Tracheostomy Guidelines for NHS Wales

Transcription

1 Tracheostomy Guidelines for NHS Wales Prepared by the All Wales Tracheostomy Advisory Group, chaired by Duncan Ingrams, Assistant Medical Director ABUHB. 1

2 Introduction April 2018 Formulating one set of guidelines to cover all of the different indications for all types of tracheostomy in adults and children, in hospital and the community is a difficult task but it is hoped that this attempt will be useful in providing a reference document. It was decided to try and look particularly at those points in the management of tracheostomy patients that are associated with the greatest risk and to see how these risks can be reduced. The guidelines are aimed at all healthcare professionals involved in the management of patients with a tracheostomy. Tracheostomy is the placement of an opening into the trachea to allow for unobstructed breathing. It can be done in an emergency or as an elective procedure, in an operating theatre, critical care setting, ward or street, and under general, local or no anaesthetic. Patients may then undergo mechanical ventilation for a short period or for the rest of their lives or they may breathe for themselves. They may be discharged from a hospital to live at home or be cared for in a community care setting. The tracheostomy itself may be a temporary opening for a few hours or permanent. The opening is usually held open by a plastic or metal tube but some types may be formed by suturing the skin to the wall of the trachea to create a stable stoma. These guidelines were commissioned by Dr Chris Jones, Deputy Chief Medical Officer for Wales, to create a single document that will allow all members of the multi-disciplinary teams that manage tracheostomies in Wales rapid access to information. The aim is to reduce adverse incidents that may occur when correct procedures are not known or are not followed. Several Health Boards already have their own guidelines and this document has been prepared with reference to those and to the National Tracheostomy Safety Project, the NCEPOD document of 2014, On the Right Trach?, and the Intensive Care Society Standards of 2014, amongst other publications. Acknowledgment is given to the help of Professor Brendan McGrath and Professor Tony Narula and to my co-authors Sandeep Berry, Marileze Du Preez, Campbell Edmondson, Karen James, Vijay Kumar, Chris Roberts, Anthony Turley, and Jonathan Whelan. I am also grateful to Anne Llewellyn- Edwards and John Gorst for their comments. Duncan Ingrams, Assistant Medical Director ABUHB 2

3 Contents 1 Pre-treatment, technique and tube selection 2 Tube Changing 3 Decannulation 4 Movement between units, wards and theatres communication needs. 5 Transfer to the community. 6 Emergency Management 3

4 Executive Summary All Health Boards and Trusts in Wales should have a multidisciplinary tracheostomy team to monitor adherence to these guidelines via appropriate audit. The team may formulate their own operational policy. Staff caring for patients who have had a tracheostomy need to be appropriately trained. Patients should be managed by a multi disciplinary team. An appropriate tracheostomy tube should usually be selected in advance of the procedure. For safety reasons a dual lumen tube should always be used. Accessory equipment may be specific to the type of tube used. Care must be taken to ensure that incompatible equipment is not used. Reducing the range of tubes available in a Health Board should be considered. Ultrasound examination of the neck should be used in all patients who have had previous neck surgery, including a previous tracheostomy and in those where altered anatomy is suspected. Tubes need to be changed regularly, either when they are becoming obstructed or cannot be cleaned or within 30 days of placement. Attention to detail is important during tube changing. The checklist should be completed. Decannulation must be carried out in a controlled fashion by appropriately trained staff. Facilities for recannulation must always be available. For that reason decannulation in the community is rarely appropriate. Movement of a patient with a tracheostomy increases risk, particularly tube displacement. Good communication between teams is essential and the transfer form should be used. Additional equipment must go with the patient. Transfer to the community is a particular time of risk and involvement of all appropriate staff, including the Welsh Ambulance service is mandatory. Management of emergencies should start with assessment of the patient. If the tube is obstructed and cannot be cleared it must be removed to allow spontaneous respiration or pulmonary resuscitation. Laryngectomy patients have no airway via the mouth and nose. If it is not clear if a patient has had a laryngectomy or a simple tracheostomy, resuscitation with oxygen and ventilation must be given via the neck stoma, even if additional measures are duplicated via the mouth. It must be made clear on a ward if a patient has a laryngectomy or other tracheostomy 4

5 1. Pre-treatment, technique and tube selection Definition A tracheostomy is the surgical creation of an opening into the trachea through the neck which can be permanent or temporary. Indications Emergency airway - Oral or nasal intubation impossible Trauma - Facial fractures Airway oedema (swelling) - Burns - Drug sensitivities - After upper airway surgery Need for prolonged artificial ventilation - Reduces anatomical dead space - Aids weaning from ventilation Upper airway obstruction - Foreign body - Tumour Prolonged absence laryngeal reflexes or an inability to swallow safely Airway access for mucus suctioning Types of tracheostomy Percutaneous Tracheostomy The majority of tracheostomies are now carried out in a critical care unit. Most patients within critical care will have tracheostomies performed using a percutaneous, dilatational technique. This procedure may require a general anaesthetic, but increased sedation and a local anaesthetic can be used. Surgical tracheotomy Surgical procedures are carried out in an operating theatre in most cases. The surgical tracheotomy (i.e. the cut into the trachea) may be a vertical slit, a window (fenestration), or may utilise an inferiorly based Björk flap. The skin edges may be sutured to the tracheal edge to create a semi permanent opening. This is almost always the case in children. In emergencies the operation may be performed 5

