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					                                                                                Cheshire and Merseyside
                                                                                   Critical Care Network




                            Tracheostomy Care Bundle
                                                  Guide to implementation and audit




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                                            Contents



        Introduction                                              3


        Tracheostomy Care Bundle: A Brief Summary                 4


        The Tracheostomy Care Bundle:

                Oxygen therapy and humidification                6


                Safety equipment and emergency algorithms        8


                Weaning and Decannulation                        13


                Dressings and stoma care                         15


                Suction                                          16


                Cuff pressures                                   18


                Single v double lumen tracheostomy tubes         20


                Audit Forms                                      22


        Acknowledgements                                          25




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                                                    2
                            THE CARE BUNDLES CONCEPT


The theory behind care bundles is that when several evidence-based
interventions/guidelines are grouped together and applied in a single
‘protocol’, it will improve patient outcome1


       It is a simple method of monitoring adherence/existence of local guidelines, and
        as such is a valid assessment of quality.


       It will provide rapid easily interpreted and easily analysed information.


       It is a form of auditing process only.


       It can identify areas for improvement.


       It can result in reducing costs, length of stay, complications and outcomes.


       It is NOT research.


       It is NOT about dictating uniformity of local practice across the Network.


       It will NOT audit the effectiveness of each element comprised within the ‘bundle’
        independently.


       It is NOT prescriptive. Each unit can identify their own criteria for each element.




    1. Fulbrook,P and Mooney, S (2003) Care Bundles in Critical Care: a practical
       approach to evidence based practice. Nursing in Critical Care Vol 8 no 6.




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                                                    3
                 Guidelines for the use of Care Bundles in Critical Care


 Introduction

 The concept of care bundles was introduced by the NHS Modernisation Agency
 following an Intensive Care quality improvement Conference in Chicago USA.

 The theory behind care bundles is that when several evidence-based interventions
 are grouped together in a single protocol, it will improve patient outcome1.

  Nine elements of care were identified as improving patient outcome. These elements
 are:

     o   Oxygen therapy and humidification
     o   Safety equipment
     o   Emergency Treatment Algorithm available
     o   Weaning and decannulation
     o   Dressings and stoma care
     o   Suction
     o   Practitioner trained in suction
     o   Cuff pressures
     o   Single v double cannula tracheostomy tubes


 Application of these elements together should be considered for each patient every
 day. Evidence shows that compliance with this model improves quality of care and
 patient outcomes.


 Aim
 The aim of implementing the tracheostomy care bundle is:


 Explanatory notes on the above guidelines:

 1. Due to the risk of tube occlusion, damage to the respiratory tract, and tenacity of
    secretions, oxygen and room air should be heated and humidified via a heated
    circuit in order to maintain optimum humidity. If this data is being collated from a
    Ward patient, if they have humidification but not heated due to trust safety policy
    then record Y*.

 2. Safety equipment available at the bedside should be as per individual trust policy.
    An algorithm should be available for the management of a blocked or displaced
    tracheostomy

 3. Each patient should have a documented weaning plan and a multidisciplinary
    assessment prior to decannulation

4.   Dressings and tapes should be changed at least every 24 hours or sooner if
     required. Actual dressings used should be as per individual trust policy.

 5. The need for suction should be assessed regularly by the multidisciplinary team
    and should be clearly documented.
    Staff should receive training in correct suction technique.
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                                                     4
    Saline should not be used routinely but following assessment by a specialist practitioner.

6. Cuff pressure should be checked and documented each shift as well as
   whenever air is removed from or added to it. This assessment should only be
   made by staff who are competent and confident to do so.
   There is a need to monitor measure and adjust the cuff pressure, with a simple,
   reliable and safe device.
   When checked the amount of air should be documented in the patients’ notes.

7. Patients should have a double-lumen tracheostomy tube, unless deemed
   inappropriate for that individual.

    The inner tube must be removed and inspected for secretions regularly (as per
    individual trust policy).
    The inner tube should be cleaned or disposed of as per individual trust policy.




                         Oxygen Therapy And Humidification

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Background
In a normal airway, inspired gas arrives at the carina at core temperature (37ºC) and
fully saturated with moisture (100% relative humidity [RH] = 44mg/L). This maintains
the function of the mucosa and enables sputum clearance.

