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Laryngectomy and Tracheostomy In

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					Laryngectomy and Tracheostomy Information

For Community Nurses

Acknowledgement: Thanks to T Feber Cookridge Hospital, Leeds

Authors: ELMC/MR Version 1 Page 1 of 38 Implementation Date: September 2006 Review Date: September 2008

Contents

Page Introduction Emergency flow chart Temporary Tracheostomy Caring for the patient with a temporary Tracheostomy Types of tracheostomy tube Cleaning a tracheostomy tube Changing a tube Safe Suctioning Tracheostomy Tube sizes Troubleshooting Nasal function and the mucociliary escalator Humidification & filtration Communication Stoma care Laryngectomy Product and Ordering information Contact Numbers References Standard Care Plans 14 20 22 23 24 25 26 27 32 35 36 37 3 4 5 6 6 10 11

Introduction
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This resource file is intended to give practical information on the management of the person with a tracheostomy. It is not exhaustive and further specialist advice and information should be sought if you are unsure about any aspects of care.

This information covers both tracheostomy and laryngectomy. It is important to understand that the two are very different. Tracheostomy is the insertion of a tube through the neck tissues, into the trachea, leaving the whole of the voice box intact, maintaining the connection of the lungs to the mouth and throat. Laryngectomy is the complete removal of the voice box, with the remaining end of the trachea then being sewn into an opening in the neck (an end tracheostomy). This means that the lungs have been disconnected from the mouth and nose, and are now only connected to the stoma in the patient’s neck. (Please see figure 1 below).

Figure 1 Tracheostomy Patient Laryngectomy Patient

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Neck Breather (Laryngectomy) Emergency flow chart

Difficulty breathing Cyanosis Agitation Decreased O2 Hyperventilation

 



CHECK Is O2 on? Is suctioning required? Is speaking valve on? If yes, remove speaking valve immediately.

Able to pass suction catheter?

N0 Is there an inner tube? YES Remove and unblock

YES

Improving?

NO Improving? NO NO

YES

YES
Monitor need for further intervention

EMERGENCY Ring 999
Monitor need for further intervention

If required, contact FPH F12A for advice. 01276 524130

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Temporary Tracheostomy

A temporary tracheostomy is performed for the following reasons      after trauma or surgery to the head and neck which causes obstruction of the airway to bypass a neoplasm which obstructs the upper airway for prolonged ventilation for some types of chronic lung disease For other airway problems, e.g. sleep apnoea

If a tracheostomy is temporary, the patient may still be able to use their voice box and mouth for speech. Once the obstruction/problem is resolved the tracheostomy tube can be removed and the stoma allowed to heal (decannulation). For some patients however, this is never possible.

The diagram below shows a temporary tracheostomy tube.

the upper airway is still intact.

Voicebox (larynx) Cuff

Oesophagus

Trachea

Figure 2

Picture courtesy of Portex

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Caring for the Patient with a Temporary Tracheostomy.

Maintain a patent airway

A study in 1980 by El Kilany (cited in Feber T, 2000) showed that obstruction of the tube was the third most common cause of death in patients with tracheostomies.  Check patient can breathe freely and easily - use your hand to feel a good flow of air as the patient breathes out.  Wherever possible use a tube which has an inner tube (e.g. Shiley or Negus silver tube) - the inner tube can be removed and cleaned as often as necessary with the outer tube being left in situ for several days/weeks, thus minimising the risk of trauma to the stoma and trachea (Feber 2000). The outer tube should be changed once per month or more frequently if required. o If, in exceptional circumstances, an inner tube system cannot be used, constant humidification is essential to prevent crusts occluding the tube. Tubes must also be changed as frequently as necessary. This varies from more than once per day to only once in several days and the patient must be carefully assessed and monitored on an individual basis.

Common types of tracheostomy tubes

The majority of patients transferred to the community with a tracheostomy will have either: 1) Shiley Tracheostomy Tube 2) Silver Negus Tube 3) Portex uncuffed tube

1. Shiley Tracheostomy Tube (disposable)
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This consists of a plastic tracheostomy tube consisting of an outer tube, introducer and two inner tubes. The Shiley tube may be: Plain Cuffed Plain (fenestrated) Cuffed (fenestrated) The fenestrated tubes have a hole (fenestration) in the middle of the outer tube. This enables the passage of air and secretions into the oral and nasal passages. This type of tube is useful when encouraging a return to normal function for the patient who has had a long-term temporary tracheostomy. Shiley Plain Tracheostomy Tube (Figure 3a) This is a plastic tube with an introducer and two inner tubes one of which has an extension on its upper aspect to facilitate connection to other equipment e.g. nebulisers and speaking valves. It is used for:    keeping the tract patent if the patient requires further surgery for radiotherapy in place of a metal tube in place of regular length tubes for patients who have had laryngectomy operations

Shiley Cuffed Tracheostomy Tube (Figure 3b) This is a plastic tube with an introducer and two inner tubes. The outer tube has an inflatable cuff to give an airtight seal. Shiley Plain Fenestrated Tube (Figure 3c) This is a plastic tube with an introducer and two inner tubes. The outer tube has a fenestration in the middle of the cannula. This is to encourage the passage of air and secretions into the oral and nasal passages. It is used to encourage a return to normal function following long-term use of a temporary tracheostomy. Shiley Cuffed Fenestrated Tube (Figure 3d)
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This is a plastic tube with an introducer and two inner tubes. The outer tube has a fenestration in the middle of the cannula again to encourage a return to normal function. The outer tube also has an inflatable cuff, to give an airtight seal; this prevents secretions from reaching the lungs. The tube is useful for patients with swallowing problems but who are starting to return to normal function.

