Tracheostomy care on the wards
Version
4
Name of responsible (ratifying) committee
CHAT G&Q Committee
Date ratified
08/01/2015
Document Manager (job title)
Dr Sara Blakeley (Consultant ICU)
Sr Sue Moorse (Lead nurse outreach)
Matthew Quint (Physiotherapy Clinical Specialist)
Fiona Buck (Specialist Speech Therapist)
Mr Jonathan Buckland (Consultant ENT)
Date issued
26 January 2015
Review date
25 January 2016
Electronic location
http://pht/Departments/CriticalCare/tracheostomy%20su
pport%20team/The%20Tracheostomy%20Support%20T
eam/default.aspx
Related Procedural Documents
Ward tracheostomy daily care chart
Essential bedside equipment checklist
Tracheostomy educational handbook
Key Words (to aid with searching)
Tracheostomy
Version Tracking
Version
Date Ratified
Brief Summary of Changes
Author
2
01/11/2013
Inclusion of tracheostomy red flags and bedhead signs
Dr Sara Blakeley Consultant Critical Care
4
08/01/2014
Modification of audit targets
Dr Sara Blakeley Consultant Critical Care
Tracheostomy care on the wards: Version 4
Issue date: 26/01/2015
Review date: 25/01/2016 (unless requirements change)
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CONTENTS
QUICK REFERENCE GUIDE....................................................................................................... 3
1. INTRODUCTION.......................................................................................................................... 5
2. PURPOSE ................................................................................................................................... 5
3. SCOPE ........................................................................................................................................ 6
4. DEFINITIONS .............................................................................................................................. 6
5. DUTIES AND RESPONSIBILITIES .............................................................................................. 6
6. PROCESS ................................................................................................................................... 6
7. TRAINING REQUIREMENTS .................................................................................................... 24
8. REFERENCES AND ASSOCIATED DOCUMENTATION .......................................................... 24
9. EQUALITY IMPACT STATEMENT ............................................................................................ 24
10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS ........................................ 25
Tracheostomy care on the wards: Version 4
Issue date: 26/01/2015
Review date: 25/01/2016 (unless requirements change)
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QUICK REFERENCE GUIDE
Flow chart for review of patients with a tracheostomy on the wards
Patient admitted to ward* with tracheostomy in place
Have they been discharged from the ICU?
Yes
No
Patient will automatically be
reviewed by Outreach
Ensure Outreach is aware of
patient’s admission (Bleep 1676)
For all patients:
•
•
•
Follow trust policy ‘Tracheostomy care on the wards’. This policy refers to
temporary tracheostomies but can be used for permanent tracheostomies
All patients will be reviewed at least weekly by the Tracheostomy Support
Team#. Outreach will provide extra support where needed
Day to day care of the patient is the responsibility of the patients own
medical/surgical team
Notes:
* Excludes patients admitted to the Head & Neck Unit unless Tracheostomy Support Team or
Outreach input is specifically requested. The Head and Neck unit will follow departmental
guidelines with regards to the care of tracheostomy patients
# Tracheostomy Support Team – Medical led multidisciplinary team review of patients with
reference to care and management of the tracheostomy
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Summary of daily tracheostomy care
Note: One shift = One 8 hour period
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1. INTRODUCTION
Patients who require tracheostomies are generally managed on the head and neck unit or the Intensive
Care Unit (ICU) by the respective specialist teams. Some patients however may be discharged from the
ICU with a tracheostomy still in place and therefore will need to be managed on a general ward with
specialist input. The tracheostomy will be reviewed at least weekly by the Tracheostomy Support Team
(TST) and as needed by ICU outreach, however daily nursing care of the tracheostomy will be provided
by ward staff.
The tracheostomy may still be needed for airway protection in the case of neurological conditions
leading to a reduced level of consciousness or the inability to protect the airway (e.g. stroke, head
injury). The tracheostomy may also be needed to aid secretion clearance in patients who have an
ineffective cough due to muscular weakness (e.g. prolonged ICU stay) or an underlying neurological
condition (e.g. multiple sclerosis). Patients who have a tracheostomy for an upper airway obstruction
will mostly be managed on the specialist head and neck unit.
Most of the tracheostomies placed on the ICU are temporary, and may stay in for a couple of days up to
a few months. Occasionally some patients require a long term tracheostomy. While the tracheostomy
is in place it needs to be cared for to maintain the patency of the tube, to prevent infections and to
prevent or manage complications associated with a tracheostomy. In the case of temporary
tracheostomies there will be ongoing assessment as to when the tracheostomy can be removed, a
process called decannulation.
The elements of care associated with a tracheostomy together form a care bundle and fall under the
following headings.
1. Assessment of patient
2. Maintenance of the tracheostomy and stoma
a. Humidification to prevent secretions blocking the tracheostomy
b. Regular cleaning and inspection of inner tube to prevent narrowing and blockage
c. Regular suctioning to prevent secretion build up
d. Change of tracheostomy dressing and attention to tracheostomy tapes/ties
3. Infection control
a. Correct method of suctioning to avoid introduction of infection
b. Regular assessment of tracheostomy stoma
c. Regular assessment of respiratory secretions
4. Safety
a. Check list of essential bedside equipment
b. Bedside emergency algorithms with key contact numbers
c. Use of bedhead signs containing key information regarding the tracheostomy for use in an
emergency
2. PURPOSE
This document has been developed to:

