ICID > Clinical Management > ENT > Removing and changing a tracheostomy tube  
 

Removing and changing a tracheostomy tube 

  •  
  • 1. Indications
  • 2. Clinical Management
  • 3. Patient Information
  • 4. Audit
  • 5. Evidence Base
  • 6. Appendices
  • 1. Indications

    1.1 Background

    1.1.1 Tracheostomies should be routinely changed:

    • Whenever the high pressure or low volume alarm on the ventilator is not corrected by any other means.
    • If difficult or blocked access for suctioning is not remedied by changing inner cannula (if present), or other means.
    • On tube displacement or inadvertent removal of the tube.
    • To change the type of tracheostomy tube (i.e. from cuffed to uncuffed)
    • In accordance with manufacturer guidelines, tracheostomy tubes should be changed every 28 days unless clinical condition dictates wotherwise.

    1.1.2  Decannulation, refers to the permanent removal of the tracheostomy tube. The patient is ready for decannulation when the reason for tracheostomy tube insertion has resolved and when the patient is able to maintain a patent airway and adequately clear secretions without suction.

    1.2 Aim/purpose

    • To provide guidance for staff changing patient's tracheostomy tubes
    • To ensure understanding of the decannulation process

    1.3 Patient/client group

    All patients with tracheostomy tubes

    1.4 Options

    Staff on the spinal unit should refer to theSpinal Unit Decannulation protocol(appendix one) for steps required in the permanent removal of tracheostomy tubes.


    2. Clinical Management

    2.1 Staff & equipment

    2.1.1  Staff

    Two people should be present for routine tracheostomy changes. One person to perform the aseptic part of the procedure, and the other for general assistance and suctioning etc.[5]  The primary person should be an anaesthetist, member of ENT medical staff or registered nurse or physiotherapist with appropriate experience and training.

    A doctor should be present for all initial changes and for any with potential problems or a history of difficulties.

    The second person may be qualified, unqualified, a carer or the patient themselves, if able.

    2.1.2  Equipment

    All equipment for tracheostomy dressing as per protocol plus[2], [7], [10]:

    Correct size tracheostomy set   Suction equipment with correct size catheters for tracheostomy
    2nd tracheostomy set 1 or ½ size smaller Manometer for measuring cuff pressure
    Tracheal dilators Saturation monitor if an initial change or patient receiving O2
    Sachet or new tube of lubricating gel Ambubag and connector for tracheostomy AND mask
    2 x 10ml syringes (if tracheostomy is cuffed) For spinal injured patients - Atropine IM / IV 600mg/ml standing by if initial changes or patient prone to bradycardic episodes

    2.2 Method/procedure

    2.2.1 Changing the tube

    Action

    Rationale

    1.  Arrange with medical staff time change to take place if first change, or there are any other known possible complications.

    To ensure that an experienced Dr is available should there be a problem. [5], [1].

    2.  Explain procedure to the patient.[5], [11]

    To allay anxiety and obtain verbal consent.

    3.  Prepare equipment, wash hands according to policy and put on apron. (Both people involved). [5], [6]

    To ensure that all equipment that might be needed is to hand.

    Reduce the risk of cross infection.

    4.  Position the patient in slight neck extension if not contraindicated by their injuries. [1], [5], [10], [11]

    Enables easier removal and insertion of the tracheostomy tube.

    5.  Check all the components of the new tracheostomy tube fit well and function properly (cuff inflation / deflation and obturator /introducer). Lubricate the tracheostomy tube sparingly with the lubricating gel.[5], [8], [11]

    Ensures new tube functions correctly.

    Lubricating gel minimises trauma during the procedure.

    6.  Ask the patient to cough or perform an assisted cough and / or suction if required.

    Removes excess secretions, which may cause obstruction of the stoma. [7]

    7.  Pre-oxygenate if the patient is oxygen dependent. [5]

    Reduce risk of hypoxia.