Figure 3

2. Silver Negus Tube (not disposable) (figure 4)

A silver tracheostomy tube that consists of a tube, an introducer and a choice of inner tubes with and without speaking valves. The outer tube of a silver Negus tube does not have a catch to secure the inner tube, consequently the inner tube may be coughed out inadvertently. The parts of a Silver Negus tube consist of: i. Introducer - assists with initial introduction of outer cannula to prevent damage to the tracheal wall. ii. iii. Outer Cannula - this is secured firmly to the neck with tapes. Inner Cannula (for suctioning) - sits inside the outer cannula and may easily be removed for cleaning purposes (leaving the outer cannula insitu.) It is used when suctioning tracheal secretions.
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iv.

Inner Cannula (for speech, with flap) - again this sits inside the outer cannula. Air is forced up through the larynx, which then closes the delicate valve mechanism. This then allows air to pass up through the trachea, into the larynx and through the vocal cords, therefore enabling the patient to speak. It is important that suctioning is not undertaken when the speaking valve is in situ, because this may:  

push the valve into the trachea. damage the valve, thus preventing the flap opening or closing properly. This will affect the 02 concentration by either diluting the 02, or preventing 02 inspiration.

The silver negus tube is used when it is considered that there is no danger of aspiration and when the patient no longer requires artificial ventilation, but access may be required for suctioning, or to maintain stoma patency, because further ventilation may be required e.g. return to theatre, post operative ventilation.

Another type of silver tracheostomy tube is a Jackson tube (figure a). This is a silver tube with an introducer and an inner tube. The inner tube is locked in position by a small catch on the outer tube and may be removed and cleaned as necessary without disturbing the outer tube.

Figure 4

3. Portex Cuffed Tracheostomy Tube (Disposable)
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It is highly unlikely that you will see this type of tube in the community. However, please contact either Emma Cowdrill or Margaret Rotherham (contact details on page 38) should you require any information on this type of tube.

Cleaning a tracheostomy tube

Plastic tubes

Senna (2000) recommends placing the plastic tube under running tap water and then leaving it to soak if required in a weak solution of sodium bicarbonate for 2 hours, shaking off excess moisture and allowing to air dry. There are also sponge swabs available from Kapitex for cleaning plastic tubes (again see page 35). The use of a brush to clean or remove encrustations is not advisable on plastic tubes because it may damage the tube (Barnett 2005.)  Inner tubes should be cleaned in hot soapy water and allowed to air dry - soaking tubes in disinfectants is bad practice because:

a) Organic matter (e.g. mucous) neutralises the disinfectant b) All disinfectants will grow bacteria after a short period of time (20 mins) c) The plastic absorbs the disinfectant and may then cause mucosal irritation (Maurer I, 1985, cited in Feber 2000).

Silver tubes Tracheostomy cleaning brushes are available on prescription for cleaning Silver tubes (details on page 35). The 8mm size is probably the best to choose. Tubes should be cleaned thoroughly in hot soapy water then left to air dry in a clean place. They can then be stored in a dry container (e.g. Tupperware). Silver tubes go black over time and can be cleaned with silver cleaner. It is vital that the tube is washed thoroughly afterwards to remove all traces of silver cleaner.
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Changing a Tube

This is a simple procedure - the old tube is removed and replaced with a new tube - but many people are very anxious about it. Patients often believe they will not be able to breathe whilst the tube is out and many nurses believe the stoma will close as soon as the tube is removed. Feber (2000) states that in reality, the stoma will not close, and the patient will continue to breathe freely whilst the tube is out. Care must be taken to explain the procedure to the patient to alleviate any anxiety.

It is good practice to have 2 nurses present, one to remove the old tube and one to insert the new one.

Equipment required 1. new tube of appropriate size 2. dressing pack 3. 0.9% Sodium chloride to clean 4. Trachi-hold tracheostomy holders (these are on prescription) 5. lubricating gel 6. tracheostomy dressing 7. barrier cream 8. scissors 9. forceps 10. head lamp 11. smaller size Portex tube – for emergency use only, if unable to put present tube back in (Woodrow 2002). 12. Gloves, apron & eye protection (Barnett 2003)

Procedure
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Action 1 Explain and discuss the procedure with the patient. 2 Wash hands using bactericidal soap and water or bactericidal alcohol hand rub. 3 Perform the procedure using clean technique. 4 Assist the patient to sit in an upright position, supported by pillows with the neck extended. 5 Remove the dressing pack from its outer wrappings and open the tracheostomy dressing. 6 Put on a disposable plastic apron. 7 Clean hands with bactericidal alcohol hand rub. 8 Put on clean disposable plastic gloves. 9 Prepare the tracheostomy tube as outlined in steps 11–14. 10 Secure trachi-hold ties to both flanges.

Rationale To ensure that the patient understands the procedure and gives his/her valid consent. To prevent contamination.

To prevent contamination. To ensure the patient's comfort and to maintain a patent airway. If the neck is not extended, skin folds may occlude the tracheostomy when the tube is removed. Technique should be clean to reduce the risk of cross-infection.

