caring for the patient with a tracheostomy
TRANSCRIPT
Best Practice Statement ~ March 2007
Caring for the patient with a tracheostomy
© NHS Quality Improvement Scotland 2007
ISBN 1-84404-453-X
First published January 2003Reviewed April 2007
You can copy or reproduce the information in this document for use within NHS Scotland and foreducational purposes. You must not make a profit using information in this document.Commercial organisations must get our written permission before reproducing this document.
www.nhshealthquality.org
Contents
Introduction i
Key stages in the development of best practice statements ii
Best practice statement: Caring for the patient with a tracheostomy iii
Section 1: Education and training 1
Section 2: Communication 3
Section 3: Swallowing and nutrition 5
Section 4: Stoma care 7
Section 5: Tracheostomy tube management 9
Section 6: Suctioning 14
Section 7: Humidification 15
Appendix 1: Volume of tracheostomies in Scotland 18
Appendix 2: Factors that affect communication 19
Appendix 3: Factors that may affect swallowing 20
Appendix 4: Types of tracheostomy tube 21
Appendix 5: Illustrations 22
Appendix 6: Audit tool 26
Glossary 28
References 30
Who was involved in developing the statement? 35
Caring for the patient with a tracheostomy
i
Introduction
NHS Quality Improvement Scotland (NHS QIS) was set up by the Scottish
Parliament in 2003 to take the lead in improving the quality of care and
treatment delivered by NHSScotland.
The purpose of NHS QIS is to improve the quality of healthcare in
Scotland by setting standards and monitoring performance, and by
providing NHS Scotland with advice, guidance and support on effective
clinical practice and service improvements.
A series of best practice statements has been produced within the
Practice Development Unit of NHS QIS, designed to offer guidance on
best and achievable practice in a specific area of care. These statements
reflect the current emphasis on delivering care that is patient-centred,
cost-effective and fair. They reflect the commitment of NHS QIS to
sharing local excellence at a national level.
Best practice statements are produced by a systematic process, outlined
overleaf, and underpinned by a number of key principles.
• They are intended to guide practice and promote a consistent,
cohesive and achievable approach to care. Their aims are realistic but
challenging.
• They are primarily intended for use by registered nurses, midwives,
allied health professionals, and the staff who support them.
• They are developed where variation in practice exists and seek to
establish an agreed approach for practitioners.
• Responsibility for implementation of these statements rests at local
level.
Best practice statements are reviewed, and, if necessary, updated after 3
years in order to ensure the statements continue to reflect current thinking
with regard to best practice.
ii
Topic selection and Scoping Process.
Establish working group. Establish reference group to
advise on consultation drafts.
Review literature on topic.
Source grey literature.
Ascertain current policy and legislation.
Seek information from manufacturers,
voluntary groups and other relevant
sources. Determine focus and content
of statement.
Review evidence for
relevance to practice.
Determine how patients’
views will be incorporated.
Draft document sent to
reference group.
Wide consultation process.
Review and revise statement
in light of consultation
comments.
Publish and disseminate
statement.
Review and update process.
Identify new research/findings
affecting topic.
Consider challenges of using statement
in practice.
Feedback on impact
of statement is
sought/ impact
evaluation.
Key stages in the development of best practice statements
Caring for the patient with a tracheostomy
iii
Best practice statement: Caring for the patient with atracheostomy
A tracheostomy is an opening in the front of the trachea that can be
temporary or permanent. Temporary ones usually have a tracheostomy
tube in place to keep them open. Indications for the formation of a
tracheostomy will include protection from aspiration in cases of
swallowing impairment, to facilitate breathing and weaning from artificial
ventilation and to facilitate clearance of secretions. Examples of patients
who may have a tracheostomy are those with neuromuscular disorders
who have impaired swallowing and coughing, those who have a poor
cough or gag reflex after a head injury or a protracted critical illness and
patients who have had their larynx removed surgically. As with the
original, this revised statement does not refer to care of patients with a
laryngectomy.
The different nature of the situations in which a tracheostomy could be
employed means that it is difficult to track the epidemiology of this
procedure. Due to the increasing sophistication of medical technology
and higher survival rates from diseases such as motor neurone disease,
the incidence of tracheostomy in general wards and in the community is
increasing. In Scotland, the volume of tracheostomy operations over the
last decade has increased (Appendix 1). In 2002, the Ear, Nose and Throat
(ENT) Nursing network from the Nursing and Midwifery Practice
Development Unit, which subsequently merged with other organisations
to become NHS QIS, identified this topic as one where guidance and
support in the form of professional consensus would help promote
consistent practice across Scotland.
This statement was originally designed for healthcare professionals,
especially nurses, who may not necessarily work in a specialist
environment and where there is access only to professional support
available as ‘outreach’ from specialist clinical areas. The management of a
tracheostomy involves other professionals such as dietitians,
physiotherapists, specialist nurses, and speech and language therapists.
The membership of the working groups convened first to develop the
statement and then to review it reflects this.
iv
In reviewing the statement, it was agreed that little new formal evidence
with the potential to change practice had been published since the
statement had been first developed. Information gathered from users of
the statement as part of the review process suggested that the revised
statement should refer only to adults.
The working group identified several significant principles to consider
when caring for the patient with a tracheostomy. Firstly, there is a need to
acknowledge that there will be differences between the practices and
procedures involved in caring for a patient with a tracheostomy who lives
in the community, and where the stoma is established, to those which are
typical of intensive care units (ICUs) and specialist wards, eg thoracic
wards, where the stoma is relatively new.
Secondly, the working group, recognised that in addition to the
continuum of management requirements, there is a continuum of factors
which come into play in the patient journey. There is a requirement, for
example, to cater for the psychological, nutritional and communication
needs of the patient which may also vary along the care pathway as the
balance of risks changes.
This statement is designed primarily for the non-specialist practitioner, as
an introductory statement and as a guide to best practice and what
support should be available locally. The working group acknowledges,
however, that some specialist units have used the statement. It is not
designed as a ‘how to’ document, since the group envisage that local
protocols and agreements will determine this, but where professional
consensus exists on particular procedures, this is recorded in the
statement. The statement will support local policies and procedures. It is
the hope of the Practice Development Unit that, in time, the best practice
statements will stimulate research and the development of a more formal
evidence base; the statements are targeted at areas of clinical practice
where the formal evidence base is still in the process of being developed
and where there is a variation in practice across Scotland.
Since the statement was first published, the concept of risk management
has become more familiar to healthcare practitioners, and the working
group reviewing the statement was keen to stress that any consideration
of the patient with a tracheostomy should be within such a risk
management framework. Examples of this could include consideration of
Caring for the patient with a tracheostomy
v
the risk of occlusion, the risk of infection and the realistic management of
cuff pressure testing in the community. Similarly, the working group
discussed suctioning pressures, aware that this is a high risk procedure,
and emphasised that the lowest possible pressure should be used,
recognising that, as in all situations, the professional practitioner will be
responsive to the context and address relative risks accordingly. In
addition to acknowledging risk, the group recognised that all healthcare
workers have a professional responsibility to ensure they have the
knowledge and skills necessary to care for the patient with a
tracheostomy. A separate section on education and training in the revised
statement highlights the importance of this.
Since the publication of the original statement, the group acknowledged
that an increased awareness of the special resuscitation requirements of
patients with a tracheostomy is necessary and patient safety information
from the National Patient Safety Agency (2005) has drawn attention to
this. If the number of people with a tracheostomy in Scotland is
increasing, as the data from ISD would suggest (Appendix 1), there is a
need for enhanced awareness-raising in resuscitation training.
In addition to keeping technical skills at a suitable level, which is
mandatory for professionals, good communication skills are very
significant; not only in relieving anxiety in the patient, but also in
involving the carer and educating both to undertake confident self-care in
the community. This is particularly important where there are additional
factors affecting the patient’s capacity to communicate such as visual
impairment, a learning disability, or the patient’s use of English as a
second language.
The statement focuses on the physical care of the patient, but the
working group recognises that psychological support may well be
necessary if the patient with a tracheostomy is to be integrated
successfully into the community and that the best care will go beyond the
recognition and addressing of physical need.
Responding to requests from users of the original statements, this revised
version contains an audit tool. This could be used for the individual
healthcare practitioner to monitor his or her own practice with an
individual patient, or by a ward or larger service unit.
vi
Caring for the patient with a tracheostomy
1
Sect
ion
1:
Ed
ucat
ion
an
d t
rain
ing
Key
Po
ints
~
1 Th
ere
is a
n i
ncr
easi
ng
inci
den
ce o
f pa
tien
ts w
ith
a tr
ach
eost
omy
both
in
hos
pita
l an
d in
the
com
mu
nit
y. N
HS
boa
rds
have
a r
espo
nsi
bili
tyto
wa
rds
thes
e pa
tien
ts a
nd
als
o fo
r pr
epa
rin
g he
alth
care
sta
ff to
ca
re fo
r th
em.
2
A pa
tien
t-cen
tred
app
roa
ch, g
ood
com
mu
nic
ati
on s
kills
, an
d te
chn
ica
l com
pete
nce
are
req
uir
ed to
ca
re fo
r, a
ssu
re a
nd
ass
ist p
ati
ents
in
ada
ptin
g to
an
d m
an
agi
ng
a tr
ach
eost
omy.
3Pa
tien
ts a
nd
thei
r ca
rers
req
uir
e ed
uca
tion
an
d su
ppor
t in
ada
ptin
g to
an
d li
vin
g w
ith
a tr
ach
eost
omy.
Hea
lthca
re p
ract
ition
ers
carin
g fo
r a
pat
ient
with
atr
ache
osto
my
have
acc
ess
to:
•ed
ucat
ion
and
trai
ning
to
mee
t lo
cal n
eed,
and
•st
anda
rdis
ed lo
cal p
roto
cols
or
guid
elin
es d
evel
oped
by
loca
l sp
ecia
lists
.
Hea
lthca
re p
ract
ition
ers
who
com
e in
to c
onta
ct w
ith a
pat
ient
with
a t
rach
eost
omy
(no
mat
ter
how
infr
eque
ntly
)un
ders
tand
:
•th
e p
artic
ular
indi
catio
ns f
or t
rach
eost
omy
•ris
ks a
ssoc
iate
d w
ith a
tra
cheo
stom
y•
pot
entia
l com
plic
atio
ns
•th
e ty
pes
of
tube
s an
d eq
uip
men
t in
volv
ed in
eac
h ca
se,
and
•th
e im
por
tanc
e of
Sta
ndar
d In
fect
ion
Con
trol
Pr
ecau
tions
(SI
CPs
).
Hea
lthca
re p
rofe
ssio
nals
and
car
ers
who
are
in c
onta
ctw
ith t
rach
eost
omy
pat
ient
s ha
ve a
cces
s to
and
rec
eive
trai
ning
on:
•ai
rway
, an
d•
vent
ilatio
n m
anag
emen
t of
pat
ient
s w
ith a
tra
cheo
stom
y.
Hea
lthca
re p
rofe
ssio
nals
nee
d to
be
equi
pp
ed w
ith t
heap
pro
pria
te k
now
ledg
e an
d sk
ills
to m
eet
the
uniq
uene
eds
of t
hese
pat
ient
s co
mp
eten
tly a
nd e
ffect
ivel
y.
It is
a p
rofe
ssio
nal r
esp
onsi
bilit
y to
be
able
to
addr
ess
pat
ient
nee
ds c
omp
eten
tly.
It is
the
pro
fess
iona
l res
pon
sibi
lity
of h
ealth
care
sta
ff to
be p
rep
ared
and
com
pet
ent
to d
eal w
ith e
mer
genc
ysi
tuat
ions
.
Ther
e ar
e lo
cal t
rain
ing
and
educ
atio
n op
por
tuni
ties
for
heal
thca
re p
rofe
ssio
nals
to
mee
t lo
cal n
eed.
Ther
e ar
e lo
cal p
roto
cols
or
guid
elin
es t
o su
pp
ort
staf
fca
ring
for
the
pat
ient
with
a t
rach
eost
omy.
Educ
atio
n is
pro
vide
d to
dev
elop
and
up
date
kno
wle
dge
ofhe
alth
care
pro
fess
iona
ls w
orki
ng w
ith p
atie
nts
with
atr
ache
osto
my.
Resu
scita
tion
trai
ning
sp
ecifi
c to
pat
ient
s w
ith a
trac
heos
tom
y is
aud
ited,
and
tai
lore
d to
loca
l nee
d.
