Tracheostomy Management Adult Patients



Canberra Hospital and Health ServicesClinical ProcedureTracheostomy Management – Adult PatientsContents TOC \h \z \t "Heading 1,1,Heading 2,2" Contents PAGEREF _Toc454367222 \h 1Purpose PAGEREF _Toc454367223 \h 5Scope PAGEREF _Toc454367224 \h 5Section 1 – General Principles PAGEREF _Toc454367225 \h 6Indicators for a tracheostomy PAGEREF _Toc454367226 \h 6Tracheostomy insertion PAGEREF _Toc454367227 \h 6General Principles PAGEREF _Toc454367228 \h 6Role of the Multidisciplinary Team with the Tracheostomised Patient PAGEREF _Toc454367229 \h 7Section 2 – Stoma Care and Dressing PAGEREF _Toc454367230 \h 8Section 3 – Suctioning PAGEREF _Toc454367231 \h 10Training Requirements PAGEREF _Toc454367232 \h 10Objectives of Suction PAGEREF _Toc454367233 \h 11Indications PAGEREF _Toc454367234 \h 11Contraindications & Precautions PAGEREF _Toc454367235 \h 11Assessment Criteria PAGEREF _Toc454367236 \h 12Monitoring PAGEREF _Toc454367237 \h 12Types of Airway Suctioning: PAGEREF _Toc454367238 \h 12Preparation for all airway suctioning PAGEREF _Toc454367239 \h 13Airway Suctioning via Tracheostomy Tubes PAGEREF _Toc454367240 \h 14Airway Suctioning via Tracheostomy Tubes PAGEREF _Toc454367241 \h 15Airway Suctioning via Oropharynx PAGEREF _Toc454367242 \h 15Airway Suctioning via Above Cuff Suction Aid Tracheostomy Tube PAGEREF _Toc454367243 \h 16Suctioning Fenestrated Tracheostomy Tubes PAGEREF _Toc454367244 \h 16Suctioning Mini Tracheostomy Tubes PAGEREF _Toc454367245 \h 16Suctioning UniPerc Tracheostomy Tubes PAGEREF _Toc454367246 \h 17Selecting Appropriate Suction Procedure Closed vs Open PAGEREF _Toc454367247 \h 17Frequency of Suction PAGEREF _Toc454367248 \h 17Collecting a Sputum Sample PAGEREF _Toc454367249 \h 17Progression/Outcome Measures PAGEREF _Toc454367250 \h 17Cleaning of Equipment PAGEREF _Toc454367251 \h 18Section 4 – Managing an Above Cuff Suction Port Tracheostomy PAGEREF _Toc454367252 \h 18Competency PAGEREF _Toc454367253 \h 19Indications for insertion of a tracheostomy with an above cuff suction port PAGEREF _Toc454367254 \h 19Suctioning via the above cuff suction port PAGEREF _Toc454367255 \h 20Voicing with the above cuff port: PAGEREF _Toc454367256 \h 21Section 5 – Humidification PAGEREF _Toc454367257 \h 22Types of Humidification PAGEREF _Toc454367258 \h 22Mechanisms of Humidification PAGEREF _Toc454367259 \h 22Selecting Appropriate Humidification PAGEREF _Toc454367260 \h 23Speaking Valve use and Humidification PAGEREF _Toc454367261 \h 23Procedure for HME (Swedish Nose Attachment) PAGEREF _Toc454367262 \h 24Heated Humidification Systems PAGEREF _Toc454367263 \h 24Fisher & Paykel MR850 PAGEREF _Toc454367264 \h 24Fisher&Paykel AIRVOTM Series PAGEREF _Toc454367265 \h 26Monitoring (Humidifiers as labelled above) PAGEREF _Toc454367266 \h 27Drager Ventilator – Oxygen Therapy Mode PAGEREF _Toc454367267 \h 28Section 6 – Care of the Inner Cannula for Portex and Shiley Tracheostomy Tube PAGEREF _Toc454367268 \h 28Frequency of Inner Cannula Changes PAGEREF _Toc454367269 \h 29Indications for disposal of old inner cannula PAGEREF _Toc454367270 \h 29Cleaning the inner cannula tube of the “Portex Blue Line Ultra” tracheostomy tube PAGEREF _Toc454367271 \h 29Cleaning the inner cannula tube of the “Portex Uniperc” tracheostomy tube PAGEREF _Toc454367272 \h 31Cleaning the inner cannula tube of the “Shiley” tracheostomy tube PAGEREF _Toc454367273 \h 32Considerations PAGEREF _Toc454367274 \h 33Section 7 – Cuff Management PAGEREF _Toc454367275 \h 34Purpose PAGEREF _Toc454367276 \h 34Objectives of Cuff Management PAGEREF _Toc454367277 \h 34Procedure PAGEREF _Toc454367278 \h 34Measuring and Maintaining Ideal Cuff Pressure PAGEREF _Toc454367279 \h 34Cuff Deflation PAGEREF _Toc454367280 \h 36Cuff Reinflation PAGEREF _Toc454367281 \h 37Section 8 – Use of Speaking Valves PAGEREF _Toc454367282 \h 37Purpose PAGEREF _Toc454367283 \h 37Scope PAGEREF _Toc454367284 \h 38Background PAGEREF _Toc454367285 \h 38Competency PAGEREF _Toc454367286 \h 38Procedure for fitting of a speaking valve PAGEREF _Toc454367287 \h 39Considerations PAGEREF _Toc454367288 \h 39Section 9 – Decannulation PAGEREF _Toc454367289 \h 40Purpose PAGEREF _Toc454367290 \h 40Procedure PAGEREF _Toc454367291 \h 40Decannulation Pathway PAGEREF _Toc454367292 \h 40Indication/Assessment of Readiness for Decannulation Pathway PAGEREF _Toc454367293 \h 40Considerations prior to decannulation PAGEREF _Toc454367294 \h 41Risks with premature decannulation PAGEREF _Toc454367295 \h 41Decannulation PAGEREF _Toc454367296 \h 41Section 10 – RACC Community Care Program Tracheostomy Management PAGEREF _Toc454367297 \h 45Purpose PAGEREF _Toc454367298 \h 45Scope PAGEREF _Toc454367299 \h 45Emergency Equipment Kit Preparation Prior to Discharge from Hospital to Home PAGEREF _Toc454367300 \h 45Stoma Care and Dressing PAGEREF _Toc454367301 \h 46Suctioning PAGEREF _Toc454367302 \h 46Humidification PAGEREF _Toc454367303 \h 46Selecting Appropriate Type of Humidification, consider the following indicators PAGEREF _Toc454367304 \h 46General Information PAGEREF _Toc454367305 \h 46Nebuliser Administration PAGEREF _Toc454367306 \h 47Cleaning Nebuliser and Tracheostomy Mask PAGEREF _Toc454367307 \h 48Care of Inner Cannula for Portex and Shiley PAGEREF _Toc454367308 \h 48Tracheostomy Tube Change PAGEREF _Toc454367309 \h 48Care of a Patient with a Tracheostomy Stoma after Removal of a Tracheostomy Tube PAGEREF _Toc454367310 \h 50Tracheostomy Stoma Care, Dressing and “Strappit” Velcro Tracheostomy Tube Holder Change PAGEREF _Toc454367311 \h 51Inner Cannula Care PAGEREF _Toc454367312 \h 51Measuring Cuff Pressure in a Cuffed Tracheostomy Tube PAGEREF _Toc454367313 \h 53Managing an Above Cuff Suction Port Tracheostomy Tube PAGEREF _Toc454367314 \h 53Suctioning PAGEREF _Toc454367315 \h 53Suctioning of a Tracheostomy Tube PAGEREF _Toc454367316 \h 53Implementation PAGEREF _Toc454367317 \h 54Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc454367318 \h 54References PAGEREF _Toc454367319 \h 54Definition of Terms PAGEREF _Toc454367320 \h 58Search Terms PAGEREF _Toc454367321 \h 59Attachments PAGEREF _Toc454367322 \h 59Attachment A: Summary Tracheostomy Management Guideline PAGEREF _Toc454367323 \h 60Attachment B: Tracheostomy Observations Chart – Medical Record 60355 PAGEREF _Toc454367324 \h 61Attachment C: Guidelines for Completion of “Tracheostomy Observations Chart” Medical Record – 60355 PAGEREF _Toc454367325 \h 62Attachment D: Tracheostomy Tube types PAGEREF _Toc454367326 \h 67Attachment E: Resources PAGEREF _Toc454367327 \h 73Attachment F: Mandatory Tracheostomy Equipment PAGEREF _Toc454367328 \h 74Attachment G: Inter-Ward Transfers of Patients with a Tracheostomy Tube PAGEREF _Toc454367329 \h 77Attachment H: Interhospital Transfer of Patients with a Tracheostomy Tube form PAGEREF _Toc454367330 \h 79Attachment I: Discharge of a Patient with a Tracheostomy Tube Home form PAGEREF _Toc454367331 \h 81Attachment J: Suctioning Equipment PAGEREF _Toc454367332 \h 85Attachment K: Humidifier Equipment PAGEREF _Toc454367333 \h 87Attachment L: Cleaning instructions (as per Passy Muir website) PAGEREF _Toc454367334 \h 90Attachment M: Mini Tracheostomy tube (Figure 2) PAGEREF _Toc454367335 \h 91Attachment N: Discharge Planning and Procedures for Education of the Patient and/or Carer PAGEREF _Toc454367336 \h 92Attachment O: Consumable Purchasing Information PAGEREF _Toc454367337 \h 93Attachment P: Portable Suction Unit - Hire PAGEREF _Toc454367338 \h 94PurposeThe purpose of this clinical procedure is to outline safe evidence based management of adult patients with a tracheostomy tube at Canberra Hospital and Health Services (CHHS).Exclusions:This procedure does not apply to:The management of a paediatric patient with a tracheostomy tubeThe management of a patient with a laryngectomy tubeScopeThis document pertains to all Canberra Hospital and Health Service (CHHS) staff involved in the care and management of adult patients with a tracheostomy tube including:Medical OfficersPhysiotherapistsSpeech PathologistsNurses and Midwives working within their scope of practice Students under direct supervision.Training RequirementsAll nursing staff caring for patients with a tracheostomy are to be deemed competent by their CNC or CDN. Completion of the Staff Development Unit “Tracheostomy Management” course and/or the Self Directed Learning Package’ are highly recommended. (These educational resources are listed in Attachment E).Speech Pathologist and Physiotherapist staff working with patients with a tracheostomy must be deemed competent in this specialist area by their clinical supervisor/senior.Medical staff working with patients with a tracheostomy must be deemed competent by their clinical supervisor or department director.Note:Section 3 Suctioning: Scope for this section is limited to certain members of the multidisciplinary team. Please refer to statement of scope in this section.Section 10 RACC Community Care Program Tracheostomy Management: Scope for this section is limited to Registered Nurses. Please refer to statement of scope in this section.Section 1 – General PrinciplesPurposeTo provide staff with the best practice standards to manage adult patients with a tracheostomy tube.Indicators for a tracheostomy There are several reasons why a patient may have a tracheostomy tube:To bypass upper airway obstruction – subglottic, glottic, supraglottic (e.g. tumours, foreign bodies, vocal cord paralysis)Potential upper airway obstruction (e.g. following head and neck surgery)Uncontrolled aspiration (e.g. decreased conscious state, inability to managesecretions)Inability to remove secretionsProlonged intubationTo facilitate long term ventilator support/airway managementTo facilitate weaning from ventilator supportTracheostomy insertion Tracheostomy insertion may be percutaneous or surgical.Percutaneous tracheotomyThe procedure is normally done in the Intensive Care Unit by an Intensivist. A small incision is made into the neck to allow insertion of the tube via a guide wire and dilating instruments. The tracheostomy tube is inserted between the 2nd and 3rd or 3rd and 4th tracheal rings.Surgical tracheotomyThis procedure is performed in the operating theatre, usually by an ENT surgeon. An incision is made over the 2nd and 3rd or 3rd and 4th tracheal rings. The procedure is done surgically if there are anatomical reasons that exclude percutaneous procedure (e.g. large thyroid glands, obesity, deformities of the airway, coagulopathy, inability to optimally extend the patient’s neck e.g. cervical spine trauma, arthritis). General PrinciplesUltimate responsibility for the clinical management of the patient with a tracheostomy tube rests with the admitting consultant and the treating team.All patients with newly inserted tracheostomy tubes will be managed on a designated tracheostomy ward (5B, 7A or 9B) or ICU. The Summary Tracheostomy Management Guideline provides a summary of patient care and for easy reference, is to be displayed at the bedside of all ward patients with a tracheostomy (see Attachment A).Staff are to complete the Tracheostomy Observations Chart (Attachment B). The form and guidelines on how to complete this form are also available (Attachment B & Attachment C).The Tracheostomy Assessment and Consultation Service (TRACS) ward rounds provide an assessment and intervention service for patients with newly inserted tracheostomies on designated tracheostomy wards. A multidisciplinary model of care will ensure optimal tracheostomy management. Any deviation from the management recommended in this procedure is to be documented in the patient’s clinical record.All tracheostomy cares provided are to be documented in the patient’s clinical record.Health Directorate staff must ensure valid, informed and documented consent is obtained from patients before treatments or commencement of procedures. Patients / families should receive education regarding the tracheostomy tube and any planning and treatments required.Staff should refer to general information on tracheostomy tube types and brands as listed (Attachment D).Staff are to complete the Inter-hospital Transfer of a Patient with a Tracheostomy Tube form when patients are transferred to an external hospital with a tracheostomy tube (Attachment H).Staff are to complete the Discharge of a Patient with a Tracheostomy Tube Home for patients discharged home (Attachment I). Role of the Multidisciplinary Team with the Tracheostomised PatientDefined roles and responsibilities for each team member in the care of a patient with a tracheostomy tube enables a successful team approach to patient management. The Admitting or Treating Team:Has overall responsibility for the clinical management of the patient whilst they remain in hospital and under their careIs the primary decision maker regarding decannulation Is responsible for the actual change or removal of tracheostomy tube (also trained nursing staff role)Where relevant the admitting or treating team may seek the assistance of the ENT Specialist, ICU Specialist, or Respiratory Physician when managing a patient with tracheostomy tube, particularly with:Assessment and management of airway patency/complications in the process towards decannulationAssessment and management of respiratory function/disorders (e.g. sleep apnoea, COPD) in the process towards decannulation.The Physiotherapist Assesses and manages respiratory status including suctioning, cough effectiveness, weaning of oxygen, variances in sputum load, sputum retention and appropriate humidification.Optimises level of function through strengthening, splinting, positioning and mobility/gait training. Provides advice with regard to suitability for decannulation based on the above findings/assessment.Assists with discharge planning.The Speech Pathologist Assesses and manages saliva tolerance/airway protection including, making recommendations on tracheostomy tube type, cuff deflation and speaking valve trials to progress towards decannulation.Assesses swallowing and provides dietary recommendations and rehabilitation/compensatory techniques Assesses speech and language and advises on appropriate communication rehabilitation options. Nursing Staff Provide overall care in accordance with the nursing care plan.Provide daily care of the patient including tracheostomy/respiratory needs ( e.g. suctioning, dressings, stoma care, respiratory monitoring, following through and monitoring of allied health programs, monitoring ventilation parameters and liaising with team as required).May change or remove tracheostomy tube only in consultation with medical staff.The DietitianProvides assessment and recommendations regarding meeting nutritional needs of the patient and liaises with team regarding possible impact on team plans (e.g. TPN/enteral/oral).The Occupational Therapist (OT)Assesses and manages activities of daily living of patient. May facilitate successful use of an augmentative aid or may be involved in promoting patients independence in self feeding.May be involved with the cognitive assessment of patients and liaise with the team regarding the impact on functional activities.The Social WorkerProvides emotional support for the patient and family/carersProvides guidance and assistance with financial, travel and social support structures available.Back to Table of Contents Section 2 – Stoma Care and DressingPurposeTo detail the procedure of care of the tracheostomy stoma and tracheostomy dressings to maintain skin integrity and prevent infection around the tracheostomy stoma.Tracheostomy dressings should be changed daily at a minimum to prevent infection and protect the skin surrounding the stoma from mucous secretions. Tracheostomy dressings and strappits are not changed for 24 hours postoperatively. This is due to the risk of accidental dislodgement before there is a fully formed tract. Thereafter tracheostomy dressings are changed a minimum of once daily and more frequently if required. If the stoma is exudative then an appropriate dressing should be applied i.e. allevyn, drain sponge for the exudate. A second nurse is required to assist during the procedure in order to stabilise the tracheostomy tube. Only gauze swabs soaked in saline are used for cleaning the stoma site to prevent the inhalation of wool fibres. Squeeze excess fluid from the