To prevent infection. To prevent infection. So that the tube is ready for immediate insertion when required. The ties are kept behind the flange to prevent it occluding the passage of air into the tracheostomy tube. Trach-hold ties are made of Velcro and are more comfortable to wear and easy to adjust. To prevent abrasion of the patient's skin by the tube. To facilitate insertion. Too much gel will irritate the trachea.

11 Put the tracheostomy dressing around the tube. 12 Lubricate the tube sparingly with a lubricating jelly.

Conscious expiration relaxes the patient and 13 Remove the soiled tube from the patient's neck while asking the patient to reduces the risk of coughing. Coughing can result in unwanted closure of the tracheostomy. breathe out. 14 Clean around the stoma with 0.9% sodium chloride and dry gently. Apply barrier cream with topical swabs. (An aqueous cream may be used if the patient is having the site irradiated.)
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To remove superficial organisms and crusts. Skin around the stoma is at risk of breakdown due to the constant presence of moisture in this area (Allan 1987). Meticulous skin care is therefore essential in order to prevent infection.

15 Insert a clean tube with introducer in Introduction of the tube is less traumatic if place, using an ‘up and over’ action. Ask directed along the contour of the trachea. patient to take a deep breath just before insertion. 16 Remove the introducer immediately. 17 Place the inner tube in position. The patient cannot breathe while the introducer is in place. The inner tube can be changed as necessary when the outer tube is in position, thus minimizing the risk of trauma to trachea and stoma. The quantity of secretions present will determine the frequency with which the inner tube is changed. To secure the tube. Leave enough slack to be able to insert a finger inside on either side of neck. Trim excess length off. Flow of air will be felt if the tube is in the correct position.

18 Fasten trachi-hold tapes.

19 Remove gloves and ask the patient to breathe out onto the palm of your hand. 20 Ensure that the patient is comfortable. 21 Clear away the equipment.

22 Clean the soiled tube as per cleaning To remove debris that may occlude the tube and/or become a source of infection. guidelines on page 11 .

Teaching It is vital that the patient and/or carer know how to change the inner tubes and outer tube before discharge and an appropriate teaching programme should have been put in place. Patients should also be discharged with the appropriate tracheostomy pack and contact details.

Refreshers If you feel you need your skills updating please contact either the head & neck specialist nurse at Frimley Park Hospital or District Nurse Margaret Rotherham via the numbers at the end of this document. Safe Suctioning

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It is rare for a patient to require suctioning at home. Anyone with a half decent cough can cough up their secretions and should be strongly encouraged to do so. Long term suctioning can be highly detrimental.

Patients should be encouraged to drink plenty of water, as this will reduce the viscosity of secretions.

Indications for suctioning  No cough reflex  Depressed cough reflex  Inadequate cough

Complications  Mucosal damage  Hypoxia  Pulmonary collapse  Pulmonary perforation The Don’ts  Do not perform suction routinely - only when indicated (Feber 2000, Day et al 2002)  Do no instil saline prior to suction (Ackerman 1993) t  Do not apply suction for more than 15 seconds The Do’s Inform patient and elicit their co-operation – Day et al 2002 – to relieve distress & anxiety and maximise effectiveness of suctioning.

 Insert an withdraw catheter gently (Smith 1993) d  Use a low suction pressure - 120mmHg
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 Use an aero flow tip catheter - see chart for size  Use a vacuum breaker - do not fold and release catheter as this applies a rapid vacuum and can be dangerous

A physiotherapist should always be involved in the care of a patient who requires suction therapy.

Tracheostomy Suctioning Tracheostomy suctioning is performed to maintain a clear airway and optimize respiratory functions. Suctioning via a tracheostomy is performed when patients are unable to clear their own secretions. Most patients should however, may be able to clear their secretions into the tracheostomy tube by means of expectorating, thus reducing the need for suctioning.

Suction catheters Suction catheters are now made from polyvinyl chloride and do not require any lubrication. Multihole catheters are often preferred over single-hole catheters as these dissipate the focus of suction pressure, making it less likely for the mucosa to be sucked into the catheter. Furthermore, multihole catheters produce a cushion of air at the tip, thus preventing the catheter coming into contact with the tracheal mucosa (Griggs 1998). Choosing the correct suction catheter size depends on the size of the tracheostomy tube. As a guide, the diameter of the suction catheter should be half of the tracheostomy tube size (Griggs 1998; Hough 2001). NB In a study by Griggs 1998, patients said that suctioning caused sensations of pain, choking, coughing and pressure. Some of this group commented that they did not have these sensations ''if nurses were gentle''.