Staf
f p
erso
nal d
evel
opm
ent
pla
ns id
entif
y re
susc
itatio
ntr
aini
ng r
equi
rem
ents
for
rel
evan
t p
rofe
ssio
nals
.
Key
staf
f id
entif
ied
as c
omp
eten
t ar
e re
adily
ava
ilabl
e to
atte
nd t
o em
erge
ncie
s.
Stat
emen
tR
easo
ns
for
stat
emen
tH
ow
to
dem
on
stra
te s
tate
men
t is
bei
ng
ach
ieve
d
2
Hea
lthca
re p
rofe
ssio
nals
kno
w w
hen
to s
eek,
and
hav
eac
cess
to,
pro
fess
iona
l adv
ice
and
assi
stan
ce f
rom
the
rele
vant
sp
ecia
lists
on
the:
•co
mp
lex
nutr
ition
•
ches
t p
hysi
othe
rap
y•
infe
ctio
n co
ntro
l•
com
mun
icat
ion
•re
susc
itatio
n, a
nd
•sp
ecia
list
equi
pm
ent
req
uire
men
ts o
f p
atie
nts
with
a
trac
heos
tom
y.
Hea
lthca
re p
rofe
ssio
nals
mai
ntai
n co
mp
eten
cy in
car
ing
for
a p
atie
nt w
ith a
tra
cheo
stom
y.
Educ
atio
n an
d re
assu
ranc
e of
the
pat
ient
and
car
er s
tart
sp
rior
to a
tra
cheo
stom
y be
ing
per
form
ed a
nd c
ontin
ues
thro
ugh
the
pat
ient
jour
ney.
The
educ
atio
n of
pat
ient
s an
d th
eir
care
rs,
and
acce
ss t
oad
vice
and
sup
por
t is
nec
essa
ry if
pat
ient
s ar
e to
live
succ
essf
ully
in t
he h
ome
envi
ronm
ent.
Prof
essi
onal
dis
crim
inat
ion
is r
equi
red
to id
entif
y th
e p
oint
at w
hich
it is
ap
pro
pria
te t
o se
ek s
pec
ialis
t ad
vice
, eg
fro
mp
hysi
othe
rap
ists
, di
etiti
ans,
and
sp
eech
and
lang
uage
ther
apis
ts.
It is
a p
rofe
ssio
nal o
blig
atio
n to
mai
ntai
n co
mp
eten
cy.
In a
dditi
on t
o ca
re,
heal
thca
re p
rofe
ssio
nals
are
inst
rum
enta
l in
insp
iring
con
fiden
ce a
nd o
fferin
g su
pp
ort
to p
atie
nts
with
a t
rach
eost
omy.
Patie
nts
with
a t
rach
eost
omy
who
rec
eive
ade
qua
teed
ucat
ion
and
sup
por
t ca
n be
saf
ely
tran
sfer
red
out
ofho
spita
l to
live
in t
he c
omm
unity
.
Ther
e ar
e cl
ear
lines
of
com
mun
icat
ion
and
agre
edar
rang
emen
ts b
etw
een
the
diffe
rent
hea
lthca
rep
rofe
ssio
nals
who
may
be
req
uire
d to
pro
vide
car
efo
r th
e p
atie
nt w
ith a
tra
cheo
stom
y.
Ther
e is
evi
denc
e of
com
pet
ency
bas
ed t
rain
ing
and
educ
atio
n p
rovi
sion
for
rel
evan
t he
alth
care
sta
ff.
Pers
onal
Dev
elop
men
t Pl
ans
refle
ct t
he le
vel o
f co
mp
eten
cyac
hiev
ed o
r re
qui
red.
Reco
rds
or a
udits
of
info
rmat
ion
give
n to
pat
ient
san
d ca
rers
at
par
ticul
ar s
tage
s of
the
pat
ient
jour
ney
dem
onst
rate
tha
t ap
pro
pria
te in
form
atio
n is
conv
eyed
effe
ctiv
ely.
Patie
nts
and
care
rs in
the
com
mun
ity h
ave
cont
act
deta
ils o
f sp
ecia
list
help
, eg
a h
ome
vent
ilatio
n te
amor
tra
cheo
stom
y nu
rse
spec
ialis
t.
Stat
emen
tR
easo
ns
for
stat
emen
tH
ow
to
dem
on
stra
te s
tate
men
t is
bei
ng
ach
ieve
d
Key
Ch
alle
ng
es ~
1Id
enti
fyin
g th
e ed
uca
tion
an
d tr
ain
ing
nee
ds o
f a d
iver
se g
rou
p of
sta
ff a
nd
add
ress
ing
thes
e n
eeds
wit
hin
res
ourc
e co
nst
rain
ts.
2Ra
isin
g a
wa
ren
ess
of th
e sp
ecif
ic r
esu
scit
ati
on r
equ
irem
ents
of p
ati
ents
wit
h a
tra
cheo
stom
y.
Caring for the patient with a tracheostomy
3
Sect
ion
2:
Co
mm
unic
atio
n
Key
Po
ints
~
1Th
e im
pact
of t
he lo
ss o
f nor
ma
l voi
ce fo
llow
ing
tra
cheo
stom
y sh
ould
not
be
un
der-
esti
ma
ted
an
d, w
hen
ever
pos
sibl
e, p
ati
ents
an
d th
eir
fam
ilie
ssh
ould
be
prep
are
d fo
r th
is. D
evel
opin
g a
ltern
ati
ve m
ean
s of
com
mu
nic
ati
on, i
ncl
udi
ng
the
use
of a
spe
aki
ng
valv
e, i
s a
vit
al p
art
of c
are
.
2Th
e sp
eech
an
d la
ngu
age
ther
api
st h
as
a k
ey r
ole
in th
e ca
re o
f pa
tien
ts w
ith
a tr
ach
eost
omy
whe
n th
ere
are
com
mu
nic
ati
on d
iffi
culti
es.
3
Ven
tila
tor-
depe
nde
nt p
ati
ents
, wit
h re
spir
ato
ry s
tabi
lity
an
d th
e a
bili
ty to
voc
ali
se, c
an
ach
ieve
spe
ech
an
d sh
ould
be
con
side
red
for
spec
iali
stsp
eaki
ng
valv
es (
Dik
ema
n &
Ka
zan
djia
n 1
995,
Ma
na
nzo
et a
l 199
3, T
ippe
ts &
Sie
ben
s 19
91).
Com
pute
rise
d sp
eech
ou
tpu
t sys
tem
s sh
ould
be
con
side
red
for
pati
ents
wit
h lo
ng-
term
com
mu
nic
ati
on p
robl
ems
(Dik
ema
n &
Ka
zan
djia
n 1
995)
.
Hea
lthca
re p
rofe
ssio
nals
are
kno
wle
dgea
ble
abou
tco
mm
unic
atio
n p
robl
ems
asso
ciat
ed w
ith p
atie
nts
with
atr
ache
osto
my
and
fact
ors
that
affe
ct c
omm
unic
atio
n(A
pp
endi
x 2)
.
The
heal
thca
re p
ract
ition
er s
houl
d be
aw
are
ofco
mm
unic
atio
n di
fficu
lties
and
rec
ogni
se w
hen
to in
volv
eth
e sp
eech
and
lang
uage
the
rap
ist.
A c
omm
unic
atio
n as
sess
men
t st
arts
pre
-op
erat
ivel
y fo
r an
elec
tive
trac
heos
tom
y.
Spec
ialis
t co
mm
unic
atio
n as
sess
men
t by
the
sp
eech
and
lang
uage
the
rap
ist
incl
udes
a h
isto
ry a
nd p
hysi
cal
exam
inat
ion.
Initi
al a
sses
smen
t in
clud
es t
he p
atie
nt’s
abi
lity
to s
ee,
hear
, to
uch,
writ
e, u
nder
stan
d, o
r us
e fa
cial
exp
ress
ions
suc
h as
sm
iling
or
code
d bl
inki
ng.
Follo
win
g as
sess
men
t, a
com
mun
icat
ion
care
pla
n,re
cogn
isin
g th
e in
volv
emen
t of
fam
ilies
and
car
ers,
incl
udin
g co
nsid
erat
ion
of a
sp
eaki
ng v
alve
, an
d sp
ecifi
c to
indi
vidu
al n
eeds
, is
dra
wn
up.
Patie
nts
with
a t
rach
eost
omy
may
hav
e co
mm
unic
atio
np
robl
ems
that
affe
ct t
heir
abili
ty t
o in
tera
ct a
nd b
ein
volv
ed in
the
ir ow
n ca
re.
Att
entio
n is
giv
en t
o th
e p
sych
olog
ical
imp
act
of t
he lo
ss o
fvo
ice.
Ass
essm
ent
allo
ws
pro
blem
s w
ith c
omm
unic
atio
n to
be
qui
ckly
iden
tifie
d an
d im
med
iate
act
ion
can
be t
aken
to
min
imis
e th
e co
nseq
uenc
es o
f th
ese
pro
blem
s.
Patie
nts
with
a t
rach
eost
omy
may
hav
e co
mp
lex
com
mun
icat
ion
need
s an
d re
qui
re a
com
bina
tion
ofap
pro
ache
s to
min
imis
e p
robl
ems
(act
ual o
r p
oten
tial).
Succ
essf
ul m
anag
emen
t of
com
mun
icat
ion
pro
blem
s an
dth
e us
e of
sp
eaki
ng v
alve
s ar
e on
ly p
ossi
ble
thro
ugh
invo
lvem
ent
and
educ
atio
n of
fam
ilies
and
car
ers.
In-s
ervi
ce e
duca
tion
to d
evel
op a
nd u
pda
te k
now
ledg
e of
nurs
es w
orki
ng w
ith p
atie
nts
with
a t
rach
eost
omy,
incl
udin
gco
mm
unic
atio
n, is
pro
vide
d.
Ther
e ar
e w
ritte
n cr
iteria
for
ref
erra
l to
the
spee
ch a
ndla
ngua
ge t
hera
pis
t.
Com
mun
icat
ion
asse
ssm
ent
is d
ocum
ente
d in
the
pat
ient
reco
rd.
Whe
re d
ysfu
nctio
n is
iden
tifie
d, a
pp
rop
riate
reco
mm
enda
tions
for
alte
rnat
ive
met
hods
of
com
mun
icat
ion
are
mad
e.
Ther
e is
an
agre
ed p
roto
col o
n th
e m
anag
emen
t of
com
mun
icat
ion
issu
es,
incl
udin
g th
e us
e of
sp
eaki
ng v
alve
san
d p
oten
tial i
nvol
vem
ent
of t
he s
pee
ch a
nd la
ngua
geth
erap
ist
to e
ncou
rage
voc
alis
ing
tech
niq
ues.
Stat
emen
tR
easo
ns
for
stat
emen
tH
ow
to
dem
on
stra
te s
tate
men
t is
bei
ng
ach
ieve
d
4
Hea
lthca
re p
rofe
ssio
nals
pla
n, im
ple
men
t an
d ev
alua
te t
heco
mm
unic
atio
n ca
re p
lan
spec
ific
to t
he p
atie
nt’s
nee
dsan
d re
view
thi
s at
pre
-det
erm
ined
inte
rval
s or
whe
n he
alth
need
s ch
ange
.
The
com
mun
icat
ion
care
pla
n re
qui
res
an in
terd
isci
plin
ary
app
roac
h an
d a
pro
toco
l tha
t is
agr
eed
and
adhe
red
to.
Hea
lthca
re p
rofe
ssio
nals
are
aw
are
of t
he p
artic
ular
com
mun
icat
ion
need
s of
ven
tilat
or-d
epen
dent
pat
ient
sw
ho h
ave
a tr
ache
osto
my.
Vent
ilato
r-de
pen
dent
pat
ient
s w
ith a
tra
cheo
stom
y ar
egi
ven
the
opp
ortu
nity
to
spea
k an
d co
mm
unic
ate
with
min
imal
ass
ista
nce.
Patie
nts
have
a m
eans
of
sum
mon
ing
sup
por
t an
d ad
vice
par
ticul
arly
dur
ing
emer
genc
y si
tuat
ions
.
Nee
ds c
hang
e w
ith a
ltera
tions
in h
ealth
sta
tus.
Man
y di
ffere
nt h
ealth
care
pro
fess
iona
ls a
re in
volv
ed in
sup
por
ting
the
pat
ient
and
a r
ecog
nise
d p
roce
dure
sho
uld
faci
litat
e co
mm
unic
atio
n.
