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CARE OF THE ADULT
WITH A TRACHEOSTOMY
A Practical Guide
May 2005
CONTENTS
Background/Membership .......................................................................................... 1
Introduction ............................................................................................................... 2
Staff Roles ................................................................................................................ 3
Definition of a Tracheostomy..................................................................................... 6
Indications for a Tracheostomy ................................................................................. 6
Physiological Changes .............................................................................................. 6
Techniques of Tracheostomy .................................................................................... 7
Open ............................................................................................................. 7
Percutaneous Dilatational .............................................................................. 7
Mini Tracheostomy ........................................................................................ 9
Complications of a Tracheostomy ........................................................................... 10
Types of Tracheostomy Tube.................................................................................. 11
Care of Patients with a Tracheostomy..................................................................... 14
Patient Assessment ..................................................................................... 14
Essential Equipment .................................................................................... 14
Checking Cuff Pressure ............................................................................... 14
Deflating/Inflating Cuff ................................................................................. 16
Suction ........................................................................................................ 19
Oxygen Therapy .......................................................................................... 27
Stoma Care ................................................................................................. 30
Oral Hygiene ............................................................................................... 33
Personal Hygiene ........................................................................................ 33
Humidification ......................................................................................................... 34
Changing of a Tracheostomy Tube ......................................................................... 43
Weaning and Removal of a Tracheostomy.............................................................. 49
Bedside Evaluation of Swallowing, Eating and Drinking .......................................... 56
Feeding ................................................................................................................... 60
Communication ....................................................................................................... 61
Speaking Valves ..................................................................................................... 61
Appendices
Suction Chart............................................................................................... 62
Transfer Sheet............................................................................................. 63
Tracheostomy Emergency Algorithm ........................................................... 64
"Blue Dye" Swallow Test ............................................................................. 65
Communicating with a patient with a tracheostomy ..................................... 67
Grampian Dysphagia Management of Solid/Liquid Feeds ........................... 68
Abbreviation List ..................................................................................................... 70
References ............................................................................................................. 71
i
BACKGROUND
The working group was set up in response to the increasing number of patients with a
tracheostomy who were being cared for in general wards throughout the Trust by staff who
had little knowledge and experience in this area of practice. An increasing number of
enquiries to specialist areas seeking advice on tracheostomy care demonstrated this gap in
knowledge.
An audit of the nursing care of patients with a tracheostomy was carried out in the wards at
Aberdeen Royal Infirmary in August 2001. The results of the audit showed that although
basic care was good, the depth of knowledge and understanding required to ensure a safe
pathway of care from surgery to tube removal was lacking. (1)
The development of this guideline reflects the current emphasis on safe effective care and
will reduce existing variations in practice. Implementation will promote best practice
wherever patients receive care.
Membership
Jacqui Connelly
Elma Cruickshank
Rhona Davidson
Dorothy Dawson
Trish Ferguson
Mary Glasgow
Penny Gravill
Alison Hamilton
Lesley Hastings
Karin Massie
Janice McKinlay
Marina Mearns
Carolyn Reid
Kate Scorgie
Judith Scott
Yvonne Skinner
Dr Stephen Stott
Lesley Taylor
Gillian Thain
Rose McKechnie
Heather Allan
Staff Nurse ENT
Clinical Nurse Manager Neurosciences
Superintendent Physiotherapist
Sister General Medicine
Staff Nurse Cardiothoracic
Clinical Nurse Educator General/Vascular/GI HDU
Specialist Speech and Language Therapist
Specialist Speech and Language Therapist
Sister Renal Medicine
Senior Physiotherapist
Senior Dietitian
Sister Respiratory Medicine
Practice Educator ITU
Sister Respiratory Medicine
ITU Research/Follow Up Nurse
Staff Nurse Neurosciences
Consultant Anaesthetist
Specialist Speech and Language Therapist
Respiratory Clinical Specialist Physiotherapist
Clinical Nurse Manager, Neurosciences
ITU Research/Follow Up Nurse
1
INTRODUCTION
Care of the tracheostomy patient "takes insight into the physiological changes caused by the
tracheostomy tube, careful monitoring to prevent complications, meticulous wound care and
expert suction technique". (2)
The guideline has been drawn up by a multidisciplinary group using evidence where it exists
and best practice standards. It is intended for use by all NHS Grampian healthcare
professionals involved in the care of adults with a tracheostomy.
The guideline is general and will apply in the majority of cases throughout the various areas
of care.
It is recognised that in some specialist areas eg Ear Nose and Throat (ENT) there may be
the need for clinical staff and management to discuss and decide the need for local specific
arrangements to be derived and implemented.
Significant departures from the guideline should be fully documented and the reasons for the
differences explained.
The guideline is not intended to be construed or to serve as a standard of care. Standards
of care are determined on the basis of all clinical data available for an individual case and
are subject to change as scientific knowledge and technology advance and patterns of care
evolve.
Trust guidelines on consent must be followed.
We wish to acknowledge reference to St George's Healthcare NHS Trust "Guidelines for the
Care of Patients with Tracheostomy Tubes" in some sections of this document.
2
STAFF ROLES
Care of the patient with a tracheostomy is the responsibility of the multidisciplinary
healthcare team.
This team comprises of





Medical Staff
Nursing Staff
Physiotherapist(s)
Speech and Language Therapist(s)
Dietitian(s).
Together the team ensures safe management of the patient through:





Regular assessment
Facilitation of the weaning process
Education and development
Regular communication
Documentation.
Details of each individual's responsibilities follow.
The Role of Medical Staff
To take overall responsibility for the patient with a tracheostomy.
Specifically:
1. To prescribe oxygen therapy and humidification.
2. To provide clinical leadership regarding





type of tracheostomy
changing of the tracheostomy tube
swallowing assessment
weaning
removal of tracheostomy.
3. To ensure effective communication with the patient, multidisciplinary team and relatives.
3
The Role of Nursing Staff
1. To maintain a patent airway through suctioning and humidification.
2. To administer oxygen as prescribed.
3. To provide holistic tracheostomy care including stoma care, cuff pressure checks,
swallow assessments.
4. To ensure all essential equipment is present and in good working order.
5. To ensure effective communication with the patient, multidisciplinary team and relatives.
6. To continually assess respiratory function.
7. To assist in the weaning process in conjunction with the multidisciplinary team.
8. To refer patients to appropriate disciplines.
9. Psychological care.
The Role of the Physiotherapist
To assess and treat patients with a tracheostomy.
Specifically:
1. To improve/maintain lung volume eg breathing exercises, positioning, use of mechanical
aids.
2. To facilitate the removal of secretions eg humidification, manual techniques, cough
facilitation, suction.
3. To reduce the work of breathing eg positioning, breathing re-education, relaxation
techniques, use of mechanical aids.
4. To assist in the weaning process in conjunction with the multidisciplinary team.
5. To ensure effective communication with the patient, multidisciplinary team and relatives.
4
The Role of the Speech and Language Therapist
1. To assess and treat patients presenting with communication difficulties as a result of
tracheostomy, eg communication aids, voicing ability, use of speaking valves.
2. To identify other communication deficits, eg dysphasia, dysarthria, cognitive deficits and
to treat as appropriate.
3. To help and advise the staff and family to understand the difficulties and how to
communicate effectively with the patient.
4. To help patients and those around them to develop strategies for maintaining
communication.
5. To assess, treat and offer advice on swallowing difficulties in order to promote safe oral
intake and minimise the risk of aspiration.
6. To ensure effective communication with the patient, multidisciplinary team and relatives.
The Role of the Dietitian
1. To assess nutritional status and requirements of individual patients.
2. To advise on the most appropriate and effective form of nutritional support.
3. To prescribe oral and enteral tube feeds in accordance with the patient's requirements.
4. To monitor provision and effectiveness of nutritional support.
5. To ensure effective communication with the patient, multidisciplinary team and relatives.
5
DEFINITION OF A TRACHEOSTOMY
A tracheostomy is a surgical incision into the trachea through the neck. A tracheostomy tube
is inserted into this providing a patent opening. The tube enables air flow to enter the
trachea and lungs directly, bypassing the nose, pharynx and larynx.
Figure 1:
Diagram of larynx and trachea illustrating the sites of the
tracheostomy tube inserted
INDICATIONS FOR TRACHEOSTOMY

To secure and clear the airway in upper respiratory tract obstruction.

To facilitate the removal of bronchial secretions.

To facilitate weaning from artificial ventilation in acute respiratory failure and prolonged
ventilation.

To protect the airway of patients who are at high risk of aspiration eg neuromuscular
disorders, unconsciousness.

To secure and maintain a safe airway in patients with injuries to the face, head or neck
and following surgery to the head and neck.
PHYSIOLOGICAL CHANGES




The upper airway anatomical dead space can be reduced by up to 50%. (3)
The patient's ability to speak is removed.
The ability to swallow is adversely affected.
The warming, humidification and filtering of air that usually takes place in the upper
airway is lost. (4)
6
TECHNIQUES OF TRACHEOSTOMY
Open Tracheostomy
Most surgeons prefer to perform standard elective tracheostomy in an operating room where
sterility is more easily maintained and specialised lighting is readily available. Most also
prefer to use general anaesthesia, although local anaesthesia is sometimes used. The
patient is positioned supine, usually with a roll beneath the shoulders to extend the neck.
After the anterior neck has been cleaned and painted with antiseptic, a 4 cm transverse
incision is made over the second, third, or fourth tracheal ring. The subcutaneous tissues
are divided and the anterior neck muscles and vessels are retracted. If the thyroid isthmus
overlies the region selected for tracheostomy, it is ligated and transected. After the trachea
has been exposed, one or more cartilages are incised to create an opening into which to
place the tube. In some cases, a plug of cartilage is excised from one or more rings. The
tracheostomy tube is inserted into the opening and the incision is closed with sutures or
staples. Some surgeons elect to suture the flanges of the tube to the skin, whereas others
are content to secure the tube with cloth ties. Some techniques form a flap of tracheal wall
that has sutures placed in it that are brought to the surface out through the stoma. If the
tube is displaced these can be used to re-open the hole for re-cannulation.
Percutaneous Dilatational Tracheostomy
The most commonly used method involves the insertion of a needle through the neck into
the trachea, followed by passage of a guide-wire through the needle. The needle is
removed and its tract gradually enlarged by inserting a series of progressively larger dilators
over the wire. After a sufficiently large opening has been created, a tracheostomy tube is
inserted. Bronchoscopic guidance is often used to ensure proper tube placement and
promote safety. The percutaneous technique is attractive because of its simplicity and
speed. Furthermore, percutaneous tracheostomy can be safely performed under local
anaesthesia at the bedside in the intensive care unit, obviating the sometimes precarious
exercise of transporting the critically ill patient to and from the operating room. Current
evidence suggests that percutaneous and surgical tracheostomies are equally safe
procedures. It is increasingly considered the technique of choice in critically ill patients. (5)
7
Figure 2:
The anatomical position of a cuffed tracheostomy tube
8
Mini Tracheostomy
Mini tracheostomy is the insertion of a small 4 mm non-cuffed tracheostomy tube through the
cricothyroid membrane. This can be done under local anaesthesia. It is primarily inserted to
facilitate the removal of secretions. It does not protect the airway from aspiration and will
only provide a route for oxygenation in the emergency situation.
Figure 3:
Mini Tracheostomy
9
COMPLICATIONS OF A TRACHEOSTOMY
"Historically, tracheostomy was associated with a high risk of complications and a significant
mortality rate. The reported complication rates in adults undergoing tracheostomy vary
considerably but it is generally held that complications are more frequent after emergency
tracheostomy for airway obstruction." (6)
1. Immediate