Suction Catheter Sizing

Trache tube internal diameter (on the
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Recommended suction catheter size

box and the flange) 4.0 - 5.0 5.5 - 6.0 6.5 - 7.0 7.5 - 8.0 8.5 - 9.0 5 Ch 8 Ch 10 Ch 12 Ch 14 Ch

Procedure Action 1 Explain procedure to patient Rationale Suctioning has been identified as a frightening and unpleasant experience for patients, leading to anxiety. Therefore, reassurance and explanation should always be given before and after suctioning. To obtain the patient's co-operation and to help him or her relax. Reassurance is vital. Self-control of the patient's suction is preferable if the patient is able to manage it. Suctioning may not be as effective if the secretions become too tenacious or dry. A 0.9% sterile sodium chloride nebuliser will assist in loosening dry and thick secretions (Hough 2001). To minimize the risk of cross-infection and protect against contact with body substances. Some patients may accidentally cough directly ahead at the nurse; standing to one side with tissues at the patient's tracheostomy minimizes this risk. Recommended suction pressure is 60–150 mmHg or 8–20 kPa for adults (Pryor & Prasad 2001). Sputum, which is more tenacious, requires more powerful suction, the maximum level being 200 mmHg. If pressures up to and
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2

Suctioning should be taught if the patient is able to perform his/her own suction. Otherwise inform the patient what is to be done. Patients should use a 0.9% sterile sodium chloride nebuliser 2 hourly or more frequently as prescribed, if secretions are tenacious. Wash hands with bactericidal soap and water or bactericidal alcohol hand rub, and put on a disposable plastic apron, and eye protection.

3

4

5

Check that the suction machine is set to the appropriate level.

Action

Rationale above 200 mmHg are used, then vacuuminterrupted suctioning techniques are recommended to prevent pressure build-up should the catheter become occluded (Young 1984). The use of excessive high pressure may result in mucosal trauma of the main bronchi.

6

Select the correct size catheter. As a guide, the diameter of the suction catheter should be half the tracheostomy tube size (Griggs 1998; Hough 2001).

The size of suction catheter is dependent on tenacity and volume of secretions, that is, the thicker the secretions and the larger the volume, the greater the bore of the tube (Hough 2001). This ensures that hypoxia does not occur while suctioning. To reduce the risk of transferring infection from hands to the catheter and to keep the catheter as clean as possible.

7

Open the end of the suction catheter pack and use the pack to attach the catheter to the suction tubing. Keep the rest of the catheter in the sterile packet.

8

For new surgically formed tracheostomy Gloves minimize the risk of infection transfer and laryngectomy stomas, use an to the catheter or from the sputum to the individually packaged, sterile, disposable nurse's hands. glove on the hand manipulating the catheter (Ward et al. 1997). (A clean disposable glove can be used on the other hand.) Clean, disposable gloves can be used for established stomas. Put clean glove on dominant hand without touching its outer surface. Withdraw the catheter from the sleeve. With the dominant hand, hold the catheter, ensuring the glove only touches the catheter and nothing else. Insert the catheter gently to about one-third of its length without applying suction. Gentleness is essential; damage to the tracheal mucosa can lead to trauma and respiratory infection. The catheter should go no further than the carina to prevent trauma. Saline bolus prior to suctioning is not recommended. To prevent the catheter from adhering to the tracheal mucosa, negative pressure should only be applied during withdrawal. To remove secretions from around the mucous membranes. Prolonged suctioning may result in acute hypoxia, cardiac arrhythmias, mucosal trauma, infection and the patient experiencing a feeling of choking.

9

10 Apply suction by placing the thumb over the suction port control and withdraw the catheter gently with a rotating motion. Do not suction the patient for more than one breath cycle, 10–15 seconds (Maclntyre & Branson 2001).
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Action 11 If resistance is present when passing the catheter, disconnect the suction, move catheter until free, recommence suction and withdraw.

Rationale Stuck catheters should rarely happen, but may indicate that the inner cannula is blocked with secretions and needs to be changed. If problems persist after cleaning, contact either Emma Cowdrill or Margaret Rotherham. Catheters are used only once to reduce the risk of introducing infection. Catheters are only used once to reduce the risk of infection. The number of suction passes may contribute to the occurrence of complications. To minimise risk of hypoxaemia.

12 Wrap catheter around gloved hand, then pull back glove over soiled catheter, thus containing catheter in glove, then discard. 13 If the patient requires further suction, repeat the above actions using new gloves and a new catheter. No more than 3 suction passes should be made during any one suction episode. 14 If the patient is on oxygen, allow a minute of oxygen therapy (via a tracheostomy mask) between each suction, to ensure oxygen saturations are above 95%. 15 Assess the patient’s respiratory status following suctioning. 16 Note colour, quantity and tenacity of secretions. Record in patient’s progress notes and trachy chart. 17 If sputum looks infected send specimen for M,C & S (use sputum trap.)

18 Rinse the suction tubing by dipping its end To loosen secretions that have adhered to into the jug of sterile water or sodium the inside of the tube. bicarbonate solution and applying suction until the solution has rinsed the tubing through. 19 Wash hands at end of procedure. To limit potential cross infection to other patients.

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Patient Name ______________________________ Hospital Number____________________________ Tracheostomy Care.
Patient has:

Tube type: Portex/ shiley/ negus / other tracheostomy tube in situ

Humidification method: Oxygen/ air Via: - mechanical humidifier - Swedish nose - bib/ veil Saline nebulisers: 1 / 2 / 3 / 4 hourly.
Time Date Tube Clear Partial Blocked Suction Colour of secretions

Size of tube = Tube is: uncuffed fenestrated Tube ties/ dressings: = Change if not intact or when soiled. Suction requirements: Suction according to need Suction pressure not to exceed 150mmHg Suction: 1 / 2 / 3 / 4 hourly.
Viscous Y/N Nebuliser needed Y/N Tube secure Y/N Inner tube replaced Y/N Signed

Tube changed:

Next outer tube change on: Catheter Size: Tube size: 9mm 8mm 7mm
Comments

Catheter: 14CH (green) 12CH (cream) 10CH (black)

