1. Tracheostomy Tubes

2. Tracheostomy

3. Indications facilitate prolonged mechanical ventilation and weaning
by-pass upper airway obstruction (ex. sleep apnea, tumor …)
maintain patent airway in severe head and neck injury or surgery
airway anomalies
secretion removal
recurrent aspiration

4. Contraindications coagulopathy enlarged thyroid
abnormal airway anatomy
lack of patient consent for procedure
poor surgical candidate

5. Advantages decreased work of breathing
decreases the risk of upper airway complications due to endotracheal tube
increase patient comfort and compliance
improved oral hygiene
oral movement for communication
easier to stabilize and secure compared to endotracheal tubes
increased mobility

6. Disadvantages increased risk of infection impairs speech
bypasses normal humidification system
invasive surgical procedure
may impair swallowing

7. Tracheostomy Terms to Remember
Flange – Is the part that is attached to the outer cannula. It assists in stabilizing the tube in the trachea. It also provides the holes necessary for proper securing of the tube to the neck of the patient.
Outer Cannula - The outer cannula forms the body of the tracheostomy tube.
Inner Cannula - Fits into the outer cannula like a liner. Can be removed for cleaning or changing. (Disposable and Non-disposable) (Twist lock or Ring-pull inner cannula) Note - not all tubes have an inner cannula.

8. Tracheostomy Terms to Remember (cont’d)
Obturator - The obturator is only used during insertion of the tracheostomy tube. It replaces the inner cannula during insertion. Must always be present at patient bedside in case of accidental decannulation.
Cuff – Is the balloon around the outer cannula that is inflated to maintain a seal around the tube. ** Note: not all trachs have cuffs.
Inflation Line – Used to facilitate inflation of the cuff.
Pilot Balloon – Is an external indicator that the cuff is inflated.

9. Tracheostomy Terms to Remember (cont’d)
Tracheostomy Sutures – 2 Types
Stay Sutures – Inside the trachea that can be gently pulled to bring the tracheal opening to the skin in case of early, unplanned decannulation.
Skin Sutures – Placed in the O.R. attaching the tracheostomy flanges to the skin to prevent decannulation.
Fenestration – Opening in the outer cannula that allows for more air flow through the upper airway (facilitates speech).

10. Figure 1(Portex Tube) FLANGE OUTER CANNULA INFLATION LINE CUFF
PILOT BALLOON

11. Figure 2 (Inner Cannula/Obturator)

12. Types of Tubes
Cuffed or uncuffed. **Most pediatric tubes do not have cuffs and inner cannulas due to smaller diameter. Most adult tubes have inner cannula to allow for less frequent outer cannula changes.
Metal (Jackson) or plastic (bivona, portex, shiley)
Single or double cannula
Fenestrated or non-fenestrated
Short or long term
Custom

13. Shiley® fenestrated cuffless tube
Types of Trach Tubes
Shiley® cuffless tube
Bivona® Uncuffed Neonatal and Pediatric Silicone Tracheostomy Tubes
Shiley® fenestrated cuffless tube
Metal Jackson tube

14. Tracheostomy Policies
Tracheostomy Stoma Care
Policy Statement – Tracheostomy stoma care should be performed every shift and on an as needed basis.
Care of the Inner Cannula
Policy Statement- Corks and inner cannula should be cleaned or changed daily as well as PRN. Pediatric and neonatal inner cannula should be cleaned or changed Q6H to Q12H and/or PRN. Inner cannula should be checked Q4H or immediately if patient appears to be in respiratory distress, the inner cannula needs to be removed and inspected for encrustation.

15. Suctioning Oral-Nasal-Tracheal Adult 150-200mmHg Pediatric 120-150mmHg
Infant 100mmHg
Review HHS policy Resp-Suctioning
Attach the suction catheter to the suction tubing.
Put clean gloves on both hands.
Apply mask or goggles (optional).
Remove catheter from package with dominant hand.
Apply water soluble gel to tip of catheter, if necessary
Wrap catheter around dominant hand.
Disconnect tracheostomy mask with non-dominant hand.
Using your dominant hand gently and quickly insert the catheter into the airway until a resistance is met, or patient coughs.
Pull the catheter out slightly and apply continuous suction while withdrawing the catheter out of the airway.
Ensure the whole procedure from catheter insertion to withdrawal does not take longer than seconds.
Reapply the mask between suctioning procedures.
Repeat the procedure, if required, allowing appropriate time for recovery.

