Professionally Approved by Dr Kath Rowe January 2018

Transcription

1 Care of Adult Patients with front of neck airways Developed in response to: Type: Clinical Guideline Register No: Status: Public Best practice Contributes to CQC Fundamental Standards: 9, 12 Consulted With Post/Committee/Group Date Mr Mark Puvanendran Dr Sarah Smailes Dee Hannis Clare Leppich Vanessa Bell Judith Harriott Jo Sirkett David Curtin Andreia Santos Dr Natasha Lawrence ENT Consultant Physiotherapy Consultant Sister ICU CNS (Head and Neck) CNS (Head and Neck) Sister Burns ICU Specialist SLT Specialist SLT Sister ENT Consultant December 2017 Professionally Approved by Dr Kath Rowe January 2018 Version Number 4.0 Issuing Directorate Nursing Ratified by: DRAG Chairmans Action Ratified on: 6 th March 2018 Trust Executive Sign Off Date March/April 2018 Implementation Date 19 th March 2018 Next Review Date February 2021 Author/Contact for Information Dr Sarah Smailes, Physiotherapy Consultant Policy to be followed by (target staff) All staff involved with nursing adult patients who have a tracheostomy or laryngectomy Distribution Method Intranet & Website. Hard copies to all ward areas and managers concerned Related Trust Policies (to be read in Infection Prevention Policies conjunction with) Document Review History Version No Authored/Reviewed by Active Date Dr Ellen Makings 24th June Dr Sarah Smailes March Dr Sarah Smailes May Dr Sarah Smailes November change of tracheostomy nominated wards Dr Sarah Smailes 10 th Dec remove competency Dr Sarah Smailes 6 th Sept Dr Sarah Smailes 19 March

2 INDEX 1. Purpose 2. Equality and Diversity 3. Scope 4. Definition 5. Tracheostomy tube types 6. Staffing and training 7. Humidification 8. Tracheal suctioning 9. Infection prevention 10. Cleaning the inner cannula of tracheostomy tubes 11. Changing of stoma dressing and holder 12 Changing tracheostomy tubes 13 Communication 14 Swallowing management 15 Care of the tracheostomy tube with an inflated cuff 16 Weaning of tracheostomy tubes 17 Decannulation 18 Emergencies 19. Audit and Monitoring 20. References 21. Contributors APPENDICES 1 Tracheostomy notification sign 2 Laryngectomy notification sign 3 First Responder emergency algorithm 4 Emergency Tracheostomy algorithm 5 Emergency Laryngectomy algorithm 6. Tracheostomy equipment checklist 7. Airway Care chart 8 Airway competency document 2

3 1.0 Purpose 1.1 The aim of this policy is to provide health care professionals with practical information on the safe, appropriate management of an adult patient with a front of neck airway (tracheostomy and laryngectomy) in the general ward environment. These patients are at high risk of adverse events and need specific equipment and specially trained staff to care for them. 1.2 It is vital that everybody who is involved with the care of a patient with a front of neck airway knows whether the patient has had a tracheostomy or a laryngectomy performed and the dates of the operations. This is necessary for general and emergency management. Therefore the tracheostomy or laryngectomy notification signs as appropriate should be placed above the patient s bedhead in full view (see appendices). 1.3 The aim of the tracheostomy tube is to: Maintain a patent airway Reduce damage to the larynx, mouth or nose through prolonged endotracheal intubation Decrease the anatomical dead space by approximately 150mLs, therefore decreasing airway resistance Improve oral hygiene and patient comfort Provide access for suctioning of the airway Prevent gross aspiration of oral secretions to the lungs 1.4 The increasing number of emergency tracheostomies and demand for tracheostomies in the ICU setting has led to an increased number of patients being nursed on the wards with tracheostomies and laryngectomies. 1.5 There are increasingly more patients living in the community with a tracheostomy or laryngectomy, who may require admission to the hospital for management and treatment of conditions other than those related to their airway. Admission to the hospital may mean that they are unable to manage their airway in their usual way, and in general they should be cared for in the same way as all other laryngectomy or tracheostomy patients. 2.0 Equality and Diversity 2.1 MEHT is committed to the provision of a service that is fair, accessible and meets the needs of all individuals. 3.0 Scope 3.1 All adult patients with a front of neck airway (tracheostomy or laryngectomy) should be nursed on the following designated wards only:- Accident and Emergency, GICU, Burns ICU, GHDU, Theatre Recovery, Billericay, Stock, Burns Adult Ward, Stroke Unit. 3.2 It is recognised that there is an increasing number of patients requiring tracheostomy in critical care, where care is directed by the intensive care team. Additional input will be sought by the tracheostomy team as required and will include Speech and Language Therapy and ENT. 3

