Physiotherapy Department Adult Patients Going Home with a Tracheostomy Darent Valley Hospital Darenth Wood Road Dartford Kent DA2 8DA www.dvh.nhs.uk In case of emergencies you will need to dial 999 If you require some further general advice regarding care of the tracheostomy ring: 01322 428100 (bleep 418) There is further information regarding the care of tracheostomies on the following website: www.patient.co.uk 1
Adult Patients Going Home with a Tracheostomy Introduction This booklet has been written to help you and your family to understand more about tracheostomies. It is hoped that the information included will answer some of your questions and reassure you and your family/carers. Contents of booklet: An overview of trachesotomy tubes including a diagram of a tracheostomy to be used with the family / carer for education purposes and given to the family to keep (Page 3-4). A list of essential tracheostomy equipment required for home including humidification equipment (Page 5). Care and cleaning of the inner cannula and stoma: Step by step guide (Page 6). 4. Suctioning technique. Skills required by the patient s family and /or carer prior to discharge from hospital. Step by step guide (Page 7). 5. Tracheostomy Emergency Guidelines to be covered with the patient/family/ carer and given to the patient to keep at home (Page 8-9). 6. Competencies. All skills should be signed off, and one set filed in the patient s medical notes (Page 10-11). 2
Overview of tracheostomy tubes. TRACHEOSTOMY: The opening or stoma made by an incision. TRACHEOSTOMY TUBE: Artificial airway inserted into the trachea during Tracheotomy (incision made in the trachea). 3
Components of a tracheostomy tube: Outer tube Inner tube/cannula: Fits snugly into outer tube, can be easily removed for cleaning. Flange: Flat plastic plate attached to outer tube - lies flush against the patient s neck. 4. Cuff: Inflatable air reservoir (high volume, low pressure) - helps anchor the tracheostomy tube in place and provides maximum airway sealing with the least amount of local compression. To inflate, air is injected via the... 5. Air inlet valve: One way valve that prevents spontaneous escape of the injected air. 6. Air inlet line: Route for air from air inlet valve to cuff. 7. Pilot cuff: Serves as an indicator of the amount of air in the cuff. 4
Equipment required: Every patient with a tracheostomy tube may have the following equipment available:. Suction catheters (size dependent on trache size). Trache mask with elephant tubing. Oxygen cylinder/ concentrator. Spare tracheostomy tubes Tracheal dilator. Suctioning equipment: Portable Suction machine fitted with filter; suction tubing. Yankeur suction tubes. Gloves for suctioning. Bottle of sterile water to rinse tubing. Infectious waste bag. Dry clean container for holding the spare inner cannula when not in use. Tracheostomy dressings (lyofoam). Tracheostomy holder/ ties. Tracheostomy shower shield. Swedish nose. Buchanan bib protector. Room humidifier. Sats monitor. Gauze swabs. Cleaning sponges. Normal saline. Disposable aprons. NB: Not all patients will have or need all the items listed above. Humidification equipment: When patient is off the humidified oxygen it is important for the patient to wear a Heat Moisture Exchanger (HME) also known as a Buchanan Bib or a Swedish Nose over the tracheostomy tube all the time. This is especially important at night, to help keep the secretions loose. 5
CARE OF THE INNER CANNULA, STOMA SITE AND TRACHEOSTOMY TIES AIM: To maintain a patent airway. To prevent infection. To maintain skin integrity. 4. To prevent tube displacement To check inner cannula: Wash hands. Wearing gloves, remove inner cannula. Handle only the outer portion of the cannula. If clean, reinsert and lock into place. If soiled - continue with steps below. Frequency of cleaning: Inner cannula: Check Twice Daily. Stoma and ties: Check Once Daily. Procedure: Wash hands. Wearing gloves remove and dispose of the soiled dressing/lyofoam. Wash hands. Put on gloves. First, remove and clean the inner cannula using sterile water. Dry. Reinsert. Secondly, clean the stoma site using gauze and normal saline. Pat dry. Apply lyofoam. Lastly, if ties are soiled and need changing, have a second carer hold the tracheostomy tube securely in place, remove and replace tracheostomy ties. (Leave 1 finger space between ties and the patient s neck.) Ensure patient comfort. Discard of used equipment. Wash Hands. 6