    8.  Wearing gloves, assistant removes dressing and loosens tapes, then holds tracheostomy in situ while the area is cleaned with warmed saline, using an aseptic technique. [5], [8]

    To minimise contamination of the new tube.

    To prevent tube being inadvertently removed or dislodged.

    9.  Deflate cuff using the syringe.

    To release the seal inside the trachea.

    10.  Assistant to disconnect the patient from the ventilator (if present).

    (This is not applicable for self ventilating patients.)

    11.  The assistant to remove the old tracheostomy tube ensuring that they pull along the curve of the tube[10], [11] This should be done on exhalation, [8] and if they are able the patient should be asked to take a deep breathe just prior to the tube being removed [1]

    To minimise trauma and discomfort to the patient and maximise ease of removal.

    To facilitate coughing out any secretions /debris and so avoid aspiration.

    12.  The new tube is inserted immediately using an aseptic technique preferably when the patient is exhaling, following the line of the curve of the tube. [5], [8], [11]

    Speed is essential as the patient may have no means of ventilation until the tube is sited; this can lead to hypoxia.

    13.  Remove the obturator. (The assistant holds the tube in place until the tapes are fastened).[5], [8]

    No ventilation through the tracheostomy is possible until the cannula is opened.

    14.  Replace the ventilator tubing immediately.

    The patient may not be able to breathe until their ventilator is reconnected which may cause hypoxia if delayed.

    15.  Reinflate cuff as per protocol.

    The cuff provides the seal which prevents any air leak and thereby ensures adequate ventilation. Excessive cuff pressures can cause tracheal necrosis. [4], [9]

    16.  Observe the patient to ensure they are able to ventilate through their new tracheostomy: auscultation, oxygen saturations, ventilator readings, etc.

    Indicates effective functioning of the tracheostomy.

    Alerts the clinician if there is a problem.

    17.  Ask the patient to cough or perform assisted cough and / or suction if required, with the assistant continuing to hold the tracheostomy in situ.

    The procedure may irritate the airways; this produces secretions and / or blood which may enter the airway and affect gaseous exchange.

    18.  Replace new tapes and fasten them firmly, [12] to minimise any movement of the tracheostomy in the stoma. [5]

    The tracheostomy can cause erosion of the tissues if the tapes are not fastened correctly.

    19.  Re-clean the area if necessary using an aseptic technique. [5]

    To prevent contamination of the dressing.

    20.  Apply keyhole dressing. [5]

    The dressing acts as a barrier to small foreign bodies penetrating the stoma.

    Protects the skin.

    21.  Replace spare tubes on patients locker in correct sizes.

    To ensure spare tubes always at hand in patients size and ½ size smaller.

    22.  Record the change in the patient's care plan and medical notes and the date for the next change.

    To ensure the information is available to all staff.

     

    2.2.2  Decannulation

    This process is explained to increase understanding but will be planned according to individual patient need by appropriate ITU or ENT medical staff or the Patient at Risk Team. The Head Injury Co-ordinator may be involved for head injury patients. On the spinal unit staff should follow the Spinal Unit Decannulation protocol (appendix one).

    Action

    Rational

    1.  The first step employed may be the insertion of a fenestrated tube or cuffless fenestrated tube.

    With the cuff deflated, this tube allows the patient to breathe through and around the tube, using both the tube and the upper airway for ventilation.

    2.  If a cuffed tube is in place, the cuff must be deflated to allow air movement around the tube to the upper airway. An appropriate member of staff will hold their finger over the tube.

    To ensure adequate air circulation around the tube, if there is not, it will be changed for a smaller size.

    3.  The tracheostomy tube will then be capped with a red decannulation plug for at least 24 hours.

    A plug stops air movement through the tracheostomy tube opening.

    4.  The patient must be suctioned prior to applying the plug.

    To ensure the airway is clear.

    5.  Any patient whose tube is capped must be observed closely for signs of respiratory distress

    Any respiratory distress requires immediate removal of the decannulation plug.

    6.  When the tube is removed, a hydrocolloid dressing (e.g. comfeel) is placed over the stoma. The wound should close completely in a matter of days.