4 3.3 The tracheostomy team should be notified as soon as possible when such a patient is admitted, or if there are any concerns, on bleep number # (Mon-Fri) or via the on-call physiotherapist (Sat-Sun). 4.0 Definition of Tracheostomy and Laryngectomy 4.1 A tracheostomy is an opening into the anterior wall of the trachea and is used to facilitate ventilation, protect the lungs against gross aspiration or as a port for suctioning. It may be temporary or permanent depending on the patient s diagnosis. The tracheostomy may be formed as an elective or emergency procedure and it may be performed surgically or percutaneously. The tube facilitates airflow to the trachea and lungs directly, bypassing the nose, pharynx and larynx if the tracheostomy tube cuff is inflated. Alternatively, the patient may breathe through the tube and their upper airway if the tracheostomy cuff is deflated. 4.2 A laryngectomy involves removal of the larynx (voicebox) and terminalisation of the trachea at the neck, called an end tracheostome. There is no potential for the patient to breathe through their upper airway following a laryngectomy operation 5.0 Tracheostomy tube types 5.1 Every patient with a new tracheostomy should have a double lumen tracheostomy tube ie a tracheostomy tube with a removable inner cannula in place. If a patient is transferred from another hospital with a single lumen tracheostomy tube, this should be changed to a double lumen tube as soon as safely possible*. There are many types and makes of tubes available; the main tube used within the Mid Essex Hospital Trust is the Kapitex tracoetwist Plus. The tube is made from polyurethane, which is light and flexible and becomes supple at body temperature. Tracheostomy tubes can be of standard length or longer length eg tracoetwist Plus. Some patients living in the community with long term tracheostomy may have a single lumen silver tube in place. In these patients it is usually appropriate to leave this in situ. Patients with laryngectomy generally do not have a tracheostomy tube in place beyond the first 2 3 days post op. Instead they may wear a laryngectomy tube, buchanan bib, stoma button or heat and moisture exchanger mounted on a baseplate depending on the shape of their stoma and their personal preference. 5.2 Tracoetwist Plus has a unique swivelling neck plate, which reduces pressure at the distal end of the tube, where digging into the tracheal mucosa can occur. This allows the patient to turn their head freely and comfortably in all directions. 5.3 The fenestrated tube comes with two inner cannulae, one plain and one fenestrated. An unfenestrated tube comes with two plain inner cannulae. The inner cannulae are inserted using a twist-lock mechanism providing confidence that the tube is securely in place. 5.4 Tracoetwist Plus tubes can either be cuffed or uncuffed. By putting air into the pilot balloon, it will inflate the cuff so the patient s only way of breathing is via the tracheostomy tube. This is necessary for mechanical ventilation or for protection of the airway against gross aspiration. 5.5 For a fenestrated tube, the fenestrations on the outer tracheostomy tube are multiple small holes. This helps reduce the risks of granulated tissue entering the airway and suction catheters penetrating the tracheal wall. 4

5 5.6 The Tracoetwist Plus comes in a range of sizes (7-10). Within the Trust, the most commonly used sizes are 7 and 8. All tubes have additional cannulae either plain, fenestrated or with built in speaking valves. Always check which tube the patient has in, the size is marked on the flange. Check which inner cannula the patient has in; white (plain) or blue (fenestrated). Check if it is a cuffed or uncuffed tube; is a pilot balloon present? 5.7 Some Tracoe twist tubes have a subglottic suction port facility. This is an extra port which enables removal of pooled secretions from above the inflated cuff with a syringe. The recommended frequency of secretion removal is every 4 hours Tracheostomy tube parts 6.0 Staffing and Training General 6.1 A patient with a front of neck airway is exposed to many potential risks and complications and therefore is usually more dependent on nursing care than other patients. This dependence should be reflected in the numbers of nurses on the ward. 6.2 Access to work-based education and training is essential for ward and department staff in order to ensure that they are competent to assess and manage acutely ill patients who are at risk of deterioration. All staff caring for patients with tracheostomies must first attend formal in house Trust tracheostomy training. This is followed by the staff member completing the Tracheostomy Competence document (see Appendix) and being signed off by a tracheostomy competent staff member every 2 years. 6.3 Individualised nursing care must be given to each patient with a tracheostomy. A tracheostomy specific nursing care plan must be implemented and updated daily by the health care professional caring for the patient. The planning of care for each patient should involve communication with all members of the multidisciplinary team as well as the patient. 6.4 It is essential that each person caring for a patient with a tracheostomy has received the correct training and is competent. The expected level of individual competency can be 5

6 identified in the MEHT general technical competency framework which is accessible on the intranet. 6.5 Bed Head Signage Appropriate Bed head signs must be in place for all patients with a front of neck airway. There should be 2 signs:- 1. Tracheostomy versus Laryngectomy 2. The first Responder Emergency Algorithm The full National Tracheostomy Safety Project Emergency algorithms for Tracheostomy and Laryngectomy should be attached to the difficult airway trolley for each appropriate ward area. See appendices for these documents. 6.6 Emergency Equipment (Blue Box) and Airway Care Chart The availability of equipment at the bedside is imperative to save the patient s life should an emergency occur, for example a blocked tube. A fully stocked Blue Box must be positioned on top of the tracheostomy trolley for all patients with front of neck airways. The equipment checklist (see Appendix) should be completed once on each shift and any equipment, once used, should be replaced immediately. The Airway care chart should be updated after all tracheostomy related interventions e g suction. 6.7 Tracheostomy Passport Each patient who has a tracheostomy in place for more than 30 days needs a tracheostomy passport. The passport is completed by the team looking after the patient and it stays with the patient following discharge into the community and on subsequent hospital admissions. This important document details the date of initial tracheostomy, type of tube in place and dates of tube changes therefore facilitating good airway care. 7.0 Humidification 7.1 The normal mechanisms of warming, moistening and filtering inspired air by the ciliated epithelial cells in the nose and upper airways are bypassed when a tracheostomy or laryngectomy is present. This leaves patients prone to atelectasis and infection. Inhaling dry air leads to paralysis of cilia, desiccation of mucus and physiological changes to the tracheal mucosa. Scabs and crusts form in the airway which are difficult to cough up or suction out and may obstruct the tracheostomy tube. Humidification is therefore an important aspect of tracheostomy and laryngectomy care. If it is assessed and delivered appropriately then the need for suctioning may be reduced. The method used for humidification can be altered as the patient s condition changes. Firstly, always ensure a patient is systemically well hydrated. 7.2 Artificial humidification is necessary to increase the moisture content of inspired air and: Prevent drying of the tracheal mucosa and interruption of the mucociliary transport process Guard against thick tenacious secretions Prevent encrustation or blocking of the tube ALL PATIENTS WITH FRONT OF NECK AIRWAYS SHOULD HAVE HUMIDIFICATION IN PLACE. PATIENTS WITH LARYNGECTOMY SHOULD HAVE ACTIVE (HEATED) HUMIDIFICATION FOR AT LEAST 48 HOURS POST OP. 7.3 Some common methods of artificial humidification are: 6

