These guidelines aim to standardise adult tracheostomy care. The guidelines do not cover care of either the paediatric patient or patients in the community with a tracheostomy. The information in this document is comprehensive but not exhaustive and details best practice at this time; however, deviation from these guidelines may be required based upon individual patient assessment and clinical judgment.

Introduction

The multi-disciplinary group advocates that, due to knowledge and skills, patients with a tracheostomy tube are only nursed on specific wards/units. The designated wards/units are ITU, Ward 11, Ward 9, MADU.

Tracheostomy patients are all discussed in our weekly MDT meetings, held via Teams. The MDT Team consists of:

Mr Moorthy Head and Neck Consultant

Piotr Szawarski ITU Consultant

Bally Sall Head/Neck CNS

Celia Cullen Head/Neck CNS

Amy Rock Senior Physiotherapist

Verity Stokes and James Martin Senior Speech and Language Therapists

Ward staff from MADU/Ward 11/Ward 9 and ITU attend when they have a pt with an altered airway.

The team above is dedicated to the care of Patients with an altered airway and has developed the tracheostomy policy, set up the weekly MDT, and organizes and delivers a study session twice a year in the Post Grad Medical Centre.

The team has been chosen to be part of the Global Tracheostomy Collaborative (GTC) for standardising and improving Tracheostomy Care.

Data has been collected from July 2017 to Dec 2018.

Tracheostomy: Definition

A tracheostomy is an incision into the trachea through which a tracheostomy tube is inserted. A tracheostomy bypasses the protective mechanisms of the upper airway and knowledge of airway management is an essential component of caring for tracheostomised patients.

A tracheostomy may be performed

• to provide and secure a patent airway where there is an absence of laryngeal reflexes

• to bypass any obstruction of the upper respiratory tract

• to facilitate aspiration of bronchial secretions

• to enable weaning from positive pressure ventilation or facilitate long-term intubation in patients with respiratory failure

• as part of a laryngectomy where the patient has a permanent tracheostomy fashioned.

A fenestrated tube has an opening midway down the tube to aid speaking (by allowing air flow to the larynx) or future decannulation, by encouraging air and secretions to pass into the oral and nasal passages. Any tube which does not have a midway opening is a non- fenestrated tube.

Cuffed fenestrated Tracoe Tube

Uncuffed Fenestrated Tracoe Tube

Moore Tube

This is a long term tube which must be changed every 6 months

Silver Negus

This is a long term tube

Passy Muir Speaking Valve

To only be used when the cuff is deflated and to be removed at night

Adjustable Flange Tracheostomy Tube

For patients who require a longer tube

The tracheostomy tubes discussed above may come with a removable and disposable inner cannula in situ. These are not interchangeable between manufacturers. The inner cannula is an essential safeguard against emergency and life-threatening tube obstruction and must be present at all times. The use of tracheostomy tubes without an inner cannula in the ward environment should be avoided and should be changed as soon as possible to a double lumen tube.

Subglottic Tubes

When a tracheostomy is cuffed, it prevents air flow to the nose and mouth, bypassing the larynx, which means patients cannot vocalise and the ability to communicate is impacted. This can negatively affect psychological well-being, delirium and mood leading to anger, frustration and withdrawal.

Above-cuff vocalisation may be beneficial for such patients. This technique uses the subglottic suction port of specific tracheostomy tubes to deliver a low flow of gas (air or oxygen) back up through the subglottic port, which exits above the cuff. This flow is then directed up through the larynx passing through the vocal cords. This can result in audible vocalisation in the majority of patients who otherwise would not be able to speak. This is particularly useful for patients who require prolonged cuff inflation due to ventilator dependence because of the risk of aspiration.

Subglottic tubes are used in ITU, on Ward 9/Ward 11 and MADU.

