TRACHEOSTOMY TUBES

TRACHEOSTOMY TUBES

Definitions:

TRACHEOTOMY: Incision made below the
cricoid cartilage through the 2nd-4th
tracheal rings

TRACHEOSTOMY: The opening or stoma made
by this incision.

TRACHEOSTOMY TUBE: Artificial airway
inserted into the trachea during
tracheotomy

INDICATIONS FOR TRACHEOSTOMY

• Bypass acute upper airway obstruction.
• Chronic upper airway obstruction.
• Facilitate weaning from mechanical ventilation by decreasing anatomical deadspace.
• Prevention / treatment of retained tracheobronchial secretions.
• Prevention of pulmonary aspiration.

COMPONENTS OF TRACHEOSTOMY TUBE

1. Outer tube
2. Inner tube: Fits snugly into outer tube, can be easily removed for cleaning.
3. Flange: Flat plastic plate attached to outer tube - lies flush against the patient’s
neck.
4. 15mm outer diameter termination: Fits all ventilator and respiratory equipment.
All remaining features are optional
5. Cuff: Inflatable air reservoir (high volume, low pressure) - helps anchor the
tracheostomy tube in place and provides maximum airway sealing with the least amount of local compression. To inflate, air is injected via the...
6. Air inlet valve: One way valve that prevents spontaneous escape of the injected air.
7. Air inlet line: Route for air from air inlet valve to cuff.
8. Pilot cuff: Serves as an indicator of the amount of air in the cuff
9. Fenestration: Hole situated on the curve of the outer tube - used to enhance airflow in
and out of the trachea. Single or multiple fenestrations are available.
10. Speaking valve / tracheostomy button or cap: Used to occlude the tracheostomy tube
opening (a) former - during expiration to facilitate speech and swallow,
(b) latter - during both inspiration and expiration prior to decannulation.

BEDSIDE EQUIPMENT
Every patient with a tracheostomy tube should have the following equipment available at the bedside:

• Spare tracheostomy tubes Same size and type as patient is wearing.
Smaller size

• Tracheal dilator.

• Suctioning equipment Suction machine fitted with filter; suction tubing;
suction catheters (see suctioning page for sizes);
gloves (as below); bottle of sterile water to rinse tubing - change daily.
Ensure equipment is assembled and working
properly.

• Humidification equipment Equipment depends on method used - see
humidification page.
Ensure equipment is assembled and working
properly.

• Gloves Non-sterile **
Sterile gloves (for suctioning)

• Infectious waste bag

• Dry clean container for holding the speaking valve, occlusive cap/button or spare inner cannula when not in use. (Get from theatre)

**Natural rubber latex gloves to be used by all except those who have latex allergy.
Nitrile gloves to be used by those with latex allergy.

CARE OF THE INNER CANNULA, STOMA SITE AND TRACHEOSTOMY TIES

Purpose:
1. To maintain a patent airway.
2. To prevent infection.
3. To maintain skin integrity.
4. To prevent tube displacement

FREQUENCY OF CLEANING

Inner Cannula:
1.Check every shift
2.Clean PRN

Stoma:
1.PRN to keep clean and dry

Ties:
1.PRN to keep clean and dry

EQUIPMENTS FOR STOMA CARE

1. Dressing trolley Dressing pack
2. Pair of sterile gloves Unsterile gloves
3. Normal saline solution Scissors
4. Lyofoam dressing Suctioning equipment
5. New trach. ties
6. Infectious waste bag (Sterile pipe cleaners - single use only)

To check inner cannula:
-Wash hands.
-Wearing a non-sterile glove,
-remove inner cannula.
-Handle only the outer portion of the cannula.
-If clean, reinsert and lock into place.
-If soiled - continue with step (d) below.
(a) Wash hands.
(b) Wearing unsterile gloves remove and dispose of the soiled dressing.
(c) Wash hands. Put on sterile gloves.
(d) First, remove and clean the inner cannula using sterile pipe cleaners and normal saline. Dry. Reinsert.
(e) Secondly, clean the stoma site using gauze and normal saline. Pat dry. Apply lyofoam / keyhole dressing if necessary.
(f) Lastly, if ties are soiled and need changing, have a second nurse hold the tracheostomy tube securely in place, remove and replace tracheostomy ties. (Leave 1 finger space between ties and the patient’s neck.)
(g) Ensure patient comfort.
(h) Discard of used equipment as per hospital policy.
(i) Wash Hands.
(j) Document procedure in the patient’s notes.
Note:
Leave first dressing intact for 24hrs if possible as the tracheostomy is a fresh wound.