swab to prevent fluid entering the trachea.EquipmentBasic dressing packGauze swabsTracheostomy dressing (either drain sponge or foam tracheostomy dressing) Disposable glovesSodium chloride 0.9%StrappitsClean gownScissors (sterile)Personal Protective Equipment (PPE)Procedure 1.Explain the procedure to the patient2. Ensure privacy3. Gain Consent4.Have assistant in attendance (ensure assistant dons PPE and attends to hand hygiene)5.Apply required Personal Protective Equipment and attend hand hygiene6.Position the patient in a semi-recumbent position7.Wash hands and don gloves8.Remove soiled dressing. Do not remove strappits9.Discard gloves10. Perform hand hygiene and don PPE11.Clean around the stoma site with gauze dampened with sodium chloride 0.9%. ALERT: Patients who have had a flap formation will have their tracheostomy sutured in place. Do not use tracheostomy tapes (strappits or cotton ties) on these patients due to the risk of compromising vascular supply to the flap.Dry the areaInspect the skin for any sign of irritation or infection such as maceration, redness, tenderness, excoriation or strong odourDress the tracheal stoma with dressing If using a drain sponge that requires resizing to fit under flange or between sutures only trim from outside edge. This will avoid the possibility of loose fibres being inhaled through the stomaAssistant to hold tracheostomy tube in place while strappits are being changed Manipulation of the strappits or dressings may cause the patient to cough so the tracheostomy tube must be held firmly after the strappits have been removed.Cut and remove soiled strappits at the same time. Ensure that the tracheostomy tube is held firmly to prevent dislodgment throughout the change of strappits Thread and secure new strappitsTension of the strappit is to equal one finger space. Discard equipment. Perform hand hygiene.Document in the patient's clinical record the following: Condition of stoma Patient's response to procedure. ALERT: If the patient has large amounts of mucous and secretions it may be beneficial to use no sting barrier film (i.e. 3M Carilon) around the tracheostomy site to prevent skin breakdown.Back to Table of ContentsSection 3 – SuctioningSuction of a tracheostomy tube is a common technique used to maintain a patent airway and assist the removal of secretions in patients who are unable to clear secretions independently. It is used in both the acute and chronic respiratory setting, as well as in ventilated and non-ventilated patients. Suction can be via an open or closed circuit. ScopeSuctioning of adult patients with a tracheostomy tube is within the scope of trained Medical, Nursing and Physiotherapy staff.Training RequirementsNursing Staff: All nursing staff caring for patients with tracheostomies will be deemed competent at suctioning by their CNC or CDN. Completion of the Staff Development Unit “Tracheostomy Management” course and / or the Self Directed Learning Package are highly recommended. (These educational resources are listed in Attachment E.)Physiotherapists: All Physiotherapy staff will be deemed competent by their clinical supervisor according to a competency checklist.Medical Staff: must be deemed competent by their clinical supervisor or department director. Objectives of Suction To remove accumulated pulmonary secretions, blood, vomit, and other foreign material from the trachea and oropharynx that CANNOT be removed by the patients spontaneous cough To maintain a patent airway To ensure adequate oxygenation and ventilationTo reduce the patients work of breathingTo assess and stimulate a cough To prevent infection and atelectasisTo obtain a sputum sample for microbiological investigation.IndicationsSuctioning is a potentially hazardous technique. Documented adverse effects include hypoxia, bradycardia, cardiac arrest/arrhythmia, respiratory disturbances, tracheobronchial trauma, bronchial obstruction and atelectasis, infection, increased intracranial pressure, bronchospasm, pneumothorax, loss of ciliary function, and emotional trauma.Indication of suction includes the need to remove accumulated pulmonary secretions as evidenced by one or more of the following:Coarse breath sounds on auscultationTactile fremitus (palpable secretions in chest)Inability to generate an effective spontaneous coughAs part of a respiratory assessment The need to maintain patency and integrity of the artificial airway.Visible secretions in the tracheostomyAudible upper respiratory tract noisesDeterioration of ABGs or SpO2Suspected aspirationClinically apparent increased work of breathingCXR changes consistent with sputum retentionThe need to obtain a sputum specimenReversible increased peak inspiratory pressures during volume controlled ventilation or decreased tidal volume on pressure controlled ventilation.Contraindications & PrecautionsSuctioning is relatively contraindicated in patients with:Platelets less than 50 (high risk of bleeding) Pulmonary Haemorrhage.Precautions:Severe bronchospasm Unstable haemodynamics Uncontrolled intercranial pressure (ICPs greater than20). If the patient has a ‘precaution’ to suction, the benefits need to be weighed against the associated risks. If in doubt, the decision to suction needs to be made early in consultation with the medical team and documented clearly.Assessment Criteria If indicators for suctioning are evident, prior to suctioning, a thorough assessment is recommended and may include the following:PARAMETERRELEVANT FINDINGSAuscultationUpper respiratory tract noisesCoarse cracklesAbsent breath soundsPalpationTactile fremitusCoughAbsent/ineffectiveSpO2Low or deteriorating (for patient)ABGsLow PaO2/High PaCO2 (for patient)CXRConsolidationAtelectasisRespiratory RateAbnormally high or lowIntracranial pressureShould be less than 20PlateletsShould be greater than 50 to prevent bleedingGeneral obsBP, HR etc MonitoringIt is strongly recommended to continuously monitor: SpO2 & HR with pulse oximeterICP & BP if relevantPatient pallor and response. Types of Airway Suctioning:Tracheostomy TubeClosed SuctionOpen Suction (STERILE PROCEDURE)OropharynxYankauer SuckerY CatheterEquipmentEquipment that may be required:Wall suction, suction canister and tubing (Attachment K, Figure 1 & Figure 2)Closed suction circuit system (Attachment K, Figure 4)Y suction catheters (open suction) (Attachment K, Figure 5)Yankauer Sucker (Attachment K, Figure 3)PPE, including Gloves (sterile and clean), gown, goggles, face maskSaline 10mL syringe OxygenResuscitation bagWater for irrigation bottlePulse Oximeter Suction Catheter SizingThe external diameter of the suction catheter should not exceed one-half of the internal diameter of the tracheostomy tubeThe smaller the suction catheter, the lower the risk of hypoxemia, however the more difficult it will be to clear large plugs of sputumGuideline:TubeCatheter Size6.0mm or Mini Tracheostomy10 FG7.0mm – 8.0mm12 FGgreater than 8mm 14 FGPreparation for all airway suctioning Hand hygiene and don required PPEAssessment of patient to determine timing and appropriateness of interventionExplain procedure to patientGain informed consent from patient (where able)Preparation of required equipment and assistance (from list above) – with particular emphasis on infection control, monitoring, and supplemental O2)Check the wall suction device is attached to the wall correctly:Check canister is attached to wall suction deviceReplace canister insert once three quarters full or the suction pressure is adversely affected Check suction tubing is attached to the canisterSet desired suction pressure using the dial or tap on the wall suction device Note – Wall dials may not be accurate so recommend glove test to check pressureAdults 100-150 mmHg ‘Glove test’ (suction pressure should just pull glove away from a gloved hand for adult airway) Position patient appropriately within medical limitsE.g. for adults, in high sitting if ableEnsure adequate oxygenation, pre-oxygenate if necessaryMonitor SpO2Apply supplemental O2 if required. Airway Suctioning via Tracheostomy TubesClosed SuctionAdditional EquipmentEnsure appropriate closed suction system is attachedLength: 30.5cm length Size: 12 FG or 14 FG (Refer to suction catheter sizing section of this SOPALERT: ETT length (closed suction catheters) are only to be used for patients with an adjustable flange tracheostomy due to the increased length of tracheosotomy tube.? Due to length (54cm), these suction catheters are NOT to be used to suction any other tracheostomy tube due to the risk of tracheal trauma and partial airway obstruction. Perform hand hygiene and don PPE (sterile gloves not required)Attach suction tubing to the closed circuit systemPre-oxygenate patient as appropriateCheck control valve is rotated into the ‘unlocked’ positionAdminister saline through port if required – NB this is not routinely performed in adults due to insufficient evidence. Consider this option in the presence of particularly thick sticky sputumAsk the patient to cough (if appropriate)Stabilise tracheostomy with one handPass the catheter down airway to desired depth with the other hand. If the carina is reached withdraw 1cm before applying suction. Depress control valve to apply suction Continue to stabilise tube with designated handWithdraw suction catheter with suction appliedSuction should be applied for no longer than 15 seconds. Cease suction pressure when sputum yield has ceased or 15seconds has lapsed Withdraw catheter until the BLACK MARK on the catheter lines up with the back of the elbow connectorBetween passes, clear suction tubing with pre-prepared syringe of NaCl if required, ensuring not to pass NaCl into airway. Repeat suction procedure as required until objectives of suction are met and/or treatment is no longer tolerated. Clear suction catheter with pre-prepared syringe of NaCl. Ensure the black mark on the catheter lines up with the back of the elbow connector, insert syringe into side port, as administering NaCl into side port apply suction until all NaCl is removed and the catheter is clean.Clean suction tubing once disconnected from patient with water for irrigationEnsure closed suction catheter is re-locked and (blue) end cap is replaced.Airway Suctioning via Tracheostomy TubesOpen SuctionALERT: Open suction must be performed as a sterile procedure. Tracheostomy tubes bypass the upper respiratory tract defence mechanism, putting patients at greater risk of developing infections. For suction catheter sizing refer to suction catheter sizing section of this SOP. Ensure appropriate suction catheter length (43cm)ALERT: If possible avoid using 54cm suction catheters due to the increased risk of tracheal trauma if inserted too far.Perform hand hygiene and don PPE Place glove on non-dominant hand or on both hands if you prefer to perform a double gloved procedureOpen suction catheter packet to expose adaptor only. Hold with dominant hand. Use non-dominant hand to attach to suction tubingSecure suction catheter with attached tubing under axilla of dominant arm so both hands are freePut sterile glove on dominant hand (over the top of glove if performing a double gloved procedure)Carefully slide catheter out of packaging with clean hand on adaptor and with sterile hand securing suction catheter to ensure sterility is maintainedAsk patient to cough (if appropriate)Introduce catheter into tracheostomy tube using dominant/sterile hand without applying any suctioningInsert catheter until a cough reflex is stimulated or gentle resistance is feltWithdraw catheter 1 cm and commence suction by placing the thumb over the suction portSuction should be applied for no longer than 15 seconds during each pass of the catheterAssess whether the patient needs further suctioning by listening for audible secretions and assessing the amount of sputum obtainedThe suction catheter may be reintroduced a second time if the tubing has remained sterile.Dispose of suction catheters, gloves and packaging Clean suction tubing with water for irrigationMonitor patient appropriatelyDocument any significant findings on Tracheostomy Observation Chart and/or medical file and notify medical team if necessary.Airway Suctioning via Oropharynx Oropharyngeal suction is a clean procedure, not sterile.Yankauer Sucker/Y catheterCarry out preparation as outlined in preparation for all airway suctioningAttach suction tubing to catheter or Yankauer Sucker attachment while the catheter is still in its packagingPass the catheter or Yankauer Sucker into the mouth no further than the pharynxUse patient comfort as guide for duration of suctionAirway Suctioning via Above Cuff Suction Aid Tracheostomy TubeSuctioning the Tracheostomy Tube Procedure as per suctioning via tracheostomy tubes closed suction or open suction as detailed aboveAbove Cuff SuctioningApply suction tubing to above cuff suction port; where possible use low pressure or use intermittent suction. Refer to Section 4 – Managing an Above Cuff Suction Port Tracheostomy for further detailRemove when secretions have cleared.ALERT: Above cuff suction should be performed prior to attaching air to the above cuff suction port to facilitate speech. Suctioning Fenestrated Tracheostomy TubesOpen suction technique for non-mechanically ventilated patientsFenestrated inner cannula (orange – Portex tracheostomy tubes; green – Shiley tracheostomy tubes) MUST be replaced with a non-fenestrated inner cannula prior to suctioning. ALERT: Fenestrated inner cannula must be replaced with non-fenestrated inner cannula prior to suction to ensure patient is not at risk of tracheal trauma. Suctioning Mini Tracheostomy TubesMini Tracheostomy TubesInserted purely for sputum removalUn-cuffedNot suturedAdditional Equipment RequiredInstil saline with 1ml syringe as tube easily blocked Size 10 catheter Oxygenate via face as requiredProcedure as per airway suctioning via tracheostomy tubes open suction section above as detailed aboveOxygenate via face as requiredEnsure cap is closed when not suctioningSuctioning UniPerc Tracheostomy TubesProcedure as per closed or open suction section detailed aboveAlert: may need to consider using 54cm length (endotracheal length) suction catheter if large component of the tracheostomy tube sitting external to the stoma as 43cm length suction catheter may not be long enough to stimulate a cough and effectively clear secretions. Selecting Appropriate Suction Procedure Closed vs OpenBased on individual patient assessmentIt is recommended that:If frequent suction is required a closed system is preferredMechanically ventilated patients with a tracheostomy are suctioned via a closed suction systemUn-cuffed tracheostomy tubes are suctioned via an open technique Fenestrated tracheostomy tubes are suctioned via an open technique ensuring non-fenestrated inner cannula is inserted prior to suction for non-mechanically ventilated patients. Frequency of SuctionBased on clinical need (not necessarily routine)Patients with no bulbar function (cough reflex) will require suctioning a minimum 4 hourly to ensure airway patency.Collecting a Sputum SampleSputum specimen collection can be incorporated into any of the suction techniques described in this procedure. Sterility should be maximised to avoid contamination of the sample. Attach sputum trap (Attachment I, Figure 6) to suction circuit (suction to one port, catheter to the other)Perform suction as outlined above, attempting to keep sputum trap vertical (may be easier with assistance)Flush with sterile saline if necessary to capture maximum sputumA minimum of 1mL of sputum is required for testing purposesFollowing suction, remove suction pressure from sputum trap first, fold plastic tubing over on to the port where suction tubing was attached to seal sample.Label sample and follow protocol for forwarding for processing to pathology.Progression/Outcome Measures Auscultation – improvement in breath soundsPalpation for tactile fremitusSpO2 (please note that pre-oxygenation will artificially elevate SpO2 for up to 10minutes post suction)Arterial blood gases (ABGs) if availableNature of secretion removal (amount, colour, consistency, mucoid v purulent)Work of breathing Respiratory rate Heart Rate.ALERT: Suction should cease if:There is unchanging pink frothy sputum returned (indicates pulmonary oedema and suction is ineffective). Inform medical