CARE OF THE ADULT

WITH A TRACHEOSTOMY

A Practical Guide

May 2005

CONTENTSBackground/Membership.............................................................................................1

Introduction..................................................................................................................2

Staff Roles....................................................................................................................3

Definition of a Tracheostomy.......................................................................................6

Indications for a Tracheostomy....................................................................................6

Physiological Changes.................................................................................................6

Techniques of Tracheostomy.......................................................................................7

Open.................................................................................................................7

Percutaneous Dilatational................................................................................7

Mini Tracheostomy...........................................................................................9

Complications of a Tracheostomy..............................................................................10

Types of Tracheostomy Tube....................................................................................11

Care of Patients with a Tracheostomy.......................................................................14Patient Assessment........................................................................................14

Essential Equipment.......................................................................................14

Checking Cuff Pressure.................................................................................14

Deflating/Inflating Cuff....................................................................................16

Suction...........................................................................................................19

Oxygen Therapy.............................................................................................27

Stoma Care....................................................................................................30

Oral Hygiene..................................................................................................33

Personal Hygiene...........................................................................................33

Humidification.............................................................................................................34

Changing of a Tracheostomy Tube............................................................................43

Weaning and Removal of a Tracheostomy................................................................49

Bedside Evaluation of Swallowing, Eating and Drinking............................................56

Feeding......................................................................................................................60

Communication..........................................................................................................61

Speaking Valves........................................................................................................61

AppendicesSuction Chart..................................................................................................62

Transfer Sheet................................................................................................63

Tracheostomy Emergency Algorithm.............................................................64

"Blue Dye" Swallow Test................................................................................65

Communicating with a patient with a tracheostomy.......................................67

Grampian Dysphagia Management of Solid/Liquid Feeds.............................68

Abbreviation List.........................................................................................................70

References.................................................................................................................71i

BACKGROUND

The working group was set up in response to the increasing number of patients with a tracheostomy who were being cared for in general wards throughout the Trust by staff who had little knowledge and experience in this area of practice. An increasing number of enquiries to specialist areas seeking advice on tracheostomy care demonstrated this gap in knowledge.

An audit of the nursing care of patients with a tracheostomy was carried out in the wards at Aberdeen Royal Infirmary in August 2001. The results of the audit showed that although basic care was good, the depth of knowledge and understanding required to ensure a safe pathway of care from surgery to tube removal was lacking. (1)

The development of this guideline reflects the current emphasis on safe effective care and will reduce existing variations in practice. Implementation will promote best practice wherever patients receive care.

Membership

Jacqui Connelly Staff Nurse ENTElma Cruickshank Clinical Nurse Manager NeurosciencesRhona Davidson Superintendent PhysiotherapistDorothy Dawson Sister General MedicineTrish Ferguson Staff Nurse CardiothoracicMary Glasgow Clinical Nurse Educator General/Vascular/GI HDUPenny Gravill Specialist Speech and Language TherapistAlison Hamilton Specialist Speech and Language TherapistLesley Hastings Sister Renal MedicineKarin Massie Senior PhysiotherapistJanice McKinlay Senior DietitianMarina Mearns Sister Respiratory MedicineCarolyn Reid Practice Educator ITUKate Scorgie Sister Respiratory MedicineJudith Scott ITU Research/Follow Up NurseYvonne Skinner Staff Nurse NeurosciencesDr Stephen Stott Consultant AnaesthetistLesley Taylor Specialist Speech and Language TherapistGillian Thain Respiratory Clinical Specialist PhysiotherapistRose McKechnie Clinical Nurse Manager, NeurosciencesHeather Allan ITU Research/Follow Up Nurse

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INTRODUCTION

Care of the tracheostomy patient "takes insight into the physiological changes caused by the tracheostomy tube, careful monitoring to prevent complications, meticulous wound care and expert suction technique". (2)

The guideline has been drawn up by a multidisciplinary group using evidence where it exists and best practice standards. It is intended for use by all NHS Grampian healthcare professionals involved in the care of adults with a tracheostomy.

The guideline is general and will apply in the majority of cases throughout the various areas of care.

It is recognised that in some specialist areas eg Ear Nose and Throat (ENT) there may be the need for clinical staff and management to discuss and decide the need for local specific arrangements to be derived and implemented.

Significant departures from the guideline should be fully documented and the reasons for the differences explained.

The guideline is not intended to be construed or to serve as a standard of care. Standards of care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advance and patterns of care evolve.

Trust guidelines on consent must be followed.

We wish to acknowledge reference to St George's Healthcare NHS Trust "Guidelines for the Care of Patients with Tracheostomy Tubes" in some sections of this document.

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STAFF ROLES

Care of the patient with a tracheostomy is the responsibility of the multidisciplinary healthcare team.

This team comprises of

Medical Staff Nursing Staff Physiotherapist(s) Speech and Language Therapist(s) Dietitian(s).

Together the team ensures safe management of the patient through:

Regular assessment Facilitation of the weaning process Education and development Regular communication Documentation.

Details of each individual's responsibilities follow.

The Role of Medical Staff

To take overall responsibility for the patient with a tracheostomy.

Specifically:

1. To prescribe oxygen therapy and humidification.

2. To provide clinical leadership regarding

type of tracheostomy changing of the tracheostomy tube swallowing assessment weaning removal of tracheostomy.

3. To ensure effective communication with the patient, multidisciplinary team and relatives.

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The Role of Nursing Staff

1. To maintain a patent airway through suctioning and humidification.

2. To administer oxygen as prescribed. 3. To provide holistic tracheostomy care including stoma care, cuff pressure checks,

swallow assessments.

4. To ensure all essential equipment is present and in good working order.

5. To ensure effective communication with the patient, multidisciplinary team and relatives.

6. To continually assess respiratory function.

7. To assist in the weaning process in conjunction with the multidisciplinary team.

8. To refer patients to appropriate disciplines.

9. Psychological care.

The Role of the Physiotherapist

To assess and treat patients with a tracheostomy.

Specifically:

1. To improve/maintain lung volume eg breathing exercises, positioning, use of mechanical aids.

2. To facilitate the removal of secretions eg humidification, manual techniques, cough facilitation, suction.

3. To reduce the work of breathing eg positioning, breathing re-education, relaxation techniques, use of mechanical aids.

4. To assist in the weaning process in conjunction with the multidisciplinary team.

5. To ensure effective communication with the patient, multidisciplinary team and relatives.

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The Role of the Speech and Language Therapist

1. To assess and treat patients presenting with communication difficulties as a result of tracheostomy, eg communication aids, voicing ability, use of speaking valves.

2. To identify other communication deficits, eg dysphasia, dysarthria, cognitive deficits and to treat as appropriate.

3. To help and advise the staff and family to understand the difficulties and how to communicate effectively with the patient.

4. To help patients and those around them to develop strategies for maintaining communication.

5. To assess, treat and offer advice on swallowing difficulties in order to promote safe oral intake and minimise the risk of aspiration.

6. To ensure effective communication with the patient, multidisciplinary team and relatives.

The Role of the Dietitian

1. To assess nutritional status and requirements of individual patients.

2. To advise on the most appropriate and effective form of nutritional support.

3. To prescribe oral and enteral tube feeds in accordance with the patient's requirements.

4. To monitor provision and effectiveness of nutritional support.

5. To ensure effective communication with the patient, multidisciplinary team and relatives.

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DEFINITION OF A TRACHEOSTOMY

A tracheostomy is a surgical incision into the trachea through the neck. A tracheostomy tube is inserted into this providing a patent opening. The tube enables air flow to enter the trachea and lungs directly, bypassing the nose, pharynx and larynx.

Figure 1: Diagram of larynx and trachea illustrating the sites of thetracheostomy tube inserted

INDICATIONS FOR TRACHEOSTOMY

To secure and clear the airway in upper respiratory tract obstruction.

To facilitate the removal of bronchial secretions.

To facilitate weaning from artificial ventilation in acute respiratory failure and prolonged ventilation.

To protect the airway of patients who are at high risk of aspiration eg neuromuscular disorders, unconsciousness.

To secure and maintain a safe airway in patients with injuries to the face, head or neck and following surgery to the head and neck.

PHYSIOLOGICAL CHANGES

The upper airway anatomical dead space can be reduced by up to 50%. (3)

The patient's ability to speak is removed. The ability to swallow is adversely affected. The warming, humidification and filtering of air that usually takes place in the upper

airway is lost. (4)

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TECHNIQUES OF TRACHEOSTOMY

Open Tracheostomy

Most surgeons prefer to perform standard elective tracheostomy in an operating room where sterility is more easily maintained and specialised lighting is readily available. Most also prefer to use general anaesthesia, although local anaesthesia is sometimes used. The patient is positioned supine, usually with a roll beneath the shoulders to extend the neck. After the anterior neck has been cleaned and painted with antiseptic, a 4 cm transverse incision is made over the second, third, or fourth tracheal ring. The subcutaneous tissues are divided and the anterior neck muscles and vessels are retracted. If the thyroid isthmus overlies the region selected for tracheostomy, it is ligated and transected. After the trachea has been exposed, one or more cartilages are incised to create an opening into which to place the tube. In some cases, a plug of cartilage is excised from one or more rings. The tracheostomy tube is inserted into the opening and the incision is closed with sutures or staples. Some surgeons elect to suture the flanges of the tube to the skin, whereas others are content to secure the tube with cloth ties. Some techniques form a flap of tracheal wall that has sutures placed in it that are brought to the surface out through the stoma. If the tube is displaced these can be used to re-open the hole for re-cannulation.

Percutaneous Dilatational Tracheostomy

The most commonly used method involves the insertion of a needle through the neck into the trachea, followed by passage of a guide-wire through the needle. The needle is removed and its tract gradually enlarged by inserting a series of progressively larger dilators over the wire. After a sufficiently large opening has been created, a tracheostomy tube is inserted. Bronchoscopic guidance is often used to ensure proper tube placement and promote safety. The percutaneous technique is attractive because of its simplicity and speed. Furthermore, percutaneous tracheostomy can be safely performed under local anaesthesia at the bedside in the intensive care unit, obviating the sometimes precarious exercise of transporting the critically ill patient to and from the operating room. Current evidence suggests that percutaneous and surgical tracheostomies are equally safe procedures. It is increasingly considered the technique of choice in critically ill patients. (5)

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Figure 2: The anatomical position of a cuffed tracheostomy tube

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Mini Tracheostomy

Mini tracheostomy is the insertion of a small 4 mm non-cuffed tracheostomy tube through the cricothyroid membrane. This can be done under local anaesthesia. It is primarily inserted to facilitate the removal of secretions. It does not protect the airway from aspiration and will only provide a route for oxygenation in the emergency situation.

