Chapter 12: Respiratory care, CPR and blood transfusion
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Pre‐procedural considerations
Equipment
Caring for a patient with a tracheostomy requires the availability of various pieces of equipment, outlined in Box 12.5. These should be readily available at the patient's beside. Additional equipment required for patients with a laryngectomy is listed in Box 12.6.
Box 12.5
Essential equipment required for tracheostomy care
In an emergency
- Personal protective equipment: gloves, aprons and eye protection
- Resuscitation equipment/trolley: bag valve mask, endotracheal tubes, laryngeal mask airway (LMA), laryngoscope and blade, bougie and Cook exchange catheter
- Advanced airway equipment/trolley
- Fibreoptic scope
- Waveform capnography
At the patient's bedside
- Oxygen supply and equipment: tracheostomy mask, reservoir mask and tubing
- Suction device with a selection of fine‐bore suction catheters and Yankauer suction tips
- Bottle of sterile water
In a ‘tracheostomy box’ at the patient's bedside (and to accompany the patient on any transfers)
- Cuffed tracheostomy tube of the same size as the patient's current tube
- Cuffed tracheostomy tube at least half a size smaller
- 10 mL syringe
- Tracheal dilator (Figure 12.37)
- Suture cutter
- Scissors
- Water‐soluble lubricating gel
- Spare tracheostomy tapes
- Cuff pressure manometer (Figure 12.38)
- Catheter mount
- Inner cannula(s)
Figure 12.37 Tracheal dilator.
Figure 12.38 Cuff pressure manometer.
Box 12.6
Additional equipment required for laryngectomy
In a ‘laryngectomy box’ at the patient's bedside
- The contents kept in a ‘tracheostomy box’ (see Box 12.5)
- Spare laryngectomy tube
- Tilley's forceps (angled forceps used to remove crusts or plugs of mucus from in and around the stoma)
- Pen torch (or access to a light source)
- Micropore or Elastoplast tape for patients with a tracheo‐oesophageal puncture, to secure the catheter keeping the puncture patent
- 14 Fr red rubber catheter to be used in the event of accidental voice prosthesis dislodgement
Source: Adapted from NTSP ([206]).
Tracheostomy tubes
Tracheostomy tubes are made of silicone, plastic or metal, and therefore differ considerably in rigidity, durability and kink resistance. However, the majority of tracheostomy tubes are manufactured from plastics of varying types, some of which become softer at body temperature (e.g. polyvinyl chloride construction). Most tracheostomy tubes come in a sterile pack with an obturator to assist with insertion. The obturator should be removed as quickly as possible after insertion as it completely occludes the tracheostomy tube when in place (NTSP [206]).
The main components of a tracheostomy tube are predominantly universal. Most are dual lumen incorporating an outer tube and inner cannula, with a universal diameter of 15 mm at the upper aspect to allow connection to other equipment. Most tubes also have a neck flange to which tube ties or tapes can be attached; the ties or tapes are then fitted around the patient's neck to secure the tracheostomy.
The outer tube of a dual‐lumen tracheostomy maintains the patency of the airway, while the inner tube (which fits snugly inside the outer tube) can be removed for cleaning or changing without disturbing the stoma site. Removal of the inner cannula allows immediate relief of life‐threatening airway obstruction in the event of a blocked tracheostomy tube due to tenacious secretions. For this reason, dual‐lumen tubes are recommended as they are inherently safer (Wilkinson et al. [286]). Disposable single‐use inner tubes are available from certain manufacturers; these minimize the risk of cross‐infection as no cleaning is required.
Tubes vary in their length and shape, and are sized according to their internal diameter in millimetres. The type of tube chosen will depend on the size of the trachea and the needs of the individual patient. A selection of commonly used tube types are described below and grouped in the following categories:
- the presence or absence of a cuff
- the presence or absence of a hole or ‘fenestration’
- specialist‐function tubes.