6 elsewhere, such as on a ward. It can be performed under general or local anaesthetic. The term tracheostomy relates to the finished operation, which can be temporary or long term, and can be formed either electively or as an emergency procedure. Any patient who requires a tracheostomy with a history of, 1. Surgery to the neck. 2. A previous tracheostomy. 3. Difficult cases due to spinal injury, bariatric problems and known altered anatomy including blood supply. May need to be taken to theatre for a surgical tracheostomy as opposed to a percutaneous tracheostomy. If there is any suggestion of altered anatomy an ultrasound scan of the neck must be undertaken prior to the operation. Laryngectomy Patients who have had a total laryngectomy have a permanent tracheostomy. This involves creating a stoma where the top of the trachea is brought to the surface and sutured to the neck skin. This stoma is kept open by the rigidity of the tracheal cartilage. This is the patient s only airway as there is no connection between the mouth and nose and the trachea, and there may be no connection between the pharynx and the trachea unless one has been specially created. Any ventilation or oxygen support must be via this stoma. Mini Tracheostomy This is for sputum clearance and not for ventilation. An uncuffed small bore tube is inserted through the cricothyroid membrane or tracheostome after decannulation. Tracheostomy Tubes There is a wide range of tubes available, with differing characteristics. Clinicians need to recognise that the requirements of a tracheostomy tube may vary with time and changing clinical circumstances. Clinical staff must therefore make an informed choice of which to tubes to stock, and which to use for a particular patient. Single lumen tubes have been associated with Serious Incidents and should not be used. If a patient is transferred with such a tube it should be changed to a dual lumen tube as soon as it is safe to do so. The incident should be reported back to the referring team and reported. Dual lumen tubes (with an outer tube intended to remain in the patient and an inner cannula which is removed for cleaning), are inherently safer and should always be used. 6

7 Adjustable flange tubes are needed in those patients with large necks, significant swelling or other changed anatomy. They may have additional ports to clear subglottic secretions with suction. Tracheostomy tubes require different features depending on their intended use. There are a large variety of tubes available which provide some or all of these features. Introducers All tracheostomy tubes should be inserted using an introducer to prevent damaging the trachea during insertion of the tube. Once the tracheostomy tube has been inserted the introducer should be disposed of. The clear plastic universal cap should also be disposed of to avoid accidental capping off of the tracheostomy. When changing tubes, a bougie or similar can be used to ensure placement, in which case the introducer is not needed. Cuffs Some tracheostomy tubes have a cuff which when inflated, provides a seal which facilitates artificial ventilation. It also reduces the risk of aspiration of oral secretions, vomit and blood from the upper airways. Inner tubes Dual lumen tracheostomy tubes consist of an outer tube, which remains in situ, through which a smaller inner tube is inserted. The inner tube can be connected directly to other equipment. It can be removed for cleaning but must be replaced immediately after cleaning. Fenestrations Fenestrated tracheostomy tubes are dual lumen tubes which have a window in the middle of the upper aspect of both tubes. If the tracheostomy tube is then occluded digitally, with a cap, speaking valve etc., then air and secretions can pass into the mouth and nose in the normal way rather than directing them out via the tracheostomy tube. These tubes will always have an optional non-fenestrated inner tube which may be inserted if the patient requires further respiratory support. A nonfenestrated inner tube should always be inserted prior to performing tracheal suction to ensure the suction catheter does not pass through the fenestration and into the larynx instead of into the trachea. A non-fenestrated inner tube is also recommended overnight to help reduce the drying out, or swelling, of the mucous membrane through the fenestrated area 7

8 Characteristics of tubes The characteristics of the tube to be considered when selecting a tracheostomy tube for temporary use include: Construction dimensions internal and outer diameter (ID and OD respectively) proximal and distal length (i.e. the length of the tube proximal and distal to its angulation) shape and angulation compatibility with percutaneous insertion kit presence and nature of tube cuff presence of inner cannula fixed versus adjustable flange presence of fenestration specialist features, e.g. low contour on deflation tight to shaft cuffs, subglottic secretion control systems, voice enhancement tubes etc It is essential that the staff caring for a patient with a tracheostomy know the type of tube in place at any time. This should be clearly documented in the patient s notes Structural Construction Material Tracheostomy tubes can be constructed of either metal or plastic, and thereby vary considerably in rigidity, durability and kink resistance. This may be clinically relevant. Metal tracheostomy tubes are constructed of either silver or stainless steel and are seldom used. They do provide a cost effective management choice for lifelong tracheostomies. Temporary tracheostomies are constructed of polyurethane, polyvinyl chloride or silicone. Products made of polyurethane are more rigid than those constructed of silicone, whilst those of polyvinyl chloride construction are of an intermediate stiffness (although some become softer at body temperature). 8

9 Shape Many tubes have an inherent curvature or angulation; others are completely flexible and only assume a correct anatomical alignment through appropriate stabilisation at the stoma and the level of the cuff. Some flexible tubes are reinforced with a spiral wire in order to avoid kinking and airway obstruction. Whilst the design of some tracheostomy tubes has been modified to facilitate percutaneous introduction, others are only appropriate for insertion once a formal track has been formed (either surgically or through the prior placement of an alternative tube). Dimensions In most circumstances a tracheostomy tube is both described and selected on the basis of its size, or more specifically its diameter. This is simple in theory but may easily be confusing in practice. Tracheostomy tubes with the same internal diameter ( size ) may have quite different external diameters and length. Choosing the correct size Diameter When selecting the size of tube for a patient there is an unavoidable compromise to be made between a desire to maximise the functional internal diameter (and thereby reduce airway resistance and the work of breathing during weaning) and a need to limit the outer diameter (OD) to approximately three-quarters of the internal diameter of the trachea (in order to facilitate airflow through the upper airway when the cuff is deflated). Furthermore, selection of a tube that is too small may result in the need to over-inflate the cuff, thereby increasing the risk of mucosal pressure necrosis, which in turn increases the risk of complications such as tracheal stenosis and tracheooesophageal fistula. A need to exceed the quoted nominal cuff volume is often an early indicator that too small a tube has been selected. As a general rule, most adult females can accommodate a tube with an OD of 10mm, whilst a tube with an OD of 11mm is suitable for most adult males. Length and shape Although a temporary tracheostomy is most commonly selected on the basis of its diameter, there may be situations where the length, angulation or curvature of a tube is of relevance. Thus, whilst many tracheostomy tubes are smoothly curved, others are clearly angulated, thereby allowing a distinction to be made between the proximal (or horizontal) length of a tube (i.e. the distance between the neckplate and 9

