Tracheostomy Nursing Care in the Critical Care Setting

Tracheostomy is a procedure in which an artificial opening a.k.a. stoma is created at the level of the second or third cartilaginous ring from where the tracheo-bronchial tree is accessed and a tracheostomy tube is inserted. Proper tracheostomy nursing care in the critical care setting ensures patient safety.

Retrieved from https://entokey.com/laryngeal-anatomy/ (left) and https://www.pinterest.com/pin/83387030589729256/ (right) on 1st November 2022

Tracheostomy indications

• airway obstruction in relation to problems with tongue, pharynx, larynx, trachea and oesophagus
• anaphylaxis
• foreign body
• facial trauma
• facial or respiratory burns
• prior to extensive head and neck surgery
• vocal cord paralysis
• sleep apnoea
• instable cervical spine
• inflammation
• tumor
• congenital anomalies (structural or functional anomalies which occur in-utero)

NOTE: Tracheostomy is preferred as a prolonged airway maintenance and ventilation method. It is also used in cases of failed and/or repeated intubation, following intubation complications, and where there is need for deep secretion removal.

Tracheostomy Advantages

• less restricting for the patient
• enables swallowing
• enables better communication
• less sedation requirement
• allows better mouth hygiene
• helps avoid upper airway complications related to ETT use
• easier secretion removal
• reduces anatomical dead space (shorter, wider and less curved tube = better breathing = quicker weaning from ventilator use)

Tracheostomy Preparation & Surgical Procedure

• explain tracheostomy procedure to the patient and accompanying relatives
• gain operation consent
• ensure availability of needed drugs (sedatives/analgesics/muscle relaxants), blood in reserve, suction equipment, cautery machine (helps in cutting and stopping bleeding immediately and effectively), and procedure trolley
• help patient in supine position with blanket roll between shoulder blades to ensure neck is adequately exposed.

1. an incision is made between the sternal notch and cricoid cartilage
2. a midline vertical incision is made to divide strap muscles
3. thyroid isthmus between ligatures is divided
4. cricoid is elevated along with the cricoid hook
5. an incision is made through the tracheal wall
6. a tracheostomy tube is inserted while the endotracheal tube is withdrawn
7. cuff is inflated
8. keyhole dressing is applied
9. tube is secured either with tape around the neck or with stay sutures
10. tube is connected to the ventilator tubing

Percutaneous Dilational Tracheostomy

As seen above, a surgical tracheostomy requires a surgical dissection to be made down to the trachea, the creation of a window in the trachea with the insertion of a tracheostomy tube for ventilation…

Compared to surgical technique, the percutaneous dilational tracheostomy (PDT) uses a modified Seldinger technique where the trachea is accessed with a needle and then a guidewire is inserted. The tracheostomy tube is introduced over the guidewire after dilation.

Rashid & Islam, 2017

Thus, a percutaneous dilational tracheostomy avoids surgical incision, is less traumatic, and carries a lower bleeding risk.

1. a large bore needle is inserted into the tracheal lumen between the 2nd and 3rd ring
2. a flexible guidewire is then inserted
3. serial dilations are made
4. tube is inserted

NOTE: Ideally, a percutaneous dilational tracheostomy are done under ultrasound or bronchoscopy guidance. The procedure is contraindicated in patients with goitre, obesity, and acute upper airway obstruction.

Tracheostomy Complications

During placement of tracheostomy, arising complications may include:

• haemorrhage (due to the area being very vascular)
• pneumothorax (accidental pleura laceration)
• oesophageal trauma
• laryngeal nerve injury (may cause hoarseness, difficulty in swallowing or breathing, or loss of voice)
• vagal nerve stimulation (may lead to bradycardia, hypotention, or cardiac arrest)
• incorrect placement

Post-op complications following a tracheostomy may include:

• haemorrhage
• aspiration
• wound infection
• infection in the trachea
• infection in the lungs
• tube obstruction caused by blood or secretions
• tube displacement
• subcutaneous emphysema (usually this is solved without any interventions)

Late complications related to tracheostomy use may include:

• tracheal stenosis (abnormal narrowing of the trachea which restricts the patient’s ability to breathe)
• tracheo-oesophageal fistula (abnormal connection between the trachea and oesophagus which causes swallowed liquids or food to be aspirated into the lungs)
• tracheoinnominate artery erosion by cuff or tip of tube (may require resuscitative and operative measures)
• stoma does not close following removal of tube
• overgranulation and scarring

Types of Tracheostomy Tubes

Retrieved from https://www.exportersindia.com/product-detail/white-fenestrated-tracheostomy-tube-6433292.htm (left) and https://www.magonlinelibrary.com/doi/abs/10.12968/bjon.2019.28.16.1060 (right) on 1st November 2022

Cuffed Tube with Disposable Inner Cannula – Used to obtain a closed circuit for ventilation.