Haemorrhage (minor or severe).
Misplacement - pretracheal tissues or to main bronchus. (7)
Pneumothorax.
Occlusion of the tube by cuff herniation.
2. Delayed







Tube blockage with secretions. May be sudden or gradual. Rare with adequate
hydration, humidification and suction.
Infection of the stoma site.
Infection of the bronchial tree.
Distension of the trachea with an overinflated cuff leading to ulceration, necrosis.
Mucosal ulceration due to asymmetrical inflation of the cuff, excessive cuff pressures
or tube migration (due to loose tapes or patient intervention).
Risk of occlusion of the tracheostomy tube in obese or fatigued patients who have
difficulty extending their neck.
Tracheo-oesophageal fistula formation.
3. Late





Granulomata of the trachea may cause respiratory difficulty when the tracheostomy
tube is removed.
Persistent sinus at the tracheostomy site.
Tracheal dilation.
Tracheal stenosis at the cuff site.
Scar formation requiring revision.
10
TYPES OF TRACHEOSTOMY TUBE
A variety of tracheostomy tubes are available and tube selection is dependent on the
patient's specific needs.
Tracheostomy tubes vary in size, composition, number of parts and shape.
Single Cannula Tubes
Single cannula tubes are usually the first tube to be sited. The system is less complicated
than double cannulation and is usually for temporary use only.
Double Cannula Tubes
Double cannula tubes have an outer cannula to keep the airway open and an inner cannula
which acts as a removable liner to facilitate cleaning of impacted secretions. Some inner
cannulae are disposable, others must be cleaned and re-inserted.
Cuffed Tubes
Cuffed tubes have a soft balloon around the distal end of the tube which inflates to seal the
airway. Cuffed tubes are necessary when positive pressure ventilation is required or in
situations where airway protection is essential to minimise aspiration of oral or gastric
secretions

Oral feeding should not be commenced with an inflated cuff because an inflated cuff can
anchor the larynx and reduce laryngeal elevation. It also prevents pulmonary air from
clearing the larynx during swallowing. If a patient is aspirating it is vital to know
immediately so suctioning can be carried out and management planned.

Cuff pressures should be checked regularly with a cuff manometer because excessive
pressure (>30 cmH2O) may result in tracheal-mucosal damage including capillary
occlusion, tissue necrosis and stenosis. Refer to page 14 (Checking Cuff Pressures).
If the tracheostomy tube lumen is occluded when the cuff is inflated, the patient will not be
able to breathe. In this situation, it is important to deflate the cuff and call for medical
assistance immediately (refer to Emergency Algorithm Appendix III).
Uncuffed Tubes
Uncuffed tubes do not have a cuff that can be inflated inside the trachea and tend to be
used in longer-term patients who require ongoing suction to clear secretions. It is essential
that patients have an effective cough and gag reflex to protect themselves from aspiration.
Cuffless tubes are rarely used in acute care and are not suitable for patients receiving
positive pressure ventilation.
11
Figure 4:
Figure 5:
Single cannula, cuffed tracheostomy
Double cannula, uncuffed tracheostomy
12
Fenestrated Tubes
Fenestrated tubes have an opening(s) on the outer cannula, which allows airflow to pass
through the patient's oral/nasal pharynx as well as the tracheal opening. The air movement
allows the patient to speak and produces a more effective cough.
However, the fenestrations increase the risk of oral or gastric contents entering the lungs. It
is therefore essential that patients who are at high risk of aspiration or on positive pressure
ventilation do not have a fenestrated tube unless a non-fenestrated inner cannula is used to
block off the fenestrations. Suctioning with a fenestrated tube should only be performed with
the non-fenestrated inner cannula in situ, to ensure correct guidance of the suction catheter
into the trachea.
Note: Additional information on specialised tracheostomy tubes should be sought from
senior nursing and medical staff on ENT/Maxillo Facial Surgery or the Speech and
Language Therapy Department.
Figure 6:
Double cannula, fenestrated cuffed tracheostomy
13
CARE OF PATIENTS WITH A TRACHEOSTOMY
There should be a detailed plan of care for all patients with a tracheostomy. This should be
reviewed on a daily basis and updated if there is any change.
The patient with a tracheostomy needs diligent observation and assessment. The nurse
caring for the patient is responsible for this seeking advice from other professionals as
appropriate.
PATIENT ASSESSMENT
Patient assessment should include:






Type and size of tracheostomy tube
Respiratory rate, pattern and skin colour
Oxygen saturations – if indicated
Amount and consistency of secretions
Oxygen percentage
Checking cuff pressure
This should be documented on the Suction Sheet (Appendix I).
ESSENTIAL EQUIPMENT
When caring for a patient with a tracheostomy there are several essential pieces of
equipment that should always be at the bedside.










2 tracheostomy tubes
-
one same size
one size smaller
10ml syringe for inflating/deflating cuff
1 pair tracheal dilators
Oxygen supply and humidification
Suction equipment
Disposable gloves (both clean and sterile)
Stethoscope
Ambubag with catheter mount should be available on resuscitation trolley.
Pulse oximeter (if indicated)
Cuff manometer - there should be one available per ward.
This equipment should be checked at the beginning of each shift and all but the cuff
manometer should accompany the patient if they are being transferred to another area.
CHECKING CUFF PRESSURE
Each ward area caring for patients with tracheostomies should have a hand held cuff
manometer available. The manometer should only be used to measure cuff pressure, not
to inflate or deflate the cuff.
It is recommended that cuff pressure should be measured every shift by using a hand
pressure manometer and recorded in the suction sheet. This will indicate the pressure
exerted by the cuff on the tracheal wall.
14
The cuff inflation pressure should range from 1530 cmH2O. Pressure exerted on to the
tracheal wall greater than 30 cmH2O may result in capillary occlusion, tissue necrosis and
tracheal stenosis(8). If the pressure is greater than 30 cmH2O and an air leak is still present 
seek medical advice as the tube may require to be upsized.
Figure 7:
Cuff Manometer
Caution
Estimation of cuff pressure by fingertip pressure on the external pilot balloon or filling until no
air leak is heard is an inaccurate measure of this pressure and puts unnecessary extra
pressure on the tracheal wall.
Complications of Unsatisfactory Cuff Pressure

Cuff pressure too high
- tracheal wall weakening
- tracheal necrosis

Cuff pressure too low
- Increased risk of aspiration
- Unable to achieve optimal positive pressure ventilation
15
DEFLATING/INFLATING A CUFF
Indications for Cuff Deflation

Weaning:
Please refer to Guidelines for Weaning from a Cuffed
Tracheostomy page 50.
.

Swallow Assessment:
Please refer to Bedside Evaluation of Swallowing, Eating and
Drinking page 56.
Equipment Required






Two practitioners – one should be suitably experienced.
Suction unit and sterile suction catheters appropriate for the size of tracheostomy tube.
10 ml syringe
Cuff manometer
Pulse oximeter
Sterile gloves and protective eye wear.
Action
Rationale

Full explanation of procedure must be
given to the patient and carers where
appropriate.

Alleviates any anxiety.

Turn off NG or gastrostomy feeding if in
situ – 1 hour prior to cuff deflation.

Reduces risk of aspiration. (9)

Patient must
position.

Optimum lung expansion achieved in this
position. (10)

Wash hands.
Wear goggles, gloves and apron.

Reduces risk of cross infection. (11)

Prior to cuff deflation suction briefly with
a suction catheter in the oropharynx.

Saliva and bile may collect above the cuff
which on deflation will enter the bronchus if
the patient has an inadequate cough. (12)

Continue oxygen flow via tracheostomy
mask or T-piece during procedure.
be
sitting
in
upright
16
Action



Rationale
Perform
synchronised
suction/cuff
deflation technique as follows:

Simultaneous suction should enable
secretions to be caught and removed as
they pass the gradually deflating cuff.
 Pass a sterile suction catheter into
the tracheostomy tube approximately
0.5 cm longer than the tracheostomy
tube tip.

Minimise the risk of cross infection and
trauma.
Simultaneously the second practitioner
should remove air in 0.5 ml increments
from the tracheostomy cuff until fully
deflated using a 10 ml syringe. The
whole procedure should take no longer
than 15 seconds and the patient should
be encouraged to cough.

Gradual deflation assists the patient to
adjust to changes in airflow and allows the
patient to adapt to the feeling of being able
to breathe through their nose and mouth
again. (12)

Coughing reduces the risk of aspiration.
Observe patient for signs of respiratory
distress.

The patient is at risk of aspiration. These
signs will provide early indication that the
patient is unable to maintain their own
airway. (9)





Increased respiratory rate
Desaturation
Fatigue
Cardiovascular instability
Failure to protect airway eg audible
gurgle
 Stridor

Observe spontaneous swallow and the
patient's ability to manage oral
secretions.

No respiratory distress
 Continue monitoring for signs of
respiratory distress during weaning
and swallow assessment.
17
(13)
Indications for Cuff Inflation

Signs of respiratory distress
*Re-inflate tracheostomy cuff immediately*

Trial deflation complete.
Action
Rationale

Inflate the cuff using a 10 ml syringe
inserting the air gradually in 0.5 ml
increments until the balloon is inflated.

Assess cuff pressure using a manometer
(cuff inflation should not exceed 30
cmH2O) and adjust as required using the
syringe.

Reassess and observe the patient.





Suction as required
SpO2 stable
Respiratory rate stable
Cardiovascularly stable
No audible gurgle.
18

Pressure exerted on the tracheal wall
greater than 30 cmH2O may result in
capillary occlusion, tissue necrosis and
tracheal stenosis. (8)
TRACHEOBRONCHIAL SUCTION
Indications

Presence of retained secretions which are detrimental to the patient as indicated by:






visible secretions in the airway.
increased work of breathing
coarse crackles on auscultation, or 'noisy' breathing
suspected aspiration of gastric or upper airway secretions
deterioration of arterial blood gases
radiological changes consistent with retention of pulmonary secretions eg
atelectasis/consolidation
 increased peak inspiratory pressures or decreased tidal volume during ventilation

Inability to clear retained pulmonary secretions due to ineffective spontaneous cough.

To maintain the patency and integrity of the airway.
Equipment
Ensure an adequate supply of equipment at the bedside

Vacuum source

Calibrated, adjustable regulator set at 150-170 mmHg/20-23kPa (14)

Collection bottle and connecting tubing

Sterile disposable gloves (not required for CSMU catheter)

Sterile suction catheters of appropriate size whether open or closed system.
 size 14 FG = size 9 tracheostomy
 size 12 FG = size 8 tracheostomy
 size 10 FG = Mini tracheostomy (15)

Correct catheter design (eg catheters with a rounded tip and multiple eyes cause less
invagination of the mucosa - 'Gentle-flo'). (13)

Bowl containing water

Sterile saline (NaCl 0.9%) - if instillation is desirable.

Goggles, mask and other appropriate equipment if necessary for universal precautions.

