Tracheostomy care

Chapter 30 Tracheostomy care



Sue Fidment



CHAPTER CONTENTS


Introduction 284
Learning outcomes 285

Rationale 286

Safety equipment 286

Factors to note 286

Tracheostomy suction 289
Rationale 289

Equipment 289

Method 290

Observations 290

Cleaning the tracheostomy site 290
Factors to note 290

Equipment 290

Method 291

Observations 291

Changing the tracheostomy tube tape 291
Equipment 291

Method 291

Observations 292

Changing a tracheostomy tube 292
Equipment 292

Method 292

Observations 293

Tips for day-to-day life 294

Decannulation 297

Acknowledgements 297


INTRODUCTION


A tracheostomy is an artificial opening into the trachea via the neck (Fig. 30.1). It therefore provides an alternative route for effective respiration and for the removal of tracheobronchial secretions. A tracheostomy is required when circumstances make breathing impossible or difficult via the mouth and nose (Wilson 2005).


image

Figure 30.1 Landmarks of the neck and the incision site for tracheostomy.


Indications for a tracheostomy (Wilson 2005, Trachsel & Hammer 2006) include:


• Congenital abnormalities, which may occlude or obstruct the airway such as: laryngeal papilloma, laryngeal haemangioma, laryngeal webbing, vocal cord paralysis, choanal atresia, subglottic stenosis, tracheo-oesophageal anomalies and micrognathia (underdevelopment of the mandible as in Pierre–Robin syndrome and Treacher–Collins syndrome)

• Trauma, which may occlude or obstruct the airway such as: subglottic stenosis (could be caused by prolonged or repeated intubations) and emergency situations, e.g. road traffic accidents and burn injuries to face and neck

• Facilitating long-term ventilation, for conditions such as: tracheomalacia, bronchopulmonary dysplasia, spinal muscular atrophy and polyneuritis (e.g. Guillain–Barré syndrome).

• Traumatic brain and spinal injury

• Face and neck tumours

• Foreign body may occlude the upper airway resulting in the need for an emergency tracheostomy

• Infections, which may cause acute swelling around the airway such as: acute epiglottitis or laryngo-tracheobronchitis (the introduction of the HIB vaccine has caused this category of patient to diminish significantly).

To be able to provide safe effective care, it is essential that children’s nurses are aware of the signs and symptoms of respiratory distress and airway obstruction:


• Increased respiratory rate: at rest, tachypnoea can indicate that increased effort of breathing is needed, indicating further assessment is required (ALSG 2005)

• Stridor: a high-pitched sound produced by narrowing within the more rigid confines of the larynx or trachea. In laryngeal obstruction the stridor is inspiratory; in tracheal lesions it is usually both inspiratory and expiratory (Bull 2002)

• Stertor: the noise produced by obstruction in the throat, i.e. above the larynx; it is usually a low-pitched choking type of noise (Bull 2002)

• Recession and use of accessory muscles: intercostal, subcostal or sternal recession indicates increased effort of breathing (Fig. 30.2). Babies and younger children may use their diaphragm and abdominal muscles to aid respiration

• Pallor: due to hypoxia causes sweating and restlessness

• Nasal flaring: seen especially in infants with respiratory distress

• Tachycardia: due to hypoxia and anxiety

• Cyanosis: this is a late sign of respiratory distress (ALSG 2005)

• Exhaustion: a late and pre-terminal sign of hypoxia. The child makes less effort to breathe, stridor and recession become less pronounced and apnoea is not far off (Bull 2002, ALSG 2005).

image

Figure 30.2 Sternal and intercostal recession.



LEARNING OUTCOMES


By the end of this section you should be able to:


• Identify the conditions which require the formation of a tracheostomy in children

• Discuss the nursing care required to maintain a patent airway in a child with a tracheostomy

• List the equipment required for safe, effective care

• Discuss the rationale of when different procedures are required

• Describe the skills that staff and the child’s carers need to acquire (achieve competency in) to care for a child with a tracheostomy

• Discuss the multidisciplinary support required by the family prior and after the child’s discharge.


