The basic principles of nursing care and monitoring for patients with tracheostomies
Dan Higgins,RGN, ENB 100, ENB 998, is senior charge nurse, critical care, University Hospitals Birmingham NHS Foundation Trust.
Higgins D (2009) Basic nursing principles of caring for patients with a tracheostomy. Nursing Times; 105: 3, 14-15.
This one-part unit outlines background information to complement a series of Practical Procedures articles, starting in next week’s issue, on caring for patients with a tracheostomy. This article outlines general principles of tracheostomy care, while the series details specific procedures such as suction, inner tube change and dressing.
A tracheostomy is an opening into the trachea. The patency of this opening is usually maintained by inserting a specifically designed plastic tube (tracheostomy tube). Tracheostomies, in the main, are temporary procedures performed when indicated (see Box 1). However, some patients, such as those who have undergone laryngectomy, may have a permanent stoma, which may or may not have a tracheostomy tube in situ. Box 1 outlines indications for the procedure.
Box 1. Indications for tracheostomy
A tracheostomy is usually performed as a surgical procedure in an operating theatre, although percutaneous methods are used in critical care areas.
Tracheostomies are commonplace in critical care units and ENT departments. They are also becoming increasingly common in acute hospital settings and the community (Serra, 2000). However, there is evidence of a lack of knowledge and skills when caring for patients with tracheostomies outside specialist areas (Russell, 2005; Heafield et al, 1999). Given the morbidity and mortality associated with inappropriate or inadequate tracheostomy care, the need for specialised support is obvious (Russell and Harkin, 2001).
Essential care principles
The essential principles when caring for patients with a tracheostomy are based on maintaining patient safety, facilitating communication and preventing complications associated with the procedure.
Airway occlusion is the most serious complication arising from a tracheostomy. It is a medical emergency and can result in cardiac arrest (Woodrow, 2002). Patients with a tracheostomy should be nursed under close observation, in an area with functional oxygen and suction apparatus. Basic vital signs monitoring, particularly respiratory rate, should be complemented by more advanced monitoring such as pulse oximetry.
Nurses caring for tracheostomised patients should be skilled and competent in all aspects of care. They should be able to detect partial and total airway obstruction and should also have the necessary skills to secure an airway if this occurs.
The most common cause of obstruction is a build-up of respiratory secretions in the tube. Suction via the tube can immediately remedy this.
Most tracheostomies are of an ‘inner tube design’ - where a small plastic inner tube sits inside a larger one. If partial/total occlusion is suspected, this inner part can be removed and a temporary spare inner tube will replace the occluded one, creating a clear route. These spare tubes should be kept nearby in the patient’s bed space.
If the tube is not an inner tube design and occlusion is evident, the tube should be removed and the patient’s ability to breathe without the tracheostomy should be assessed.
In some patients the stoma may be patent, and/or they may be able to breathe through the normal route.
However, if this is not the case - which is particularly likely if the tracheostomy is permanent - tube reinsertion will be required. If the stoma is patent, a tube of the same size can be reinserted without difficulty. However, it may only be possible to insert a smaller tube until more experienced help arrives. Tracheal dilators may be of some use to dilate the stoma and these should be kept nearby in the bed space, alongside spare tubes of the same and smaller size.
The provision of humidification to prevent drying of secretions and suction, as required, to clear secretions will go some way to preventing tube occlusion.
There are many devices available, which can provide humidification. These range from water humidifiers to small heat moisture exchange units or foam ‘protection bibs’. In most acute situations cold water/aerosol devices are used, particularly as this can facilitate fixed-rate oxygen delivery.
The majority of patients with tracheostomies will be unable to speak, as the tube/stoma is positioned below the level of the vocal cords. However, this is not always the case. A patient may breathe around the tracheostomy, particularly if the tube does not have a cuff, or the cuff is deflated. In some cases exhaled air passes through specially designed holes in the tube (fenestrations) and through the vocal cords. Specific ‘speaking valves’ have also been developed to allow patients to talk.
Effective communication can be a challenge with patients with tracheostomies, and written and other non-verbal communication strategies are necessary. Many nurses experienced in caring for this group of patients develop considerable ‘lip-reading’ skills, which are of great value. Regardless of the communication strategies used, nurses must always consider how the loss of speech will affect patients and the anxieties this may evoke. If permanent tracheostomy is planned, as in the case of laryngectomy, specific counselling and psychological support will need to be in place for some time before the procedure.
Most of the nursing problems that arise after tracheostomy are due to the upper airway being bypassed, resulting in reduced ability to heat, moisten and filter incoming gases and to cough (Serra, 2000). This can lead to retention and ‘drying out’ of secretions, leading to potential infection. The provision of humidification and tracheobronchial toilet can reduce this risk. The procedure of tracheostomy suction will be discussed separately in the Practical Procedures series.
The importance of involving physiotherapists in the management of tracheostomised patients cannot be overstated.
Physiotherapists can advise on suction techniques, patient positioning and optimal respiratory therapy, in addition to assessment and treatment.
It is not uncommon for tracheostomy tubes to become displaced. If this occurs, urgent assessment of the patient’s ability to maintain an airway should be undertaken - assessing airflow via the tube can give some indication of tube position. If the tube is displaced appropriate action to maintain an airway should be implemented as outlined above. Expert help should be sought immediately.
Other complications of tracheostomy
Other possible complications include:
Constipation - the ability to increase intrathoracic pressure, an action generally required to defecate, is lost;
Altered body image - patients’ ability to adjust to altered body image is made especially difficult by the communication challenges presented. Specific counselling/psychological support may be needed;
Dysphagia - a tracheostomy tube can hinder swallowing. The presence of a tracheostomy does not necessarily preclude patients from eating or drinking, however, some experience difficulty. Specialist advice from a speech and language therapist may be needed. Comprehensive nutritional assessment should be undertaken and supportive therapy started as necessary;
Haemorrhage - from the procedure;
Ulceration - potentially leading to tracheal stenosis;
Development of granulomas (a mass of inflammatory tissue that forms in response to the tube) and other pathologies can also impact on both respiratory and swallowing function (Denison, 2004).
Tracheostomy care needs a multidisciplinary approach, particularly from physiotherapists and nurse specialists. Critical care outreach/patient at-risk teams can also provide vital support and education to ward areas. They should be accessed from the outset of care, and if the device is permanent, support continued beyond discharge.
Nursing patients with a tracheostomy can be challenging. Since such patients are becoming more common in acute areas, nurses must ensure that knowledge and skills are maintained both from a theoretical and practical perspective. Practitioners who care for this group must have received approved training. The onus is also on individual nurses to ensure that care is delivered according to organisational protocols, policies and guidelines.
Related article on NursingTimes.net: Decannulation of patients with long-term tracheostomies
Related article on NursingTimes.net: The benefits of tracheostomy specialist nurses
Denison, S. (2004) Decannulation of patients with long-term tracheostomies. Nursing Times; 100: 38, 58.
Heafield, S. et al (1999) Tracheostomy management in ordinary wards. British Journal of Hospital Medicine; 60: 4, 261-262.
Russell, C. (2005) Providing the nurse with a guide to tracheostomy care and management. British Journal of Nursing; 14: 8, 428-433.
Russell, C., Harkin, H. (2001) The benefits of tracheostomy specialist nurses. Nursing Times; 97: 46, 40-41.
Serra, A. (2000) Tracheostomy care. Nursing Standard; 14: 42, 45-52.
Woodrow, P. (2002) Managing patients with a tracheostomy in acute care. Nursing Standard; 16: 44, 39-46.