Pass
y-M
uir
valv
es a
re a
t p
rese
nt t
he o
nly
valv
es d
esig
ned
for
use
with
a v
entil
ator
. N
ot a
ll p
atie
nts
are
suffi
cien
tlyst
able
to
use
a va
lve.
In a
dditi
on t
o th
e re
stor
atio
n of
sp
eech
, sp
ecia
lised
spea
king
val
ves
for
use
with
pat
ient
s on
a v
entil
ator
may
be b
enef
icia
l in
the
wea
ning
pro
cess
and
dec
reas
ese
cret
ions
effe
ctin
g co
nsid
erab
le im
pro
vem
ent
in w
ellb
eing
(Dik
eman
& K
azan
djia
n 19
95).
Patie
nts
with
res
pira
tory
sta
bilit
y w
ho h
ave
an u
ncuf
fed
tube
in s
itu s
omet
imes
evo
lve
voca
lisin
g te
chni
que
s us
ing
the
vent
ilato
r ai
rflo
w,
eg ‘l
eak
spee
ch’.
Thes
e te
chni
que
sca
n be
enc
oura
ged
by t
he s
pee
ch a
nd la
ngua
ge t
hera
pis
t.
Patie
nts
are
at r
isk
if th
ey a
re u
nabl
e to
sum
mon
hel
pbe
caus
e of
com
mun
icat
ion
diffi
culti
es.
Ther
e is
a r
ecor
d of
whe
n re
-ass
essm
ent
is d
ue.
The
pro
toco
l has
bee
n ag
reed
with
in t
he m
ultid
isci
plin
ary
team
.
An
audi
t of
pat
ient
rec
ords
indi
cate
s ad
here
nce
to t
hep
roto
col.
Fact
ors
that
affe
ct in
divi
dual
com
mun
icat
ion
need
s(A
pp
endi
x 2)
are
doc
umen
ted
in t
he c
are
pla
n.
Ap
pro
pria
te e
qui
pm
ent
is a
vaila
ble
in h
osp
ital a
nd h
ome
to s
umm
on h
elp
, eg
nur
se c
all s
yste
m,
‘car
e ca
ll’,
slee
pap
noea
mon
itor,
text
pho
ne a
nd in
terc
oms.
Tra
inin
gin
the
ir us
e is
giv
en b
efor
e di
scha
rge
from
hos
pita
l.
Stat
emen
tR
easo
ns
for
stat
emen
tH
ow
to
dem
on
stra
te s
tate
men
t is
bei
ng
ach
ieve
d
Key
Ch
alle
ng
es ~
1Pr
ovis
ion
of i
n-s
ervi
ce e
duca
tion
wit
h th
e su
ppor
t of s
peci
ali
st s
peec
h a
nd
lan
gua
ge th
era
pist
s to
dev
elop
kn
owle
dge
of tr
ach
eost
omy
com
mu
nic
ati
on i
ssu
es.
2D
evel
opm
ent o
f gu
idel
ines
an
d pr
otoc
ols
rela
tin
g to
com
mu
nic
ati
on o
f pa
tien
ts w
ith
a tr
ach
eost
omy.
3Ef
fect
ive
disc
harg
e pl
an
nin
g to
faci
lita
te a
sm
ooth
tra
nsi
tion
in
to th
e co
mm
un
ity.
4En
suri
ng
tha
t acc
ess
to s
peci
ali
st a
dvic
e a
nd
supp
ort i
s a
vail
abl
e pa
rtic
ula
rly
for
thos
e pa
tien
ts w
ith
com
plex
com
mu
nic
ati
on n
eeds
.
5Pr
ovid
ing
add
itio
na
l res
ourc
es fo
r eq
uip
men
t an
d ed
uca
tion
for
pati
ents
an
d th
eir
fam
ilie
s in
thei
r ow
n h
ome.
Caring for the patient with a tracheostomy
5
Sect
ion
3:
Sw
allo
win
g a
nd
nut
riti
on
Key
Po
ints
~
1Sw
allo
win
g di
fficu
lties
ma
y be
ca
use
d by
ma
ny
fact
ors
(App
endi
x 3)
.
2Th
e pr
esen
ce o
f a tr
ach
eost
omy
tube
ma
y im
pair
sw
allo
win
g a
nd
can
com
prom
ise
pati
ents
’ nu
trit
ion
al s
tatu
s. A
ll he
alth
care
pra
ctit
ion
ers,
an
d
regi
ster
ed n
urs
es, a
nd
diet
itia
ns
in p
art
icu
lar,
ha
ve a
n i
mpo
rta
nt r
ole
in e
nsu
rin
g th
e pr
ovis
ion
of g
ood
nu
trit
ion
al c
are
for
the
pati
ent w
ith
a
tra
cheo
stom
y.
3Pa
tien
ts w
ith
a tr
ach
eost
omy
ma
y ex
peri
ence
loss
of a
ppet
ite
due
to th
e a
ltere
d a
irw
ay,
whi
ch c
au
ses
redu
ctio
n i
n th
e a
bili
ty to
sm
ell.
4Pa
tien
ts u
nde
rgoi
ng
radi
othe
rapy
ma
y ex
peri
ence
alte
red
tast
e se
nsa
tion
s a
nd/
or a
pa
infu
l, u
lcer
ate
d m
outh
.
5Pa
tien
ts s
hou
ld n
ot
be fe
d w
hen
they
ha
ve a
n i
nfla
ted
cuff.
By
defla
tin
g th
e cu
ff, th
e ef
fect
s of
the
tra
cheo
stom
y m
ay
be r
edu
ced
(App
endi
x 3)
.
Hea
lthca
re p
rofe
ssio
ns a
re k
now
ledg
eabl
e ab
out
nutr
ition
alp
robl
ems
asso
ciat
ed w
ith p
atie
nts
with
a t
rach
eost
omy.
An
app
rop
riate
ly t
rain
ed n
urse
will
und
erta
ke a
n in
itial
asse
ssm
ent
of s
wal
low
ing
func
tion
and
reco
gnis
e w
hen
toin
volv
e th
e di
etiti
an,
spee
ch a
nd la
ngua
ge t
hera
pis
t/sp
ecia
list
help
, an
d do
so
with
out
dela
y.
Spec
ialis
t sw
allo
win
g as
sess
men
t by
the
sp
eech
and
lang
uage
the
rap
ist
incl
udes
a h
isto
ry a
nd p
hysi
cal
exam
inat
ion
of s
wal
low
ing
func
tion.
Die
titia
ns u
nder
take
ass
essm
ent
of n
utrit
iona
l nee
ds.
Patie
nts
with
a t
rach
eost
omy
may
hav
e sw
allo
win
gp
robl
ems
and
be a
t ris
k fr
om a
spira
tion
and
inad
equa
tenu
triti
on.
Ther
e ar
e m
any
fact
ors
that
can
affe
ct s
wal
low
ing
(Ap
pen
dix
3).
If p
robl
ems
with
sw
allo
win
g an
d nu
triti
on a
re id
entif
ied
qui
ckly
, ac
tion
can
be t
aken
to
min
imis
e th
e p
oten
tial
cons
eque
nces
of
thes
e p
robl
ems,
eg
the
risk
of a
spira
tion.
If sw
allo
win
g is
ful
ly a
sses
sed,
pro
blem
s ar
e th
en id
entif
ied
and
actio
n ta
ken
to m
inim
ise
thei
r p
oten
tial c
onse
que
nces
eg t
he r
isk
of a
spira
tion,
or
of in
adeq
uate
nut
ritio
n.
A c
lear
pre
scrip
tion
of n
utrit
iona
l req
uire
men
ts s
pec
ific
toth
e in
divi
dual
pat
ient
is r
equi
red
to e
nsur
e th
at a
deq
uate
nutr
ition
is r
ecei
ved
safe
ly.
Patie
nts
with
a t
rach
eost
omy
may
exp
erie
nce
loss
of
app
etite
bec
ause
of
redu
ctio
n in
sen
se o
f sm
ell.
Patie
nts
unde
rgoi
ng r
adio
ther
apy
may
exp
erie
nce
alte
red
tast
ese
nsat
ions
and
/or
a p
ainf
ul,
ulce
rate
d m
outh
/thr
oat.
Educ
atio
n an
d tr
aini
ng o
n nu
triti
onal
issu
es is
pro
vide
d to
deve
lop
and
up
date
the
kno
wle
dge
of n
urse
s w
orki
ng w
ithp
atie
nts
with
a t
rach
eost
omy.
Ther
e ar
e ag
reed
crit
eria
for
ref
erra
l to
the
spee
ch a
ndla
ngua
ge t
hera
pis
t, t
he d
ietit
ian
and
othe
r sp
ecia
list
help
.
Ther
e is
a r
ecor
d of
ass
essm
ent
and
refe
rral
in t
he p
atie
nt’s
reco
rd.
Whe
re d
ysfu
nctio
n is
iden
tifie
d, a
pp
rop
riate
inve
stig
atio
nsar
e un
dert
aken
und
er t
he g
uida
nce
and
pro
fess
iona
l ris
kas
sess
men
t of
the
sp
eech
and
lang
uage
the
rap
ist,
eg
Mod
ified
Eva
ns B
lue
Dye
tes
ts,
fibre
optic
eva
luat
ion
ofsw
allo
win
g (F
EES)
and
vid
eoflu
oros
cop
y of
sw
allo
w.
Ther
e ar
e gu
idel
ines
rel
atin
g to
the
nut
ritio
n of
pat
ient
sw
ith a
tra
cheo
stom
y, in
clud
ing
the
adm
inis
trat
ion
of
naso
-gas
tric
and
gas
tros
tom
y fe
edin
g.
Fact
ors
that
affe
ct in
divi
dual
die
tary
inta
ke a
re d
ocum
ente
din
the
car
e p
lan.
Stat
emen
tR
easo
ns
for
stat
emen
tH
ow
to
dem
on
stra
te s
tate
men
t is
bei
ng
ach
ieve
d
6
For
oral
fee
ding
, th
e p
atie
nt s
houl
d:
•be
con
side
red
at r
isk
of a
spira
tion
•N
OT
have
the
cuf
f in
flate
d•
be in
the
up
right
pos
ition
, un
less
con
trai
ndic
ated
•be
giv
en t
he c
orre
ct f
ood
cons
iste
ncy
and,
whe
re
app
rop
riate
, ha
ve c
omp
ensa
tory
str
ateg
ies
as id
entif
ied
by t
he s
pee
ch a
nd la
ngua
ge t
hera
pis
t.
Con
side
ratio
n sh
ould
be
give
n to
:
•th
e sp
eaki
ng v
alve
, an
d •
effe
ctiv
e an
alge
sic
for
mou
th p
ain.
Ora
l hyg
iene
sho
uld
be m
aint
aine
d th
roug
h re
gula
r or
alca
re.
For
naso
gast
ric a
nd g
astr
osto
my
feed
ing,
bes
t p
ract
ice
guid
elin
es s
houl
d be
fol
low
ed.
Follo
win
g as
sess
men
t, h
ealth
care
pro
fess
iona
ls p
lan,
imp
lem
ent
and
eval
uate
a n
utrit
iona
l car
e p
lan
spec
ific
toth
e p
atie
nt’s
nee
ds a
nd r
evie
w t
his
at p
re-d
eter
min
edin
terv
als
or w
hen
heal
th n
eeds
cha
nge.
Unl
ess
asse
ssed
oth
erw
ise,
pat
ient
s ar
e at
ris
k of
asp
iratio
n.
Infla
ted
cuffs
will
not
pre
vent
asp
iratio
n of
foo
d (L
eder
and
Ross
200
0) (
Ap
pen
dix
3).
The
spea
king
val
ve m
ay n
ot h
ave
to b
e re
mov
ed f
or o
ral
feed
ing.
Goo
d or
al h
ealth
will
ass
ist
effe
ctiv
e nu
triti
on (
Serr
a 20
00,
Dik
eman
& K
azan
djia
n 19
95,
St G
eorg
e’s
Hea
lthca
re N
HS
Trus
t 20
06).
(NH
S Q
IS 2
003)
.
The
asse
ssm
ent
and
deve
lop
men
t of
a n
utrit
iona
l car
ep
lan
whi
ch is
imp
lem
ente
d an
d ev
alua
ted
is a
clin
ical
stan
dard
. (N
HS
QIS
200
3).
Nut
ritio
nal n
eeds
cha
nge
with
alte
ratio
ns in
hea
lth s
tatu
s.
