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Safe Tracheostomy Care

Safe tracheostomy care video by the tracheostomy team at Barts Health NHS Trust
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3.9
This video will provide you with the information and the tools you’ll need to safely care for your patient with a tracheostomy. All patients with tracheostomies will need good ongoing care to prevent the development of both short-term and long-term complications. The most important of these are bleeding, blockage, and displacement. Any nurse looking after patients with tracheostomies needs to ensure they have the correct number of trained nurses to do so. We have a risk assessment tool that we use to help us to do this. It takes into account the conscious level of the patient, the oxygen requirements, and the frequency with which they need suctioning.
47.3
The bedside nurse needs to ensure that they have the correct equipment available to safely take care of their patients. This will require suctioning equipment. It may be portable like this or you could have wall suctioning at the bedside. Humidification is vital, which also could be portable oxygen or connected to a wall supply.
68.2
We also need to ensure that we have spares– tracheal dilators, spare tracheostomy tubes, one the same size that the patient has in situ and one tube a size smaller– 10ml syringe for inflating and deflating the cuff, spare tracheostomy ties, spare inner tube the same size that the patient has in situ, a stitch cutter should the patient’s tracheostomy be sutured in place, spare gauze, and lubricant in case of emergency tube change. We need to ensure that the stoma site stays clean and dry and we use sterile pack to ensure that this is done at least once a shift.
114.9
Tube ties need to be changed every 24 hours, and it is a two-person technique to ensure that the tube stays in situ and is safe at all times. Within our trust, we utilise a checklist, which ensures that all the equipment has been checked at the beginning of each shift and also a nursing care checklist where we document that we have checked the inner tube at least every four hours and also performed suctioning at least every four hours and also as the patient requires.
145.4
I am an ENT surgeon, and I form part of the tracheostomy multidisciplinary team. I can perform a camera test via a flexible camera within the nose and through the tracheostomy to try and ascertain any anatomical problems that may be causing issues for our tracheostomy patients. I am a point of contact for the nursing staff on the ward so that they are aware of who to call should there be an emergency with the tracheostomy.
181.5
The role of the physiotherapist for the patient with the tracheostomy not only needs to focus on the tracheostomy, but the wider patient. This includes positioning, mobility, function, seating regimes, strength, cough strength, as well as looking at their chest status and helping clear any secretions that they may have. They work with the MDT and the speech and language therapy, especially, to look at the wean status and appropriateness for decannulation. Once competencies have been achieved, physiotherapists can participate in decannulations and changes. I am going to show you how to safely care for your tracheostomy patient. There are many brands and models available on the market, and it is important that you know which type your patient has.
228.2
We have found that it is safer and simpler to use only one brand and model. This way, we have available appropriate spares and inner tubes for all the patients. Firstly, we have the outer tube, which is the main body of the tracheostomy tube and thus dictates the size of the tube. The tube measurements and the corresponding tracheostomy size make and model are found on the phalange. It is this information which helps you to decide whether your spare tubes are of the correct size and type. It is important to be aware that the sizing between the various brands is not consistent. So review the outer diameters closely if you are unable to supply like-for-like spare tubes.
277.6
In our experience, the safest tracheostomy tube is one with a removable inner tube. The inner tube facilitates tube cleaning and airway hygiene. It is therefore a key component in maintaining a patent airway. Depending on the patient’s clinical need, a tracheostomy could also have a cuff. This is a small balloon that sits on the outer tube within the windpipe. The cuff creates a soft sealed barrier within the windpipe. It is important that the cuff is not inflated too much as this causes harm to the windpipe that it rests against. The pressure the internal balloon creates against the windpipe can be recorded on a manometer. The mouth and nose form our natural humidification mechanisms.
334.3
A patient with a cuffed tracheostomy tube no longer breathes through these airways, but via the tube. Subsequently, the natural humidification methods are lost. Inadequate humidification can lead to inner tube blockages. This can be serious to the patient and potentially fatal. We advocate cold water humidification whilst the patient is in the hospital setting like this. There may be times when heated humidification is necessary, such as when chest secretions are thick or if blood is visible when suctioning. We use a device called the Airvo, and there are strict guidelines for their use. These circuits should be changed weekly. A bib is commonly used by neck breathers in the community, such as this one.
382.6
Sadly, it is not reliable enough in the dry atmosphere of a hospital ward. You may come across devices similar to this, which is called a Swedish nose. Likewise, these are not suitable for adults in the hospital setting, but may be seen in the community.
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Three main areas that we look at as speech and language therapists– and those are tracheostomy weaning, swallowing, and communication. The first stage would be to do an initial assessment of cuff deflation, which we would normally do jointly with a physiotherapist. We would then monitor to see how the patient was doing.
431.1
So having done a cuff deflation and established that the patient is managing their secretions fairly well, we might try to put the speaking valve on. And at that point, the patient is still breathing in via the upper airways, the mouth, the nose, but also through the one-way valve– so breathing in through the tube as well. But when they breathe out, the valve closes, and the patient– then the air comes up through their vocal cords, and they may be able to get voice.
462.6
And we may do a bedside assessment to look for any signs of aspiration. So that would be food or drink going down the wrong way. If we were unsure as to whether the swallow was effective, we may do a FEES assessment, which is a fiberoptic endoscopic evaluation of swallow where we pass a nasendoscope through the nose so that we can visualise the upper airway.
491.1
Our criteria for decannulation is that the patient has managed 24 hours with the cuff deflated and at least four hours with the speaking valve in that state that they’re able to effectively swallow their secretions and that they are able to cough and clear their secretions without being dependent on suction by the tracheostomy.
516.8
Some of our patients have difficulty managing the saliva. So using the subglottic suction port, you can actually aspirate secretions that have accumulated above the and remove them.
532.3
The 2014 UK NCEPOD report called “On the Right Track?” emphasise that all staff who look after tracheostomies should be competent in managing the common complications, including displacement and obstruction. I hope that you found this short video useful to help you care for your patient with a tracheostomy. Be assured that most complications are in fact preventable. Hopefully this video will give you the confidence to safely manage the patient, whether it be in the hospital or at home.