RATIONALE


Children requiring a tracheostomy formation may initially be nursed on an intensive care unit or in a high dependency area. Another child with a tracheostomy, who’s condition is more stable will be cared for on a children’s ward or at home. The main safety concern when caring for a child with a tracheostomy is to maintain patency of the tube, ensuring a clear airway at all times. Suction via the tracheostomy is required to achieve this. The frequency of suction varies from child to child, and is dependent upon the age of the child and the viscosity and amount of secretions. The child may need humidification of inspired gases to help keep the secretions thin and easily removable, preventing inspissation (thickening and drying of secretions through evaporation) (DoH 2007). This can occur because the normal mechanisms of warming and humidifying air as it is breathed (i.e. passage through the nose) are bypassed while a tracheostomy is in place (Harkin & Russell 2001). If necessary, humidity can be administered, with a humidifying unit and tracheostomy mask or with a heat and moisture exchanger (e.g. Artificial/Swedish nose). Regardless of the method of humidification used, the equipment must be used according to the manufacturer’s instructions and local policy.



Family support and training


Nurses and the multidisciplinary team need to support and empower the family of a child with a tracheostomy. To do this they must provide information, support and resources, to ensure that the family can learn and eventually provide care competently and safely for their child. Skills families require include suction, cleaning the stoma site, changing the tapes and changing the tracheostomy tube. Theoretical knowledge they require includes recognising changes in secretions, signs of infection or aspiration, signs of a mucus plug or blocked tracheostomy tube, and cardiopulmonary resuscitation (CPR).


To be able to achieve this, nursing staff who are to teach and support family training should be competent at teaching and assessing clinical skills to others. In addition they must have sound knowledge and understanding of the airway anatomy; predisposing factors which may lead to the formation of a tracheostomy; operative procedures; preparation of safety equipment; immediate postoperative care (including the treatment of potential complications); care of a child following decannulation; care of a humidifier; and discharge planning. Nurses should also advocate and facilitate the development of evidence based practice in regard to tracheostomy care.



SAFETY EQUIPMENT


The following pieces of equipment are required to be with the child with a tracheostomy at all times, both in hospital and at home. So that accidental displacement, or obstruction of the tracheostomy tube and suctioning can be dealt with immediately. See Figure 30.3 for emergency care of the child with a tracheostomy.


• Oxygen point (or oxygen cylinder), oxygen tubing and tracheostomy mask (not required in the community unless the child is oxygen dependent)

• Suction apparatus with tubing and a box of suction catheters of appropriate size; one catheter attached to the suction tubing

• Spare tracheostomy tube with tapes attached (same size as the child has in situ)

• Spare smaller tracheostomy tube with tapes attached (one size smaller)

• Disposable gloves (latex free, non sterile, non-powdered) and disposable aprons

• Water based lubricant

• Water (to rinse the suction tubing)

• Disposal bag for hazardous waste

• Spare tracheostomy tape

• Scissors.

• 10 mL syringe (only required if the child has a cuffed tracheostomy tube in situ).

image

Figure 30.3 Sheffield Children’s Hospital emergency tracheostomy management flow chart (with permission).



FACTORS TO NOTE



• Hand washing and universal precautions are used (disposable gloves and disposable aprons are worn) when providing tracheostomy care. This is to prevent the spread or introduction of infection (DoH 2007). Parents may prefer not to wear gloves and apron, when caring for their child.

• Latex-free gloves should be worn to reduce the incidence of latex allergy.

• Non-sterile gloves are used because tracheostomy care does not need to be performed as a sterile procedure. A clean ‘non-touch’ technique, i.e. thorough hand washing and not touching the part of the suction catheter that goes inside the tracheostomy, is sufficient.