10 the mid-point of the angulation) and the distal length (i.e. the distance from the midpoint of the angulation and the tip). It should be appreciated that these respective lengths are quite short in standard tubes and may be too short even in the patient with apparently normal anatomy. There may be occasions where the proximal length of a standard tube is inadequate (e.g. in the obese, or when cellulitis around a tracheostomy site increases the depth of the anterior cervical tissues after insertion), and leads to the tube tip then abutting against the posterior tracheal wall. This can result in: Obstruction of the tube, and consequent difficulties with ventilation and weaning Injury to the posterior tracheal wall, thereby increasing the risk of tracheooesophageal fistula formation Suboptimal positioning of the tube cuff, with the associated risk of aspiration, inadequate ventilation and high cuff pressures There may also be occasions where the proximal length is too long, with the result that the knuckle of the tube abuts against the posterior tracheal wall, whilst the tip is pivoted towards the anterior tracheal wall (the latter increasing the risk of granuloma formation and the development of a tracheal innominate arterial fistula). Less commonly, there may be a need to review the distal length of a temporary tracheostomy. For instance, there may be occasions where there is a need for additional distal length in order to bypass fistulae or obstructing lesions such as tracheomalacia, tracheal stenosis or excessive granuloma formation. Clinically significant anatomical and pathological variances such as these can be circumvented by using either extended length tracheostomy tubes with an adjustable flange or pre-formed extended tubes which are offered with a range of extended proximal or distal lengths. Extended length adjustable flange tubes are suitable for short term situations but are often difficult to introduce percutaneously and may not be supplied with an inner cannula. These should only be used if no alternative is available in an emergency. Whilst adjustable flange devices are considered suitable for short terms problems, patients who are likely to need airway access for a considerable length of time may be better served with pre-formed non standard products such as the Shiley Tracheosoft XLT range or the Portex Blue Line Extra Horizontal and Vertical length products. Some manufacturers offer a bespoke service should none of their stock items be suitable. 10

11 Inner cannula (dual cannula tracheostomies) Many tracheostomies are now manufactured with an inner cannula. The design of some makes the use of this optional (e.g. Portex Blue Line Ultra ), whilst for others it is mandatory, as it is the inner cannula that has a standard 15mm attachment to connect to the breathing circuit of a mechanical ventilator (e.g. Shiley, Kapitex Tracoetwist ). Whilst some inner cannulae are disposable and designed for single use, others can be cleaned and re-used. The principal (and very major) advantage of an inner cannula is that it allows the immediate relief of life-threatening airway obstruction in the event of blockage of a tracheostomy tube with blood clot or encrusted secretions. Whilst traditionally, this has been seen to be particularly advantageous for patients once they have been discharged to a ward environment, it is now recognised that tube obstruction can occur even while the patient is in a critical care facility, and that in such circumstances removal of an obstructed inner cannula may be preferable to removal and repeat tracheal intubation. The principal disadvantage of dual cannula tubes is that the inner cannula may significantly reduce the effective inner diameter of the tracheostomy tube, and thereby increase the work of breathing and impair weaning. Failure to properly lock the inner tube in place may also result in disconnection of the breathing circuit in circumstances where it is connected to this rather than the outer cannula. Tracheostomy tubes with an inner cannula are inherently safer and are normally preferred Fenestrated tracheostomy tubes Tracheostomy tubes may come with the option of a fenestration in the posterior wall of the shaft above the cuff, in both inner and outer tube. Manufacturers do not recommend the use of such tubes at the time of percutaneous tracheostomy, and generally they should not be used whilst a patient still requires mechanical ventilation because of significant risk of surgical emphysema (even when a non-fenestrated inner cannula is in place). Although a correctly sited fenestrated tube may aid both phonation and weaning (by facilitating the flow of air both through as well as around the tracheostomy tube), in practice the fenestrations are frequently poorly positioned within the trachea, and when abutting against the posterior tracheal wall may increase airway resistance and as well as promote the development of granulation tissue in the tracheal mucosa. The design of the fenestrations varies between manufacturers, with some clinicians favouring tubes with multiple smaller openings to a single large one, although both patterns are at risk of blockage by encrusted 11

12 secretions. If a fenestrated tube is used, it is important that the position and on-going potency of the fenestration(s) are checked regularly if the patient is to benefit from this option. In practice down sizing or switching to an uncuffed tracheostomy tube may be enough to improve flow of air through the upper airway. Fenestrated tracheostomy tubes should be used with caution in mechanically ventilated patients, and only with patients who are weaning from ventilation. Cuffed tracheostomy tubes In a critical care setting, most patients will require an air filled cuffed tracheostomy tube initially, both to facilitate effective mechanical ventilation and also to protect the lower respiratory tract against aspiration. The cuff should be of a high volume / low pressure design, and should effectively seal the trachea at a pressure of no more than cmh 2 O in order to minimise the risk of tracheal mucosal ischaemia and subsequent tracheal stenosis. Although many manufacturers offer tracheostomy tubes with suitable cuffs, there is considerable variation between them in the length of the cuff and its precise shape when inflated. Furthermore, there is now considerable evidence to suggest that the current high volume / low pressure design is unable to guarantee isolation of the lower respiratory tract. The intra-cuff pressure should be monitored regularly Causes of excessive cuff pressures include: the use of a tube that is too small (an indication for which would be a need to inflate with more than the nominal cuff volume in order to achieve an effective seal) poor tube positioning in the trachea tracheal dilatation over inflation of the cuff One proposed solution to the problem of cuff-related tracheal mucosal ischaemia is the use of a foam rather than air-filled cuff (Bivona Adult Fome-Cuf tracheostomy tube). The cuff is constructed of air-filled polyurethane foam within a silicone envelope that is deflated prior to insertion and then allowed to expand once sited by opening the pilot port to atmosphere. Correct sizing and placement is crucial to their use, which tends to be limited to patients with existing tube related tracheal injury. The prevention of phonation is a further significant drawback to the device. 12

