Brendan Docherty, MSc, RN, PGCE.
Cardiology and Critical Care Manager, Queen Elizabeth Hospital NHS Trust, London
Tracheostomies are becoming increasingly commonplace both within the acute hospital setting and in the community (Serra, 2000). It has also been recognised that very seriously ill patients are increasingly being nursed outside the critical care environment (DoH, 2000). As a result, there is an expectation of increased knowledge and more advanced nursing and health-care skills in ward staff caring for these patients (DoH, 2000; DoH, 2001).
Nurses must be able to readily identify the needs of tracheostomy patients. They should apply evidence-based practice to care to ensure the patient’s condition does not deteriorate and that he or she is supported to achieve adequate respiratory function. Readmission to an intensive care unit (ICU) following a respiratory arrest caused by a blocked tracheostomy is common and well documented (Day, 2000).
To investigate current knowledge on the subject a literature search was undertaken. Medline, Cinahl and Cochrane databases were searched for the years 1995 to 2002. The key words used were ‘tracheostomy’, ‘humidification’, ‘suctioning’, ‘respiratory assessment’ and ‘critical care’. All terms were exploded and subsets included. The yield was high in terms of case studies, physiology papers and psychomotor skill attainment. The papers were retrieved and critiqued for robustness and application to ward patients using the model provided by Benton and Cormack (2000), and are considered throughout this paper.
Tracheostomy is a surgical opening in the anterior wall of the trachea, inferior to the cricoid cartilage, which is created for airway maintenance, clearing of secretions or as an emergency procedure for upper airway obstruction (Mallett and Dougherty, 2000; RCUK, 2000).
Most tracheostomies are temporary following respiratory failure and weaning from mechanical ventilation or following trauma or oromaxillofacial surgery where there is a potential risk to airway patency or protection. Some are permanent, for example following laryngectomy (Mallett and Dougherty, 2000; RCUK, 2000).
Several types of tracheostomy tube are available; they may be made of metal or plastic, cuffed or uncuffed, and have a single or double lumen (Figure 1). Some may also be fenestrated (the tube has holes that allow for speech when the cuff is deflated). Fenestrated, double-lumen tubes are considered the safer option for general ward patients as they have a removable inner tube to allow for cleaning and can aid communication (Thelan et al, 1998; Harkin, 1998). However, the effort required to breathe is slightly increased due to the narrower lumen. Some patients may therefore not tolerate these, particularly if their underlying respiratory pathology has not resolved. All patients must be assessed carefully to ensure that their tracheostomy is suited to their needs at that particular time.
Anatomy and physiology
The larynx (sometimes called the voice box) connects the pharynx to the trachea (Tortora and Grabowski, 2001). The trachea is separated from the larynx by the vocal cords. The oesophagus is situated posterior to the trachea (Tortora and Grabowski, 2001) (Figure 2).
A tracheostomy is created by a surgical incision from the skin into the tracheal wall, and reduces the anatomical dead space of the upper airway by approximately 150ml (Serra, 2000). This is usually performed 10 to 14 days after initial intubation if respiratory support is expected to continue (St John, 1999).
Cleaning and securing
A tracheostomy incision is a surgical wound and therefore prevention of infection is paramount. Obvious indicators that infection of the tracheostomy incision has occurred include (Gould, 2001):
- A purulent discharge
- The patient reporting pain
- An odour develops
- Abscess formation
- Cellulitis and discoloration.
Good practice in wound cleaning includes keeping the patient’s environment clean, good hand hygiene, strict asepsis when cleaning wounds, not changing the dressing unless it is necessary and using non-adherent dressings to prevent trauma to healing wounds (Blunt, 2001; Gould, 2001). The aim is therefore to clean the tracheostomy only if it is indicated, and to maintain a moist wound-healing environment (Gould, 2001).
Normal saline (0.9%) is advocated for cleaning rather than antiseptics and disinfectant agents (Blunt, 2001), with irrigation and swabbing being the two most common techniques used (Blunt, 2001). However, swab-cleansing wounds with cotton wool and gauze may leave fibres and can increase the incidence of infection. Irrigation therefore should be initially considered (Blunt, 2001).
In critical care settings, where most tracheostomies are performed, nosocomial infection rates are higher than in ward settings due to the use of multiple-antibiotic therapies, invasive monitoring and endotracheal intubation (Platt, 2001). The likelihood of acquiring methicillin-resistant Staphylococcus aureus (MRSA) in the tracheostomy site may therefore be higher when the patient leaves a critical care area to be nursed in a ward (Platt, 2001). This patient may then require isolation, presenting the ward-based staff with the challenge of caring for the tracheostomy patient in a side-room, where direct observation may not be continuous.
Securing the tracheostomy
Measures to secure the tracheostomy tube are vital to prevent it becoming dislodged or removed altogether. This procedure should always be performed by two people to prevent accidental tube removal during patient movement or coughing. The type of dressing used may depend on local facilities, but the use of a specially designed Velcro tracheostomy holder, together with a non-adherent dressing (such as Lyofoam) (Figure 3) is desirable as it provides optimal patient comfort and is easy to apply (Harkin and Russell, 2001).