The
nutr
ition
car
e p
lan
iden
tifie
s fa
ctor
s to
be
cons
ider
edfo
r th
e in
divi
dual
.
Indi
vidu
al c
are
pla
ns in
clud
e ag
reem
ent
on r
epea
t sc
reen
ing
inte
rval
s.
Stat
emen
tR
easo
ns
for
stat
emen
tH
ow
to
dem
on
stra
te s
tate
men
t is
bei
ng
ach
ieve
d
Key
Ch
alle
ng
es ~
1Pr
ovis
ion
of i
n-s
ervi
ce e
duca
tion
wit
h th
e su
ppor
t of t
he s
peec
h a
nd
lan
gua
ge th
era
py a
nd
diet
etic
s de
part
men
ts to
dev
elop
kn
owle
dge
oftr
ach
eost
omy
swa
llow
ing
an
d n
utr
itio
n i
ssu
es.
2D
evel
opm
ent o
f gu
idel
ines
an
d pr
otoc
ols
rela
tin
g to
nu
trit
ion
of p
ati
ents
wit
h a
tra
cheo
stom
y a
nd
mu
ltidi
scip
lin
ary
ref
erra
ls.
3En
suri
ng
acc
ess
to s
peci
ali
st a
dvic
e a
nd
supp
ort p
art
icu
larl
y fo
r th
ose
pati
ents
wit
h co
mpl
ex n
utr
itio
na
l nee
ds.
4Av
ail
abi
lity
of s
wa
llow
ing
ass
essm
ent s
ervi
ces,
eg
app
ropr
iate
acc
ess
to v
ideo
fluor
osco
py.
5Ef
fect
ive
disc
harg
e pl
an
nin
g to
faci
lita
te a
sm
ooth
tra
nsi
tion
from
hos
pita
l to
the
com
mu
nit
y.
Caring for the patient with a tracheostomy
7
Sect
ion
4:
Sto
ma
care
Key
Po
ints
~
1Pa
tien
ts w
ith
a tr
ach
eost
omy
are
at i
ncr
ease
d ri
sk o
f in
fect
ion
.
2Ef
fect
ive
ma
na
gem
ent o
f the
sto
ma
wil
l aid
the
prev
enti
on o
f per
isto
ma
l in
fect
ion
an
d ir
rita
tion
.
3A
wel
l-for
med
tra
chea
l tra
ct w
ill u
sua
lly b
e ev
iden
t abo
ut 5
–7 d
ays
pos
t-ope
rati
vely
; su
ture
s, i
f pre
sen
t, ca
n u
sua
lly b
e re
mov
ed 7
–10
days
aft
erth
e pr
oced
ure
dep
endi
ng
on th
e n
atu
re o
f the
pro
cedu
re.
4Th
e m
an
age
men
t req
uir
emen
ts o
f a n
ew s
tom
a in
the
acu
te c
are
en
viro
nm
ent a
nd
subs
equ
ently
, whe
n th
e pa
tien
t is
in th
e co
mm
un
ity,
are
diff
eren
t.
5If
the
pati
ent i
s u
nde
rgoi
ng
radi
othe
rapy
thei
r sk
in i
nte
grit
y w
ill b
e gr
eatly
com
prom
ised
, req
uir
ing
furt
her
ass
essm
ent a
nd
eva
lua
tion
of s
tom
a
ma
na
gem
ent.
Adv
ice
from
spe
cia
list
cen
tres
reg
ard
ing
stom
a c
are
sho
uld
be
sou
ght d
uri
ng
this
tim
e.
All
pat
ient
s w
ith a
tra
cheo
stom
y st
oma
shou
ld h
ave
freq
uenc
y of
sto
ma
care
ass
esse
d in
acc
orda
nce
with
indi
vidu
al p
atie
nt n
eed.
All
pat
ient
s sh
ould
hav
e an
eva
luat
ion
of s
tom
al c
ondi
tion
docu
men
ted
in t
he p
atie
nt r
ecor
d an
d an
ap
pro
pria
te p
lan
of c
are
initi
ated
.
The
stom
a sh
ould
be
clea
ned
with
nor
mal
sal
ine
and
aba
rrie
r fil
m m
ay h
elp
to
pro
tect
the
sur
roun
ding
ski
n.C
otto
n w
ool s
houl
d n
ot
be u
sed
to c
lean
se a
roun
d th
est
oma.
Use
of
dres
sing
s ar
ound
the
sto
ma
site
is n
ot a
lway
sne
cess
ary
but
can
help
to
abso
rb s
ecre
tions
and
aid
com
fort
for
silv
er t
ubes
.
Trac
heos
tom
y st
omas
are
a p
oten
tial a
venu
e fo
r re
spira
tory
trac
t in
fect
ion
and
pot
entia
l site
of
per
isto
mal
infe
ctio
n.
Cle
an t
echn
ique
is a
dvoc
ated
as
the
skin
is c
olon
ised
with
orga
nism
s.
To a
llow
ong
oing
ass
essm
ent
of t
he s
tom
a.
To p
rote
ct t
he s
kin
from
tra
chea
l sec
retio
ns a
nden
cour
agem
ent
of w
ound
hea
ling.
Nor
mal
sal
ine
is n
on-ir
ritan
t to
the
ski
n an
d tr
ache
alm
ucos
a. A
bar
rier
film
may
hel
p t
o p
rote
ct t
he s
urro
undi
ngsk
in f
ollo
win
g an
ass
essm
ent
of p
atie
nt n
eed.
Ther
e is
a r
isk
of in
hala
tion
of f
ibre
s fr
om c
otto
n w
ool.
Trac
heos
tom
y tu
bes
have
sof
t fla
nges
(ex
cep
t si
lver
tub
es)
that
do
not
alw
ays
req
uire
a d
ress
ing
betw
een
the
tube
and
the
skin
.
Dre
ssin
gs c
an p
rovi
de a
n id
eal e
nviro
nmen
t fo
r ba
cter
ial
mul
tiplic
atio
n.
Hea
lthca
re p
rofe
ssio
nals
are
abl
e to
dem
onst
rate
ap
plic
atio
nof
the
fun
dam
enta
l prin
cip
les
of in
fect
ion
cont
rol i
nclu
ding
clea
n st
oma
care
.
Inci
denc
e of
per
isto
mal
infe
ctio
n in
pat
ient
s w
ith a
trac
heos
tom
y is
kep
t to
a m
inim
um.
Ther
e is
doc
umen
ted
evid
ence
of
stom
al c
ondi
tion
in t
hep
atie
nt r
ecor
d an
d lo
cal p
olic
ies/
guid
elin
es a
re a
vaila
ble.
Hea
lthca
re p
rofe
ssio
nals
are
aw
are
of t
he r
isks
and
ben
efits
of a
pp
lyin
g ba
rrie
r fil
m a
nd m
etho
ds t
o en
cour
age
wou
ndhe
alin
g.
Hea
lthca
re p
rofe
ssio
nals
are
kno
wle
dgea
ble
in t
he t
ypes
of
dres
sing
s av
aila
ble
and
able
to
sele
ct t
he m
ost
app
rop
riate
one
base
d on
an
asse
ssm
ent
of p
atie
nt n
eed.
Loca
l pol
icie
s an
d gu
idel
ines
are
ava
ilabl
e on
wou
nd c
are
pro
duct
s.
Stat
emen
tR
easo
ns
for
stat
emen
tH
ow
to
dem
on
stra
te s
tate
men
t is
bei
ng
ach
ieve
d
8
If dr
essi
ngs
are
indi
cate
d, b
ased
on
clin
ical
nee
d, g
auze
swab
s sh
ould
no
tbe
use
d. A
man
ufac
ture
d tr
ache
osto
my
dres
sing
is r
ecom
men
ded,
pre
fera
bly
slim
-line
to
caus
em
inim
al d
isp
lace
men
t of
the
tub
e.
Ties
sec
urin
g th
e tr
ache
osto
my
tube
sho
uld
be c
heck
ed f
orse
curit
y p
rior
to u
nder
taki
ng a
ny p
roce
dure
esp
ecia
llyfo
llow
ing
rem
oval
of
the
flang
e su
ture
s.
Patie
nts
and/
or c
arer
s ar
e ta
ught
to
man
age
thei
r ow
nst
oma
care
prio
r to
dis
char
ge.
Fibr
es m
ay b
reak
off
the
gauz
e sw
abs
and
ente
r th
ere
spira
tory
tra
ct.
To r
educ
e th
e in
cide
nce
of a
ccid
enta
l tub
e di
slod
gem
ent
To e
ncou
rage
inde
pen
denc
e in
pat
ient
s w
ith a
trac
heos
tom
y.
The
typ
e of
dre
ssin
g is
doc
umen
ted
in t
he p
atie
nt r
ecor
d.
Trac
heos
tom
y tu
bes
rem
ain
secu
re.
Ther
e is
doc
umen
ted
evid
ence
tha
t th
e p
atie
nt a
nd c
arer
have
bee
n ta
ught
to
care
for
sto
ma.
Patie
nts
and
care
rs a
re a
war
e of
the
imp
orta
nce
of k
eep
ing
the
stom
a cl
ean
and
avoi
ding
use
of
aero
sols
and
tal
car
ound
the
sto
ma
site
.
Stat
emen
tR
easo
ns
for
stat
emen
tH
ow
to
dem
on
stra
te s
tate
men
t is
bei
ng
ach
ieve
d
Key
Ch
alle
ng
es ~
1D
evel
opm
ent o
f loc
al p
olic
ies/
guid
elin
es r
ela
tin
g to
tra
cheo
stom
y st
oma
ca
re.
2D
evel
opm
ent o
f evi
den
ce to
su
ppor
t cu
rren
t pra
ctic
e.
3En
suri
ng
pati
ents
wit
h a
tra
cheo
stom
y a
nd
thei
r ca
rers
are
con
fide
nt a
nd
com
pete
nt i
n s
tom
a c
are
pri
or to
dis
cha
rge.
4Pr
ovid
ing
pati
ents
an
d th
eir
fam
ilie
s w
ith
info
rma
tion
on
ca
rin
g fo
r th
eir
stom
a.
Caring for the patient with a tracheostomy
9
Sect
ion
5:
Tra
cheo
sto
my
tub
e m
anag
emen
t
Key
Po
ints
~ G
ener
al t
ube
man
agem
ent
1Th
ere
is a
va
riet
y of
tra
cheo
stom
y tu
bes
ava
ila
ble.
Tra
cheo
stom
y tu
bes
are
ma
de fr
om e
ithe
r pl
ast
ic o
r si
lver
. All
fit i
nto
the
follo
win
g ca
tego
ries
:cu
ffed/
un
cuffe
d; fe
nes
tra
ted/
un
fen
estr
ate
d; d
oubl
e/si
ngl
e ca
nn
ula
; min
itra
cheo
stom
y; a
nd
thos
e w
ith
an
adj
ust
abl
e fla
nge
. Ea
ch tu
be ty
pere
quir
es s
peci
fic
ma
na
gem
ent*
.
2St
aff
invo
lved
in
tra
cheo
stom
y m
an
age
men
t sho
uld
be
aw
are
of t
he s
urg
ica
l tec
hniq
ue
use
d to
form
the
tra
cheo
stom
y, i
e op
en o
r pe
rcu
tan
eou
s,
as
tube
ma
na
gem
ent w
ill v
ary
acc
ordi
ngl
y.
3M
an
y tr
ach
eost
omy
tube
s ha
ve i
nn
er c
an
nu
lae;
som
e a
re d
ispo
sabl
e, b
ut s
ome
are
des
ign
ed to
be
clea
ned
an
d re
use
d fo
r th
e sa
me
pati
ent.
4Ef
fect
ive
tube
ma
na
gem
ent c
ombi
ned
wit
h su
ctio
n a
nd
hum
idif
ica
tion
ca
n r
edu
ce th
e in
cide
nce
of c
ompl
ica
tion
s in
the
tra
cheo
stom
y pa
tien
ta
nd
is i
nte
gra
l to
the
redu
ctio
n o
f cli
nic
al r
isk.
5Th
e pa
tien
t an
d a
ca
rer
or r
ela
tive
sho
uld
be
con
fide
nt a
nd
com
pete
nt i
n tu
be m
an
age
men
t pri
or to
dis
cha
rge
from
hos
pita
l.
Indi
vidu
al a
sses
smen
t of
the
mos
t ap
pro
pria
te t
ube
shou
ldbe
mad
e by
the
mul
tidis
cip
linar
y te
am t
akin
g in
to a
ccou
ntth
e p
atie
nt’s
pre
fere
nce.