13 Weaning Most patients can wean to decannulation by simply deflating the existing cuff or alternatively by down sizing to a smaller or uncuffed tube. In circumstances where a patient still requires periods of airway protection, but is unable to satisfactorily breathe past a deflated cuff, it may be advantageous to switch to a so-called tight to shaft tube in which the deflated cuff makes no distinguishable contribution to the external profile of the tracheostomy tube. Percutaneous tracheostomy tubes / kits Several manufacturers have modified aspects of the construction of their standard tracheostomy tubes such as cuff and distal tube profiles in order that they are more easily introduced as part of a percutaneous dilatational technique (e.g. Portex Per- Fit and Shiley PERC). Such changes frequently go unnoticed when the tube comes as a component of a percutaneous tracheostomy kit and may have unpredictable functional consequences. Clinicians are advised to carefully evaluate situations where such product consolidation occurs. Specialist functionality Some specialist tracheostomy tubes incorporate a facility for aspiration of sub-glottic secretions (e.g. Portex Blue Line Ultra Suctionaid tracheostomy tube, Tracoetwist 306). Initially advocated in the prevention of ventilator-associated pneumonia, they may also benefit patients with poor bulbar function who are unable to effectively clear secretions that accumulate above the tracheostomy tube, although they carry a high risk of significant laryngeal injury if suction is applied continuously. When considering changing to one of these devices clinicians are also advised that in order to accommodate the additional suction channel these tubes may have a wider OD than the standard device that it is replacing. Other options include features that enhance phonation such as the Portex Vocalaid cuffed Blue Line tracheostomy, in which an external air source is used to deliver gas via a separate pilot channel to the sub-glottic area, or the introduction one-way speaking valves such as the Passy- Muir valve, the latter also improving swallowing and secretion control. 13

14 Summary recommendations 1. All staff involved in the placement and management of tracheotomy tubes need to be aware of the wide variability in the construction, design and functionality of the tubes that are currently available, and recognise that the anatomical variation of their patients limits the universal applicability of a single tube type. 2. Most adult patients who require a temporary tracheostomy as part of their critical illness will initially need a non-fenestrated semi-soft tube with an air-filled cuff. As a standard, a dual cannula tube (i.e. a tube with an inner cannula) should be used from the outset unless there is a requirement to insert an extended adjustable flange tracheostomy. Dual lumen versions of adjustable flange tubes are available but may best be ordered as a customized order for an individual patient. 3. Patients with single cannula adjustable flange tracheostomies should not be discharged from a critical care environment without review of their on-going need for a device that puts them at particular risk of the consequences of tube obstruction. A change to a pre-formed extended tracheostomy with an inner cannula should be considered as soon as the patient is actively weaning from mechanical ventilation and certainly before discharge from critical care. 4. When considering changing an existing tracheostomy to that of another type or manufacturer, clinicians should compare the relative lengths and external diameters of the two tubes, particularly if the proposed new tracheostomy has a wider OD (because the existing stoma may not accommodate it), shorter length (in case cuff related granulation tissue obstructs the tube) or different curvature / angulation. 5. Specialist features such as fenestrations, foam or tight to shaft cuffs or a subglottic suction facility may be useful in specific circumstances, although are not recommended as a routine. 14

15 2. Tube changing Changing tracheostomy tubes Introduction Changing a tracheostomy tube is potentially hazardous, but so is failure not to do so. Unfortunately, recommendations for the frequency of changing tracheostomy tubes are inconsistent and unsupported by evidence. Basic principles guiding replacement of a tracheostomy tube are listed in the box below. A more detailed example is given in appendix. Basic principles for changing a tracheostomy tube Single lumen tubes should not be used, but if present they should be changed every 7-14 days. This is to prevent obstruction of the lumen with secretions. Subsequent frequency may decrease once the patient has reduced the amount of pulmonary secretions and has a well formed clean stoma.. A European Economic Community Directive (1993) states that tracheostomy tubes with an inner cannula can remain in place for a maximum of 30 days to help prevent infection, maintain a healthy stoma, and prevent degradation of the composition material. Individual manufacturers have recommendations for maximum use of their devices. This assumes the inner cannula is changed or cleaned according the manufacturer s instructions at least daily. In patients with very productive chests the inner cannula may need reviewing and cleaning every few hours. The first routine tracheostomy tube change: Should not be performed within 4 days following a surgical tracheostomy and 7-10 days after a percutaneous tracheostomy to allow the stoma to become established. The decision to change the tube is usually a multi-disciplinary one, considering weaning, swallowing, ventilation, speaking and the ongoing need for a cuff. Must be carried out by a person competent to do so and with advanced airway expertise and equipment immediately available. Techniques involving exchange over a bougie or airway exchange catheter may be safer for the first change. Technique used and ease should be recorded, along with recommendations for future exchanges. 15

