▪ Understand the rationale for tracheostomy

▪ Identify the equipment used in this nursing practice

▪ Discuss the care of a patient with a tracheostomy in situ

▪ Identify the potential problems a patient with a tracheostomy may experience.

▪ the need to bypass potential or actual airway obstructions, e.g. tumour, inflammation, trauma, foreign body

▪ to support prolonged and assisted ventilation in certain neuromuscular disorders, e.g. motorneurone disease, certain chronic respiratory disorders, e.g. chronic obstructive pulmonary disease, and in patients who are sedated or comatose

▪ to aid in the expectoration and/or removal of bronchial secretions, thus reducing the risk of respiratory infection or to prevent other respiratory complications such as atelectasis

▪ in laryngectomy, where a permanent tracheostoma is formed.

1. Plastic disposable or single-patient tracheostomy tubes are usually used in the management of both temporary and long-term tracheostomies. Tubes can either have a single cannula or consist of two parts – an outer and inner cannula. Each healthcare provider will have guidelines on the type of tube they prefer to use. A tube without an inner cannula can be left in situ for a few days or removed and replaced as and when necessary. A two-part tube can be left for a longer period. In both cases the manufacturer’s instructions should be read carefully as this will give guidance as to the length of time the tube can remain in situ – this refers to the licensed use of the product.

2. Most of your patients will have a tracheostomy tube that incorporates an inner cannula that can be changed and cleaned regularly, reducing the need to perform a complete change of the outer tracheostomy tube. The inner cannula also provides essential protection against potentially life-threatening problems, such as tube obstruction, as it can be removed quickly and safely thus providing prompt relief to your patient (Oxford Radcliffe NHS Hospital Trust 2005). A patient may occasionally have a silver tube in situ that also incorporates an inner cannula, although this is now rare due to the extensive range of plastic tubes available.

3. A cuffed tube (Fig. 42.2) may be used in your patient’s immediate postoperative phase of care as they assist in airway maintenance and prevent the potential aspiration of secretions from the recently formed wound around the tube. Your patient may feel the cuff pressing against their throat so you should provide meaningful explanation at this point. Once any secretions from the wound have ceased an uncuffed tube may be considered. Finally, tubes can either be fenestrated or unfenestrated. Fenestrated tubes are used when weaning off the tube or to enable phonation. Therefore tubes can be (Fig. 42.3):

4. Tracheostomy tubes come in a variety of sizes for adult use: 7.0 mm, 7.5 mm, 8.0 mm, 8.5 mm and 9 mm. The diameter and length of the tube selected will be dependent upon your patient’s needs and will always be slightly smaller than the diameter of the trachea (Dickson & Martindale 2002).

1. Spare tracheostomy tubes – same size and type as well as a tube the next size down

2. Tracheal dilators

3. Stitch cutter (if the tracheostomy tube is stitched to the skin)

4. Suction equipment: suction catheters (no larger in diameter than half the diameter of the tracheostomy tube), connection tubing, suction container, gloves, aprons

5. Sterile water and normal saline

6. Humidification equipment and tracheal masks

7. Tracheostomy dressings

8. Scissors

9. Cuff manometer if cuffed tube in situ

10. Tracheostomy tapes

11. Catheter mount (so as to enable attachment to an Ambu bag should your patient require resuscitation)

▪ nurses

▪ consultant surgeon and medical team

▪ specialist nurse

▪ speech and language therapist

▪ physiotherapist

▪ dietician

▪ pharmacist.