With a tracheostomy patient, the warming, humidifying and filtering function of the
upper airway is bypassed and unless substituted, can cause serious respiratory
dysfunction. Room air, and worse still oxygen is cold and dry, causing heat and
moisture to be removed from the respiratory tract.

There are three main methods of humidification suitable for the ward environment:
Cold Humidifiers (CH), Heated Humidifiers (HH) and Heat Moisture Exchange
devices (HME)

Evidence
Although humidification is a well researched subject, the vast majority focuses on
mechanically ventilated subjects. Of the available literature, there are three
Randomized Controlled Trials and one Systematic Review that compare
humidification methods.

Thomachot et al (1998) compared a HH, a CH and a HME in spontaneously
breathing tracheostomized patients. The CH was unable to provide adequate
humidification (P<0.001), whereas both the HME and HH provided comparable
levels.

Martin et al (1990) evaluated HME and HH in the intensive care setting. They found:-
    6 incidents of tube occlusion with HME and none with HH (P<0.01)
    Increased incidence of tenacious secretions with HME versus HH (P<0.02)
    Increased occurrence of Hypothermia with HME compared to HH (P<0.01)
    Increased contamination rates of circuits with HH compared to HME (P<0.01)

Lacherade et al (2005) however found no difference in the incidence of ventilator
associated pneumonia when comparing HH with HME (P=0.48)

Williams et al (1996) in an extensive review of the literature, examined temperature
and humidity of inspired gas and mucosa function. They concluded that there is one
level of humidity that optimises all of the mucosal functions, and this is core
temperature (37ºC) and 100% RH (44mg/L)

A double case report by Edwards and Byrnes (1999) found both subjects to
demonstrate tube occlusion due to tenacious secretions when using HME, and
resolved when HH were applied.

Recommendations

       Due to the risk of tube occlusion, damage to the respiratory tract, and tenacity
        of secretions, oxygen and room air should be heated and humidified via a
        heated circuit in order to maintain optimum humidity.




Implementation Date:
August 2007
Review Date:
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                                                    6
August 2008


References
Edwards EA. Byrnes CA. Humidification difficulties in two tracheostomized children.
Anaesthesia and Intensive Care 1999; 27, 6: p656-658

Lacherade JC, Auburtin M, Cerf C, Van de Louw A, Soufir L, Rebuffat Y, Rezaiguia S, Ricard
JD, Lellouche F, Brun-Buisson C, Brochard L. Impact of humidification systems on ventilator
associated pneumonia: a randomised multi-centre trial. Am J Respir Crit Care Med 2005; Aug
26 – Abstract only

Martin C, Perrin G, Gevaudan MJ, Saux P, Gouin F. Heat and moisture exchangers and
vaporizing humidifiers in the intensive care unit. Chest 1990; 97: p144-149

Thomachot L, Viviand X, Arnaud S, Vialet R, Albanese J, Martin C. Preservation of humidity
and heat of respiratory gases in spontaneously breathing tracheostomized patients. Acta
Anaesthesiol Scand 1998; 42:p841-844

Williams R, Rankin N, Smith T, Galler D, Seakins P. Relationship between the humidity and
temperature of inspired gas and the function of airway mucosa. Crit Care Med 1996); 24:
p1920-1929




                  Safety Equipment And Emergency Procedures

Background
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A tracheostomy is an artificial airway and staff caring for the patient need to be able
to recognize signs of obstruction of the airway.
Staff should have an algorithm to follow should the airway be compromised.
All the necessary equipment to maintain the patency of the tracheostomy should be
available in the patient’s bed space, along with equipment to for replacing displaced
or blocked tubes.

Evidence
Is not research based. Recommendations come from experience and practice.
Hospitals should develop emergency algorithms and equipment lists. The St Georges
tracheostomy guidelines could be used as a basis for developing a local protocol.