16 Subsequent changes can be made by relevant staff who are competent to do so, e.g. specialist tracheostomy nurses or therapists. In practice, the frequency with which the tube needs to be changed will be affected by the individual patient s condition and the type of tube used. Elective changes are inherently safer than those done in an emergency. Tracheostomy tubes should only be changed by staff who are competent to do so. This includes trained doctors, but also specialist non-medical practitioners who have been assessed to have the necessary skills. Although problems can occur in any patient they are particularly likely in the obese, those with a deep trachea, and other anatomical difficulties. In these circumstances the patient should be pre-oxygenated and monitored appropriately, which could include pulse oximetry and the availability of capnography or bronchoscopy to confirm placement. Whilst the same principles apply to subsequent changes, the first change is usually the most difficult and technically challenging. Significant numbers of patients in NCEPOD report experienced unplanned early tube changes at less than 7 days. Prior to tube exchange, consideration should be given to equipment, personnel, procedure and the environment required should problems arise when inserting the new tube. Subsequent changes in the community are possible without monitoring if the tracheostomy is well established and the staff are competent. It is essential that if the new tube cannot be inserted or is misplaced, there is an agreed procedure for responding to the situation. The procedure for changing a tube When planning a tracheostomy tube change always consider: Is this the best time to be doing this? Am I the best person to do this? Is the patient adequately/appropriately prepared? Have I got all the essential/appropriate equipment? Is there adequate support? The type of tracheostomy tube used should be tailored to the patients condition and will depend on various factors such as length of weaning time, original reason for tracheostomy and type of secretions. This is a two person technique, with one person supporting the tube and the patient and the other performing the change. In patients who are at risk of aspiration it is 16

17 recommended that any enteral feed be stopped 3-4 hours prior to the procedure and the enteral tube aspirated immediately prior to the procedure. The procedure used for changing any tracheostomy tube will depend on the circumstances of that change. There are two commonly used methods: Guided exchange using a tube exchange device -usually required for early changes and for patients with a high risk of airway loss Blind exchange using an obturator for patients with formed stomas and a low risk of airway loss Equipment Dressing pack Suture cutter Appropriately sized tracheostomy tube and one a size smaller Adjustable tracheostomy tube holder. Ties have been associated with problems and should be avoided if possible. 10ml syringe for cuffed tubes Water-soluble lubricant Sterile normal saline Pre-cut slim line key hole dressing e.g. Metalline or if large secretions use a more absorbent dressing such as Allevyn or Lyofoam Gloves, apron and protective eye wear Tracheal dilators Functioning suction unit and appropriate sized suction catheters (tracheostomy tube size x3, divide by 2) Stethoscope Airway exchange catheter Resuscitation equipment Microbiological swab Blind exchange using an obturator/bougie Check emergency equipment Explain procedure to patient and gain patient consent Position patient in semi-recumbent position Where required pre-oxygenate Ensure assistant is clear regarding what is expected of them Check and lubricate tube Insert obturator into the tracheostomy tube Ask assistant to suction if required, remove old dressing, inner cannula and tapes and support tube (Deflate cuff with suction applied) 17

18 Remove tube on expiration If patient not oxygen dependent and stoma well formed, observe site, swab if site looks infected and clean stoma Insert tube on expiration, remove obturator (inflate cuff) Check for airflow through tube. If possible, identify presence of CO 2 using a CO 2 detector Ask assistant to support the new tube Dress and apply holder allowing 2 finger clearance for comfort and safety. Replace inner cannula where used Check patient is stable (and cuff pressure) Document procedure in the case notes using printed label where available and check patient again. If using a fenestrated tube, place spare inner cannula in emergency pack and clearly label tube Guided exchange using an airway exchange device Check emergency equipment Explain procedure to patient and gain patient consent Position patient in semi-recumbent position Where required pre-oxygenate Ensure assistant is clear regarding what is expected of them Check and lubricate tube Ask assistant to suction if required, remove old dressing, inner cannula (if required) and tapes and support the tube Insert exchange device to length of tube Ask assistant to deflate the cuff Remove old tube over exchange device Insert new tube over exchange device Check for airflow through tube. Inflate cuff. Remove exchange device. Identify presence of CO 2 using a CO 2 detector Observe site, swab if required and clean while assistant support the tube Dress and apply holder allowing 2 finger clearance for comfort and safety Replace inner cannula (if removed) Check patient is stable (and cuff pressure) Document procedure in the case notes using printed label where available and check patient again. If using a fenestrated tube, place spare inner cannula in emergency pack and clearly label tube 18

19 If unable to re-insert tube successfully or the patient become compromised: Call the on-call anaesthetist/ent/resus team immediately and as appropriate to the situation, to assist and/or orally intubate where appropriate Maintain oxygenation via stoma and nose and mouth with a facemask Use tracheal dilator and attempt to re-insert tube Reposition patients neck and attempt to re-insert tube Consider using a smaller size tube 19

20 Tracheostomy Tube Change Checklist Indications for Change Tube >30 days for those with inner tube Downsizing Convert to cuffless tube Convert to fenestrated tube Appropriate for tracheostomy Tube Change: YES / NO Team Briefing - Roles established Operator - Assistant - Type of tube change: Blind obturator / Over airway catheter Confirm new tube to be sited: YES / NO Pre- tube change Checklist Safety equipment check Oxygen Suction Suction catheters Gloves Yankauer sucker Tube available in smaller size End tidal CO2 monitor Resuscitation equipment Tube Change Tray Dressing pack Saline Tracheostomy dressing and tapes Bougie / Airway catheter (if required) Stitch cutter (if sutures present) Syringe (if cuffed tube) Tracheal dilators Appropriate sized tracheostomy Aqua gel Cautions / Considerations Feed stopped YES / NO Anaesthetic cover needed YES / NO Tube change process as per ICS Guidelines YES / NO Airway stable throughout YES / NO Documentation in medical notes Signed Date 20