7 7.3.1 A heat and moisture exchange device (HME device), known as a Swedish Nose (a condenser humidifier that fits over the tracheostomy tube and acts as an artificial nose, recycling exhaled heat and moisture). Caution should be taken with those patients who have copious amounts of secretions since the HME may become blocked. Therefore all HME devices should be observed regularly for blockage by secretions or over-saturation and changed when these are in evidence. All HME devices should be changed at least daily Active (heated) humidification - A sterile, closed circuit heated water system and large bore tubing attached to a tracheostomy mask. The humidification dome, circuit and mask should be changed every 7 days Saline nebulisers 5ml 0.9% normal saline connected to normal gas source, flowing at 6-8 litres/minute, delivered using a tracheostomy mask. These are recommended 4-6 hourly in addition to other methods of humidification. The nebuliser should be rinsed in sterile water and dried thoroughly after each treatment ENT Bibs, otherwise known as Buchanan Bibs, can be placed over tracheostomy tubes or, more commonly, are used for the end tracheostome for patients who have had laryngectomy. Patients can wash and re-use these bibs three times 8.0 Tracheal suctioning 8.1 It is important that all health professionals who come into contact with tracheostomised patients know the reasons for, and the complications of, tracheal suction. 8.2 Suctioning should be performed and documented on the tracheostomy care chart (see Appendix) as often as necessary based on repeated assessment of the patient s respiratory function. 8.3 Each patient needs individual assessment and constant re-assessment to ascertain the frequency of suctioning required. Newly tracheostomised patients commonly require more frequent suction. 8.4 Suction is indicated if any of the following are noted:- 7

8 Crackles audible from the bedside (noisy or moist respirations) Shallow respirations or an irregular breathing pattern Increased breathlessness The patient becoming restless and/or anxious The patient is coughing but not clearing their secretions Reducing oxygen saturation or cyanosis 8.5 Suction Pressure The lowest possible vacuum pressure should be used during suction to reduce complications, including atelectasis. However the pressure should be sufficient to be effective in removing secretions. The maximum vacuum pressure should be kpa ( mmhg). 8.6 Suction catheters with fingertip control and side-eye ports are essential for this procedure to minimise tracheal mucosa damage. The outer diameter of the suction catheter should be no greater than half the size of the inner diameter of the tracheostomy tube. As a guide see table 1 below. Table 1- Recommended suction catheter size for different sized tracheostomy tubes Tracheostomy Tube I.D. (F.G.) Suction Catheter F.G. (E.D.) 10 (38) 14 (4.5) 9 (35) 14 (4.5) 8 (30) 14 (4.0) 7 (27) 12 (3.3) 6 (23) 12 (3.3) 5 (19) 10 (2.6) 4 (16) 8 (2.0) 3 (14) 6 (1.6) I.D. Internal Diameter F.G. French Gauge E.D. External Diameter 8.7 Equipment Needed for Suction A functional suction unit (wall source or portable) Suction tubing (labelled with date/ change every 24 hours) Sterile catheters (appropriate size) Disposable gloves, apron and eye protection Sterile normal saline 0.9% ampoules Oxygen therapy wall flow meter and tracheostomy mask Bottled water (labelled for cleaning suction tubing with opening date) Yankauer suction catheter Protective eye wear Pulse oximeter 8

9 8.8 Suction Technique Never suction a patient with a fenestrated tracheostomy tube with the fenestrated inner cannula in situ Wash hands and put on a disposable apron and gloves Explain the procedure to the patient Wear protective eyewear throughout the procedure Turn on the suction apparatus and attach a sterile catheter. The vacuum pressure should be no more than kpa ( mmhg) Put a clean, disposable glove onto the dominant hand and avoid touching anything with it except for the sterile catheter With the suction port uncovered i.e. with no suction, introduce the catheter gently into the tracheostomy tube to about 1/3 of the catheter s length or until the patient coughs Withdraw the tip of the catheter approximately 0.5 cm then apply suction, withdraw the catheter slowly with continuous suction, out of the tracheostomy tube. Do not suction for more than 15 seconds Release the suction, remove the catheter and glove and discard into an orange clinical waste bag If the patient is requiring oxygen, re-apply the oxygen supply immediately Using a fresh, clean glove and new sterile catheter repeat the above steps as indicated until the secretions are cleared and the patient is breathing comfortably NB. In an acute situation only, where the tube is at risk of blocking and/or the secretions are pluggy and tenacious, a small amount of sterile 0.9% normal saline may be used to aid clearance of secretions by initiating a cough. A competent person should instil 2 5 mls of sterile 0.9% normal saline into the tracheostomy tube prior to suctioning. Record the intervention on the tracheostomy care chart (see Appendix) 8.9 Complications of suctioning Hypoxia has been documented as an adverse effect of airway suction in many studies. This is minimised by adopting a good suction technique Cardiac arrhythmias can occur, usually as a result of vagal stimulation. Bradycardia can also occur as a result of vagal stimulation. Preoxygenation may reduce the incidence of these from occurring Trauma to the tracheal mucosa - Ulceration and necrosis of the tracheal mucosa can be reduced by avoiding excessive suctioning, using the correct type and size of catheter and adopting a good technique. 9