SUCTIONING VIA A TRACHEOSTOMY TUBE

Purpose: To maintain a patent airway by removing endotracheal secretions.
FREQUENCY OF SUCTIONING
1. Suctioning is performed only as needed
2. Be aware that suctioning will be needed more frequently in the immediate post-operative period

WORKING OUT SUCTION CATHETER SIZE
Size of trach. tube (mm) x 3
2
E.g. 8 x 3 = size 12 suction
2 catheter

Instructions:

(a) Explain the procedure to the patient - wash hands, put on gloves. Put on apron and fluid shield mask if necessary for standard (universal) precautions). Turn on suction apparatus and test that vacuum pressure is < -150mmHg. (b) Open / expose only the vacuum control segment of the suction catheter and attach to the suction tubing. (c) Put on disposable sterile gloves over the non-sterile gloves and withdraw the sterile catheter from the protective sleeve. (d) Maintaining sterility, insert the suction catheter with NO suction applied until resistance is met, then pull back about 1-2 cms before applying continuous suction as the catheter is smoothly withdrawn from airway. NOTE: Recommended suction time (i.e. from insertion to removal of suction catheter) = <15secs
-Use a new sterile catheter for each suction pass.
-No more than 3 passes recommended per treatment.

(e) On completing procedure, ensure patient comfort, discard of equipment as per hospital policy, wash hands and document procedure in the patient’s notes.

HUMIDIFICATIONOF INSPIRED GASES

Purposes:
1. To prevent drying of pulmonary secretions.
2..To preserve muco-ciliary function.
NOTE: All patients with tracheostomy tubes require humidification of inspired gases.

CHOOSING METHOD
A) HEATED HUMIDIFIERS - Recommended for:
• patients with new tracheostomy tubes
• dehydrated patients
• immobile patients
• patients with tenacious secretions
B) HEAT MOISTURE EXCHANGE FILTERS - Recommended for:
• patients that are adequately hydrated
• mobile patients
• Not suitable for patients with copious secretions
C) NEBULIZERS - nebulized normal saline is effective in helping to loosen secretions and soothing irritable
airways.

EQUIPMENTS NEEDED
A) * Heating unit,
* Sterile water ,
* Oxygen tubing,
* Tracheostomy mask.
B) * Heat moisture exchange
filter
* Oxygen tubing to fit filter
if O2 therapy requested
C) * Nebulizer
* Oxygen tubing
* Sterile saline
• The method used for humidification can be altered as the patient’s condition changes
• Do not combine methods - use one at a time.
.
NURSING MANAGEMENT
HEATED HUMIDIFERS
• Set up as per operators manual.

• Monitor temperature of inspired gases. This is easily achieved if the system used has a digital temperature display. If it does not, then test the temperature by holding the oxygen tubing against a clean bared inner arm. Gas flow should feel at body temperature.

• Monitor water level and change bottles PRN.

• If condensation collects in tubing, - drain tubing into a sterile jug and dispose of into sluice.

• Using clean technique, change all tubing weekly. (Date tubing when changed)

HEAT MOISTURE EXCHANGERS

• Change daily and PRN to keep clean and dry. (Swedish noses/thermovents can be easily “coughed off” - apply new Swedish nose each time this happens).

• Discard of soiled Swedish noses in infectious waste.

NEBULIZERS
• Administer as prescribed.
• Wash in warm soapy water, rinse and dry thoroughly after each treatment.

CARE OF CUFFED TRACHEOSTOMY TUBE
• Immediately post-operatively - to prevent aspiration of blood or serous fluid from the wound

INDICATIONS FOR CUFFED TUBE
• To seal the trachea during mechanical
ventilation
• To seal the trachea during swimming!
• To prevent aspiration of leakage from
tracheo-oesophageal fistula
• To prevent aspiration due to laryngeal incompetence

NURSING MANAGEMENT
• It is unusual for ward patients to need their cuff inflated.

• Tracheostomy cuff is inflated only - (a) if the patient is being mechanically ventilated, (b) if inflation is specifically ordered by doctor.
• Check with doctor that it is OK to do so , and then proceed with cuff deflation......