Guide all staff in the care of adult patients with temporary tracheostomies within Portsmouth
Hospitals Trust.
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


To provide best available local/national evidence for the management of temporary
tracheostomies.
To help reduce potential complications associated with tracheostomies.
To provide clear guidance in who to contact in the event of an emergency.
3. SCOPE
This guideline applies to all patients within Portsmouth Hospitals Trust who have a tracheostomy in
place, excluding patients on the Intensive Care Unit. For patients on the head and neck unit who have a
surgical tracheostomy placed as part of their treatment, the document may be used along side
departmental guidelines. It is predominately aimed at patients with temporary tracheostomies, but can
be applied to patients who are admitted who have long term tracheostomies.
This guideline does not apply to paediatric patients with tracheostomies.
4. DEFINITIONS
Tracheostomy: A tube placed through an incision at the base of the neck into the trachea.
Airway: This refers to the structures that air passes through leading from the nose and mouth down to
the lungs.
Patent airway: An airway that allows free flow of air down to the lungs, and allows expelled air to pass
from the lungs back out again is called a patent airway.
Obstructed airway: This is an airway where there is complete or partial obstruction to the free flow of
air. This could be due to a blockage (e.g. tumour, swelling) or due to reduced muscular tone leading to
the collapse structures.
Protected airway: This is an airway where reflexes are in place to prevent fluid (e.g. stomach contents,
drink) going into the lungs. An airway can be patent yet not protected.
Tracheostomy support team: This is a multi disciplinary team who will review at least once a week, all
in patients who have a tracheostomy in place. They will guide the management and care of the
tracheostomy till the tracheostomy is either removed, or the patient is discharged with the
tracheostomy. Contact is made via the Critical Care outreach team.
5. DUTIES AND RESPONSIBILITIES
The authors and Tracheostomy Support Team
6. PROCESS – see following
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1. ASSESSMENT OF PATIENT
As part of patient assessment at the start of each shift, the tracheostomy should be specifically discussed and
important points communicated.
When taking over the care of a patient with a tracheostomy: Think TRACHE
When was it inserted?
What type of trache? (e.g. size, adjustable flange)
Why do they have a tracheostomy?
e.g. stroke, head injury, long ICU stay
Airway secretions - what are they like?
How often do they need suctioning?
Is there a cuff, is it inflated or deflated?
Do I know who to call for help?
Is the bedside safety equipment all checked?
Is the bedhead sign in place?
Am I familiar with the emergency algorithms?
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2. MAINTENANCE OF TRACHEOSTOMY AND STOMA
A. Humidification
Inadequate humidification may lead to life-threatening blockage of the tracheostomy tube
Self ventilating patient requiring oxygen therapy
Action
Rationale
All patients require regular physiotherapy and should be
encouraged to cough
To aid removal of secretions
Ensure inspired oxygen is humidified
To moisten inspired gases.
Indications for cold water humidification:
 Minimal/loose secretions
To ensure adequate humidification.
Indications for warm water humidification:
 Thick/dry secretions
 Difficult to clear secretions
 Evidence of consolidation
Warm water carries a greater relative
humidity
Check water supply 2 hourly
If secretions remain problematic consider nebulized saline
To aid removal of secretions
Review daily the degree of humidification needed
To reduce unnecessary interventions and to
assess whether present level of
humidification adequate
Self ventilating patient not requiring oxygen therapy
Action
Rationale
All patients require regular physiotherapy and should be
encouraged to cough
To aid removal of secretions
For all patients with minimal or no secretions use an HME
such as a Swedish nose
Replace HME every 24 hours or more frequently if
contaminated by secretions.
To moisten inspired gases by trapping and
rebreathing humidity, to prevent inhalation
of particulate matter.
HME filter may not be needed in certain clinical situations
(e.g. while speaking valve in place).
To maintain effectiveness and reduce
infection risk.
For patients with thick/dry secretions, difficult to clear
secretions or evidence of consolidation For patients with
thick/dry secretions, consider nebulised saline or a change
back to humidified oxygen
To loosen and thin secretions, to prevent
atelectasis and sputum thickening.
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To highlight problem and introduce an early
intervention where required. To assess if