4. SUCTIONING VIA A TRACHEOSTOMY TUBE AIM: To maintain a patent airway by removing secretions Frequency of suctioning: Suctioning is performed only as needed, NOT to a pre-set schedule. Procedure: Explain the procedure to the patient - wash hands, put on gloves. Put on apron if indicated. Turn on suction apparatus and test that vacuum pressure is 20 mmhg. Open / expose only the vacuum control segment of the suction catheter and attach to the suction tubing. Put on disposable clean glove over the non-sterile glove and withdraw the sterile catheter from the protective sleeve. Maintaining sterility, insert the suction catheter with NO suction applied until resistance is met, then pull back about 1-2 cms before applying continuous suction as the catheter is smoothly withdrawn from airway. NB: Recommended suction time (i.e. from insertion to removal of suction catheter < 15 secs). Use of a new sterile catheter for each suction pass. On completing procedure, ensure patient comfort, discard of equipment and wash hands. 7
5. Tracheostomy Emergency Guidelines IF THE TRACHEOSTOMY TUBE FALLS OUT. DON T PANIC! The patient will still be able to breathe. Once the tracheostomy tube has been in place for about 5 days the tract is well formed and will not suddenly close. Reassure the patient. Ask the patient to breathe normally via their stoma. Try to put the whole tube back into the hole. It goes in the same direction as when you put the inner tube into the outer one. Use some water based gel e.g. Aquagel or KY jelly, to make this easier. If this is difficult, try to put the next size down tube in the hole. If trache is resited get a medical r/v. If you can t do this, call for medical help immediately, call 999. The tracheal dilator may be used to help keep the stoma open if necessary. Stay with patient until medical help arrives. If the patient is struggling with breathing or short of breath (Dyspnoea): This is most commonly caused by partial or complete blockage of the tracheostomy tube by retained secretions. To unblock the tracheostomy tube: ASK THE PATIENT TO COUGH: A strong cough may be all that is needed to expel secretions. REMOVE THE INNER CANNULA: If there are secretions stuck in the tube, they will automatically be removed when you take out the inner cannula. The outer tube - which does not have secretions in it - will allow the patient to breath freely. Clean and replace the inner cannula. SUCTION: If coughing or removing the inner cannula does not work, it may be that the secretions are lower down the patient s airway. Use the suction machine to remove the secretions. If these 3 steps do not relieve your breathing difficulty you should call your GP or go to your local hospital casualty department. 8
Emergency Tracheostomy Pathway: RESPIRATORY DISTRESS Remove inner cannula, clean then replace. No longer distressed Remains distressed Check O2 saturations No respiratory effort. 999 Call help Chest movement, making respiratory effort. Check O2 saturations. Deliver O2 via tracheostomy. Suction tracheostomy tube. Call for help. Inform GP. SIGNS OF RESPIRATORY DISTRESS De-saturation No/some or reduced chest movement. Patient becomes blue. Difficulty with breathing. Gasping. Noisy breathing. Difficulty passing suction catheter. 9
6. COMPETENCIES TRACHEOSTOMY SKILLS REQUIRED BEFORE DISCHARGE FROM HOSPITAL ANATOMY&PHYSIOLOGY Patient/Family/Carer demonstrates understanding of basic anatomy of tracheostomy patients. Patient/Family/ Carer demonstrates understanding of the tracheostomy stoma site. Patient/Family/ Carer can identify the type and parts of the tube they possess. Patient/Family/Carer feels confident Print and sign (By Patient/ Family/Carer) Print Name: Patient/Family/Carer demonstrates confidence/ competence - Print and sign (By Healthcare Professional) Print Name: STOMA CARE Patient/Family/ Carer demonstrates understanding of the importance of daily stoma cleaning. Patient/Family/Carer demonstrates effective cleaning of stoma. INNER TUBE CARE Patient/Family/Carer demonstrates understanding of the importance of inner tube cleaning and frequency Patient/Family/Carer demonstrates ability to remove inner cannula, clean it and then re-site it. DRESSING CARE Patient/Family/ Carer demonstrates an understanding of the importance of 10
dressing care and frequency of changes. Patient/Family/Carer demonstrates how to change tracheostomy dressing. TRACHEOSTOMY VELCRO HOLDER/ TIES CARE Patient/Family/Carer demonstrates how to change tracheostomy holder and adjust fit using the ties. SUCTIONING Patient/ Family/ Carer demonstrates awareness of the indications of suction. Patient/Family/ Carer demonstrates an awareness of oral suction using yankeur suction and tracheal suction using catheters. Patient/ Family/ Carer demonstrates an effective suction technique. HUMIDIFICATION Patient/Family/Carer demonstrates awareness of the indication of using appropriate humidification equipment i.e. Swedish Nose, Buchanan bib. EMERGENCY PROCEDURES Patient/Family/Carer is aware of what constitutes a tracheostomy emergency. Patient/Family/Carer indicates he knows what to do if the tracheostomy becomes blocked Patient/Family/Carer indicates he knows what to do if the tracheostomy becomes displaced. 11