Oxygen source with a calibrated metering device.

Manual resuscitation bag (ambubag) with an oxygen enrichment device.

Appropriate monitoring devices to enable measurement of (eg SpO2, haemodynamic,
neurological, ventilatory parameters) prior to, during and after the procedure.

Stethoscope (16) (17)
19
Monitoring
The following should be monitored:

Oxygen saturation
 Pulse oximeter

Respiratory rate and pattern

Breath sounds

Haemodynamic parameters
 Blood pressure (if indicated and available)
 Heart Rate/ECG (if indicated and available)

Sputum characteristics




Colour
Volume
Consistency
Odour

Cough effort

Arterial blood gases (if indicated and available).

Intracranial pressure (if indicated and available)

Ventilator parameters (if indicated and available).
Action
Rationale
1. Assess patient and determine whether
suction is indicated and appropriate.
To ensure stability of patient's medical
status and rule out any contraindications to treatment.
2. Wash hands and put on disposable plastic
apron, gloves and goggles.
To reduce risk of cross-infection.
3. Explain the procedure to the patient
To gain verbal consent, co-operation,
confidence and to re-assure.
4. Position patient appropriately.
To ensure head is in mid-position to
prevent deviation of the tube.
20
5. Consider
pre-oxygenation
for
>30
seconds prior to the suctioning event.
To maintain adequate arterial oxygen
levels and to reduce the risk of
arrhythmia and hypoxia. (18)
A 'closed suction system' may be used
to
facilitate
oxygenation
during
suctioning.
6. COPD patients should be assessed to
ascertain the need for hyperoxygenation.
COPD patients may have an altered
carbon dioxide response mechanism
and therefore should not routinely be
given 100% oxygen. (19)
7. Ensure suction unit is functioning and set
to suggested vacuum pressure of
150-170mmHg/20-23 kPa. (12)
Experimental data to support an
appropriate maximum suction pressure
is lacking.
However high negative
pressure can cause mucosal trauma,
subsequently increasing the risk of
infection and atelectasis. Meanwhile,
low pressures are ineffective at clearing
sputum.
8. Peel the outer sheath of an appropriate
suction catheter (considering size and
design) to reveal the suction control port
and connect the catheter to the suction
tubing. A sputum trap may be connected
at this stage if a specimen of sputum is
required.
9. Place a sterile glove on your dominant
hand and gently remove the catheter
sheath with your non-dominant hand,
controlling the sterile catheter with your
sterile hand.
Take care not to
contaminate the catheter once it has been
removed from the sheath. (20)
To reduce the risk of cross-infection and
ensure the technique is as 'clean' as
possible.
10. Consider installation of 1-3mls of normal
saline via the tracheostomy, prior to the
suctioning procedure. The saline should
be administered during the patient's
inspiratory phase.
(Discuss with
physiotherapist or medical staff prior
to utilisation.)
The value of saline is questionable.
However, it may be beneficial in
initiating a cough reflex, which aids the
removal of secretions.(21) It should not
be routine practice as it may reduce
baseline saturation levels, induce
bronchospasm or increase bacterial
colonisation. (22)
21
11. Gently, without suction, introduce the
catheter into the patient's airway until a
'hard-end feel' or resistance is reached.
At this stage the catheter will probably be
on the 'carina' and a cough may be
stimulated. Withdraw the catheter slightly,
then apply suction, gently removing the
catheter in one continuous movement.(23)
Rotation is not necessary and the
duration of the suction procedure should
not exceed 15 seconds. (24)
Resistance on passing the catheter
probably indicates that the inner tube of
the tracheostomy is crusted with
secretions. It will therefore need to be
changed or cleaned.
12. Reapply the patient's oxygen supply
immediately by replacing the catheter
mount/tracheostomy mask.
To reduce the risk of further hypoxia
and restore arterial oxygen levels as
quickly as possible.
13. Dispose of catheter and gloves in clinical
waste (orange) bag.
14. Monitor patient throughout the procedure
and modify treatment as appropriate.
Assess for signs of distress and/or
variation in haemodynamic, ventilatory
or neurological parameters.
15. Repeat procedure as often as required.
This will depend on the clinician's
assessment,
individual
patient's
condition and response. Continual reassessment of the patient's status is
essential.
16. On completion flush the suction tubing
with tap water, leaving the bowl dry.
Turn off suction pressure and wash hands
at end of procedure. Tidy bedspace
ensuring patient comfort.
To reduce risk of cross-infection and
suction tube blockage
22
To ensure patient comfortable/stable.
CLOSED SYSTEM MULTIPLE USE SUCTION UNITS (CSMUSU)
Figure 8:
Closed System Multiple Use Suction Unit (CSMUSU)
Indications
1. A patient who requires a high FiO2/PEEP where disconnection results in a drop in
oxygen saturation and tissue hypoxia. (25)
2. A patient with copious/infected secretions. (26)
See Action/Rationale numbers 1-7 on pages 20-21.
Action
Rationale
1. Unlock the suction application port.
2. If installation of saline is desirable
following
consultation
with
the
Physiotherapist or Medical Staff (to
stimulate a cough reflex) attach syringe
or prefilled saline ampule to installation
port and pass the tip of the catheter until
the black marking is visible in the Tpiece.
23
Normal saline 0.9% will naturally follow the
tip of the catheter ensuring delivery of fluid
into the lower airways (pooling of saline in
the T-piece can otherwise occur).
The
introduction of normal saline (0.9%) may aid
secretion removal by stimulating a cough
reflex.(21)
However, it should not be
routine practice as it may reduce baseline
saturation levels, induce bronchospasm
or increase bacterial colonisation.(22)
3. Introduce the catheter into the trachea,
withholding the outer plastic sheath.
Take care not to bunch the outer plastic
sheath in front of your hand but pass it
behind
your
hand
with
each
advancement.
The outer plastic sheath allows repeated reuse protecting the catheter from external
pathogens and reducing the need for the
user to wear sterile gloves. Bunching of the
outer sheath at the distal end of the catheter
may reduce the 'feel' that the operator gets
from the catheter.
4. On stimulating a cough and/or reaching a
'hard end' feel, take hold of the 'T'
connector and the tracheostomy tube.
To support, therefore reducing the risk of
disconnection of the system and tube
migration which may cause trauma to the
trachea wall.
5. Apply suction by depressing the
application port and withdraw the
catheter taking no more than 15
seconds.(24)
To reduce the risk of hypoxia.
6. Monitor the patient throughout
repeat the procedure as required.
Previously discussed.
and
When suctioning is complete
7. Withdraw the tip of the suction catheter
so that the black marking is visible
externally to the T-piece (the tip of the
catheter and side port holes should be
level with the installation port).
To reduce the risk of any normal saline 0.9%
passing into the patient's airways producing
an unnecessary cough.
8. Apply suction by depressing the
application port and instil 5-10 mls of
normal saline 0.9% via the installation
port.
To flush the suction catheter and tubing after
use assuring continued patency.
9. 'Lock off' the suction application port.
To reduce the risk of inadvertent suctioning
which may result in hypoxia.
10. Change and date the CSMU catheter
every 24-48 hours,(27) or as per
manufacturer's guidelines.
To reduce the risk of bacterial contamination.
24
HAZARDS/COMPLICATIONS OF SUCTIONING
1. Hypoxia/Hypoxaemia (28)




Removal of oxygen
Temporary atelectasis
Reflex bronchospasm
Interruption of ventilation/respiration.
Hypoxaemia can be minimised by:





Limiting the procedure time to 10-15 seconds.
Pre-oxygenation.
Correct catheter size and negative pressure.
Maintain a closed system for patients requiring a high FiO2.
Appropriate frequency of suctioning.
2. Tissue trauma to tracheal and/or bronchial mucosa (23)
This can be modified by:



Correct suction pressure.
Good technique for insertion and withdrawal.
Correct catheter design.
3. Cardiac Arrhythmia's/Bradycardia/Arrest: (28)
Causation Mechanism:




Irritation of respiratory tract.
Vaso-vagal reflex response.
Narrowing of coronary arteries and alternation in conductivity.
Arrhythmias, Bradycardia and Asystole.
Cardiac Arrhythmias etc may be minimised by:



Pre-oxygenation.
Careful patient selection with regards to timing and necessity of suctioning.
Good technique.
(Note:
If concerned regarding vagal stimulation and suctioning is essential ensure atropine available.)
25
4. Infection (patient or clinician) (29)
This can be minimised by:



Sterile fresh catheter for each application
Sterile technique at all times
Goggles and mask.
5. Raised ICP (30)

Increased ICP may occur because arterial carbon dioxide levels increase during
suctioning causing cerebral vasodilation. The degree of hypoxia and impairment of
venous outflow from coughing may also affect the ICP.

To minimise this, suctioning should be carried out sparingly, and contact with the
carina should be avoided.
6. Pulmonary Atelectasis (31)

Due to removal of air, dynamic compression, airway closure and interruption of
ventilation/respiration.
7. Bronchospasm/Laryngospasm (32)
8. Patient Anxiety
Other Considerations:





Stridor
Pulmonary oedema
Tracheo/oesphageal fistula
Clotting Disorders
Hypotension/Hypertension
26
OXYGEN THERAPY
Oxygen Therapy is the administration of oxygen at concentrations greater than that in
ambient air with the intent of treating or preventing the symptoms and manifestations of
hypoxia. (33)
Note: Oxygen is a fire hazard.
Indications for Instituting Oxygen Therapy

Post-operatively as prescribed by the anaesthetist.

Hypoxaemia where PaO2/SpO2 are below desirable range for specific clinical situation

Cardiovascular instability including hypotension, tachycardia, myocardial ischaemia or
myocardial infarction

Critically ill patients

Acute head injury

Cardiac or respiratory arrest

Carbon monoxide poisoning
Note: Some non-specific clinical features of hypoxia may include:



Altered mental state
Cyanosis
Arrhythmias.
Complications of Oxygen Therapy

Discomfort from oxygen therapy may be associated with dry mucus membranes or
increased work of breathing due to inadequate flow.

Oxygen toxicity is an inflammatory response of the lung tissue following exposure to 70100% oxygen for between 48 hours and 7 days. It impairs the action of the cilia,
macrophages and surfactant and the patient may experience substernal pain, cough,
dyspnoea, interstitial oedema, decreased lung compliance and possible pulmonary
fibrosis. (34)

Absorption atelectasis may occur if absorption of oxygen from alveoli exceeds
replenishment of alveolar gas, so that the alveoli are no longer held open by inert
nitrogen (nitrogen washout). This tends to occur most commonly in mechanically
ventilated patients receiving greater that 70% oxygen for more than 48 hours. (35)

A small proportion of patients with chronic Type II respiratory failure may develop
apnoea if their central hypoxic drive is removed by supplemental high dose oxygen
therapy. However, this is seldom (if ever) abrupt and a period of desaturation and
increasing drowsiness will alert staff before apnoea occurs. In these patients, initial
oxygen concentrations should be low (24-28%) and progressively increased on the basis
of repeated blood gas analysis. (19)

Psychological oxygen dependency.
27
Oxygen Delivery Systems
Oxygen delivery systems are conduits through with oxygen flows from the oxygen source to
the patient. They are classified into two major categories:

A fixed performance device which will deliver a known FiO2 by providing a sufficiently
high flow rate of premixed gas to exceed the patient's peak inspiratory flow rate. (36) For
example:
 spontaneously breathing tracheostomy patient with tracheostomy mask and venturi
valve. The venturi valve ensures that a proportion of room air is entrained through a
fixed-size port, so that specific oxygen concentrations can be delivered. The valves
are colour coded, according to the entrainment port size and the oxygen
concentration is pre-printed on the valve and ranges from 24-60%.
Figure 9:
Venturi Valve
 spontaneously breathing tracheostomy patient on a CPAP circuit or T-piece.
 mechanically ventilated tracheostomy patient.