21 3. Decannulation Tracheostomy Decannulation Background Decannulation describes the process of tracheostomy tube removal once the need for the tube has resolved. There are many advantages to decannulation, including improved vocal cord function, swallowing, patient comfort and communication. As such decannulation should be considered as soon as clinically safe and possible after the need for a tracheostomy tube has reversed. In assessing the patient for decannulation it is important firstly to consider the reason for insertion. As mentioned above this might vary from planned head and neck surgical procedures, weaning from prolonged mechanical ventilation, inability to protect the airway due to impaired neurological status or an emergency upper airway obstruction. In all these situations however there are some common features and steps that need to be considered during the decannulation process. In attempting to provide some clear indicators as to when decannulation can safely be attempted the literature is of limited value consisting of mainly expert opinions together with international current practice surveys. Not surprisingly given the difficulties in attempting such studies in this patient cohort there is a paucity of clinical trials and no randomised controlled trials. As yet no validated quantitative scoring system has been devised to aid the decision process for decannulation although a quantitative semi quantitative clinical score has been proposed. There can also be disagreement between different groups over the best time to decannulate but seeking the views of all of the multi disciplinary team is clearly important. Chronic co-morbidities and the lack of evidenced-based weaning and decannulation guidelines make it difficult to predict outcomes for individual patients. Process of decannulation The most important determinants commonly reported when considering and assessing readiness for decannulation are: Availability of suitably trained staff level of consciousness tolerance of cuff deflation resolution of condition that necessitated the tracheostomy tube ability to tolerate tracheostomy tube capping 21

22 cough effectiveness quantity of secretions and ability to manage secretions Other relevant factors in reaching a decision include the following: the patient s co-morbid disease state the cause of any respiratory failure swallowing dysfunction the respiratory rate ongoing requirements for supplementary oxygen Criteria for Decannulation For any patient the decision to decannulate MUST be a multidisciplinary (MDT) one and the following criteria should be fulfilled: There should be a person present who is able to recannulate should decannulation prove unsuccessful. Emergency bedside equipment should be available The optimal time for decannulation is usually in the morning when the patient has rested overnight and their condition can be observed during the daytime. In a non-neurologically compromised patient the subject should be able to obey commands. Respiratory function should be stable. The SpO 2 must be over 94% breathing room air or at a suitable level (86-92%) in patients with chronic obstructive pulmonary disease (COPD). Supplementary oxygen may be required but should not exceed FiO There must be an adequate cough and the ability to clear secretions effectively and independently. The need for mechanical aspiration / suction can be assessed by the number of tracheal aspirations over a 24-hour period (although a cut-off number has not been established). Abundant chest secretiopns (bronchorrhoea), and need for frequent suction should be considered relative contraindications to decannulation. Assessment of protective reflexes is also essential, in particular to evaluate the effectiveness of the cough reflex. The intensity of the cough can be demonstrated either spontaneously or induced by tracheal aspiration. The absence of an effective cough is also a relative contraindication to decannulation. However a Peak Cough Flow over 160 L/min, with adjuvant techniques such as manually or mechanically assisted cough devices has been shown to indicate that decannulation should be successful. Cardiovascular stability 22

23 Tolerates cuff deflation for 24 hours and/ or tolerates speaking valve 12 hours or more (usually during daytime) or decannulation cap for up to four hours (if air flow is present on finger occlusion). In patients following head and neck surgery, the decannulation cap may be left for longer periods at the discretion of the surgeon. Alternatively, if the tracheostomy was placed to allow for surgical oedema it can be removed as soon as the airway is deemed to be safe, sometimes without a period of occlusion. Usually however, airway assessment should be performed clinically by occlusion of the tracheostomy with the cuff deflated or with an uncuffed tracheostomy tube. Airflow over the cords should allow phonation and if the patient is unable to phonate, has stridor or laboured breathing, or manifests any respiratory distress, a thorough endoscopic examination of the airway, including the vocal cords and subglottic space, is recommended. Endoscopic inspection of the airway, although not routinely performed prior to decannulation, can be helpful in revealing tracheal abnormalities or vocal cord dysfunction. No new lung infiltrates on x-ray (when indicated) If the criteria for decannualtion are met - explain procedure to patient, ensure cuff is completely deflated (if applicable), cut any holding sutures and remove tracheostomy tube. Cover stoma with a semi-permeable dressing. Post Decannulation Monitor patient closely for hours post decannulation. The emergency tracheostomy equipment tray should be kept by the patient s bedside for hours post decannulation in case of emergency. Decannulation failure Currently there is no universally accepted definition for decannulation failure however literature has suggested the need to reinsert an artificial airway within 24h or up to 3 days post decannulation as potential definitions of failure to decannulate. A variety of reasons may contribute to failure to decannulate. It is therefore essential that any patient who has had their tracheostomy removed should be closely observed in the immediate post decannulation period. Some patients may have an increase in their work of breathing however the changes in work of breathing between individuals are considerable and are closely related to altered airway resistance. Those weaning from prolonged ventilator support in Critical Care being particularly at risk of fatigue. Inadequate cough reflex may result in an inability to clear secretions and removal of the tracheostomy tube may unmask tracheal damage including stenosis, tracheomalacia and granuloma that may not been previously recognised. These complications may present as stridor, altered quality in vocalization and/or an increase in work of breathing. A patient should be referred to the ENT team if concerned or the emergency team if acute respiratory distress is observed. 23

24 FLOW CHART FOR DECANNULATION TRACHEOSTOMY TUBE INSERTION MECHANICAL VENTILATION NO LONGER REQUIRED TRACHEOSTOMY OCCLUSION TOLERATED NO YES FIBEROPTIC AIRWAY EVALUATION ADEQUATE MENTAL STATUS EFFECTIVE COUGH SECRETIONS CONTROLLED AIRWAY PATENTCY ESTABLISHED / RE- ESTABLISHED NO LONG TERM TRACHEOSTOMY TUBE TRACHEOSTOMY OCCLUSION TOLERATED ADEQUATE MENTAL STATUS EFFECTIVE COUGH SECRETIONS CONTROLLED DECANNULATE MONITOR PATIENT CLOSELY FOR HOURS 24