Figure 3: Mini Tracheostomy

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COMPLICATIONS OF A TRACHEOSTOMY

"Historically, tracheostomy was associated with a high risk of complications and a significant mortality rate. The reported complication rates in adults undergoing tracheostomy vary considerably but it is generally held that complications are more frequent after emergency tracheostomy for airway obstruction." (6)

1. Immediate Haemorrhage (minor or severe). Misplacement - pretracheal tissues or to main bronchus. (7)

Pneumothorax. Occlusion of the tube by cuff herniation.

2. Delayed Tube blockage with secretions. May be sudden or gradual. Rare with adequate

hydration, humidification and suction. Infection of the stoma site. Infection of the bronchial tree. Distension of the trachea with an overinflated cuff leading to ulceration, necrosis. Mucosal ulceration due to asymmetrical inflation of the cuff, excessive cuff pressures

or tube migration (due to loose tapes or patient intervention). Risk of occlusion of the tracheostomy tube in obese or fatigued patients who have

difficulty extending their neck. Tracheo-oesophageal fistula formation.

3. Late Granulomata of the trachea may cause respiratory difficulty when the tracheostomy

tube is removed. Persistent sinus at the tracheostomy site. Tracheal dilation. Tracheal stenosis at the cuff site. Scar formation requiring revision.

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TYPES OF TRACHEOSTOMY TUBE

A variety of tracheostomy tubes are available and tube selection is dependent on the patient's specific needs.

Tracheostomy tubes vary in size, composition, number of parts and shape.

Single Cannula Tubes

Single cannula tubes are usually the first tube to be sited. The system is less complicated than double cannulation and is usually for temporary use only.

Double Cannula Tubes

Double cannula tubes have an outer cannula to keep the airway open and an inner cannula which acts as a removable liner to facilitate cleaning of impacted secretions. Some inner cannulae are disposable, others must be cleaned and re-inserted.

Cuffed Tubes

Cuffed tubes have a soft balloon around the distal end of the tube which inflates to seal the airway. Cuffed tubes are necessary when positive pressure ventilation is required or in situations where airway protection is essential to minimise aspiration of oral or gastric secretions

Oral feeding should not be commenced with an inflated cuff because an inflated cuff can anchor the larynx and reduce laryngeal elevation. It also prevents pulmonary air from clearing the larynx during swallowing. If a patient is aspirating it is vital to know immediately so suctioning can be carried out and management planned.

Cuff pressures should be checked regularly with a cuff manometer because excessive pressure (>30 cmH2O) may result in tracheal-mucosal damage including capillary occlusion, tissue necrosis and stenosis. Refer to page 14 (Checking Cuff Pressures).

If the tracheostomy tube lumen is occluded when the cuff is inflated, the patient will not be able to breathe. In this situation, it is important to deflate the cuff and call for medical assistance immediately (refer to Emergency Algorithm Appendix III).

Uncuffed Tubes

Uncuffed tubes do not have a cuff that can be inflated inside the trachea and tend to be used in longer-term patients who require ongoing suction to clear secretions. It is essential that patients have an effective cough and gag reflex to protect themselves from aspiration. Cuffless tubes are rarely used in acute care and are not suitable for patients receiving positive pressure ventilation.

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Figure 4: Single cannula, cuffed tracheostomy

Figure 5: Double cannula, uncuffed tracheostomy

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Fenestrated Tubes

Fenestrated tubes have an opening(s) on the outer cannula, which allows airflow to pass through the patient's oral/nasal pharynx as well as the tracheal opening. The air movement allows the patient to speak and produces a more effective cough.

However, the fenestrations increase the risk of oral or gastric contents entering the lungs. It is therefore essential that patients who are at high risk of aspiration or on positive pressure ventilation do not have a fenestrated tube unless a non-fenestrated inner cannula is used to block off the fenestrations. Suctioning with a fenestrated tube should only be performed with the non-fenestrated inner cannula in situ, to ensure correct guidance of the suction catheter into the trachea.

Note: Additional information on specialised tracheostomy tubes should be sought from senior nursing and medical staff on ENT/Maxillo Facial Surgery or the Speech and Language Therapy Department.

Figure 6: Double cannula, fenestrated cuffed tracheostomy

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CARE OF PATIENTS WITH A TRACHEOSTOMY

There should be a detailed plan of care for all patients with a tracheostomy. This should be reviewed on a daily basis and updated if there is any change.

The patient with a tracheostomy needs diligent observation and assessment. The nurse caring for the patient is responsible for this seeking advice from other professionals as appropriate.

PATIENT ASSESSMENT

Patient assessment should include:

Type and size of tracheostomy tube Respiratory rate, pattern and skin colour Oxygen saturations – if indicated Amount and consistency of secretions Oxygen percentage Checking cuff pressure

This should be documented on the Suction Sheet (Appendix I).

ESSENTIAL EQUIPMENT

When caring for a patient with a tracheostomy there are several essential pieces of equipment that should always be at the bedside.

2 tracheostomy tubes - one same sizeone size smaller

10ml syringe for inflating/deflating cuff 1 pair tracheal dilators Oxygen supply and humidification Suction equipment Disposable gloves (both clean and sterile) Stethoscope Ambubag with catheter mount should be available on resuscitation trolley. Pulse oximeter (if indicated) Cuff manometer - there should be one available per ward.

This equipment should be checked at the beginning of each shift and all but the cuff manometer should accompany the patient if they are being transferred to another area.

CHECKING CUFF PRESSURE

Each ward area caring for patients with tracheostomies should have a hand held cuff manometer available. The manometer should only be used to measure cuff pressure, not to inflate or deflate the cuff.

It is recommended that cuff pressure should be measured every shift by using a hand pressure manometer and recorded in the suction sheet. This will indicate the pressure exerted by the cuff on the tracheal wall.

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The cuff inflation pressure should range from 1530 cmH2O. Pressure exerted on to the tracheal wall greater than 30 cmH2O may result in capillary occlusion, tissue necrosis and tracheal stenosis(8). If the pressure is greater than 30 cmH2O and an air leak is still present seek medical advice as the tube may require to be upsized.

Figure 7: Cuff Manometer

Caution

Estimation of cuff pressure by fingertip pressure on the external pilot balloon or filling until no air leak is heard is an inaccurate measure of this pressure and puts unnecessary extra pressure on the tracheal wall.

Complications of Unsatisfactory Cuff Pressure

Cuff pressure too high

- tracheal wall weakening- tracheal necrosis

Cuff pressure too low

- Increased risk of aspiration- Unable to achieve optimal positive pressure ventilation

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DEFLATING/INFLATING A CUFF

Indications for Cuff Deflation

Weaning: Please refer to Guidelines for Weaning from a Cuffed Tracheostomy page 50.

. Swallow Assessment: Please refer to Bedside Evaluation of Swallowing, Eating and

Drinking page 56.

Equipment Required

Two practitioners – one should be suitably experienced. Suction unit and sterile suction catheters appropriate for the size of tracheostomy tube. 10 ml syringe Cuff manometer Pulse oximeter Sterile gloves and protective eye wear.

Action Rationale

Full explanation of procedure must be given to the patient and carers where appropriate.

Alleviates any anxiety.

Turn off NG or gastrostomy feeding if in situ – 1 hour prior to cuff deflation.

Reduces risk of aspiration. (9)

Patient must be sitting in upright position.

Optimum lung expansion achieved in this position. (10)

Wash hands.Wear goggles, gloves and apron.

Reduces risk of cross infection. (11)

Prior to cuff deflation suction briefly with a suction catheter in the oropharynx.

Saliva and bile may collect above the cuff which on deflation will enter the bronchus if the patient has an inadequate cough. (12)

Continue oxygen flow via tracheostomy mask or T-piece during procedure.

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Action Rationale

Perform synchronised suction/cuff deflation technique as follows:

Pass a sterile suction catheter into the tracheostomy tube approximately 0.5 cm longer than the tracheostomy tube tip.

Simultaneous suction should enable secretions to be caught and removed as they pass the gradually deflating cuff.

Minimise the risk of cross infection and trauma.

Simultaneously the second practitioner should remove air in 0.5 ml increments from the tracheostomy cuff until fully deflated using a 10 ml syringe. The whole procedure should take no longer than 15 seconds and the patient should be encouraged to cough.

Gradual deflation assists the patient to adjust to changes in airflow and allows the patient to adapt to the feeling of being able to breathe through their nose and mouth again. (12)

Coughing reduces the risk of aspiration. (13)

Observe patient for signs of respiratory distress.

Increased respiratory rate Desaturation Fatigue Cardiovascular instability Failure to protect airway eg audible

gurgle Stridor

The patient is at risk of aspiration. These signs will provide early indication that the patient is unable to maintain their own airway. (9)

Observe spontaneous swallow and the patient's ability to manage oral secretions.

No respiratory distress

Continue monitoring for signs of respiratory distress during weaning and swallow assessment.

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Indications for Cuff Inflation

Signs of respiratory distress

*Re-inflate tracheostomy cuff immediately*

Trial deflation complete.

Action Rationale

Inflate the cuff using a 10 ml syringe inserting the air gradually in 0.5 ml increments until the balloon is inflated.

Assess cuff pressure using a manometer (cuff inflation should not exceed 30 cmH2O) and adjust as required using the syringe.

Pressure exerted on the tracheal wall greater than 30 cmH2O may result in capillary occlusion, tissue necrosis and tracheal stenosis. (8)

Reassess and observe the patient.

Suction as required SpO2 stable Respiratory rate stable Cardiovascularly stable No audible gurgle.

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TRACHEOBRONCHIAL SUCTION

Indications

Presence of retained secretions which are detrimental to the patient as indicated by:

visible secretions in the airway. increased work of breathing coarse crackles on auscultation, or 'noisy' breathing suspected aspiration of gastric or upper airway secretions deterioration of arterial blood gases radiological changes consistent with retention of pulmonary secretions eg

atelectasis/consolidation increased peak inspiratory pressures or decreased tidal volume during ventilation

Inability to clear retained pulmonary secretions due to ineffective spontaneous cough.

To maintain the patency and integrity of the airway.

Equipment

Ensure an adequate supply of equipment at the bedside

Vacuum source

Calibrated, adjustable regulator set at 150-170 mmHg/20-23kPa (14)

Collection bottle and connecting tubing

Sterile disposable gloves (not required for CSMU catheter)

Sterile suction catheters of appropriate size whether open or closed system. size 14 FG = size 9 tracheostomy size 12 FG = size 8 tracheostomy size 10 FG = Mini tracheostomy (15)

Correct catheter design (eg catheters with a rounded tip and multiple eyes cause less invagination of the mucosa - 'Gentle-flo'). (13)

Bowl containing water

Sterile saline (NaCl 0.9%) - if instillation is desirable.

Goggles, mask and other appropriate equipment if necessary for universal precautions.