• Cuff should be inflated when using with ventilators
• Cuff should be inflated just enough to allow minimal airleak
• Cuff should be deflated if patient uses a speaking valve
• Cuff pressure should be checked twice a day
• Inner cannula is disposable

Cuffed Tube with Reusable Inner Cannula – Used to obtain a closed circuit for ventilation.

• Cuff should be inflated when using with ventilators
• Cuff should be inflated just enough to allow minimal airleak
• Cuff should be deflated if patient uses a speaking valve
• Cuff pressure should be checked twice a day
• Inner cannula is not disposable; you can reuse it after cleaning it thoroughly

Cuffless Tube with Disposable Inner Cannula – Used for patients with tracheal problems and for patients who are ready for decannulation.

• Save the decannulation plug if the patient is close to getting decannulated
• Patient may be able to eat and may be able to talk without a speaking valve
• Inner cannula is disposable

Cuffed Tube with Reusable Inner Cannula – Used for patients with tracheal problems and for patients who are ready for decannulation.

• Save the decannulation plug if the patient is close to getting decannulated
• Patient may be able to eat and may be able to speak without a speaking valve
• Inner cannula is not disposable; you can reuse it after cleaning it thoroughly

Fenestrated Cuffed Tracheostomy Tube – Used for patients who are on the ventilator but are not able to tolerate a speaking valve to speak.

• There is a high risk for granuloma formation at the site of the fenestration (hole)
• There is a higher risk for aspirating secretions
• It may be difficult to ventilate the patient adequately

Fenestrated Cuffless Tracheostomy Tube – Used for patients who have difficulty using a speaking valve.

• There is a high risk for granuloma formation at the site of the fenestration (hole)

Metal Tracheostomy Tube – Not used as frequently anymore. Many of the patients who received a tracheostomy years ago still choose to continue using the metal tracheostomy tubes.

• Patients cannot get a MRI
• One needs to notify the security personnel at the airport prior to metal detection screening

CUFFED VS NON-CUFFED VS FENESTRATED

SINGLE VS DOUBLE TUBE

Double lumen tubes contain an inner cannula which can be removed for cleaning.

TRACHEOSTOMY VS LARYNGECTOMY

SHILEY TUBE

Upper Airway Bypass Effects

In normal upper airway functions there is humidification, warming and filtration of inspired air, ability to taste, smell and swallow, speech production by the passing of exhaled air through the larynx, and involvement in the cough reflex.

When bypassing the upper airway, lack of humidification leads to impaired mucociliary function, thicker secretions which can easily cause tube obstruction, as well as atelectasis (partial or full lung collapse) and infection. Similarly, air below body temperature may cause bronchoconstriction, reduced air flow, decreased PO2 (partial pressure of oxygen) and decreased SaO2 (oxygen saturation of arterial blood).

Humidification

Requirements for optimal gas exchange, which are in normal circumstances achieved through the upper airway, include:

• a temperature of 37 degrees celsius
• 100% humidity
• filtered air

Adequate humidification may reduce the need for suctioning, thus, in situations where the upper airway is bypassed by an ETT or tracheostomy, an external method providing warmth, humidity and filtration is needed.

Through an external humidification system, inspired gas is passed over heated water with a set temperature of about 60 degrees celsius. As the air passes along the tubing, it cools down to around 37 degrees celsius when reaching the patient.

Although this system provides a setting similar to what is required for optimal gas exchange, it poses a couple of problems: it requires equipment care, it restricts patient mobility, and it may also become an infection source for the patient.

The HME Filter – Heat Moisture Exchanger

HME filters a.k.a. heat moisture exchanger filters are devices used in patients who are mechanically ventilated to help prevent mucus plugging and endotracheal tube occlusion due to lack of humidification.