25 4. Movement between units, wards and theatres communication needs. Transferring tracheostomy patients Patients with tracheostomies often need to be moved. From an operating theatre to a ward or critical care unit, between wards or unit and between hospitals. Transfers from hospital to home or back again are covered in the next section. This is a potential time of risk to the patient as movement from bed to trolley or wheelchair increases the risk of tube displacement. The precise circumstances of the transfer will determine the personnel and equipment needed, but communication is key. The initial decision must be agreed by the team looking after the patient and the team, family etc who will receive them. Particular care must be given to patients being discharged home on their own that the communication with community teams is functional. Planning the transfer must include an assessment of the times when the patient is at risk. This is usually at the point of transfer from a bed into a trolley or chair, and again when the patient is transferred back to a bed. Personnel trained in recannulation must accompany the patient as if the tube is displaced it may need to be replaced during the journey. It is completely unacceptable for a tracheostomy patient to be moved from one area of the hospital to another (or from one hospital to another) until both areas have agreed that a bed and trained personnel are available, Particular care must be taken with ventilated patients who may have to be transferred onto a portable system for the transfer itself. Adequate oxygen and power must be assured before the move commences. An emergency drug box must also accompany the patient under these circumstances. Although sometimes unavoidable for logistical reasons, it is poor practice to transfer a patient with a tracheostomy during the night. 25

26 ALL WALES TRANSFER INFORMATION FOR PATIENTS WITH TRACHEOSTOMIES Between wards, units and hospitals 1. Primary Reason for Tracheostomy: Assist weaning from ventilation Maintain an airway Post facial surgery Secretion clearance Risk of aspiration Other Name: Hospital Number: DOB: Address 2. Type of Tracheostomy: Percutaneous Surgical 3. Date of Tracheostomy procedure: 4. Advised tube change date (max 30 days): 5. Sutures present? Yes / No Date for removal: Brand of Tracheostomy Size Type of Tube Cuff present? Y / N Inner tube present? Y / N Fenestrated? Y / N Adjustable flange? Y / N 6. Current Requirements: Humidification Oxygen Suction Catheter Size Secretion Heated Cold Water Swedish Nose Buchanan Bib Regular Saline Nebulisers % Quantity Type 26

27 Date of transfer: Professional completing form: Name: Designation: Sign: Professional receiving form: Name: Designation: Sign: 27

28 ALL WALES TRANSFER INFORMATION FOR PATIENTS WITH TRACHEOSTOMIES 1. Primary Reason for Tracheostomy: From Theatre to ITU/Ward To assist weaning from the ventilator Maintain an airway Post Maxillofacial/ENT surgery Secretion clearance Risk of aspiration Other Name: Hospital Number: DOB: Address 2. Type of Tracheostomy: Percutaneous Surgical 3. Date of Tracheostomy procedure: 4. Advised tube change date (max 30 days): 5. Sutures present? Yes / No Date for removal: Brand of Tracheostomy Size Type of Tube Cuff present? Y / N Inner tube present? Y / N New inner tube included Y/N Fenestrated? Y / N Adjustable flange? Y / N 6. Current Requirements: Humidification Oxygen Suction Catheter Size Secretion 28

29 Heated Cold Water Swedish Nose Buchanan Bib Regular Saline Nebulisers % Quantity Type Date of transfer: Professional completing form: Name: Designation: Sign: Professional receiving form: Name: Designation: Sign: 29

30 ALL WALES TRANSFER INFORMATION FOR PATIENTS WITH TRACHEOSTOMIES 1. Primary Reason for Tracheostomy: From ITU to Ward To assist weaning from the ventilator Maintain an airway Post Maxillofacial/ENT surgery Secretion clearance Risk of aspiration Other Name: Hospital Number: DOB: Address 2. Type of Tracheostomy: Percutaneous Surgical 3. Date of Tracheostomy procedure: 4. Advised tube change date (max 30 days): 5. Sutures present? Yes / No Date for removal: Brand of Tracheostomy Size Type of Tube Cuff present? Y / N Inner tube present? Y / N New inner tube included Y/N Fenestrated? Y / N Adjustable flange? Y / N 6. Current Requirements: Humidification Oxygen Suction Catheter Size Secretion 30

31 Heated Cold Water Swedish Nose Buchanan Bib Regular Saline Nebulisers % Quantity Type Microbiology: Sputum Swallow/Nutritional status Weaning to date Date of Culture Sputum culture results Secretion type 24 hrs prior to transfer Assessed by SALT: Assessed by Dietetics: NBM? If not NBM, please describe current oral intake: Cuff deflation and current cuff status: Finger occlusion/capping: Speaking Valve: Suggested tube change date Date of transfer: Professional completing form: Name: Designation: Sign: Professional receiving form Name: Designation: Sign: Name: Designation: Sign: 31

32 Checklist for transfer of tracheostomy patients from hospital to the community. Patients are not to be transferred until all boxes are ticked. Please place list in patient s notes or scan to digital file. Action Required Refer to tracheostomy CNS or equivalent specialist nursing service and plan discharge with MDT Tick when complete Assess patient s physical and psychological ability to manage tracheostomy. Training for patient and or relatives/carers on tube management including nebulisers and suction as appropriate. Emergency situations discussed e.g. displaced tube, bleeding from tracheostomy or tubal occlusion Emergency contact number given to patient/carers. Facility for text (the patient may not have a voice). Inform local ambulance service who will highlight the patient status in advance as a neck breather. Refer to GP and community nurses for possible tracheostomy management training and future input. E.g. provision of suction catheters. Suction unit and nebuliser provided. Consumable equipment given and ongoing prescription from GP assured. Hospital pack including spare tracheostomy tube with printed information on type of tube, reason for tracheostomy and any pertinent information regarding the airway. Advise patient to bring pack with them if they need to reattend hospital. Arrangements made for future tube changes. In community or within the hospital 32