Cuffed tracheostomy tubes
Cuffed tracheostomy tubes (Figures 12.39 and 12.40) are single‐use tracheostomy tubes that when inflated provide an airtight seal, facilitating effective ventilation and protecting the lower respiratory tract against aspiration. Some are of a ‘high‐volume, low‐pressure’ design, which distributes the pressure evenly on the tracheal wall and aims to minimize the risks of tracheal ulceration, necrosis and stenosis at the cuff site (Cipriano et al. [47]). To further reduce these risks, the cuff pressure should not exceed 25 cmH2O (NTSP [206]). The pressure should be checked at least once per shift or more regularly if there is any change in the patient's clinical condition or if there are concerns regarding the patient's airway (Wilkinson et al. [286]). The cuff is kept inflated in the immediate post‐operative phase, during mechanical ventilation, if the patient has a reduced consciousness level or if there are concerns regarding aspiration (NTSP [206]). Once the patient is awake and able to follow commands, the cuff can be deflated as part of the weaning plan. The cuff should always be deflated when a speaking valve or decannulation plug is in place (Mitchell et al. [161]).
Figure 12.39 Cuffed tracheostomy tube in situ.
Source: Reproduced with permission from the National Tracheostomy Safety Project (www.tracheostomy.org.uk).
Figure 12.40 Portex® Blue Line Ultra® tracheostomy tube shown with introducer.
Cuffed tubes with subglottic port
These are single‐use tracheostomy tubes that have an additional port for aspiration of subglottic secretions (above the cuff) (Figure 12.41). They are often used for the prevention of ventilator‐associated pneumonia in critically ill patients but are also indicated for some patients to enable effective clearance of secretions accumulating above the tracheostomy tube (Hess and Altobelli [108]).
Figure 12.41 Portex® Blue Line Ultra® Sucationaid tracheostomy tube.
Uncuffed tracheostomy tubes
Uncuffed tubes (Figure 12.42) are predominantly used for long‐term patients who are able to protect their own airway due to having an adequate cough and gag reflex (Hess and Altobelli [108]). An uncuffed tube removes the risk of tracheal damage and can be used in the weaning and decannulation process and to aid swallowing and communication with the concomitant use of a speaking valve.
Figure 12.42 Uncuffed tracheostomy tube in situ.
Source: Reproduced with permission from the National Tracheostomy Safety Project (www.tracheostomy.org.uk).
Fenestrated tracheostomy tubes
Tubes may also be fenestrated or non‐fenestrated. A fenestrated uncuffed tube (Figure 12.43) is a double‐lumen tracheostomy tube with holes or fenestrations midway down the outer tube. If a fenestrated inner tube (often a different colour to highlight the fenestration) is used, air can move through the fenestrations and past the vocal cords within the larynx (Figure 12.44), facilitating voice production (Hess and Altobelli [108]).
Figure 12.43 Portex® uncuffed fenestrated tracheostomy tubes with red inner tube to highlight that the inner tube is also fenestrated.
Figure 12.44 Fenestrated uncuffed tube in situ.
Source: Reproduced with permission from the National Tracheostomy Safety Project (www.tracheostomy.org.uk).
Fenestrated cuffed tubes
A fentestrated tube that incorporates a cuff is particularly useful for weaning as it provides the benefits of both the cuffed tube and the fenestrated uncuffed tube. These are most suited to patients who require periods of both cuff inflation (to protect the airway) and cuff deflation (to enable a speaking valve to be used).
Specialist‐function tracheostomy tubes
Longer length tracheostomy tubes
The standard design of tracheostomy tube may be unsuitable for some patients because of the short length and angulation of the tube. Extra proximal length is needed for patients with a deep‐set trachea (i.e. large neck due to obesity, goitre or neck mass). Extra distal length may be needed for patients with tracheal problems but who have normal neck anatomy (i.e. tracheomalacia or tracheal stenosis). For these types of patient, a flexible (reinforced) tracheostomy tube with an adjustable flange (Figure 12.45) can be used (Hess and Altobelli [108]). It is important that the length of the adjustable flange is documented in the patient's tracheostomy passport on insertion and after any adjustments are made. Additionally, the position of the flange should be checked and documented daily (NTSP [206]).
Figure 12.45 Portex® Uniperc® adjustable flange tracheostomy tube with Soft Seal® cuff and inner cannula.
Metal tubes
Metal tubes are not commonly used but may still be seen in older patients who have had a permanent tracheostomy (Figure 12.46).
Figure 12.46 (a) Jackson silver tube. (b) Negus silver tube.
