TRACHEOSTOMY GUIDELINES
This is a guide you may find useful if you have a patient admitted to your ward with a Tracheostomy.
Compiled by Sue Casey Head and Neck Clinical Nurse Specialist, Bradford NHS Trust
May 2002
For Review May 2003
1. Why has the tube been put in?
Tracheostomy tubes are put in patients for many and varied reasons. The patient may require one following surgery of any sort. If patients have to be intubated for some time in intensive care to lessen the dead space, and ease of care.
Patients following CVA and have breathing and or swallowing difficulties, and others who have problems with degenerative diseases or have been born with congenital problems requiring a tracheostomy tube. Find out why your patient has a tracheostomy tube.
2. What type of trachea stoma was made?
This relates to how the initial incision was made. Is it a Percutaneous tracheostomy?
(Often performed in Intensive care units where a small hole is made into the Trachea below the Vocal Cords, and then the hole is stretched up to the required size).
Or is it a Surgical incision where an actual cut has been made and a window fashioned to the Trachea.
You can tell just by the explanation of each type, that the percutaneous stoma may be at risk from closure if you remove the tube and don’t replace it. Find out which type your patient has.
3. When was the Tube put in?
Patients can be transferred from other units or hospitals, many times the accompanying letter tells you everything, but the most important, How long has this present tube been in? Has it ever been changed?
You need to be aware of these factors, as some tubes require changing within 2weeks, some can stay in up to 28days.
The Marsden Manual page 566 tells us a doctor or a trained nurse who has been instructed in this procedure should only change Tracheostomy tubes. However if the tube has never been changed it is advisable for a doctor to do the first change to ensure the tract has properly formed. Find out if the tube has been changed.
4. What type of tube is in situ?
There are many different types of tube your patient may have in situ and depending on the reason for the tube, the tube may need to be changed to a different type throughout their care and depending on their progress.
Most patient’s start with a cuffed tube, the cuff is there to form a seal to prevent secretions passing into the Lungs. Also the cuff may be required to prevent aspiration of food and/or drink. This cuff is around the base of the tube and is inside the patients Trachea; it is filled with air the pressure of which should be measured, some types of tubes are set at 25mm pressure this prevents necrosis from the pressure of the tube on the mucosal lining of the Trachea. You can tell the tube has a cuff as there is a tube with a small balloon on the outside where you can see if the cuff is inflated if the balloon is up.
Some other types of tube may be in situ and you will be able to find out which by referring to your patients notes and the Trust policy or the Marsden Manual. Find out what type of tube your patient has and why.
5. Is the tube Fenestrated?
Some tubes have a hole or series of small holes on the upper aspect of the inner length of the tube. This enables the expired air to pass both through the tube and also through the normal airway. This type of tube is often put in place to prepare the patient for closure of the trachea stoma, but sometimes if a patient requires a long term cuffed tube they may have a fenestrated-cuffed tube in, to enable them to talk. Find out what a fenestrated tube looks like, would your patient benefit from having a fenestrated tube?
6. Has the tube got inner cannula?
Some tracheostomy tubes have a main tube and one or more inner tubes, these are to help in keeping the main tube patent. Some inner tubes have connector ends enabling T Tubes, valves, Heat moisture exchangers and other equipment to be attached. Some tubes have disposable inner – tubes, others require cleaning and changing regularly. Find out if your patient’s tube has an inner cannula.
7. Can the patient speak?
A patient with a clear, patent, well positioned, tracheostomy tube should be unable to speak as the expired air is released through the tracheostomy below the vocal cords. If the patient is speaking the tube may be blocked with secretions and the tube may require changing or the inner – cannula may need cleaning.
Patient’s can be taught to speak using the finger occlusion method, as long as there is no cuff on the tube or there is a fenestration. The patient will be asked to breath – in and then put a finger over the end of their tube, air will pass around the tube and or through a fenestration to the vocal cords and the patient will be able to phonate. If the patient has an inner tube with a speech valve either attached or included in it’s structure, then when the patient breathes in the valve will open, and on breathing out the valve will close and the air will again pass up to the vocal cords and phonation should be possible (This relies on the patients vocal cords and surrounding structures working as normal). Check if your patient has the ability to speak.
8. Is the tube for long or short - term use?
Some patients may only require a tube for a few days following surgery, or for a few weeks following an exacerbation of a chronic condition. If this is the case the tube may not require changing and may be removed when the medical staff instruct.
There are some patients who will require a tracheostomy long – term and possibly for the rest of their lives. Special tubes may then be needed, for long – term use and cost effectiveness. Patient choice and comfort must also be ascertained, and full information of choice should be available for the patient, with reasons for the doctor’s choice given. The continued spiralling cost of some tubes may become an issue if the patient is discharged home with the tube in situ. Who is going to pay? Find out the short or long term prospects for your patients reliance on the tracheostomy tube.