All
pat
ient
s, w
hene
ver
pos
sibl
e, w
ill h
ave
a do
uble
cann
ulat
ed t
ube
in s
itu.
Exce
ptio
ns in
clud
e p
atie
nts
with
am
initr
ache
osto
my
and
pae
diat
rics.
It is
goo
d p
ract
ice
for
the
pat
ient
to
have
ano
ther
tub
eav
aila
ble.
If th
e p
atie
nt is
usi
ng a
silv
er t
ube
(whi
ch d
oes
not
have
an
inne
r ca
nnul
a) it
sho
uld
be c
hang
ed e
very
5–7
day
s. T
his
shou
ld b
e as
sess
ed o
n an
indi
vidu
al b
asis
as
pat
ient
s w
ithex
cess
ive
secr
etio
ns m
ay r
equi
re m
ore
freq
uent
cha
nges
.
Con
side
ratio
n ne
eds
to b
e gi
ven
to:
•th
e cl
inic
al n
eed/
reas
on f
or t
rach
eost
omy
•th
e am
ount
of
secr
etio
ns•
whe
ther
the
pat
ient
will
be
taug
ht s
elf-
care
with
a v
iew
to
hom
e tr
ache
osto
my
care
, an
d•
whe
ther
rad
ioth
erap
y is
req
uire
d.
Tube
blo
ckag
e ca
n be
red
uced
by
the
use
of a
n in
ner
cann
ula
that
can
be
easi
ly r
emov
ed in
an
emer
genc
y.
Usu
ally
tra
cheo
stom
y tu
bes
with
inne
r ca
nnul
ae d
o no
tne
ed t
o be
rem
oved
or
chan
ged
and
can
be u
sed
up t
o 30
days
in s
itu.
This
min
imis
es r
isk.
This
pre
vent
s in
fect
ion
and
the
tube
bec
omin
g bl
ocke
dw
ith s
ecre
tions
.
Ther
e ar
e lo
cal a
sses
smen
t p
rogr
amm
es r
elev
ant
to c
linic
alne
ed a
nd in
divi
dual
req
uire
men
ts.
Hea
lthca
re p
rofe
ssio
nals
hav
e kn
owle
dge
of t
he t
ubes
avai
labl
e an
d in
dica
tions
for
use
and
are
abl
e to
pro
vide
app
rop
riate
adv
ice
on t
ube
usag
e.
Hea
lthca
re p
rofe
ssio
nals
are
kno
wle
dgea
ble
in r
isk
man
agem
ent
issu
es a
nd h
ow t
o p
reve
nt t
ube
obst
ruct
ion.
Trac
heos
tom
y tu
be c
are
is e
ffect
ivel
y m
anag
ed in
the
clin
ical
are
a.
Stat
emen
tR
easo
ns
for
stat
emen
tH
ow
to
dem
on
stra
te s
tate
men
t is
bei
ng
ach
ieve
d
* Tr
ache
osto
my
tube
s ar
e co
mm
only
ref
erre
d to
by
the
nam
e of
the
man
ufac
ture
r, eg
Shi
ley,
Por
tex
or K
apite
x.
Illus
trat
ions
of
avai
labl
e tu
bes
are
pro
vide
d in
Ap
pen
dix
5.
10
The
firs
t tu
be
chan
ge
is a
hig
h r
isk
pro
ced
ure
and
shou
ld b
e un
dert
aken
und
er m
edic
al d
irect
ion.
Thi
s ta
kes
pla
ce 3
–7 d
ays
afte
r th
e su
rgic
al p
roce
dure
(on
ly if
atr
ache
osto
my
tube
with
no
inne
r ca
nnul
a is
use
d).
Inp
atie
nts
with
a p
ercu
tane
ous
trac
heos
tom
y, a
t le
ast
7 da
yssh
ould
pas
s be
fore
the
firs
t tu
be c
hang
e.
A n
ote
shou
ld b
e m
ade
of t
he t
echn
ique
use
d to
for
m t
hetr
ache
osto
my
and
in p
artic
ular
whe
ther
the
tra
chea
isst
itche
d up
to
the
skin
.
Loca
l gui
delin
es a
re a
vaila
ble
for
staf
f co
mp
eten
t to
unde
rtak
e a
first
tub
e ch
ange
.
Tube
s w
ith in
ner
cann
ulae
can
rem
ain
in p
lace
for
29–
31da
ys d
epen
ding
on
the
man
ufac
ture
r.
All
pat
ient
s w
ith a
tra
cheo
stom
y ha
ve t
ubes
cle
aned
or
rep
lace
d as
ap
pro
pria
te f
ollo
win
g th
e m
anuf
actu
rer’s
guid
elin
es a
nd in
line
with
infe
ctio
n co
ntro
l pol
icie
s.
Brus
hes
are
not
used
on
pla
stic
tub
es u
nles
s sp
ecifi
cally
reco
mm
ende
d by
the
man
ufac
ture
r.
All
pat
ient
s w
ith a
tra
cheo
stom
y ha
ve t
ubes
rep
lace
dfo
llow
ing
the
man
ufac
ture
r’s g
uide
lines
(A
pp
endi
ces
4an
d 5)
.
The
time
dela
y al
low
s a
trac
t to
bec
ome
esta
blis
hed
with
inth
e tr
ache
a th
eref
ore
min
imis
ing
the
risk
of s
tom
al c
losu
reon
tub
e re
mov
al.
Stitc
hes
and
typ
e of
sut
urin
g w
ill a
ffect
car
e.
Exp
erie
nced
sta
ff ar
e re
qui
red
to u
nder
take
firs
t ch
ange
of
the
trac
heos
tom
y tu
be.
The
inne
r ca
nnul
a is
fre
que
ntly
cha
nged
the
refo
re t
heou
ter
tube
pat
ency
is m
aint
aine
d (E
urop
ean
Uni
on 1
993)
.
Tube
s in
situ
are
a p
oten
tial r
eser
voir
for
path
ogen
ic b
acte
ria
Brus
hes
may
cau
se d
amag
e to
the
lini
ng o
f th
e tu
be.
To c
omp
ly w
ith s
afet
y re
gula
tions
and
pre
vent
tub
eda
mag
e w
ith in
app
rop
riate
cle
anin
g.
Ther
e ar
e lo
cal g
uide
lines
and
pol
icie
s on
man
agem
ent
ofth
e tu
be in
clud
ing
info
rmat
ion
on t
he f
req
uenc
y of
tub
ech
angi
ng.
The
pat
ient
rec
ord
will
con
tain
thi
s in
form
atio
n.
Gui
delin
es a
re a
vaila
ble
in t
he c
linic
al a
rea,
and
com
pet
ency
of s
taff
to u
nder
take
the
rol
e is
ass
esse
d.
Ther
e is
doc
umen
ted
evid
ence
of t
he d
ate
and
ease
of c
hang
e.
A r
ecor
d of
out
er t
ube
chan
ges
is a
vaila
ble
in t
he p
atie
nt’s
reco
rds
with
ap
pro
pria
te d
ates
.
Loca
l pol
icie
s/gu
idel
ines
are
ava
ilabl
e on
how
tra
cheo
stom
ytu
bes
are
clea
ned.
The
se a
re in
line
with
the
man
ufac
ture
r’sgu
idel
ines
, lo
cal i
nfec
tion
cont
rol a
nd d
econ
tam
inat
ion
pol
icie
s.
Loca
l pol
icie
s/gu
idel
ines
are
ava
ilabl
e on
tra
cheo
stom
y tu
bere
pla
cem
ent
in li
ne w
ith t
he m
anuf
actu
rer’s
gui
delin
es a
nd a
writ
ten
reco
rd o
f se
rial n
umbe
rs a
nd d
ates
rep
lace
d.
Stat
emen
tR
easo
ns
for
stat
emen
tH
ow
to
dem
on
stra
te s
tate
men
t is
bei
ng
ach
ieve
d
Caring for the patient with a tracheostomy
11
In a
dditi
on t
o st
anda
rd r
esus
cita
tion
equi
pm
ent,
all
pat
ient
s w
ith a
tra
cheo
stom
y in
hos
pita
l req
uire
the
follo
win
g eq
uip
men
t to
be
read
ily a
cces
sibl
e fo
rem
erge
ncy
pro
cedu
res:
•tr
ache
al d
ilato
rs•
a cu
ffed
trac
heos
tom
y tu
be a
nd a
n un
cuffe
dtr
ache
osto
my
tube
the
sam
e si
ze a
s th
e pa
tient
is w
earin
g•
a tr
ache
osto
my
tube
sm
alle
r th
an t
he s
ize
the
pat
ient
is
wea
ring
•st
itch
cutt
ers,
and
•10
ml s
yrin
ge.
All
pat
ient
s fo
r w
hom
dec
annu
latio
n is
con
side
red
shou
ldbe
indi
vidu
ally
ass
esse
d by
the
mul
tidis
cip
linar
y te
am.
Mon
itorin
g an
d ob
serv
atio
n of
the
pat
ient
tak
es p
lace
durin
g de
cann
ulat
ion.
Trac
heal
dila
tors
and
a s
mal
ler
size
d tr
ache
osto
my
tube
are
avai
labl
e at
the
pat
ient
’s b
edsi
de d
urin
g th
e de
cann
ulat
ion
pro
cess
.
Follo
win
g tu
be r
emov
al,
an a
irtig
ht d
ress
ing
is p
lace
d ov
erth
e st
oma.
To c
omp
ly w
ith s
afet
y re
gula
tions
.
To e
nsur
e ap
pro
pria
te e
qui
pm
ent
is a
vaila
ble
in a
nem
erge
ncy.
Use
of
a 20
ml s
yrin
ge a
s p
art
of t
he r
esus
cita
tion
equi
pm
ent
may
pos
e a
risk
of o
verin
flatio
n of
a c
uffe
dtr
ache
osto
my
tube
and
sub
sequ
ent
dam
age
to t
he t
rach
ea.
This
will
fac
ilita
te s
afe
and
effe
ctiv
e de
cann
ulat
ion
and
avoi
d re
-inse
rtio
n of
tra
cheo
stom
y.
To a
llow
ear
ly d
etec
tion
of a
ny d
iffic
ultie
s du
ring/
afte
rth
e p
roce
ss.
Emer
genc
y eq
uip
men
t is
ava
ilabl
e to
man
age
any
resp
irato
ry d
iffic
ultie
s.
To e
ncou
rage
the
sto
ma
to c
lose
as
qui
ckly
as
pos
sibl
ew
ith m
inim
al d
amag
e to
ski
n in
tegr
ity.
Loca
tion
of e
mer
genc
y eq
uip
men
t is
cle
arly
sta
ted
inlo
cal p
roto
cols
.
Hea
lthca
re p
rofe
ssio
nals
are
aw
are
of h
ow t
o re
susc
itate
a p
atie
nt w
ith a
tra
cheo
stom
y.
Ther
e ar
e lo
cal p
olic
ies
and
guid
elin
es o
n th
ede
cann
ulat
ion
pro
cedu
re.
The
stom
a cl
oses
with
min
imal
ski
n da
mag
e fr
omth
e dr
essi
ng.
Stat
emen
tR
easo
ns
for
stat
emen
tH
ow
to
dem
on
stra
te s
tate
men
t is
bei
ng
ach
ieve
d
Key
Po
ints
~ I
nn
er c
ann
ula
man
agem
ent
1In
ner
ca
nn
ula
e re
duce
the
lum
en o
f the
ou
ter
tra
cheo
stom
y tu
be i
ncr
easi
ng
resp
ira
tory
effo
rt.
2In
ner
ca
nn
ula
e a
re d
esig
ned
to a
llow
ea
sy r
emov
al f
or c
lea
nin
g w
itho
ut h
avi
ng
to r
emov
e th
e ou
ter
tube
.
All
pat
ient
s w
ith a
tra
cheo
stom
y tu
be w
ith a
n in
ner
cann
ula
req
uire
indi
vidu
al a
sses
smen
t of
the
fre
que
ncy
ofin
ner
cann
ula
care
.
To e
nsur
e th
e in
ner
cann
ula
rem
ains
fre
e fr
om s
ecre
tions
.D
ocum
enta
tion
iden
tifie
s th
e:
•ty
pe
of t
ube
in s
itu•
amou
nt o
f se
cret
ions
the
pat
ient
pro
duce
s, a
nd
•fr
eque
ncy
of c
lean
ing.
