EirianEdwards(SeniorStaffNurse,CriticalCare,BCUHBWest)(September,2013.UpdatedMay,2015)

TRACHEOSTOMY

CAREBUNDLE

GUIDELINES

Author:EirianEdwards(SeniorStaffNurse,CriticalCare,BCUHBWest)

ContributionsfromAshaMetharam-Jones(SeniorPhysiotherapist,BCUHBWest)

(September,2013.UpdatedMay,2015)

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CONTENTS

• Aims• Definition• Indicationsfortemporarytracheostomy• Tracheostomytubes• CareBundleElement

1. Tracheostomytubecare2. Suction3. Humidification4. Tracheostomydressingsandstomacare5. Safety6. Communication7. Swallowing

• Referencesandfurtherreading• Appendix1–Tracheostomy/LaryngectomyEmergencyalgorithm

&bedsigns• Appendix2–Dischargeform&Bedareachecklist• Appendix3–

a) Swallowingassessmentforcuffedtracheostomyb) Swanseaswallowscreenforuncuffed/deflatedcuffed

tracheostomyc) SwanseaTrackingsheet

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AIMS

Theaimofthetracheostomycarebundleistostandardisethecareofadultpatientswithtemporarytracheostomiesinacriticalcareenvironment.

ThetracheostomycarebundlefollowstherecommendationsontracheostomycarefromtheNCEPOD(2014)report“OntheRightTrach”providingguidanceonhumidification,cuffpressure,monitoringandcleaningofinnercannula.

Thecarebundlehasbeendevelopedutilisingthe‘IntensiveCareSocietyStandardsandGuidelinesforthecareofadultpatientswithatemporarytracheostomy’(Mackenzieetal,2008&2014),‘StGeorge’shealthcareNHSTrust,Guidelinesforthecareofpatientswithtracheostomytubes’(Laws-Chapmanetal,2000),‘theRoyalMarsdenHospital’smanualofclinicalnursingprocedures’(DoughertyandLister,2011),andevidenceobtainedfromrelevantliteraturesupportingbestclinicalpracticefortracheostomymanagement.Imagesareusedforillustrationonly,andtubesmaydiffertoimagesshowndependingonthemanufactures.

DEFINITION

Atracheostomyisthesurgicalopening(stoma)intothetracheathroughtheneck,andiskeptpatentwithatracheostomytube(DoughertyandLister,2011).Tracheostomiescaneitherbetemporaryorpermanent.Permanenttracheostomyisformedfollowingatotallaryngectomy.

Atracheostomymaybeperformedsurgicallyorpercutaneously,andasanemergencyorelectiveprocedure.

INDICATIONSFORTEMPORARYTRACHEOSTOMY

• Airwayprotectione.g.bulbarpalsy• Tomaintaintheairwaye.g.reducedlevelofconsciousness,upper-airwayobstruction,

intubationdifficulties• Toenabletheaspirationoftracheobronchialsecretionse.g.excessivesecretions,inadequate

cough• Long-termmechanicalventilatione.g.weaningfromIPPV,patientcomfort,reductionof

sedation

TheinsertionofaTracheostomywhereverperformedisidentifiedasasurgicalprocedure.TheNCEPOD(2014)recommendsthataWHOstylechecklistisusedinrelationtotracheosotomyproceduresinCriticalCareunits.

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TRACHEOSTOMYTUBES

Tracheostomytubesshouldbechosentakingintoaccountthepatientandtubecharacteristicsandnotjusttheeaseofinsertion(ICS,2014).Itisrecommendedthattheentiretubeshouldbechangedatleastevery30daysoraspermanufacturer’srecommendations.

Itisrecommendedthatallpatientshaveadualcannulatracheostomyinserted.Atracheostomywithaninnercannulaaresafer,theinnercannulacanprovideimmediatereliefoflife-threateningairwayobstructionintheeventofablockedtracheostomytube.Manytracheostomytubesarenowmanufacturedwithaninnercannula.

SINGLELUMEN

Thesinglelumenhasalargerinnerdiameterthanadoublelumentube,anddoesnothavearemovableinnercannula.DOUBLELUMEN(INNERCANNULA)Theinnercannulahasastandard15mmattachmenttoconnecttothebreathingcircuitofamechanicalventilator.Whilstsomeinnercannulasaredisposableforsingleuse,otherscanbecleanedandre-used.Theadvantageofaninnercannulaisthatitallowstheimmediatereliefoflife-threateningairwayobstructionintheeventofablockedtracheostomytube.Thesedualcannulatubesmayeitherbecuffedofuncuffedandfenestratedorunfenestrated.Thedoublelumenhasalargerexternaldiameterthanthesinglelumen.CUFFEDTRACHEOSTOMYTUBESIntheIntensiveCaresetting,mostpatientswillrequireacuffedtracheostomytubeinitially,bothtofacilitateeffectivemechanicalventilationandalsotoprotectthelowerrespiratorytractagainstaspiration.

UNCUFFEDTRACHEOSTOMYTUBES

Thistypeoftracheostomytubedoesnothaveacuffthatcanbeinflatedinsidethetrachea.Anuncuffedtubeissuitableforapatientnotrequiringpositiveventilation,butrequiredforsecretionclearanceandairwaymaintenance.

FENESTRATEDTRACHEOSTOMYTUBEAfenestratedtracheostomytubemaybeusedtoassistindirectingairflowtopassthepatient’soral/nasalpharynx(mouth,noseandvocalcords)aswellastheirtrachealstomawhenbreathing.Itdoescreateariskfororalandstomachcontentstoenterthelungsthroughthefenestrations.

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Manufacturesdonotrecommendtheuseofsuchtubesatthetimeofpercutaneoustracheostomy,andgenerallytheyshouldnotbeusedwhilstapatientstillrequiresmechanicalventilationbecauseofsignificantriskofsurgicalemphysema(ICS,2014).PatientswhoareatriskofaspirationorareonIPPVshouldnothaveafenestratedtubeunlessanon-fenestratedinnercannulaisusedtoblockoffthefenestration.TheICS(2014)recommendsthatafenestratedtracheostomytubeshouldbeusedwithcautioninmechanicallyventilatedpatients,andonlywithpatientswhoareweaningfromventilation.Afenestratedtubeisthemostsuitableforweaningpatientsfromtheirtemporarytracheostomytube.Itismostusefulforpatientswhorequirebothperiodsofcuffinflation(toprotecttheairway)andcuffdeflation(toenableaspeakingvalvetobeused)(DoughertyandLister,2011).