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Review daily.
adequate humidification.
This can be shown as a ‘humidification ladder’ with a stepwise increase, or degree in the intensity of
humidification depending on the clinical situation.
No oxygen
Active humidification
(discuss with outreach)
Specific mucolytics
(seek specialist advice)
Saline nebulisers: 5-10mls 0.9% saline
Start prn, increase to 2 hourly as needed
Saline nebulisers: 5-10mls 0.9% saline
Start prn, increase to 2 hourly as
needed
Encourage coughing
Regular physiotherapy
Swedish Nose (if tolerated)
Oxygen
For all patients: Encourage coughing and regular physiotherapy
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B. Care of inner cannula
The inner cannula must be removed, inspected and cleaned at least 4 hourly to prevent narrowing
and blockage.
Action
Rationale
Explain procedure to patient
To gain verbal consent, co-operation and
reassure the patient
Apply oxygen while preparing equipment, monitor
saturations if required.
To prevent hypoxia
Oxygen should be prescribed as per trust policy.
Target saturation as directed by medical team.
Screen bed space and prepare all equipment prior to
commencing procedure.
Position patient with neck slightly extended.
To provide privacy and reduce
interruptions.
To provide patient comfort and ease
procedure.
Wash and dry hands, don apron, gloves and goggles
To reduce cross infection.
With one hand stabilize the actual tracheostomy tube and
with the other hand remove the inner cannula and insert
clean inner cannula
To maintain airway, prevent early build up
of secretions and to maintain
oxygenation.
Ensure that the clean inner cannula is locked in position
Clean inner cannula with sterile water/saline, use cleaning
brush if heavily soiled
To reduce infection risk
Cannula should not be left to soak in
water as it is an infection risk
Dry and store in a dry clean container
If very heavily soiled then dispose of an place a new inner
cannula at the bedside
Document procedure on tracheostomy care chart
Tracheostomy care on the wards: Version 4
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Review date: 25/01/2016 (unless requirements change)
To facilitate communication and
evaluation.
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C. Suctioning
Any difficulty in passing the suction catheter should lead to consideration that the tube may be
partially blocked or misplaced and requires immediate attention.
Note: If the patient is able to cough secretions to the opening of the tracheostomy then a Yankeur sucker can
be used to suction the secretions from the opening rather than perform a deep suction
Pre procedure
Action
Rationale
Explain the procedure to the patient.
To obtain consent, co-operation and
reassure the patient
Wash hands and don apron, gloves and goggles.
To reduce the risk of cross infection.
Apply oxygen while preparing equipment, monitor
saturations if required. Oxygen should be prescribed as
per trust policy. Target saturation as directed by medical
team.
To prevent hypoxia
Where possible sit patient upright with head in neutral
alignment.
To provide patient comfort and ease
procedure.
Ensure correct suction catheter size and correct suction
pressure is used. Suction pressure on circuit occlusion
should not exceed -150mmHg (20 kPa pressure)
Too great a suction pressure can cause
prevent mucosal trauma, hypoxaemia and
atelectasis
Suctioning should be performed with the inner cannula in
place.
If a fenestrated tube is being used ensure a nonfenestrated inner tube is in place
This prevents the suction catheter from
damaging the mucosa by passing through
the fenestrations.
Put a sterile disposable glove on the dominant hand
(double glove)
To reduce cross infection.
Observe the patient throughout the period to ensure no
adverse effects
Tracheal suction may cause vagal
stimulation (leading to bradycardia),
hypoxia and stimulate bronchospasm
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Sequence of events
1. Insert suction catheter without applying suction until approximately 1/3 of the catheter is in situ or
until the patient coughs
2. Withdraw the catheter 0.5-1cm and apply suction by occluding the suction port with gloved thumb
3. Continue withdrawing the catheter applying continuous suction until it is removed from the
tracheostomy tube
4. The entire process should not exceed 10 seconds
5. Remove the glove from the dominant hand by inverting over the used catheter and dispose of in a
clinical waste bag
6. Reattach oxygen within 10 seconds
7. If another suction is needed a new sterile catheter and sterile glove must be used
8. Do not do more than 3 episodes of suctioning in succession
9. If oxygen was increased prior to suctioning then return to previous levels
10. Flush through the connection tubing with clean water and wash hands after
11. Record procedure and secretions on tracheostomy care chart
If the suction catheter will not pass easily





