Tracheostomy Tubes

Tracheostomy

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

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

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

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

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.

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.

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).

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

Figure 2 (Inner Cannula/Obturator)

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

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

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.

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 10-15 seconds. Reapply the mask between suctioning procedures. Repeat the procedure, if required, allowing appropriate time for recovery.

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

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

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.

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).

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.

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.

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.

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!!

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.

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!!

References Harkin, H. & Russell, C. (2001) Tracheostomy Patient Care. Nursing Times, Volume 97, No. 25, pages 34-36. Serra, A. (2000) Tracheostomy Care. Nursing Standard. Volume 14, No. 42, pages 45-52. Smith, S., Duell D., Martin, B. (2000) Clinical Nursing Skills, 5th Edition, Chapter 25, page 776. Prentice-Hall. Kacmarek, R.M. et al. The Essentials of Respiratory Therapy, 2nd Edition, Chapter 25, pgs381-390. 1985. 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; 38:500-504) 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;37:898-901) Suctioning of the Patient in the Home AARC Clinical Practice Guideline St. George’s Healthcare NHS Trust August 2000 published by Sims Portex Ltd. http://www.portex.com/airway/products/select5.asp?autonum=25 http://www.portex.com/airway/products/select5.asp?autonum=44 http://www.tracoe.de/pix/prod/twist/r306.gif http://www.supportnet.us/trach_pics/sh_cfs.jpg http://faculty.icc.edu/gcarr/images/equip/gc40.jpg http://www.tracheostomy.com/images/trach4.gif