ADJUSTABLEFLANGETracheostomytubeswithadjustableflangearespecificallydesignedforpatientswhohave‘deepsettracheas’,suchasthosewhoareobeseorhavedistortedanatomywithintheneckduetoinflammationandoedema.Patientswithspinalabnormalitiesmayalsobenefitfromthistypeoftube.

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CAREELEMENT

1. TRACHEOSTOMYTUBECAREINNERCANNULAMANAGEMENTTheinnercannula(ifadoublelumentube)shouldberemoved,inspectedandwhennecessarychanged(ifdisposable)orcleaned(non-disposable)ifneeded.TheICS(2014)recommendsthatinanon-ventilatedpatienttheinnercannulashouldberegularlyremoved,cleanedorchangedatamaximumintervalof4hourlyinapatientwithaproductivechest,andatleast8hourlyinallcases,beingconsiderateofthepatient’sneedforsleepandrest.However,Laws-Chapmanetal(2000)recommendedthattheinnertubeshouldbeinspectedatleast4hourly,ormorefrequentlyifindicated.Ifthepatientappearstobeinrespiratorydistress,theinnercannulaneedstoberemovedandinspectedforencrustationimmediately.Therecommendationsof4-8hourlyinspectionoftheinnertubewillbeusedforthecarebundleincriticalcare.

Forapatientundergoingmechanicalventilation,itmaynotbesafetorepeatedlydisconnecttheventilatorcircuitandchange/cleantheinnertuberoutinely.Cleaningorchanginganinnertubeshouldalwaysrepresentthebestbalanceofrisktopatient.Ifaninnertubeisnotchanged/clean,thenitshouldbeclearlydocumentedandcommunicatedalongwiththerational(NationalTracheostomySafetyProject,2010).

GUIDELINESFORCHANGING/CLEANINGINNERCANNULAESSENTIALEQUIPMENT:

• Steriledressingpack• 0.9%sodiumchlorideorsterilewaterforcleaning• Disposableplasticapron,powder-freeglovesandeyeprotection• Bactericidalalcoholhandrub• TemporaryInnercannulaofthesamesizeasthetracheostomytubethatisinsitu(donot

useaninnercannulafromanewset,asallsetsareevidentlyhandfinished).Preprocedure,preoxygenatepatientifknowntodesaturate,andclearanysecretions.ACTION RATIONALEPerformprocedureusingacleantechnique. Tominimisetheriskofcontamination.

Positionpatientwithneckslightlyextended. Extendingtheneckwillmakeremovaland

insertionofthetubeeasier.Removethedressingpackfromitsouterwrappings.

Putonadisposableapronandeyeprotection.

Minimisecontaminationofsecretionsontonurse.

Cleanhandswithbactericidalhandrub.

Minimisetheriskofinfection.

Putoncleandisposablegloves.

Removetheinnercannulaandifdisposable,disposeinclinicalwaste.Ifnon-disposable,cleancannulawithsterile0.9%sodiumchlorideorsterilewateranddrythoroughly.Donotleavetheinnercannulatosoak.Atemporaryreplacementinnertube(ofthesamesize)canbeinsertedwhilstcleaningtakesplace.Trachy

Soakingtubescouldresultinabsorptionofthesolutionintothematerial,causingirritationtothetrachea,aswellasbacterialcolonizationinstagnantcleaningsolution.Placingatemporaryinnertubereducestheriskoftheoutertracheostomytubeobstructingwhilstcleaningisbeingundertaken.

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cleaningspongescanbeusedtohelpcleaninsideinnertubeifneededReplacethecleaninnertubeandensureitissecuredina‘locked’position.

Documentthetimewheninnercannulawaschanged/cleaned,andthetypeofsecretionsthepatienthas.

Toensurestaffareawareoftheneedforandfrequencyofinnercannulachanges.

DougheryandLister(2011)

CUFFMANAGEMENTThetracheostomycuffprovidesasealtoenablepositivepressureventilationandalsoprovidessomeprotectionagainstaspirationofsecretions.Overinflatedcuffmaycauseischaemiaofthetrachealmucosaandtherebyleadtotrachealstenosis.Toolittlepressuremaymeanthatthecufffailstomakeanadequatesealagainstthetrachealmucosaandthepatientisatriskofaspiration.Thepressurewithinthecuffshouldbecheckedregularlywithahandheldpressuremonometerandshouldnotexceed25cmH₂O(ICS,2014).Cuffpressureneedstobecheckedeachnursingshiftor2-3timesdaily,andfollowinganytracheostomyrelatedintervention,anddocumentedonthechart.Ifanairleakoccurswiththecuffpressureatthemaximumrecommended,thetracheostomymayhavebecomedisplacedormayrequirechangingorresizing,askanaesthetiststoreviewpatient.

2. SUCTIONAneffectivecoughrequirestheclosureoftheglottis,thenthereopeningoftheglottisonceanadequateintrathoracicpressureisachieved.Whenatracheostomyisinsituthemechanismofclosingtheglottisiscompromised,sothepatient’sabilitytoremovesecretionsisreducedastheyareunabletogeneratethehighflowsrequiredforcoughing.Trachealsuctionisanessentialcomponentofmanagingsecretions,maintainingrespiratoryfunctionandapatientairway,DoughertyandLister(2011).However,suctioningmaybebothpainfulanddistressingforthepatient,andcanalsobecomplicatedbyhypoxemia,bradycardia(particularlyinpatientswithautonomicdysfunctionsuchasspinalinjuries),trachealmucosaldamage,bleeding,andintroductionofinfection(ICS,2014).Therefore,thesuctionrequirementsofanindividualpatientshouldbereassessedeachshiftanddocumented(ICS,2008).INDICATIONSFORSUCTIONING

• Coarsebreathsounds(crackles)onauscultation• Noisybreathing• Stridor• Increasedordecreasedrateofrespiration• Decreasedoxygensaturation(Sp0₂)• Copioussecretions• Patientattemptingtocough/clearsecretions• Distress• Poororabsentcough• Deterioratingskincolour

Edgtton-WinnandWright(2005),ChoateandBarbetti(2003).