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Table comparing different sizes of tracheostomy tubes. To find the NEAREST equivalent size, follow the tubes along the same row. For example size 8 Shiley = Size 8 Portex = Size 36 Silver Negus Shiley Portex Silver Negus LPC/FEN/CFS/C Blue Line & Blue Approx sizes FN Line Ultra Size OD ID Lgth Size OD ID Lgth Size OD Lght MM MM MM MM MM MM FG MM MM 3 3

4 5 6

9.4

5.0

62

4 5

10.8

6.4

74

6

9.2

5.0

64.5

30

10.1 . 10.3 11.0 12.2 12.4 13.0

72

7 7.5 8 8.5 9 10 11 12 13.8 8.9 79 12.2 7.6 79

7 7.5 8 8.5 9 10 11 12

10.5 11.3 11.9 12.6 13.3 14

5.5 6.0 6.5 7.0 7.5 8.5

70 73 75.5 78 81 87.5

32 34 36 38 40

74 76 82 86 90

Tracheostomy Tube Sizes
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Size 4 6 8 10

ID (mm) 5.0 6.4 7.6 8.9

SHILEYTM OD (mm) 9.4 10.8 12.2 13.8

Length (mm) 65 76 81 81

Size 6.0 7.5 9.0

ID (mm) 6.0 7.5 9.0

PORTEXTM OD (mm) 8.3 10.4 12.4

Length (mm)

Size 6.0 7.0 8.0 9.0

PORTEXTM Adjustable Flange ID (mm) OD (mm) 6.0 8.3 7.0 9.7 8.0 11.0 9.0 12.4 PORTEXTM BLUELINE ULTRA ID (mm) OD (mm) 5.0 9.2 5.5 10.5 6.0 11.3 6.5 11.9 7.0 12.6 7.5 13.3 8.5 14.0 Silver Negus/ Johnson ID (mm) OD (mm) 5.0 9.2 5.5 10.5 6.0 11.3 6.5 11.9 7.0 12.6 7.5 13.3 8.5 14.0

Length (mm)

Size 6.0 7.0 7.5 8.0 8.5 9.0 10.00

Length (mm) 64.5 70.0 73.0 75.5 78.0 81.0 87.5

Size 6.0 7.0 7.5 8.0 8.5 9.0 10.00

Length (mm) 64.5 70.0 73.0 75.5 78.0 81.0 87.5

Troubleshooting Problem
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Cause

Suggested action

Profuse tracheal secretions.

Local reaction to tracheostomy tube.

Suction frequently, e.g. every 1–2h. Spray frequently with 0.9% sodium chloride, e.g. every 1–3h, and suction. Change the inner tube regularly, e.g. 1- to 3-hourly. Provide humidified air. See section on humidified air. Put in spare tube. This should be clean and ready near to hand. Note: tracheal dilators must be kept patients with tracheostomies. Remain calm since an outward appearance of distress may cause the patient to panic and lose confidence. Lubricate the tube well and attempt to reinsert at various angles. If unsuccessful, attempt to insert a smaller-size tracheostomy tube. If this is impossible, keep the tracheostomy tract open using tracheal dilators and inform the doctor. Insert a smaller-size tracheostomy tube. If insertion still proves difficult, do not leave the patient but ask for a tube to be brought to the bed. Keep the tracheostomy patent with tracheal dilators if stenosis is pronounced until the tube is reinserted. Change the tube as planned if bleeding is minimal. For profuse bleeding dial 999. Perform tracheal suction to remove the blood from the trachea.

Lumen of Tenacious or dried tracheostomy tube mucus in tube. occluded.

Tracheostomy tube dislodged accidentally. Unable to insert clean tracheostomy tube.

Tapes not secured adequately.

Unpredicted shape or angle of stoma.

Tracheal stenosis due to patient coughing, very anxious or because the tube has been left out too long. Tracheal bleeding following or during change of the tube. Trauma due to suction or to the tube being changed. Presence of tumour. Granulation tissue forming in fenestration of tube. Nature of surgery and condition of patient often predispose to infection.

Infected sputum.

Encourage the patient to cough up secretions and/or suction regularly. Change the tube and clean the stoma area frequently, e.g. 4-hourly. Protect permanent stomas with a bib or gauze. Following result of sputum specimen, commence appropriate antibiotics as needed.

Nasal Function and the Mucociliary Escalator.
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Filtering.

Hairs inside the nose filter out large airborne particles and glandular secretions containing antibacterial enzymes catch smaller particles and bacteria. The body's natural defence mechanism in the respiratory tract is the mucociliary escalator. Inhaled foreign matter, bacteria and debris are transported in the mucous by cilia upwards to the throat at 2 cm per minute. The mucous also protects against harmful gases. Dehydration of the mucous blanket, which compromises 95% water, seriously increases the risk of infection - gram-negative bacteria such as pseudomonas multiply in 24 hours to numbers large enough to cause serious respiratory infections.

Moisture.

Inspired air can be at a wider range of temperatures and humidities, but alveolar air is always at a constant 370C and 100% relative humidity. This warming and humidification starts in the nose and continues down the upper respiratory tract, so that the air is at constant temperature and humidity from just below the carina. This process is achieved by superficial blood vessels radiating heat and glandular secretions from the mucous membrane producing moisture. Bypassing this mechanism means a considerable increase in heat and moisture loss. (Shelley MP et al, 1988) Under normal circumstances, the nose and upper respiratory tract heat and humidify inspired air, so that conditions remain constant within the lung. Heat and moisture are conserved during expiration, but 250ml water and 350kcal heat are lost per day (Shelley et al 1988). Tracheostomy bypasses the normal heat and moisture conserving areas, so that more heat and moisture is lost, causing pulmonary mechanisms to change.