A variable performance device which will deliver a variable FiO2 as the flow of oxygen is
less than the patient's peak inspiratory flow so that room air is entrained to dilute the
oxygen.(36) For example:
 spontaneously breathing tracheostomy patient on a tracheostomy mask with no
venturi valve.
Note: All oxygen dependent tracheostomy patients should receive humidified oxygen
therapy. The only exception to this is tracheostomy patients receiving oxygen
therapy via a venturi valve, where moisture condenses on reaching the valve which
affects the proportion of room air entrained through the fixed-size port. In this
circumstance, humidified oxygen therapy should be avoided but regular saline
nebulisation should be administered.
28
Prescription of Oxygen Therapy
Oxygen therapy should be prescribed.
The following information should be documented: (37) (38)

Flow rate

Concentration

Delivery device

Humidification

Duration

Method of monitoring
In the acute setting oxygen should be continuous and administered for the duration
prescribed. Intermittent oxygen prescription should only be considered if hypoxaemia occurs
during specific circumstances, for example during sleep or exercise.(33)
Monitoring Oxygen Therapy
Clinical assessment during oxygen administration should focus on the respiratory, cardiac
and neurological systems and should be performed on a regular basis throughout the day,
especially if any change in clinical condition or oxygen dosage has occurred.(33)
Adequacy and changes in arterial oxygenation should be monitored by pulse oximetry and/or
arterial blood gas analysis.(39)
Arterial blood gas analysis is considered the gold standard, however pulse oximetry is very
useful within the clinical setting as long as its limitations are recognised which include:(40)

inability to detect hypoventilation and a rising carbon dioxide level.

inaccurate reading associated with poor peripheral circulation, substance interference or
malpositioning.
(Note: Improper probe placement, or failure to monitor or change probe placement
may cause pressure injuries. As a result, the probe site should be changed
every 2-4 hours.) (12)
Discontinuation of Oxygen Therapy
In the post-operative patient oxygen therapy can be discontinued after the existing oxygen
prescription has elapsed if the patient is clinically stable and is maintaining a SpO2 above
94% at all times on room air.
In the critically ill patient, oxygen therapy can be discontinued when the patient has
recovered from critical illness and is clinically stable and maintaining a SpO 2 above 94% at
all times on air.
Oxygen therapy should always be restarted if clinically indicated.
29
STOMA CARE
Tracheostomy stoma care aims to keep the area clean and dry, reducing the risk of skin
irritation and infection. Secretions collected above the tracheostomy tube cuff may ooze out
of the surgical incision and stoma site. The resultant wetness can promote irritation of the
skin and can lead to skin maceration and excoriation. This increased moisture may act as a
medium for bacterial growth or prevent the stoma site from healing. (41)
Although the frequency of dressing changes will be indicated by the amount of secretion
oozing around the tracheostomy stoma and should be reviewed each shift, they should be
changed at least every 24 hours.
Assessment of the tracheostomy tube holder should be done every shift and changed at
least every 24 hours.
Requirements








Two practitioners
Sterile powder-free gloves
Dressing pack
Normal saline 0.9%
Pre-cut keyhole dressing
Tracheostomy tube holder
Orange clinical waste bag
Appropriate goggles and mask.
Emergency equipment and functional suction equipment should be readily available
at the bedside.
Prepare all equipment prior to the procedure.
Action
Rationale
Explain the procedure to the patient.
Gain consent (where appropriate) and
reduce anxiety.
Wash hands.
Wear goggles, mask, gloves and apron.
Reduces the risk of contamination.
If copious secretions are present, suction
prior to changing the tracheostomy tube
holder and dressing.
The patient is less likely to cough or
require suctioning during the procedure.
Position the patient with their neck slightly
extended.
The positioning of the patient allows easier
access to the stoma site.
30
Action
Rationale
Continue to administer oxygen throughout
the procedure if appropriate.
To reduce the risk of hypoxia.
One practitioner holds the tracheostomy
tube and the oxygen in place whilst the
second practitioner removes the tapes and
dressing.
To stabilise the tracheostomy tube and
reduce the risk of dislodgement of the
tracheostomy tube.
Discard these into the clinical waste
disposal bag immediately.
To reduce the risk of cross-infection.
If the tracheostomy tube has an inflated
cuff ensure the tube leading to the
external balloon is not damaged. If this
does occur the tracheostomy tube will
need to be replaced, therefore, inform
medical staff promptly.
This will deflate the cuff of the
tracheostomy tube and there will no longer
be a viable seal against the trachea
therefore the risk of aspiration is
increased.
Assess the tracheostomy stoma for signs
of trauma, infection or inflammation and
document in the Suction Chart.
Early detection and treatment reduces the
risk of deterioration of the stoma. (42)
Clean around the stoma with Normal
Saline 0.9%, if required, using a clean
technique. Dry thoroughly.
Other cleaning agents may cause irritation
to the tracheal mucosa and surrounding
skin.
Apply the keyhole dressing - starting from
below the tracheostomy tube.
A keyhole dressing is most appropriate as
bulky dressings raise the tracheostomy
tube and may cause discomfort to the
patient and can cause tube dislodgement.
Secure the tracheostomy tube in position
preferably with a tracheostomy tube
holder. The tube holder should be tight
enough to keep the tube securely in place
but loose enough to allow two fingers to fit
between the tube holder and the neck.
For patient comfort and to reduce trauma
from a migrating tracheostomy tube.
Dispose of used/soiled equipment in the
orange clinical waste bag and wash hands.
31
If the patient has a tracheostomy with an inner cannula then this should be removed at least
every 8 hours for assessment. The cannula should then be cleaned as required and/or
replaced and locked back in position.
Action
Rationale
To change the inner cannula firstly remove
the old one. With one hand hold the
tracheostomy in place.
To prevent the tube from dislodging when
the inner cannula is removed.
With the other hand twist the inner tube till
it unlocks and then remove in a downward
motion.
To ensure the tube slides out smoothly.
Insert the new tube and lock into place
If the tube is disposable then place in
orange clinical waste bag immediately.
To reduce the risk of cross-infection.
If the tube is non-disposable then it should
be cleaned with warm soapy water or
hydrogen peroxide 0.5%, rinsed and left to
dry.
The tube should never be left to soak due
to the increased risk of bacterial
contamination.
Do not clean inner tube with a brush.
Brushes can scratch the inside of the tube
causing an area for bacteria to grow.
32
ORAL HYGIENE
Patients with tracheostomies require regular oral care due to the reduced evaporation of oral
secretions, which accumulate in the mouth. This is due to the disruption of normal airflow
during inhalation and exhalation.
Aspirated infective saliva contributes to respiratory problems.
If the patient presents with a dry mouth then consider artificial saliva.
Important Points





Hardened plaque causes tartar.
Tartar tends to form faster in NG/PEG tube fed patients - plaque removal is a priority.
Regular oral hygiene - minimum x 2 per day but preferably every 2-4 hours.
Patient’s teeth should be brushed with toothbrush and toothpaste at least twice a day.
(Remember the patient may be self-caring.)
There is no reason why patients with tracheostomies can’t wear their dentures.
PERSONAL HYGIENE
Showering is permitted if the patient will tolerate oxygen being off for the duration of the
shower and the tracheostomy is covered with a Heat Moisture Exchange Device
(HME)/Thermovent/Swedish Nose. Ensure the patient is angled away from shower spray. It
is easier if the shower is angled from behind.
33
HUMIDIFICATION
INDICATION
It is mandatory that a method of artificial humidification is utilised when a
tracheostomy tube is in situ.(43) The type of humidification will be dictated by the
needs of the patient. Advice may be sought from the physiotherapist.
Rationale
In normal breathing, inspired air is warmed, filtered and moistened by ciliated epithelial cells
in the nose and upper airways. However, these humidifying functions are impaired by:(4)
a) a tracheostomy tube, which bypasses natural mechanisms for warming/moistening
inspired air.
b) administration of cold, dry inspired gases (eg oxygen therapy).
Inadequate humidification can result in a number of physiological changes including:(44)
a) Retention of viscous, tenacious secretions
b) Impaired mucociliary transport
c) Inflammatory changes and necrosis of epithelium
d) Impaired ciliary activity
e) Destruction of cellular surface of airway
(eg
inflammation/ulceration)
f)
(eg
atelectasis/pneumonia)
Reduction in lung function
g) Increased risk of bacterial infiltration.
As a result, humidification must be artificially supplemented to assist normal function and
facilitate secretion removal.
Failure to adequately humidify could result in tube occlusion because secretions
become dry and viscous, forming a crust around the tracheostomy. (17)
34
SUMMARY OF METHODS OF ARTIFICIAL HUMIDIFICATION
Systemic Hydration
Heated Humidification
Cold Humidification
Saline Nebulisation
Heat Moisture Exchanger
Buchanan Bib/Foam Filter

It is essential that oral and IV fluids are monitored to
ensure satisfactory hydration of the tracheostomised
patient.

Dehydration may lead to an increased viscosity of
sputum.

Over-hydration
oedema.

Operates actively by increasing the heat and water
vapour content of inspired gas, so that gas is delivered
fully saturated at core temperature.

It is indicated for tracheostomy patients requiring
mechanical ventilation or oxygen therapy for  96 hours.

Bubbles gas through cold water, but only delivers a
relative humidity of 50% at ambient temperatures.

It is indicated for tracheostomy patients on high
inspiratory flow rates of oxygen with tenacious secretions
or patients complaining of subjective dryness.

A heated device can be incorporated into the circuit.

The nebuliser unit converts saline into a supersaturated
aerosol of liquid droplets which penetrates the lung
moistening the airways.

It may be indicated in tracheostomy patients who are
mechanically ventilated, receiving oxygen therapy or selfventilating on air.

Saline nebulisers have been shown to increase sputum
yield, but the cold irritant effect may induce
bronchospasm.

Operates passively by storing heat and moisture
obtained from condensation during expiration.

It is indicated for tracheostomy patients who are
mechanically ventilated or on oxygen therapy for short
periods (< 96 hours) or who are self-ventilating on air.

Acts in a similar way to a heat moisture exchange device.

It is indicated for longterm tracheostomy/laryngectomy
patients to ensure moisture of the stoma/airways.
35
may
result
in
peripheral/pulmonary
METHODS OF ARTIFICIAL HUMIDIFICATION
(A)
Systemic Hydration
It is essential that oral and IV fluids are monitored to ensure satisfactory hydration of the
tracheostomised patient.(20)
Rationale


Dehydration

excessive loss of water leads to an increased viscosity of sputum.