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SUCTIONCATHETERSIZEChoosingthecorrectsuctioncathetersizedependsonthesizeofthetracheostomytube.Thefollowingformulacanbeusedtodeterminethecorrectsizecatheter:Suctioncathetersize(Fg)=2x(sizeoftracheostomytube–2)Forexample,8.00mmIDtube:2x(8–2)=12Fg(ICS,2008)

SUCTIONPRESSURE

Excessivelyhighsuctionpressuremayleadtomucosaltrauma.Thelowestpossiblevacuumpressureshouldbeused,≤100–120mmHg(13-16kPa),tominimiseatelectasisandmucosaldamage(ICS,2008).

CLOSED-CIRCUITSUCTIONCATHETER

Closed-circuitsuctioncatheteristhepreferredwayofsuctioningamechanicallyventilatedpatientwithinthecriticalcareenvironment.Itisimportantthataclosedsuctiontracheostomycatheterisused,andnotanendotrachealcatheter,sincethesevaryinlength.Usinganendotrachealcatheterwithatracheostomytubecouldleadtodamageofthetrachealmucosaandtrauma.However,ifthepatienthasanadjustableflangedtracheostomytube,thenitmaybenecessarytouseanendotrachealsuctioncatheterduetothelengthoftheflangedtube.Theuseoftheclosed-circuitcatheterreducesthenumberoftimesthepatientisdisconnectedfromtheventilator,avoidingcross-infection,hypoxia,andlossofPEEP.

CLOSED-CIRCUITSUCTIONINGGUIDELINES

ACTION RATIONALEWashhandswithbactericidalsoapandwaterorbactericidalalcoholhandrub,andputonadisposableplasticapron,disposableglovesandeyeprotection.

Tominimisetheriskofcross-infection,incaseofaccidentaldisconnection.

Preoxygenatepatientpriortosuctioningifpatientisknowntodesaturatewithsuctioning.

Toreducetheriskofhypoxiaandarrhythmias.

Turnonthesuctionandcheckthesuctionpressure(≤100-120mmHg,13-16kPa).

Tominimiseatelectasis.

Passtheclosed-circuittracheostomysuctioncatheterintothetracheostomytube,whenthepatientcoughsorthepassageofthecatheterisobstructed,withdrawtipofthecatheterby0.5-1cm

Theclosed-circuitcatheterisinsertedwiththesuctionofftoavoidtrauma.Toreducetheriskoftraumatothetrachealmucosaandcarina.

Takeholdofthetracheostomytubeandclosed-circuitcatheter,applysuctionandwithdrawcatheter,takingnomorethan10seconds.

Tosupporttubeandminimisetheriskofdisconnection.Toreducetheriskofhypoxia.

Repeatthisactionasnecessary,allowingpatienttimetorecoverbetweeneachsuctioning.

Toensuregeneralconditionisstable.

Whensuctioniscomplete,ensureclosed-circuitcatheteriswithdrawnfully,andflushwith0.9%sodiumchloridebyapplyingsuctionwhileflushingviatheinstallationportontheclosed-circuitcatheter.

Toreducetheriskofany0.9%sodiumchloridepassingintopatient’sairways.Toflushsuctioncatheterandtubingafteruseassuringcontinuedpatency.

Laws-Chapmanetal(2000).

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OPENSUCTIONGUIDELINESESSENTIALEQUIPMENT:

• Suctionsource(wallorportable),collectioncontainerandtubing• Disposableplasticapron,eyeprotection,selectionofnon-sterile,powder-free,cleanboxed

gloves• Bactericidalalcoholhandrub• Sterilesuctioncatheters(assortedsizesaccordingtotubesize)• Sterilebottledwater(labelled‘suction’withopeningdate),changedevery24hoursto

preventthegrowthofbacteria

ACTION RATIONALEIfapatienthasafenestratedoutertube,ensurethatanon-fenestratedinnercannulaisinsituforsuctioning.

Suctionviaafenestratedtubeallowsacathetertopassthroughthefenestrationandcausetraumatothetrachealwall.

Washhandswithbactericidalsoapandwaterorbactericidalalcoholhandrub,andputonadisposableplasticapron,disposableglovesandeyeprotection.

Tominimisetheriskofcross-infection.

Ifpatientisoxygendependentpreoxygenatepatient

Minimiseriskofhypoxia.

Ensurethesuctionpressureissetattheappropriatelevel.

Recommendedsuctionpressureis≤100-120mmHg(13-16kPa)tominimiseatelectasis.

Selectthecorrectcathetersize(seeaboveformula)

Incorrectchoiceofcathetersizecancausemucosaldamage.

Opentheendofthesuctioncatheterpackandusethepacktoattachthecathetertothesuctiontubing.Keeptherestofthecatheterinthesterilepacket.Useanasepticnon-touchtechniquethroughout.

Toreducetheriskoftransferringinfectionfromhandstothecatheterandtokeepthecatheterascleanaspossible.

Anadditionalclean,disposableglovecanbeusedonthedominanthandatthisstage.

Tofacilitateeasydisposalofthesuctioncatheteraftersuction.

Removethecatheterfromthesleeveandintroducethecathetertoaboutone-thirdofitslengthorapproximately10-15cmoruntilthepatientcoughs.Ifresistantisfelt,withdrawcatheterapproximately1cmbeforeapplyingsuctionbyplacingthethumboverthesuctionportcontrolandslowlywithdrawtheremainderofthecatheter.

Thecathetershouldgonofurtherthanthecarinatopreventtrauma.Thecatheterisinsertedwiththesuctionofftoreducetheriskoftrauma.

Donotsuctionthepatientformorethan10seconds.

Prolongedsuctioningmayresultinacutehypoxia,cardiacarrhythmias,mucosaltrauma,infectionandthepatientexperiencingafeelingofchoking.