10 8.9.4 Anxiety and discomfort is experienced by many patients during suctioning. Adequate explanation and reassurance should be routine prior to and during suction Infection - Repeated suctioning may cause tracheal mucosal trauma, this in turn leads to an increased risk of infection. Suction should be performed only when indicated and not routinely. 9.0 Infection prevention Alcohol gel +/- hand washing is essential both before and after all procedures. Gloves must be worn and contaminated gloves must be changed between procedures. Sterile gloves must be worn for changing tracheostomy tubes. For suctioning the gloves may be clean rather than sterile. Aprons should be worn at all times and changed between procedures and patients. Eye protection should be worn for suctioning, dressing or tube changes or at any time when there is a risk of coughing secretions over the caregiver Patients with resistant infections should be nursed in a side room on advice of the Infection Prevention team. 10 Cleaning the inner cannula of tracheostomy tubes 10.1 The tracheostomy inner cannula must be assessed regularly (2-6 hourly) to ensure it does not become blocked with secretions. The frequency with which cleaning is required will vary widely between patients. The factors that should be considered are: Amount and consistency of secretions The presence of secretions not cleared by tracheal suction Patient request 10.2 Equipment needed for cleaning of inner cannula Labelled, dated designated bowl only to be used for inner cannula storage (changed daily) Labelled, dated designated bowl only to be used for inner cannula cleaning (changed daily) Labelled, dated bottle of sterile water only to be used for inner cannula cleaning (changed daily) Tracheostomy cleaning swabs 10.3 Cleaning Procedure The inner cannula should be cleaned at least every 2-6 hours, or immediately if the patient looks to be in respiratory distress (as per First Responder s Emergency algorithm see Appendix) Wash hands and put on disposable plastic apron and gloves Wear protective eyewear throughout the procedure 10

11 Assess whether the patient needs suction prior to this procedure and give suction as required as per guidelines (see 8.8) N.B. In the case of an emergency where tube obstruction is the likely cause, the inner cannula should be removed, inspected and cleaned immediately Stabilise the tracheostomy tube with one hand whilst removing the inner cannula by turning it anti-clockwise with the other. Place the dirty inner cannula into a designated bowl for cleaning. Insert the spare clean inner cannula. Whilst stabilising the tracheostomy tube with one hand ensure the inner cannula is locked in place by turning it clockwise, replace humidification/ oxygen as appropriate Cover the dirty inner cannula with sterile water and clean inside it using a tracheostomy cleaning swab. Inner cannulae should not be cleaned or rinsed with tap water. Inner cannulae should also not be soaked Gently tap any excess water from the clean cannula and leave in designated bowl for storage to dry. Rinse the designated bowl for cleaning with sterile water and leave to dry. This bowl should not be used for any other purpose Record the intervention on the tracheostomy care chart (see Appendix) Wash your hands 11. Changing of stoma dressing and holder 11.1 This is a two person technique for tracheostomy patients, one person must stabilise the tube in place whilst the other changes the dressing. Secretions often ooze out of the stoma causing wetness and irritation of the surrounding skin. Therefore the stoma must be assessed at least every 24 hours for trauma, infection or inflammation and the dressing and holder should be replaced. The back of the neck should also be assessed at the same time for signs of rubbing and soreness from the tracheostomy holder/ tapes All findings should be documented on a wound assessment chart. Use of a broad soft tracheostomy holder should prevent skin damage at the back of the neck If the skin around the stoma becomes wet or irritated a barrier cream may be helpful to facilitate healing. Should this be the case the stoma dressing and holder will need to be changed more frequently Equipment needed Normal saline Non adhesive dressing Wound swab 11

12 Absorbent and non-adhesive dressing e.g.lyofoam TM. Tracheostomy tube holder Light source 11.5 Procedure Explain procedure to the patient Position patient to allow easy access to stoma The tracheostomy dressing and holder should be removed whilst the second person is securing the tracheostomy in place observe skin for signs of infection, oedema or redness/excoriation Take swab if necessary Clean stoma with normal saline Apply clean non adhesive dressing shiny side to skin e.g. Lyofoam TM A second nurse is required to change the dirty tracheostomy tapes to ensure the tube is held in place securely Padded strapping should be cut to allow satisfactory securing of the tapes Velcro tapes should be fastened comfortably but tight enough to allow only 2 fingers to fit between the tape and neck If the Velcro straps are consistently being tampered with or undone by the patient consult the tracheostomy team 12 Changing Tracheostomy Tubes 12.1 According to the Medical Device Directive 93/EEC, a device should be changed every 30 days. The Kapitex Company therefore stipulates a double lumen tracheostomy tube should be changed every 30 days. It is good practice to change a single lumen tube every 7-10 days. It is recommended that a tracheostomy tube should not be changed until the tube has been in situ for 5 days post surgical tracheostomy and 7-10 days post percutaneous tracheostomy formation. Earlier removal of the tube may result in loss of the stoma and formation of false passage. Please consult the head and neck team before changing the tube in head and neck cancer patients Only professionals who are deemed competent by the Mid Essex Hospital Trust should change tracheostomy tubes. The highest risk tube change is one in a newly formed stoma or when there is respiratory compromise and the grade of the professional changing the tube should reflect the risk involved. Two persons should always be present and can be the following: ITU Doctor (usually SpR or above) or Consultant The on-call anaesthetic team 12