team immediately if pulmonary oedema is a new clinical sign and/or presents with respiratory compromise There is frank blood (i.e. bright red, moderate/large and unexpected) , call immediate medical review/METThe patient withdraws consent and is competent to do soThe patient becomes unstable – further suction may be required to protect the airway, but medical assistance should be sought Please note that suction can cause stimulation of the vagus nerve and result in alterations in heart rate (bradycardias) and blood pressure.Cleaning of EquipmentClosed suction system should be changed by nursing staff according to ward/unit practice.Suction catheters, gloves, sputum traps etc are SINGLE USE ONLY and should be disposed of accordingly.At present the literature is unclear as to the safe number of passes per catheter.If patency or sterility of the suction catheter is compromised then the catheter should be replaced.Back to Table of Contents Section 4 – Managing an Above Cuff Suction Port Tracheostomy PurposeTo provide guidelines on suction and voicing with tracheostomy tubes with an above cuff suction port. Procedure Definition of an above cuff suction port tracheostomyTracheostomy tubes with an above cuff suction port are cuffed tracheostomy tubes. These tubes have a side port on the outer cannula of the tracheostomy tube that enables secretions to be removed from above the cuff and for the patient to voice, in the presence of an inflated cuff. The two brands of tracheostomy tubes with an above cuff suction port which are available are:The Portex Suction aid Tracheostomy TubeMallinckrodt tracheostomy with above cuff suction portThe use of the Portex Suctionaid Tracheostomy Tube is recommended on TCH campus because it has a double cannula, whereas the Mallinckrodt tube is single cannula (no inner cannula). CompetencyAbove cuff suctioning can be performed by Nurses, Medical Staff, Physiotherapists, and Speech Pathologists trained in this procedure. Indications for insertion of a tracheostomy with an above cuff suction portPatients with large amounts of aspirated secretions (can be removed from above the cuff without cuff deflation).Long term ventilated patients with good cognition who require cuff inflation for ventilation.ALERT: Suctioning:Suction above the cuff, with caution. When possible, use low pressure suctioning; otherwise use intermittent suctioning. Do not apply continuous suction above the cuff as this may cause trauma to the tracheal wall. Stop suctioning once the majority of secretions have been cleared from above the cuff line. Do not continue to suction for minimal secretions due to the risk of trauma to the upper airwayVoicing/Talking:Wait at least 72 hours post-insertion of the tracheostomy tube before using voicing/talking, to avoid subcutaneous emphysema.EquipmentThumb control valve (stored in specimen jar and not to be discarded) Suction tubing attached to portable or wall suction at less than 20mmHgYankauer SuckerSterile waterSuctioning via the above cuff suction portRationaleRoutinely removing above cuff secretions assists in improving patient tolerance for cuff deflation. Suctioning above the cuff reduces the risk of bacterial laden secretions accumulating above an inflated cuff and leaking into the airway. Figure C: Connection of above cuff suction port for suctioningProcedurePerform hand hygiene and don PPEInsert the thumb control valve into the connector of the above-cuff suction line portConnect the suction tubing to the suction line of the tracheostomy with an above cuff suction portSet the wall pressure at gauge 20mmHg Low pressure suctioning, intermittent suctioning (with thumb valve) or use of a syringe to suction is recommendedIf the above cuff suction line is blocked, a small amount of water can be inserted via a 5 ml syringe and immediately suctioned out (to reduce the risk of aspiration).Voicing with the above cuff port:Tracheostomy tubes with an above cuff suction port facilitate voicing in the presence of an inflated cuff. This allows patients who require the cuff to be inflated (for ventilation or airway protection) to be able to communicate.Voicing/Talking: Patient ability to voice via a tracheostomy tube with an above cuff suction port is initially assessed by the Speech Pathologist. The Speech Pathologist will advise the parameters for use of voicing in patient progress notes. ProcedurePerform hand hygiene and don PPEInsert the thumb control valve into the connector of the above-cuff suction line portConnect the oxygen tubing to thumb valve and into the tracheostomy via the cuff suction port. Figure D: Tubing connected to medical air or wall oxygen with thumb valve and attached to above cuff suction port.Voicing/Talking:If the patient is stable since last seen by the medical team, proceed with trial of voicingPerform hand hygiene and don PPEExplain the procedure to the patientSuction as appropriate (above the cuff, in the mouth and via tracheostomy, if required)Connect medical air (or oxygen source) via tubing to the suction line of the tracheostomy tube and ensure thumb valve is in place. There should not be continuous air through the above cuff line as this dries the vocal cords and upper airway. The flow rate should be set as recommended by the speech pathologist (normal range 2-8L per minute) and specified on the Clinical Instruction Sheet: Use of Tracheostomy Tubes with an above cuff suction port.Finger occludes the thumb control valve to direct the air into the larynx in synchrony with the patient’s attempt to voice/speak.Length and frequency of use is dependent on the individual patient. Back to Table of ContentsSection 5 – HumidificationPurposeTo ensure that all patients with a tracheostomy tube have appropriate humidification.BackgroundAll patients with a tracheostomy require artificial humidification.During normal respiration the upper respiratory tract filters, warms and humidifies inspired air. As a tracheostomy bypasses the upper respiratory tract, it is therefore necessary for inspired gas to be heated and humidified. Consequences of inadequate humidification include increased viscosity of secretions, mucosal damage and impaired ciliary function. This may result in lower respiratory tract infection, atelectasis and airway obstruction.Types of HumidificationHumidification can occur via:Heat and Moisture Exchange (HME) Device Swedish Nose Heated Water Humidification (humidification circuit)T-pieceTracheostomy maskDirect tracheostomy interface (Fisher&Paykel)All of the above methods are able to provide oxygen delivery as well as humidification.Mechanisms of HumidificationHME (Swedish Nose)Stores a portion of heat and moisture during expiration and returns it to the patient on inspiration.Filtration properties.Heated Water HumidificationGas passes over a heated water bath prior to inspiration. This enables humidification by evaporation.Heated Water Humidification provides greater humidification and temperature regulation than HMEs.Selecting Appropriate HumidificationSelection is based on patient assessment and type of tracheostomy tube. Quantity and viscosity of secretions will determine what type of humidification is appropriate. The medical team in consultation with Physiotherapy and Nursing Staff usually make decisions regarding the most appropriate type of humidification.Single lumen tracheostomy tubes i.e. tubes without inner cannulas (e.g. adjustable flange) MUST receive heated water humidification.ALERT: Type of humidification may change as a patient’s clinical condition changes. Patients should be assessed each day regarding appropriate type of humidification. Indications: HME (Swedish Nose):Small quantity of sputum, infrequent suction, thin secretions.When mobilising patients.During changing of heated water humidification circuits.Heated Water Humidification:Moderate-large quantity of secretions, frequent suction, thick secretions.Dehydrated patients.Newly inserted tracheostomy tubes.Precautions:HME (Swedish Nose):Failure to identify and replace the HME filter when contaminated by sputum will result in an increase work of breathing and may lead to respiratory compromise. Heated Water Humidification use overnight may need to be considered in some patients who are on HME filters during the day. ALERT: Signs of inadequate humidification may include:Thick secretions OR increase in viscosity of secretionsIncrease frequency of suctionIncrease frequency of inner cannula changePartially occluded or occluded tracheostomy tube.Consider full time use of Heated Water Humidification and referral to Physiotherapy.Speaking Valve use and HumidificationPatients cannot receive artificial humidification when the speaking valve is insituIf the patient has oxygen attached to the speaking valve, the drying effect may be exacerbatedThe multidisciplinary team (Speech Pathology, Medical, Physiotherapy and Nursing staff) will determine the duration of time the patient spends on the speaking valve Procedure for HME (Swedish Nose Attachment)Equipment Refer to Attachment K for pictures HME (Swedish Nose) Note: HME devices are SINGLE USE ONLYPPEOxygen tubing (if required)ProcedureCheck medical order for humidification via HME or documented humidification plan on the Tracheostomy Management Observation ChartPerform hand hygiene and don PPEAttach HME (Swedish Nose) directly onto tracheostomy tube or onto the side port of the closed suction system (if being used)Attach oxygen via the oxygen port (as required)Discard gloves and complete hand hygieneDocument on the Tracheostomy Management Observation Chart MonitoringHME (Swedish Nose) should be checked a minimum of four hourly (with inner cannula changes). It may need to be checked more frequently depending on the quantity of secretionsHME should be changed at least daily or PRN Heated Humidification SystemsFisher&Paykel MR850Fisher&Paykel AIRVOTM SeriesDrager Ventilator – Oxygen Therapy ModeRefer to Attachment K for pictures Equipment and Procedure Fisher & Paykel MR850EquipmentHumidifier IV pole (humidifier attached) Air Entrainer – OxyflowOxygen tubingSterile water (1000ml)Corrugated humidification tubingConnector straight flexi tubeY ConnectorTracheostomy mask/Tracheostomy Direct Connection (if in use will not need T-piece connector or Connector straight flexi tube)All equipment is single patient use, excluding the humidifier and wires.Procedure Perform hand hygiene and don PPE before setting up humidifier .Slide the humidification chamber onto the humidifier base. Remove blue caps.Hang sterile water from the IV pole.Unwind the waterfeed set from around the humidification chamber and insert spike into the sterile water bag. Keep bag above the chamber. Water will run into humidification chamber. The Fisher&Paykel Autofeed humidification chamber has a dual-float mechanism and will maintain an adequate level in the chamber provided there is enough sterile water in the bag above. Connect blue corrugated tubing to the humidification chamber. Connect the Air Entrainer – oxyflow to the humidification chamber. Ensure there is enough flow to achieve desired FiO2 (please refer to side of the Air Entrainer for guidelines).Connect the electronic circuit: Connect the blue temperature probe to the blue socket on the side of the humidifier.Connect the blue twin probe into the side of the breathing socket above chamber.Connect the blue single probe into port at patient end of the circuit.Connect the yellow heater wire plug into the yellow socket on the side of the humidifier.Connect the clover leaf end into the socket at the rear of the breathing circuit above the chamber.Plug humidifier into power socket. Turn humidifier on. Ensure humidifier is set to correct mode (tracheostomy/intubated). Fisher&Paykel MR850 sets the temperature and humidity (37 °C, 44 mg/L) based on mode selected and will be displayed on the humidifier.T-pieceConnect blue corrugated tubing to the inspiration outlet of the ‘Y Connector’. A Connector straight flexi tube may be used on the expiration outlet. When humidifier has reached the desired temperature connect Y-piece to side port of the closed suction system on the tracheostomy tube (a Connector straight flexi tube may be inserted between the T-piece and suction system, please note that this will increase the dead space). Manufacture’s guidelines/laminated card with set up instructions should be located with the T-piece set up.Tracheostomy MaskConnect corrugated tubing to tracheostomy mask.When humidifier has reached desired temperature apply to patient.Use hand hygiene once procedure is completed.Alert: Humidification circuits must be changed weekly.Fisher&Paykel AIRVOTM SeriesEquipmentHumidification circuits must be changed weekly.AIRVO humidifierDisinfection tube (cleaning tube)Corrugated humidification tubing/heated breathing tubeHumidification chamber/water chamberIV pole Sterile water (1000ml)Power cordConnector straight flexi tubeY ConnectorTracheostomy mask/Tracheostomy Direct Connection (if in use will not need T-piece connector or Connector straight flexi tube) Oxygen inlet extension kitOxygen chart stickerAll equipment is single patient use, excluding the humidifier and disinfection tube. The air filter maximum period of use is 3 months or 1000 hours. Procedure Perform hand hygiene and don PPE. Water chamber: Remove water chamber from packaging, remove blue port caps from chamber, insert supplied adapter over the two vertical ports. Fit water chamber to the unit by pushing the blue finger guard, the chamber should firmly lock into place. Hang sterile water bag on IV pole 10cm above the unit, insert spike from the humidification chamber into the sterile water bag. Check water flows into the chamber and is maintained below the fill line (arrow around circumference of chamber). If the water rises above the line, change the chamber immediately.Insert the blue plastic connector of the heated breathing tube into the humidifier; connect the other end of the heated breathing tube into the inspiration outlet of the ‘Y Connector’. A connector straight flexi tube may be used on the expiration outlet. If using a Tracheostomy mask/interface attach to the end of the heated breathing tube.Plug the unit’s power cord into the power socket.Turn the unit on by pressing “on/power” button, when the unit has warmed up the “Ready for Use symbol - tick” will be displayed with the temperature below. The unit will continue to warm up until 37?C is reached. Flow setting: is preset to a selected flow in Hospital Mode. Flow can be set in 5L/min increments, range 15-45L/min. To check the preset flow press right arrow button. If the lock symbol is displayed the flow is locked at displayed flow rate. To unlock flow press the up and down buttons simultaneously until a beep sounds (3 seconds). Use the up-down buttons to adjust the flow. Press the button on the right to return to the main display.Oxygen Therapy: Check the oxygen inlet port on the back of the unit is connected properly to the filter holder and check filter holder is connected correctly to the unit. Connect oxygen tubing onto oxygen port and dial up oxygen to achieve FiO2 based on flow setting. Refer to oxygen chart sticker titled “Unit Airflow Settings on AIRVO (L/min)”. Note: maximum FiO2 AIRVO humidifier can deliver is FiO2 0.63.The humidification air/oxygen mixture is ready for use when the “Ready for Use symbol - tick” appears and the temperature is displayed.Attach the interface to the patient.When unit is no longer required press the on/off button for 3 plete hand hygiene.CleaningDisconnect the unit from the power supply, remove and dispose of water chamber and breathing tubes, clean the internal elbow connected to the connection port with specified wipe (Tuffie Wipes, Intercept Wipes, Matrix Wipes i.e. a pH-neutral, non-abrasive, non-toxic, non-corrosive wipes). Wipe from both ends, up to and including the internal protrusion.Wipe all surfaces of the unit with a clean cloth.Carry out high-level disinfection with AIRVO disinfection mode; fit the blue filter to the right chamber, connect the disinfection tube, insert the blue plastic connector into the top of the humidifier, connect the red end of the disinfection tube to the left chamber port.Connect power cable, start the disinfection cycle by holding the disinfection button (top left) down for 3 seconds. The