Peri-Operative Complications

• Haemorrhage

• Pneumothorax, surgical emphysema, pneumomediastinum

• Tracheal or tracheoesophageal laceration

• Recurrent laryngeal nerve injury

• Displacement of the tube

Early Post-Operative Complications (< 7 days)

• Haemorrhage

• Infection

• Sputum plugging/ blood clot leading to tube occlusion

• Displacement of the tube

• Tissue damage, peri-stomal abscess, mucosal ulceration, cellulitis

Late Post-Operative Complications (> 7 days)

• Tracheal stenosis (tracheal narrowing secondary to scar tissue)

• Tracheo-oesophageal or trachea-vascular fistula

• Tracheomalacia (weakness of the tracheal wall and supporting cartilage)

• Infection and delayed healing of the stoma

The tracheostomy care bundle

The tracheostomy care bundle focuses on seven areas of patient care: humidification, suctioning, care of the inner tube, safety equipment, tracheostomy dressings, cuff pressure and mouth care. All general care given and routine checks made for the tracheostomised patient must be documented on the tracheostomy care chart to act as a legal record of care provision.

Any patient discharged from the Intensive Care Unit with a tracheostomy in situ will have a completed tracheostomy status sheet.

A tracheostomy bypasses the body’s normal mechanisms for the filtering, warming and humidifying of inspired air: therefore every patient with a tracheostomy in situ must receive adequate humidification. The method of humidification should be agreed on an individual patient basis and reviewed regularly to ensure appropriate interventions are taking place.

Cold water Humidification and Buchanan Bib/Swedish noses are used on the Wexham site.

The frequency of suction varies with individual patients. Patients only require suctioning when they are unable to clear secretions from coughing. There is no benefit in routine suction.

Patients, with thick secretions, who are not receiving humidified oxygen therapy, may require regular normal saline nebulisers (4-6 hourly) to loosen secretions prior to suctioning and reduce the risk of atelectasis and sputum thickening.

• Portable or wall suction set at 8-20 kPa

• Sterile suction catheters (tracheal suction) – correct sizes

• Non sterile gloves

• Aprons and eye protection

• Oxygen therapy via a tracheostomy mask

• Bottle of sterile water

• Yankeur catheter (oral suctioning)

1. Hypoxia

2. Cardiac instability/arrhythmias

3. Tracheal mucosa trauma

4. Infection

• The soiled inner tube should be removed using standard infection control measures, i.e., apron, gloves and eye protection

• A clean temporary inner tube needs to be inserted during the procedure. The temporary inner tubes should only be left in situ whilst cleaning the inner tube.

• If the patient needs oxygen then ensure that the oxygen mask is replaced once the temporary inner tube is in situ to prevent hypoxia.

• The soiled inner tube needs to be cleaned under warm running water. The inner tube must never be left to soak as this increases the risk of infection. Brushes should not be used as they may contain microorganisms.

• Tracheostomy cleaning swabs are available on prescription and available on the wards.

Once clean, the inner tube must be dried and replaced. The temporary inner tube must be cleaned and stored in a clean dry labelled container for later use.

Essential Equipment

The following equipment must be available at the bedside for all patients with a tracheostomy at all times:

• Spare tracheostomy tubes–same sized cuffed tracheostomy tube and a smaller cuffed size

• Tracheal dilators

• Spare inner tube (check the size of the tracheostomy)

• Suction catheters in a range of sizes

• 10ml syringe (cuff inflation)

• Humidified oxygen circuit with a tracheostomy mask

• Clean disposable gloves

• Bottle of sterile water (to clean the tubing after suctioning).

• Stitch cutter (if tracheostomy is sutured)

The inner tube must be checked 2-4 hourly (dependent upon secretions) to ensure that the tube remains patent and the airway is maintained. Where secretions are very tenacious, the frequency of inner tube care must be increased. Narrowing or blocking of the inner tube is life-threatening and could cause the patient to have a cardiorespiratory arrest if intervention is delayed.

• The soiled inner tube should be removed using standard infection control measures, i.e., apron, gloves and eye protection

• A clean temporary inner tube needs to be inserted during the procedure. The temporary inner tubes should only be left in situ whilst cleaning the inner tube.

• If the patient needs oxygen then ensure that the oxygen mask is replaced once the temporary inner tube is in situ to prevent hypoxia.

• The soiled inner tube needs to be cleaned under warm running water. The inner tube must never be left to soak as this increases the risk of infection. Brushes should not be used as they may contain microorganisms.

• Tracheostomy cleaning swabs are available on prescription and available on the wards.