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Humidification and filtration

Humidification and filtration of air is vital. Some kind of humidification should be used at all times. It cannot be stressed too heavily that the majority of readmissions to hospital are due to a blocked stoma from crusting. This can be life threatening. It is vital therefore that humidification is used after discharge home. Basic humidification at home can be achieved by putting damp towels on warm radiators or sitting in the bathroom/kitchen with the door closed and the kettle repeatedly boiling or running a hot bath (NB: actually getting into a bath is not recommended for people with a tracheostomy. Showers with a shower aid to cover the stoma are far safer.) Teach the patient to keep the tracheostomy moist by using a spray containing 0.9% sodium chloride. This will loosen secretions and prevent crust formation.

Humidification can be achieved by a heat moisture exchanger (HME) 

The Buchanan protector consists of a special type of foam, which acts as a HME. It is available as standard size or large size. This is the main option for ‘temporary’ tracheostomy patients. There is a good range of effective HME’s for laryngectomy patients.

 

Trachinaze, Provox, and Humidifilter stoma filters are HME’s, which fit neatly over the stoma with an adhesive baseplate. Trachinaze Plus is a filter, which fits into a button. (see brochures for prescribing details). Special note – make sure you get the correct code on the prescription as there are a lot of different sizes and styles, the chemist will have an impossible task without the correct number. This is especially important for Trachinaze Plus filters which are different to the ordinary Trachinaze filters – they are not interchangeable!



Laryngofoam is an older type of HME, not very effective but some patients still like to use them.

Please do not hesitate to discuss any of these options with the Head & Neck Specialist Nurse.

For people requiring oxygen therapy - dry oxygen should never be given to someone with a tracheostomy - a single use sterile closed system should be used (eg Aquapak).
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Nebuliser

Useful for people with an acute problem of crusting. However, moisture left in the chamber can cause infection. The mask and chamber should be washed in hot soapy water and dried thoroughly after each use (Critchley & Roulsten 1993). Electric humidifier – available on loan from the Head & Neck Nurse Specialist.

Communication  If the patient can still exhale via the normal upper airway and thus use the voice box, a speaking valve can be used on the tracheostomy tube to allow normal speech. This is a valve that is either built into one of the inner tubes, or fits on to the end of the inner tubes (NB: A valve cannot be used if the patient is wearing a cuffed tube.)  If speech is not possible use written communication. A referral may be made to the speech therapist. The following are useful pointers for communicating with someone who cannot speak:     

Ensure pad & pencil are nearby to write with at all times. Ensure a relaxed atmosphere; this gives the patient confidence in their ability to mouth words, so that the family/carers can lip-read. Encourage family/carers to be patient. Ask the patient to repeat words or speak slowly if it is difficult to lip read. Remember that writing is a slower form of communication. Non-verbal skills will become more important. Encourage regular visits from friends & family, to prevent feelings of isolation.

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Stoma Care

Patients and/or carers will have been taught stoma care whilst an inpatient. Stoma care should become a part of the patient’s daily routine, thus maintaining a patent airway and preventing peristomal infection, tracheitis and secondary chest infection.

Soggy dressings encourage the growth of bacteria, which can cause wound infections and they can also be inhaled, so meticulous hygiene is essential.

The stoma should be inspected with a torch for signs of infection and crusting. Crusts should be removed with forceps and the stoma cleaned with gauze swabs – not cotton wool as the fibres may be inhaled – and cooled, boiled water. This is a clean, not sterile procedure, but patients should be reminded of the need to wash their hands prior to performing stoma care.

The stoma should be kept clean and dry at all times and sufficient dressings should be available to ensure that regular dressing changes are possible.

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Laryngectomy A permanent tracheostomy is formed after laryngectomy. The larynx is removed and the trachea is then brought out onto the neck to form a permanent stoma through which the patient breathes. There is no longer any connection between the lungs and the mouth and nose. Laryngectomy is mainly performed for cancer of the throat. See the diagrams below.
Pictures courtesy of Forth Medical

Area to be removed Tracheal stump sewn into neck (permanent stoma)

Larynx

Oesophagus has been stitched up here

Oesophagus Trachea Air to & from lungs Air to and from lungs

A normal airway, before laryngectomy

After laryngectomy, the tracheal stump has been sewn into a hole made in the neck. The lungs are now disconnected from the upper airway, and connected only to the neck hole (interchangeably called either a stoma, tracheostome, or laryngostome)

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Preoperative Preparation

The patient will require information and counselling; they will see the speech therapist and the Head and Neck Specialist Nurse. It is very helpful for the patient to meet the community nursing team prior to their laryngectomy, whilst they can still talk. It is much more difficult to do assessments just after laryngectomy when communication is a big problem!

Postoperative care

Maintaining a patent airway

Immediately postoperatively, a tracheostomy tube will be worn in the stoma until the wound heals and oedema settles. This is normally removed after 48 hours and replaced with a silicone stoma button. (In some cases a patient may need to continue to wear a long tube if there is persistent oedema, flaps of tissue, or some other problem with their stoma).

