in this procedure. Once the parents are deemed competent and confident and the community team are satisfied, the child can be discharged home. Paediatric pathway documentation
All patients should have a tracheostomy pathway booklet at the bedside at all times and this should be filled in from the day of the tracheostomy surgery listing all the information needed. It is extremely important all staff document all details at all times. Staff caring for these children should be fully competent and confident in tracheostomy care.
Important tip: if the tube will not go in do not panic
1. Reposition the child and try a smaller tube 2. If you still can’t get the tube in insert a suction catheter through the
stoma to keep an airway. Hold on to it 3. Call for help.
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Communication
Following tracheostomy placement the child should be referred to the speech and language therapist with regard to the development of sound and any swallowing problems that might develop. A decision can then be made with regard to the use of a speaking valve in the rehabilitation of voice. Discharge
Planning meetings need to be arranged as soon as possible to arrange equipment and care and involves the whole team that have been caring for him/her and also the team that will take over the care in the community. A follow up should be made for clinic. Contact numbers need to be given for all those involved. Open access will need to be arranged at these meetings to give a direct route back to the hospital if necessary.
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TRACHEOSTOMY EMERGENCIES
THE TWO COMMON SCENARIOS THAT CAN LEAD TO A TRACHEOSTOMY EMERGENCY ARE:- ● A BLOCKED TRACHEOSTOMY TUBE ● A DISPLACED OR DISLODGED TRACHEOSTOMY TUBE THE PROCEDURE FOR EACH SCENARIO IS PRESENTED IN AN ALGORITHM FORMAT. DISLODGED OR DISPLACED TRACHEOSTOMY TUBE Tracheostomy tubes may become dislodged or displaced for a number of reasons. It is important to ensure that the tapes are secure and comfortable (2hrly). Tracheostomy tubes may become dislodged when a ventilated child is turned or moved; children themselves may pull tubes out. A partly dislodged tube is just as dangerous, if not more dangerous than a completely removed tracheostomy tube. Paediatric ward setting
1. DON’T PANIC
2. Call for help - put out crash call
3. Stimulate the child by calling their name, gently tugging hair or shaking an
arm
4. Assess Airway and Breathing. Look, Listen Feel
5. If no air passing through tracheostomy and not breathing through mouth or nose change tracheostomy tube - if unsuccessful try smaller size
6. If unsuccessful remove tracheostomy tube and occlude stoma with pad and sleek
7. Give 5 rescue breaths via pocket mask or with bag and mask i/c 100% oxygen
8. Once oxygen saturations above 95%- If child breathing effectively monitor
oxygen saturations and observe respiratory pattern.
9. If no or poor respiratory effort, using the catheter mount give 5 RESCUE BREATHS either with a resuscitation bag or by blowing into the mount until
you see the chest rising
10. Remember if blowing into mount remove your mouth between breaths to allow air to escape
11. Assess circulation - feel for pulse (infants brachial, children carotid)
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12. Commence cardiac massage and continue basic life support
13. If unable to ventilate through tracheostomy tube return to face mask ventilation and prepare for endotracheal intubation.
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YES
YES NOT ABLE TO
VENTILATE
YES
NO
NO
DISLODGED/DISPLACED TRACHEOSTOMY TUBE General Ward setting
DON’T PANIC! Emergency call for help
and Crash team
Is the child breathing?
Change tracheostomy tube
and secure. (If unsuccessful
try one attempt of a smaller
size and secure. One
attempt only)
Remove tracheostomy tube and
cover stoma with pad
Ventilate with bag and mask
with 100% oxygen
Monitor oxygen saturation (pulse oximeter) and
observe respiratory pattern
Is the child breathing?
Able to ventilate via
tracheostomy tube
Continue basic life
support
Endotracheal tube
for intubation
Sats ≥ 95%
Sats ≥ 95%
NO
Change tracheostomy tube.
If unsuccessful try one
attempt of a smaller size and
secure.
If unsuccessful
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BLOCKED TRACHEOSTOMY TUBE
If a child with a tracheostomy shows signs of respiratory distress suspect a blocked or partially blocked tube. If you are able to pass the appropriate size suction catheter and the child is maintaining normal oxygen saturations commence a saline nebuliser and call for urgent medical review. If you are unable to pass the appropriate size suction catheter and if breathing is labored - Put out crash call and commence basic life support. CHANGE TRACHEOSTOMY TUBE If unsuccessful try smaller size tube If not possible -
occlude tracheostomy stoma
commence ventilation via bag and mask with 100% oxygen
prepare for urgent endotracheal intubation if anatomically possible. If new tube successfully inserted -
Assess breathing, if breathing adequate give saline nebuliser and observe respiratory pattern and nature of secretions obtained on suction or coughing. If breathing not adequate commence basic life support.
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NO
YES YES
NO
YES
NO YES YES
BLOCKED TRACHEOSTOMY TUBE
Child with tracheostomy shows signs of respiratory
distress
DON’T PANIC!
Assess Airway Patency –a suction
catheter should pass easily
Change tracheostomy tube
New tube inserted successfully?
Does the child cough with
suction?
Is the child breathing? Bag and mask ventilate
with 100% oxygen
Emergency call for help and Crash team
1. Try smaller tube 2. If unsuccessful occlude tracheal stoma
3. Facemask and
bag ventilation
Is ventilation adequate?
Intubation required
urgently if
anatomically possible
Assess circulation
follow basic life support
Give saline nebuliser
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Summary
The majority of children have single lumen tracheostomy. As there is no inner cannula, parents, carers, staff and community teams caring for the child must be able to change a tracheostomy tube.
Children will need constant supervision until the first tube change and wherever they are cared for should always have sufficient qualified tracheostomy staff.
Parents must be deemed competent and performed 3 tube changes and shown basic life support plus emergency procedures. The child cannot be discharged until the parents have been signed off by senior qualified staff.
Children crawl, play and pull at their tubes they must be supervised at all times.
Ward staff should have link nurses who have been deemed competent to train other staff.
Documentation and good communication is the key to safe total care.
Emergency equipment must be with the child at all times.