disinfection cycle will take 55 minutes to complete. When cycle is completed a number will appear under the disinfection symbol. Record this number for future reference.Press the power button for 3 seconds to turn the unit off, unplug from power, remove the disinfection tube and filter. The unit is ready for next patient. Refer to AIRVOTM Hospital Use Operating Manual Fisher&Paykel HEALTHCARE for full product and safety information, refer to Airvo 2 Use Manual, $category-abc/airvo.html Monitoring (Humidifiers as labelled above)Oxygen therapy supply and humidification must be checked with nursing observations to ensure equipment is functioning properly.Empty sterile water bags MUST be replaced immediately or patients are at increased risk of respiratory distress and sputum plugging as no humidification is being supplied to the patient. The AIRVO humidifier will alarm if the chamber runs out of water “water out” alarm will sound within 30 minutes. The chamber float may be damaged and need to be replaced, changing water chamber is recommended. If the humidifier appears faulty or if red light is illuminated, consult the operating manual/product instruction sheet or a Fisher&Paykel representative to troubleshoot. If unable to rectify problem, the humidifier and all accessories should be immediately removed and sent for servicing and a new system set up and applied to patient. Drager Ventilator – Oxygen Therapy ModeLocation: Intensive Care UnitStaff must have completed Drager Ventilator CompetencyEquipmentDrager Ventilator Ventilator tubing ProcedureVentilator to T-piecePlace ventilator in standby mode.In stand-by mode select oxygen therapy (last tab on screen).Turn oxygen therapy mode on.Set prescribed oxygen flow and FiO2.Disconnect expiratory hose (white), Connector straight flexi tube may be applied.T-piece to VentilatorReconnect expiratory hose.Turn oxygen therapy off.Select start-standby screen.Re-start ventilator.Back to Table of ContentsSection 6 – Care of the Inner Cannula for Portex and Shiley Tracheostomy TubePurposeTo provide staff with procedures on the use and care of the inner cannula of a Portex Blue Line Ultra, Portex Uniperc and Shiley tracheostomy tube.Note: this procedure does not apply to any other brand of tracheostomy tube.ProcedureALERT: All newly inserted tracheostomy tubes used in CHHS should have an inner cannula insitu. If the patient requires an adjustable flange tracheostomy, the Portex Uniperc should be used (see Attachment D) as this tracheostomy has an inner cannula.RationaleDouble (dual) lumen tracheostomy tubes offer a safety mechanism in the event of a partially blocked or blocked tube, as the inner cannula can be removed as a first method of unblocking the tube without having to remove and replace the whole tracheostomy tube.It is also important to consider that presence of an inner cannula reduces the inner lumen diameter. Secretions in the inner cannula can result in increased work of breathing and airway obstruction.Frequency of Inner Cannula ChangesInner cannula changes should be performed at least every 4 hours or more frequently if requiredTo reduce risk of encrustation of secretions on the inner cannulaTo reduce risk of airway obstruction due to a blocked tracheostomy tubeThe inner cannula change is to be documented on the Tracheostomy Observations Chart. Any relevant information with regard to the inner cannula must be documented in the patient progress notes.Indications for disposal of old inner cannulaThe inner cannula should be replaced with a new inner cannula (not just cleaned) If any evidence of cracks on the inner cannula tube Secretions cannot be successfully removedAs per the tracheostomy tube itself, the manufacturers of the Portex tubes recommend replacement after 30 days. A spare inner cannula (SIC) red 15mm connector for temporary replacement of inner cannula of Shiley tubes is available as part of the tracheostomy tube kit. EquipmentPPE Sterile gauzePipe cleanersKidney dish for placing inner cannula in while cleaningClean airtight container for spare cannula storage (e.g. denture container)Spare inner cannula of correct size. Cleaning the inner cannula tube of the “Portex Blue Line Ultra” tracheostomy tubeProcedureExplain procedure to the patientEnsure privacyGain consent (see Consent and Treatment Policy)Place patient in semi-recumbent positionPerform hand hygiene and don PPE Portex Tracheostomy Tube- to remove inner cannula stabilise the tube by holding the neck plate, gently pull the inner cannula out in an outward and downward direction using the small ring ‘pull’ at the outer end of the cannula (See Figures 1,2 and 3)Remove inner cannula and place in kidney dishReplace with the spare clean inner cannulaEnsure the inner cannula "clicks" into positionClean the removed cannula under warm running tap water. Do not soak the cannula If secretions are difficult to remove, clean the cannula with a pipe cleaner (ensure the end is bent over so sharp metal does not scratch the tube)Assess the inner cannula to make sure it is clean Discard the pipe cleanerCheck the cannula for kinks or damageAir-dry the cannula thoroughly and store in an airtight containerRegularly change the container for storage of the spare cannula to reduce risk of bacterial proliferationFigure 1: Portex inner cannulas (clear- unfenestrated; red- fenestrated)Figure 2: Partially inserted inner cannula (Portex fenestrated)Figure 3: Fully inserted inner cannula (Portex fenestrated)Cleaning the inner cannula tube of the “Portex Uniperc” tracheostomy tubeProcedure1.Explain procedure to the patient2.Ensure privacy3.Gain consent (see Consent and Treatment Policy)4.Place patient in semi-recumbent position5.Perform hand hygiene and don PPE 6.To remove inner cannula stabilise the tube by holding the neck plate, gently pull the inner cannula out in an outward and downward direction using the small ring ‘pull’ at the outer end of the cannula (See Figures 1,2 and 3 on page 31)7.Remove inner cannula and place in kidney dish8.Replace with the spare clean inner cannula9.Ensure the inner cannula "clicks" into position10.Clean the removed cannula under warm running tap water. Do not soak the cannula 11.If secretions are difficult to remove, clean the cannula with a foam cleaning swab 12. Assess the inner cannula to make sure it is clean 13.Discard the foam swab14.Check the cannula for kinks or damage15.Air-dry the cannula thoroughly and store in an airtight container16.Regularly change the container for storage of the spare cannula to reduce risk of bacterial proliferationALERT: Do not use pipe cleaners to clean the inner cannula of a Uniperc tracheostomy. If secretions are difficult to remove only a Uniperc foam swab should be used (figure 5A).Figure 4: Portex Uniperc Tracheostomy TubeFigure 5: Flexible inner cannula of Portex UnipercFigure 5a: Uniperc foam cleaning swabCleaning the inner cannula tube of the “Shiley” tracheostomy tubeProcedureExplain procedure to the patientEnsure privacyGain consent (see Consent and Treatment Policy)Place patient in semi-recumbent position. Perform hand hygiene and don PPE Remove inner cannula. For Shiley tubes - to remove inner cannula, this tube has a twist lock action system. Stabilise the tube by holding the neck plate, and twist the inner cannula in an anti-clockwise direction to ‘unlock’ the inner cannula. Gently pull the inner cannula out in an outward and downward direction.Place it in the kidney dish used for cleaning and set aside for cleaning. Replace with the temporary red inner cannulaReinsert the spare inner cannula immediately by gently following the curve of the main tube: support the neck flange during this manoeuvre. Clean the cannula under warm running tap water. Do not soak the cannula. If secretions are difficult to remove, clean the cannula with a pipe cleaner (ensure the end is bent over so sharp metal does not scratch the tube). Discard pipe cleaner.Air-dry the cannula thoroughly. When dry reinsert the cannula.For Shiley tube, turn the twist-lock inner cannula clockwise until the blue dot on the inner cannula lines up with the blue dot on the tube. Clean the temporary red inner cannula, as above, dry and store in an airtight container. ConsiderationsThe Shiley tracheostomy tube must have an inner cannula in-situ for respiratory apparatus to be connected such as the closed suction catheter, Swedish nose, etc. Ensure that the red temporary inner cannula of the Shiley tracheostomy tube does not remain in situ and that the original inner cannula tube is thoroughly dried before being replaced after cleaning.If the tracheostomy tube is encrusted with secretions, this may be an indicator that the level of humidification needs to be increased or the inner cannula may require more frequent cleaning. Use pipe cleaners to clean the inner cannula with caution as they can scratch the inside of the inner cannula. Bend the tip of the pipe cleaner over before use. Avoid soaking the inner cannula in hydrogen peroxide, Milton or hot water. This will shorten the life of the inner cannula. Figure 6: Shiley Tracheostomy Tube (showing cuffless tube with inner cannula out of tube)Back to Table of ContentsSection 7 – Cuff ManagementPurposeTo provide staff with consistent evidence based procedures for the management of the cuff of a tracheostomy tube including checking of cuff pressure, cuff deflation and cuff reinflation. This procedure does not apply to uncuffed tracheostomy tubesObjectives of Cuff ManagementTo reduce aspiration in patients who are unable to manage secretionsTo ensure adequate oxygenation and ventilationTo assess secretion management as an indicator of readiness for decannulation To reduce the risk of infection Objectives of an inflated cuff:To reduce aspiration in patients who are unable to manage secretionsTo ensure adequate oxygenation and ventilationTo reduce the risk of infectionObjectives of cuff deflation:To assess secretion managementTo progress length of cuff deflation as patient tolerates and as directed by the multidisciplinary team. To aim for a minimum of 24 hours of cuff deflation prior to decannulation (removal of the tracheostomy tube). Refer to Section 9 Decannulation.ALERT: Cuff deflation or cuff leak can lead to aspiration of oropharyngeal secretions, respiratory distress and aspiration pneumonia. Clinicians must monitor the patient for signs of intolerance of cuff deflation and for signs of a cuff leak.Procedure Correct cuff inflation is essential. Over-inflation can cause damage to the tracheal wall. Under-inflation can lead to aspiration of oropharyngeal secretions and/or air leak through the upper airway (and inadequate ventilation) in the ventilated patient. Measuring and Maintaining Ideal Cuff PressureManagement of the cuff of a tracheostomy includes:Measuring and maintaining ideal cuff pressureCuff deflationCuff reinflationSigns of cuff leak/inadequate inflation:Reduction in cuff pressure from previous measurement, following reinflation and re-measurement cuff pressure remains below the target range (see ALERT below)Increase in frequency of suctioningIncrease in frequency of coughingPatient producing voice with the cuff inflatedCuff pressure should be checked once per shift or more frequently if there are any concerns about the cuff status or a potential cuff leak. EquipmentIn addition to the availability of bedside emergency equipment, the following is required for cuff management:10 ml syringe Suctioning equipment (Suction catheters or closed suction unit)Clean disposable gloves, sterile gloves (open suction)Cuff manometerYankauer SuckerOxygen saturation monitor (cuff deflation)Cuff ManometerPilot Cuff ProcedureExplain to the patient your intention to measure the cuff pressure. Perform hand hygiene and don PPEOpen the cap on the pilot cuff and attach cuff manometer by pressing the valve of the pilot cuff firmly onto the manometer. The ideal cuff pressure should be 15-25 cmH2O (green range on manometer) unless otherwise directed by the medical team.Document cuff pressure on the Tracheostomy Observations Chart.Cuff pressure should be checked once per nursing shift or more frequently if cuff pressure is unable to be maintained.ALERT: Ensure patient is not coughing while you are measuring the cuff pressure as you will receive erroneously high readings.If the cuff is over-inflated attach a 10 ml syringe to the pilot cuff and remove 1ml air from the cuff by slowly withdrawing the plunger then remeasure. Repeat if necessary.If the cuff is under-inflated, attach 10mL syringe filled with air to the pilot cuff. Add 1ml of air at a time to the cuff and recheck pressure with the cuff manometer. When the cuff is adequately inflated you will not be able to hear the patient’s voice when he/she attempts to speak, or during coughing.Document cuff pressure on the Tracheostomy Observations Chart.ALERT: In the case of a cuff being unable to maintain adequate pressure, it is possible there is a persistent cuff leak and a tracheostomy tube change may be required. The medical team should be notified and the patient reviewed.Cuff DeflationCuff Deflation – The removal of all air from the cuff via the pilot balloon. Deflation of the cuff of the tracheostomy tube will allow air to pass from below the cuff into the upper airway. Communication with the upper airway means the patient can talk, if they can create enough flow of air through their vocal cords. A deflated cuff provides the opportunity to assess voicing and coughing, and the patient’s ability to manage their oral secretions.IndicationsSuitability for cuff deflation and periods of time for cuff deflation should be directed by the multidisciplinary team including the Medical team, Physiotherapist and Speech Pathologist. Patients should be reviewed if there are any concerns regarding aspiration of secretions, and cuff deflations should cease and the cuff reinflated.Any aspirated saliva and gastric contents may collect above the cuff, which on deflation will enter the bronchus if the patient has an inadequate cough. Therefore the patient needs to have an adequate cough prior to commencement of cuff deflations. ProcedureThis is ideally a two person procedure. Physiotherapists and Senior Nursing Staff deemed competent may choose to perform this as a one-person procedure. 