13 Trained physiotherapists Members of the ENT medical team Trained Nurses 12.3 There are 2 methods of changing tracheostomy tubes, the Blind exchange using an introducer and Guided exchange using an airway exchange catheter for patients at high risk of airway loss or for the first tube change Equipment needed Tracheal dilators Sterile wound pack Suture cutter 10 ml syringe for cuffed tubes Normal saline 0.9% sachet Tracoetwist tracheostomy tube of the appropriate size and one a size smaller Pulse oximeter Oxygen mask Oxygen supply Suction equipment Protective eyewear Tracheostomy dressing and holder Water soluble lubricant Stethoscope Airway exchange catheter (for guided exchange) Difficult airway trolley 12.5 Recommended Procedure for Blind exchange Check emergency equipment is present and working Two persons must be present Consider stopping feed in accordance with local practice Explain the procedure to the patient and gain consent Ensure assistant is clear about what is expected of them Wash hands Wear disposable gloves, protective eyewear and plastic aprons throughout the procedure Position patient on the bed in sitting position with neck slightly extended Prepare equipment (check tube cuff inflation of new tube if applicable and insert introducer) Consider preoxygenating patient and monitor oxygen saturations Perform oral and tracheal suction if required Remove soiled tracheostomy dressing and discard in an orange clinical waste bag Clean around stoma with normal saline Ensure cuff is deflated if present Remove soiled tube from the patient s neck in a curved downward movement Insert the clean tube with introducer in situ, using an up and over action Remove the introducer and ensure the plain inner cannula is inserted Attach and adjust tapes as described in 11.5 Observe patient and their vital signs Listen for bilateral air entry using a stethoscope Check tube is in place using C0 2 detector 13

14 Clear away equipment according to trust policy 12.6 Recommended Procedure for Guided exchange Check emergency equipment is present and working Two persons must be present Consider stopping feed in accordance with local practice Explain the procedure to the patient and gain consent Ensure assistant is clear about what is expected of them Wash hands Wear disposable gloves, protective eyewear and plastic aprons throughout the procedure Position patient on the bed in sitting position with neck slightly extended Prepare equipment (check tube cuff inflation of new tube if applicable and insert introducer) Pre-oxygenate patient and monitor oxygen saturations Perform oral and tracheal suction if required Ask assistant to remove soiled tracheostomy dressing and discard in an orange clinical waste bag, and clean around stoma with normal saline. Insert exchange device to length of tube Ask assistant to deflate cuff (if present). Remove old tube over exchange device Insert new tube over exchange device Check for airflow through tube and inflate cuff (if applicable) Remove exchange device and attach C0 2 detector to check correct airway placement. Ensure the plain inner cannula is inserted Attach and adjust tapes as described in 11.5 Observe patient and their vital signs Listen for bilateral air entry using a stethoscope Clear away equipment according to trust policy 13.0 Communication 13.1 The presence of a tracheostomy can affect the patient s voice production. The loss of verbal communication can have a devastating effect on both the patient s communication effectiveness and his or her well-being It is the role of the Speech & Language Therapist (SLT) to assess and advise on an individual s ability to communicate their needs and feelings effectively It is recommended that patients who have communication difficulties due to organic, concomitant or psychogenic disorders should have access to an early, timely, responsive and appropriately skilled Speech and Language therapy service Communication may be assisted by the appropriate use of any of the following: Mouthing words Pen & paper Alphabet boards, picture boards & phrase boards Coded eye blinks Electro-larynx Electronic communication aids (when available) Speaking valves/caps, where appropriate 14

15 13.5 Importance is placed on achieving the appropriate method of communication for the patient. Not all methods will suit all patients. The restoration of oral communication should be facilitated wherever possible, for example; using speaking valves, cuff deflation, fenestrated tubes at an appropriate time, whilst taking into account their individual medical needs Swallowing Management 14.1 The presence of a tracheostomy tube can adversely affect swallowing in patients who previously had no dysphagia, and may further impair the swallowing function in those who already have neurological or mechanical disorders of swallowing The potential impact of a tracheostomy on swallowing function may include the following: Reduction in the elevation and anterior movement of the larynx Tracheal irritation at rest and during swallowing Laryngeal stenosis Reduced and uncoordinated laryngeal closure Fixation of the trachea and compression of the oesophagus by the tracheostomy tube cuff Reduced laryngeal sensitivity Loss of protective reflexes Insufficient, excessive or thick saliva production Disruption of airway pressures Reduction of airflow through the glottis Blunting of reflexive cough 14.3 It is recommended that referral to a Speech and Language Therapist for swallow assessment should be considered for patients in whom oropharyngeal dysphagia is identified on screening, oral intake cannot be safely established or for patients who are at risk of dysphagia Where swallowing dysfunction is identified, appropriate investigations are undertaken by a SLT. A bedside assessment of a patient s swallowing ability will be made initially. Thereafter, specialised instrumental methods of swallowing assessment such as fibreoptic endoscopic evaluation of swallowing (FEES) and videofluoroscopy will be considered by the SLT with the medical team, as appropriate Following the assessment, recommendations regarding safety of swallow, patient positioning, swallow manoeuvres and textured diets will be advised All observations will be recorded in relevant notes. Any concerns should be brought to the attention of the SLT Care of Tracheostomy Tube with an Inflated Cuff 15.1 Patients breathing through a tracheostomy with an inflated cuff have no potential to breathe through their upper airway since the inflated cuff forms a seal between the lower and upper airways. In this instance the tracheostomy is the patient s only airway and this increases the nursing dependence of patients (see Appendix regarding staffing numbers). 15