Do not force it
Withdraw and ensure the patient’s head is in alignment
If the catheter will still not pass check inner tube for blockages
If the catheter will still not pass call for senior assistance
If tube occluded and patient in respiratory distress call 2222 and follow the emergency algorithm
If blood noted on suctioning
 Ensure oxygen applied, check observations, call for senior assistance
 If patient in respiratory distress or haemodynamically unstable call 2222 and follow the emergency
algorithm
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D. Tracheostomy dressing and ties
This is a two person procedure which needs to be performed at least once per 24 hour
period. The tracheostomy should be adequately secured to prevent displacement.
Action
Rationale
Explain procedure to patient.
To gain verbal consent, co-operation and
reassure patient.
Screen bed space, prepare all equipment prior to
commencing procedure on sterile dressing trolley and
position patient with neck slightly extended.
To provide privacy and reduce
interruptions.
To provide patient comfort and ease
procedure.
Wash and dry hands, don apron, clean gloves and goggles.
To reduce the risk of cross infection.
One practitioner should hold the tube and oxygen (if
required) while the other removes tapes and dressing and
discards dirty gloves.
To reduce the risk of dislodgement.
Assess tracheostomy site for signs of trauma, infection or
maceration
Take a swab if there are clinical signs of infection
 Purulent discharge
 Pain
 Odour
 Abscess formation
 Cellulitis and discolouration
Observe the back of the neck for signs of redness/soreness
from tapes.
To take further action if required.
Gently clean around stoma using sterile gauze squares
soaked in saline and then pat dry
Apply new tracheostomy dressing starting from below the
stoma with shiny side to skin.
To remove debris while not causing
irritation.
To protect area around stoma.
Secure in place with tracheostomy tapes/holder.
Not too tightly - 2 fingers should be a comfortable fit
between the tapes and patients neck
For patient comfort and to prevent
migration of the tube.
Dispose of all soiled dressings as per trust policy.
To reduce infection risk.
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Document assessment and procedure on tracheostomy care
and suction chart
To facilitate communication and
evaluation.
E. Cuff pressure check
The cuff pressure should be checked a minimum of once every 8 hour shift
Action
Rationale
Explain procedure to patient.
To gain verbal consent, co-operation and
reassure patient.
Check pressure in cuff using pressure device
Cuff pressure should be 22-32cmH2O (in the green safe
zone)
To ensure cuff is not over or under inflated
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3. SAFETY
Essential bedside equipment
This must be checked and documented at the beginning of each shift
Emergency equipment






Spare tracheostomy tubes: same size as in place plus one size smaller,
CUFFED AND UNFENESTRATED
10ml syringe
Tracheal dilators
Bag valve mask (BVM)
Lubricating gel
Spare inner cannula






Suctioning





Working suction unit (80 -150mmHg unless otherwise directed)
Appropriately sized suction catheters (see formula below)
Yankeur sucker x 2
Personal protective equipment: sterile and non sterile gloves, apron/eye
protection
Sterile water and container