Factors influencing this include:





fever
hyperventilation
administration of dry medical gases
restriction of oral fluid intake
bypass of upper respiratory tract.
Signs of Dehydration include:







reduced urine output
increased respiratory rate
reduced systolic blood pressure
increased heart rate
reduced central venous pressure
reduced pulse pressure
pallor
Clinical features which may
indicate Dehydration





dark urine
postural hypotension with tachycardia
dry, velvety axilla
inelastic skin over sternum
electrolyte imbalance
Over-Hydration 
oedema.
Surplus circulating fluid may result in peripheral/pulmonary
Signs of Over-Hydration include
Clinical features which may
indicate Over-Hydration






peripheral oedema
increased systolic blood pressure
increased heart rate
increased central venous pressure
late inspiratory, gravity dependent crackles
on auscultation.
weight gain




shortness of breath
cough with production of frothy sputum
distended neck veins
orthopnoea
36
(B)
Heated Humidification

Operates actively by increasing the heat and water vapour content of inspired gas, so
that gas is delivered fully saturated at core temperature.(45)

Equipment should include:
(i)
humidification device.
(ii)
a system to monitor inspired gas temperature which should range between 3740°C.
an inspired gas temperature of 41-42° will cause mucosal damage.)(46)
(Note:
(iii)

sterile water (because NaCl crystallises)
Equipment should comply with universal standards.
Indications for Use

Tracheostomy patients requiring longterm mechanical ventilation/oxygen therapy ( 96 hrs).(47)
Contra-Indications/Hazards

Thermal injury to the airway due to improper temperature settings or thermostat failure.

Superficial burn or tubing meltdown if heated wire circuits are covered or circuits and
humidifiers are incompatible.

Tracheal drowning

Elevated airway pressures

Patient/ventilator dysynchrony

Increased risk of nosocomial infection from contaminated water (eg bacterial growth pseudomonas) (48)
Figure 10:
secondary to pooled water in
patient circuit
Fisher and Paykel heated humidifier
37
(C)
Cold Water Humidification

Bubbles gas through cold water, however only delivers a relative humidity of 50% at
ambient temperatures. (49)

A heated device (Kendall adapter) and thermostat can be incorporated within the circuit.
Indications for Use

Tracheostomy patients on high inspiratory flow rates of oxygen with tenacious
secretions.

Tracheostomy patients complaining of subjective dryness.
Contra-Indications/Hazards

Condensation



impede FiO2 delivery
elevate airway pressures
result in tracheal drowning, secondary to pooled water in the patient circuit.

Risk of bacterial contamination from contaminated condensate (48)

Bronchoconstriction (cold irritant) (50)
Note: Condensation from heated or cold humidification should be considered infectious
waste and disposed of according to hospital policy using strict universal precautions.
Because condensate is infectious waste, it should never be drained back into the
humidifier reservoir.
Figure 11:
Respiflo sterile water bottle with aerodyne heater, nebuliser unit and
liquid crystal thermometer
38
(D)
Nebulisation

The selection of a device for administration of saline which is converted into a
supersaturated aerosol of liquid droplets which penetrates the lung, moistening the
airways. (50)

Other indications for nebulisation include
corticosteroids, antibiotics and mucolytics. (50)
administration
of
bronchodilators,
Indications for Use

Tracheostomy patients who are mechanically ventilated/receiving oxygen therapy/or selfventilating on air.
Relevant Information

Procedure involves administration of 5 mls 0.9% sterile normal saline into the nebuliser
unit 2-4 hourly or as required.

Nebulisers must be connected to a gas source with a flow rate of 6-8 litres/minute (or
follow manufacturer's guidelines).

Lung deposition is enhanced by slow deep breathing and the side lying or upright sitting
position.

Hypertonic saline increases sputum clearance by increasing production, so is only used
to induce sputum for diagnostic purposes.(51)

Ensure nebulisation is given via the tracheostomy (not the face mask!). A nebuliser can
be attached to tracheostomy mask or T-piece circuit.
Figure 12:
Tracheostomy mask with jet nebuliser
39
Limitations of Procedure/Device

Only small percentage of output deposits in the airway (<10%).(52)

Efficiency of device is
(i)
technique dependent
eg
co-ordination
breathing pattern
inspiration hold
(ii)
design dependent
eg
output
particle size
(iii)
patient dependent
eg
compliance
Hazards/Complications

Bronchospasm(50)

Bacterial contamination(48)

Hypercapnic COPD patients may suffer loss of respiratory drive if uncontrolled oxygen is
used as the driving gas.(19)
(E)
Heat Moisture Exchanger (HME)
eg Thermovent, Swedish nose

Operates passively by utilising the principle of replication of the functions of the nasooropharynx, by storing heat and moisture obtained from condensation during
expiration.(53)

Consists of rolls of metal gauze or a condensor element like propylene sponge/fibre
sheet/corrugated paper.(53)
Indications for Use

Tracheostomy patients who are mechanically ventilated or on oxygen therapy for short
periods ( 96 hrs) and have adequate systemic hydration.(47)

Tracheostomy patients who are self-ventilating on air.
Advantages

Economical

80% efficient. However efficiency does depend on gauze surface area, thermal capacity,
inspired gas humidity and temperature.(54)

Protects against bacterial contamination (99.9%).(55)

Supplemental oxygen therapy may be added.
40
Hazards/Complications
HME devices should be avoided in patients with:


thick, copious secretions(56)
body temperature <32°C(43)
Hazards associated with the use of HME devices include:



Possible hypoventilation due to increased dead space
Possible increased resistive work of breathing which would be exacerbated by
mucus plugging in the airways.
HME devices should be checked every 4 hours and replaced if soiled, as secretions can
block the filter and increase work of breathing.(4)
Figure 13:
Figure 14:
Heat Moisture Exchanger (HME)
Heat Moisture Exchanger/Thermovent/Swedish Nose
41
(F)
Buchanan Bib/Foam Filter

Operates passively by storing heat and moisture obtained from condensation during
expiration.(53)

Acts in a similar way to an HME device.
Indication for Use

Longterm tracheostomy/laryngectomy patients to ensure moisture of the stoma/airways.
Relevant Information

The Buchanan Bib or disposable Foam Filter dressing is applied directly over the stoma.

In the acute/hospitalised patient the protector should be replaced every 24 hours.(4)

Community patients can wash and re-use the protector, according to the manufacturer's
instructions.
Figure 15:
Buchanan Bib
42
CHANGING OF TRACHEOSTOMY TUBES
Changing of the tracheostomy tube should be a multidisciplinary decision. The first change
should always be performed or supervised by a suitably trained member of the medical staff.
This is because the stoma and tract to the skin from the patient's trachea may not be well
formed. Thereafter changing the tube can be performed by a competent and suitably trained
person but medical assistance should be readily available at all times.
Indications for Tube Change

Every 28-30 days or as clinical need dictates.(57)

Evidence of tracheostomy tube obstruction that may lead to a rapid deterioration in the
patient's respiratory status.

Infection around stoma site.

Part of weaning process.
Equipment Required
1. Two tracheostomy tubes of appropriate make.
 1 same size
 1 size smaller.
2. Tracheostomy tube tape
3. Tracheostomy tube holder
4. Dressing Pack
5. Normal saline (0.9%) to clean
6. 10 ml syringe
7. Sterile gloves and protective eye wear
8. Water soluble lubricating gel
9. Tracheal dilators
10. Forceps and scissors
11. Pen torch
12. Suction and suction catheters
13. An exchange device/Bougie
14. Precut keyhole tracheostomy dressing – uncut gauze swabs are not recommended.
15. Cuff manometer.
Action
Rationale

Explain procedure to the patient and the
rationale for why the tracheostomy tube
needs changed.

The patient should give verbal consent
where possible unless the tracheostomy
tube is changed as an emergency.

Stop enteral tube feeding or ensure nil by
mouth 1 hour prior to tracheostomy tube
change.

Removal of tracheostomy tube means
the airway is unprotected. It is therefore
important to reduce the risk of aspiration
during tube change.(9)
43
Action
Rationale

Position patient on bed in upright sitting
position with neck extended.

The patient should be comfortable during
the procedure. Extending the neck will
make the removal and insertion of the
tracheostomy tube easier.

Wash hands and put on disposable
plastic apron, gloves and goggles.

Reduces risk of cross infection(11)

Hyperoxygenate patient with 100%
oxygen if they are oxygen dependent
(>40% oxygen) and monitor their oxygen
saturation levels.

During tracheostomy tube change the
patient will not receive oxygen and may
be at risk of hypoxia.
Medical staff should be present if the
patient is oxygen dependent.

COPD patients may have an altered
carbon dioxide response mechanism and
therefore should not routinely be given
100% oxygen.(19)

Two skilled practitioners should perform
the procedure.

One person to deflate the cuff prior to
tube removal and the other to perform
suctioning while reassuring the patient.

Open the new tracheostomy tube on to
an opened dressing pack. Put on sterile
gloves.

To reduce the risk of cross infection.

If new tracheostomy tube is cuffed, check
the cuff by inflating it, removing the
syringe and observing that it does not
deflate spontaneously, then deflate with
a 10 ml syringe before insertion.

To check for air leaks within the cuff.

Check that the exchange device can be
removed.

To become familiar with removing the
exchange device prior to insertion.

Lubricate
the
tracheostomy
sparingly with water soluble gel.

To facilitate insertion.

tube
Do not use the tube if
spontaneously deflates.
the cuff
Too much gel may irritate the trachea.
Remove the old dressing and clean
around stoma site.
44

To clean skin of debris and superficial
organisms.
Action
Rationale

Use a pen torch to ensure tissue is
healthy.

Prior to deflating the cuff, suction briefly
with a suction catheter in the oropharynx.

Secretions may pool at the top of the cuff
and when it is deflated may enter the
lungs.

Perform
synchronised
suction/cuff
deflation technique as follows:

Saliva and bile may collect above the
cuff, which on deflation will enter the
bronchus if the patient has an inadequate
cough.
Simultaneous suction should
enable secretions to be caught and
removed as they pass the gradually
deflating cuff.(12)
 Pass a sterile suction catheter into
the tracheostomy tube approximately
0.5 cm longer than the tracheostomy
tube tip.

Minimise risk of cross infection and
trauma.
 Simultaneously
the
second
practitioner should remove air in 0.5
ml increments from the tracheostomy
cuff until fully deflated using a 10 ml
syringe. Encourage the patient to
cough.

The cuff needs to be fully deflated to
reduce the risk of trauma from removing
the tracheostomy tube. Gradual deflation
of the cuff allows the patient to adapt to
the feeling of being able to breathe
through their nose and mouth again.

Coughing reduces the risk of aspiration.

Release tracheostomy ties and remove
the old tracheostomy tube in a firm
outward and downward motion.

The tube may be slightly resistant and
firm pressure may be required.

Ensure the stoma does not occlude due
to a large double chin.

This will ensure that the patient can
breathe whilst the tube is out.
45
Changing the Tracheostomy Tube without an Exchange Device/Bougie
Action

Rationale
Insert the new tracheostomy tube with
the obturator in place, while the patient is
exhaling using an up and over action.

Immediately remove the obturator.

Observe
distress.

Feel for respirations via tracheostomy
tube. Observe for chest movements.
Auscultate for equal air entry.
the
patient
for

The obturator guides the tracheostomy
tube along the contour of the trachea.
Relaxation of the neck muscles during
exhalation makes insertion easier.