16 15.2 Patients who require an inflated cuff are at particularly high risk of complications and therefore require continuous airway monitoring by trained nursing staff. Patients who are nursed in isolation (single side room) should always have a dedicated competent airway trained nurse (one nurse to one patient) (see Appendix regarding staffing numbers) If a tracheostomy tube lumen is occluded by a decannulation cap or other device when the cuff is inflated the patient will not be able to breathe. In this situation the tracheostomy tube acts as a foreign body or obstruction within the trachea, and if the cap is not removed immediately (or the cuff deflated) respiratory arrest will occur. NEVER CAP OFF A TRACHEOSTOMY WITH AN INFLATED CUFF 15.4 Before capping off a tracheostomy tube or applying a speaking valve, ensure that the cuff is deflated; the tracheostomy is fenestrated, and it has a fenestrated inner cannula insitu. To deflate the cuff, attach a 10mL syringe to the pilot balloon and withdraw syringe until no more air can be aspirated The cuff should be deflated if: the patient is allowed to eat or drink, providing there is no risk of aspiration a speaking valve or decannulation cap is applied to the end of the tracheostomy tube 15.6 The pressure of the inflated cuff should be closely monitored. Excessive pressure may reduce perfusion to the tracheal mucosa resulting in mucosal ischaemia, necrosis and possible stenosis (narrowing of the airway) A cuff manometer should be available on each ward designated to care for tracheostomy patients Checking the cuff pressure Each shift and each time the cuff is re-inflated; check the cuff pressure using a cuff manometer Cuff pressure should be maintained between 15 and 30`cm H2O (10 to 18 mm Hg) unless directed otherwise by medical staff Explain to the patient the intention to measure the cuff pressure Wash hands and put on a pair of clean gloves Connect the pilot balloon to the manometer (an extension tube connector is optional). Depress the one-way valve by pushing the two together Note the pressure indicated on the gauge and document on the airway care chart. Disconnect and cap off the pilot balloon (not all models) Take care not to deflate the balloon by accidentally depressing the automatic deflate button. If this does occur the cuff should be re-inflated and the pressure re-measured. Wash the gauge with warm soapy water. Do not immerse. 16

17 Dry thoroughly after each use 15.9 Sub-glottic secretions drainage Use of endotracheal tubes with a sub-glottic suction port to allow removal of secretions from above the cuff has been shown to reduce the incidence of ventilator associated pneumonia in critically ill patients. This is because the likelihood of aspiration of colonised oropharyngeal secretions past the cuff into the lower airways is reduced. Although there is no similar evidence to support the use of tracheostomy tubes with a sub-glottic suction port, it is reasonable to assume that regular removal of secretions from above the cuff should reduce leakage into the lungs. Recommended frequency of aspiration of secretions from the sub-glottic suction port is 4 hourly using a 10 ml syringe Weaning off the Tracheostomy Tube 16.1 Once the initial reason for the tracheostomy tube has resolved a plan for weaning off the tube can be made. Weaning may occur over a short period of time, for example with head and neck surgical patients who have intact airway protection mechanisms. For other patients with neurological deficits, for example severe muscle weakness, a longer period of weaning is indicated. In these patients the weaning process should take the form of a programme designed to build endurance where the work of breathing and effort required for coughing is gradually increased Weaning is commenced when: The primary reason for the tracheostomy has resolved or been considered The patient s condition is stable and improving There are no signs of bronchopulmonary infection or excessive secretions 16.3 The weaning programme must be planned and clearly documented. For complex patients advice should be sort from the tracheostomy team Good communication and documentation is essential to ensure smooth progression through the weaning process to decannulation. The programme of tube weaning will vary between ward areas but the order of the three weaning stages described below is set and should not vary. The patient should be nursed within maximum view of the nurses station, with a call bell within easy reach and be sitting in an upright position. The speech and language therapist is integral to the weaning process and should be involved with every patient at an early stage. Key stages of weaning are outlined below: 16.5 Stage 1 Cuff deflation The inflated cuff provides some protection against aspiration of orophryngeal secretions and therefore patients become unaccustomed to managing these and swallowing saliva. A physiotherapist or competent person assesses cuff deflation tolerance, or the swallowing capability of the patient Give a full explanation of the procedure to the patient and carers, warn them that they may have a change in breathing sensation and may cough for a few minutes after the cuff is deflated. 17