Wrapcatheterarounddominanthand,thenpullbackgloveoversoiledcatheter,thuscontainingcatheteringlove,thendiscard.

Cathetersareusedonlyoncetoreducetheriskofintroducinginfection.

Ifthepatientisoxygendependent,reapplyoxygenimmediately.

Topreventhypoxia.

Rinsethesuctiontubingbydippingitsendintothesterilewaterbottleandapplyingsuctionuntilthesolutionhasrinsedthetubingthrough.

Toloosensecretionsthathaveadheredtotheinsideofthetube.

Ifthepatientrequiresfurthersuction,repeatthe Toensuregeneralconditionisstable.

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aboveactionsusingnewglovesandanewcatheter,andallowthepatientsufficienttimetorecoverbetweensuction.DoughertyandLister(2011).

Anydifficultyinpassingthesuctioncathetershouldleadtoconsiderationthattheinnercannulamaybepartiallyblockedandthereforerequirechanging(ICS,2014).

3. HUMIDIFICATION

Innormalbreathing,inspiredairiswarmed,filteredandmoistenedbyciliatedepithelialcellsinthenoseandupperairway.Cellsintheepithelialliningproducemucus.Atracheostomytubewillby-passthesenaturalmechanismsforwarmingandmoisteninginspiredairandadministrationofdrygascausesphysiologicalchanges.Therefore,humidificationmustbeartificiallysupplementedtoassistnormalfunctionandfacilitatesecretionremoval,Laws-Chapmanetal(2000).Inadequatehumidificationmayleadtolife-threateningblockageofthetracheostomywithtenacioussputum,ulcerationofthetrachealmucosa,sputumretention,atelectasisandimpairedgasexchangeICS(2008).

HumidificationisessentialforALLhospitalisedpatientswithtracheostomies(andlaryngectomies).TheICS(2014)providesausefulHumidificationladderguide:

• Self-ventilatingpatients(nooxygen)–HME(Buchanonbib,Swedishnose)• Self-ventilatingpatientsonoxygen–coldwaterhumidification• Self-ventilatingpatientsonoxygenwiththicksecretions–heatedwaterhumidification• Ventilatedpatient/CPAPcircuit–heatedwaterhumidification(wetcircuit)

Patientswiththicksecretions,orwhorequirehighflowoxygentherapywillrequireheatedwaterhumidification(e.g.FisherandPaykel),andmayrequiresalinenebulisersprescribing.WetcircuitshouldbeusedifCPAPorPositivePressureVentilationisappliedviaatracheostomy.

Whenusingaheatedwaterhumidifier,monitoranddocumenttemperature2hourly,checkwaterlevel,andchangesterilewaterPRN.

HumidificationofinspiredgascanbeachievedinpatientswithminimalorlowoxygenrequirementsusingacoldwaterventurihumidifiersystemconnectedtoaT-pieceortracheostomymask.However,ifwarmedhumidificationisrequired,thiscanbeachievedusingtheAIRVOhumidifier.

4. TRACHEOSTOMYDRESSINGSANDSTOMACARE

Atracheostomyisasurgicalopeningintothetracheaandhenceapotentialrouteofinfection,sotheareashouldbekeptclean.Damagecanalsobecausedtothesurroundingtissuesthroughpressureandthepresenceofirritantsecretions,DoughertyandLister(2011).ICS(2008)recommendsthatthesiteshouldbeassessedandstomacleanedatleastoncein24hoursusingacleantechnique.Whenassessingthewound,ifinfectionissuspected,i.e.theareaisreddened,excoriated,painful,discolouredorexudateispresent,amicrobiologyswabshouldbesentforculture.Toprotectthesurroundingskinfrombecomingredandexcoriated,aCavilonwandcanbeused(Hampton,1998).

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Contraindication:occasionallyasurgicalteammayrequestthattheoriginaldressingremainintactforaperiodoftime.Theremaybeanincreasedriskofbleedingassociatedwiththestomaformationandinthisinstancethedressingshouldnotbechangeduntilconsultationwiththesurgeonhasoccurred(DoughertyandLister,2011).

TRACHEOSTOMYDRESSINGCHANGEGUIDELINES

ESSENTIALEQUIPMENT:• Steriledressingpack• Tracheostomydressingandholder• Cleaningsolution,suchas0.9%sodiumchloride• Bactericidalalcoholhandrub

Thisprocedurerequirestwonurses.Oneisrequiredtoholdthetracheostomyinplace,andtheothertochangethedressing.ACTION RATIONALEWashhandsusingbactericidalsoapandwaterorbactericidalalcoholhandrub,andpreparethedressingtrolley.

Tominimisetheriskofinfection.

Performtheprocedureusingaseptictechnique. Removethesoileddressingfromaroundthetube,cleanaroundthestomawith0.9%sodiumchlorideusinggauze.

Toremovesecretionsandanycrusts.

Replacewithatracheostomydressing. Toavoidpressurefromthetube.Renewtracheostomytapes,checkingthat1–2fingerscanbeplacedbetweenthetapesandneck.

Tosecurethetube.Tominimisetheriskofreducedcerebralbloodflowfromthecarotidarteriesduetoexcessiveexternalpressure.

DoughertyandLister(2011).

5. SAFETY

Thefollowingequipmentshouldbeimmediatelyavailableatalltimesforapatientwithatracheostomy,bothbythebedsideaswellasduringtransfers.SomeequipmentmaybeavailableontheDifficultAirwayTrolley(see*).TheICS(2014)suggeststhata‘tracheostomybox’shouldbeusedtokeepequipmentthatgoeswiththepatientfromcriticalcaretotheward,’includingtransfer.