Where traditional tape is used, it is important to ensure that, in securing the tube, a reef knot is tied at each side of the neck as opposed to near the flange of the tracheostomy tube (St George’s Healthcare, 1997). This prevents pressure on the spinal column and ensures that the tube remains in central alignment. The tapes should be tight enough to enable two fingers to be inserted between the tape and the neck. Patients with longer term tracheostomies may not require a dressing underneath the flange once the stoma site has healed and secretions around the site are minimal. This may also be the case for the few patients who have a tracheostomy stitched in place.
Suctioning - Always encourage a patient to cough up secretions (Thomson et al, 2000). However, if a patient is unable to clear respiratory secretions, especially if he or she has a chest infection, then stimulated cough and suction of the bronchial tree will be necessary at regular intervals, as clinically indicated, to maintain airway patency. Suctioning should never be a routine procedure, and should be tailored to the individual patient and clinical situation (Buglass, 1999). Ideally, a maximum of two suction catheter passes should be used (Thomson et al, 2000). Repeated attempts may result in detrimental cardiovascular changes (Thomson et al, 2000).
Some common indications for suction are listed in Box 1. Although suctioning can be performed in any position, the Fowler’s position (sitting with the back at right angles to the legs, or as near as possible) with a neutral head alignment will optimise the procedure (Proehl, 1999).
Hyper-oxygenation is recommended before and after suctioning (usually with 100% oxygen therapy) to prevent hypoxia related to the suctioning procedure and the risk of vasovagal incidence (Adam and Osborne, 1997; Buglass, 1999; Thomson et al, 2000). The level of pre- and post-oxygenation must be carefully considered in patients with chronic obstructive airway disease, as these patients may not tolerate increased oxygen saturation (Thomson et al, 2000). However, a general indicator may be that such patients can tolerate 20% above their current oxygen therapy.
Hyperinflation using a rebreathe bag is also sometimes recommended before and after suction to decrease the risk of hypoxia and to re-open any collapsed alveolar spaces following negative pressure suction (Adam and Osborne, 1997). A physiotherapist or other respiratory practitioner/specialist would usually perform this manoeuvre in the ward.
Suction pressure should be checked before suctioning to reduce barotrauma and minimise the risk of mucosal damage. This is done by switching the suction on, occluding the suction tubing and reading and altering the gauge to approximately 100mmHg negative pressure (14kPa) (Adam and Osborne, 1997; Buglass, 1999; McEleney, 1998).
The suction catheter size should be no more than half the diameter of the tracheostomy tube to avoid greater negative pressure and to minimise falls in arterial oxygen (Thomson et al, 2000). Therefore, no greater than a size 12 French gauge suction catheter should be used for a size 8 tracheostomy tube. Multiplying the tracheostomy size by three, and then dividing by two will calculate this. The suction catheter should have multiple eyes to minimise mucosal trauma (Buglass, 1999).
The suction catheter should be inserted using an aseptic technique (Thomson et al, 2000), until resistance is met (at the bifurcation of the trachea). The catheter should then be withdrawn one to three centimetres before the application of negative suction pressure, thus preventing tissue damage at the bifurcation point (McEleney, 1998). The suction pressure is then applied on withdrawing the catheter only. It is not necessary to rotate the catheter in the fingers as withdrawal takes place if the preferred multiple eyelet catheters are being used (Day, 2000). The suction should be applied constantly, but the complete suction procedure time should not exceed 10-15 seconds to ensure that prolonged suctioning does not lead to hypoxia and potential bradycardia (Adam and Osborne, 1997; Buglass, 1999). If the patient has a fenestrated tube, the inner tube with no hole should be in situ during suction in order to prevent the suction catheter gaining access to the tracheal wall, which could result in mucosal damage (Harkin, 1998).
Gloves and aprons should be worn as part of normal universal precautions, with a sterile disposable glove donned on top of the hand touching the catheter for insertion and withdrawal - this is usually the practitioner’s dominant hand. Protective eyewear should also be worn. These actions will minimise contamination and increase safety (Buglass, 1999; Day, 2000).
The normal mechanisms of warming and humidifying air as it is breathed are bypassed while a tracheostomy is in place (Harkin and Russell, 2001). Dry gases can damage ciliary function. Therefore dry humidification (provided by a thermovent for use with respiratory support equipment or a ‘Swedish nose’ for self-ventilating patients) (Figure 4) or wet (water bath) humidification, should be provided for all tracheostomy patients (Docherty, 2001; Jevon and Ewens, 2001). This minimises the risk of developing thick and tenacious secretions and thus reduces the risk of tube blockage.
Nebulised saline can also be useful (using a flow rate greater than 6L/min) but the instillation of saline boluses before suctioning for the thinning of tenacious secretions is controversial (Ackerman, 1993). The use of adequate systemic hydration and continuous airway humidification therefore should be used instead, based on the assessment of need of each individual patient (Proehl, 1999). Adequate hydration of the oral mucosa is important as dry gases and the inability to take oral diet or fluids can lead to oral drying and discomfort. This can in turn increase the susceptibility of the individual to infection (Xavier, 2000). Oral discomfort can also have psychological effects, which need to be considered as part of the holistic care of the patient.