It may be necessary to downsize the new
tracheostomy tube as the stoma may
have shrunk in size.

The patient is unable to breathe with
the obturator blocking the lumen.

The flow of air will be felt via the
tracheostomy tube if it is in the correct
position. If the airflow is not felt, remove
the tracheostomy tube and try again
using a smaller lubricated tracheostomy
tube.
respiratory
Changing the Tracheostomy Tube with a Tube Exchange Device/Bougie
This should be performed by a member of medical staff.
Action
Rationale

Insert tube exchange device/flexible
bougie into the old tracheostomy tube.

Remove the old tube from the trachea
leaving exchange device or bougie in
airway.

Thread over the new tube and remove
bougie.

Check tube
status.
airflow
and
respiratory
46

To direct bougie into airway.
Successful Tube Insertion
Action

Rationale
Secure the tracheostomy tube with a
tube holder or tapes. Clean around
stoma site again if necessary. Renew
tracheostomy dressing.

Inflate the cuff using a 10 ml syringe
inserting air gradually in 0.5 ml
increments until the balloon is inflated.

Assess cuff pressure using a manometer
(cuff inflation should not exceed 30
cmH2O) and adjust as required using the
syringe.

Ensure the patient is breathing
comfortably.
Return oxygen to preprocedure setting and observe saturation
levels.

Record the tube change in the medical
and nursing notes. Document time, date,
size, type of tube and any complications
experienced during the procedure.

There may be a small amount of
bleeding following a tracheostomy tube
change. If there is excessive bleeding,
ensure the cuff is inflated and seek
medical assistance.
47

To reduce the risk of dislodgment,
maintain patient comfort and reduce the
risk of infection.

Ensure tapes are not secured too tightly.

Pressure exerted on the tracheal wall
greater than 30 cmH2O may result in
capillary occlusion, tissue necrosis and
tracheal stenosis.(8)

An inflated cuff reduces the risk of
aspiration.

Trauma can occur to stoma site and the
patient's trachea when changing the
tube. An inflated cuff will protect the
patient's airway.
Unsuccessful Tube Insertion
Action
Rationale

If the tube insertion fails or the patient
appears distressed and cyanosed call an
anaesthetist.

Insert the sterile tracheal dilators and
attempt to re-insert firstly the same tube
and then move to a smaller tracheostomy
tube.

If this fails follow the EMERGENCY
ALGORITHM see Appendix III.
48

The tract may not have formed or the
tracheostomy tube may have become
inadvertently blocked during insertion
causing failure to re-intubate the patient.
WEANING FROM A CUFFED TRACHEOSTOMY AND
REMOVAL OF A TRACHEOSTOMY TUBE
Meets requirements for deflation of tracheostomy cuff
(see guidelines)
Deflate cuff (as guidelines)
Observe for signs of respiratory distress
(see guidelines)
No signs of respiratory distress
Signs of respiratory distress
Observe for 24 hours
Re-inflate cuff
Observations stable
Ongoing sputum
retention
Consider
Mini-Tracheostomy
Meets requirements for
tracheostomy tube removal
(see guidelines)
Remove tracheostomy
(see guidelines)
Re-assess patient to ensure
observations stable
Consider reasons for failed attempt
(see guidelines)
Treat and wean as appropriate
Observe for signs of respiratory distress
No signs of respiratory distress
Signs of respiratory distress
Observe closely for 24 hours
MEDICAL EMERGENCY
(see guidelines)
Review dressing and change as necessary
49
GUIDELINES FOR WEANING FROM A CUFFED TRACHEOSTOMY AND
REMOVAL OF A TRACHEOSTOMY TUBE
Weaning can be commenced once the following have been ensured/initiated:




the primary cause for the tracheostomy has been resolved
there is stable lung status (with oxygen therapy less than 40%)(58)
effective swallow and cough reflex are present (where possible)
safe oral feeding and/or artificial nutrition has been established.
Action
Rationale

Full explanation of procedure must be
given to the patient and carers.

Alleviates any anxiety.

The weaning programme must be
planned, clearly documented and
regularly evaluated by the members of
the multi-disciplinary team.

Ensures continuity and individualised care.

The patient should be placed in
maximum view of nursing staff with a call
bell within easy reach, if appropriate.

Ensures maximum observation of the
patient and allows the patient to summon
urgent assistance if necessary.

Turn off NG or gastrostomy feeding one
hour prior to cuff deflation.

Reduces risk of aspiration.(9)

Patient must
position.
upright

Optimum lung expansion achieved in this
position.(10)
Nursing staff assesses cuff deflation
tolerance and screens swallowing safety
of the patient.

To ensure that the patient can protect their
own airway.
Motor and sensory
impairment can result from the presence of
the tracheostomy tube(59) and may not
resolve until after the tube is removed.

Reduce risk of cross infection.(11)

Saliva and bile may collect above the cuff
which on deflation will enter the bronchus if
the patient has an inadequate cough.(12)
be
sitting
in
Cuff Deflation

 Wash hands and put on a disposable
plastic apron, gloves and goggles
 Prior to cuff deflation, suction briefly
with a suction catheter in the
oropharynx
 Continue
oxygen
flow
via
tracheostomy mask or T-piece during
procedure
50
Action
Rationale
 Perform synchronised suction/cuff
deflation technique as follows:


Simultaneous suction should enable
secretions to be caught and removed as
they pass the gradually deflating cuff.

Pass the sterile suction catheter
into the tracheostomy tube
approximately 0.5 cm longer than
the tracheostomy tube tip.

To minimise the risk of cross infection and
trauma.

Simultaneously
the
second
practitioner should remove air in
0.5 ml increments from the
tracheostomy cuff until fully
deflated using a 10 ml syringe.
Encourage the patient to cough.

Gradual deflation assists the patient to
adjust to changes in airflow(12) and allows
the patient to adapt to the feeling of being
able to breathe through their nose and
mouth again.

Coughing reduces the risk of aspiration.

The patient is at risk of aspiration. These
signs will provide early indication that the
patient is unable to maintain their own
airway.
Observe the patient for signs
increased respiratory distress.
of





Increased respiratory rate
Desaturation
Fatigue
Cardiovascular Instability
Failure to protect airway eg audible
gurgle.
 Stridor.

Observe spontaneous swallow and the
patient's ability to manage oral
secretions.
Signs of Respiratory Distress

Any indication of respiratory distress
following cuff deflation
*re-inflate tracheostomy cuff immediately*
(Follow cuff inflation guidelines page 18.)

Assess cuff pressure using a manometer
(cuff inflation should not exceed 30
cmH2O).

Re-assess and observe the patient until
stabilised.
 Suction as required
 Respiratory rate stable
 SpO2 stable
 Cardiovascularly stable
 No audible gurgle.
51

Pressure exerted on the tracheal wall
greater than 30 cmH2O may result in
capillary occlusion, tissue necrosis and
tracheal stenosis.(8)
Consider following reasons for failed attempt:

Aspiration of oral secretions and compromised airway protection eg dysphagia.





Maintain cuff inflation
Multidisciplinary assessment prior to further attempts of cuff deflation.
Consider other types of tracheostomy tube.
Consider referral for assessment for use of speaking valve (see page 61).
Severe weakness or neurological impairment.
 Maintain cuff inflation.
 Consider other types of tracheostomy tube.
 Consider referral for assessment for use of speaking valve (see page 61).

Continuation of initial reason for tracheostomy.






Maintain cuff inflation
Address initial problem
Re-assess if patient meets requirements for further attempts of cuff deflation.
Consider other types of tracheostomy tube.
Consider referral for assessment for use of speaking valve (see page 61).
Upper airway oedema.





Maintain cuff inflation
Allow oedema to resolve
Re-assess if patient meets requirements to attempt further cuff deflation.
Consider other types of tracheostomy tube.
Consider referral for assessment for use of speaking valve (see page 61).
No Respiratory Distress
Action

Rationale
If no signs of respiratory distress are
noted, leave the cuff deflated.

Builds patient's confidence and ensures
patient has coped well with cuff deflation.
Observe the patient for 24 hours ensuring
they have a call bell within easy reach if
appropriate.

Removal of the tracheostomy tube should
be considered and planned by the
multidisciplinary
team
and
ideally
performed within normal working hours.
The ultimate responsibility
decision lies with medical staff.
for
this
52
To ensure adequate availability of medical,
nursing and physiotherapy staff if the patient
experiences difficulties post tracheostomy
removal.
Action

Rationale
Indications for tracheostomy removal
include:
 maintaining own airway
 tolerates full cuff deflation for more
than 24 hours
 adequate cough
 oxygen weaned to 40% or less(58)
 CV stable
 SpO2 stable
 minimal secretion production.

A mini tracheostomy should be
considered by the multidisciplinary team
if:
 reduced ability to clear secretions
 all other observations stable

The patient is fully informed about the
procedure.

Ensure that the essential equipment is at
the bedside:

A mini tracheostomy should only be
considered if the patient is able to maintain
their own airway and is not at risk of
aspiration.

This will allow nursing staff and
physiotherapists to aid clearance of
patient's secretions.

Oxygen therapy must be administered via
a face mask.

Alleviates unnecessary anxiety.
 Refer to page 43.

Ensure the patient is sitting in an upright
position.

To optimise lung expansion and facilitate
swallowing. (10)

Wash hands and put on a disposable
plastic apron, gloves and goggles.

Minimise cross infection.(11)

Release tracheostomy ties.
53
Action


Rationale
With a sterile gloved hand, pass a
connected suction catheter in to the
tracheostomy tube 0.5 beyond the tip.
The second person should then gently
but firmly withdraw the tube in an
outward and downward movement.
Suction should be applied while the tube
is removed.

The tracheostomy tube has to follow the
anatomical formation of the track. Rapid
jerking or pulling the tube upwards will
cause trauma to the trachea and acute
discomfort for the patient.
Suction is
applied to clear secretions and mucus as
tube is withdrawn.

The tube may be slightly resistant and firm
pressure may be required.

Sleek is no longer advocated as it is
difficult to
(a) ensure an effective seal
(b) remove – causing blisters etc.
(c) observe when there is soakage.
Monitor patient for signs of distress
during the procedure.





 Respiratory Rate
Cyanosis
Desaturation
Cardiovascular Instability
Failure to protect airway eg audible
gurgle.
 Stridor.

Once the tracheostomy tube is removed
ensure the area is clean and dry. Note
any inflammation etc at the stoma site.
Clean if necessary with normal saline
and gauze.

Apply a dry dressing (gauze) secured
with an occlusive film dressing.
54
No Signs of Respiratory Distress Following Tracheostomy Removal

Observe the patient closely for 24 hours
ensuring they have a call bell within easy
reach if appropriate.

To detect any signs of deterioration in
respiratory status and promote confidence
in the patient.

Frequently review the dressings and
change as necessary.
Observe the
stoma for signs of infection

To reduce the risk of pooled secretions
that may delay wound healing and cause
maceration increasing the risk of infection.

Keep the emergency tracheostomy
equipment by the patient's bedside for 24
hours.

In the event of respiratory distress it may
be necessary to facilitate rapid reinsertion
of tracheostomy tube.
Signs of Respiratory Distress Following Tracheostomy Removal
- this is a MEDICAL EMERGENCY

Attempts to replace tracheostomy tube
should only be carried out by a
competent and suitably trained person.