• Operationalsuctionunit,whichshouldbecheckedatleastdaily,withsuctiontubingattached

• Appropriatesizedsuctioncathetersandyankeurs• Non-powderedlatexfreegloves,apronsandeyeprotection• Sparetracheostomytubesofthesametypeasinserted:oneofthesamesizeandoneasize

smaller• Trachealdilators(availableatthebedsideorimmediatelyavailableontheDifficultyAirway

Trolley,tobeagreedlocally)• Watercircuitandfilter• Cathetermountorconnection• Tracheostomydisconnectionwedge

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• Tracheostomytubeholderanddressing• 10mlsyringe(iftubecuffed)• ScissorsorStitchcutter(iftracheostomytubeissutured)• Oxygentubingandmask• Re-intubationequipment/resuscitationequipment• Trachealhook(seenotebelow)• Intubationdrugsfortransfer• Tracheostomy/Laryngectomyemergencyalgorithm• Tracheostomy/Laryngectomybedsign• Humidificationequipment• Cleanpotforspareinnercannula• Sterilewaterforcleaningthesuctiontubing(labelledanddated,changeevery24hours)• Watersolublelubricatingjelly• Steriledressingpack• Nursecallbell(whereavailable):thepatientmaybeunabletocallforhelpverbally• Communicationaids:thepatientmaynotbeabletoverbalise• Bedsideequipmentchecklist

ICS(2014)

Trachealhookshouldbeavailableonallcriticalcareunit(toanchoranteriortrachealwallduringtubechangesrecommendedbyENTsurgeonsforopenproceduresbutunfamiliartomanyotherstaff).TrachealhooktobeavailableontheDifficultAirwayTrolley.

Anemergencymanagementalgorithmshouldbeavailableatthepatientbedside,atracheostomymanagementalgorithmforatracheostomypatient,andaLaryngectomymanagementalgorithmforalaryngectomypatient.Thetracheostomy/laryngectomybedheadsignshouldcontainkeyinformationregardingthenatureanddateofthetracheostomy,includingemergencycontactdetails,seeappendix1.

Atthebeginningofeachshiftthenurseisresponsibleforcheckingthatallequipmentisavailableandinworkingorderincaseofanycomplicationsarising.

Atransfer/dischargechecklistneedstobecompletedwhentransferringapatientwithatracheostomytoanotherward/hospital,andplacedinthenursingnotesofthereceivingward(appendix2).

6. COMMUNICATION

Whenapatienthasatracheostomy,majorityoftheairisnolongerdirectedthroughthelarynx,sopatientsmaybeunabletocommunicateverbally,especiallywhenthecuffisinflated.EverypatientwithatracheostomyneedstobereferredtoSpeechandLanguagetherapy.

NON-VERBALCOMMUNCIATION

Itisimportantthatnon-verbalcommunicationisfacilitatedfromthebeginning:

• YES/NOquestions• Penandpaper

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• Communicationchart:pictures,alphabetchart

VERBALCOMMUNICATION

PASSYMUIRVALVE(VENTILATORDEPENDENT)/SPEAKINGVALVE(SELFVENTILATINGPATIENT)

Ifapatientisventilatordependent,andfitsthefollowingcriteria,followinganagreementwithasenioranaesthetistandaseniorphysiotherapistaPassymuirvalvecouldbeusedtoaidcommunication(cuffmustbedeflated).Foraself-ventilatingpatient,consideraspeakingvalve.Speakingvalveshouldonlybeusedwithanuncuffedtube,acuffedtubewithcuffdeflatedorafenestratedtracheostomytubewithcuffdeflated,ICS(2014).Priortofittingaspeakingvalve,cuffmustbefullydeflatedandpatientassessedtoensurethereisasignificantleak.

ThePassy-Muirvalveisaone-wayvalvethatallowsventilatedpatienttovocalise.Theairpassesthroughthevalveintothelungsasnormalbuttheone-wayvalveredirectstheexpirationupthroughthevocalcords.ThePassy-MuirvalveshouldonlybeusedwithpatientsonCPAPASBwithaPEEP<10andASB<15andFi0₂<60%.However,theseareonlyguidelines,andthedecisionoftryingthePassy-Muirvalveshouldbedoneonanindividualbasisfollowingdiscussionswithasenioranaesthetistandseniorphysiotherapist.WhenthepatientisusingaPassy-Muirvalvetheventilatoralarmswillkeepalarmingbecausetheventilatorisnotabletodetectanoutbreath,thereforealarmsettingswillneedadjustingtocompensatethis.WhenthePassy-Muirvalveisremovedtheventilatorsettingsandalarmneedtoberesetasbefore.

CONTRAINDICATIONSFORUSINGPASSYMUIRVALVE/SPEAKINGVALVE:

• Unconsciousand/orcomatosepatients• Inflatedtracheostomytubecuff• Severeairwayobstructionwhichmaypreventsufficientexhalation• Verythickandtenacioussecretions• Severelyreducedlungelasticity• Severeaspiration• Notforusewithendotrachealtubes• Lessthan48-72hoursposttracheostomy• Postlaryngectomy• Postheadandnecksurgery

PRIORTOFITTINGPASSYMUIRVALVE/SPEAKINGVALVE:

• Patientisalert• Tracheostomytubewasinsertedatleast48-72hoursago• Allcontraindicationshavebeenoutruled• Thepatient’spulmonarystatusisstable(vitalsigns,O₂saturation>92,respiratoryrate<30,

airwaypatency)• Abletotoleratecuffdeflation• Ventilatorsettingsassessedbyanaesthetist(Ifventilated)• TracheostomytubecuffmustbefullydeflatedbeforeplacingthePassyMuirvalveor

speakingvalve• Iffenestratedtubeinsitu,ensuretheinnertubeisfenestratedforusewithspeakingvalve

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Ifalloftheabovecriteriacannotbemet,donotfitaPassyMuirvalve/speakingvalveatthepresenttime.

Iftheabovecriteriaareallmetyoucanproceedwithcaution,followingagreementwithsenioranaesthetistandseniorphysiotherapist.

WHENFITTINGASPEAKINGVALVE:• MonitorOxygensaturations• Explainproceduretopatient• Suction• Deflatecuff(ifpresent),suction,changeinnertubetofenestrated(ifafenestrated

tracheostomyisinsitu),• Attachspeakingvalveandcontinuetomonitorpatient• Removeifpatientnottolerating

7. SWALLOWING

Patientswithtracheostomiesmayexperienceproblemswithswallowing.Thepresenceofaninflatedcuffcompressestheoesophagus,andmakesswallowingdifficultforsomepatients,increasingtheriskofaspiration.Theriskisgreatestinthosepatientswithassociatedneurologicalormechanicalcauseofdysphagia,orthosewithsignificanton-goingrespiratoryfailures,ICS(2014).Thedecisiontoallowfeedingwithcuffinflatedshouldbemadeonanindividualbasisafteraswallowingassessment.