• Patients can be extremely sensitive to changes in cuff pressure. A little coughing is not unusual during manipulation. Take care to explain the procedure to the patient and to inflate / deflate the cuff slowly.

• To deflate cuff: First, suction the oropharynx to remove any secretions that may have pooled on top of the inflated cuff. Then, using a syringe, slowly aspirate air from the air inlet port. Once deflated, expiratory noises may be heard as air passes up around the tracheostomy tube. Reassure the patient that these are normal and will settle.

• To inflate cuff: Inject approximately 5-7mls of air via the air inlet port to achieve airway seal. A one-way valve system prevents injected air from escaping.
NOTE:
• If used correctly, there is no need for low pressure cuffs to be deflated ever hour. (Powaser et
al 1976, Bryant et al 1971)
• Cuff pressures can be measured by using a spirometer attached to the air inlet port of the tracheostomy tube. Recommended cuff pressure is <25mmhg.>
CARE OF FENESTRATED TRACHEOSTOMY TUBE

USES OF FENESTRATED TUBES
1. To facilitate / improve speech - The fenestration (hole) allows increased volumes of air to be forced up through the larynx during exhalation.
2. To improve swallow function - Restoring more normal airflow restores some of the protective mechanisms of normal swallow.

NURSING CONSIDERATIONS WHEN USING FENESTRATED TUBES.
• A fenestrated tracheostomy tube can only function as such if both the outer and inner cannulas contain a fenestration (hole)!

• The fenestration allows secretions as well as air to pass up and down the patient’s airway. If needed, give the patient a sputum container or tissues and bag for secretions.

• Speaking: Speech is facilitated by inserting the fenestrated inner cannula, and occluding the tracheostomy tube opening by using one of the following: (CUFF SHOULD BE DEFLATED) a) the patients finger
b) a speaking valve
c) a decannulation plug / cap / button.
• Suctioning: If suctioning is required, change to a non-fenestrated inner cannula. This is to prevent the suction catheter passing through the fenestration and traumatising the delicate lining of the posterior tracheal wall.
• Eating: While using a fenestrated tube restores some of the normal swallow protection mechanisms, nurses should be aware of and observe for signs of aspiration. Swallowing is further improved by having the cuff deflated and the tracheostomy opening occluded at the moment of swallow - methods outlined above.
• Cleaning of a fenestrated inner cannula is the same as for non-fenestrated tube.
• Store cleaned speaking valve, cap and spare inner cannula in a sealed, clean, dry container at the patient’s bedside (specimen containers available from theatre).

CARE OF PASSY MUIR SPEAKING VALVE

HOW IT WORKS
The speaking valve contains a movable plastic disc that opens on inspiration but closes on expiration. This means that during expiration no air can escape through the tracheostomy tube opening. It is redirected up through the larynx instead.

CLEANING INSTRUCTIONS
-Clean daily - as per inner cannula or Wash in soapy water.
-Rinse thoroughly in cool-tepid water (not hot).
-Air dry.
-WHILE WEARING THE VALVE, THE PATIENT WILL NOTICE.
• Air exhaling via the nose and mouth.
• Speech is improved, full sentences are
possible.
• Expectoration returns to the normal
route, i.e. the oral cavity.
• Patients are able to blow their nose/sneeze
• Oral + nasal secretions lessen because of
evaporation of secretions as air is exhaled.
• Occassional dryness of mucosa may occur.
• Lung backpressure - normal feeling of
• Energy levels may increase.
• Strong coughing may blow off valve.
restored volume - may take getting used to.

NURSING CONSDERATIONS WITH THE PASSY MUIR VALVE.

• To use the valve the tracheostomy cuff should be deflated (see page on cuff care)
• To use the valve patients should also be medically stable, and have enough pulmonary compliance to exhale around the tracheostomy tube, and out through the nose and mouth.
• Stay with the patient during first wearing. (i.e.5-10mins or until patient is confident wearing valve).
• Increase wear-time as tolerated.
• Ensure patient has a sputum container or tissues and bag for orally expectorated secretions.
• Increased mouthcare is necessary if the patient experiences dry mouth.
• Assess the patient’s work of breathing. Observe for adequate exhalation - so that stacking of breaths is avoided
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