Once clean, the inner tube must be dried and replaced. The temporary inner tube must be cleaned and stored in a clean dry labelled container for later use.

Essential Equipment

The following equipment must be available at the bedside for all patients with a tracheostomy at all times:

• Spare tracheostomy tubes–same sized cuffed tracheostomy tube and a smaller cuffed size

• Tracheal dilators

• Spare inner tube (check the size of the tracheostomy)

• Suction catheters in a range of sizes

• 10ml syringe (cuff inflation)

• Humidified oxygen circuit with a tracheostomy mask

• Clean disposable gloves

• Bottle of sterile water (to clean the tubing after suctioning).

• Stitch cutter (if tracheostomy is sutured)

• Cuff manometer

• Rebreathing bag (ambubag) and tubing – available on the crash trolley at all times

• Aprons and eye protection (eye visors or face shields)

• Spare dressings (Trachi-dress,Advazorb Lite ^TM) and tracheostomy tapes

• Suction

The above equipment must also be available during patient transfers.

Communication aids are essential as tracheostomy patients are unable to speak.

Various aids are available on the ward and in outpatients departments, e.g., white board, alphabet board and LCD Writing Tablet.

The tracheostomy dressing and tapes should be changed at least every 24 hours or as necessary. Increased frequency of dressing changes may be required if the wound is “oozing” or secretions are copious and the dressing becomes soiled and wet. This reduces the risk of skin maceration and excoriation around the stoma site. An absorbent dressing, e.g., Advazorb Lite,Trachi-dress^TM, should be applied to the stoma as they are designed to remove moisture away from the skin.

Dressing and tape change is a two-person technique to reduce the risk of tube displacement. The dressing change must be performed using an aseptic technique. Once the dressing is changed the tracheostomy tapes should be replaced, allowing one to two fingers to slide comfortably between the patient’s neck and the tapes.

Cuff manometer

The cuff (balloon filled with air) on a tracheostomy tube prevents blood/secretions from reaching the lungs and the seal created by the cuff facilitates ventilation at the time of use, e.g., surgery, intensive care patients. These tubes are used for patients who are deemed to be at risk of aspiration and patients requiring positive pressure ventilation. In order to prevent tracheal injury, cuff pressures should be measured once a shift and should not exceed 25cmH₂O. Cuff deflation should only be practised with guidance from the Tracheostomy MDT. This pressure should be recorded.

Uncuffed tracheostomy tubes do not protect the airway from secretions or maintain an airtight seal; however, they enable the patient to swallow and facilitate voice production. For artificial ventilation a cuffed non-fenestrated tube is required.

Oral hygiene is an essential aspect of care for the tracheostomised patient. The patient’s mouth needs to be checked 2-4 hourly and mouth care given as required. The oral assessment must include checks for signs of infection (viral, bacterial or fungal) and ulceration. Patients should be encouraged to use a toothbrush, toothpaste and mouthwash (either water or prescribed mouthwash) on a regular basis.

It is important to understand the difference between a tracheostomy, which is a temporary hole into the trachea, and a laryngectomy, which is an end stoma and is permanent.

A patient who has had a laryngectomy has no upper airway (see diagram). The trachea is brought out onto the surface of the neck and is not connected to the upper airway. The stoma does not require a tube as it is permanent, but some patients do wear a laryngectomy tube or stoma stud to house an HME (Heat/Moisture Exchange) or to prevent stoma stenosis.

A laryngectomee (neck breather) patient would always need Oxygen and/or artificial ventilation delivered to the neck stoma in the event of an emergency.

Suctioning and humidification is the same as for a tracheostomy patient.

If the casualty is a Laryngectomee, air movement (either spontaneous or ventilated) is not possible via the nose and mouth. Laryngectomees are also at increased risk of airway obstruction. In this case the following adaptations must be made:

• Remove the clothing from the casualty’s neck.

• Do not routinely remove any tube that is in place

• Wipe any mucus from the stoma making sure that the stoma or tube is clear. If there is any doubt about the patency of the tube. Remove it and carry out airway management direct to the stoma as directed below.

• Listen and feel for air movement at the stoma whilst looking for chest wall movement.

• If he is not breathing or is making only occasional gasps or weak attempts at breathing you must ensure emergency services are contacted, either by someone else or if you are alone, either by mobile phone or by leaving the casualty, to make the call.