Dependent on ward area
 Call 2000 and request an anaesthetist.
 Competent and suitably trained person
on ward.

Use of emergency bedside equipment
will be required (see page 43 for list).

Insert the sterile tracheal dilators and
attempt to re-insert firstly the same tube.
If
unsuccessful
try
a
smaller
tracheostomy tube.

If this fails follow the EMERGENCY
ALGORITHM see Appendix III.
55

This will ensure minimisation of trauma to
the patient and maintenance of a
controlled situation.

Stoma site may have shrunk in size not
allowing replacement of original size
tracheostomy.
BEDSIDE EVALUATION OF SWALLOWING, EATING AND DRINKING
- to be performed by an appropriately trained nurse
Meets requirements for deflation
of tracheostomy cuff
(see weaning guidelines)
Turn off NG or gastrostomy feeding
Deflate cuff (see weaning guidelines)
Observe for signs of respiratory distress
(see weaning guidelines)
Administer Blue Dye Test
(as per guidelines)
Monitor oxygen saturations
Suction via tracheostomy
Positive Test
(ie blue dye present)
Terminate test (as per guidelines)
Negative Test
ie no blue dye present on
suction (as per guidelines)
Record secretions on
blue dye trial sheet.
Follow procedure for oral intake for
patients who do not present with
dysphagia (as per guidelines).
Reinflate cuff
(see weaning guidelines)
Reinstate alternative feeding
Refer to Speech and Language Therapist for
comprehensive evaluation of swallowing.
56
BEDSIDE EVALUATION OF SWALLOWING, EATING AND DRINKING
Not all patients with a tracheostomy will have a swallowing problem.(60)
The "gold standard" is feeding the patient with a deflated tracheostomy cuff. Feeding a
patient with an inflated cuff is not recommended, however under special circumstances it is
recognised that this may be necessary. The decision to feed the patient with an inflated cuff
should be a multidisciplinary team decision.
Speech and language therapists are only involved in the assessment and management of
tracheostomised patients who present with swallowing difficulties.
1. Screening Procedure for Swallowing Difficulties in Tracheostomised Patients(61)
Action
Rationale
1. A senior nurse, who is trained in the Blue
Dye Test procedure, will screen patient's
swallowing ability where appropriate.
To ensure correct administration and
interpretation of the Blue Dye Test.(61)
A Blue Dye Test should be carried out to help
determine gross airway competence.
2. It is not usually recommended that patients
eat with a fully inflated cuff and it is
advisable that the tracheostomy cuff be
deflated for all oral intake.(62)
The purpose of the tracheostomy cuff is to
promote respiration not to stop aspiration.(12)
Laryngeal elevation is reduced by the
anchoring effect of an inflated cuff. Normal
clearing of the larynx by pulmonary air during
swallowing is prevented by an inflated cuff.(12)
3. Before the cuff is deflated, senior medical
staff agreement is necessary. This must
be documented in the medical notes.
Aspiration
risk
should
be
avoided.
Respiratory support processes will be affected
by ventilated cuff deflation.
4. It is recommended that nasogastric/
gastrostomy feeding be turned off one hour
prior to cuff deflation and the swallow
assessment.
This is to reduce the risk of vomiting and
regurgitation and subsequent aspiration.
5. The patient should be sitting in an upright
position either in bed or in a chair, the head
flexed slightly towards the chest.
The patient is at increased risk of aspiration if
in a semi-upright position with the neck
extended.(63)
6. If not already in situ, attach Pulse Oximeter
to monitor oxygen saturations.
A decrease in oxygen saturations may
indicate aspiration.(64) (65)
7. Deflate cuff following "Deflating /Inflating a
Cuff" Guidelines (page 16).
57
Action
Rationale
8. Follow the "The Blue Dye Test for
Tracheostomised Patients" Appendix IV. If
the test is positive, refer to the speech and
language therapist.
If negative, follow
"Introduction
of
oral
intake
with
Tracheostomised Patients who do not
Present with Dysphagia" see below.
It is essential that the Blue Dye Test(66) (67)
results are taken along with other clinical
indicators to ensure reliability.
2. Introduction of Oral Intake with Tracheostomised Patients who do not Present with
Dysphagia
Action
Rationale
Turn off nasogastric/gastrostomy feed one
hour prior to feeding.
This is to reduce the risk of vomiting and
regurgitation and subsequent aspiration.
The patient should be sitting in an upright
position either in bed or on a chair, the head
flexed slightly towards the chest.
The patient is at increased risk of aspiration if
in a semi-upright position and the neck
extended.(63)
Before cuff deflation, suction the oropharynx
and through the tracheostomy tube.
Pooling of secretions may occur above an
inflated cuff and these may enter the lungs
following cuff deflation.
The cuff should be fully deflated for all oral
intake, providing the patient's toleration of this
has been agreed.
Pressure on the oesophagus can be a result
of a fully inflated cuff. Refer to rationale for
cuff deflation in "Screening Procedure" (part 1
above).(68)
The cuff MUST BE DEFLATED BEFORE a
speaking valve is applied (refer to page 61,
point 9).
Where a speaking valve is used, attach it to
the tracheostomy tube. Refer to each patient's
weaning plan to check toleration times for the
speaking valve.
This will
airflow.(69)
create
optimum
supraglottic
Where the tracheostomy tube is fenestrated,
ensure the inner cannula is also fenestrated if
possible. If not, the inner cannula should be
removed prior to attachment of the speaking
valve.
The patient should be fed by a nurse.
The nurse will be able to control bolus size
and observe for signs of aspiration.
Cautiously introduce Stage 2 (puréed) diet
(see Appendix VI) and thin fluids. Use a
teaspoon for both consistencies.
Stage 2 (puréed) diet is considered the most
manageable consistency for initial swallow
trials.
58
Action
Rationale
Patient's voice quality and cough should be
regularly
checked
by
occluding
the
tracheostomy tube with a gloved finger and
asking the patient to say "ah". If a speaking
valve is in situ, similarly ask the patient to say
"ah" or count to 5. If the voice quality is "wet"
or "gurgly" then ask the patient to cough and to
swallow again. Oral intake must then be
discontinued and referral made to the speech
and language therapist.
If voice quality is "wet" or "gurgly" then this
may be indicative of aspiration.
If voice quality is clear then continue with
swallow trial process.
Observe for the following signs during oral feeding trials:






the patient’s condition deteriorates
the patient fatigues
if indicated by the patient’s respiratory status (eg signs of distress, increased respiratory
rate, decreased oxygen saturations)
voice is consistently sounding wet
persistent coughing is evident (in association with eating and drinking)
there are signs of aspiration on tracheal suctioning.
Consider referral to the Speech and Language Therapy Department if these symptoms
occur in relation to oral intake
3. When to Consider a Referral to the Speech and Language Therapy Department for
a Swallowing Assessment
Referral would be appropriate for tracheostomised patients with:
(i)
Neurological involvement eg bulbar involvement.
(ii)
Head and neck surgery.
(iii)
Evidence of aspiration of food/fluid/oral secretions on tracheal suctioning.
(iv)
Persistent wet or weak voice when cuff is deflated and speaking valve or decannulation
cap is in place.
(v)
Evidence of blue dye on suctioning following a Blue Dye Test.
4. Nursing Management
Action
Rationale
Follow the recommendations of the speech
and language therapist regarding swallow
safety guidelines, such as patient positioning,
swallow manœuvres and modified textures
(Stage Diet). This must be recorded in the
nursing kardex and medical records.
The patient may be at risk of aspiration of
one or more consistencies.
59
FEEDING
Most patients will initially be fed via a nasogastric tube. All patients must be referred to a
dietitian for assessment and prescription of appropriate feed. Please refer to ward protocols
for care of nasogastric feeds.
When patients are to progress to oral diet for the first time a blue dye screening assessment
should be performed by nursing staff (see Bedside Evaluation of Swallowing, Eating and
Drinking page 56). If the patient shows any signs of difficulty or if there are any concerns for
the safety of the patient's swallow, then the patient should be referred to the speech and
language therapist. Individual care plans will then be drawn up and documented in the
nursing kardex.
The dietitian should be informed of patient's progress from tube feeding to oral diet so that
advice on transitional feeding may be given. Patients following Stage 2 and Stage 3 diets
are unlikely to meet their nutritional requirements without the intervention of a dietitian.
The following terminology was agreed by the Grampian Dysphagia Management Group
(Appendix VI).
STAGING OF DIET
Stage1:
(nil orally)



Nothing to eat or drink.
Administration of medications should be through an NG tube.
Swallow assessments should be ongoing.
Stage 2:
(puréed diet)






Thick smooth consistencies only.
If not managing normal fluids then they can be thickened.
Order thick and creamy yoghurts, weetabix, etc from the menu card.
Document Stage 2 on the menu card for lunch and supper.
The patient should be sitting upright and be fed by the nurse.
Medication should still be given via the NG tube yet can be crushed
and given in food also.
Stage 3:
(soft diet)





Soft food only.
Order the soft option from the normal menu.
Order thick and creamy yoghurts for dessert with each meal.
Again fluids may need to be thickened.
Patients can this time feed themselves if able but should still have
close nursing supervision.
Patients will probably be able to manage medication orally yet it may
still have to be crushed or syrup used.

Stage 4:
(normal diet)



