TRACHEOSTOMY CARE
Rosie Ratcliffe (Previous Macmillan Head and Neck Clinical Nurse Specialist)
Amended 2012
Aims
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To provide basis awareness of caring for patients
with tracheostomy tubes
To understand the safety implications when dealing
with tracheostomies
To understand complications and emergency
procedures with tracheostomy tubes
What is a Tracheostomy?
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A tracheostomy is a surgical procedure that is usually
performed under a GA or LA (tracheotomy). It is an
incision into the trachea (windpipe) that forms a
temporary or permanent opening called a stoma
A tube is inserted through the opening to facilitate
breathing, protection from aspiration in cases of
swallowing impairment and facilitate clearance of
secretions
Reasons for a Tracheostomy
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Airway obstruction e.g. Upper airway tumours
Lower airways toilet
Neurological disease e.g. MND
Vocal Cord Paralysis
Laryngeal injury or spasms
Severe neck / mouth injuries
Airway burns from inhalation smoke/steam
Anaphylaxis
Types of Tracheostomy Tubes
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Double lumen tubes – consist of inner and outer tubes
to aid clearance of secretions without changing the
complete tube. Tracoetwist, Tracoecomfort, Shilleys
Fenestrated tubes – these are double lumen with
holes built into the shaft to allow air to flow through
the vocal cords to facilitate speaking
Both these tubes come either non-cuffed or cuffed
Cuffed tubes - low pressure air filled cuff at the distal
end of the tube allows sealing of the airway used to
prevent aspiration and facilitate ventilation
Cuffed tubes
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Seal the airway to facilitate the delivery of positive
ventilation
Prevent airflow through larynx
Protect the airway
Prevent risk of aspiration
External pilot balloons which indicate when the cuff is
inflated or deflated
The cuff may impair swallowing due to pressure on
the oesophagus
Un-cuffed tubes
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Maintain airway patency
Do not protect from aspiration
Enable voice around the tube
May be used to wean
Used for long term tracheostomy patients
Not commonly seen in the acute setting
Cuff pressures
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Cuff pressure should be maintained between 15 –
22mmHg
Check pressure by using manometers – every shift,
minimum of twice in 24 hours
Minimal occlusion pressures / minimal leak
texhnique (auscultation around suprasternal notch)
not recommended due to risk of silent aspiration
Voice
Syringe
Common complications
Tracheostomy complications are usually divided into
3 categories
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Intra-operative
Early post-operative
Late post-operative
Intra-operative
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Bleeding
Tube malpostion
Tracheal / trache-oesophageal laceration
Recurrent laryngeal nerve damage
Pneumothorax
Early post-operative
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Bleeding
Tube blockage
Infection
Subcutaneous surgical emphysema
Tube malpostion
Displacement
Late post-operative
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Granuloma (growth of inflammatory tissue caused
by irritation)
Tracheal stenosis (abnormal narrowing of trachea
e.g. from tracheal tumour)
Tracheomalacia (flaccidity of tracheal cartilage
causing tracheal collapse e.g. from fistula)
Trachoesophageal fistula
Mucosal ulceration
Main life-threatening complications and
their management - Bleeding
Bleeding – this is the most common complication of a
tracheostomy. It may occur early or late.
 Minor- settles with conservative management
 Major- requiring blood transfusion, surgical
exploration / other intervention
 Management depends on the context in which the
bleeding occurs
 Palliative management: Dark green towels, crisis
medication, psychological support, suction, external
pressure to bleeding site, communication to patient
/ family debated. Priority - STAY WITH PATIENT
Tube blockage
Tracheostomy tubes can become blocked with thick
tracheal secretions, blood or foreign bodies.
Presentation may be increasing respiratory distress
over a few hours or more rapid deterioration
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This can be LIFE THREATENING if not rapidly
resolved
Prevention - adequate humidification, regular inner
tube changes, suction
Displaced trachesotomy tubes
Tubes can become displaced through a loose or
inadequately positioned neck tape, excessive
movement of the patient, patient agitation or pulling
of equipment that is attached to the tracheostomy
tube. A dislodged tube is more dangerous than a
completely removed tube
Prevention - regular checks of neck tape, ensure
equipment is attached safely, manage agitation,
regular observation of patient.
Suctioning
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Suctioning can be both uncomfortable and
distressing for the patient, therefore where possible
patients should be encouraged to expectorate their
own secretions
Patients individual needs need to be assessed
frequently
Indications for suctioning - unable to expectorate,
blockage in tracheostomy tube
Suctioning Complications
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Hypoxia
Bradycardia
Tracheal mucosal damage
Bleeding
Infection
Types of humidification
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Heat and Moisture Exchanger (HME)
Thermovent –T, Inter-surgical HME common in acute
settings
Trachi-naze filters, Buchanan bibs common in long
term settings
Water humidifiers - Fischer-Paykel (heated)
Respiflow (cool)
Saline nebulisers
Trachi-spray
NORMAL MECHANISM OF
HUMIDIFICATION
20°C
50%
34°C
75%
Temp 37°C, Rel. Humidity 100%
5cm below carina
Tube changes
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Tracheostomy tubes should be changed every 28
days as per the European Economic Community
Directive (1993)
The first tube change should be carried out by a
medical practitioner with appropriate, advanced
airway skills
Health professionals who have undergone training
and confident / competent
INDICATIONS FOR CHANGING
TRACHEOSTOMY TUBE:
Elective:
Monthly
 Assess stoma/ trachea and granulation tissue at stoma site and / or
fenestration
 Facilitate weaning
 Speech production
 Patient comfort
Emergency
 Blocked tube
 Misplaced or displaced tube
 Cuff failure
 Faulty tube
 Aspiration
 Hypoxia
 Anxiety/Discomfort
Stoma care
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Review stoma each shift
Assess stoma
Clean with NaCl and dry carefully
Use barrier cream to protect skin
Apply trachi dressing under tube
Change neck tapes at least weekly
Ensure neck tapes are secure allow 2 fingers to fit
between the tapes and neck
Communication
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The impact of the loss of normal voice following a
tracheostomy should not be under estimated
Loss of voice occurs because no air is passing over
the vocal cords
Communication facilitates- expression of feeling,
reassurance, patients needs, advice, counselling,
social interaction, information giving
Alternative methods of Communication
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Non-verbal
Lip reading
Coded eye blinking
Hand gestures
Alphabet board / Picture borad
Light writer
Cuff deflation / fenestrated tubes
Intermittent finger occlusion
Speaking valves
SPEECH
Teaching patient to live with Tracheostomy
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Need lots of reassurance and advice
Involve patient in stoma care from an early stage,
changing inner tube frequently
Involve SALT with swallowing and speaking
Show patient how to clean around stoma and
encourage this on a daily basis
Advice re: looking after skin around stoma site
Altered body image
TROUBLE SHOOTER
deflation
Leak due to deflation cuff.
Partial withdrawal
Ulceration into oesophagus
Leak due to deflation and surgical emphysema
Obstruction due to herniation of cuff over end of tube.
Obstruction due to kinking
Misplacement into pre-tracheal tissues.
Blockage by secretions
Dilation of trachea by over inflated cuff.
Summary
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Each shift always check the tracheostomy tube is
patent
Know what type / size of tube is in place
Know patients normal observations if appropriate
Know if the cuff is inflated / deflated
Know emergency procedures
Refer to protocol
Always know the patients resuscitation status
Any questions?