Please see algorithms below.

An adjunct such as a Laerdal pocket mask or bag-valve-mask (BVM) may still be of value, providing a seal can be obtained over the stoma site.If there is a tube in place and the BVM can be attached directly to the tube.

The registered health care professional assigned to the patient with the tracheostomy is accountable for the patient’s care. Support and advice can be gained from the following teams:

The Head and Neck/Thyroid Clinical Nurse Specialists and the ENT Team are available for advice and assistance to any ward that may have a patient with a tracheostomy.

This may involve changing a patient’s tube, decannulation, cuff deflation, teaching, advice and support. This service runs alongside the ITU outreach team, and is accessed by contacting the Head and Neck/Thyroid Clinical Nurse Specialists Mobile 07795 812526.

Removal of a patient’s tracheostomy (decannulation) is a multidisciplinary decision and must include the Head and Neck/Thyroid Clinical Nurse Specialists and ENT Medical Team. Contributing factors to this decision are if the patient has a patent upper airway, can tolerate the tube being occluded and 0₂ saturations are maintained. A Passy Muir speaking valve needs to be worn in the day and removed at night and always with the cuff deflated.

The ENT team would initially change the patient’s tube to a smaller uncuffed tube with a fenestration to enable air to pass up to the upper airway (downsizing to uncuffed fenestrated tube). The decannulation process would then commence, i.e. tube capped off with decannulation button for 24hours and patient observed. The prescribed management plan would depend on the patient’s condition and clinical judgement. The tracheostomy tube would subsequently be removed under the supervision of the ENT team.

The dressing of choice to cover the stoma is Advazorb Fixation,which forms a good seal and enables the patient to be able to cough without the dressing becoming loose.

The Outreach Team offers an out of hours service and is available to provide advice and support for ward-based patients with tracheostomy tubes. The Team can assist ward staff with the provision of specialist care.

All patients with a tracheostomy must be referred to the speech and language therapist (SLT)

All SLT referrals are to be made via EPIC.

Ideally patients will have a fenestrated uncuffed tube in situ and to be able to tolerate passy muir valve at time of the referral.

SLT will assess for oral intake (food and fluids) and make recommendations, post signs above the bed and handover to staff.

Communication aids are available on the wards and in the outpatient clinic.

All patients with a tracheostomy must be referred by the ward. Emergency chest physiotherapy is available out of hours for any tracheostomy patient whose chest condition is deteriorating. A member of the medical team or outreach nurse can contact the on-call physiotherapist via switchboard (Wexham Park Hospital).

Patients being discharged with a tracheostomy/laryngectomy are discussed in the Tracheostomy board round.

The team will liaise with the ward staff to ensure the safe discharge of these patients. All patients are registered with a prescription delivery service.

The Head/Neck CNSs have a tracheostomy changing clinic once a month. This enables discharged patients to have their tube changed safely in the clinic setting. It also enables us to troubleshoot any problems to prevent readmission.

The community patients are issued with a tracheostomy box for their equipment and a trachi passport (Trachi-pass).

The Tracheostomy MDT Team offer a half-day Tracheostomy Practical Skills course twice a year.

These Study days are well attended by qualified nurses from the designated airway wards.

All new staff attend a study day and we welcome staff for a refresher course.

The course incorporates lectures but focuses on the practical aspect of caring for an altered airway.

We also have a patient who has a tracheostomy who attends the day and helps with our training.

The training is always well evaluated by the delegates.

National Association of Laryngectomee Clubs (2024) The National Association of Laryngectomee Clubs. Available at: https://www.laryngectomy.org.uk/ (Accessed: 05 February 2024).

Paasy Muir (no date) Passy Muir. Available at: https://www.passy-muir.com/ (Accessed: 05 February 2024).

National Tracheostomy Safety Project (no date) NTSP Resources. Available at: https://tracheostomy.org.uk/resources/documents (Accessed: 05 February 2024).

National Confidential Enquiry into Patient Outcome and Death (2014) Tracheostomy Care: On the Right Trach? Available at: https://www.ncepod.org.uk/2014tc.html (Accessed: 05 February 2024).

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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