Normal diet.
Normal fluids.
Patient may still require supervision.
60
COMMUNICATION
Points to consider:
1. Where appropriate before the tracheostomy procedure, the patient and relatives should
be informed, that the patient may be unable to create a voice while the tracheostomy
tube is in place. This is because as air is no longer passing through the vocal cords.
They should be reassured that it is expected that the patient's voice will return once the
tube is removed or manipulated (except when a laryngectomy has been performed).
Alternative means of communication can be provided by the multidisciplinary team and
an information sheet is available (see Appendix V).
2. For tracheostomised patients, the initial assessment should include a focus on the
patient’s ability to see, hear, touch, write, understand or use facial expressions such as
smiling and blinking.(70)
3. Some tracheostomy patients may only be able to communicate by mouthing words or by
use of a predetermined coded blink.
4. If lip-reading is used, ask the patient to exaggerate their lip movements and to speak in
short but complete sentences in order to make the message clearer.
5. Watch the patient’s facial expressions and gestures for clues and listen for key words,
which may indicate what the patient is saying.
6. If a coded eye-blink is the only means of communication available, instruct the patient to
blink once for "YES" and twice for "NO" in response to your questions.
7. Consider referral to the Speech and Language Therapy Department if individualised
boards or communication aids are felt to be appropriate to meet the patient’s needs.
8. Electronic larynx and electronic communication aids may be appropriate. The speech
and language therapist will assess the patient for the appropriate equipment and advise
the patient and their carers on how to use them.
9. Where the patient can tolerate cuff deflation it may be appropriate, in consultation with
the Multidisciplinary Team, to consider a one-way speaking valve. This is attached to
the hub of the tracheostomy tube redirecting expired air through the larynx providing the
potential to produce speech. Referrals to the Speech and Language Therapy
Department for assessment of patient's suitability for a speaking valve should be
considered. A speaking valve may have additional benefits in improving the patient's
swallowing ability or in facilitating the weaning process.
61
Appendix I
SUCTIONING CHART
All shaded areas have to be completed every time the patient is suctioned. Other areas are to be completed once per shift or if any change is made.
SURNAME:
UNIT NO
Size and make of tracheostomy: .......................................................................................
FIRST NAME:
ADDRESS:
SEX
Initially inserted on:
.......................................................................................
Due changed:
.......................................................................................
MARITAL STATUS
POST CODE:
DOB
DATE
TIME
Position
B - Back
R - Right
L - Left S - Sitting
SpO2 (if applicable)
Sputum (see below)
Saline Required
Respiratory Rate
FiO2
Humidification
C-Cold H-Heated T-Thermovent
Sputum Specimen Obtained
Cuff
I-Inflated
D-Deflated
Cuff Pressure
Dressing Changed
Stoma Site
S-Satisfactory
R-Red
I-Inflamed
Blue Dye Test Performed
Blue Dye Yielded on Suction
Initials
Sputum:
1 - Scant
2 - Moderate
3 - Profuse
M - Mucoid
P - Purulent
Comments:
62
B - Blood
Appendix II
TRANSFER SHEET FOR PATIENTS WITH A TRACHEOSTOMY TUBE
Name
Date of birth
Ward
Hospital number
REASON FOR
TRACHEOSTOMY
Pls
tick
Risk of aspiration
Secretion clearance
Maintenance of
airway
Other (please
indicate)
MAKE/TYPE OF
TUBE IN SITU
Pls
tick
YES
Standard single lumen
with cuff
Tube with inner cannula
Cuff inflated
Tracheostomy size
Cuff pressure
Mini tracheostomy
Other
NO
Speaking valve
Date of and type of tracheostomy procedure performed ......................................................................
Date of last tracheostomy change ........................................................................................................
Date of next recommended change ......................................................................................................
Oxygen percentage requirement at time of transfer .............................................................................
Condition of stoma site..........................................................................................................................
Date sutures are to be removed ..........................................................................................................
TYPE OF HUMIDIFICATION
Please
tick/describe
Cold water
Dry (thermovent)
Regular saline nebulisers
Humidity bib
Heated circuit system
SUCTION REQUIREMENTS (REVIEW DAILY)
Size of suction catheter
Frequency
Saline instillation required
Yes / No
COMMENTS
Cuff Deflation
Swallow Ability
Diet
Has cuff deflation been attempted?
Is the patient tolerating cuff deflation?
Has a blue dye swallow assessment
been carried out?
Has the patient been referred to the
Speech and Language Therapist?
Nil by mouth
Type of diet
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Stage 1 / 2 / 3 / 4
General Information
Including communication,
effect of altered body image
Upon handing over to ward staff please complete the following:
Signature
Print name
Date
Print name
Date
Receiving Nurse
Signature
63
Appendix III
TRACHEOSTOMY EMERGENCY ALGORITHM
The following algorithms have been designed to guide practitioners when dealing with
situations outside the critical care environment. Treat each situation individually. Always
stay calm and reassure the patient throughout.
This is an urgent medical emergency
Tube Occlusion/Displacement
Does the patient have any of the following that appear related to tracheostomy tube
occlusion?
1
2
3
4
5
6
7
8
Difficult or laboured breathing.
Use of accessory muscles.
None or limited expired air from tracheostomy tube.
Pale/cyanosed skin colour.
Anxiety.
Increased pulse and respiratory rate.
Clamminess.
Difficulty passing suction catheter.
Yes







No
Call for medical assistance immediately
Reposition the patient in the semi-recumbent position
Ask the patient to cough or attempt to clear secretions
Manipulate the head and neck on the tube to eliminate
kinking or to allow tube reposition.
Deflate the cuff
Administer O2 via face mask except for laryngectomy
patients
If this does not work then the tube will need to be changed
immediately.

Continue normal tracheostomy care.



Call 2000 and ask for anaesthetist
Lie patient flat
Ensure the cuff is inflated and manually ventilate the
patient using a catheter mount attached to an ambubag.
If tube occluded deflate cuff and ventilate via a face mask.
If the patient has some respiratory effort try to synchronise
manual ventilation with the patient's own breath.
Do not force O2 into the trachea as you may cause a
pneumothorax
Is there cessation of respiration?
Yes



No

No further action taken.
64
Appendix IV
“BLUE DYE” SWALLOWING TEST FOR TRACHEOSTOMISED PATIENTS
Patient must be AWAKE and reasonably ALERT. They must be in an UPRIGHT
position for assessment.
Patient’s Name: .................................... DOB: ......................... Unit/Chi No: ................
Locality: ................................................
As part of the screening process please consider the following (please circle)
Has the patient got a chest condition?
YES
NO
Has a swallow been observed?
YES
NO
Is the patient positioned correctly?
YES
NO
Can the patient follow instructions?
YES
NO
Is the patient alert enough?
YES
NO
Can the patient cough?
YES
NO
Has medical consent been given?
YES
NO
Please state ....................................
PLEASE DO NOT PROCEED WITH BLUE DYE SWALLOWING TEST OVERLEAF
IF THE PATIENT IS NOT ALERT.
Following completion of screening procedure, please complete the section below.
SUMMARY
 Passed Blue Dye screening procedure
 Failed Blue Dye screening procedure
 Referral to SLT made
Comments on any difficulty: .......................................................................................
....................................................................................................................................
....................................................................................................................................
Nurse's Name:.............................................. Signature: ...........................................
Designation: ................................................. Date: ...................................................
65

Patient must be AWAKE and reasonably ALERT. They must be in an UPRIGHT
position for assessment.
 SENIOR medical staff permission must be sought for trache cuff deflation.
 Has the patient tolerated periods of cuff deflation over last 24 hours?
If NO to any of the above - Assessment not indicated
- Re-evaluate in 24 hours if appropriate
If YES to all of the above points – the following procedure should be administered:
a)
b)
c)
Turn of NG/PEG feed
Deflate cuff (refer to Deflating/Inflating Cuff Guidelines)
Tracheal Suction
Use ½ cup of water with 23 drops blue dye in it. The following procedure should
then be administered:
Give the patient a teaspoon of blue dyed water

watch for swallow

observe for following risk signs

no swallow
YES
NO

blue dye on suctioning
YES
NO

significant decrease in O2 sat levels
YES
NO

immediate or delayed coughing
YES
NO

15 mins interval, blue dye on suctioning
YES
NO



If YES to any of
the risk signs

reinflate cuff
nil orally
discuss with medical
staff
consider SLT referral
If NO to all of these
continue with screening

Leave cuff deflated

Repeat above test with blue dye using
4 teaspoons water 3 x daily over 24 hours

Observe for following risk signs

no swallowing
YES
NO

blue dye on suctioning
YES
NO

significant decrease in O2 sat levels
YES
NO

immediate or delayed coughing
YES
NO

15 mins interval, blue dye on suctioning
YES
NO



If YES to any of
the risk signs

reinflate cuff
nil orally
discuss with medical
staff
consider SLT referral
If NO to all of these
Follow procedure for oral intake for patients who do not
present with dysphagia, as per Guidelines.
© Speech & Language Therapy Department 2005
66
Appendix V
COMMUNICATING WITH A PATIENT WITH A TRACHEOSTOMY
Communication serves to meet many patient needs including “social interaction, information
giving, reassurance, discussion of feelings, advice and counselling”.(71)
“The purpose of communication for critically ill patients is to help them maintain their identity
as well as psychological, structural, personal and social integrity.”(71)
The psychological status of the patient must be considered as they may be unable to speak
and will often be anxious in the hospital environment.
These points are intended for those patients who are unable to talk.
The patient has most of their day to day needs met however they may have questions or
concerns.
Following some of these ideas may help to structure communication
opportunities.

Keep conversations short.

Share interesting information about family and friends.

While in the patient's presence, talk to the person – not about the person.

When talking pause frequently to give the person time to try to respond, this may be
limited to eye movement or facial expression.

Can the patient indicate "yes" and "no" (for example, nodding and shaking head; one
blink for "yes" and two for "no"; thumbs up/down)? Can they use a pen and paper?
If "yes" and "no" is established, please structure your questions to allow the patient to
respond.

If using a communication aid eg alphabet board/picture board/lightwriter, you need to
know the following:

Does the patient know how to use it?

Does the patient want to complete words/sentences or are they happy for you to
predict what they say?

Are they using it appropriately?
67
Appendix VI
Grampian Dysphagia Management
Texture Classification of SOLIDS
Stage
Stage Name
1
Nil Orally
2
Pureed Diet
Description of texture






3
4
Soft Diet
Normal Diet
Food that has been pureed
A thickened, smooth, uniform consistency
A thickener eg natural (potatoes) or prescribed thickener may be
added to maintain stability of texture
Must not separate into liquid and solid components during swallow
It should be moist, not sticky
Will hold its own shape on a plate and can be moulded, layered and
piped.




Dishes consisting of soft, moist, bite-sized pieces (1cm ½ inch)
Suitable foods could be mashed with the flat edge of a fork
Sandwiches are not allowed
Avoid foods which pose a choking hazard
 Dry and crispy: muesli, crisps, battered or breaded foods, hard
confectionery
 Sticky:
white bread/rolls, peanut butter
 Stringy:
gristle, fruit skins, shells of peas, beans and
sweetcorn.


No modification of texture is necessary
Some foods may be restricted.
Note: Medication – discuss with Pharmacist
Consistency to aim for




Mousse
Smooth fromage frais
Whipped cream
Angel Delight


Mince
Moist Pasta
eg macaroni and cheese
Flaked tuna in sauce
Cauliflower cheese
Mashed banana



GUHT/GPCT – July 2001
69
Grampian Dysphagia Management
Texture Classification of LIQUIDS
Name
Normal Fluids
Description of texture



A thickener is not required
A straw falls freely through the liquid
Can be drunk or sipped from a cup and easily taken through a
drinking straw.
Thickened Fluids
Single Cream Consistency



A thickener may be required
A straw will move easily through the liquid
Can be sipped from a cup or through a drinking straw.
Thickened Fluids
Yoghurt Consistency



A thickener must be added
A straw will stand on its own in this liquid
Difficult to sip from a cup, may require a spoon.
Note: Medication – discuss with Pharmacist
Consistency to aim for




Water
Tea
Coffee
Milk


Single cream
Fortified drinks as prescribed by Dietitian

Yoghurt
GUHT/GPCT – July 2001
70
ABBREVIATION LIST
ENT
-
Ear, Nose and Throat
mmHg
-
millimeters of mercury
cmH2O -
centimetres of water
NG
-
nasogastric
SpO2
-
extend to which haemoglobin in arterial blood is saturated with oxygen when
measured with a pulse oximeter.
kPa
-
kilopascal
CSMU
-
Closed System Multiple Use
FG
-
French Gauge
NaCl
-
Sodium Chloride
ECG
-
Electrocardiogram
COPD
-
Chronic Obstructive Pulmonary Disease
FiO2
-
Fraction of inspired oxygen
PEEP
-
Positive end expiratory pressure
ICP
-
Intracranial pressure
PaO2
-
partial pressure of oxygen dissolved in plasma of arterial blood
CPAP
-
Continuous positive airway pressure
PEG
-
Percutaneous Endoscopic Gastrostomy
HME
-
Heat Moisture Exchange
IV
-
intravenous
CV
-
Cardiovascular
MDT
-
Multidisciplinary Team
71
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