Oxygen source with a calibrated metering device.

Manual resuscitation bag (ambubag) with an oxygen enrichment device.

Appropriate monitoring devices to enable measurement of (eg SpO2, haemodynamic, neurological, ventilatory parameters) prior to, during and after the procedure.

Stethoscope (16) (17)

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Monitoring

The following should be monitored:

Oxygen saturation

Pulse oximeter

Respiratory rate and pattern

Breath sounds

Haemodynamic parameters

Blood pressure (if indicated and available) Heart Rate/ECG (if indicated and available)

Sputum characteristics

Colour Volume Consistency Odour

Cough effort

Arterial blood gases (if indicated and available).

Intracranial pressure (if indicated and available)

Ventilator parameters (if indicated and available).

Action Rationale

1. Assess patient and determine whether suction is indicated and appropriate.

To ensure stability of patient's medical status and rule out any contra-indications to treatment.

2. Wash hands and put on disposable plastic apron, gloves and goggles.

To reduce risk of cross-infection.

3. Explain the procedure to the patient To gain verbal consent, co-operation, confidence and to re-assure.

4. Position patient appropriately. To ensure head is in mid-position to prevent deviation of the tube.

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5. Consider pre-oxygenation for >30 seconds prior to the suctioning event.

To maintain adequate arterial oxygen levels and to reduce the risk of arrhythmia and hypoxia. (18)

A 'closed suction system' may be used to facilitate oxygenation during suctioning.

6. COPD patients should be assessed to ascertain the need for hyperoxygenation.

COPD patients may have an altered carbon dioxide response mechanism and therefore should not routinely be given 100% oxygen. (19)

7. Ensure suction unit is functioning and set to suggested vacuum pressure of 150-170mmHg/20-23 kPa. (12)

Experimental data to support an appropriate maximum suction pressure is lacking. However high negative pressure can cause mucosal trauma, subsequently increasing the risk of infection and atelectasis. Meanwhile, low pressures are ineffective at clearing sputum.

8. Peel the outer sheath of an appropriate suction catheter (considering size and design) to reveal the suction control port and connect the catheter to the suction tubing. A sputum trap may be connected at this stage if a specimen of sputum is required.

9. Place a sterile glove on your dominant hand and gently remove the catheter sheath with your non-dominant hand, controlling the sterile catheter with your sterile hand. Take care not to contaminate the catheter once it has been removed from the sheath. (20)

To reduce the risk of cross-infection and ensure the technique is as 'clean' as possible.

10. Consider installation of 1-3mls of normal saline via the tracheostomy, prior to the suctioning procedure. The saline should be administered during the patient's inspiratory phase. (Discuss with physiotherapist or medical staff prior to utilisation.)

The value of saline is questionable. However, it may be beneficial in initiating a cough reflex, which aids the removal of secretions.(21) It should not be routine practice as it may reduce baseline saturation levels, induce bronchospasm or increase bacterial colonisation. (22)

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11. Gently, without suction, introduce the catheter into the patient's airway until a 'hard-end feel' or resistance is reached. At this stage the catheter will probably be on the 'carina' and a cough may be stimulated. Withdraw the catheter slightly, then apply suction, gently removing the catheter in one continuous movement.(23)

Rotation is not necessary and the duration of the suction procedure should not exceed 15 seconds. (24)

Resistance on passing the catheter probably indicates that the inner tube of the tracheostomy is crusted with secretions. It will therefore need to be changed or cleaned.

12. Reapply the patient's oxygen supply immediately by replacing the catheter mount/tracheostomy mask.

To reduce the risk of further hypoxia and restore arterial oxygen levels as quickly as possible.

13. Dispose of catheter and gloves in clinical waste (orange) bag.

14. Monitor patient throughout the procedure and modify treatment as appropriate.

Assess for signs of distress and/or variation in haemodynamic, ventilatory or neurological parameters.

15. Repeat procedure as often as required. This will depend on the clinician's assessment, individual patient's condition and response. Continual re-assessment of the patient's status is essential.

16. On completion flush the suction tubing with tap water, leaving the bowl dry. Turn off suction pressure and wash hands at end of procedure. Tidy bedspace ensuring patient comfort.

To reduce risk of cross-infection and suction tube blockage

To ensure patient comfortable/stable.

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CLOSED SYSTEM MULTIPLE USE SUCTION UNITS (CSMUSU)

Figure 8: Closed System Multiple Use Suction Unit (CSMUSU)

Indications1. A patient who requires a high FiO2/PEEP where disconnection results in a drop in

oxygen saturation and tissue hypoxia. (25)

2. A patient with copious/infected secretions. (26)

See Action/Rationale numbers 1-7 on pages 20-21.

Action Rationale

1. Unlock the suction application port.

2. If installation of saline is desirable following consultation with the Physiotherapist or Medical Staff (to stimulate a cough reflex) attach syringe or prefilled saline ampule to installation port and pass the tip of the catheter until the black marking is visible in the T-piece.

Normal saline 0.9% will naturally follow the tip of the catheter ensuring delivery of fluid into the lower airways (pooling of saline in the T-piece can otherwise occur). The introduction of normal saline (0.9%) may aid secretion removal by stimulating a cough reflex.(21) However, it should not be routine practice as it may reduce baseline saturation levels, induce bronchospasm or increase bacterial colonisation.(22)

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3. Introduce the catheter into the trachea, withholding the outer plastic sheath. Take care not to bunch the outer plastic sheath in front of your hand but pass it behind your hand with each advancement.

The outer plastic sheath allows repeated re-use protecting the catheter from external pathogens and reducing the need for the user to wear sterile gloves. Bunching of the outer sheath at the distal end of the catheter may reduce the 'feel' that the operator gets from the catheter.

4. On stimulating a cough and/or reaching a 'hard end' feel, take hold of the 'T' connector and the tracheostomy tube.

To support, therefore reducing the risk of disconnection of the system and tube migration which may cause trauma to the trachea wall.

5. Apply suction by depressing the application port and withdraw the catheter taking no more than 15 seconds.(24)

To reduce the risk of hypoxia.

6. Monitor the patient throughout and repeat the procedure as required.

Previously discussed.

When suctioning is complete

7. Withdraw the tip of the suction catheter so that the black marking is visible externally to the T-piece (the tip of the catheter and side port holes should be level with the installation port).

To reduce the risk of any normal saline 0.9% passing into the patient's airways producing an unnecessary cough.

8. Apply suction by depressing the application port and instil 5-10 mls of normal saline 0.9% via the installation port.

To flush the suction catheter and tubing after use assuring continued patency.

9. 'Lock off' the suction application port. To reduce the risk of inadvertent suctioning which may result in hypoxia.

10. Change and date the CSMU catheter every 24-48 hours,(27) or as per manufacturer's guidelines.

To reduce the risk of bacterial contamination.

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HAZARDS/COMPLICATIONS OF SUCTIONING

1. Hypoxia/Hypoxaemia (28)

Removal of oxygen Temporary atelectasis Reflex bronchospasm Interruption of ventilation/respiration.

Hypoxaemia can be minimised by:

Limiting the procedure time to 10-15 seconds. Pre-oxygenation. Correct catheter size and negative pressure. Maintain a closed system for patients requiring a high FiO2. Appropriate frequency of suctioning.

2. Tissue trauma to tracheal and/or bronchial mucosa (23)

This can be modified by:

Correct suction pressure. Good technique for insertion and withdrawal. Correct catheter design.

3. Cardiac Arrhythmia's/Bradycardia/Arrest: (28)

Causation Mechanism:

Irritation of respiratory tract. Vaso-vagal reflex response. Narrowing of coronary arteries and alternation in conductivity. Arrhythmias, Bradycardia and Asystole.

Cardiac Arrhythmias etc may be minimised by:

Pre-oxygenation. Careful patient selection with regards to timing and necessity of suctioning. Good technique.

(Note: If concerned regarding vagal stimulation and suctioning is essential - ensure atropine available.)

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4. Infection (patient or clinician) (29)

This can be minimised by:

Sterile fresh catheter for each application Sterile technique at all times Goggles and mask.

5. Raised ICP (30)

Increased ICP may occur because arterial carbon dioxide levels increase during suctioning causing cerebral vasodilation. The degree of hypoxia and impairment of venous outflow from coughing may also affect the ICP.

To minimise this, suctioning should be carried out sparingly, and contact with the carina should be avoided.

6. Pulmonary Atelectasis (31)

Due to removal of air, dynamic compression, airway closure and interruption of ventilation/respiration.

7. Bronchospasm/Laryngospasm (32)

8. Patient Anxiety

Other Considerations:

Stridor Pulmonary oedema Tracheo/oesphageal fistula Clotting Disorders Hypotension/Hypertension

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OXYGEN THERAPY

Oxygen Therapy is the administration of oxygen at concentrations greater than that in ambient air with the intent of treating or preventing the symptoms and manifestations of hypoxia. (33)

Note: Oxygen is a fire hazard.

Indications for Instituting Oxygen Therapy

Post-operatively as prescribed by the anaesthetist.

Hypoxaemia where PaO2/SpO2 are below desirable range for specific clinical situation

Cardiovascular instability including hypotension, tachycardia, myocardial ischaemia or myocardial infarction

Critically ill patients

Acute head injury

Cardiac or respiratory arrest

Carbon monoxide poisoning

Note: Some non-specific clinical features of hypoxia may include:

Altered mental state Cyanosis Arrhythmias.

Complications of Oxygen Therapy

Discomfort from oxygen therapy may be associated with dry mucus membranes or increased work of breathing due to inadequate flow.

Oxygen toxicity is an inflammatory response of the lung tissue following exposure to 70-100% oxygen for between 48 hours and 7 days. It impairs the action of the cilia, macrophages and surfactant and the patient may experience substernal pain, cough, dyspnoea, interstitial oedema, decreased lung compliance and possible pulmonary fibrosis. (34)

Absorption atelectasis may occur if absorption of oxygen from alveoli exceeds replenishment of alveolar gas, so that the alveoli are no longer held open by inert nitrogen (nitrogen washout). This tends to occur most commonly in mechanically ventilated patients receiving greater that 70% oxygen for more than 48 hours. (35)

A small proportion of patients with chronic Type II respiratory failure may develop apnoea if their central hypoxic drive is removed by supplemental high dose oxygen therapy. However, this is seldom (if ever) abrupt and a period of desaturation and increasing drowsiness will alert staff before apnoea occurs. In these patients, initial oxygen concentrations should be low (24-28%) and progressively increased on the basis of repeated blood gas analysis. (19)

Psychological oxygen dependency.