Ifthepatienthasacuffedtracheostomytubewithcuffinflated,swallowingassessmentshouldbeperformedusingtheBCUHBguidelinesonassessingfordysphagiawithtracheostomytube(seeappendix3a),alongsidetheSwanseatrackingsheet(appendix3c)andresultdocumentedclearlyontheBCUHBassessmentform(appendix3a).Donotattemptaswallowingassessmentifthepatientisdrowsy,semi-consciousordoesnotopeneyestospeech.Ensurepatientisinanupright,supportedpositionpriortocommencingaswallowingassessment.Swallowingshouldbereassessedifcuffisdeflated.

Ifthepatienthasanuncuffedtubeoracuffedtubewithcuffdeflated,thentheswallowingassessmentshouldbedoneusingtheSwanseaSwallowingscreenguidelines(appendix3b)andmonitorusingtheSwanseatrackingsheet(appendix3c).DocumentassessmentandresultontheBCUHBassessmentform(appendix3a).Seeflowchartbelow.

Ifapatientshowssignsofaspirationwhennoneurologicalcomponentpresent,thenitisextremelyprobablethattheywillcontinuetoaspiratewhilethetracheostomytubeisinsituunlessthereisasignificantchangesuchaschangingtoadifferenttypeoftubeordeflatingthecuffifitwasinflated.

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FlowchartforassessingswallowingwithTracheostomypatients:

Ifthepatientfailstoswalloweffectively,thenassessmentbyaspeechandlanguagetherapistisrecommended.Ifneurologicaldysphagiaissuspected,refertoSpeechandLanguageTherapyearly.

TheICS(2014)providedifferentriskfactorsforswallowingproblemsinpatientswithatracheostomy:

• Neurologicalinjury• Disuseatrophy• Headandnecksurgery• Evidenceofaspirationofenteralfeedororalsecretionsontrachealsuctioning• Increasedsecretionload,orpersistentwet/weakvoice,whencuffisdeflated• Coughingand/ordesaturationfollowingoralintake• Patientanxietyordistressduringoralintake• HighFiO₂

SWALLOWINGASSESSMENTFORTRACHEOSTOMYPATIENTINCRITICALCARE

CUFFEDTRACHEOSTOMYTUBEWITHINFLATEDCUFF

UNCUFFEDTRACHEOSTOMYTUBEorCUFFEDTUBEWITHDEFLATEDCUFF

• ASSESSSWALLOWINGUSINGBCUHBASSESSMENTFORDYSPHAGIAWITHTRACHEOSTOMYTUBE(appendix3a)

• RECORDSUCTIONONTHESWANSEATRACKINGSHEET(appendix3c)

• CLEARLYDOCUMENTRESULTONTHEBCUHBASSESSMENTFORDYSPHAGIAWITHTRACHEOSTOMYTUBE(appendix3a)

• ASSESSSWALLOWINGUSINGTHESWANSEASWALLOWSCREENGUIDELINES(appendix3b)

• RECORDSUCTIONONTHESWANSEATRACKINGSHEET(appendix3c)

• CLEARLYDOCUMENTASSESSMENTANDRESULTONTHEBCUHBASSESSMENTFORDYSPHAGIAWITHTRACHEOSTOMYTUBE(appendix3a)

15

REFERENCES.

Dougherty,L.andLister,S.(2011)TheRoyalMarsdenHospitalManualofClinicalNursingProcedures,8thed,Wiley-Blackwell,Chichester.

Choate,K.andBarbetti,J.(2003)Tracheostomy:Yourquestionsanswered.AustralianNursingJournal,10(11),1CU-4CU.

Edgtton-Winn,M.andWright,K.(2005)Tracheostomy:aguidetonursingcare.AustralianNursingJournal,13(5),17-20.

Hampton,S.(1998)Filmsubjectswintheday.NursingTimes,94(24),80-82.

ICS(2008)StandardsfortheCareofAdultPatientswithaTemporaryTracheostomy.IntensiveCareSociety,London.www.ics.ac.uk/intensive_care_professional/standards_and_guidelines/care_of_the_adult_patient_with_a_temporary_tracheostomy_2008

ICS(2014)StandardsfortheCareofAdultPatientswithaTemporaryTracheostomy;STANDARDSANDGUIDELINES.IntensiveCareSociety,London.http://www.ics.ac.uk/ics-homepage/guidelines-and-standards

Laws-Chapman,C.etal(2000)StGeorge’sHealthcareNHSTrust,CareofPatientswithTracheostomyTubes.London:SIMSPortexLtd.

NationalTracheostomySafetyProject(2010)Informationresourceforthesafermanagementofpatientswithtracheostomiesandlaryngectomies.www.tracheostomy.org.uk

PassyMuir(2008)PassyMuirTracheostomyandVentilatorSwallowingandSpeakingValvesInstructionBooklet.

FURTHERREADING

Bernhard,W.N.andCothalis,S.(1985)Intracuffpressuresinendotrachealandtracheostomytubes.Chest,87(6),720-725.

Burglass,E.(1999)Tracheostomycare:trachealsuctioningandhumidification.BritishJournalofNursing,8(8),500-504.

Day,T.,Haynes,S.,Waimwright,S.andWilson-Barnett,J.(2002)Trachealsuctioning:anexplorationofnurses’knowledgeandcompetenceinacuteandhighdependencywardareas.JournalofAdvancedNursing,3991),35-45.

Harkin,H.andRussell,C.(2001)Tracheostomypatientcare.NursingTimes,97(25),34-36.

Hettige,R.,Arora,A.,Ifeacho,S.&Narula,A.(2008)Improvingtracheostomymanagementthroughdesign,implementationandprospectiveauditofcarebundle:howwedoit.ClinicalOtolarynology,33(5),488-491.