    This will promote healing and allow communication without damaging the skin.

     

    2.3  Potential complications2.3.1  Inability to insert the new tracheostomy tube

    Cause
    The muscles of the neck may spasm causing the stoma to close or if the stoma is immature it may not remain patent when the original tube is removed.

    Action

    • Use the sterile tracheal dilators to dilate the stoma enough to insert the smaller size tracheostomy tube. 5
    • If this fails, administer oxygen [5] via the stoma or face mask;
    • If the patient is ventilator dependent and therefore unable to breathe unaided, ventilate manually with the ambubag and either mask to face, occluding stoma, or paediatric mask to stoma, if a laryngectomy patient.

    2.3.2  Excessive bleeding

    Cause
    The site of a tracheostomy is close to the path of several blood vessels. Although rare, bleeding can occur following a tracheostomy change.

    Action

    • If there is excessive bleeding following the procedure, inflate the tracheostomy cuff [4] and tip the patient's bed head down.
    • Suction may also be useful to prevent a large amount of blood entering the lungs.

    IF THE PATIENT IS BLEEDING EXCESSIVELY, OR NOT BREATHING

    CRASH CALL 2222 (or 999 in the community)


    3. Patient Information


    4. Audit

    4.1 Standards

    Aspect of care

    %

    Exception

    Definition

    1.  All staff involved in the care of patients with a tracheostomy will be aware of this policy.

    100

    None

    Knowledge Audit – see main document

    2.  All staff carrying out tracheostomy tube changes will be trained in the correct procedures

    100

    None

    Tracheostomy pathway (see main document) and ward training record

    3.  All patients will have there first tracheostomy tube change within seven days of insertion

    100

    None

    Tracheostomy pathway (see main document)

    4.  All subsequent tracheostomy tubes will be changed within four weeks of insertion.

    100

    None

    Tracheostomy pathway (see main document)

    5.  Two people will always be present when changing tracheostomy tubes

    100

    None

    This can include the patient or carer

    Knowledge Audit – see main document

     

    4.2 Audit tool

     

    4.3 Patient survey

    4.4 Risk management

    4.4.1  All variances in care will be noted on the tracheostomy integrated care pathway

    4.4.2  All clinical incidents related to the changing of tracheostomy tubes should be reported according to trust policy

    5. Evidence Base

    5.1 Sources of evidence

    1. Kerr A, Groves J, & Stell P, editors. Scott-Brown's otolaryngology 5 - laryngology. 5th Ed. London: Butterworths. 1987.
    2. De Carle B. Tracheostomy care. Nursing Times. 1985; 81(6) 50-54.
    3. EEC Directive. Class IIA-Rule 7. Council directive concerning medical devices. 93/42 EEC. 1993.
    4. Foss M. Thoracic surgery. London: Austen Cornish Publishers Ltd. 1989.
    5. Gibbs. Care of patients with tracheostomy tubes. St George's Healthcare N.H.S Trust. In ssociation with Sims Portex. 1997.
    6. Gill J, Slater J. Building barriers against infection. Nursing Times. 1991; 87(50) 53-54.
    7. Hooper M. Nursing care of the patient with a tracheostomy. Nursing Standard. 1996: 10(34) 40-43.
    8. Dougherty L. Mallett J . The Royal Marsden manual of clinical nursing procedures. 5th Ed. Oxford: Blackwell Scientific Publications. 2001
    9. Paparella M, Shumrick D. Otolaryngology. Volume III Head and Neck. 2nd Ed. London: W.B. Saunders Company. 1980
    10. Tayal S. Tracheostomies. Emergency Medicine Clinics of North America. 1994; 12(3) 707-727.
    11. Zejdlik CP. Management of spinal cord injury. 2nd Ed. Boston: Jones & Bartlett. 1992

     


    6. Appendices

    Appendix 1 -

    Spinal Unit Decannulation Protocol



    Document Owner Gill Payne 
    Department
    Review Date
    Document Status
    Revision Number
    1.3