The silicone button is worn until the stoma is well established. It is used to prevent the skin around the stoma edge tightening up, due to scar tissue, and causing stoma shrinkage. Some patients are fine without a button after a few months. The patient should try without the button and observe the stoma. If the stoma then tends to shrink the button should be replaced. If shrinkage is severe, the stoma may need to be dilated using a rigid trache tube, or refashioned surgically; advice should be sought from the Head and Neck Nurse.

Stoma care The stoma should be kept clean and dry and should be regularly inspected for crusts using a good torch. Clean with cool, boiled water and cotton swabs – not cotton wool as this can leave fibres around stoma which can be inhaled Crusts can be removed with curved Tilley’s forceps (supplied by the hospital in the neck breather green bag given prior to discharge. The patient and carer should usually be competent to do this themselves. Crusts are a particular problem during radiotherapy treatment and can be severe enough to totally occlude the airway. The patient will

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probably require help during this time. Do not be afraid of putting the forceps right down the trachea to pull out crusts. Good humidification is essential in minimising these problems.

Communication Surgical voice restoration – a puncture is made in the back wall of the trachea, through into the oesophagus. This hole is kept open by placing a valve. The valve also stops food/fluid leaking into the trachea.
Finger occlusion of stoma to direct air through valve

Speech

The valve must be cleaned at least twice per day. Leakage of fluids indicates that it needs replacing.
Air from lungs
Tracheoesophageal valve Hands-free valve

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Electronic Speech Aid.

This is called an electrolarynx. There are a few different makes; Servox, Cooper Rand, Nuvois. They are supplied by the speech therapist. They have a ‘metalmickey’ sort of sound but are an excellent way of communicating. Vibrations from the electrolarynx are transmitted through the neck, tongue and floor of mouth and create sound in the mouth, which can then be used for speech.
Pictures courtesy of Forth Medical

Vibrations

Speech

Electrolarynx

Oesophageal Speech The patient swallows air then regurgitates it to use for speech. This technique requires fairly intensive training from the speech therapist. It is good because it is hands-free and does not require any aids at all. Not all patients can achieve it.

Pictures courtesy of Forth Medical

Speech

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Initially the patient will feel very frustrated and isolated by loss of voice. Communication may need to be written until new speech is mastered - magnetic writing boards are very useful. Patients who have difficulty with writing obviously will feel upset and embarrassed and will need creative help and support.

Using the telephone Most patients will learn to communicate very well over the phone. For those who cannot, or are worried about coping alone in an emergency, British Telecom provide a text service from home phone lines that translates the message into speech using a celebrity voice. Go to BT.com and look under phone services to find out more.

The Speech Therapist is the key worker in this area and a referral will have been made preoperatively.

Equipment/aids for tracheostomy patients
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All tracheostomy patients should have a green ‘trachy’ bag on discharge from Frimley Park Hospital. This includes: suction catheters deltanex bibs smaller size Portex tube trachihold tapes tracheostomy cleaning brushes/swabs Tilleys forceps Gauze swabs Countrywide information

Most of these supplies can be restocked via Countrywide Supplies, but suction catheters, trachihold tapes and tracheostomy cleaning brushes or swabs need to be ordered by the district nurse.

Available on prescription

Buchanan Protectors Deltanex Protectors Trachi-naze / Trachinaze Plus Provox stomafilters Forth Medical humidifilters Forth Medical stoma filters Laryngofoam Tracheostomy cleaning brushes Valve cleaning brushes

Order codes are in the relevant product brochures.

**** Any person with a tracheostomy is entitled to free prescriptions (use Form P11, available at the post office) ****

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Kapitex, Forth Medical and Platon (Provox)

There is a large range of products, some of which have to be purchased by patients. Please ask the Head & Neck Specialist Nurse if you would like to see a catalogue, or contact the companies direct: Kapitex Healthcare: Kapitex House, 1 Sandbeck Way, Wetherby, West Yorkshire. LS22 7GH Their products include:     tracheostomy cleaning brushes tracheostomy cleaning swabs trachi-hold tube holders trachi-dress dressings

Platon Medical: PO Box 2568, Eastbourne, East Sussex, BN21 3HZ platon@mistral.co.uk

Their products include:  valve cleaning brushes  lary tubes  hands free devices

Forth Medical: Forth House, 42, Kingfisher Court, Hambridge Road, Newbury, Berkshire. RG14 5SJ. service@forth medical.ltd.uk their products include:    Blom-Singer valves and equipment Baseplates & housing Hands free devices

Many products can be supplied straight to your door, free of charge, by Countrywide Supplies. www.countrywidesupplies.co.uk
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Free phone: 0800783 1659 Fax: 0115 987 0144 This is an excellent service, which provides equipment quickly and easily where pharmacists often struggle. Magnadoodle - magnetic writing board - from Argos Swimming Aids (available only to recognised swimming instructors – contact head and neck nurse, or NALC)

From Speech Therapist Electronic voice replacement aids Cooper Rand Electrolarynx Batteries Nebulisers & suction pumps - from hospital or community equipment pool, Macmillan nurse, Electric humidifiers - head and neck nurse TypeTalk – from BT