McGrath,B.A.,Bates,L.,Atkinson,D.andMoore,J.A.(2012)Multidisciplinaryguidelinesforthemanagementoftracheostomyandlaryngectomyairwayemergencies.Anaesthesia,67(9),1025-1041.

16

Ontherighttrach?Areviewofthecarereceivedbypatientswhounderwentatracheostomy(2014)http://www.ncepod.org.uk/2014report1/downloads/On%20the%20Right%20Trach_FullReport.pdf

Russell,C.(2005)Providingthenursewithaguidetotracheostomycareandmanagement.BritishJournalofNursing,14(8),428-433.

17

Appendix1.

ReproducedfromMcGrathBA,BatesL,AtkinsonD,MooreJA.Multidisciplinaryguidelinesforthemanagementoftracheostomyandlaryngectomyairwayemergencies.Anaesthesia.2012Jun26.doi:10.1111/j.1365-2044.2012.07217,withpermissionfromtheAssociationofAnaesthetistsofGreatBritain&Ireland/BlackwellPublishingLtd."

18

ReproducedfromMcGrathBA,BatesL,AtkinsonD,MooreJA.Multidisciplinaryguidelinesforthemanagementoftracheostomyandlaryngectomyairwayemergencies.Anaesthesia.2012Jun26.doi:10.1111/j.1365-2044.2012.07217,withpermissionfromtheAssociationofAnaesthetistsofGreatBritain&Ireland/BlackwellPublishingLtd."

19

ReproducedfromMcGrathBA,BatesL,AtkinsonD,MooreJA.Multidisciplinaryguidelinesforthemanagementoftracheostomyandlaryngectomyairwayemergencies.Anaesthesia.2012Jun26.doi:10.1111/j.1365-2044.2012.07217,withpermissionfromtheAssociationofAnaesthetistsofGreatBritain&Ireland/BlackwellPublishingLtd."

20

ReproducedfromMcGrathBA,BatesL,AtkinsonD,MooreJA.Multidisciplinaryguidelinesforthemanagementoftracheostomyandlaryngectomyairwayemergencies.Anaesthesia.2012Jun26.doi:10.1111/j.1365-2044.2012.07217,withpermissionfromtheAssociationofAnaesthetistsofGreatBritain&Ireland/BlackwellPublishingLtd."

21

Transfer/DischargeFormforTracheostomyPatient Appendix2.Tobecompletedbythetransferringnurseandtoaccompanythepatientontransfer/discharge.

Tobeplacedinthenursingnotesofthereceivingward/hospital.Name:

Addressographlabel

Dateoftransfer:

Date:

Time:

Transferfrom: Wardreceiving:

Dateoftracheostomy:

Typeoftracheostomy:

Reasonfortracheostomy:

Tubechanged: YesDate: No

Dateofnextchange:

Staysuturestotrachealwall: Yes No

Make/Typeoftube:

Innertube: Yes No

Cuffstatus:inflated? Yes No

Size:

Frequencyrequiredforcleaninginnertube:

Reasonforcuffinflation:

Reasonforcuffdeflation(e.g.uncuffed):

Swallowscreen: YesDate: No

Ifno,why?

Referraltospeechtherapyforformalswallowassessment:

YesDate: No

Typeofhumidification:

PrescribedO2therapy:

Sparetube: Yes

Suction: Yes

Patientmustnotbeleftwithouttheseitems.

Trachealdilators: Yes

Disconnectionwedge: Yes

PleaseseeoverleafforequipmentlistasperICSGuidance

Stomasite:Pleasetick Dry Inflammation Excoriation

Secretions:Type:Amount:

Comments:Signaturetransferringnurse:

Signaturereceivingnurse:

Printname:

Printname:

22

Bedsideequipmentforalltracheostomypatients(Ref:ICS2014)Thefollowingequipmentshouldbeimmediatelyavailableatalltimesforapatientwithatracheostomy,bothbythebedsideaswellasduringtransfers.SomeequipmentmaybeavailableontheDifficultAirwayTrolley(see*):

Operationalsuctionunit,whichshouldbecheckedatleastdaily,withsuctiontubingattachedandYankeursucker

Appropriatelysizedsuctioncatheters Non-powderedlatexfreegloves,apronsandeyeprotection Sparetracheostomytubesofthesametypeasinserted:onethesamesizeandone

asizesmaller Trachealdilators Rebreathingbagandtubing Cathetermountorconnection Tracheostomydisconnectionwedge* Tracheostomytubeholderanddressing 10mlsyringe(iftubecuffed) Resuscitationequipment Trachealhook*(toanchoranteriortrachealwallduringtubechanges

recommendedbyENTsurgeonsforopenproceduresbutunfamiliartomanyotherstaff).

Humidificationequipment Cleanpotforspareinnercannula Sterilewaterforcleaningthesuctiontube Scissorsorstitchcutteriftracheostomytubeissutured) Watersolublelubricatingjelly Steriledressingpack Nursecallbell(whereavailable):thepatientmaybeunabletocallforhelpverbally Communicationaids:thepatientmaynotbeabletoverbalise Bedsideequipmentlist

23

Appendix3a.

Assessed by:

Patient's Label

Date:

Consultant: Medical consent for assessment: YES MDT discussion: YES

Ward:

Type of tracheostomy tube and is it cuffed? Percutaneous or surgically performed

Type:_________ Size:______

cuffed: Yes No Date:_______

Percutaneous o surgical o Is the patient confused?

Yes

No Yes o No o

Any neurological problems, head & neck surgery, Wet/weak voice or drooling?

Yes

No

**If yes then likely to aspirate ** - Refer to SALT for neurological swallowing assessment

Does the patient have any respiratory secretions? What colour and how much?

Yes

No

Secretions thick o looseo Colour………… min / mod / large

Does the patient have pain on dry swallow

Yes

No

**If yes then likely to aspirate **

Does the patient have an ineffective cough?