Patient Care












Tracheostomy mask/Swedish nose
Humidified oxygen (if indicated)
Tracheostomy dressing, tapes/ties
Tissues for patient (if appropriate)
Working call bell or other means of communication
Bedside documentation
Formula for suction catheter size
Tube size x 3 divided by 2
e.g. tube size 8 x 3 = 24 divided by 2 = size 12
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Tracheostomy emergency algorithm
Call 2222 if any of following present
A: No/minimal air via tracheostomy or mouth
B: Extreme difficulty in breathing/no breathing
C: No/weak pulse felt
 Start CPR as appropriate
 Ventilate patient via tracheostomy with 15l
oxygen and self inflating bag
Life threatening features not present
but concerns regarding
tracheostomy
Call for senior ward help
Call outreach bleep 1676
For out of hours assistance call
ICU extension 5752
Can you ventilate through the tracheostomy?
Yes
Continue bag
ventilation via
tracheostomy +/CPR until help
arrives
For concerns regarding patency of
tracheostomy or mild/moderate
respiratory distress
No
 Suction through trache
 Check inner cannula
not blocked (then replace)
 Ensure cuff inflated (if
present)







Keep calm & reassure patient
Apply 15l oxygen via tracheostomy
Remove speaking valve if present
Check inner cannula not blocked
Inflate cuff if present
Encourage coughing
Suction via tracheostomy
If tracheostomy appears dislodged
 Give oxygen 15l via tracheostomy
AND 15l via face mask till help arrives
Yes
Can you ventilate through
the tracheostomy?
If patient deteriorates at any stage
call 2222 if appropriate and move
to red algorithm
No
Consider removal of tracheostomy
 Cover hole with gauze & apply
pressure
 Ventilate via face mask
Massive haemorrhage from tracheostomy call 2222




Give 15l oxygen via tracheostomy
Hyperinflate cuff (if present) with 15mls air
Help – contact ENT registrar via switchboard (state emergency call)
Haematology – contact blood bank, blood will be needed
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BEDHEAD SIGNS
These should be in place for every patient. They will be completed by the tracheostomy support
team and on one side will display the immediate information that is required in an emergency, and
on the reverse they will have the tracheostomy emergency algorithm for first responders.
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Summary of RED FLAGS
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Summary of daily tracheostomy care
Note: One shift = One 8 hour period
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Ward care charts
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7. TRAINING REQUIREMENTS
Training will be disseminated through the Critical Care outreach team.
A ‘Guide to tracheostomies on the ward’ providing further background reading is also available.
Tracheostomy competencies have been developed and a link person for tracheostomies will be created
on the wards where patients with tracheostomies are likely to be admitted.
8. REFERENCES AND ASSOCIATED DOCUMENTATION
Documents used when preparing this care bundle are:
1. National Tracheostomy Safety Project http://www.tracheostomy.org.uk/
2. Standards for the care of adult patients with a temporary tracheostomy. Intensive Care Society 2008.
http://www.ics.ac.uk/intensive_care_professional/standards_and_guidelines/care_of_the_adult_pati
ent_with_a_temporary_tracheostomy_2008
This document will be updated as further evidence becomes available.
9. EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably
practicable, the way we provide services to the public and the way we treat our staff reflects
their individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly
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10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
This document will be monitored to ensure it is effective and to assurance compliance.
Minimum requirement to
be monitored
Presence of bedside
emergency equipment
Correct documentation of
tracheostomy care
Compliance with
tracheostomy care standards
Lead
Dr Sara
Blakeley Consultant
Critical Care
Tool
Real time observation
Frequency of Report
of Compliance
Rolling process to
occur at each
Tracheostomy Support
Visit
Reporting arrangements
Yearly summary of activity to be
generated by Dr Sara Blakeley Consultant Critical Care
Lead(s) for acting on
Recommendations
Dr Sara Blakeley - Consultant
Critical Care
Comment: In view of the nature of the process surrounding tracheostomy care and the relatively small numbers of patients, compliance with
the policy document will take the form of real time observation when the patient is reviewed by the Tracheostomy Support Team. Data can be
presented on a yearly basis as a report on the Tracheostomy Support Team’s activity.
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