1 to 2 suitably qualified staff members are required to carry out the cuff deflation procedure. Ensure the patient is comfortable and observations are stable.Explain the procedure to the patient and warn that it may cause coughing.Perform hand hygiene and don PPEEncourage the patient to cough and clear secretions to reduce the amount of secretions in the airwayIf the patient has a Suctionaid tracheostomy tube, suction above the cuff using the recommended technique (Section 3 Airway Suctioning via Above Cuff Suction Aid Tracheostomy Tube).Prepare a suction catheter for use or attach closed suctioning unit (see Section 3 Suctioning).One person attaches a 10 mL syringe to the valve of the pilot cuff and slowly withdraws the plunger to deflate the cuff.The other staff member inserts the suction catheter into the airway and suctions any secretions that may have been released into the trachea by the cuff deflation.Leave the cuff down as per the cuff deflation schedule. If patient displays clinical signs of not tolerating cuff deflation, reinflate cuff and document the reason for reinflation on the Tracheostomy Management Observation Form in the comments section. ALERT: Indications for poor tolerance of cuff deflation and need for cuff reinflation generally include the following:Respiratory distress e.g., coughing, SpO2, SOB, work of breathing/ respiratory rate, secretions or need for suctioning ↑temperature in which the chest is considered a potential source and patient demonstrates other sign/s of not tolerating cuff deflation Saliva or gastric contents suctioned from tracheostomy Once the cuff is reinflated (see procedure below), return patient to previous oxygen, humidification or ventilator settings if necessary.Cuff ReinflationCuff Reinflation – Is the insertion of air via the pilot balloon into the cuff to achieve the ideal cuff pressure of 15-25 cm H2O. IndicationsCuff reinflation should occur as per the multi-disciplinary plan for cuff management. Cuff deflation/reinflation regime should be carried out as documented in the medical file unless patient displays signs of not tolerating cuff deflation. For indications of poor tolerance of cuff deflation, see alert above.ALERT: If speaking valve is insitu the speaking valve MUST be removed prior to cuff reinflationProcedureExplain the procedure to the patient.Perform hand hygiene and don PPEAttach the 10 mL syringe to the valve of the pilot cuff and slowly push the plunger to reinflate the cuff. Measure cuff pressure, add/remove air to achieve the target cuff pressure. Check the cuff pressure with the cuff manometer and follow procedure above for measuring and maintaining ideal cuff pressure.Back to Table of ContentsSection 8 – Use of Speaking ValvesPurposeTo provide staff with the process on the use of speaking valves in a patient with a tracheostomy tube.Speaking valves are one way valves that fit the 15mm hub of any standard tracheostomy tube.PMVs open upon inspiration and close completely upon expiration. Other speaking valves may not close completely on expiration. Figure 1: Passy Muir Speaking valve with Warning Safety Sticker attachedScopeThis section applies to the management of all patients at CHHS with a tracheostomy tube suitable for the use of a speaking valve. Speaking valves should only be used on recommendation of a speech pathologist or medical officer.BackgroundA speaking valve restores airflow through the upper airway which facilitates voicing, coughing, swallowing, return of sensation and smell. Use of a speaking valve can be part of the progression towards petencyThe fitting of speaking valves (once recommended) can only be fitted by staff who are deemed:Competent in the management of patients with tracheostomy tubes;To have good knowledge of the function of speaking valves; and To have good knowledge of the procedure in fitting speaking valves.There are three brands of speaking valves available:Passy-Muir Speaking Valve +/- oxygen adaptor Shiley Phonate (SSV without oxygen port, SSVO with oxygen port). Portex Orator speaking valve with cosmetic cap and oxygen cap Canberra Hospital campus only uses the Passy Muir Speaking ValveALERT: A speaking valve can only be used on an uncuffed tracheostomy tube or when the cuff is completely deflated on a cuffed tracheostomy tube. Speaking valves should not be used without medical/speech pathology recommendation. Procedure for fitting of a speaking valveEquipment10 ml syringePPESpeaking valve (+/- oxygen adaptor)Suctioning equipmentPulse oximeter (recommended)ProcedurePerform hand hygiene and don PPE Ensure patient is medically stable prior to proceeding Explain the procedure to the patientEnsure pink Passy-Muir Safety Sticker is attached to the speaking valve prior to fitting on patient.Pulse oximetry is recommended prior to placing a speaking valve if there are concerns regarding tolerance. Any closed suctioning unit, attachment to humidification or a Swedish nose must be removed prior to fitting a speaking valve.If a cuffed tracheostomy is insitu, ensure the cuff is fully deflated.If a Suctionaid tracheostomy tube is insitu, suction above the cuff via the above cuff port (low pressure suction) and suction the mouth if required. Suction via tracheostomy if required.Clear mouth with Yankauer sucker as necessary.If the patient usually requires oxygenation via the tracheostomy, oxygen should also be delivered via the oxygen port when the patient is wearing a speaking valve. Note: The amount of oxygen that can be delivered through a speaking valve varies depending on the type of valve. Please refer to manufacturer’s guidelines (e.g. Passy Muir Valve can deliver a maximum of 6L per minute via the O2 port)A speaking valve is placed directly on the hub of a tracheostomy tube on the outer cannula.To reduce irritation caused by movement of the tracheostomy tube, hold the outer cannula of the tube with one hand and secure valve with quarter clockwise twist.Perform hand hygiene at completion of procedure.Remain with patient for initial 5 minutes after placing speaking valve on tracheostomy, to ensure patient is tolerating valve and experiencing nil problems with breathing.ConsiderationsThe amount of time a patient wears a speaking valve for should be determined by the multi-disciplinary team following Speech Pathology assessment and recommendation.Remove the speaking valve when the patient is sleeping.Remove the speaking valve if the patient exhibits increased work of breathing or respiratory distress.If patient cannot voice as per previous trials, do not use the speaking valve and request Medical/Speech Pathology review.Do not use the speaking valve in the presence of copious tracheal secretions.Do not use a speaking valve if the patient has an upper airway obstruction.A patient cannot receive humidification while wearing a speaking valve, therefore the time for wearing a speaking valve should be discussed with the multi-disciplinary team, particularly the physiotherapist.Cleaning the speaking valve should occur daily or more frequently, as per the manufacturer’s recommendation.Back to Table of ContentsSection 9 – DecannulationDecannulation is defined as the removal of a tracheostomy tube.PurposeTo provide staff with evidenced based consistent guidelines on decannulation including:Methods of weaning from tracheostomy tube (excluding weaning from mechanical ventilation)/Decannulation pathwayIndications and assessment of patient for decannulation Decannulation procedureMultidisciplinary assessment for decannulation is essential as failed decannulation can result in readmission to the Intensive Care Unit, increased morbidity and increased length of stay. Procedure Decannulation PathwayCanberra Hospital and Health Services generally use initial cuff deflation assessment and progressive tolerance of cuff deflation time as the method of weaning from a tracheostomy tube and progressing to decannulation. Capping of the tracheostomy is infrequently used by medical staff, and generally when there is concern about airway patency. If capping is requested by medical team, please refer to the procedure for capping as documented in this section. As part of the decannulation pathway, speaking valves can be considered (Section 8 Speaking Valves). Downsizing of the tracheostomy tube should be considered in the decannulation pathway only if the tube is too big to allow secretion clearance into upper airway and/or to tolerate a speaking valve. Note: Although not used often, in failed decannulation due to difficulties with sputum retention, a mini tracheostomy tube may be recommended by the medical team (see Attachment N for further information).Indication/Assessment of Readiness for Decannulation PathwayA multidisciplinary assessment involving Medical, Nursing, Speech Pathology and Physiotherapy is important. Decannulation should be progressed through collaboration with the multidisciplinary ward team, the Tracheostomy Assessment and Consultation Service (TRACS) as appropriate, and agreed to by the treating medical team.For the procedure for cuff deflation, it is recommended that patients have tolerated a minimum of 24 hours of cuff deflation prior to decannulation. Longer periods of cuff deflation may be recommended by the multidisciplinary team and/or TRACS prior to decannulation in some cases.Considerations prior to decannulationThe following reasons may be considered prior to decannulation, (all of these may not be necessary): Resolution of initial need for tracheostomyWeaned from/off mechanical ventilation for greater than24-48 hoursCuff deflation tolerated for 24 hoursAirway patencyMedical stabilityRespiratory stabilityEffective cough for airway clearance Airway protection from gross aspirationControlled secretions (oral and pulmonary)OxygenationNo imminent surgery requiring endotracheal airway managementAdequate level of consciousness Ability to tolerate tracheostomy occlusion Risks with premature decannulationSputum retention (primary reason) Aspiration PneumoniaReintubation/RecannulationRespiratory Failure/ArrestRisks with delayed decannulationInfectionStoma site, lower respiratory tract/pneumoniaIncreased risk of ongoing complications of tracheostomy tubesTracheal erosions, tracheomalacia, tracheal stenosis, tracheo-oesophageal fistula, laryngeal problems, occlusion (sputum plug)Potential for further impact/deterioration of swallowingDelayed restoration of optimal speech/communicationDecannulationWhen the patient is deemed suitable for decannulation, this should be clearly documented by the treating team in the medical notes.A management plan should be clearly documented in the event that the patient fails decannulation including Advanced Patient Directives, unexpected outcomes and suitability for recannulation.Note: Removal of the tracheostomy tube is generally completed by an RN working within their scope of practice, having completed the Tracheostomy Self Directed Learning Package and/or having attended the Tracheostomy Management Staff Development Unit course, who is deemed competent in tracheostomy management (including decannulation procedure) by their CDN/CNC. On some occasions a medical officer may complete the decannulation. EquipmentEmergency and bedside equipment as per Tracheostomy Management Standard Operating ProcedureAppropriate oxygen source (e.g. Facemask or nasal prongs) if requiredPPEPulse oximeterDressing pack and stitch cutter (if sutures present)Dressing of choice ProcedureEnsure all emergency and bedside equipment is present.Explain the procedure to the patient.Perform hand hygiene, don PPE.Connect the pulse oximeter and pre-oxygenate the patient (if indicated).Position the patient comfortably, lying or sitting in bed some neck extension.Suction the patient if required.Ensure cuff is fully deflated (cuff should already be deflated as part of patient assessment for decannulation).Undo the tracheal tapes or Velcro ties and remove the tracheostomy dressing, remove sutures if present.Ensure stoma site is clean. Gently withdraw the tube on exhalation.If patient receiving oxygen via tracheostomy prior to decannulation, change to face mask or nasal prongs.Apply the dressing over the stoma site and ensure it is sealed properly (if dressing is not sealed correctly it can cause the patient some distress as air escapes out of the stoma site as well as the mouth). Check that the patient is able to breathe properly. Ensure that the patient is comfortable and that his/her observations are stable.Educate patient or family members to apply firm pressure over the stoma dressing with his/her fingers when coughing on vocalising (if patient able).Ensure call bell in reach. Monitor patient with pulse oximetry recommended for approximately 2 hours post decannulation.Document in medical file.Closely monitor patient for the next 4 hours to ensure no signs of respiratory distress.If the patient experiences respiratory distress or stridor, recannulation may be required.Decannulation is ideally performed Monday through Thursday during daylight and in the morning. ALERT: If the patient experiences respiratory distress or stridor, call a MET/Code Blue. Monitor patient’s oxygen saturation and apply oxygen to the stoma or mouth as indicated.Stoma management post decannulationThe length of time for the stoma to close varies depending on how long the tracheostomy has been insituDaily replacement of dressing) required until stoma has healed. Possible ComplicationsRespiratory compromise and need for recannulation. If this occurs acutely during decannulation, this may be due to dried secretions attached to tracheostomy tube being aspirated down the airway.Bleeding/trauma.Paradoxical vocal cord movement – there are rare occasions where patients may appear to fail decannulation initially with inspiratory stridor, yet this may be due to temporary paradoxical vocal cord movement, which should settle.Problematic recannulation e.g. quick stomal closure.If the patient requires recannulation, it cannot be assumed that they will retain the same level of function prior to decannulation. Therefore, cuff deflation, oral intake and speaking valve trials would need to be reassessed.ALERT: Decannulation failure is most likely to occur in the first 48 hours therefore patient needs to be closely monitored in this time period.CappingCapping (also known as corking or spiggotting) of tracheostomy tube is sometimes used as a transition to decannulation in limited circumstances. The main indications for considering capping as a transitional stage to tracheostomy decannulation are:Assessment of airway patencyConcern as to capacity for sputum clearance (Clinical Indication: Assess patient’s ability to consistently clear secretions into mouth, i.e. not requiring suctioning.)Note: It is recommended that a tracheostomy tube be downsized to a size 6mm prior to considering capping. Because the capped tracheostomy tube is a partial upper airway obstruction, patient will find breathing easier once tracheostomy removed.Procedure for CappingEnsure there is clear documentation by the medical officer requesting capping of the tracheostomy tube in the patient’s clinical record.Perform hand hygiene and don PPE Inform patient of procedure.Check cuff is fully deflated. Remove inner cannula (cap will not fit on end of Portex tracheostomy tube with inner cannula insitu).Apply oxygen therapy as indicated. Oxygen therapy can be applied via nasal prongs (including high flow nasal prongs) or mask.Educate patient (if able) on how to remove cap if patient develops respiratory distress.Document the time the cap was applied on the Tracheostomy Management Observations form in the comments section.If patient develops signs of respiratory distress, or patient is unable to clear secretions with cough alone, remove cap and suction. If concerned about reapplication of the cap, leave cap off, apply humidification and contact Medical/Physiotherapy Staff. Document reason for removal of cap on the Tracheostomy Management Observation form in the comments section.ALERT: Cuff MUST be deflated prior to application of cap otherwise airway is completely occluded i.e. patient cannot breathe in or out.Figure 1: Portex Cap for Portex Tracheostomy TubesBack to Table of ContentsSection 10 – RACC Community Care Program Tracheostomy ManagementPurpose The purpose of this section is to provide Community Registered Nurses (RNs) with agreed best practice standards to manage a patient with a tracheostomy tube in the community. The patient and/or carer must be assessed as competent in tracheostomy tube management prior to discharge home and are responsible for providing all tracheostomy equipment and all ongoing tracheostomy consumables. This section includes procedures for staff in providing education to the patient and/or carer for discharge planning (see Attachment N).ScopeThis document pertains to RNs involved in the care and management of adult patients with a tracheostomy tube in the community. This document applies to:RNs within the Community Care Program who are working within their scope of practice (refer to Nursing & Midwifery Continuing Competence Policy)Students under direct supervision.ProcedureThe principles of care of a patient with a tracheostomy tube in the community are the same as the care in the hospital except for the following variances.Emergency Equipment Kit Preparation Prior to Discharge from Hospital to HomeCommunity Nurses to complete the following:Remove the tracheostomy tube (the same brand, type and size as the one in situ) and the tracheostomy tube (one size smaller than the tracheostomy tube insitu) from the sterile packaging.Package each tube with the introducer inserted and tracheostomy tube holder “strappits” attached to the tube in a separate sealed clean plastic bag labelled with the size of the tube along with the inner cannulas, clean gloves (2) and water-soluble lubricant (1).Put the two plastic bags containing the tubes into a third larger bag labelled with the patient’s name and contact details – this will be the patient’s Emergency Kit, to be carried by the patient at all times. Patients who require suctioning will need to carry addition equipment including a portable suction unit and suction catheters.Patients undergoing radiation therapy are provided with a loan humidifier and ongoing consumables while undergoing treatment.To ensure adequate and timely support, Community Nursing