27

Oxygen Delivery Systems

Oxygen delivery systems are conduits through with oxygen flows from the oxygen source to the patient. They are classified into two major categories:

A fixed performance device which will deliver a known FiO2 by providing a sufficiently high flow rate of premixed gas to exceed the patient's peak inspiratory flow rate.(36) For example:

spontaneously breathing tracheostomy patient with tracheostomy mask and venturi valve. The venturi valve ensures that a proportion of room air is entrained through a fixed-size port, so that specific oxygen concentrations can be delivered. The valves are colour coded, according to the entrainment port size and the oxygen concentration is pre-printed on the valve and ranges from 24-60%.

Figure 9: Venturi Valve

spontaneously breathing tracheostomy patient on a CPAP circuit or T-piece.

mechanically ventilated tracheostomy patient.

A variable performance device which will deliver a variable FiO2 as the flow of oxygen is less than the patient's peak inspiratory flow so that room air is entrained to dilute the oxygen.(36) For example:

spontaneously breathing tracheostomy patient on a tracheostomy mask with no venturi valve.

Note: All oxygen dependent tracheostomy patients should receive humidified oxygen therapy. The only exception to this is tracheostomy patients receiving oxygen therapy via a venturi valve, where moisture condenses on reaching the valve which affects the proportion of room air entrained through the fixed-size port. In this circumstance, humidified oxygen therapy should be avoided but regular saline nebulisation should be administered.

28

Prescription of Oxygen Therapy

Oxygen therapy should be prescribed.

The following information should be documented: (37) (38)

Flow rate

Concentration

Delivery device

Humidification

Duration

Method of monitoring

In the acute setting oxygen should be continuous and administered for the duration prescribed. Intermittent oxygen prescription should only be considered if hypoxaemia occurs during specific circumstances, for example during sleep or exercise.(33)

Monitoring Oxygen Therapy

Clinical assessment during oxygen administration should focus on the respiratory, cardiac and neurological systems and should be performed on a regular basis throughout the day, especially if any change in clinical condition or oxygen dosage has occurred.(33)

Adequacy and changes in arterial oxygenation should be monitored by pulse oximetry and/or arterial blood gas analysis.(39)

Arterial blood gas analysis is considered the gold standard, however pulse oximetry is very useful within the clinical setting as long as its limitations are recognised which include:(40)

inability to detect hypoventilation and a rising carbon dioxide level.

inaccurate reading associated with poor peripheral circulation, substance interference or malpositioning.

(Note: Improper probe placement, or failure to monitor or change probe placement may cause pressure injuries. As a result, the probe site should be changed every 2-4 hours.) (12)

Discontinuation of Oxygen Therapy

In the post-operative patient oxygen therapy can be discontinued after the existing oxygen prescription has elapsed if the patient is clinically stable and is maintaining a SpO2 above 94% at all times on room air.

In the critically ill patient, oxygen therapy can be discontinued when the patient has recovered from critical illness and is clinically stable and maintaining a SpO2 above 94% at all times on air.

Oxygen therapy should always be restarted if clinically indicated.

29

STOMA CARE

Tracheostomy stoma care aims to keep the area clean and dry, reducing the risk of skin irritation and infection. Secretions collected above the tracheostomy tube cuff may ooze out of the surgical incision and stoma site. The resultant wetness can promote irritation of the skin and can lead to skin maceration and excoriation. This increased moisture may act as a medium for bacterial growth or prevent the stoma site from healing. (41)

Although the frequency of dressing changes will be indicated by the amount of secretion oozing around the tracheostomy stoma and should be reviewed each shift, they should be changed at least every 24 hours.

Assessment of the tracheostomy tube holder should be done every shift and changed at least every 24 hours.

Requirements

Two practitioners Sterile powder-free gloves Dressing pack Normal saline 0.9% Pre-cut keyhole dressing Tracheostomy tube holder Orange clinical waste bag Appropriate goggles and mask.

Emergency equipment and functional suction equipment should be readily available at the bedside.

Prepare all equipment prior to the procedure.

Action Rationale

Explain the procedure to the patient. Gain consent (where appropriate) and reduce anxiety.

Wash hands.Wear goggles, mask, gloves and apron.

Reduces the risk of contamination.

If copious secretions are present, suction prior to changing the tracheostomy tube holder and dressing.

The patient is less likely to cough or require suctioning during the procedure.

Position the patient with their neck slightly extended.

The positioning of the patient allows easier access to the stoma site.

30

Action Rationale

Continue to administer oxygen throughout the procedure if appropriate.

To reduce the risk of hypoxia.

One practitioner holds the tracheostomy tube and the oxygen in place whilst the second practitioner removes the tapes and dressing.

To stabilise the tracheostomy tube and reduce the risk of dislodgement of the tracheostomy tube.

Discard these into the clinical waste disposal bag immediately.

To reduce the risk of cross-infection.

If the tracheostomy tube has an inflated cuff ensure the tube leading to the external balloon is not damaged. If this does occur the tracheostomy tube will need to be replaced, therefore, inform medical staff promptly.

This will deflate the cuff of the tracheostomy tube and there will no longer be a viable seal against the trachea therefore the risk of aspiration is increased.

Assess the tracheostomy stoma for signs of trauma, infection or inflammation and document in the Suction Chart.

Early detection and treatment reduces the risk of deterioration of the stoma. (42)

Clean around the stoma with Normal Saline 0.9%, if required, using a clean technique. Dry thoroughly.

Other cleaning agents may cause irritation to the tracheal mucosa and surrounding skin.

Apply the keyhole dressing - starting from below the tracheostomy tube.

A keyhole dressing is most appropriate as bulky dressings raise the tracheostomy tube and may cause discomfort to the patient and can cause tube dislodgement.

Secure the tracheostomy tube in position preferably with a tracheostomy tube holder. The tube holder should be tight enough to keep the tube securely in place but loose enough to allow two fingers to fit between the tube holder and the neck.

For patient comfort and to reduce trauma from a migrating tracheostomy tube.

Dispose of used/soiled equipment in the orange clinical waste bag and wash hands.

31

If the patient has a tracheostomy with an inner cannula then this should be removed at least every 8 hours for assessment. The cannula should then be cleaned as required and/or replaced and locked back in position.

Action Rationale

To change the inner cannula firstly remove the old one. With one hand hold the tracheostomy in place.

To prevent the tube from dislodging when the inner cannula is removed.

With the other hand twist the inner tube till it unlocks and then remove in a downward motion.

To ensure the tube slides out smoothly.

Insert the new tube and lock into place

If the tube is disposable then place in orange clinical waste bag immediately.

To reduce the risk of cross-infection.

If the tube is non-disposable then it should be cleaned with warm soapy water or hydrogen peroxide 0.5%, rinsed and left to dry.

The tube should never be left to soak due to the increased risk of bacterial contamination.

Do not clean inner tube with a brush. Brushes can scratch the inside of the tube causing an area for bacteria to grow.

32

ORAL HYGIENE

Patients with tracheostomies require regular oral care due to the reduced evaporation of oral secretions, which accumulate in the mouth. This is due to the disruption of normal airflow during inhalation and exhalation.

Aspirated infective saliva contributes to respiratory problems.

If the patient presents with a dry mouth then consider artificial saliva.

Important Points

Hardened plaque causes tartar. Tartar tends to form faster in NG/PEG tube fed patients - plaque removal is a priority. Regular oral hygiene - minimum x 2 per day but preferably every 2-4 hours. Patient’s teeth should be brushed with toothbrush and toothpaste at least twice a day.

(Remember the patient may be self-caring.) There is no reason why patients with tracheostomies can’t wear their dentures.

PERSONAL HYGIENE

Showering is permitted if the patient will tolerate oxygen being off for the duration of the shower and the tracheostomy is covered with a Heat Moisture Exchange Device (HME)/Thermovent/Swedish Nose. Ensure the patient is angled away from shower spray. It is easier if the shower is angled from behind.

33

HUMIDIFICATION

INDICATION

It is mandatory that a method of artificial humidification is utilised when a tracheostomy tube is in situ.(43) The type of humidification will be dictated by the needs of the patient. Advice may be sought from the physiotherapist.

Rationale

In normal breathing, inspired air is warmed, filtered and moistened by ciliated epithelial cells in the nose and upper airways. However, these humidifying functions are impaired by:(4)

a) a tracheostomy tube, which bypasses natural mechanisms for warming/moistening inspired air.

b) administration of cold, dry inspired gases (eg oxygen therapy).

Inadequate humidification can result in a number of physiological changes including:(44)

a) Retention of viscous, tenacious secretions

b) Impaired mucociliary transport

c) Inflammatory changes and necrosis of epithelium

d) Impaired ciliary activity

e) Destruction of cellular surface of airway (eg inflammation/ulceration)

f) Reduction in lung function (eg atelectasis/pneumonia)

g) Increased risk of bacterial infiltration.

As a result, humidification must be artificially supplemented to assist normal function and facilitate secretion removal.

Failure to adequately humidify could result in tube occlusion because secretions become dry and viscous, forming a crust around the tracheostomy. (17)

34

SUMMARY OF METHODS OF ARTIFICIAL HUMIDIFICATION

Systemic Hydration It is essential that oral and IV fluids are monitored to ensure satisfactory hydration of the tracheostomised patient.

Dehydration may lead to an increased viscosity of sputum.

Over-hydration may result in peripheral/pulmonary oedema.

Heated Humidification Operates actively by increasing the heat and water vapour content of inspired gas, so that gas is delivered fully saturated at core temperature.

It is indicated for tracheostomy patients requiring mechanical ventilation or oxygen therapy for 96 hours.

Cold Humidification Bubbles gas through cold water, but only delivers a relative humidity of 50% at ambient temperatures.

It is indicated for tracheostomy patients on high inspiratory flow rates of oxygen with tenacious secretions or patients complaining of subjective dryness.

A heated device can be incorporated into the circuit.

Saline Nebulisation The nebuliser unit converts saline into a supersaturated aerosol of liquid droplets which penetrates the lung moistening the airways.

It may be indicated in tracheostomy patients who are mechanically ventilated, receiving oxygen therapy or self-ventilating on air.

Saline nebulisers have been shown to increase sputum yield, but the cold irritant effect may induce bronchospasm.

Heat Moisture Exchanger Operates passively by storing heat and moisture obtained from condensation during expiration.

It is indicated for tracheostomy patients who are mechanically ventilated or on oxygen therapy for short periods (< 96 hours) or who are self-ventilating on air.

Buchanan Bib/Foam Filter Acts in a similar way to a heat moisture exchange device.

It is indicated for longterm tracheostomy/laryngectomy patients to ensure moisture of the stoma/airways.

35

METHODS OF ARTIFICIAL HUMIDIFICATION

(A) Systemic Hydration

It is essential that oral and IV fluids are monitored to ensure satisfactory hydration of the tracheostomised patient.(20)

Rationale

Dehydration excessive loss of water leads to an increased viscosity of sputum.