Inner tubes - Cleaning of the inner tube should also be performed where possible in the Fowler’s position with neutral head alignment (Proehl, 1999). This should be carried out every four hours or when indicated by signs of respiratory distress (Harkin, 1998).
After preparing the patient, yourself and the required equipment, unlock the inner cannula (usually by turning anti-clockwise). A spare inner tube should be inserted into the tracheostomy while the inner tube is being cleaned. The tube should be placed under running tap water to clean the inner aspect of the tube (Harkin and Russell, 2001a; Harkin, 1998). Some authors also advocate the use of a pipe cleaner or brush to gently clean the inside and remove any encrustations (Proehl, 1999). However, this may cause abrasion to the side of plastic tubes and increase the effort that is required to breathe through them (Serra, 2000). This method should therefore be considered only in tubes where encrustation is difficult to remove. Rinse and dry well with clean gauze before reinserting into the outer tracheostomy, and turn clockwise to lock it into position (Figure 5). Patients will often require suctioning following this procedure as it may stimulate a cough and the production of secretions.
Respiratory observations - The literature has identified that respiratory observations are not practised frequently and therefore respiratory compromise and dysfunction may go unnoticed until a critical event happens (Kenward et al, 2001). Respiratory rate is a sensitive measure of respiratory deterioration (Jevon and Ewens, 2001). Respiratory assessment is described in Box 2.
A respiratory rate of less than eight breaths a minute (hypoventilation) will lead to a build up of carbon dioxide (CO2) in the blood, resulting in a high CO2 level and respiratory acidosis (RCUK, 2000). Respiratory acidosis can be managed using techniques such as deep breathing exercises and clearing any obstruction (RCUK, 2000; Smith, 2000). A respiratory rate greater than 30 breaths a minute (hyperventilation) will lead to a low CO2 level and resultant respiratory alkalosis (RCUK, 2000). Blood acid-base disturbances will alter metabolic and cellular function and can lead to oxygenation problems in the patient.
Cuff management - Some tracheostomy tubes have a cuff - a balloon inflated with air that occludes the area of the trachea around the tube thus allowing mechanical ventilation without leakage and preventing gastric aspiration, as well as ensuring that it remains in position.
If the patient is at risk of aspiration due to neurological deficits or dysphagia, or if continued respiratory support in the form of continuous positive airways pressure (CPAP) or non-invasive positive pressure ventilation (NIPPV) is required the cuff will usually need to remain inflated.
Patients with inflated cuffs must have the cuff pressure checked daily to prevent any leaks and to ensure that capillary closing pressure of 24-30cmH2O is not exceeded as this may cause tracheal tissue damage (St John, 1999). This is done using a cuff pressure manometer (Figure 6). Air is then inserted or removed using a 10ml syringe until the minimum amount required preventing any leak is ascertained. Placing a stethoscope over the patient’s trachea, and asking him or her to breathe out as you deflate the cuff may allow you to assess this. When air-rushing/bypassing is heard, 1ml of air should be inserted. This is known as achieving the minimal occlusion volume (Harkin, 1998; St George’s Healthcare, 1997). If in order to achieve this the cuff pressure exceeds 30cmH2O the medical staff should be informed as a larger tracheostomy may be required.
Both swallowing and verbal communication are affected by an inflated cuff, so achieving cuff deflation is a priority once the patient is considered ready. This is usually following a swallowing assessment by a specifically trained nurse or speech-and-language therapist. Blue-dye tests are commonly used to assess this, although there have been reports that the sensitivity of this method is low (St John, 1999). Until they are assessed, patients should usually be kept nil by mouth with the cuff inflated. Before deflating the cuff the patient should be suctioned as secretions may accumulate above the cuff and enter the lungs on deflation (Harkin, 1998; St George’s Healthcare, 1997).
Once the cuff is deflated speech is possible with the use of a fenestrated tube, which allows air to flow past the vocal cords during expiration. Speaking valves are also available to aid the process and help to maintain adequate air pressures to aid effective swallowing (Dikemann and Kazandjian, 1995).
There is always a risk that a tracheostomy tube may become blocked, dislodged or removed completely or that the condition of the patient may deteriorate. All of these are emergency situations, which the nurse must watch for. If an emergency occurs, then your hospital medical emergency team or critical care outreach team should be summoned urgently. In cases where a complete blockage or tube removal occurs, the senior anaesthetist should be summoned. Table 1 provides a safety checklist.
The number of patients being nursed in ward areas with tracheostomies is increasing. Nurses have a professional responsibility to ensure that they can respond to this need and are able to provide competent, evidence-based care for these individuals (NMC, 2002). The importance of the role of the nurse in this area of care has also been recently highlighted by Department of Health documents, which address the needs of critically ill patients outside traditional locations (DoH, 2000; DoH, 2001).
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