18 Attach pulse oximeter to patient Ask patient to cough and clear secretions, aspirate subglottic suction port (if available) and ensure patient s mouth is clear of secretions. This will minimise aspiration of secretions when the cuff is deflated. Caution with patients who have had intra-oral surgery With a fresh suction catheter suction either whilst gradually deflating the cuff, or deflate the cuff and immediately follow with suction Closely monitor the patient for persistent coughing and or desaturation. This indicates that the patient may be aspirating their oral secretions or may have inadequate cough strength and excessive secretions. In both cases the cuff should be re-inflated using the minimum volume of air to reach the desired pressure. Refer to Speech and Language Therapy for issues with aspiration. Some patients will require a slow increase in the amount of time the cuff is deflated due to muscle weakness whereas others may be able to tolerate 24 hours of cuff deflation at the first attempt. The aim is for the cuff to stay deflated all of the time if possible. Once the patient can tolerate periods with the cuff deflated they may progress to vocalising and swallowing. A double lumen fenestrated tracheostomy tube is optimal for further weaning 16.6 Stage 2 Cuff deflation and Tube Occlusion with a gloved finger/ speaking valve Remove the plain inner cannula and deflate the cuff (stage 1 above) Initially try occluding the tracheostomy tube with a gloved finger Listen for airflow through the nose and mouth and monitor saturations during this procedure. If the patient s work of breathing increases, stridor is heard or saturations drop remove finger and do not wean further. The patient may require a smaller fenestrated tracheostomy tube before they are able to progress to stage 3. If tube occlusion with a gloved finger is well tolerated insert the fenestrated inner cannula and place the speaking valve over the tube opening. Encourage throat clearing, expectoration, vocalisation and dry swallowing. Remain with the patient to observe for signs of respiratory distress, a wet gurgly voice and dropping saturations when using a speaking valve for the first time. Each patient is an individual and may require shorter or longer periods of stage 2 weaning. Some patients may take several days or weeks to achieve successful weaning. The aim is to increase tolerance to a minimum of 4-6 hours in the day. Some patients may require use of the speaking valve at night before decannulation is considered. It is advised that the speaking valve is not used for very long periods because the patient is not receiving any humidification (i.e breathing dry air through the valve). Remove the speaking valve for nebulisers as it can become sticky when wet Stage 3 Capping Off (cuff deflated) This is the final stage of tracheostomy weaning. Some patients can be dacannulated from a speaking valve (stage 2). With stage 3, the tube is effectively blocked off by the cap. At this stage the patient is breathing around the tube through the normal route. As 18

19 with stage 2, monitor the patient closely when progressing from a speaking valve to a cap. Stage 3 weaning is not a mandatory step for all patients with tracheostomies since some may be decannulated from a speaking valve (stage 2). Check with the tracheostomy team for advice. Repeat stage 2 substituting speaking valve for a decannulation cap Apply a fenestrated inner cannula and decannulation cap The patient is allowed to build up tolerance with the decannulation cap Patients with multiple problems will need to be capped off for short periods (eg 15 minutes) initially with careful monitoring and the time extended as per weaning plan The period of time required before decannulation is considered will vary depending on many factors, including the reason for the insertion of the tracheostomy tube and the patient s general condition. A minimum of 4 hours is required for most patients. Head and Neck surgical patients are usually required to tolerate capping off for up twelve hours a day for two days before decannulation is considered If the patient experiences respiratory distress during any stage of tracheostomy weaning, go back to the earlier step and refer to the tracheostomy team. always deflate the cuff before applying a speaking valve or decannulation cap (if in doubt seek advice from the tracheostomy team) 17.0 Decannulation 17.1 Decannulation occurs when the tracheostomy is no longer required. Each patient will have been assessed carefully by the tracheostomy team, throughout the weaning process The weaning processes will have been completed and the removal of the tracheostomy will be a planned procedure The removal should occur early in the day Decannulation Criteria 1. Physiologically stable 2. Adequate cough strength, able to clear all of their own secretions independently 3. Adequate level of mobility 4. Tolerates cuff deflation for at least 24 hours 5. Tolerates speaking valve or cap for at least 12 hours (usually longer for head and neck surgery patients) 6. Able to obey commands 7. MDT agreement 8. No surgery planned for 48 hours 17.5 The tracheostomy tube should only be removed by those members of staff whom are deemed competent by the Trust. 19

20 17.6 Equipment needed Tracheal dilators Spare unopened tracheostomy x 2, same size and I size smaller Sterile wound pack Wound swab Normal sachet 0.9% saline Oxygen face mask Oxygen supply Suction equipment Gauze Occlusive dressing Protective eyewear Pulse oximeter 17.7 Procedure Check all emergency equipment is present and working Two persons must be present Ensure the second person knows what is expected of them e.g. remove stitches, stabilise tube Position patient on the bed in semi recumbent position with the neck slightly extended Explain the procedure to the patient Wear protective eyewear throughout the decannulation process Wear gloves and apron Open sterile wound pack Give supplemental oxygen if deemed necessary Monitor oxygen saturations Perform oral and tracheal suction if necessary Ask the patient to take a deep breath. Remove tube in a curved downward movement while they are exhaling Observe stoma site for any signs of infection and consider swabbing Clean stoma, dress with occlusive dressing Show the patient how to apply light pressure over the stoma site which will facilitate coughing and talking without displacement of the dressing. They may need to do this for a period of between 2 days to approximately 2 weeks depending on how quickly the stoma heals 20