Yes

No

IF YES TO ANY OF THE ABOVE THEN NEEDS FULL MDT AGREEMENT TO PROCEED NB: Do not assess swallow if patient on ventilator or CPAP with cuff deflated without full MDT agreement. Cuff Inflated - Using water coloured with blue food dye please follow steps 1- 5 over page and record outcome below.FordeflatedcuffpleasefollowSwanseascreenguidelinesandrecordoutcomebelow

Is patient obviously aspirating? Yes No coughing o choking o stridor o hoarseness o wet/gurgly voice o

Evidence of aspiration on suction Yes No Large amt o Mod o Min o

PLEASE RECORD OUTCOME OF SWALLOW ASSESSMENT HERE CUFF INFLATED CUFF DEFLATED

PASS FAIL PASS FAIL • Trial of blue water for 24 hrs • Stop if blue dye on suction. • Record suction on tracking sheet

• Evidence of aspiration • KEEP PATIENT

NIL BY MOUTH • MDT Discussion

• Trial with blue

water for 24 hrs • Stop trial if blue dye

on suction • Record suction on

tracking sheet

• Evidence of aspiration • KEEP PATIENT NIL BY

MOUTH • MDT Discussion

Adapted by Asha Metharam-Jones, Band 7 Respiratory Physiotherapy Clinical Specialist, from the swallowing screening form developed by the Speech and Language Therapy Department from an original idea by Sister Carol Shamas RGN, Ysbyty Gwynedd, Bangor. Combined with The Swansea Tracking Sheet. Version 5.1 - 07/05/15

ASSESSMENT FOR DYSPHAGIA WITH

TRACHEOSTOMY TUBE.

Do not attempt the assessment if the patient is drowsy, semi-conscious or does not open eyes to speech.

Remember to fill in ALL SECTIONS.

Post 24 Hrs Monitoring with trial blue water PASS FAIL

Post 24 Hrs Monitoring with trial blue water PASS FAIL

24

COMMENTSANDADVICE

Signature:

Advice on Conducting Swallow Assessments with Cuff Inflated

1. Obtain medical consent for swallow assessment. 2. Ensure the patient is in an upright position as possible 3. Give the patient 3 teaspoonful of blue water 4. Ensure the patient swallows each mouthful several times before taking the next mouthful. 5. If evidence of aspiration is not immediate wait 5 minutes before suctioning as sometimes

secretions pool at back of throat and it takes a few minutes for aspirant to become evident.

6. If no evidence of aspiration then allow small sips of blue water via cup not straw and

monitor closely for 24 hours 7. Record the monitoring on the Swansea tracking sheet. Stop oral fluids if evidence of blue

dye on suction and refer back to MDT. 8. If they have a speaking tube in situ have the suction tube in place for the initial

assessment so you can suction. If they pass then monitor swallow with speaking valve in situ.

9. Advise the patient not to try to talk while eating and drinking Adapted by Asha Metharam-Jones, Band 7 Respiratory Physiotherapy Clinical Specialist, from the swallowing screening form developed by the Speech and Language Therapy Department from an original idea by Sister Carol Shamas RGN, Ysbyty Gwynedd, Bangor. Combined with The Swansea Tracking Sheet. Version 5.1 - 07/05/15

25

Appendix 3b. Swansea NHS trust. Swallow Screen for Patients with Tracheostomy

(Uncuffed tube or Deflated cuff) (Prior to the commencement of oral feeding)

To be performed by nurses who have attended a dysphagia training session.

1. YES NO 2. Does the patient have any of the following?

YES NO 3. Ensure patient is sitting upright and as straight as possible

4. Deflate the cuff and suction via Tracheostomy tube

YES NO 5. YES

NO

6. If patient is using a fenestrated inner cannula and a speaking valve, put fenestrated tube and valve in place and go to Step 7.

NB – ensure cuff is deflated

Istheremedicalconsentforfullcuffdeflation?

ProceedDeferswallowscreenuntilmedicalconsentobtained

• Headandnecksurgery• Neurologicalsymptoms• Weak/absentcough• Drooling

• Beawarethesepatientsareathighriskofaspirating.Proceedwithcaution

• IfnecessaryrefertoSALT

GotoStep3IsPatient:

Desaturating?Coughing?WetVoice?Distressed?

• Ceasetest• Reinflatecuff.Check

pressureusingpressuregauge

• Resumepreviousrespiratorysupport

• Re-testin24hoursorwhenrequired

Gotostep5CanPatientswallowtheirsaliva?

GotoStep6Proceedwithcaution–thismayindicateaswallowingproblem

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7.Oral Trial

Give patient 1 teaspoon of sterile H₂0 coloured with blue food colouring

Observe for ϴ indicators:-

YES

NO

8.Give patient a further 3 teaspoons of H₂0 coloured blue and observe the above

YES

NO

9.Give patient small sips of H₂0 coloured blue from a cup (no straws or spouted beakers).

YES

NO

10. Trial with teaspoons of yoghurt consistency, dyed blue.

YES

NO

ϴIndicators

• Immediateordelayedcoughing

• Desaturation• H₂0lostfromorheldinthe

mouth• Bluedyefromstomasiteor

suctioning–immediateordelayed(usetrackingsheettoobservecolourofsecretions)

• Ceasetestandinformmedicalteam

• Repeatin24hours• ConsiderSALTreferral

GotoStep8Areϴindicatorspresent?(Seestep7)

CeasetestasStep7GotoStep9Aresecretionsclear(notblue)over24hoursofsuctioningusingtrackingsheet?

GotoStep10ConsiderreferraltoSALTAresecretionsclear(notblue)over24hoursofsuctioningusingtrackingsheet?

• Consideroralintake• Cautiouslyincreasing

quantityandobservingforϴindicatorsasinStep7

• Refertodietitian

• ConsiderreferraltoSALT• ContinuewithH₂0trials

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Appendix 3c. Swansea NHS Trust

Blue Dye Tracking Sheet

A speech and language therapist or a nurse who has attended a dysphagia training session should perform the Modified Evans Blue Dye Test.

Name:

Hospital Number:

Ward:

Date of Test:

Trialled with:

Consistency:

Amount:

SUCTION

Blue Dye Presence at Suction

Date Time None Minimal Intermittent trace

Moderate Consistently tinged blue

Significant Consistently concentrated

Signature

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