Management of Patient with Tracheostomy

1. Management of Patient with Tracheostomy Maya Govender Practice Educator – CTICU Foundations of Critical Care (FCCN) 17th January 2018

2. Learning Outcomes • List the indications for a tracheostomy • List the types of different tracheostomy tubes • List the bed side equipment for a tracheostomy tube • Explain how to decannulate a patient from with a tracheotomy tube • Documentation

3. A tracheostomy is an artificial surgically created airway fashion by an hole in the anterior wall of the trachea and the insertion of a tracheostomy tube, which may or may not be permanent What is a Tracheostomy?

4. Indications • Upper airway obstruction secondary to: trauma, burns corrosive poisoning laryngeal dysfunction foreign body infections, inflammatory conditions obstructive sleep apnoea • Access for pulmonary toilet • Prolonged ventilation support • Airway protection in head injury or comatose patient

5. Advantages of Tracheostomy • Increased patient mobility • More secure airway • Increased comfort • Improved airway suctioning • Early transfer of ventilator dependent patients from ITU • Enhance communication • Assists in weaning from the ventilator • Decreased risk of pneumonia

6. How to create a Tracheostomy • Percutaneous Tracheostomy Can be done in the ITU at the bedside • Surgical Tracheostomy • Cricothyroidotomy For urgent procedures

7. Anatomical position oftracheostomy tube

8. Types of tracheostomy tube used on the unit • Portex blue line without inner tube • Portex blue line ultra with inner tube • Portex blue line ultra fenestrated tube with fenestrated and clear non fenestrated inner tube • Portex blue line adjustable flange tube

9. Tube sizing ICS, 2008 The essential principles of tracheostomy care / St George’s University Hospitals NHS Foundation Trust

11. Flange 15mm connector Shaft Cuff Obturator Pilot balloon

12. Cuff Tracheostomy tube • Cuffed tracheostomy tubes: allow airway clearance protect from aspiration positive airway pressure ventilation • It is recommended that cuff pressure be maintained 20 – 25 cmH02

13. Fenestrated Trachesotomy Tube • The fenestrated tracheostomy tube is similar to the standard tracheostomy tube with the addition of the opening in the posterior portion of the tube above the cuff

14. Fenestrated Tubes • This allows for assessment of the patient's ability to breath through the normal oral/nasal route • Preparing the patient for decannulation • Patient can talk with the Fenestrated Tube

15. Air flow with a fenestrated tube

16. Longer tubes The essential principles of tracheostomy care / St George’s University Hospitals NHS Foundation Trust

17. Impaired humidification • Increased viscosity of mucus • Depressed ciliary function • Increased risk of infection • Micro-atelectasis • Impaired secretion removal • Obstruction of major airways • Tube blockage • Decreased cough • Infection Presentation title / St George’s University Hospitals NHS Foundation Trust

18. Humidification • Systemic humidification • Humidify gases • Nebulise • HME and protection from particulate matter The essential principles of tracheostomy care / St George’s University Hospitals NHS Foundation Trust

19. Suctioning • Assessment needed • Reserved for patients unable to clear own secretions • Cough yankeur suction • Pre-oxygenate? • 10-16kPa vacuum • ID mm -2 x2  • Insert 10-15cm, stop if resistance felt and withdraw 2cm The essential principles of tracheostomy care St George’s University Hospitals NHS Foundation Trust

20. Equipment at the bedside Rebreathe bag, catheter mount, face mask • Ambubag & mask • Working suction, yanker and suction catheters • Tracheal dilators • 2 spare tracheostomy tubes one the same size and one smaller (of the same type of trachy tube in situ) • 10 ml syringe • Clean gloves, aprons and eye protection • Humidification – HME, wet humidification Poster

21. Care • Inner cannula • Routine use • Inspected four hourly • Cuff • Cuff manometer (20-25cmH2O) • Oral hygiene • Acutely ill patients four - six hourly • Oral fluids where possible The essential principles of tracheostomy care / St George’s University Hospitals NHS Foundation Trust

22. Procedure for cleaning inner tube Wash hands, apply gloves, apron & eye protection • Remove inner tube and replace with the spare inner tube • Rinse the tube through with the sterile water using the disposable bowl • If necessary remove secretions with swabs and rinse with water • Dry with clean gauze • If the inner tube remains soiled and cleaning is ineffective dispose of this inner tube and replace with a new inner tube.

23. Dressing and fixation The essential principles of tracheostomy care / St George’s University Hospitals NHS Foundation Trust

24. Swallow • Cuff will interfere with swallowing mechanics of larynx • The muscles can waste if not used • Predictors of swallowing difficulty: • Head and neck surgery • Lower cranial nerve palsy • Clinical signs of aspiration • Weak wet or gurgly cough during trials of cuff deflation The essential principles of tracheostomy care / St George’s University Hospitals NHS Foundation Trust

26. Speaking valve The essential principles of tracheostomy care / St George’s University Hospitals NHS Foundation Trust

27. Weaning • Cuff deflation • One way (speaking) valve • Change to a cuffless tube (if needed) • Downsize tracheostomy (if needed) • Capping (if needed) • Decannulation • Airway Patency • Resolved Condition • Effective Cough Strength • Following MDT Discussion The essential principles of tracheostomy care / St George’s University Hospitals NHS Foundation Trust

28. Decannulation of tracheostomy tube Prior to removal patient should: • Be alert and orientated • Have a good cough reflex and managing secretions • Be breathing spontaneously with the cuff deflated • Have a normal respiratory rate, good Spo2 saturations. Check blood gases • Require less than 40 % oxygen via trachy mask • Have anaesthetic review & decision to remove tube agreed with team

29. Decannulation of tracheostomy tube Ensure all emergency equipment is at hand: • Rebreathe bag, catheter mount & face mask • Ambu bag & mask • Working suction, yanker and suction catheters • Tracheal dilators, 2 spare tracheostomy tubes one the same size and one smaller (of the same type of trachy tube in situ) • 10 ml syringe, clean gloves, aprons and eye protection face mask and oxygen for use following decannulation

30. Decannulation of tracheostomy tube –(continued) • Ensure cuff is already deflated before removal of tracheostomy • Have emergency equipment attached and ready for use • Connect humidified facial oxygen mask for use after decannulation • Explain the procedure to the patient • Sit patient upright • Suction the mouth and down the tracheostomy tube

31. continued • Pre oxygenate the patient for 1-2 minutes • Re check respiratory rate, colour and saturations • Remove tube • Place occlusive sterile dressing over stoma • Place oxygen mask on patient • Continue monitoring respiratory rate, saturations and patient colour for any changes.

32. Post Decannulation Observations The patient should be observed for signs of respiratory distress including: • Dyspnoea • Laboured or noisy respiration, stridor • Increased respiratory rate and heart rate • Excess use of accessory muscles • Diaphragmatic respiration • Agitation • Oxygen desaturation

33. https://www.stgeorges.nhs.uk/gps-and-clinicians/clinical-resources/tracheostomy-guidelines/https://www.stgeorges.nhs.uk/gps-and-clinicians/clinical-resources/tracheostomy-guidelines/

34. Presentation title / St George’s University Hospitals NHS Foundation Trust

35. Documentation • ICP • Type and size of tracheostomy • Tracheostomy procedure • Patent/non patent upper airway • Equipment check • Care record inc. inner cannula, cuff and suctioning • Weaning record The essential principles of tracheostomy care / St George’s University Hospitals NHS Foundation Trust