The creation of a surgical airway in the form of a tracheostomy is a common procedure in which an incision is made into the trachea and a tube inserted (Serra, 2000) (Figure 1). Tracheostomies can be temporary or permanent, and are categorised as being either percutaneous or surgical.
It is important for nurses to be able to distinguish between tracheostomies and laryngectomies because, collectively, patients who have undergone these procedures may be referred to as ‘neck breathers’ but there are significant differences in the resultant anatomy (McGrath et al, 2012). A tracheostomy is performed to help patients breathe. A laryngectomy involves the removal of the larynx and separation of the airway from the mouth, nose and oesophagus, usually because of cancer. Patients with tracheostomies are at high risk of complications and have many complexities associated with their care. Therefore, historically, they were cared for within specialised areas such as ear, nose and throat and critical care environments.
Although the total number of tracheostomies performed in the NHS is unknown, the literature suggests it is a common procedure (Kollef et al, 1999; Brook et al, 2000; Gilony et al, 2005; Young et al, 2013). It is particularly common in critical care environments, with approximately 15 000 procedures carried out in the UK annually and approximately 24% of critically ill patients undergoing the procedure (Intensive Care Society (ICS), 2014). More than 5000 tracheostomies are performed in England in head and neck surgery yearly (National Tracheostomy Safety Project (NTSP), 2013).
With the pressure on intensive care beds and the drive to de-escalate care, patients with tracheostomies are increasingly being cared for on general wards and therefore nurses working in a range of clinical (and community) settings will be required to care for patients with tracheostomy tubes.
Rationale for insertion
Tracheostomy insertion is rarely a primary procedure and is usually a response to a patient's actual or potential deterioration in clinical condition; it is routinely performed as part of the ongoing management of critically ill patients (Cameron et al, 2009). Despite earlier studies (Arabi et al, 2004; Griffiths et al, 2005; Scales et al, 2008) the ICS (2014) recognises that early versus late tracheostomy insertion has failed to show benefits from early procedures in terms of a reduction in mortality or hospital length of stay. Indications for placing tracheostomy tubes include: for ventilation, airway obstruction, airway protection, facilitated weaning from mechanical ventilation, and removal of secretions (Morris et al, 2013; Myatt, 2015).
Types of tracheostomy
Tracheostomies can be categorised as either temporary or permanent. A temporary tracheostomy will usually be carried out as an elective procedure to facilitate long-term airway management and the patient will potentially maintain a patent upper airway. A permanent tracheostomy (or laryngectomy) will result in the patient breathing through the stoma for the rest of their life as there is no patent upper airway (Dougherty and Lister, 2015).
Surgical tracheostomies are performed under general anaesthetic and although this procedure has largely been replaced by the percutaneous method, it is still performed on patients undergoing head and neck surgery or those at risk of bleeding (NTSP, 2013; ICS, 2014). Percutaneous tracheostomy insertion is carried out at the critical care bedside under local anaesthetic, requires fewer resources and may result in less scarring than a surgical insertion. However, in the initial period following insertion, displacement of a percutaneous tracheostomy will result in the stoma closing, whereas a surgical tracheostomy stoma will remain patent (NTSP, 2013).
The tracheostomy tube will be distinguished by the presence or lack of a cuff. Cuffed tubes are predominately used within the critical care environment to facilitate mechanical ventilation when a patient is unable to protect their own airway through coughing or swallowing (National Confidential Enquiry into Patient Outcome and Death (NCEPOD), 2014). It is vital that cuff pressures are monitored and the pressure remains within the manufacturer's guidance to avoid damage to the tracheal lining. Persistent high pressures may result in tracheal stenosis (NTSP, 2013; NCEPOD, 2014).
Uncuffed tubes are used in patients who do not require invasive respiratory support and have an effective gag and cough reflex. Depending on the patient's requirements, tracheostomy tubes can be further categorised by the absence or presence of a removable inner cannula and the presence of a fenestration (hole) (Table 1).
| Tube type | Description |
|---|---|
| Cuffed | These have a soft balloon around the distal end of the tube to seal the airway and allow positive pressure ventilation |
| Uncuffed/mini-tracheostomy | Used in patients who require a tube in the longer term and who need secretions clearing frequently. |
| Fenestrated tube | These have openings on the outer curvature and may be used to facilitate weaning |
Source: Russell, 2005
Nursing care and complications
Tracheostomy insertion allows for a reduction in the use of sedation and patients to be discharged from critical care to general wards. Once discharged from critical care environments, the usual progression is from reliance on the tracheostomy as an airway to mouth breathing and subsequent decannulation (removal). Throughout this trajectory, proficiency in nursing care and interventions is essential to ensure adequate ventilation, oxygenation and communication. Without this specialist level of care, patients are at risk of life-threatening complications. Despite this, research continues to demonstrate that anxiety and a lack of competence among nurses caring for these patients is evident (Day et al, 2002; Freeman, 2011).
Complications can arise following tracheostomy insertion immediately, in the short term or long term. Life-threatening immediate and short-term complications include:
Long-term issues include:
Without prompt interventions, any of these problems can lead to death, with 50% of airway-related deaths being associated with tube displacement (McGrath et al, 2012). The NTSP (2013) refers to these events as red flags and emergencies that require rapid assessment utilising an ABCDE approach. NCEPOD (2014) identified that practitioners caring for patients with tracheostomies should possess the appropriate expertise gained through mandatory training and their trust's evidence-based guidelines.