HMEs are made of hydrophylic material which retains heat and moisture in exhaled air, which are then recycled in subsequent inspirations, following filtration of inspired air.

HMEs improve patient mobility and lower risk of infection. However, they can still become easily blocked by secretions, and so, require frequent filter changes (usually changed within a couple of days based on manufacturer’s recommendations) or even cessation of use in case of profuse secretions.

Suctioning in Airway Management

Secretions are cleared by coughing under normal conditions. Cough involves pressure build-up in the lungs which depends on closure of the glottis. The use of a tube prevents the patient from increasing enough abdominal pressure to produce a cough that clears secretions in the airway. Additionally, the tube may also cause irritation which leads to increased sputum production.

Suctioning is a procedure that needs to be performed as often as required based on the patient’s individual needs, so as to clear secretions and maintain a patent tube.

• suctioning should not be performed routinely but as needed
• suctioning should be performed using a sterile technique
• suctioning can be scary and unpleasant for the patient, thus, it needs to be performed with confidence and speed

Suctioning Indications

• coughing
• respiratory distress
• increased peak airway pressure
• decreased SaO2 (oxygen saturation of arterial blood) and PO2 (partial pressure of oxygen)
• audible and/or visible secretions
• suspected aspiration
• signs of discomfort

Open Suctioning Procedure

1. explain procedure to the patient
2. provide the patient with hyperoxygenation at 100% oxygen
3. whilst keeping the catheter in its wrapper, attach it to suction tubing and switch it on
4. wear mask and sterile suction glove
5. insert catheter up to 1cm more than the tube length
6. apply suction on the way out; oropharyngeal cavity may also need suctioning
7. hyperoxygenate again
8. monitor patient

NOTES:

• do not exceed 15 seconds in performing suctioning so as to prevent hypoxia
• maintain aseptic technique whilst performing procedure
• catheter width should not exceed half the tube’s diameter
• catheters with multiple eyes produce less damage
• negative pressure should not exceed 120mmHg
• instillation of saline is not recommended any more, however, saline nebulisation may help in loosening secretions

Suctioning Complications

HYPOXAEMIA – arterial blood oxygen level lower than normal: happens due to the patient being disconnected from the oxygen source whilst suctioning is being performed; reduce risk by performing suctioning for not longer than 15 seconds and ideally using a closed suction system instead of the open suction one.

ATELECTASIS – complete or partial collapse of the entire lung or lobe of the lung: happens when excessive pressure is being used while suctioning; reduce risk by ensuring that pressure does not exceed 120mmHg.

BRONCHOSPASM – tightening of the muscles lining the bronchi a.k.a. airway tightening: happens due to catheter use stimulating the airway.

DYSRHYTHMIAS – abnormal or irregular heartbeat (especially bradycardia following suctioning): happens due to hypoxaemia and vagal stimulation.

HAEMODYNAMIC CHANGES – increased blood pressure and intracranial pressure; reduce risk by avoiding suctioning in patients with head injury.

TRACHEAL MUCOSA TRAUMA – reduce risk by avoiding deep suctioning, large catheters and excessive pressure.

INFECTION – reduce risk by using strict aseptic technique and using a closed suction system. NOTE: send specimens for C+S if infection is suspected.

Closed Tracheal Suctioning Procedure

Using a closed tracheal suctioning procedure allows suctioning of the airways without the need for disconnecting the patient from the ventilator. This is done by attaching the suction catheter in plastic sleeve directly to the ventilator tubing.

Advantages:

• maintains oxygenation and PEEP (Positive End Expiratory Pressure) during suction
• reduces the risk of complications related to hypoxaemia
• provides HCPs with protection from secretions

Disadvantages:

• possible auto-contamination (reduce risk by cleaning catheter after each use and change every 24 hours)
• inadequate removal of secretions
• extra weight on ventilator tubings may cause an unintentional extubation
• expensive

Cuff Management

The use of a cuff provides a seal in mechanical ventilation of a patient. This seal provides protection from gross aspiration. However, it does not offer complete protection from aspiration, and it may also disguise aspiration signs. Additionally, cuff exerts pressure on the oesophagus, anchoring the larynx, thus reducing laryngeal elevation. Considering all the above…

The patient with an inflated cuff should be kept nil-by-mouth! Provide needed nutrition through a nasogastric tube, a nasojejunal tube, gastrostomy, or jejunostomy. Important: assist the patient as needed to maintain oral hygiene!