21 The patient should be encouraged to do hourly deep breathing exercises The stoma dressing should be changed twice per day, or more, depending on the amount of secretions The emergency equipment and tracheostomy box should be kept at the bedside for the next 24 hours Document decannulation in the patient s medical notes. The most common reasons for decannulation failure include failure to clear secretions, increased work of breathing and damage to the trachea e.g. granuloma, tracheomalacia. Therefore patients should be observed for signs of respiratory distress. The patient should have continual monitoring and respiratory rate and oxygen saturations observations recorded every 15 minutes for the first 4 hours; then if the patient is stable, 4 hourly over the next 24 hours Ensure the patient has the call bell within reach and can be observed easily 18. Emergencies 18,1 In case of any breathing problems with a patient with an adjusted airway follow the First responder emergency algorithm (see Appendix). This should be placed above the patient s bedhead in full view. For secondary responders the Trust follows the National Tracheostomy Safety Project algorithm for tracheostomy and laryngectomy emergencies (see Appendix). These should be attached to the difficult airway trolley Audit and Monitoring 19.1 Compliance with this guideline will be assessed within the monthly Saving Lives, High Impact Interventions Number 5 audit for patients attached to a ventilator. This information will be included in the Infection Prevention monthly divisional scorecard and will be monitored at Divisional Bilateral meetings In addition, an annual audit of compliance with this guideline will be undertaken as part of the Infection Prevention and Control Annual audit programme. This information will be included in the Infection Prevention monthly divisional scorecard and will be monitored at Divisional Bilateral meetings The outcomes of the audits will also be reviewed and discussed by the tracheostomy group to ensure that any learning needs are identified and supported References Core standards for Intensive Care Units. The Intensive Care Society and the Faculty of Intensive Care Medicine UK National Tracheostomy Safety project. Cook, T.M., Woodall, N., Harper, J., Benger, J: Fourth National Audit Project. Major complications of airway management in the UK; results of the Fourth National Audit Project of 21

22 the Royal College of Anaesthetists and the Difficult airway Society. Part 2: intensive care and emergency departments. Br J Anaesth 2011; 106: NCEPOD Tracheostomy Care On the Right Trach (2014). Cipriano, A., Mao, M.L., Hon, H.H., Vazquez, D., Stawicki, S.P., Sharpe, R.P., Evans, D.C. An overview of complications associated with open and percutaneous tracheostomy procedures. Int J of crit Ill and inj Sci. 2015; 5 (3): Shirawi N., Arabi, Y. Bench to bedside review: Early tracheostomy in critically ill trauma patients. Crit Care. 2006; 10 (1): 201 Intensive Care Society Standards and Guidelines. (2008) Standards for the Care of Adult patients with a temporary tracheostomy. Oliver, L. (2005) Improving Tracheostomy Care for ward patients. Nursing standard. Vol. 9; No. 19 Serra, A. (2000) Tracheostomy Care. Nursing Standard. Vol. 14; No. 42; pp Dikeman, K.J.; Kazandjian, M.S. (1995) Communication and swallowing management of tracheostomized and ventilator-dependent adults. Singular Publishing Group Inc. San Diago, London DOH (2000) The Nursing Contribution to the Provision of Comprehensive Critical Care For Adults: a Strategic Programme of Action Groher, M.E. (1997). Dysphagia: Diagnosis and management. Butterworth-Heinemann. U.S.A Hooper, M. (1996) Nursing care of the patient with a tracheostomy. Nursing Standard. May 15. Vol. 10; No. 34; pp Mallett, J.; Dougherty, L. (2000) Tracheostomy Management for patients in general ward settings. Professional Nurse. October Vol.18; No. 2; pp Martin, L.K. (1989) Management of the Altered Airway in the Head and Neck Cancer Patient Seminars in Oncology. Nursing, Vol.5, No. 3, pp Russell, C. (2005) Providing the nurse with a guide to tracheostomy care and management. British Journal of Nursing. Vol. 14; No. 8. Russell, C.A.; Harkin, H. (2001) Tracheostomy Care. Tracheostomy Standard. Vol. 14; No. 42; pp Stelfox,HT., Crimi, C., Noto, A., Schmidt, U., Bigatello, LM., Hess, D. (2008). Determinants of tracheostomy decannulation: an international survey. Critical Care 12: R26. EEC Directive (1993) class IIA, Rule 7, council directive concerning medical devices, 93/42 EEC. 22

23 Muscedere, J., Rewa, O., McKechnie, K., Jiang, X., Laporta, D. Heyland, D. (2011). Subglottic suction drainage for the prevention of ventilator associated pneumonia: A systematic review and meta-analysis. Crit Care Med; 39: APPENDICES 1 Tracheostomy notification sign 2 Laryngectomy notification sign 3 First Responder emergency algorithm 4 Emergency Tracheostomy algorithm 5 Emergency Laryngectomy algorithm 6. Tracheostomy equipment checklist 7. Airway Care chart 8 Adjusted airway competency document 23

24 Appendix 1 Tracheostomy notification sign 24

25 Appendix 2 Laryngectomy notification sign 25

26 Appendix 3 First responder emergency algorithm 26

27 Appendix 4 - Emergency tracheostomy algorithm 27

28 Appendix 5 Emergency laryngectomy algorithm 28

29 Appendix 6 - Tracheostomy Equipment Checklist Appendix 6.pdf Appendix 7 Airway Care Chart Airway care chart.pdf Appendix 8 Airways Competency Record Airways Competencies.pdf 29