33 5. Transfer to the Community. INTRODUCTION Regardless of the reason for tracheostomy, the impact on the patient may be physically and psychologically profound and despite the increase in their numbers, suitably trained and experienced healthcare professionals who care for and train the tracheostomised patient remain in short supply. The tracheostomy may have been performed urgently to relieve acute or chronic upper airway obstruction or as a planned procedure to facilitate effective weaning from ventilation, but the impact of possible complete voice loss, reduced subglottic pressure and the mere presence of a tracheostomy tube in the trachea is disturbing. There should be a partnership between the patient and the multidisciplinary healthcare team to prepare for discharge ensuring all members of the clinical team are adequately trained and prepared to support the patient and their ability to self manage the tracheostomy. Procurement of a portable suction unit a clinical necessity, can take considerable time, rendering the patient hospitalised when clinically fit for discharge so early recognition of the need is important, unless the patient is an existing tracheostomy patient who has been previously self-caring and does not require suction. Many care facilities will not accept tracheostomised patients so those few who do need regular support and intervention. Many tracheostomised patients have significant co-morbidities which may impede their ability to self care hypoxic brain injury, arthritic hands, visual impairment etc, so astute clinical assessment prior to discharge is important. There should be a point of contact for the patient and scheduled tracheostomy tube changes arranged prior to discharge. The aim of any discharging MDT would be a patient educated to manage their tracheostomy at home with appropriate equipment and support network thus minimizing the risk of adverse clinical event requiring emergency hospitalization. 33

34 All Wales transfer requirements for tracheostomy patients on discharge from hospital to community Early referral to tracheostomy CNS or equivalent trained nursing team. MDT approach to advance discharge planning. Assessment of the patient s physical and psychological ability to manage their tracheostomy. Prompt start for training of the tracheostomised patient and others if appropriate, e.g. a relative or significant other, in inner tube care and suction technique prior to discharge. Printed learning objectives with point by point instructions to support learning. Discussion on emergency situations e.g. displaced tube, bleeding from tracheostomy or tubal occlusion and the appropriate course of action. Emergency contact number preferably a mobile number with text facility ( the patient may not have a voice ) Inform local ambulance service who will highlight the patient status in advance as a neck breather. Early referral to community nurses concerning their potential need for tracheostomy management training and future input particularly the provision of suction catheters (not on prescription, but available through community supplier). Early provision of portable suction unit and nebuliser. The patient should be trained on their home equipment and mechanical integrity should be checked prior to discharge. Provision of appropriate equipment and regular prescription from the general practitioner for tracheostomy consumables. There are commercial companies supporting the provision of consumables e.g. Countrywide Supplies. Provision of a hospital pack i.e. a spare tracheostomy tube with printed information on type of tube, reason for tracheostomy and any pertinent information regarding the airway. The patients are asked to bring this to hospital in the event of emergency admission. Advance arrangements for complete tube changes either on community or within the hospital setting dependant on local services. A checklist is included. Pdf versions are available and are to be completed for transfers. 34

35 ALL WALES DOCUMENT FOR THE TRACHEOSTOMISED PATIENT ON DISCHARGE FROM HOSPITAL TO THE COMMUNITY. Prompt referral to the tracheostomy MDT for advance discharge planning Refer to community nurses for the provision of a portable suction unit for home use and any training requirements pre- patient discharge. Assessment of the patient s physical and psychological ability to manage their tracheostomy. Refer to a commercial company supporting the provision of tracheostomy consumables via prescription e.g. countrywide supplies. Advance arrangements for regular complete tube changes either in community or in hospital (dependant on local services. Early start for training for the patient and a significant other in tracheostomy management and suction technique. Printed learning objectives with point by point instructions to support learning. Discussion on emergency situations e.g. displaced tube, bleeding, tubal occlusion and the appropriate course of action. Provision of an emergency pack spare tube. Printed information re: type of tube, reason for intubation and any specific details pertaining to the tracheostomy. The patient is advised to bring this with them, in the event of emergency admission to hospital. Provision of a nebuliser for discharge. Ensure any inhalers have been converted into nebules. The patient should be trained on their home equipment and its mechanical integrity checked pre-discharge. 35

36 6. Emergency Management. Emergency management in the community There are always concerns when patients with a tracheostomy are managed in the community, and yet a number of patients will be managed outside of hospital at some point in their care. The following flow charts have been prepared to assist non specialist teams when managing emergencies. Most tracheostomies will be managed without removing them, but if the airway is blocked with no airflow, no ability to pass a suction catheter (if available) and no movement of the chest if air is blown into the end of the tube, the tracheostomy must be removed. It is likely that the tube itself is blocked with mucus or blood clot. The patient may then be able to breathe on their own, but if not check for a pulse and start cardiopulmonary resuscitation if required. Pulmonary resuscitation should then proceed using either the mouth and blocking the stoma in the neck, or via the stoma and closing the mouth. It is important to try and differentiate between a patient in the community with a tracheostomy (who should therefore have a potentially patent upper airway) and a laryngectomy (who by definition will have an end-stoma and no airway via the mouth or nose). If in doubt, please follow the guidance for tracheostomy emergencies, but always ensure that oxygen and ventilation are given via the neck stoma, even if this is duplicated via the mouth. However if you are confident a patient has a laryngectomy then the laryngectomy guidance should be followed as attempts at managing the airway from the mouth or nose will be unsuccessful. Please note that a patient who has had a laryngectomy is called a laryngectomee. You may see this term on cards carried by the patient, or on stickers on car and house windows. 36

37 Emergency Management of a tracheostomy patient 37

38 Emergency management of a laryngectomy patient 38