Cuff used should be a high volume low pressure cuff. Cuff pressure should be checked at the start of every shift, after turning the patient, after physiotherapy, after dressing change and if a leak can be heard. Pressure should be kept between 15-25mmHg.

A low cuff pressure causes a drop in tidal volume due to leak of exhaled air around the tube, as well as possible aspiration of gastric content.

A high cuff pressure may create a fistula between the trachea and the oesophagus a.k.a. tracheoesophageal fistula, especially if a stiff nasogastric tube is being used on the patient. It may also cause obstruction of capillary blood flow within the tracheal wall, leading to pressure sore necrosis and tracheal stenosis following formation and healing of scar tissue.

Tracheostomy Communication Through Speaking Valves

In normal circumstances, speech is created by the passing of exhaled air through the vocal cords. Since tracheostomy tubes are inserted below the vocal cords, sound cannot be formed. This may cause the patient to become anxious and feeling isolated.

The nurse should provide reassurance to the patient by explaining that loss of sound being experienced is only temporary, and voice returns once the tracheostomy tube is removed. The nurse should also encourage the patient to use different ways of communication whilst with a tracheostomy tube is inserted, such as using electronic devices, paper and pen, or speaking valves.

Speaking Valve Use

1. When using a speaking valve, ensure that the patient has a good gag reflex and that he is using either a non-cuffed or a fenestrated tube; if patient is using a cuffed tube, ensure that the cuff is totally deflated before attempting use of speaking valve
2. Upon inspiration, the valve opens, allowing air to be inhaled through the tracheostomy
3. Upon exhalation, the valve closes; air passes around the tube and through the vocal cords, enabling exhalation from the upper airway and voice production

NOTE: DO NOT USE A SPEAKING VALVE if the patient has poor lung compliance, in the case of excessive secretions, and if laryngeal or pharyngeal problems are present.

Tracheostomy Nursing Care – Wound Care & Tape Changes

The surgical wound needs to be kept clean and dry at all times. The wound dressing used needs to be changed daily or whenever it becomes soiled. The aseptic non-touch technique should be used whilst cleaning the wound with saline, including careful cleaning of the area underneath the flange. Note that between the patient’s neck and tape there needs to be a space for one to two fingers.

prepared equipment for an arising emergency

• 1 spare tube in the same size as the one being used
• 1 spare tube in a smaller size than the one being used
• suction and suction catheters
• oxygen
• tracheostomy mask
• securing tape
• tracheal dilators
• scissors
• suture cutter
• lubricating gel
• syringe (to inflate cuff)
• drugs and equipment for resuscitation
• sterile keyhole dressing
• non-sterile gloves

Tracheostomy Tube Change

A single lumen tracheostomy tube should be changed every 7-10 days so as to prevent obstruction. Other indications for a tracheostomy tube change include:

• cuff failure
• blockage within the tube
• displacement of the tube
• needing to change to a larger or smaller tube

Tracheostomy Weaning and Decannulation

A tracheostomy is no longer needed if:

• the reason for a tracheostomy has been resolved
• the patient is alert, stable, and self ventilating on air
• the patient has no significant signs of airway obstruction
• the patient is able to swallow and cough up secretions
• the patient is able to maintain good oxygen saturation

In case of the above:

1. cuff is deflated
2. tube is occluded for 24 hours
3. if no respiratory distress is experienced by the patient, tube is removed
4. the stoma is covered with a small occlusive dressing

Important Tracheostomy Nursing Care Observations

• monitor patient for bleeding or oozing
• monitor patient for signs of infection and/or inflammation
• monitor patient for evidence of tissue damage
• monitor cuff pressure and ensure it is kept within normal limits
• monitor amount, colour and consistency of secretions

Reference

Johns Hopkins Medicine (n/d). Tracheostomy Service. Retrieved from https://www.hopkinsmedicine.org/tracheostomy/about/types.html on 12th November 2022

Rashid, A. O., & Islam, S. (2017). Percutaneous tracheostomy: a comprehensive review. Journal of thoracic disease, 9(Suppl 10), S1128–S1138. https://doi.org/10.21037/jtd.2017.09.33

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