request Canberra Hospital staff plan the discharge for early in the week when services are at the highest level. Stoma Care and DressingAs per Section 2 of this documentSuctioningPortable suction unit, canister and tubing are to be provided by the patient prior to discharge from the hospital to home if suctioning is required.Detailed instructions as per Section 3 of this documentHumidificationTypes of Humidification As detailed in Section 5, noting additional option in the community ofNebuliser – ‘cold humidification’- nebulised normal saline.Selecting Appropriate Type of Humidification, consider the following indicatorsHME Device (Swedish Nose) Small quantity of sputum, infrequent suction, thin secretions.Heated Water Humidification Moderate-large quantity of secretions, frequent suction, thick secretions.Patients undergoing radiotherapy. Dehydrated patients.HME + NebuliserSmall quantity of sputum, infrequent/no suction, thin secretions.General InformationThe tracheostomy tube should be covered by a HME device, cotton scarf or single layer of gauze when the patient leaves home.The reduction of moisture and heat loss helps maintain suitable viscosity of secretions and the barrier prevents the inhalation of dust and foreign objects. Some patients may choose to leave the tracheostomy tube uncovered at home. It is recommended the patient drinks three litres of fluid (unless instructed differently by Medical Practitioner) a day to keep secretions moist and easy to expectorate. For those patients with a concurrent dysphagia and enteral feeding tube, increased hydration can be placed through the feeding tube.If the bedroom is cold and dry, the room should be warmed and a vaporiser usedAdvise the patient to shower with the fan off to increase humidificationIf secretions increase in viscosity or quantity, consider heated humidification and liaise with medical officer and physiotherapist.When showering the patient should cover the tracheostomy tube with a cloth or a shower shield to prevent water from entering the tracheostomy tube.Alternatively a hand held shower hose can be used and the stream of water can be directed to hit below the level of the stoma. Swedish Nose:HME device should be changed every 24 hours or when secretions are coughed into the filter, as the secretions will occlude the tracheostomy tube.Remove the HME device prior to coughing and cough secretions into a tissue.HME device should be checked by a minimum of four to eight hourly (with inner cannula changes). It may need to be checked more frequently depending on the quantity of secretions.Fisher and Paykel Airvo:Empty sterile water bags must be replaced immediately. The Airvo humidifier will alarm if the chamber runs out of water “water out” alarm will sound within 30 minutes. Tracheostomy connector is cleaned in warm soapy water and rinsed in clean water on a daily basis.The air filter is replaced every 3 months.Nebuliser Administration Education of patient and/or carer in nebuliser administration is required.There are different types of nebuliser units available. Refer to the manufacturer’s instructions for specific information. They can be hired or purchased from community pharmacies.Administration of Normal Saline via a Nebuliser The administration 5 mls of normal saline via a nebuliser every four to eight hours while awake is recommended.EquipmentTracheostomy mask.‘Sidestream’ disposable nebuliser chamber. Oxygen tubing.5ml syringe.Normal saline. Nebuliser unit.Tissues.ProcedureSet up equipment.Perform hand hygiene and don PPE Draw up 5mls of normal saline into syringe. Remove top of ‘sidestream’ disposable nebuliser and place normal saline into collection chamber, replace top.Connect the disposable nebuliser to tracheostomy mask, remove the HME device or stoma cover, place the mask over the tracheostomy tube and secure around the neck with elastic.Turn on nebuliser at switch.Breathe slowly during administration of normal saline.When normal saline has been administered (the treatment may take 5 to 10 minutes), turn off the unit and remove the tracheostomy mask.Cough up secretions into a tissue.Replace HME device (if applicable).Wash hands.Cleaning Nebuliser and Tracheostomy Mask At the end of the day wash the nebuliser and tracheostomy mask in warm soapy water, rinse with tap water and allow airing dry on paper towel.Two nebulisers and tracheostomy masks are used on alternate days so one is washed and drying while one is in use.The nebuliser and tracheostomy mask are inspected daily for signs of wear and tear.The nebuliser and tracheostomy mask can be used indefinitely in the above way if they remain intact.Care of Inner Cannula for Portex and ShileyRefer to Section 6General InformationThe inner cannula should be removed for cleaning three times a day or more often if the sputum is thick or the patient experiences respiratory difficulty.If secretions are difficult to remove from the inner cannula, the length of time the cannula is left in place should be reviewed. The inner cannula may need to be removed more frequently for cleaning. The patient may benefit from increasing oral fluids and normal saline nebulisations to decrease the viscosity of their sputum, resulting in the sputum being easier to expectorate.Tracheostomy Tube ChangeGeneral InformationThe first tracheostomy tube change for a community patient is performed by the treating MO.Difficult tracheostomy tube changes are to be performed by an ENT Specialist or TRACS team in the hospital.A medical order for a tracheostomy tube change must be obtained from the treating MO for the initial tracheostomy change in the home. A medical order is not required for ongoing tracheostomy changes in the home. In general tracheostomy tubes are routinely changed every 4 weeks or as directed by the treating MO.Ongoing tracheostomy tube changes are performed by two RNs. The CNC Acute/Post Acute Care or a RN assessed as competent must be present.EquipmentSoft pre-moistened cloths and Alcohol Based Hand Rub (ABHR).Safety eyewear. Don PPEDressing pack.Normal saline.Tracheostomy tube same brand, size and type as the one insitu.Tracheostomy tube one size smaller than tube insitu (within easy reach).Water soluble lubricant.Tracheostomy dressing. Velcro tracheostomy tube holder ‘strappit’.Stethoscope.1 x Resuscitation bag (Ambu bag) with flex tubing and 15mm tracheostomy swivel connector.Pulse oximetry. Tracheal dilators (Product ID: 20023 within easy reach).10ml syringe (luer slip).Pressure gauge manometer.Suction unit and tubing. Suction catheters.Water for cleaning suction tubing.Clinical waste receptacle.ProcedureInform patient of the procedure and obtain consent, ensure patient comfort.Perform hand hygiene and don PPE .Check mandatory tracheostomy equipment is available and working.Set up equipment. Place oximeter on patient.Attend to hand hygiene.Don PPEOperator prepares the new tube by checking the: Obturator can be removed from the new tracheostomy tube.Inner cannula can be inserted and removed from new tracheostomy tube.Integrity of the cuff by inflating the cuff with a 10ml syringe, checking the cuff fills evenly and forms a seal then deflating the cuff.Keep inner cannula on open dressing pack.Re-insert the obturator.Lubricate the tracheostomy tube with a thin layer of lubricant.Attend to hand hygiene. Don gloves (operator and assistant).Position the patient comfortably with neck slightly extended (remove head pillow). Suction the oral cavity.If the tracheostomy tube has an above cuff suction port, remove the above cuff secretions.Suction via tracheostomy tube if indicated.Ensure new suction catheter is connected and ready for use.Assistant to deflate the cuff, undo the strappit and remove old tracheostomy tube.The operator promptly inserts the new tube into the stoma ensuring the tip of the tracheostomy tube is directed posterior through the stoma. Remove the obturator immediately and insert the inner cannula while the assistant holds the tube in place.Secure strappit (no more than 2 fingers can fit between the ties and skin).Inflate cuff (Refer to Section 7).Suction the patient to clear secretions.Clean around stoma with gauze soaked in normal saline, apply a dressing. Check for bilateral air entry.Discard equipment.Monitor patient’s oxygen saturation.Monitor patient’s secretion production, respiratory rate and effort for at least 20 minutes.Remove gloves, safety eyewear and gown.Attend to hand hygiene.Document - note type, brand, size and LOT number of tracheostomy tube, cuff pressure, patient’s response to the procedure and when next tube change is due. Care of a Patient with a Tracheostomy Stoma after Removal of a Tracheostomy TubeThe dressing is performed as required (e.g. daily to twice per week) until the stoma heals. Perform hand hygiene and don PPE when dressing stomaEquipmentSoft pre-moistened clothsDressing pack.Normal saline.Occlusive dressing (e.g. Mepilex Border) or; Gauze andOcclusive film dressing.Refer to section 2 for procedure.Tracheostomy Stoma Care, Dressing and “Strappit” Velcro Tracheostomy Tube Holder ChangeGeneral InformationTracheostomy stoma should be cleaned daily and more often if required.Do not use cotton wool as fibres can be inhaled through the tracheostomy tube/stoma. Squeeze excess fluid from the swabs to prevent fluid entering the trachea. Some patients prefer to manage their tracheostomy stoma without a dressing.An alcohol free skin protective wipe can be used if the stoma area requires protection from excessive moisture.Tracheostomy tube holder should be changed weekly and more often if required; an assistant is required to hold the tube in place during this procedure.EquipmentPPEDressing pack (if required)Normal saline (if required).Tracheostomy dressing. Velcro tracheostomy tube holder –“strappit”.Alternatively warm soapy water and clean cloths/gauze or disposable wipes can be used.Procedure Perform hand hygiene and don PPE Remove old tracheostomy dressing.Use gauze soaked in normal saline in a spiral pattern beginning next to the stoma site and moving outward. Clean any debris on the tube.Dry with clean gauze.Inspect tracheostomy site for signs of infection (redness, tenderness, swelling, irritation, yellow or green discharge or leakage) or pressure marks.Have assistant in attendance hold tracheostomy tube in place to prevent dislodgment.Remove old tracheostomy tube holder/strappit weekly and more often if required.Apply new tracheostomy dressing.Thread and secure new tube holder.Tension of tube holder – a maximum of two finger spaces should slip between the strappit and the patient’s neck and feel firm.Wash hands.Inner Cannula CareGeneral Information The inner cannula should be removed for cleaning three times a day or more often if the sputum is thick or the patient experiences respiratory difficulty.If secretions are difficult to remove from the inner cannula, the length of time the cannula is left in place should be reviewed. The inner cannula may need to be removed more frequently for cleaning. The patient may benefit from increasing oral fluids and normal saline nebulisations to decrease the viscosity of their sputum, resulting in the sputum being easier to expectorate.Avoid soaking the inner cannula in cleaning solution; this will shorten the life of the inner cannula.Use pipe cleaners to clean the inner cannula with caution as they can scratch the inside of the inner cannula. Bend the tip of the pipe cleaner over before use. Replace the inner cannula if the cannula has any cracks on the tube or has secretions that cannot be successfully removed.Equipment PPESpare inner cannula. Clean container (2) (e.g. kidney dish for placing inner cannula in while cleaning and e.g. denture container for spare cannula storage).Tap water.Pipe cleaner with tip bent over (if required).Procedure Set up equipment.Perform hand hygiene and don PPE Portex Tracheostomy Tube: Stabilise the tube by holding the neck plate, gently pull the inner cannula out in an outward and downward direction using the small ring ‘pull’ at the outer end of the cannula, place in clean container.Insert the spare inner cannula, ensure it “clicks” into position.Rinse the inner cannula through with warm running tap water and shake dry.If secretions are difficult to remove, clean the cannula with a pipe cleaner (ensure the end is bent over so sharp metal does not scratch the cannula).Discard the pipe cleaner.Check the cannula for kinks or damage.Air-dry the cannula thoroughly and store in an airtight container.Shiley Tracheostomy Tube (this tube has a twist lock action system): Stabilise the tube by holding the neck plate, and twist the inner cannula in an anti-clockwise direction to ‘unlock’ the inner cannula.Gently pull the inner cannula out in an outward and downward direction, place in clean container.Replace with the temporary inner cannula.Insert the spare inner cannula immediately by gently following the curve of the main tube, support the neck flange during this manoeuvre.Rinse the inner cannula through with warm running tap water and shake dry.If secretions are difficult to remove, clean the cannula with a pipe cleaner (ensure the end is bent over so sharp metal does not scratch the tube).Discard pipe cleaner.Air-dry the cannula thoroughly.When dry reinsert the cannula, turn the twist-lock inner cannula clockwise until the blue dot on the inner cannula lines up with the blue dot on the tube. Clean the temporary inner cannula, as above, dry and store in an airtight container.Wash hands.Measuring Cuff Pressure in a Cuffed Tracheostomy Tube Refer to Section 7Managing an Above Cuff Suction Port Tracheostomy TubeRefer to Section 4 SuctioningPortable Suction Unit InformationThere are different types of suction units available. Refer to the manufacturer’s instructions for specific information. A suction unit runs on battery and mains power, the battery should be charged at all times. When not in use the unit should be plugged into the charger at the power point.A list of companies that provide Portable Suction Unit Hire can be found at Attachment SSuctioning of a Tracheostomy Tube Background InformationA clean technique is used for suctioning in the home.Suctioning should be carried out because of individual patient need, not as a routine.The patient should be sitting upright to aid breathing and coughing during the suctioning procedure.Criteria for Suctioning Includes: Refer to Section 3Selection of Appropriate Suction Catheter Size for the Inner Diameter of Tracheostomy Tube for SuctioningInner diameter (ID) TubeCatheter Size7.0 – 8 mm12 FG8.5 mm14 FGCleaning of Suctioning Equipment after UseThe patient and/or carer are responsible for emptying suction canisters and cleaning suction equipment. They can refer to the manufacturer’s instructions for specific information.Back to Table of ContentsImplementation This document will be implemented and maintained through competency training programs for relevant medical, nursing and allied health staff. Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationPoliciesACT Health Consent and Treatment Policy and Procedure DG12-044ACT Health Nursing and Midwifery Continuing Competence Policy and Procedure DGD12-050ACT Health Clinical Supervision Policy CHHS 15/102CHHS Personal Protective Equipment Procedure CHHS12/251CHHS Aseptic Non Touch Procedure CHHS14/011CHHS Vital Signs and Early Warning Scores CHHS14/048CHHS Patient Identification and Procedure Matching Policy CHHS14/051CHHS Patient identification and Procedure Matching Procedure CHHS14/052CHHS Management of adult patients requiring non-invasive ventilation in the ward environment Procedure CHHS12/304Legislation Health Practitioner Regulation National Law (ACT) Act 2010Health Records (Privacy and Access) Act 1997Human Rights Act 2004Privacy Act 1988Guardianship and Management of Property Act 1991 Medical Treatment (Health Directions) Act 2006 Powers of Attorney Act 2006 National Safety and Quality StandardsStandard 1- Governance for Safety and Quality in Health Service Standard 2- Partnering with ConsumersStandard 3- Governance and systems for infection prevention, control and surveillanceStandard 4- Medication SafetyStandard 5- Patient Identification and Procedure MatchingStandard 6- Clinical HandoverStandard 9-Recognising and Responding to Clinical DeteriorationBack to Table of ContentsReferencesAaron’s Tracheostomy Retrieved August 1 2014, from: American Association for Respiratory Care. 