Contact Numbers

ENT Outpatients – via hospital switchboard (01276 604604)
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ENT Ward F12a – 01276 604130 Head and Neck Nurse Specialist – Emma Cowdrill – 01276 526747 (voice mail) or 01276 604604 bleep 544 (part time – Tues, Wed & Fri am) District Nurse – Margaret Rotherham – 01276 65390 Speech therapy – Alison Little - 01276 604050 – Monday & Friday only NALC (National Association of Laryngectomee Clubs) 0201 381 9993 Kapitex Healthcare Platon Medical Forth Medical 01937 580211 01323 431930 01635 550100

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References

Tricia Feber (2000) Head & Neck Oncology Nursing, Whurr Publishers Critchley D, Roulsten J 1993 'Nurses' knowledge of nebulised therapy' Nursing Standard; 8: 10, 37 - 39 Serra A (2000) Tracheostomy care. Nursing Standard 14(42): 45-52 Ackermann MH (1993) The effect of saline lavage prior to suctioning. Am J Crit Care 2($): 326-30 Woodrow P (2002) Managing patients with a tracheostomy in acute care. Nursing Standard; 16(44):39-48 Hough A (2001) Physiotherapy in respiratory care. Third edition. Cheltenham, Nelson Thornes. Barnett M (2004) Journal of Community Nursing 19(1): 4-8 Griggs A (1998) Tracheostomy: suctioning and humidification. Nursing Standard; 13(2): 49 Ward V (1997) Hospital Acquired Infection: surveillance, policies and practice. PHLS, London. Shelley et al (1988) A review of the mechanisms and methods of humidification of inspired gases. Intensive care medicine 14: 1-9 El-Kilany (1980) Complications of Tracheostomy. Ear, Nose 7 Throat Journal; 59(3): 123-128 Pryor J and Prasad A (2001) Physiotherapy in respiratory care. Third edition. Cheltenham, Nelson Thornes. MacIntyre & Branson (2001). Mechanical ventilation. Saunders. Feber T. Tracheostomy care for community nurses: basic principles. British Journal of Community Nursing 5(11): 186-193
Fiorentini A. (1992) Potential hazards of tracheo-bronchial suctioning. Intensive and Critical Care Nursing 8, 217–226. Marsden Manual of Clinical Nursing Procedures – 5 edition. Blackwell Scientific Publishing.
th

NAME:
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DATE

TRACHEOSTOMY CARE PLAN
AIMS To maintain airway To prevent aspiration and chest infection To help patient and family develop alternative communication strategies To help patient adjust to altered body image and new aspects of self care To prevent trauma to tracheal mucosa caused by inappropriate tubes and suctioning ACTION 1. Change inner tubes as often as necessary to maintain a patent airway. Outer tube is changed as often as required but at least once per month. 2. Clean inner and outer tubes in hot water using a tracheostomy cleaning brush. Store spare tubes and brush dry in a sealed container- never leave soaking as bacteria grow in moisture and disinfectants. 3. Prevent drying/crusting by use of a HME (e.g. Buchanan protector), and nebuliser. 4. Clean stoma site daily or more often if required, using saline or cooled boiled water. Re-apply dressing if required. 5. Change tracheostomy ties as necessary. 6. Encourage expectoration of secretions - observe signs of chest infection. 7. Only use suction if the patient is unable to expectorate secretions him/herself - Use a low trauma suction catheter and a low suction setting (120mm Hg). 8. If a speaking attachment is being used it should be removed at bedtime. 9. Discuss coping strategies for communication difficulties. Allow plenty of time to listen. 10. Assess psychological adjustment difficulties. Encourage patient to look at stoma in mirror as this helps adjustment. Discuss concerns about appearance, sexuality etc. 8 mm Tracheostomy cleaning brushes, Buchanan protectors, tracheostomy dressings and tracheostomy holders are available on prescription.

SIGNED

ELMC/MR version 1 Sept 2006 Review Sept 2008

NAME: DATE LARYNGECTOMY CARE PLAN SIGNED

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AIMS To maintain airway To help patient and family develop alternative communication strategies To help patient adjust to altered body image and new aspects of self care To prevent chest infection To prevent damage to tracheal mucosa caused by inappropriate suctioning ACTION  Ensure patient is checking stoma with a good light and removing any crusts with forceps. Stoma should be cleaned with clean water and swabs/cotton buds.  Crusts will especially be a problem towards end of and after radiotherapy: patient may require help at this time. Regular saline nebulisers should be helpful. Suction will not remove crusts – use forceps.  Ensure patient has appropriate sized stoma button if he/she prefers to wear them. If patient does not wear a button, monitor for signs of stoma shrinkage  Prevent drying/crusting by using a HME at all times. This also prevents entry of foreign objects and dust.  Encourage expectoration of secretions - observe amount and colour.  Only use suction if the patient is unable to expectorate secretions him/herself - Use a low trauma suction catheter and a low suction setting (120mm Hg).  Discuss coping strategies for communication difficulties. Allow plenty of time to listen. Ensure speech therapy referral has been made.  Give information on Laryngectomy Support Group.  If there is a speaking valve in the stoma, it should be cleaned daily using a valve brush (from ENT outpatients).  Assess psychological adjustment difficulties. Encourage patient to look at stoma in mirror as this helps adjustment. Discuss concerns about appearance, sexuality etc. All HME’s are on prescription and can be easily obtained using Countrywide Supplies – see product information.

ELMC/MR version 1 Sept 2006 Review Sept 2008

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