Factors influencing this include:

fever hyperventilation administration of dry medical gases restriction of oral fluid intake bypass of upper respiratory tract.

Signs of Dehydration include: reduced urine output increased respiratory rate reduced systolic blood pressure increased heart rate reduced central venous pressure reduced pulse pressure pallor

Clinical features which may dark urineindicate Dehydration postural hypotension with tachycardia

dry, velvety axilla inelastic skin over sternum electrolyte imbalance

Over-Hydration Surplus circulating fluid may result in peripheral/pulmonary oedema.

Signs of Over-Hydration include peripheral oedema increased systolic blood pressure increased heart rate increased central venous pressure late inspiratory, gravity dependent crackles

on auscultation. weight gain

Clinical features which may shortness of breathindicate Over-Hydration cough with production of frothy sputum

distended neck veins orthopnoea

(B) Heated Humidification

36

Operates actively by increasing the heat and water vapour content of inspired gas, so that gas is delivered fully saturated at core temperature.(45)

Equipment should include:

(i) humidification device.

(ii) a system to monitor inspired gas temperature which should range between 37-40°C.

(Note: an inspired gas temperature of 41-42° will cause mucosal damage.)(46)

(iii) sterile water (because NaCl crystallises)

Equipment should comply with universal standards.

Indications for Use Tracheostomy patients requiring longterm mechanical ventilation/oxygen therapy ( 96 hrs).(47)

Contra-Indications/Hazards Thermal injury to the airway due to improper temperature settings or thermostat failure.

Superficial burn or tubing meltdown if heated wire circuits are covered or circuits and humidifiers are incompatible.

Tracheal drowning

Elevated airway pressures

Patient/ventilator dysynchrony

Increased risk of nosocomial infection from contaminated water (eg bacterial growth - pseudomonas) (48)

Figure 10: Fisher and Paykel heated humidifier

37

secondary to pooled water in patient circuit

(C) Cold Water Humidification Bubbles gas through cold water, however only delivers a relative humidity of 50% at

ambient temperatures. (49)

A heated device (Kendall adapter) and thermostat can be incorporated within the circuit.

Indications for Use Tracheostomy patients on high inspiratory flow rates of oxygen with tenacious

secretions.

Tracheostomy patients complaining of subjective dryness.

Contra-Indications/Hazards Condensation

impede FiO2 delivery elevate airway pressures result in tracheal drowning, secondary to pooled water in the patient circuit.

Risk of bacterial contamination from contaminated condensate (48)

Bronchoconstriction (cold irritant) (50)

Note: Condensation from heated or cold humidification should be considered infectious waste and disposed of according to hospital policy using strict universal precautions.

Because condensate is infectious waste, it should never be drained back into the humidifier reservoir.

Figure 11: Respiflo sterile water bottle with aerodyne heater, nebuliser unit and liquid crystal thermometer

38

(D) Nebulisation

The selection of a device for administration of saline which is converted into a supersaturated aerosol of liquid droplets which penetrates the lung, moistening the airways. (50)

Other indications for nebulisation include administration of bronchodilators, corticosteroids, antibiotics and mucolytics. (50)

Indications for Use

Tracheostomy patients who are mechanically ventilated/receiving oxygen therapy/or self-ventilating on air.

Relevant Information

Procedure involves administration of 5 mls 0.9% sterile normal saline into the nebuliser unit 2-4 hourly or as required.

Nebulisers must be connected to a gas source with a flow rate of 6-8 litres/minute (or follow manufacturer's guidelines).

Lung deposition is enhanced by slow deep breathing and the side lying or upright sitting position.

Hypertonic saline increases sputum clearance by increasing production, so is only used to induce sputum for diagnostic purposes.(51)

Ensure nebulisation is given via the tracheostomy (not the face mask!). A nebuliser can be attached to tracheostomy mask or T-piece circuit.

Figure 12: Tracheostomy mask with jet nebuliser

39

Limitations of Procedure/Device

Only small percentage of output deposits in the airway (<10%).(52)

Efficiency of device is

(i) technique dependent eg co-ordinationbreathing patterninspiration hold

(ii) design dependent eg outputparticle size

(iii) patient dependent eg compliance

Hazards/Complications

Bronchospasm(50)

Bacterial contamination(48)

Hypercapnic COPD patients may suffer loss of respiratory drive if uncontrolled oxygen is used as the driving gas.(19)

(E) Heat Moisture Exchanger (HME) eg Thermovent, Swedish nose

Operates passively by utilising the principle of replication of the functions of the naso-oropharynx, by storing heat and moisture obtained from condensation during expiration.(53)

Consists of rolls of metal gauze or a condensor element like propylene sponge/fibre sheet/corrugated paper.(53)

Indications for Use

Tracheostomy patients who are mechanically ventilated or on oxygen therapy for short periods ( 96 hrs) and have adequate systemic hydration.(47)

Tracheostomy patients who are self-ventilating on air.

Advantages

Economical

80% efficient. However efficiency does depend on gauze surface area, thermal capacity, inspired gas humidity and temperature.(54)

Protects against bacterial contamination (99.9%).(55)

Supplemental oxygen therapy may be added.

40

Hazards/Complications

HME devices should be avoided in patients with:

thick, copious secretions(56)

body temperature <32°C(43)

Hazards associated with the use of HME devices include:

Possible hypoventilation due to increased dead space Possible increased resistive work of breathing which would be exacerbated by

mucus plugging in the airways.

HME devices should be checked every 4 hours and replaced if soiled, as secretions can block the filter and increase work of breathing.(4)

Figure 13: Heat Moisture Exchanger (HME)

Figure 14: Heat Moisture Exchanger/Thermovent/Swedish Nose

41

(F) Buchanan Bib/Foam Filter

Operates passively by storing heat and moisture obtained from condensation during expiration.(53)

Acts in a similar way to an HME device.

Indication for Use Longterm tracheostomy/laryngectomy patients to ensure moisture of the stoma/airways.

Relevant Information

The Buchanan Bib or disposable Foam Filter dressing is applied directly over the stoma.

In the acute/hospitalised patient the protector should be replaced every 24 hours.(4)

Community patients can wash and re-use the protector, according to the manufacturer's instructions.

Figure 15: Buchanan Bib

42

CHANGING OF TRACHEOSTOMY TUBES

Changing of the tracheostomy tube should be a multidisciplinary decision. The first change should always be performed or supervised by a suitably trained member of the medical staff.This is because the stoma and tract to the skin from the patient's trachea may not be well formed. Thereafter changing the tube can be performed by a competent and suitably trained person but medical assistance should be readily available at all times.

Indications for Tube Change Every 28-30 days or as clinical need dictates.(57)

Evidence of tracheostomy tube obstruction that may lead to a rapid deterioration in the patient's respiratory status.

Infection around stoma site.

Part of weaning process.

Equipment Required

1. Two tracheostomy tubes of appropriate make. 1 same size 1 size smaller.

2. Tracheostomy tube tape3. Tracheostomy tube holder4. Dressing Pack5. Normal saline (0.9%) to clean6. 10 ml syringe7. Sterile gloves and protective eye wear8. Water soluble lubricating gel9. Tracheal dilators10. Forceps and scissors11. Pen torch12. Suction and suction catheters13. An exchange device/Bougie14. Precut keyhole tracheostomy dressing – uncut gauze swabs are not recommended.15. Cuff manometer.

Action Rationale

Explain procedure to the patient and the rationale for why the tracheostomy tube needs changed.

The patient should give verbal consent where possible unless the tracheostomy tube is changed as an emergency.

Stop enteral tube feeding or ensure nil by mouth 1 hour prior to tracheostomy tube change.

Removal of tracheostomy tube means the airway is unprotected. It is therefore important to reduce the risk of aspiration during tube change.(9)

43

Action Rationale

Position patient on bed in upright sitting position with neck extended.

The patient should be comfortable during the procedure. Extending the neck will make the removal and insertion of the tracheostomy tube easier.

Wash hands and put on disposable plastic apron, gloves and goggles.

Reduces risk of cross infection(11)

Hyperoxygenate patient with 100% oxygen if they are oxygen dependent (>40% oxygen) and monitor their oxygen saturation levels.

Medical staff should be present if the patient is oxygen dependent.

During tracheostomy tube change the patient will not receive oxygen and may be at risk of hypoxia.

COPD patients may have an altered carbon dioxide response mechanism and therefore should not routinely be given 100% oxygen.(19)

Two skilled practitioners should perform the procedure.

One person to deflate the cuff prior to tube removal and the other to perform suctioning while reassuring the patient.

Open the new tracheostomy tube on to an opened dressing pack. Put on sterile gloves.

To reduce the risk of cross infection.

If new tracheostomy tube is cuffed, check the cuff by inflating it, removing the syringe and observing that it does not deflate spontaneously, then deflate with a 10 ml syringe before insertion.

To check for air leaks within the cuff.

Do not use the tube if the cuff spontaneously deflates.

Check that the exchange device can be removed.

To become familiar with removing the exchange device prior to insertion.

Lubricate the tracheostomy tube sparingly with water soluble gel.

To facilitate insertion.

Too much gel may irritate the trachea.

Remove the old dressing and clean around stoma site.

To clean skin of debris and superficial organisms.

44

Action Rationale

Use a pen torch to ensure tissue is healthy.

Prior to deflating the cuff, suction briefly with a suction catheter in the oropharynx.

Secretions may pool at the top of the cuff and when it is deflated may enter the lungs.

Perform synchronised suction/cuff deflation technique as follows:

Saliva and bile may collect above the cuff, which on deflation will enter the bronchus if the patient has an inadequate cough. Simultaneous suction should enable secretions to be caught and removed as they pass the gradually deflating cuff.(12)

Pass a sterile suction catheter into the tracheostomy tube approximately 0.5 cm longer than the tracheostomy tube tip.

Minimise risk of cross infection and trauma.

Simultaneously the second practitioner should remove air in 0.5 ml increments from the tracheostomy cuff until fully deflated using a 10 ml syringe. Encourage the patient to cough.

The cuff needs to be fully deflated to reduce the risk of trauma from removing the tracheostomy tube. Gradual deflation of the cuff allows the patient to adapt to the feeling of being able to breathe through their nose and mouth again.

Coughing reduces the risk of aspiration.

Release tracheostomy ties and remove the old tracheostomy tube in a firm outward and downward motion.

The tube may be slightly resistant and firm pressure may be required.

Ensure the stoma does not occlude due to a large double chin.

This will ensure that the patient can breathe whilst the tube is out.

45

Changing the Tracheostomy Tube without an Exchange Device/Bougie

Action Rationale

Insert the new tracheostomy tube with the obturator in place, while the patient is exhaling using an up and over action.

The obturator guides the tracheostomy tube along the contour of the trachea. Relaxation of the neck muscles during exhalation makes insertion easier.