• Irrigation (the instillation of a small amount of saline directly into the tracheostomy tube) prior to suction may be performed to aid the removal of thick tenacious secretions. However, this is a potentially hazardous procedure and must be undertaken with care (Clarke 1995). Evidence consistently shows that such instillation is detrimental in adults, most often resulting in decreased oxygen saturation and distress to patients. More recent studies are again questioning the benefit of this practice (Akgul & Akyolcu 2002, Neil 2001), and alternative practices such as: effective humidity therapy, assessing the child’s hydration status and the use of saline nebulisers are advocated as alternatives to thin secretions (O’Neal et al 2001, Klockare et al 2006). Therefore, irrigation should not be performed routinely and local policy should be followed (NHS QIS 2008).

• Tracheal dilators may cause trauma to the trachea. As a result of this these are rarely used in practice. However, some hospitals may still have them in the tray at the child’s bedside for emergency purposes; therefore local policy should be followed.

• The ward resuscitation trolley should contain an appropriately sized Ambu bag for use in an emergency. The 15 mm connector fits directly onto almost all tracheostomy tubes. Ambu bags are given to parents in the community in some areas; therefore local policy should be followed.


Tracheostomy tube selection


The type of tracheostomy tube selected for a child is primarily the responsibility of the ENT surgeon and the respiratory team. Often the most important factor in determining the appropriate type of tube is the age of the child. There are many reasons why a child may need a tracheostomy, and manufacturers produce a wide range of models and sizes of tracheostomy tubes, therefore selection of an appropriate tube should be carried out on an individualised basis (Eber & Oberwaldner 2006).



Shiley tracheostomy tubes


These are plastic tubes with an introducer (Fig. 30.4). Sizes are measured by the internal diameter (ID) in millimeters (mm) 3.0, 3.5, 4.0 and 4.5 in the neonatal design and 3.0, 3.5, 4.0, 4.5, 5.0 and 5.5 in the paediatric design. Neonatal tubes have a different design of flange from the paediatric tubes; the angle of the curve also differs although the internal diameter is the same. The Shiley tracheostomy tube needs to be changed every 29 days, although they may be changed more often depending on local practice and policies. Parents and other family members may be keen to do a weekly tube change in order to gain more practice and confidence. This type of tube is for single use only, and should be disposed of after removal (Wilson 2005).


image

Figure 30.4 Shiley tracheostomy tubes: box (left); introducer (centre); spare tracheal tube with tapes attached (right).



Cuffed and fenestrated tubes


These are tracheostomy tubes only used in older children and adults, therefore their use in paediatric patients is less common. The cuff around the outer distal end of the tube is inflated with air which then sits below the larynx, and therefore makes it more secure and less likely to fall out (cuffed tubes are not indicated in younger children and neonates as the cuff causes pressure and damage to the tracheal wall). The cuff should be assessed several times a day with a manometer, to measure the pressure. Ensuring that the cuff is not over inflated and causing damaging pressure to the trachea wall, but also is inflated enough to be secure. A 10 mL syringe needs to kept with the emergency equipment to deflate/inflate the cuff in case of an emergency tube change.


Fenestrated tubes have a hole in the wall of the tube (therefore they allow the patient to breathe through and around the tube, aiding speech and secretion clearance). They also come with two types of inner tube for each outer tracheostomy tube; a fenestrated inner tube and non-fenestrated inner tube. When the non-fenestrated inner tube is in, the tracheostomy acts as normal, and routine suctioning can take place. When the fenestrated inner tube is inserted then both tubes have a hole, this can be used for talking when the tracheostomy end is occluded (which forces air up through the larynx causing phonation). The fenestrated tube can also be used for assessing when the patient is ready for decannulation. The inner tubes need to changed regularly to clear the tracheostomy of secretions, the inner tubes can be cleaned with water/saline or mild detergent, dried and then reinserted.

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Mar 7, 2017 | Posted by in NURSING | Comments Off on Tracheostomy care

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