Stat
emen
tR
easo
ns
for
stat
emen
tH
ow
to
dem
on
stra
te s
tate
men
t is
bei
ng
ach
ieve
d
12
Key
Po
ints
~ C
uffe
d t
rach
eost
om
y tu
bes
1C
uffe
d tr
ach
eost
omy
tube
s a
re u
sed
to p
rote
ct th
e a
irw
ay.
2Pa
tien
ts w
ho a
re v
enti
late
d of
ten
ha
ve a
cu
ffed
tra
cheo
stom
y tu
be; e
xcep
tion
s m
ay
be h
ome-
ven
tila
ted
pati
ents
.
3Ap
prop
ria
te m
an
age
men
t of a
cu
ffed
tube
ca
n p
reve
nt d
am
age
to th
e tr
ach
eal m
uco
sa.
4Tr
ach
eost
omy
tube
s ha
ve a
low
-pre
ssu
re c
uff
tha
t rem
oves
the
nee
d to
def
late
the
cuff
on a
reg
ula
r ba
sis.
5M
an
omet
ers
to m
easu
re c
uff
pres
sure
, wit
h st
aff
com
pete
nt i
n th
eir
use
, sho
uld
be
ava
ila
ble.
6If
a tr
ach
eost
omy
ma
sk i
s to
be
use
d in
com
bin
ati
on w
ith
a c
uffe
d tr
ach
eost
omy
tube
, use
rs m
ay
wis
h to
con
side
r em
ploy
ing
a m
ask
ma
nn
ufa
ctu
red
from
a r
igid
ma
teri
al,
whi
ch i
s le
ss li
kely
to o
cclu
de th
e co
nn
ecto
r on
the
tra
cheo
stom
y tu
be e
ven
if d
ispl
ace
d (S
cott
ish
Hea
lthca
re S
upp
lies
200
1).
All
cuffe
d tr
ache
osto
my
tube
s ha
ve c
uff
pre
ssur
e ch
ecke
dtw
ice
daily
mai
ntai
ning
pre
ssur
e be
twee
n 15
–30
cmH
2 Ous
ing
a m
anom
eter
.
Man
omet
ers
req
uire
car
eful
man
agem
ent.
Min
imal
occl
usio
n vo
lum
e te
chni
que
s th
at d
o no
t re
qui
re t
he u
se o
fa
man
omet
er m
ay h
ave
to b
e em
plo
yed
as a
n al
tern
ativ
e.
Cuf
f p
ress
ure
abov
e 30
cm
H2 O
may
cau
se d
amag
e to
the
trac
heal
muc
osa.
If t
he p
ress
ure
is b
elow
thi
s, a
spira
tion
may
occ
ur.
Man
omet
ers
may
bre
ak,
or b
ecom
e da
mag
ed,
and
ther
efor
e, le
ss r
elia
ble.
Alte
rnat
ive
volu
me
man
agem
ent
tech
niq
ues
may
be
deve
lop
ed b
y th
e ex
per
ienc
edhe
alth
care
pro
fess
iona
l, p
atie
nt a
nd c
arer
.
Loca
l pro
toco
ls o
r gu
idel
ines
on
reco
rdin
g of
cuf
f p
ress
ure
are
avai
labl
e.
Pres
sure
is d
ocum
ente
d w
ithin
the
nur
sing
rec
ords
.
Stat
emen
tR
easo
ns
for
stat
emen
tH
ow
to
dem
on
stra
te s
tate
men
t is
bei
ng
ach
ieve
d
The
inne
r ca
nnul
a is
cle
aned
with
war
m w
ater
and
ai
r-dr
ied
in a
ccor
danc
e w
ith in
fect
ion
cont
rol
req
uire
men
ts p
rior
to r
e-in
sert
ion.
Tube
s in
situ
are
a p
oten
tial r
eser
voir
for
pat
hoge
nic
bact
eria
.It
is d
ocum
ente
d th
at t
rach
eost
omy
inne
r ca
nnul
ae a
recl
eane
d an
d st
ored
in li
ne w
ith t
he m
anuf
actu
rer’s
guid
elin
es,
loca
l inf
ectio
n co
ntro
l and
dec
onta
min
atio
np
olic
ies.
Stat
emen
tR
easo
ns
for
stat
emen
tH
ow
to
dem
on
stra
te s
tate
men
t is
bei
ng
ach
ieve
d
Caring for the patient with a tracheostomy
13
Key
Po
ints
~ F
enes
trat
ed t
ubes
1Fe
nes
tra
ted
tube
s m
ay
be c
uffe
d or
un
cuffe
d.
2Fe
nes
tra
ted
tube
s a
re u
sed
to e
nco
ura
ge w
ean
ing
from
the
tra
cheo
stom
y a
nd
als
o fo
r vo
icin
g.
3Fe
nes
tra
ted
tube
s a
re s
upp
lied
wit
h tw
o in
ner
ca
nn
ula
e; o
ne
is fe
nes
tra
ted
an
d on
e is
not
.
All
pat
ient
s w
ith a
fen
estr
ated
tra
cheo
stom
y tu
be h
ave
the
fene
stra
ted
inne
r ca
nnul
a re
mov
ed p
rior
to t
rach
eal
suct
ion
and
rep
lace
d w
ith a
n un
fene
stra
ted
inne
r ca
nnul
a.
All
pat
ient
s w
ith a
fen
estr
ated
tub
e re
qui
re a
nun
fene
stra
ted
tube
to
be r
eadi
ly a
cces
sibl
e fo
r us
ein
an
emer
genc
y.
It is
pos
sibl
e to
inse
rt t
he s
uctio
n ca
thet
er t
hrou
gh t
hefe
nest
ratio
n ca
usin
g da
mag
e to
the
tra
chea
l wal
l.
To a
llow
ven
tilat
ion
with
em
erge
ncy
equi
pm
ent
as a
ir w
ill e
xit
via
the
fene
stra
tion.
Hea
lthca
re p
rofe
ssio
nals
rec
eive
tra
inin
g in
the
use
of
fene
stra
ted
trac
heos
tom
y tu
bes.
Stat
emen
tR
easo
ns
for
stat
emen
tH
ow
to
dem
on
stra
te s
tate
men
t is
bei
ng
ach
ieve
d
Key
Ch
alle
ng
es ~
1D
evel
opm
ent o
f loc
al p
olic
ies/
guid
elin
es r
ela
tin
g to
all
asp
ects
of t
rach
eost
omy
tube
ca
re.
2Pr
ovis
ion
of e
duca
tion
al r
esou
rces
to d
evel
op n
ew s
kills
an
d te
ach
/su
perv
ise
less
exp
erie
nce
d st
aff.
3D
evel
opm
ent o
f evi
den
ce to
su
ppor
t cu
rren
t pra
ctic
e.
4As
sess
ing
the
com
pete
nce
of h
ealth
care
pro
fess
ion
als
to u
nde
rta
ke th
e hi
gh r
isk
proc
edu
re o
f the
firs
t tu
be c
han
ge.
5En
suri
ng
care
rs a
nd
pati
ents
, if a
ble,
are
edu
cate
d in
all
asp
ects
of t
ube
ma
na
gem
ent a
nd
are
con
fide
nt a
nd
com
pete
nt i
n m
an
agi
ng
the
tube
prio
r to
the
pati
ent’s
dis
cha
rge
from
hos
pita
l.
14
Sect
ion
6:
Suc
tio
nin
g
Key
Po
ints
~
1Th
e fr
equ
ency
of t
rach
eal s
uct
ion
ing
shou
ld b
e a
sses
sed
on a
n i
ndi
vidu
al p
ati
ent b
asi
s a
nd
shou
ld o
nly
be
carr
ied
out w
hen
the
pati
ents
are
un
abl
e to
cle
ar
thei
r ow
n a
irw
ay
effe
ctiv
ely.
2Su
ctio
nin
g sh
ould
ma
xim
ise
rem
ova
l of s
ecre
tion
s w
ith
min
ima
l tis
sue
dam
age
an
d hy
poxi
a.
3St
an
dard
in
fect
ion
con
trol
pre
cau
tion
s sh
ould
be
app
lied
, in
clu
din
g go
od h
an
d hy
gien
e a
nd
use
of p
erso
na
l pro
tect
ive
equ
ipm
ent (
PPE)
.
4Su
ctio
n e
quip
men
t sho
uld
be
easi
ly a
cces
sibl
e a
nd
mu
stbe
che
cked
reg
ula
rly.
5Pa
tien
ts w
ho h
ave
dif
ficu
lty c
lea
rin
g se
cret
ion
s m
ay
requ
ire
refe
rra
l to
a p
hysi
othe
rapi
st.
6In
divi
dua
l ass
essm
ent o
f the
pa
tien
t wil
l det
erm
ine
whe
ther
su
ctio
n e
quip
men
t is
requ
ired
at h
ome.
Whe
re p
ossi
ble,
the
low
est
effe
ctiv
e p
ress
ure
shou
ld b
eus
ed.
The
wor
king
gro
up r
ecom
men
ds a
suc
tion
pre
ssur
e be
low
120
mm
Hg,
and
no
mor
e th
an 2
00 m
mH
g (2
6.7
kPa)
as
am
axim
um a
nd o
nly
if ne
cess
ary
in a
dults
.
Suct
ioni
ng s
houl
d la
st n
o lo
nger
tha
n 10
sec
onds
at
a tim
e.
Ap
pro
pria
tely
siz
ed,
sing
le-u
se m
ulti-
eyed
or
clos
ed s
yste
m,
mul
ti-us
e ca
thet
ers
are
used
.
Suct
ioni
ng s
houl
d on
ly b
e ap
plie
d to
the
cat
hete
r as
it is
with
draw
n.
Ther
e is
a r
equi
rem
ent
to s
et s
uctio
n le
vels
whi
ch a
re s
afe
and
effe
ctiv
e (D
onal
d 20
00).
Pres
sure
s in
exc
ess
of 2
6.7k
Pa (
200
mm
Hg)
can
res
ult
ingr
eate
r m
ucos
al t
raum
a (Y
oung
198
4).
Ther
e is
a r
isk
of a
tela
ctas
is if
suc
tion
pre
ssur
e is
too
hig
h(G
lass
& G
rap
199
5, C
arol
l 199
4).
Low
pre
ssur
es a
re le
ss e
ffect
ive
and
pro
long
suc
tion
time
(Lom
holt
1982
).
Prol
onge
d su
ctio
ning
res
ults
in h
ypox
ia.
Trac
heal
suc
tioni
ng c
an c
ause
tra
chea
l muc
osal
dam
age.
Mul
ti-ey
ed c
athe
ters
cau
se le
ast
trau
ma
(Ode
ll et
al 1
993)
.
Ap
ply
ing
suct
ion
to t
he c
athe
ter
whe
n in
sert
ing
can
bedi
fficu
lt an
d da
mag
ing
to t
he t
rach
eal m
ucos
a.
Educ
atio
n p
rogr
amm
es in
form
hea
lthca
re s
taff
on r
isks
asso
ciat
ed w
ith t
rach
eal s
uctio
ning
.
Loca
l pol
icie
s p
rovi
de g
uida
nce
on a
pp
rop
riate
suc
tioni
ngte
chni
que
and
add
ress
the
fol
low
ing
issu
es:
•th
e p
roce
ss f
or s
elec
ting
the
corr
ect
size
of
suct
ion
cath
eter
•
dete
rmin
ing
dep
th o
f su
ctio
ning
, ie
how
far
to
inse
rt
suct
ion
cath
eter
, an
d•
ensu
ring
that
suc
tion
is a
pp
lied
only
on
rem
oval
of t
he s
uctio
n ca
thet
er.
Stat
emen
tR
easo
ns
for
stat
emen
tH
ow
to
dem
on
stra
te s
tate
men
t is
bei
ng
ach
ieve
d
Caring for the patient with a tracheostomy
15
Hyp
erox
ygen
atio
n ta
kes
pla
ce p
rior
to p
roce
dure
or
in li
new
ith h
osp
ital p
olic
y.
Cau
tion
shou
ld b
e ta
ken
with
pat
ient
s w
ith c
hron
icob
stru
ctiv
e p
ulm
onar
y di
seas
e (C
OPD
).
If a
fene
stra
ted
tube
is in
situ
, a
pla
in in
ner
tube
sho
uld
bein
sert
ed p
rior
to s
uctio
ning
.
Hea
lthca
re s
taff
are
awar
e of
the
psy
chol
ogic
al e
ffect
of
suct
ioni
ng o
n p
atie
nts.