It may be necessary to downsize the new tracheostomy tube as the stoma may have shrunk in size.

Immediately remove the obturator. The patient is unable to breathe with the obturator blocking the lumen.

Observe the patient for respiratory distress.

Feel for respirations via tracheostomy tube. Observe for chest movements. Auscultate for equal air entry.

The flow of air will be felt via the tracheostomy tube if it is in the correct position. If the airflow is not felt, remove the tracheostomy tube and try again using a smaller lubricated tracheostomy tube.

Changing the Tracheostomy Tube with a Tube Exchange Device/Bougie

This should be performed by a member of medical staff.

Action Rationale

Insert tube exchange device/flexible bougie into the old tracheostomy tube.

To direct bougie into airway.

Remove the old tube from the trachea leaving exchange device or bougie in airway.

Thread over the new tube and remove bougie.

Check tube airflow and respiratory status.

46

Successful Tube Insertion

Action Rationale

Secure the tracheostomy tube with a tube holder or tapes. Clean around stoma site again if necessary. Renew tracheostomy dressing.

To reduce the risk of dislodgment, maintain patient comfort and reduce the risk of infection.

Ensure tapes are not secured too tightly.

Inflate the cuff using a 10 ml syringe inserting air gradually in 0.5 ml increments until the balloon is inflated.

Assess cuff pressure using a manometer (cuff inflation should not exceed 30 cmH2O) and adjust as required using the syringe.

Pressure exerted on the tracheal wall greater than 30 cmH2O may result in capillary occlusion, tissue necrosis and tracheal stenosis.(8)

An inflated cuff reduces the risk of aspiration.

Ensure the patient is breathing comfortably. Return oxygen to pre-procedure setting and observe saturation levels.

Record the tube change in the medical and nursing notes. Document time, date, size, type of tube and any complications experienced during the procedure.

There may be a small amount of bleeding following a tracheostomy tube change. If there is excessive bleeding, ensure the cuff is inflated and seek medical assistance.

Trauma can occur to stoma site and the patient's trachea when changing the tube. An inflated cuff will protect the patient's airway.

47

Unsuccessful Tube Insertion

Action Rationale

If the tube insertion fails or the patient appears distressed and cyanosed call an anaesthetist.

Insert the sterile tracheal dilators and attempt to re-insert firstly the same tube and then move to a smaller tracheostomy tube.

The tract may not have formed or the tracheostomy tube may have become inadvertently blocked during insertion causing failure to re-intubate the patient.

If this fails follow the EMERGENCY ALGORITHM see Appendix III.

48

WEANING FROM A CUFFED TRACHEOSTOMY ANDREMOVAL OF A TRACHEOSTOMY TUBE

49

Meets requirements for deflation of tracheostomy cuff(see guidelines)

Deflate cuff (as guidelines)

Observe for signs of respiratory distress(see guidelines)

No signs of respiratory distress

Observe for 24 hours

Observations stable

Signs of respiratory distress

Re-inflate cuff

Re-assess patient to ensure observations stable

Consider reasons for failed attempt (see guidelines)

Treat and wean as appropriate

Ongoing sputumretention

Meets requirements for tracheostomy tube removal

(see guidelines)

ConsiderMini-Tracheostomy

Remove tracheostomy(see guidelines)

Observe for signs of respiratory distress

Signs of respiratory distress

MEDICAL EMERGENCY(see guidelines)

Review dressing and change as necessary

Observe closely for 24 hours

No signs of respiratory distress

GUIDELINES FOR WEANING FROM A CUFFED TRACHEOSTOMY AND REMOVAL OF A TRACHEOSTOMY TUBE

Weaning can be commenced once the following have been ensured/initiated:

the primary cause for the tracheostomy has been resolved there is stable lung status (with oxygen therapy less than 40%)(58)

effective swallow and cough reflex are present (where possible) safe oral feeding and/or artificial nutrition has been established.

Action Rationale

Full explanation of procedure must be given to the patient and carers.

Alleviates any anxiety.

The weaning programme must be planned, clearly documented and regularly evaluated by the members of the multi-disciplinary team.

Ensures continuity and individualised care.

The patient should be placed in maximum view of nursing staff with a call bell within easy reach, if appropriate.

Ensures maximum observation of the patient and allows the patient to summon urgent assistance if necessary.

Turn off NG or gastrostomy feeding one hour prior to cuff deflation.

Reduces risk of aspiration.(9)

Patient must be sitting in upright position.

Optimum lung expansion achieved in this position.(10)

Cuff Deflation

Nursing staff assesses cuff deflation tolerance and screens swallowing safety of the patient.

Wash hands and put on a disposable plastic apron, gloves and goggles

Prior to cuff deflation, suction briefly with a suction catheter in the oropharynx

Continue oxygen flow via tracheostomy mask or T-piece during procedure

To ensure that the patient can protect their own airway. Motor and sensory impairment can result from the presence of the tracheostomy tube(59) and may not resolve until after the tube is removed.

Reduce risk of cross infection.(11)

Saliva and bile may collect above the cuff which on deflation will enter the bronchus if the patient has an inadequate cough.(12)

50

Action Rationale Perform synchronised suction/cuff

deflation technique as follows:

Pass the sterile suction catheter into the tracheostomy tube approximately 0.5 cm longer than the tracheostomy tube tip.

Simultaneously the second practitioner should remove air in 0.5 ml increments from the tracheostomy cuff until fully deflated using a 10 ml syringe. Encourage the patient to cough.

Simultaneous suction should enable secretions to be caught and removed as they pass the gradually deflating cuff.

To minimise the risk of cross infection and trauma.

Gradual deflation assists the patient to adjust to changes in airflow(12) and allows the patient to adapt to the feeling of being able to breathe through their nose and mouth again.

Coughing reduces the risk of aspiration.

Observe the patient for signs of increased respiratory distress.

Increased respiratory rate Desaturation Fatigue Cardiovascular Instability Failure to protect airway eg audible

gurgle. Stridor.

The patient is at risk of aspiration. These signs will provide early indication that the patient is unable to maintain their own airway.

Observe spontaneous swallow and the patient's ability to manage oral secretions.

Signs of Respiratory Distress

Any indication of respiratory distressfollowing cuff deflation

*re-inflate tracheostomy cuff immediately*(Follow cuff inflation guidelines page 18.)

Assess cuff pressure using a manometer (cuff inflation should not exceed 30 cmH2O).

Pressure exerted on the tracheal wall greater than 30 cmH2O may result in capillary occlusion, tissue necrosis and tracheal stenosis.(8)

Re-assess and observe the patient until stabilised. Suction as required Respiratory rate stable SpO2 stable Cardiovascularly stable No audible gurgle.

Consider following reasons for failed attempt:

51

Aspiration of oral secretions and compromised airway protection eg dysphagia.

Maintain cuff inflation Multidisciplinary assessment prior to further attempts of cuff deflation. Consider other types of tracheostomy tube. Consider referral for assessment for use of speaking valve (see page 61).

Severe weakness or neurological impairment.

Maintain cuff inflation. Consider other types of tracheostomy tube. Consider referral for assessment for use of speaking valve (see page 61).

Continuation of initial reason for tracheostomy.

Maintain cuff inflation Address initial problem Re-assess if patient meets requirements for further attempts of cuff deflation. Consider other types of tracheostomy tube. Consider referral for assessment for use of speaking valve (see page 61).

Upper airway oedema.

Maintain cuff inflation Allow oedema to resolve Re-assess if patient meets requirements to attempt further cuff deflation. Consider other types of tracheostomy tube. Consider referral for assessment for use of speaking valve (see page 61).

No Respiratory Distress

Action Rationale

If no signs of respiratory distress are noted, leave the cuff deflated.

Observe the patient for 24 hours ensuring they have a call bell within easy reach if appropriate.

Builds patient's confidence and ensures patient has coped well with cuff deflation.

Removal of the tracheostomy tube should be considered and planned by the multidisciplinary team and ideally performed within normal working hours.

The ultimate responsibility for this decision lies with medical staff.

To ensure adequate availability of medical, nursing and physiotherapy staff if the patient experiences difficulties post tracheostomy removal.

52

Action Rationale

Indications for tracheostomy removal include:

maintaining own airway tolerates full cuff deflation for more

than 24 hours adequate cough oxygen weaned to 40% or less(58)

CV stable SpO2 stable minimal secretion production.

A mini tracheostomy should be considered by the multidisciplinary team if:

reduced ability to clear secretions all other observations stable

A mini tracheostomy should only be considered if the patient is able to maintain their own airway and is not at risk of aspiration.

This will allow nursing staff and physiotherapists to aid clearance of patient's secretions.

Oxygen therapy must be administered via a face mask.

The patient is fully informed about the procedure.

Alleviates unnecessary anxiety.

Ensure that the essential equipment is at the bedside:

Refer to page 43.

Ensure the patient is sitting in an upright position.

To optimise lung expansion and facilitate swallowing. (10)

Wash hands and put on a disposable plastic apron, gloves and goggles.

Minimise cross infection.(11)

Release tracheostomy ties.

53

Action Rationale

With a sterile gloved hand, pass a connected suction catheter in to the tracheostomy tube 0.5 beyond the tip. The second person should then gently but firmly withdraw the tube in an outward and downward movement. Suction should be applied while the tube is removed.

The tracheostomy tube has to follow the anatomical formation of the track. Rapid jerking or pulling the tube upwards will cause trauma to the trachea and acute discomfort for the patient. Suction is applied to clear secretions and mucus as tube is withdrawn.

The tube may be slightly resistant and firm pressure may be required.

Monitor patient for signs of distress during the procedure.

Respiratory Rate Cyanosis Desaturation Cardiovascular Instability Failure to protect airway eg audible

gurgle. Stridor.

Once the tracheostomy tube is removed ensure the area is clean and dry. Note any inflammation etc at the stoma site. Clean if necessary with normal saline and gauze.

Apply a dry dressing (gauze) secured with an occlusive film dressing.

Sleek is no longer advocated as it is difficult to(a) ensure an effective seal(b) remove – causing blisters etc.(c) observe when there is soakage.

54

No Signs of Respiratory Distress Following Tracheostomy Removal

Observe the patient closely for 24 hours ensuring they have a call bell within easy reach if appropriate.

To detect any signs of deterioration in respiratory status and promote confidence in the patient.

Frequently review the dressings and change as necessary. Observe the stoma for signs of infection

To reduce the risk of pooled secretions that may delay wound healing and cause maceration increasing the risk of infection.

Keep the emergency tracheostomy equipment by the patient's bedside for 24 hours.

In the event of respiratory distress it may be necessary to facilitate rapid reinsertion of tracheostomy tube.

Signs of Respiratory Distress Following Tracheostomy Removal- this is a MEDICAL EMERGENCY

Attempts to replace tracheostomy tube should only be carried out by a competent and suitably trained person.