16. Tracheostomy Emergencies
Tube Occlusion
Signs of tube occlusion include:
Difficult or laboured breathing
Use of accessory muscles
None or limited expired air from tracheostomy tube
Pale/Cyanosed skin color
Anxiety
Increase Pulse and Respiratory Rate
Clamminess
Cessation of respiration

17. Tube Occlusion (cont’d)
PLAN OF ACTION
ALWAYS STAY CALM AND REASSURE THE PATIENT
Call for help immediately, both RN and RT.
Reposition the patient into the
semi-recumbant position
Ask patient to cough or attempt to clear secretions via suctioning
Manipulate the head and neck to eliminate kinking or to allow tube reposition

18. Tube Occlusion (cont’d)
Ask person helping you for baseline oxygen saturation and vital signs, if necessary.
Administer oxygen via Face mask.
If occlusion is still present:
Attempt to remove inner cannula and inspect for blockage.
Replace inner cannula with a new one, if blocked.

19. Tube Occlusion (cont’d)
If occlusion is still present after removal of inner cannula.
Ask patient to cough to clear secretions
Suction down tracheostomy tube again to attempt to clear blockage.
If patient continues to have distress then entire tracheostomy tube may need to be changed.
PAGE PHYSICAN STAT (if they are not already there).

20. Tube Occlusion (cont’d)
ALWAYS STAY CALM AND REASSURE THE PATIENT
DO NOT REMOVE TRACH. Call the RT stat to perform trach removal.
Note: If upper airway obstruction is indication for tracheostomy, Call Team Immediately and DO NOT REMOVE TRACH.

21. Accidental Decannulation
If tracheostomy is partially out:
Note: If upper airway obstruction is indication for tracheostomy, Call Team Immediately and DO NOT REMOVE TRACH.
ALWAYS STAY CALM AND REASSURE THE PATIENT
CALL THE RT STAT
Ensure that saturation monitor is on patient.

22. Accidental Decannulation (cont’d)
Attempt to determine if patient is in distress.
Try to prevent them from coughing rest of tube out.
If patient coughs tube out, suction stoma site.
Temporarily occlude stoma with gauze and apply oxygen via face mask.
Observe patient for signs of respiratory distress. If no signs of distress then document.

23. Accidental Decannulation (cont’d)
If signs of distress assist RT in airway management and call the Emergency team.
Wait until team arrives and transfer care of patient.
IF AT ANY POINT YOU ARE UNSURE OF WHAT TO DO CALL THE RESP. THERAPIST!!

24. Accidental Decannulation (cont’d)
If tracheostomy is fully out:
ALWAYS STAY CALM AND REASSURE THE PATIENT
CALL THE RT STAT.
Once tube is removed, suction stoma site.
Temporarily occlude stoma with gauze and apply oxygen via face mask.
Observe patient for signs of respiratory distress.

25. Accidental Decannulation (cont’d)
If no signs of distress then inform RT upon arrival.
If signs of distress then assist RT with airway management and call the Emergency team.
Wait until team arrives and transfer care of patient.
IF AT ANY POINT YOU ARE UNSURE OF WHAT TO DO CALL THE RESP. THERAPIST!!

26. References
Harkin, H. & Russell, C. (2001) Tracheostomy Patient Care. Nursing Times, Volume 97, No. 25, pages
Serra, A. (2000) Tracheostomy Care. Nursing Standard. Volume 14, No. 42, pages
Smith, S., Duell D., Martin, B. (2000) Clinical Nursing Skills, 5th Edition, Chapter 25, page Prentice-Hall.
Kacmarek, R.M. et al. The Essentials of Respiratory Therapy, 2nd Edition, Chapter 25, pgs Year Book Medical Pubishers Inc.
Endotracheal Suctioning of Mechanically Ventilated Adults and Children with Artificial Airways. AARC Clinical Practice Guideline Reprinted from Respiratory Care (respir Care 1993; 38: )
Interdisciplinary Clinical Practice Guideline on Suctioning: Adult Patients. May 14, 1999
Interdisciplinary Clinical Practice Guideline on Suctioning: Infants and Children. May 14, 1999
Guidelines for Prevention of Nosocomial Pneumonia. MMWR 46(RR-1); 1-79, 01/03/97
Nasotracheal Suctioning AARC Clinical Practice Guideline
Respiratory Care (Respir Care 1999;44(1):99-104)
Respiratory Care (Respir Care 1992;37: )
Suctioning of the Patient in the Home AARC Clinical Practice Guideline
St. George’s Healthcare NHS Trust August 2000 published by Sims Portex Ltd.