Hea
lthca
re s
taff
are
awar
e of
loca
l inf
ectio
n co
ntro
l pol
icy
and
the
imp
licat
ions
for
tra
chea
l suc
tion.
To m
inim
ise
risk
of h
ypox
ia a
ssoc
iate
d w
ith s
uctio
ning
.
It is
pos
sibl
e to
inse
rt t
he s
uctio
n ca
thet
er t
hrou
gh t
hefe
nest
ratio
n ca
usin
g da
mag
e to
the
tra
chea
l wal
l.
As
pat
ient
s ar
e un
able
to
insp
ire d
urin
g th
e su
ctio
np
roce
dure
anx
iety
leve
ls a
re in
crea
sed.
Ther
e is
a r
isk
of c
onta
min
atio
n of
eq
uip
men
t, c
ross
infe
ctio
n an
d ex
pos
ure
of h
ealth
care
sta
ff to
tra
chea
lse
cret
ions
.
This
is d
ocum
ente
d in
the
pat
ient
’s r
ecor
ds.
This
is d
ocum
ente
d in
the
pat
ient
’s r
ecor
ds.
Info
rmat
ion
is a
vaila
ble
in a
var
iety
of
acce
ssib
le f
orm
ats
to p
rom
ote
pat
ient
und
erst
andi
ng a
nd r
educ
e an
xiet
y.
A lo
cal i
nfec
tion
cont
rol p
olic
y ad
dres
ses
issu
es a
ndp
reca
utio
ns r
equi
red
in r
elat
ion
to t
rach
eal s
uctio
ning
.
Stat
emen
tR
easo
ns
for
stat
emen
tH
ow
to
dem
on
stra
te s
tate
men
t is
bei
ng
ach
ieve
d
Key
Ch
alle
ng
es ~
1En
suri
ng
app
ropr
iate
equ
ipm
ent i
s re
adi
ly a
vail
abl
e, i
ncl
udi
ng
corr
ect c
ath
eter
siz
e a
nd
type
.
2Pr
ovid
ing
regu
lar
in-s
ervi
ce tr
ain
ing
for
sta
ff w
orki
ng
wit
h pa
tien
ts w
ith
a tr
ach
eost
omy.
3Pr
ovid
ing
supp
ort f
or p
ati
ents
an
d fa
mil
ies.
4En
suri
ng
the
pati
ent u
nde
rsta
nds
the
proc
edu
re.
5Pr
ovid
ing
supp
ort a
nd
tea
chin
g of
su
ctio
nin
g te
chn
iqu
e fo
r pa
tien
ts a
nd
fam
ilie
s.
16
Sect
ion
7:
Hum
idif
icat
ion
Key
Po
ints
~
1Th
e n
orm
al h
um
idif
ica
tion
an
d fi
ltra
tion
sys
tem
is
bypa
ssed
in
pa
tien
ts w
ith
a tr
ach
eost
omy;
hu
mid
ific
ati
on m
ust
be
art
ific
ially
su
pple
men
ted.
2It
is
vita
l tha
t a p
ati
ent w
ith
a tr
ach
eost
omy
rem
ain
s w
ell h
ydra
ted
an
d ha
s so
me
form
of h
um
idif
ica
tion
, as
the
mu
cou
s m
embr
an
es a
re d
rier
in a
deh
ydra
ted
pati
ent,
redu
cin
g m
uco
cilla
ry tr
an
spor
t an
d ca
usi
ng
rete
nti
on a
nd
thic
ken
ing
of s
ecre
tion
s.
3A
ddit
ion
al s
afe
ty c
onsi
dera
tion
s a
re r
equ
ired
whe
n a
cu
ffed
tra
cheo
stom
y tu
be i
s in
sit
u. D
ue
to th
e in
crea
sed
risk
of a
irw
ay
obst
ruct
ion
, a
T- p
iece
sho
uld
be
use
d w
hen
del
iver
ing
neb
uli
sed
dru
gs o
r hu
mid
ifie
d ga
s (S
cott
ish
Hea
lthca
re S
upp
lies
200
1, S
cott
ish
Hea
lthca
re S
upp
lies
200
3).
4H
um
idif
ica
tion
sys
tem
s a
re a
pot
enti
al r
eser
voir
for
infe
ctio
n. I
ndi
vidu
al s
yste
ms
shou
ld b
e ch
osen
app
ropr
iate
ly fo
r ea
ch i
ndi
vidu
al p
ati
ent
follo
win
g ri
sk a
sses
smen
t, a
nd
ma
na
ged
corr
ectly
acc
ordi
ng
to lo
cal p
roto
cols
an
d in
fect
ion
con
trol
pol
icy.
5Th
e n
eed
for
hum
idif
ica
tion
in
pa
tien
ts w
ith
a tr
ach
eost
omy
is o
ngo
ing.
A r
an
ge o
f pro
duct
s is
ava
ila
ble
for
prov
idin
g hu
mid
ific
ati
on i
n
the
pati
ent’s
hom
e en
viro
nm
ent.
Hea
lthca
re s
taff
unde
rtak
e as
sess
men
t of
hum
idifi
catio
nne
eds
in t
rach
eost
omy
pat
ient
s.
Hea
lthca
re p
rofe
ssio
nals
are
aw
are
of p
artic
ular
pro
blem
sas
soci
ated
with
art
ifici
al h
umid
ifica
tion
in t
rach
eost
omy
pat
ient
s.
The
tem
per
atur
e of
hea
ted
hum
idifi
catio
n sh
ould
ran
gebe
twee
n 37
–40o
C
The
‘nor
mal
’ hum
idifi
catio
n an
d fil
trat
ion
syst
em is
byp
asse
d in
pat
ient
s w
ith a
tra
cheo
stom
y.
Exce
ssiv
e ar
tific
ial h
umid
ifica
tion
of in
spire
d ga
ses
may
caus
e as
muc
h ha
rm a
s un
der-
hum
idifi
catio
n.
Hea
ted
syst
ems
are
pro
ne t
o ‘r
ain
out’
whe
n w
ater
vap
our
cool
s an
d co
llect
s in
the
tub
ing.
The
wei
ght
of w
ater
-bas
ed s
yste
ms
can
pul
l on
trac
heos
tom
y m
asks
cau
sing
incr
ease
d ris
k of
air
way
obst
ruct
ion
whe
n a
cuffe
d tu
be is
in s
itu.
A T
-pie
ce s
houl
dal
way
s be
use
d (S
cott
ish H
ealth
care
Sup
plie
s 20
01).
Dis
tille
d w
ater
and
sal
ine
rese
rvoi
rs in
hum
idifi
catio
nsy
stem
s ha
ve b
een
show
n to
be
a p
oten
tial s
ourc
e of
infe
ctio
n (C
ritch
ley
& R
ouls
ten
1993
).
An
insp
ired
gas
tem
per
atur
e of
41o
C o
r m
ore
will
cau
sem
ucos
al d
amag
e (B
rans
on 1
991)
.
Ther
e is
doc
umen
ted
evid
ence
of
hum
idifi
catio
n as
sess
men
tin
the
pat
ient
’s r
ecor
ds.
Trai
ning
and
edu
catio
n p
rogr
amm
es in
form
sta
ff on
the
typ
es o
f hu
mid
ifica
tion
syst
ems
avai
labl
e an
d th
e sa
fe u
se o
fsy
stem
s w
hich
are
em
plo
yed
loca
lly.
An
asse
ssm
ent
of t
he n
eed
for
a he
ated
wat
er s
yste
m is
carr
ied
out
afte
r th
e in
itial
nee
d fo
r hu
mid
ified
oxy
gen
ther
apy
has
finis
hed.
Hea
t an
d m
oist
ure
exch
ange
rs a
re u
sed
whe
neve
r in
dica
ted
as a
res
ult
of a
sses
smen
t.
Loca
l pro
toco
ls a
nd d
ocum
enta
tion
in t
he p
atie
nt’s
rec
ord
will
dem
onst
rate
thi
s.
Hum
idifi
catio
n sy
stem
s ar
e m
anag
ed in
acc
orda
nce
with
the
man
ufac
ture
r’s in
stru
ctio
ns,
loca
l gui
delin
es o
r p
roto
cols
,an
d in
fect
ion
cont
rol p
olic
y.
Ther
e is
a s
yste
m t
o m
onito
r in
spire
d ga
s te
mp
erat
ures
.
Stat
emen
tR
easo
ns
for
stat
emen
tH
ow
to
dem
on
stra
te s
tate
men
t is
bei
ng
ach
ieve
d
Caring for the patient with a tracheostomy
17
Key
Ch
alle
ng
es ~
1Pr
ovis
ion
of t
rain
ing
an
d ed
uca
tion
to d
evel
op k
now
ledg
e of
hea
lthca
re s
taff
cari
ng
for
pati
ents
who
req
uir
e a
rtif
icia
l hu
mid
ific
ati
on.
2D
evel
opm
ent a
nd
impl
emen
tati
on o
f evi
den
ce-b
ase
d pr
otoc
ols
an
d pr
oced
ure
s fo
r he
alth
care
sta
ff.
3Lo
cal p
rovi
sion
an
d a
cces
s to
a r
an
ge o
f hu
mid
ific
ati
on s
yste
ms
an
d eq
uip
men
t.
Patie
nts
and
thei
r ca
rers
are
ful
ly a
war
e of
the
nee
d fo
r,an
d ap
pro
pria
te u
se o
f, he
at a
nd m
oist
ure
exch
ange
rs(S
cott
ish
Hea
lthca
re S
upp
lies
2003
).
Prov
isio
n of
ap
pro
pria
te in
form
atio
n m
ay im
pro
ve p
atie
ntco
mp
lianc
e an
d th
eref
ore
min
imis
e lo
ng-t
erm
pro
blem
s.A
pp
rop
riate
up
-to-
date
info
rmat
ion
is a
vaila
ble
in a
ran
ge
of a
cces
sibl
e fo
rmat
s, e
g w
ritte
n, a
udio
, an
d p
icto
rial t
osu
pp
ort
verb
al d
iscu
ssio
n w
ith p
atie
nts
and
thei
r ca
rers
.
Stat
emen
tR
easo
ns
for
stat
emen
tH
ow
to
dem
on
stra
te s
tate
men
t is
bei
ng
ach
ieve
d
18
Appendix 1: Volume of tracheostomies in Scotland
Volume of tracheostomies (excluding laryngectomies) in ScotlandYears ending 31 December 1996 – 2005
Year of main Volume of
operation Population Tracheostomies1
number rate
1996 5,092,190 507 9.96
1997 5,083,340 682 13.42
1998 5,077,070 795 15.66
1999 5,071,950 839 16.54
2000 5,062,940 909 17.95
2001 5,064,200 874 17.26
2002 5,054,800 938 18.56
2003 5,057,400 823 16.27
2004 5,078,400 903 17.78
2005 5,094,800 983 19.29
Source: Information Services Division (ISD), SMR01 data
1 Based on all operations during the patients’ stay.
ICD10 codes - E42 (excluding E425, E426 and E427)
Appendix 2: Factors that affect communication
An extensive range of speaking valves is available and the majority of
patients can achieve voice (phonation) unless the structures involved in
phonation or articulation are impaired. Best practice is to achieve
communication.
1 Speaking valves are used with uncuffed tracheostomy tubes.
2 Using a speaking valve with a cuffed tracheostomy must be done with
the cuff fully deflated and with extreme caution. Failure to deflate the
cuff would lead to respiratory arrest.
3 To achieve consistent and effortless voicing, the type and size of the
tracheostomy tube may need to be changed. If voicing is not easily
achieved, involvement of a speech and language therapist should be
considered.
4 The individual care plan will record the management of speaking valves,
particularly when the patient sleeps.
5 Some patients may need to speak by finger occlusion of the tube and in
this case, hygiene should be considered.
6 Communication may also be affected by other factors, eg neurological,
mechanical or psychological.
7 A combination of alternative methods of communication may be used
and can support oral communication efforts, eg writing, gesture, coded
eye blinks, picture/word boards, computerised communication aids.
Referral to the speech and language therapist should be made if
problems with communication persist.
Caring for the patient with a trachestomy
19
20
Appendix 3 : Factors that may affect swallowing
There are several causal reasons suggested which predispose patients with
a tracheostomy to aspirate (Leder & Ross 2000, Donizelli et al 2005). By
deflating the cuff, the effect of the tracheostomy on swallowing may be
reduced.