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Endotracheal suctioning: from principles to practice. Intensive Care Medicine, 30, 1167-1174.Newmarch C. (2006). Caring for the mechanically ventilated patient: part one. Nursing Standard. 20, 17, 55-64.Norwood, M.G., Spiers, P., Bailiss, J., Sayers, R.D. (200) Evaluation of the role of a specialist tracheostomy service. From Critical care outreach and beyond. Postgrad Med J 80:478-80Pryor J.A. and Prasad, S.A. (2002). Physiotherapy for respiratory and cardiac problems 3rd edition. UK, Churchill Livingstone.Royal Brisbane Woman’s Hospital Speech Pathology Department (2006). CAHS. Speech Pathology Tracheostomy Management Training Program. Developed by RBWH Speech Pathology DepartmentRudy SF & McCullagh L. Overcoming the Top 10 Tracheotomy Self-Care Learning Barriers. ORL-Head and Neck Clinician. 2001;19(2):8-14.Smith-Miller CA. Reasons to Customize a Tracheostomy Patient Education Booklet. ORL- Head and Neck Clinician. 2005;23(4):14-21.Sudderth, GM. Multidisciplinary Team Management of the Patient with Tracheostomy. The Journal for Respiratory Care Practitioners. 2011;24(11):20-3.Speed, L. & Harding, K. (2012). Tracheostomy teams reduce total tracheostomy time and increase speaking valve use: a systematic review and meta-analysis. Journal of Critical Care, doi:10.1016/j.jcrc.2012.05.005.St Georges Healthcare NHS Trust (2006) Guidelines for the Care of Patients with Tracheostomy Tubes St George’s Healthcare: NHS Trust; Smiths Medical, LondonSt George’s Health Care NHS Trust. 2014. Tracheostomy Guidelines. 2014. Retrieved August 1 2014, from: Going Home with a Tracheostomy. Guidelines for Care and Training required prior to Discharge from Hospital. Last Updated 8 April 2012. Retrieved August 1 2014, from: , D.M & Leder, S.B. (2007) Contribution of Tracheotomy Tubes and One-way Speaking Valves to Swallowing Success. , Topics in Geriatric Rehabilitation, 23(4) pp. 341–351.Tamburri LM. Care of the patient with a Tracheostomy. Orthopaedic Clinician. 2000;19(2):49-59.The Canberra Hospital, Staff Development Unit (2007). Caring for a patient with a tracheostomy: Self-Directed Learning Package.The Joanna Briggs Institute Clinical Practice Manuals. Literature Review (2002). Retrieved July 2002 from the World Wide Web: review/htmThe Joanna Briggs Institute. JBI Clinical Online Network of Evidence for Care and Therapeutics (COnNECT+):Tracheostomy: Dressing. 2011Tracheostomy: Tape Changing. 2011Tracheostomy: Inner Cannula Care. 2011Tracheostomy: Routine Care. 2011Tracheostomy: Suctioning. 2011Ward, E. Jones, C. Solley, M. Cornwell, P. (2007) Clinical Consistency in Tracheostomy Management. Journal of Medical Speech Language Pathology 15; (1), pp 7-26. Wood C.J. (1998). Endotracheal suctioning: a literature review. Intensive and Critical Care Nursing. 14, 124-136.Young C.S. (1984). A review of the adverse effects of airway suction. Physiotherapy, 70(3), 104-108. Back to Table of ContentsDefinition of Terms Most definitions included in each section.Dead Space: Air not used for gas exchange. Decannulation: is defined as the removal of a tracheostomy tube.Tracheostomy: is an opening into the trachea through the neck to create an artificial airway. A tube is then placed to maintain this opening, which is partly internal and partly external.Tracheotomy: A tracheotomy is the surgical incision of the trachea through the skin and muscles of the neck.Back to Table of ContentsSearch Terms Tracheostomy, Tracheotomy, Trache, Speaking valve, Suctioning, Airway, Cuff, Portex, Shiley, Humidification, Ventilation, Capping, SpigottingBack to Table of ContentsAttachmentsAttachment A:Summary Tracheostomy Management GuidelineAttachment B:Tracheostomy Observations Chart – Medical Record 60355Attachment C: Guidelines for Completion of “Tracheostomy Observations Chart” Medical Record – 60355Attachment D:General Information on tracheostomy and tube typesAttachment E:ResourcesAttachment F:Mandatory tracheostomy equipmentAttachment G:Inter ward transfers of a Patient with a tracheostomy tubeAttachment H:Interhospital Transfer of a Patient with a Tracheostomy Tube form Attachment I:Discharge Home of a Patient with a Tracheostomy Tube form Attachment J:Suctioning EquipmentAttachment K:Humidifier EquipmentAttachment L: Cleaning Instructions (as per Passy Muir WebsiteAttachment M: Mini Tracheostomy Tube (Figure 2- Mini Tracheostomy Tube)Attachment N: Discharge Planning and Procedures for Education of the Patient and/or CarerAttachment O: Consumable Purchasing InformationAttachment P:Portable Suction Unit - Hire Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.Date AmendedSection AmendedApproved By30/11/2017Minor amendment to Section 8 re: Passy Muir Speaking ValvesKerry Boyd, Director of Allied HealthAttachment A: Summary Tracheostomy Management GuidelineAttachment B: Tracheostomy Observations Chart – Medical Record 60355Attachment C: Guidelines for Completion of “Tracheostomy Observations Chart” Medical Record – 60355 Purpose of form: To improve consistency of tracheostomy management on all wards by ensuring documentation of tracheostomy plan and all appropriate observations on a daily basis in the patient’s medical records.General Information:Print the Tracheostomy Management Observations Form double-sided on A4 paper A new form will need to be used every two days (one page per day)This form should be kept in the patient’s medication chartThis form is not intended for use in ICU, however should be completed by ICU prior to patient transfer to the ward. All other wards to complete the form on a daily basis.Patient identification: Affix a patient identification label or record patient identification details – medical record (UR/PMI) number, Surname, Given Names, Date of Birth and Sex on top right hand corner of form.FIRST SECTION: Daily Tracheostomy Management planThis section needs to be completed on a daily basis, and updated whenever the management plan changes. Nursing staff are responsible for accurate completion of this chart. The tracheostomy management plan is generally determined by the multi-disciplinary team (TRACS), including the treating medical team, Speech Pathology, Physiotherapy or nursing, etc.Date: ___//___Daily tracheostomy management plan: Uncuffed tube Oxygen: L/m via Room air Cuff inflated at all times Cuff deflation for: _______ (time) Oral diet: No (NBM) Yes (specify diet): ___________ Other: Special Instructions:Humidification type: Swedish nose Heated humidification Communication: Writing Speaking valve Suction-aid above cuff voicing Other:____________Date: Write the date this section is being completed (today’s date).Daily tracheostomy management plan: There are four options for cuff status. Please tick one box only. If it is an uncuffed tube, tick “uncuffed tube”. If it is a cuffed tube, and the cuff is to be inflated at all times (no cuff deflations), tick “cuff to be inflated at all times”. If the plan is for cuff deflations, tick “cuff deflation for _____” box and specify the amount of time cuff is to be deflated in the space provided. If there is a different another plan, specify under other and include details in special instructions. Special instructions can be written instructions for cuff re-inflation (e.g. “If requires suctioning more than hourly, reinflate cuff” or “if decrease in SpO2, reinflate cuff” or “speaking valve insitu when cuff deflated”) Oxygen: Specify how many litres per minute. Tick “room air” if the patient does not require oxygen.Humidification type: Please tick the box labelled “Swedish nose” if patient has a Swedish nose or heat/moisture exchange insitu) or tick “heated humidification” if a heated humidification system is in place. All patients with a tracheostomy require humidification whether it is via a Swedish nose or heated humidification.Oral Diet: Speech pathology assessment for tolerance of oral intake is highly recommended prior to feeding a patient with a tracheostomy tube. The options in this section are “no” and “yes” with regards to an oral diet. If the patient is not for an oral diet and is NBM tick “no”. If the patient has been assessed as safe for an oral diet, tick “yes” and specify diet (e.g. “blended diet and thin fluids”).Communication: Please specify how the patient is communicating e.g. Tick “writing”, with a “speaking valve” or with the use of the above cuff suction port tick “Suction-aid above cuff voicing”. The other section is for less frequent options, for example you could specify “communication board” or if the patient’s level of consciousness is too low, write N/A in “Other”.SECOND SECTION: Tracheostomy tube information The information for this section should be documented in the medical record at the time of insertion and there is usually a sticker from the manufacturer of the tracheostomy tube that is placed in the patient’s notes. This sticker includes the brand, size, whether it is cuffed or uncuffed and whether it is single cannula (lumen) or double cannula (recommended). The most common tube used on the Canberra Hospital Campus, is a cuffed Portex tube which has an inner cannula and is unfenestrated.Tracheostomy Insertion date: Last tracheostomy change: ____________Insertion technique: Surgical Percutaneous Tube type: Portex Shiley Size: Fenestrated Un-fenestrated Cuffed Un-cuffed Special tracheostomies: Uni perc (Adjustable flange) Suctionaid Other:__________Insertion date: Write the date that the tracheostomy was inserted. Last trache change: Write the date that the tracheostomy was last changed (The manufacturer recommends changes occur every 30 days).Insertion technique: Tick one box depending on the method of insertion of the tracheostomy - Percutaneous or Surgical. If the tube was inserted surgically there will be an operation record. If it was inserted percutaneously, this will be documented in the medical record.Tube Type: Tick which brand of the tube applies, Portex or Shiley. Size: Write in the Size of the tube- usually in millimetres which refers to the inner diameter of the tube. Adult tubes are usually sizes 6-10 and also come in half sizes in Portex tubes (e.g. 7.5mm).Fenestration / cuff: The tick box options are fenestrated, unfenestrated, cuffed, uncuffed- tick TWO boxes- tube will be either fenestrated or unfenestrated (most common), AS WELL AS cuffed (most common) or uncuffed.Special tracheostomies: Tick here if the patient has a special tracheostomy (in addition to the above information), for example, a Uni-perc (adjustable flange trache) or a Suction-aid (with an above cuff port) or tick other and specify if another type of tube.THIRD SECTION: Stoma care, dressings and equipmentThis section needs to be completed on a daily basis.Tracheostomy site: Dry Exudative Ulcerated Other: Dressing type: Allevyn Drain sponge Other:___________________Tracheostomy bedside equipment all present Summary Tracheostomy Management Guideline (A3) present Tracheostomy wound / stoma site: Tick box relating to tracheostomy stoma / wound site- options are Dry, Exudative, Ulcerated or if Other, please describe free text.Dressing type: Please tick the type of dressing used around the tracheostomy. Options are “Allevyn”, “drain sponge” or “other” (please describe). Tracheostomy bedside equipment: It is important that all mandatory and emergency equipment are available at the patient’s bedside at all times (see Summary Guideline for details). This should be checked on a daily basis. Tick this box when equipment is checked and present.Summary Tracheostomy Management Guideline: The A3 colour summary Guideline should be displayed at the patient’s bed head at all times for quick reference. Tick this box when the guideline is clearly displayed.FOURTH SECTION:(Daily observations)This section of the form should be completed as the cares are given to the patient.000001000200030004000500060007000800090010001100120013001400150016001700180019002000210022002300Cuff statusI = InflatedD = DeflatedCuff Pressure (check once per shift)Frequency of tracheal suctioning (times per hour)Suctioning Amount S = SmallM = MediumL = LargeSputumm = mucoidp = purulentf = frothyb = bloodyAbove cuff suction (Suction aid trache only)Inner cannula change (4 hourly)SpO2 (%)(4 hourly)Dressing changeInitialsShift 1: SignaturePrint nameDesignationContact noDateShift 2: SignaturePrint nameDesignationContact noDateShift 3: SignaturePrint nameDesignationContact noDateCuff status: In the box at the appropriate time, according to the 24 hour clock, mark in when the cuff is inflated (write “I”) or deflated (write “D”). This should be completed hourly.Cuff pressure: Cuff pressure needs to be checked once per shift. Tick the box under the time when the cuff pressure is checked with a manometer and found to be within the appropriate range (15-25 cm H20; marked green on the manometer). Write the number of the cuff pressure. If pressure is low chart what it started at and then what you increased it to so that we can monitor for a cuff leak.Frequency of Tracheal Suctioning: Keep a tally each time the patient is suctioned via the tracheostomy within a particular hour. Note: One suctioning session may involve several “passes” of the suction catheter but it is only counted as one suction. Details about “multiple passes” of the suction catheter can be written in the comments section.Suctioning Amount: Write the average amount suctioned if suctioning occurs within that hour. For small amount write (S), for moderate write (M) for large write (L)Sputum: Note the type of sputum suctioned and write type of sputum if suctioning has occurred within that hour. Write (m) for mucoid, (p) for purulent, (f) for frothy, (b) for bloody.Above cuff suction: (Complete for suction aid trache only), the number of times per hour the above cuff port is suctioned.Inner Cannula change: Tick this box when you change the inner cannula to a clean one. It is recommended this is done 4 hourly or more frequently if required.SpO2 %: Measurement of Sp O2 should be completed 4 hourly and documented as a % of oxygen saturation.Initials: The box should be initialled by the person who completed the observations for that hour.The signature and designation should also be signed by a staff member each day (medical record requirement)Comments: This box is to make any comments about the tolerance of the cuff deflations, reasons for re-inflation of the cuff, Yankeur suctioning via the mouth or any other observations regarding the tracheostomy that cannot be captured easily in other places on this form. Signature: This box is to be completed by each nursing staff shift member that completes the observation section of the form. It needs to be signed, with designation, contact no and date on the form. Attachment D: Tracheostomy Tube types Types of TubesTracheostomy tubes may be cuffed or uncuffed, single cannula (lumen) or double cannula (tracheostomy tube with removable inner cannula) and fenestrated or non-fenestrated. There are also specialised tracheostomy tubes such as the tracheostomy with an above cuff suction port (Suction-Aid), and extendable tracheostomy tubes with an adjustable flange. Laryngectomy tubes are different to tracheostomy tubes. All of these tube types are explained below.Cuffed TubesThe cuff serves a primary role in sealing the airway and allowing assisted ventilation and oxygenation to occur. The secondary role a cuff can play is to help prevent saliva or gastric contents entering the lungs in patients with a poor swallow and/or a poor gag or cough reflex. The cuff on a cuffed tube can be inflated and deflated. A cuffed tube has an external pilot balloon which indicates cuff status. Pilot balloonPilot lineCuffFigure D1: Portex cuffed unfenestrated double cannula tracheostomyUncuffed TubesThere is no cuff surrounding the lower end of this tracheostomy tube. This is not suitable for patients who have swallowing problems/aspiration risk or require ventilation. It is appropriate for those with airway compromise and those needing access to the chest for suctioning. There is no external pilot balloon on this tube.No cuff on the outer cannula (no pilot balloon)Figure D2: Portex uncuffed unfenestrated single cannula tracheostomy Single cannula (lumen) or double cannulaTubes