Multidisciplinary team involvement is particularly relevant for the care of patients with tracheostomies and laryngectomies, as they tend to have more complex and evolving needs and a longer length of stay. In this video we see how The Royal London Hospital Trachy Team at Bart’s Health, led by Dr Helen Drewery, Consultant Anaesthetist, approaches the safe care of patient with tracheostomies.

A multidisciplinary team (MDT) approach to the care of patients with tracheostomies ensures that interventions are coordinated and results in improved outcome and length of stay.

The team typicallly comprises clinicians from the various specialties involved e.g. anaesthesia, ear, nose and throat (ENT), head and neck, speech and language therapists (SLT), physiotherapy, dietetics and nursing, from both the ward area and critical care outreach. The team composition can be adapted according to the patient’s evolving needs. Centres which have provided MDT approach in comparison to their own previous practice have experienced a reduced time to decannulation; when run in conjunction with regular teaching and audit of practice, it has resulted in lower rates of complications, such as blockage or displacement.

The Report by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) – On The Right Trach? (2014)[1] looked to identify areas for improvement in the care of patients who undergo a tracheostomy or a laryngectomy. Their website offers a number of resources outlining the best practice reccomendations generated by the report.

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Simple interventions such as teaching and education tailored to the settings have been shown to have a great impact in improving tracheostomy care at a global level, as reported in these articles from Rwanda [2] and the UK [3], [4].

How is tracheostomy care organised in your workplace? Considering what you have learned so far in the course, how do you think care of tracheostomy and laryngectomy can be made safer for your patients? What simple measures can be adopted?

In this article you can find the multidisciplinary consensus recommendations for safe tracheostomy care during the COVID‐19 pandemic: the NHS National Patient Safety Improvement Programme (NatPatSIP).

References

  1. Report by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) – On The Right Trach? (2014)[1]
  2. ML Sandler, N Ayele, I Ncogoza, S Blanchette, et al. Improving Tracheostomy Care in Resource-Limited Settings. Ann Otol Rhinol Laryngol. 2019 Oct 21.
  3. B McGrath et al. Evaluating the quality improvement impact of the Global Tracheostomy Collaborative in four diverse NHS hospitals. BMJ Qual Improv Rep. 2017 May 23;6(1)
  4. P Twose P, G Jones, J Lowes , P Morgan. Enhancing care of patients requiring a tracheostomy: A sustained quality improvement project. J Crit Care. 2019 Aug 29;54:191-196.

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