Tracheostomy sutures
Sutures are usually applied to either side of the tracheostomy tube flange and attached to the patient's skin for at least 7 days after tracheostomy insertion (7–10 days if percutaneous) (Hess and Altobelli [108]). The sutures help to secure the tube until the stoma has formed around the tracheostomy, increasing safety and preventing accidental decannulation. As described earlier, a stay suture may also be placed when a surgical tracheostomy is formed to increase safety and allow rapid reintubation in the event of an accidental decannulation. The ends of the stay sutures are normally taped onto the patient's chest and labelled ‘DO NOT REMOVE’. The stay sutures can be removed by a suitably trained professional either after decannulation or during the first tube change (Mitchell et al. [161]).
Tracheostomy humidification
Humidification of an altered airway is essential since the natural mechanisms of humidification, warming and filtration normally provided by the upper airways are bypassed. A lack of humidification will cause drying of the airway, depressed mucociliary function and increased viscosity of mucous secretions (Tortora and Derrickson [272]). As well as being uncomfortable for the patient, it can impair secretion removal and cause infection, micro‐atelectasis (collapse of the alveoli) or tracheostomy tube occlusion (NTSP [206]). Providing adequate humidification to patients with a tracheostomy tube is therefore imperative in maintaining a safe airway and preventing acute deterioration (Wilkinson et al. [286]).
Humidification can be provided to patients using a disposable nebulizer set with sterile 0.9% sodium chloride (approximately 5 mL). It can be delivered using an aerosol‐driven nebulizer, or it can be attached to the oxygen or air supply with a flow rate high enough for the liquid to form humidification droplets. The nebulizer is administered using a specific tracheostomy mask every 2–4 hours, or more frequently in patients with more tenacious secretions (NTSP [206]). Where possible, a heated circuit should be used to provide humidification to patients who require continual oxygen therapy.
A heat and moisture exchanger (HME) such as a ‘Swedish nose’ (see Figure 12.11a) can be connected directly onto the tracheostomy tube to provide humidification. A humidification bib can also be worn by a patient with a well‐established tracheostomy. Both of these devices mimic the function of the upper airways by helping to filter and warm inspired air (Wong et al. [289]). Some devices, such as the TrachPhone and ProTrach DualCare valve, assist with both communication and humidification. The cuff should be disposed of every 24 hours, or sooner if saturated with secretions (NTSP [206]).
Tracheostomy adaptations for communication
Since the larynx is bypassed in patients with a tracheostomy, phonation is not typically possible unless some adaptations are made to the tube. This can often be one of the most difficult aspects for a patient with an altered airway, causing significant angst and frustration. Alternative methods of communication should be facilitated as soon as possible; one or more of the methods listed in Box 12.7 can be used (Bonvento et al. [28], Tang and Sinclair [267]).
Box 12.7
Methods of communication for patients with a tracheostomy
Non‐verbal methods of communication
- Lip reading
- Facial expression and gestures
- Coded eye blink or hand gestures
- Alphabet board, picture board or phrase book
- Notepad or wipeable board and pen
- Tablet or smartphone
Tracheostomy speaking valves
There are a range of speaking valves (Figures 12.47 and 12.48) available that, when placed on the end of the tracheostomy tube, will redirect air on expiration from the lungs through the larynx, facilitating voice production. If a cuffed tracheostomy is in place, the cuff must be fully deflated before a speaking valve is placed, otherwise there will no longer be a patent airway and the patient will not be able to breathe (Hess and Altobelli [108]).
Figure 12.47 Rusch speaking valve.
Figure 12.48 Passy Muir valve
Specific patient preparation
Education
Patient education is paramount to providing quality care. In the initial post‐operative or post‐procedure phase, this may be purely to aid comfort and relaxation, explaining and stressing the rationale and importance of suctioning, positioning and strengthening the patient's cough.
For patients with long‐term tracheostomy needs, early education is vital. Supporting an individual with a tracheostomy of any type requires an understanding of the impact the tracheostomy tube has on the patient's airway, communication and swallowing, and knowing how to manage potential complications. Education will be both practical (i.e. through demonstration with the patient's own tracheostomy, possibly using mirrors) and provided through the use of leaflets, posters and pictures. Practical tracheal suctioning on a specialized mannequin and examining tracheostomy tubes can also be beneficial. As with all elements of tracheostomy care, a multidisciplinary approach is advocated (Wilkinson et al. [286]). Patient education will come from various sources, including clinical nurse specialists, nursing, medical and surgical staff, SLTs, physiotherapists and community teams.