can be single cannula (lumen) or double cannula. Double cannula tubes have an inner cannula, which can be removed cleaned and replaced.Red fenestrated inner cannula partially in placeClear outer cannulaPilot lineFigure D3: Portex double cannula tracheostomy showing inner cannula partially in placeFenestrated TubesA fenestrated tube has an opening (fenestration) on the superior surface of the outer tube.The fenestrated tube is always double cannula with the option of a fenestrated or non-fenestrated inner cannula.The fenestration allows airflow to the larynx and into the mouth and thus facilitates voicing. It also may facilitate weaning from the tracheostomy tube. The Shiley tube has one large fenestration and the Portex tube has a ‘gunshot’ style of small holes. A fenestrated tube is used with patients who do not have a swallowing problem / aspiration risk, or those with potential to improve their swallow.It is not recommended for patients at high risk of aspiration.To avoid trauma to the tracheal wall, it is important to remember that tracheal suctioning is to be done with the inner non-fenestrated cannula insitu (to reduce the risk of the suction catheter going through the fenestrations). There is a small increase in the risk of granulation with the fenestrated tube in the area of the fenestration, as the edges of the fenestration may rub against the tracheal wall.ALERT: If the cuff is inflated, then the non-fenestrated inner cannula must also be insitu.Fenestrations in outer cannula Pilot linePilot balloonCuffRed fenestrated inner cannulaFigure D4: Portex cuffed fenestrated double cannula tracheostomyAdjustable flange Tracheostomy Tube.The adjustable flange (extendable) tracheostomy tube is designed for use in patients with large neck due to obesity, or injury, who require an extended tracheostomy tube from flange to bend. These tubes may be single cannula or double cannula depending on the brand.Adjustable flangePilot balloonCuffPilot lineScrew to open/close adjustable flange Figure D5: Portex adjustable flange single cannula tracheostomyFigure D6: Portex UniPerc TM adjustable flange double cannula tracheostomyTracheostomy with above cuff suction portTracheostomy tubes with an above cuff suction port are always cuffed. These tubes enable secretions to be removed from above the cuff and for the patient to voice, in the presence of an inflated cuff (There are two brands of tracheostomy tubes with an above cuff suction port available (Portex and Mallinckrodt)CuffAbove cuff suction port linePilot balloonPilot line Figure D7: Portex suction aid tracheostomy (double cannula) Laryngectomy Tube.Used to maintain a patent airway following a laryngectomy procedure. These tubes are usually shorter and a different shape than normal tracheostomy tubes as they are in inserted in an end stoma. They are always uncuffed.Tracheostomy tubeLaryngectomy tube Figure D8: Laryngectomy tube and tracheostomy tube5. Brands of TubesThe most common brand of tube used on the Canberra Hospital Campus is Portex. The most common type of tube is a Portex double cannula unfenestrated tube. Portex Can be single/double cannula, fenestrated/non-fenestrated, cuffed/cuffless, +/- suction line. Available in sizes 6, 7, 7.5, 8, 8.5, 9, 10.Made of thermo-sensitive PVC that is adequately rigid for insertion but then softens at body temperature to accommodate individual patient anatomy. Designed at an angle more suitable for tracheal anatomy (not to be used in end stomas- laryngectomy patients)Shiley/ MallinckrodtCan be double cannula, fenestrated/non-fenestrated, cuffed/cuffless, +/- suction line.Tends to be used for longer insitu tracheostomy.Available in sizes (adult) 6,8,10. Attachment E: ResourcesThe following tracheostomy resources are available to Health Directorate staff: Immediate Advice (Staff with expertise)For immediate advice regarding tracheostomy tubes, page ICU Outreach team or ENT registrar. Specific questions about tracheostomies can also be directed to the TRACS team on pager 50298. Clinical Nurse Consultants (CNCs) of tracheostomy dedicated wards (9B, 7A, 5B) and ICU, physiotherapist or senior speech pathologist may be of assistance for discipline specific enquiries.Staff Development Unit The Staff Development Unit regularly runs a two hour Tracheostomy Workshop. Information can be found On Capabiliti on when these courses run.A comprehensive self-directed learning package on “Caring for a patient with a Tracheostomy” can be sourced from the Staff Development UnitHealth Directorate Library Cameron, T (ed.).(2006). Tracheostomy care resources: a guide to the creation of site specific tracheostomy procedures & education. Austin Health Tracheostomy Review and Management Service. WF490 TRA 2006Cameron, T., Dabelstein, M. (2006). Tracheostomy e-Learning Packages [DVD] WF490 TRA 2006UniPercTM Adjustable Flange Tracheostomy Tubes for patients with larger necks Available: Attachment F: Mandatory Tracheostomy EquipmentALERT: The patient with a tracheostomy tube is at risk of:Respiratory failure / and or arrestTube blockageTube damageAccidental decannulation1. Equipment at the bedside When caring for patients with a tracheostomy it is mandatory to have the following equipment available at all times at the patient’s bedside:Tracheostomy tube of the same size insituTracheostomy tube, one size smallerTracheal dilators (for use of trained staff)Suction bottle, tubing and wall suction (or portable suction) Suction catheters Adult Resuscitator bag (with connector) and mask 10ml syringe Oxygen. Humidification- either heated humidification system (preferred) or Swedish nose (HME)Scissors / stitch cutterLubricantOropharyngeal airway (E.g. Guedel airway)Protective glasses or goggles Cuff manometer (for cuffed tubes)Tracheostomy dressingsTracheostomy strappits / tapesWater 1 ltr bottle (for rinsing suction tubing) Disposable gloves and sterile glovesAlcohol based handrub Rigid suction catheter (e.g. Yankaeur sucker) (for oropharyngeal suction)2. Equipment for transport to another clinical areaThe following equipment is required when transporting a patient to another clinical area:Tracheostomy tube of the same size insituTracheostomy tube, one size smaller Tracheal dilators (for use of trained staff)Suction bottle, tubing (or portable suction)A full oxygen cylinderSuction cathetersAdult Resuscitator bag (with connector) and mask 10ml syringe Lubricant Protective glasses or gogglesTracheostomy strappits / tapesDisposable glovesRigid suction catheter (e.g. Yankaeur sucker)3. Ongoing equipment needs:In addition to mandatory equipment, wards need to maintain adequate stocks of the following: Strappit (Velcro Tracheostomy tube holder) Box 10Water soluble lubricant – Jelly 2.7Gm KYGloves – non-sterile – Promed Latex (box – sizes small, medium, large)Gloves - single sterile - Latex (for suction) – sizes medium, largeGlasses – clear safetyTracheostomy Foam Dressing – fenestratedDressing packs – BasicNormal saline 0.9% - 30ml for irrigationNebuliser – Micromist DisposableOxygen tubing – 3m with connectorsTracheostomy Mask - AdultPipe Cleaners – 150mm white – 50/PktKidney dish or denture cup (to hold clean inner tubes)Filter – Swedish Nose – Tracheolife IISuction Catheters (12Fg or 14Fg depending on Tracheostomy tube size)Closed suction system for adults – Kimberley Clark Ballard Trache Care12Fr (4.00mm diameter)14Fr (4.60mm diameter)High wall suctionSuction Tubing - 3m clear Alcohol based handrub at end of bed or at the bedside4. Equipment for transport to another health care facilityTracheostomy tube, same brand, type and size as the one in situTracheostomy tube, one size smaller than the one in situTracheal Dilators – AdultSuction Catheters (12Fg or 14Fg depending on Tracheostomy tube size)Rigid suction catheter (e.g. Yankaeur sucker)StrappitsLubricantDisposable Gloves – medium/largeNormal Saline 0.9% 10ml ampoules10ml syringeTissuesEmergency equipment – Adult Resuscitator bag, portable oxygen and suction as necessary for patient’s condition5. Humidification equipment:Fisher & Paykel (F&P) Warm Humidification Unit: MR 850 (can be used with non-invasive mask ventilation & direct tracheostomy interface)MR 880 (can only be used for direct tracheostomy interface ventilation)PT 100 (refer to Humidification policy for equipment requirements)F&P Blower (air)Drip pole with mount x 2 for F&P Unit (including Allan key)F&P RT202 – Adult Heated Inspiratory Kit with autofeed MR290 chamber and blower connectionHeating wireF&P RT035 – Tracheostomy Direct ConnectionF&P RT033 – Nasal InterfaceBaxter Water for Injection 1000ml bags Wye connector (for inhalation & exhalation)Attachment G: Inter-Ward Transfers of Patients with a Tracheostomy TubeA: Sending ward responsibilities (of a patient with a tracheostomy to another area) Inform the receiving ward of:the size and type of tracheostomythe type of suction being utilised i.e. open vs closedif a closed system is being used the date it was last changed and when it is due for changeThe equipment required:Tracheostomy tube of the same type and size as the one insitu Ensure that inner cannula is in situTracheostomy tube of the same type - one smallerTracheal dilatorsO2 therapy and humidification device i.e. Swedish Nose (humidified circuit may be required – assessment made on a case by case basis) Yankauer suction“y” Suction catheters of appropriate size (open and/or closed)Emergency equipment i.e. Resuscitator Bag B: Receiving wards responsibilities (of a patient with a tracheostomy from another area) Prepare the necessary equipment for a patient with a tracheostomy. The equipment required includes:Tracheal dilatorsO2 therapy device - humidifier and T Piece circuit or Swedish Nose.Yankauer Suction catheters of appropriate size (open and/or closed)Emergency equipment i.e. Resuscitator BagEquipment brought with the patient from the sending ward that is left with the patient for infection control reasons such as tracheostomy tubes of the same type and size and one size smaller may be replaced from the receiving wards stock, through negotiation with that ward.C: Patient transportation between clinical areasBefore a patient is transported between different areas of the hospital, they must be assessed by a senior clinician to ensure it is clinically appropriate to move them AND any risk of acute deterioration can be addressed.When a patient with a tracheostomy is moved between clinical areas, they must be supervised by clinical staff who:Have tracheostomy care within their scope of practice ANDAre able to care for them as appropriate to the patient’s clinical condition, interventions and vulnerability of the airway.If a patient has a history of vomiting, strong consideration should be given to transport of the patient with cuff inflated and adequate humidification via Swedish nose.Attachment H: Interhospital Transfer of Patients with a Tracheostomy Tube formAttachment I: Discharge of a Patient with a Tracheostomy Tube Home formAttachment J: Suctioning EquipmentFigure 1 Wall Suction DeviceFigure 2 Suction CanisterFigure 3 Yankauer SuckerFigure 4 Closed Suction SystemFigure 5 CatheterFigure 6 Sputum TrapAttachment K: Humidifier EquipmentAssociated Information: EquipmentFigure 1. HME/Swedish NoseFigure 2. Humidifier Fisher&Paykel MR850 Humidifier6Figure 3. Humidification Chamber Fisher&Paykel MR290 Autofeed6Figure 4. Air Entrainer – OxyflowFigure 5. Connector straight flexi tubeFigure 6. Y ConnectorFigure 7. Electronic Circuit Set-up31972251905Figure 8. Tracheostomy Direct Connection Fisher&Paykel6Figure 9. AIRVOTM Series Fisher&Paykel6 Attachment L: Cleaning instructions (as per Passy Muir website) Swish Valve daily in soapy, warm water (not hot water).Rinse Valve very thoroughly in warm running water.Allow Valve to air dry thoroughly before placing in storage container. Do not apply heat to dry Valve.DO NOT use hot water, peroxide, bleach, vinegar, alcohol, brushes or cotton swabs to clean Valve.Further information on the Passy Muir Speaking Valve can be found here: manufacturers recommendations for cleaning care and the lifetime of the tracheostomy please see page 23 of the patient booklet: M: Mini Tracheostomy tube (Figure 2)Indication: Sputum retention, unable to clear secretions without suctioning.Size 4mm, uncuffed tube, inserted into cricothyroid membrane.Must have a gag and cough reflex, must be able to manage oral secretion.Suction with a size 10 Fg catheter.Figure 2: Mini Tracheostomy tubeAttachment N: Discharge Planning and Procedures for Education of the Patient and/or CarerOnce the need for a tracheostomy tube has been established the ability of the patient and/or their carer to successfully manage at home must be assessed. It is recommended to have a planning time line for the logistics of setting up a patient at home with a tracheostomy tube, coordinated by the hospital ward CNC covering a 1 to 2 week period. Plan the discharge for early in the week when services are at the highest level. It is recommended the patient and family carer along with the hospital social worker examine financial options regarding support with ongoing equipment and consumables early in the discharge planning process. Education of a patient and/or carer in the management of a tracheostomy tube needs to include a step-by-step program in the hospital. This helps to ensure the patient and/or carer are well informed on tracheostomy management prior to discharge. This process may take several weeks depending on the medical condition of the patient and the patient and/or carer ability to undertake the care competently. Patient and/or carer education related to tracheostomy management is divided into five areas:Technical aspects.Monitoring.Trouble shooting.Emergency Action Plan.Purchasing of ongoing supplies.As the patient and/or carer become increasingly confident and competent in the procedures, independence should be encouraged. During training the patient is encouraged to take responsibility for self-monitoring.For further information on essential equipment and consumables; and essential patient and/or carer tracheostomy training see clinical form “Discharge of a Patient with a Tracheostomy Tube to Home- Form number: 65800” Attachment O: Consumable Purchasing Information Air Liquide Healthcare (suctioning consumables only)T: (02) 9364 7474 F: (02) 8338 9797Bright Sky (ParaQuad NSW)T: 1300 886 601 W: .auCapital Medical Supplies 71 Heffernan St, Mitchell ACT 2911 T: 02 6241 5511 W: .au Independence Solutions (ParaQuad Victoria)T: 1300 788 855 W: (suctioning consumables only)T: 02 9700 1744 W: .auN.B. This list is not exhaustive and contact details may change over the period this document is in operation. These suppliers take no responsibility for the availability of products.Attachment P: Portable Suction Unit - Hire Air Liquide HealthcareT: (02) 9364 7474 F: (02) 8338 9797 W: .au“Suction Pro Pump”A doctor’s prescription is required for suction unit hire. Medi-Rent T: 02 9700 1744 W: .au“Apex Portable Suction Unit”“Flaem Desktop Suction Unit” Mega Medical Equipment & GasesT: 02 2 9944 0511?? W: .au“Zeiner Portable Suction Pump” Order Code: mega-kit-3Yultun Medical Hire ServiceT: 02 9652 2249 “Devilbiss Suction Unit”N.B. This list is not exhaustive and contact details may change over the period this document is in operation. These suppliers take no responsibility for the availability of products.Portable Suction Unit - PurchaseAir Liquide HealthcareT: (02) 9364 7474 F: (02) 8338 9797 W: .au “Port a Suction”A doctor’s prescription is required for suction unit purchase.DeVilbiss HealthcareT: 02 9899 3144 F: (02) 9899 3244 W: .au“Devilbiss Suction Unit” Order Code: 7305P-IEcomed T: 1800 675 432 F: 1800 675 433 E: enquiries@.au W: .au “Clements Carri Vac Portable Suction Pump” Item Number: SUC 81010Laerdal Australia/New Zealand T:?1800 331 565 F:?1800-635-835 W: .au “Laerdal Suction Unit” Order Code: 78000033Medi-Rent T: 1300 726 666 F: 02 9316 9998 W: .au “Portable Hersill V7 Suction Unit”Mega Medical Equipment & GasesT: 02 2 9944 0511?? W: .au“Zeiner Portable Suction Pump” Order Code: LRSPRESCUEN.B. This list is not exhaustive and contact details may change over the period this document is in operation. These suppliers take no responsibility for the availability of products. ................
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