Dependent on ward area

Call 2000 and request an anaesthetist.

Competent and suitably trained person on ward.

This will ensure minimisation of trauma to the patient and maintenance of a controlled situation.

Use of emergency bedside equipment will be required (see page 43 for list).

Insert the sterile tracheal dilators and attempt to re-insert firstly the same tube. If unsuccessful try a smaller tracheostomy tube.

Stoma site may have shrunk in size not allowing replacement of original size tracheostomy.

If this fails follow the EMERGENCY ALGORITHM see Appendix III.

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BEDSIDE EVALUATION OF SWALLOWING, EATING AND DRINKING- to be performed by an appropriately trained nurse

56

Meets requirements for deflation of tracheostomy cuff

(see weaning guidelines)

Turn off NG or gastrostomy feeding

Deflate cuff (see weaning guidelines)

Observe for signs of respiratory distress (see weaning guidelines)

Administer Blue Dye Test(as per guidelines)

Monitor oxygen saturations

Suction via tracheostomy

Negative Testie no blue dye present on suction (as per guidelines)

Follow procedure for oral intake for patients who do not present with dysphagia (as per guidelines).

Positive Test(ie blue dye present)

Terminate test (as per guidelines)

Record secretions onblue dye trial sheet.

Reinflate cuff(see weaning guidelines)

Reinstate alternative feeding

Refer to Speech and Language Therapist for comprehensive evaluation of swallowing.

BEDSIDE EVALUATION OF SWALLOWING, EATING AND DRINKING

Not all patients with a tracheostomy will have a swallowing problem.(60)

The "gold standard" is feeding the patient with a deflated tracheostomy cuff. Feeding a patient with an inflated cuff is not recommended, however under special circumstances it is recognised that this may be necessary. The decision to feed the patient with an inflated cuff should be a multidisciplinary team decision.

Speech and language therapists are only involved in the assessment and management of tracheostomised patients who present with swallowing difficulties.

1. Screening Procedure for Swallowing Difficulties in Tracheostomised Patients(61)

Action Rationale

1. A senior nurse, who is trained in the Blue Dye Test procedure, will screen patient's swallowing ability where appropriate.

To ensure correct administration and interpretation of the Blue Dye Test.(61)

A Blue Dye Test should be carried out to help determine gross airway competence.

2. It is not usually recommended that patients eat with a fully inflated cuff and it is advisable that the tracheostomy cuff be deflated for all oral intake.(62)

The purpose of the tracheostomy cuff is to promote respiration not to stop aspiration.(12)

Laryngeal elevation is reduced by the anchoring effect of an inflated cuff. Normal clearing of the larynx by pulmonary air during swallowing is prevented by an inflated cuff.(12)

3. Before the cuff is deflated, senior medical staff agreement is necessary. This must be documented in the medical notes.

Aspiration risk should be avoided. Respiratory support processes will be affected by ventilated cuff deflation.

4. It is recommended that nasogastric/gastrostomy feeding be turned off one hour prior to cuff deflation and the swallow assessment.

This is to reduce the risk of vomiting and regurgitation and subsequent aspiration.

5. The patient should be sitting in an upright position either in bed or in a chair, the head flexed slightly towards the chest.

The patient is at increased risk of aspiration if in a semi-upright position with the neck extended.(63)

6. If not already in situ, attach Pulse Oximeter to monitor oxygen saturations.

A decrease in oxygen saturations may indicate aspiration.(64) (65)

7. Deflate cuff following "Deflating /Inflating a Cuff" Guidelines (page 16).

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Action Rationale

8. Follow the "The Blue Dye Test for Tracheostomised Patients" Appendix IV. If the test is positive, refer to the speech and language therapist. If negative, follow "Introduction of oral intake with Tracheostomised Patients who do not Present with Dysphagia" see below.

It is essential that the Blue Dye Test(66) (67)

results are taken along with other clinical indicators to ensure reliability.

2. Introduction of Oral Intake with Tracheostomised Patients who do not Present with Dysphagia

Action Rationale

Turn off nasogastric/gastrostomy feed one hour prior to feeding.

This is to reduce the risk of vomiting and regurgitation and subsequent aspiration.

The patient should be sitting in an upright position either in bed or on a chair, the head flexed slightly towards the chest.

The patient is at increased risk of aspiration if in a semi-upright position and the neck extended.(63)

Before cuff deflation, suction the oropharynx and through the tracheostomy tube.

Pooling of secretions may occur above an inflated cuff and these may enter the lungs following cuff deflation.

The cuff should be fully deflated for all oral intake, providing the patient's toleration of this has been agreed.

Pressure on the oesophagus can be a result of a fully inflated cuff. Refer to rationale for cuff deflation in "Screening Procedure" (part 1 above).(68)

The cuff MUST BE DEFLATED BEFORE a speaking valve is applied (refer to page 61, point 9).

Where a speaking valve is used, attach it to the tracheostomy tube. Refer to each patient's weaning plan to check toleration times for the speaking valve.

This will create optimum supraglottic airflow.(69)

Where the tracheostomy tube is fenestrated, ensure the inner cannula is also fenestrated if possible. If not, the inner cannula should be removed prior to attachment of the speaking valve.

The patient should be fed by a nurse. The nurse will be able to control bolus size and observe for signs of aspiration.

Cautiously introduce Stage 2 (puréed) diet (see Appendix VI) and thin fluids. Use a teaspoon for both consistencies.

Stage 2 (puréed) diet is considered the most manageable consistency for initial swallow trials.

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Action Rationale

Patient's voice quality and cough should be regularly checked by occluding the tracheostomy tube with a gloved finger and asking the patient to say "ah". If a speaking valve is in situ, similarly ask the patient to say "ah" or count to 5. If the voice quality is "wet" or "gurgly" then ask the patient to cough and to swallow again. Oral intake must then be discontinued and referral made to the speech and language therapist.

If voice quality is "wet" or "gurgly" then this may be indicative of aspiration.

If voice quality is clear then continue with swallow trial process.

Observe for the following signs during oral feeding trials: the patient’s condition deteriorates the patient fatigues if indicated by the patient’s respiratory status (eg signs of distress, increased respiratory

rate, decreased oxygen saturations) voice is consistently sounding wet persistent coughing is evident (in association with eating and drinking) there are signs of aspiration on tracheal suctioning.

Consider referral to the Speech and Language Therapy Department if these symptoms occur in relation to oral intake

3. When to Consider a Referral to the Speech and Language Therapy Department for a Swallowing Assessment

Referral would be appropriate for tracheostomised patients with:

(i) Neurological involvement eg bulbar involvement.

(ii) Head and neck surgery.

(iii) Evidence of aspiration of food/fluid/oral secretions on tracheal suctioning.

(iv) Persistent wet or weak voice when cuff is deflated and speaking valve or decannulation cap is in place.

(v) Evidence of blue dye on suctioning following a Blue Dye Test.

4. Nursing ManagementAction Rationale

Follow the recommendations of the speech and language therapist regarding swallow safety guidelines, such as patient positioning, swallow manœuvres and modified textures (Stage Diet). This must be recorded in the nursing kardex and medical records.

The patient may be at risk of aspiration of one or more consistencies.

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FEEDING

Most patients will initially be fed via a nasogastric tube. All patients must be referred to a dietitian for assessment and prescription of appropriate feed. Please refer to ward protocols for care of nasogastric feeds.

When patients are to progress to oral diet for the first time a blue dye screening assessment should be performed by nursing staff (see Bedside Evaluation of Swallowing, Eating and Drinking page 56). If the patient shows any signs of difficulty or if there are any concerns for the safety of the patient's swallow, then the patient should be referred to the speech and language therapist. Individual care plans will then be drawn up and documented in the nursing kardex.

The dietitian should be informed of patient's progress from tube feeding to oral diet so that advice on transitional feeding may be given. Patients following Stage 2 and Stage 3 diets are unlikely to meet their nutritional requirements without the intervention of a dietitian.

The following terminology was agreed by the Grampian Dysphagia Management Group (Appendix VI).

STAGING OF DIET

Stage1: Nothing to eat or drink.(nil orally) Administration of medications should be through an NG tube.

Swallow assessments should be ongoing.

Stage 2: Thick smooth consistencies only.(puréed diet) If not managing normal fluids then they can be thickened.

Order thick and creamy yoghurts, weetabix, etc from the menu card. Document Stage 2 on the menu card for lunch and supper. The patient should be sitting upright and be fed by the nurse. Medication should still be given via the NG tube yet can be crushed

and given in food also.

Stage 3: Soft food only.(soft diet) Order the soft option from the normal menu.

Order thick and creamy yoghurts for dessert with each meal. Again fluids may need to be thickened. Patients can this time feed themselves if able but should still have

close nursing supervision. Patients will probably be able to manage medication orally yet it may

still have to be crushed or syrup used.

Stage 4: Normal diet.(normal diet) Normal fluids.

Patient may still require supervision.

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COMMUNICATION

Points to consider:

1. Where appropriate before the tracheostomy procedure, the patient and relatives should be informed, that the patient may be unable to create a voice while the tracheostomy tube is in place. This is because as air is no longer passing through the vocal cords. They should be reassured that it is expected that the patient's voice will return once the tube is removed or manipulated (except when a laryngectomy has been performed). Alternative means of communication can be provided by the multidisciplinary team and an information sheet is available (see Appendix V).

2. For tracheostomised patients, the initial assessment should include a focus on the patient’s ability to see, hear, touch, write, understand or use facial expressions such as smiling and blinking.(70)

3. Some tracheostomy patients may only be able to communicate by mouthing words or by use of a predetermined coded blink.

4. If lip-reading is used, ask the patient to exaggerate their lip movements and to speak in short but complete sentences in order to make the message clearer.

5. Watch the patient’s facial expressions and gestures for clues and listen for key words, which may indicate what the patient is saying.

6. If a coded eye-blink is the only means of communication available, instruct the patient to blink once for "YES" and twice for "NO" in response to your questions.

7. Consider referral to the Speech and Language Therapy Department if individualised boards or communication aids are felt to be appropriate to meet the patient’s needs.

8. Electronic larynx and electronic communication aids may be appropriate. The speech and language therapist will assess the patient for the appropriate equipment and advise the patient and their carers on how to use them.

9. Where the patient can tolerate cuff deflation it may be appropriate, in consultation with the Multidisciplinary Team, to consider a one-way speaking valve. This is attached to the hub of the tracheostomy tube redirecting expired air through the larynx providing the potential to produce speech. Referrals to the Speech and Language Therapy Department for assessment of patient's suitability for a speaking valve should be considered. A speaking valve may have additional benefits in improving the patient's swallowing ability or in facilitating the weaning process.