Providing appropriate suctioning, humidification of inspired oxygen, maintaining a patent inner tube, monitoring cuff pressures and securing of the tracheostomy tube can assist in prevention of immediate and short-term complications associated with tracheostomies. The ‘TRACHE’ care bundle developed by Great Ormond Street Hospital for Children (GOSH) (2019) identified six main areas of concern when caring for a person with a tracheostomy (Table 2).
| TRACHE acronym for the six areas of concern in tracheostomy care |
|---|
| Tapes: keep the tracheostomy tube secure |
| Resus/emergency care: know the resuscitation procedure |
| Airway clear: use the correct suction technique |
| Care of the stoma and neck |
| Humidity: essential to keep tube clear |
| Emergency equipment |
Tracheal suction is essential for the removal of secretions from the respiratory tract. Indications for the need for suctioning include audible secretions; reduced oxygen saturation (SaO2), reduced breath sounds, deterioration in arterial blood gases and evidence of cyanosis (Mallett et al, 2013). This procedure does carry risks of bleeding, hypoxia and hypoxaemia and bronchoconstriction (Pederson et al, 2009), therefore correct techniques, understanding of related anatomy, the appropriate suction pressure and choice of catheter size are essential.
The selection of suction catheter size will depend on the internal diameter of the tracheostomy; the recommendation is that the catheter should be no larger than half the internal diameter of the tracheostomy (NTSP, 2013). Suction pressures can range from as little as -80 mmHg up to -300 mmHg, although a maximum pressure of -150 mmHg is suitable for most patients with a time duration of no longer than 15 seconds (NTSP, 2013: 52; Credland, 2016). Historically, and possibly ritualistically, normal saline installation prior to suctioning has been used to facilitate the removal of secretions, but Wang et al (2017) found that this can significantly lower SaO2 levels 5 minutes after suctioning.
Humidification of inspired air is vital because ‘neck breathing’ bypasses the normal route of inhalation where air is warmed, moistened and filtered via the upper airways. McGrath et al (2012), Mallett et al (2013) and the NTSP (2013) have identified that artificial humidification is mandatory when a tracheostomy is in situ. The type of humidification system used will depend on patient requirements.
The main rationale for cleaning the inner cannula is the prevention of blockages through the mechanical removal of debris. Although the NTSP (2013) states that the inner cannula should be removed and cleaned at least once per 8-hour shift period, to prevent obstruction of the lumen with secretions, findings from NCEPOD (2014) were that 4-hourly cleaning was preferred. However, if thick, viscous or copious secretions are present, more frequent cleaning may be required.
A replacement inner cannula should be available at the bedside in case of blockage and immediate replacement is required (ICS, 2014). Patient positioning should be considered when cleaning inner cannulas, an upright position with the neck slightly extended can facilitate an easier removal of the inner cannula. The ICS (2014) recommends using an aseptic technique for this procedure. Remove and clean soiled non-disposable cannulas with 0.9% sterile saline or water. Soaking the inner cannulas is not recommended because this increases the risk of exposure to pathogens.
Monitoring of the distal cuff pressure using a handheld cuff pressure manometer should take place at the beginning of each shift, or following any procedure where movement of the tube may have taken place, eg dressing/tape change, patient repositioning, if there is an audible leak, or following any changes in the volume of the cuff. Overinflation of the cuff may result in tissue damage, necrosis and tracheoesophageal fistulas because tracheal mucosal blood supply is occluded at a tracheostomy cuff pressure of 30-32 mmHg (Mallett et al, 2013). A maximum pressure of 25 mmHg is considered as a safe upper limit with a range of 20-25 mmHg being recommended (Lorente et al, 2007).
The displacement of a tracheostomy tube can cause a life-threatening situation, therefore appropriate securing of the tube is essential (McGrath et al, 2012; NTSP, 2013; ICS, 2014). Changing the stoma dressing and tracheostomy tapes must involve two people to prevent accidental tube displacement (Freeman, 2011) and should be carried out using an aseptic technique at least once in a 24-hour period (ICS, 2014).
To prevent complications of skin damage and reduced cerebral blood flow it should be possible to place one or two fingers between the neck and the tapes (Mallett et al, 2013). During this time assessment of the stoma can take place, noting any signs of infection or wound breakdown, and cleaning the stoma with 0.9% sterile saline and replacing soiled dressings (NTSP, 2013; ICS, 2014).
NCEPOD (2014) recommends that all NHS trusts have an up-to-date protocol to manage patients with tracheostomies and the NTSP (2013) recommends that essential information is displayed at the patient's bedside, to alert all health professionals to the presence of a tracheostomy, and that emergency algorithms should be displayed, along with readily available emergency equipment. In addition to organisational guidance, nurses must possess the appropriate knowledge and skills to maintain patient safety and to determine adequate respiratory function.
Because nurses are the main caregivers and frequently first responders (Freeman, 2011; McGrath et al, 2012) an adequate understanding of the anatomy and physiology of the respiratory system and upper airways is essential to be able to competently assess patients' needs and respond to emergency airway situations (Taylor et al, 2015).
Conclusion
Placement of a tracheostomy tube is a common procedure and can facilitate timely weaning from mechanical ventilation. Consistent standardised care delivery is essential to maintain patient safety and prevent complications.
Using the TRACHE (GOSH, 2019) acronym can assist nurses in ensuring safe and effective care through cleaning of the inner cannula, securing the tracheostomy tubes, suctioning and humidification to facilitate the removal of secretions and early recognition of deterioration.