1 Compression of the oesophagus from inflated cuff.
2 Impaired laryngeal elevation as a result of a tethered larynx.
3 Reduction in laryngeal sensitivity as a result of diverted airflow.
4 Disruption of normal co-ordination between breathing and swallowing,
particularly in ventilated patients.
5 Reduced effectiveness of cough to clear secretions from upper airway.
6 Loss of subglottic positive pressure.
7 Neurological or mechanical disorders.
8 Post-operative pain and/or oedema.
9 Radiotherapy pain and/or oedema.
10 Excessively dry mouth (xerostomia) may be due to side effects of
medication.
Caring for the patient with a trachestomy
21
Appendix 4: Types of tracheostomy tube
Tube type Cleaning recommendations Tube replacement
– inaccordance with health
and safety regulations and
manufacturer’s instructions
Single use The tube must not be cleaned and Single use only.
re-used since it is for single use
only.
Single patient use Clean with warm water and air dry Every 29–31 days as required
the tube, and store in accordance by specific manufacturer.
with local policy, ready to be used
by the same patient.
Reusable (silver) Clean with a non-abrasive brush Whenever the patient no
and store dry. longer requires this type
If secretions are particularly sticky, of tube or the tube is
the tube can be soaked in sodium damaged.
bicarbonate solution. (These tubes can be
sterilised and used again
for different patients.)
22
Appendix 5: Illustrations
Anatomy
Single cannulated tube
Epiglottis
Caring for the patient with a tracheostomy
23
Uncuffed double cannula tracheostomy tube
Cuffed double cannula tracheostomy tube
Caring for the patient with a tracheostomy
24
Uncuffed fenestrated tube
Cuffed fenestrated tube
Caring for the patient with a tracheostomy
25
Speaking valve
Mini tracheostomy
Caring for the patient with a tracheostomy
26
1 Education and Training Y N Action
Education is provided to fulfil local need, and update knowledge of healthcare professionals
working with patients with a tracheostomy. This includes aspects of tracheostomy management
in the context of patient-centred care, infection control and risk management, and covers
aspects of care listed below.
1a Communication.
1b Swallowing and nutrition.
1c Methods of encouraging wound healing, types of dressings available, and assessment of these in
relation to clinical need.
1d Tubes available and indications for use.
1e Tube use, cuff tube management and management of risk of tube obstruction.
1f The types of humidification systems available and the safe use of systems which are employed
locally.
1g Tracheal suctioning procedures and risks.
1h Resuscitation of a patient with a tracheostomy.
1i Location of emergency equipment.
2 Local protocols, policies or guidelines
There are local written agreements or protocols on all aspects of care of the patient with a
tracheostomy.
2a There are written criteria agreed by the multidisciplinary team, for referral to the:
• speech and language therapist
• physiotherapist
• dietitian, and
• psychologist.
2b There is an agreed protocol on the management of communication issues, including:
• the use of speaking valves, and
• potential involvement of the speech and language therapist to encourage vocalising
techniques.
2c There are guidelines relating to the nutrition of patients with a tracheostomy, including the
administration of naso-gastric and gastrostomy feeding.
2d Local policies/guidelines relate to:
• stomal condition
• wound care products, and
• tube management.
These are in line with the manufacturer’s guidelines and include information on:
• the frequency of tube changing
• a written record of serial numbers and dates replaced
• procedures for tube cleaning in line with infection control guidelines, and
• procedures on cuff management and use of manometer.
2e Guidelines are available in the clinical area and competency of staff to undertake the role of the
first tube change is assessed.
2f Location of emergency equipment is clearly stated in local protocols.
Appendix 6: Audit tool
Audit tool, to identify good practice as outlined in the best practice statement on caring for thepatient with a tracheostomy
Caring for the patient with a tracheostomy
27
1 Education and Training Y N Action
2g Local polices provide guidance on appropriate suctioning technique and address the following
issues:
• the process for selecting the correct size of suction catheter
• determining depth of suctioning ie how far to insert suction catheter
• ensuring that suction is applied only on removal of the suction catheter
• hyperoxygenation prior to suctioning, with risk alert for patients with COPD.
2h A local infection control policy addresses issues and precautions required in relation to tracheal
suctioning.
2i Patients and carers are able to summon help in an emergency.
3 Patient care plan/Patient clinical record
3a Stomal condition is documented.
3b The type of dressing is documented.
3c There is documented evidence of the:
• date
• serial number
• ease of tube change, and
• monitoring of the security of tapes holding the tube in situ.
3d There is documented evidence of humidification assessment in the patient’s records.
3e There is a record that an assessment of the need for a heated water system is carried out after
the initial need for humidified oxygen therapy has finished.
3f There is a record of suctioning activity and discussion and the use of information to promote
patient understanding and reduce anxiety about suctioning.
3g There is a record of swallowing assessment and referral.
3h Factors that affect individual dietary intake are documented (Appendix 3).
3i There is a nutritional care plan which includes agreement on repeat nutritional screening
intervals.
3j There is a record of communication assessment and referral.
3k There is a record of when communication re-assessment is due.
3l There is a communication care plan which:
• recognises the involvement of families and carers
• includes consideration of a speaking valve
• is specific to individual needs, and
• is evaluated and reviewed at regular intervals or when health needs change.
4 Patient and carer information
Patient information in a variety of formats is available for all aspects of tracheostomy care, from
preoperative preparation to post-operative management.
4a On discharge to the community, the patient and carer have information in a variety of
accessible formats to promote patient understanding and reduce anxiety around:
• stoma care
• tube management
• humidification
• suctioning
• nutrition
• communication, and
• summoning help in an emergency.
Caring for the patient with a tracheostomy
28
Glossary
aspiration The entry of gastric secretions, oropharyngeal secretions or
food and fluid into the tracheobronchial passages (airways)
caused by dysfunction or absence of normal protective
mechanisms.
atelectasis Collapse of lung tissue preventing the exchange of carbon
dioxide and oxygen as part of normal respiration.
barrier film A protective barrier which may look like plastic skin and
protects the skin from becoming red and sore.
‘blue dye’ test Tracheal suctioning at set intervals following the
introduction of blue dye on to the tongue. This may be
modified by mixing foods and liquids with dye (the
Modified Evans Blue Dye Test).
catheter Hollow tube for removing secretions.
cuffed tube A tube with a balloon on the end which can be inflated with
air to hold the tube in position and prevent secretions
entering the respiratory tract.
decannulation Removal of the tracheostomy tube allowing ‘normal’
respiration to occur.
fenestrated tube A tube which has an opening cut into the tube wall to allow
the passage of air.
fibreoptic evaluation A flexible endoscope is placed above the epiglottis and
of swallowing (FEES) laryngeal function is assessed before, during and after
swallowing.
gastrostomy A feeding tube that is inserted surgically through the
abdominal wall into the stomach allowing liquid feed to be
delivered directly into the stomach.
heat and moisture Device to increase moisture content of inspired (breathed
exchanger (HME) in) air.
humidification Equipment for maintaining moisture when giving
system ventilation (not necessarily always oxygen).
hyperoxygenation The use of high concentrations of oxygen before and after
endotracheal suction.
leak speech The patient utilises airflow supplied by the ventilator during
the inspiratory push.
minimal occlusion The gradual inflation of the tracheostomy tube cuff by
volume 0.5 ml increments of air until no air leak is heard - using a
stethoscope held just below the thyroid cartilage.
mucociliary Lining of the respiratory tract.
multi-eyed catheter Catheter with numerous holes around tip.
nasogastric feeding Liquid feed delivered directly into the stomach by a narrow
tube that is passed into the nose and down the oesophagus
(food pipe) into the stomach.
oral feeding Food and drink taken by mouth.
peristomal The area surrounding the stoma.
single use Use once only and then discard.
single patient use Can be used more than once but on one patient only.
sleep apnoea A sleep disorder characterised by periods of absence of
breathing.
speaking valve A valve that has a one way mechanism that allows air to
enter through the tracheostomy tube but closes on
expiration to redirect the airflow past the vocal cords to
give speech.
stoma The artificial opening in the patient’s neck formed by the
tracheostomy.
suctioning The process of removing secretions.
tracheal tract The tract formed by the presence of a tracheostomy tube.
tracheostomy A surgical opening in the anterior wall of the trachea (front
of neck) to facilitate breathing.
T-Tube A device to connect a cuffed tracheostomy tube to a
humidifier.
videofluoroscopy An investigation that provides a comprehensive
examination of swallowing function at different levels.
weaning process Attempt to help patients breathe without the aid of the
tracheostomy tube or ventilator.
ventilator A machine used to assist breathing.
Caring for the patient with a trachestomy
29
30
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Useful websites
British Association of Head & Neck Oncology Nurses
www.bahnon.org.uk
ENT information
www.ENTLinx.com
Head and Neck Oncologists’ / Surgeons’ Association
www.bahnon.co.uk
Information on head and neck cancers
www.headandneckcancer.org
Kapitex airway equipment
Mallinckrodt airway equipment
www.mallinckrodt.com
Portex
www.smiths-medical.com
Caring for the patient with a tracheostomy
35
Who was involved in developing the statement?
Working Group
Susan Buchanan Staff Nurse
NHS Forth Valley
Lynne Coltart Head & Neck Clinical Nurse Specialist
NHS Dumfries & Galloway
Kathlyn Cowie Clinical Educator, Ventilation Services
NHS Greater Glasgow and Clyde
Rhona Davidson Physiotherapist
NHS Grampian
Catriona Don CCN Team Leader
NHS Tayside
Fiona Elder Staff Nurse
NHS Highland
Penny Gravill Lead Speech and Language Therapist (Neurosurgery)
NHS Grampian
Carolyn Guild Clinical Manager
NHS Greater Glasgow and Clyde
Lindy Manson Education Co-ordinator
NHS Lothian
Graeme McGibbon ENT & Maxillofacial/Checklist Co-ordinator
NHS Lanarkshire
Anita Nardi Senior Staff Nurse
NHS Grampian
Christine Rait ENT Ward Manager
NHS Grampian
Adam Wood Infection Control Nurse
NHS Borders
Caring for the patient with a tracheostomy
36
Reference Group
This group provided first consultation.
Mr Kim Ah-See ENT Consultant
NHS Grampian
Mr N Balaji ENT Consultant
NHS Lanarkshire
Dr S Bennett Consultant Microbiologist
NHS Borders
Dr T Cripps Consultant Anaesthetist
NHS Borders
Mr S Denholm ENT Consultant: Head and Neck Surgeon
NHS Highlands
Dr W T Frame Consultant Anaesthetist
NHS Greater Glasgow and Clyde
Fiona Grant Project Manager ENT Redesign/Surgical Services
Clinical Co-ordinator
NHS Forth Valley
Angela Griggs Chairperson, RCN ENT and Maxillofacial Nursing
Forum Lecturer Practitioner ENT Nursing, Royal Free
Hampstead
NHS Trust & City University, London
Janis Harvey Physiotherapy Clinical Specialist - Critical Care
NHS Lothian
Lorraine King Clinical Development Nurse
NHS 24
Gregory Hughes Patient Representative
Susan Marr Community Dietitian
NHS Dumfries & Galloway
Caring for the patient with a tracheostomy
37
Mr L McClymont Consultant Surgeon (Head and Neck) and Chairman,
Noscan
NHS Highlands
Linda Prevett Speech and Language Therapist
NHS Dumfries & Galloway
Aileen Quinn Clinical Change Governance Group
NHS 24
Lesley Sabey Beatson Oncology Centre
NHS Greater Glasgow and Clyde
Cameron Sellars Senior Speech and Language Therapist
NHS Greater Glasgow and Clyde
Dr S Stott Consultant Anaesthetist
NHS Grampian
Gillian Thain Respiratory Clinical Specialist
NHS Grampian
Claire Walkington Home Ventilation Team
NHS Lothian
Sheila Wheeler Education Advisor
NHS Grampian
Miss Aileen White Consultant Otolaryngologist
NHS Greater Glasgow and Clyde
Dr D Williams Consultant Anaesthetist
NHS Dumfries & Galloway
With NHS QIS support from:
Penny Bond Professional Practice Development Officer
Rosemary Hector Project Co-ordinator
Cliodhna Callanan Project Administrator
NHS Quality Improvement Scotland
Edinburgh Office
Elliott House, 8-10 Hillside Crescent, Edinburgh, EH7 5EA
Phone 0131 623 4300
Glasgow Office
Delta House, 50 West Nile Street, Glasgow G1 2NP
Phone 0141 225 6999
E-mail: [email protected] website: www.nhshealthquality.org
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