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SUCTIONING CHART

All shaded areas have to be completed every time the patient is suctioned. Other areas are to be completed once per shift or if any change is made.

SURNAME: UNIT NO

FIRST NAME: Size and make of tracheostomy: ......................................................................................

ADDRESS:

SEX Initially inserted on: ......................................................................................

MARITAL STATUS

POST CODE: DOB Due changed: ......................................................................................

DATE

TIME

Position B - Back R - Right L - Left S - Sitting

SpO2 (if applicable)

Sputum (see below)

Saline Required

Respiratory Rate

FiO2

Humidification C-Cold H-Heated T-Thermovent

Sputum Specimen Obtained

Cuff I-Inflated D-Deflated

Cuff Pressure

Dressing Changed

Stoma Site S-Satisfactory R-Red I-Inflamed

Blue Dye Test Performed

Blue Dye Yielded on Suction

InitialsSputum: 1 - Scant 2 - Moderate 3 - Profuse M - Mucoid P - Purulent B - Blood

Comments:

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Appendix I

Appendix II

TRANSFER SHEET FOR PATIENTS WITH A TRACHEOSTOMY TUBE

Name Date of birthWard Hospital number

REASON FOR TRACHEOSTOMY

Pls tick

MAKE/TYPE OF TUBE IN SITU

Pls tick YES NO

Risk of aspiration Standard single lumen with cuff

Cuff inflated

Secretion clearance Tube with inner cannula Speaking valve

Maintenance of airway

Tracheostomy size Cuff pressure

Other (please indicate)

Mini tracheostomy Other

Date of and type of tracheostomy procedure performed......................................................................

Date of last tracheostomy change........................................................................................................

Date of next recommended change.....................................................................................................

Oxygen percentage requirement at time of transfer.............................................................................

Condition of stoma site.........................................................................................................................

Date sutures are to be removed ..........................................................................................................

TYPE OF HUMIDIFICATION Please tick/describe SUCTION REQUIREMENTS (REVIEW DAILY)

Cold water Size of suction catheterDry (thermovent) FrequencyRegular saline nebulisers Saline instillation required Yes / NoHumidity bibHeated circuit system

COMMENTSCuff Deflation Has cuff deflation been attempted?

Is the patient tolerating cuff deflation?Yes / NoYes / No

Swallow Ability Has a blue dye swallow assessment been carried out?Has the patient been referred to the Speech and Language Therapist?

Yes / No

Yes / NoDiet Nil by mouth

Type of dietYes / NoStage 1 / 2 / 3 / 4

General Information Including communication, effect of altered body image

Upon handing over to ward staff please complete the following:Signature Print name Date

Receiving NurseSignature Print name Date

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Appendix III

TRACHEOSTOMY EMERGENCY ALGORITHM

The following algorithms have been designed to guide practitioners when dealing with situations outside the critical care environment. Treat each situation individually. Always stay calm and reassure the patient throughout.

This is an urgent medical emergency

Tube Occlusion/DisplacementDoes the patient have any of the following that appear related to tracheostomy tube occlusion?

1 Difficult or laboured breathing.2 Use of accessory muscles.3 None or limited expired air from tracheostomy tube.4 Pale/cyanosed skin colour.5 Anxiety.6 Increased pulse and respiratory rate.7 Clamminess.8 Difficulty passing suction catheter.

Is there cessation of respiration?

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Yes

Call for medical assistance immediatelyReposition the patient in the semi-recumbent positionAsk the patient to cough or attempt to clear secretionsManipulate the head and neck on the tube to eliminate kinking or to allow tube reposition.Deflate the cuffAdminister O2 via face mask except for laryngectomy patientsIf this does not work then the tube will need to be changed immediately.

Continue normal tracheostomy care.No

No

Call 2000 and ask for anaesthetistLie patient flatEnsure the cuff is inflated and manually ventilate the patient using a catheter mount attached to an ambubag.If tube occluded deflate cuff and ventilate via a face mask.If the patient has some respiratory effort try to synchronise manual ventilation with the patient's own breath.Do not force O2 into the trachea as you may cause a pneumothorax

No further action taken.

Yes

Appendix IV

“BLUE DYE” SWALLOWING TEST FOR TRACHEOSTOMISED PATIENTS

Patient must be AWAKE and reasonably ALERT. They must be in an UPRIGHT position for assessment.

Patient’s Name: .................................... DOB: .......................... Unit/Chi No: .................

Locality: .................................................

As part of the screening process please consider the following (please circle)

Has the patient got a chest condition? YES NO

Please state .....................................

Has a swallow been observed? YES NO

Is the patient positioned correctly? YES NO

Can the patient follow instructions? YES NO

Is the patient alert enough? YES NO

Can the patient cough? YES NO

Has medical consent been given? YES NO

PLEASE DO NOT PROCEED WITH BLUE DYE SWALLOWING TEST OVERLEAF IF THE PATIENT IS NOT ALERT.

Following completion of screening procedure, please complete the section below.

SUMMARY

Passed Blue Dye screening procedure

Failed Blue Dye screening procedure

Referral to SLT made

Comments on any difficulty: .......................................................................................

....................................................................................................................................

....................................................................................................................................

Nurse's Name:.............................................. Signature:............................................

Designation:................................................. Date:...................................................

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Appendix IV

Patient must be AWAKE and reasonably ALERT. They must be in an UPRIGHT position for assessment.

SENIOR medical staff permission must be sought for trache cuff deflation. Has the patient tolerated periods of cuff deflation over last 24 hours?

If NO to any of the above - Assessment not indicated- Re-evaluate in 24 hours if appropriate

If YES to all of the above points – the following procedure should be administered:

a) Turn of NG/PEG feedb) Deflate cuff (refer to Deflating/Inflating Cuff Guidelines)c) Tracheal Suction

Use ½ cup of water with 23 drops blue dye in it. The following procedure should then be administered:

© Speech & Language Therapy Department 2005

66

Give the patient a teaspoon of blue dyed water watch for swallow observe for following risk signs

no swallow YES NO blue dye on suctioning YES NO significant decrease in O2 sat levels YES NO immediate or delayed coughing YES NO 15 mins interval, blue dye on suctioning YES NO

reinflate cuff nil orally discuss with medical

staff consider SLT referral

Leave cuff deflated Repeat above test with blue dye using

4 teaspoons water 3 x daily over 24 hours Observe for following risk signs

no swallowing YES NO blue dye on suctioning YES NO significant decrease in O2 sat levels YES NO immediate or delayed coughing YES NO 15 mins interval, blue dye on suctioning YES NO

reinflate cuff nil orally discuss with medical

staff consider SLT referral

If YES to any of the risk signs

If NO to all of these continue with screening

If NO to all of these

Follow procedure for oral intake for patients who do not present with dysphagia, as per Guidelines.

If YES to any of the risk signs

Appendix V

COMMUNICATING WITH A PATIENT WITH A TRACHEOSTOMY

Communication serves to meet many patient needs including “social interaction, information giving, reassurance, discussion of feelings, advice and counselling”.(71)

“The purpose of communication for critically ill patients is to help them maintain their identity as well as psychological, structural, personal and social integrity.”(71)

The psychological status of the patient must be considered as they may be unable to speak and will often be anxious in the hospital environment.

These points are intended for those patients who are unable to talk.

The patient has most of their day to day needs met however they may have questions or concerns. Following some of these ideas may help to structure communication opportunities.

Keep conversations short.

Share interesting information about family and friends.

While in the patient's presence, talk to the person – not about the person.

When talking pause frequently to give the person time to try to respond, this may be limited to eye movement or facial expression.

Can the patient indicate "yes" and "no" (for example, nodding and shaking head; one blink for "yes" and two for "no"; thumbs up/down)? Can they use a pen and paper?

If "yes" and "no" is established, please structure your questions to allow the patient to respond.

If using a communication aid eg alphabet board/picture board/lightwriter, you need to know the following:

Does the patient know how to use it?

Does the patient want to complete words/sentences or are they happy for you to predict what they say?

Are they using it appropriately?

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Grampian Dysphagia ManagementTexture Classification of SOLIDS

Stage Stage Name Description of texture Consistency to aim for

1 Nil Orally

2 Pureed Diet Food that has been pureed A thickened, smooth, uniform consistency A thickener eg natural (potatoes) or prescribed thickener may be

added to maintain stability of texture Must not separate into liquid and solid components during swallow It should be moist, not sticky Will hold its own shape on a plate and can be moulded, layered and

piped.

Mousse Smooth fromage frais Whipped cream Angel Delight

3 Soft Diet Dishes consisting of soft, moist, bite-sized pieces (1cm ½ inch) Suitable foods could be mashed with the flat edge of a fork Sandwiches are not allowed Avoid foods which pose a choking hazard

Dry and crispy: muesli, crisps, battered or breaded foods, hard confectionery

Sticky: white bread/rolls, peanut butter Stringy: gristle, fruit skins, shells of peas, beans and

sweetcorn.

Mince Moist Pasta

eg macaroni and cheese Flaked tuna in sauce Cauliflower cheese Mashed banana

4 Normal Diet No modification of texture is necessary Some foods may be restricted.

Note: Medication – discuss with Pharmacist GUHT/GPCT – July 2001

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Appendix VI

Grampian Dysphagia ManagementTexture Classification of LIQUIDS

Name Description of texture Consistency to aim for

Normal Fluids A thickener is not required A straw falls freely through the liquid Can be drunk or sipped from a cup and easily taken through a

drinking straw.

Water Tea Coffee Milk

Thickened FluidsSingle Cream Consistency

A thickener may be required A straw will move easily through the liquid Can be sipped from a cup or through a drinking straw.

Single cream Fortified drinks as prescribed by Dietitian

Thickened FluidsYoghurt Consistency

A thickener must be added A straw will stand on its own in this liquid Difficult to sip from a cup, may require a spoon.

Yoghurt

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Note: Medication – discuss with Pharmacist GUHT/GPCT – July 2001

71

ABBREVIATION LIST

ENT - Ear, Nose and Throat

mmHg - millimeters of mercury

cmH2O - centimetres of water

NG - nasogastric

SpO2 - extend to which haemoglobin in arterial blood is saturated with oxygen when measured with a pulse oximeter.

kPa - kilopascal

CSMU - Closed System Multiple Use

FG - French Gauge

NaCl - Sodium Chloride

ECG - Electrocardiogram

COPD - Chronic Obstructive Pulmonary Disease

FiO2 - Fraction of inspired oxygen

PEEP - Positive end expiratory pressure

ICP - Intracranial pressure

PaO2 - partial pressure of oxygen dissolved in plasma of arterial blood

CPAP - Continuous positive airway pressure

PEG - Percutaneous Endoscopic Gastrostomy

HME - Heat Moisture Exchange

IV - intravenous

CV - Cardiovascular

MDT - Multidisciplinary Team

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