9. Are the Physiotherapist’s aware?
All patients with a tracheostomy should be referred to the Physiotherapy chest team. This may be only for one post surgical visit, but it is important that the patient is checked and that the tube is working correctly and the patient is managing. If the patient has been referred from another unit or Hospital, the Physiotherapy team in your area should be informed. Ensure the Physiotherapist is aware of your patient.
10. Is the Speech and Language Therapist aware?
The Speech and Language Therapist should be made aware of your patient, especially if the tube is long – term or has a cuff inflated. They can offer expert advice on swallowing problem, aspiration and also changes in speech, giving support to the patient when they may feel frustrated at all the problems the tube may have added to their overall condition. Remember to inform the Speech and Language Therapist.
11. What equipment do I need?
It is important that you have the correct equipment in place before the patient arrives on your ward: -
· Suction
· Correct size suction catheters (see chart)
· Humidification / Theramist / Swedish Nose HME
· Elephant tubing
· Tracheostomy mask
· Tracheostomy dressings
· Sterile or clean pair of gloves
· Tracheostomy Dilator / Artery Forceps
· Smaller tracheostomy tube (for sizes see chart)
· Same size tracheostomy tube
· 10ml Syringe
· Container / Kidney dish
· Barrier cream
· Hydrogen Peroxide
Check all the equipment at the bedside prior to the patient’s admission.
12. How do I clean the tubes?
For cleaning of the Inner – cannula, remove the inner – cannula and replace with another to ensure continued patency of the tracheostomy main tube.
Rinse the tube with sterile saline 0.9% or water, for non – disposable, inner – cannula it is recommended that “to loosen dried or encrusted secretions, pour Hydrogen Peroxide 0.5% or warm soapy water through the tube. Do not soak. Rinse the inner – cannula thoroughly with normal saline 0.9% to remove all traces of the cleaning fluid prior to re insertion (Malinckrodt Medical 1999). Store tube dry, in a clean, dry container until required.
Some patients may be admitted from home with a Negus (Metal) tracheostomy, the inner – cannula can be cleaned in the same way as the plastic tubes. Silver polish can be used on the spare set prior to sterilising at the central sterilising department, Metal tubes are made individually and the inner cannula should not be used on any other tube even if it’s the same size. Ensure all staff aware of the cleaning procedures.
13. How do we decannulate?
When the multidisciplinary team caring for the patient decide to remove the tracheostomy, care must be given to prepare the patient.
If the tracheostomy has only been in place for post – surgical protection of the airway the tube can be removed and the stoma cleaned and a clean air - tight dressing applied.
However for closure of a tracheostomy that has been in situ for some time it is advisable to trial the patient first.
Plan: -
1. Explain to the patient what you are going to do.
2. Ensure patient in upright position well supported by pillows.
3. Perform suction of the Oropharynx and Trachea
4. Deflate the cuff and suction
5. You may wish to change to a smaller plain tube at this time.
6. Try finger occlusion to check airflow.
7. Attach the patient to an O2 Saturation Monitor
8. Place decannulation plug on tube, block off end of tube
9. Record O2 levels over next 2 hours
10. If O2 Levels satisfactory the tube may be removed.
11. Use universal precautions at all times clean the stoma.
12. Apply a dry dressing and an occlusive film dressing.
13. Continue to monitor the patient for respiratory distress.
14. Check the dressing and change as required.
These guidelines may alter check your Hospitals Policy
14. Who do we call for Assistance?
Never be afraid to ask for help or instruction, tracheostomy patients are in some places very uncommon, so you may not have cared for one before. There are many people who can help: -
1. Anaesthetist
2. ICU Staff
3. Physiotherapist
4. Ear Nose and throat Nurses and medical staff
5. Stoma care nurses
6. Infection Control Nurses
7. Speech and Language Therapist
8. The Patient (They may have had the tracheostomy for years)
Contact Ward 18 Bradford Royal Infirmary on ext 4396. A senior Nurse will come to your unit to give advice and assess the patient’s needs.
Tube Sizes
Metric Sizes FG Sizes
3.0 -----------------------------------13.5
3.5 ----------------------------------- 15
4.0 ----------------------------------- 17
4.5 ----------------------------------- 18
5.0 ----------------------------------- 21
6.0 ----------------------------------- 24
7.0 ----------------------------------- 27
7.5 ----------------------------------- 30
8.0 ----------------------------------- 33
9.0 ----------------------------------- 36
10.0---------------------------------- 30/42
Correct
Suction Catheter to Tube size
Tracheostomy Tube Suction Catheter
ID (FG) FG (ED)
10 38 14 4.5
9 35 14 4.5
8 30 12 4
7 27 10 3.3
6 23 10 3.3
5 19 8 2.6
4 16 6 2
3 14 5 1.6
Key: ID = Inner diameter
ED = Eternal diameter
FG = French Gauge