Example:
Bedside Equipment For A Patient With A Tracheostomy:

1. Suction Equipment
    Suction unit
    Suction jar
    Suction tubing
    Suction catheters with suction control
    Gloves (sterile or non-sterile, according to local guidelines)

2. Oxygen Equipment
    Heated and humidified oxygen with temperature indicator
    Elephant tubing
    Tracheostomy mask or T-piece

3. Emergency Equipment
    Tracheal dilators
    Spare tracheostomy tube the same size as the one in-situ and one a size
      smaller.
    If the patient’s tube is uncuffed a cuffed tube should be available
    10 ml syringe
    Stitch cutter
    Lubrication
    Tracheostomy tapes
    Tracheostomy dressing
    Catheter mount
    Ambu Bag
    Oxygen mask with reservoir
    Disposable eye protection, apron and sterile gloves
    Water to rinse tubing
    Receivers
    Tissues
    Nurse call bell

Recommendations
Safety equipment available at the bedside should be as per individual trust policy. An
algorithm should be available for the management of a blocked or displaced
tracheostomy.



Implementation Date:
August 2007

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Review Date:
August 2008



References
Edge Hill Faculty of Health 2004

St George’s Health Care NHS Trust Protocol August 2000




   Emergency Treatment For Tracheostomy Tube Blockage –
       For Use On General Medical And Surgical Wards
     Algorithm Not To Be Used For Patients Who Have Had A Laryngectomy

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                                                        TUBE BLOCKED
                                                            TURN O2 UP TO 100%

                                                            REMOVE INNER TUBE
                                                              AND RE-ASSESS

                                                        APPLY TRACHEAL SUCTION



                                                              IS TUBE PATENT?



               YES                                                                         NO



Clean inner tube and replace                                                    If cuffed tube, let cuff
                                                                                 down using syringe




                                                      IS THE PATIENT
                                                         BREATHING?


               YES                                                                        NO

                                                                                 RING FOR ARREST TEAM
       CONTACT ANAESTHETIST
                                                                                 AND ANAESTHETIST TO BE
       OR OUTREACH NURSE
                                                                                 FAST BLEEPED
       FOR TUBE CHANGE
                                                                                 SUCTION ON HIGH
                                                                                 PRESSURE WITH A GREEN
                                                                                 (14g) CATHETER

                                                                                 BRING ARREST TROLLEY
       FOR USE IN ADDITION TO TRUST GUIDELINES                                   TO BEDSIDE
       & PRINCIPLES TO PRACTICE
                                                                                 RE-ASSESS PATIENT AND
       ALGORITHM TO BE USED ONLY FOR PATIENTS                                    IF TUBE STILL BLOCKED,
       DISCHARGED FROM CRITICAL CARE                                             REMOVE IT AND SEAL
                                                                                 STOMA

                                                                                 APPLY VENTILATION USING
                                                                                 AMBU-BAG AND FACE
       Emergency Treatment For Tracheostomy Tube                                 Displacement – O2
                                                                                 MASK WITH 100%
            For Use On General Medical And Surgical Wards
        Algorithm Not To Be Used For Patients Who Have Had A Laryngectomy


                                              Tube Displaced
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                                                 Turn O2 up to
                                                     100%

                                                Attempt Re-insertion
                                             And assess breathing



                                               Is the tube patent




       Yes                                                                           No
         Yes



Contact CCD Outreach or                                                       Remove tube and fast
Anaesthetist for review                                                       bleep anaesthetist



                                                   Is patient breathing
                                                      via stoma site



         Yes                                                                           No



   Apply Max O2 via                                                           Seal stoma site. Apply
   trache mask over                                                           Max O2 via face mask
       stoma site                                                             over mouth and nose




                If the patient stops breathing through their mouth or becomes pulseless –
                         Begin Basic Life Support and call the Cardiac Arrest Team

          FOR USE IN ADDITION TO TRUST GUIDELINES & PRINCIPLES TO PRACTICE
            ALGORITHM TO BE USED ONLY FOR PATIENTS DISCHARGED FROM
                                    CRITICAL CARE
                Emergency Treatment for Bleeding from the
             Trachea/Lungs or Stoma Site – For use on General
                       Medical and Surgical Wards
          FOR USE IN ADDITION TO TRUST GUIDELINES & PRINCIPLES TO PRACTICE

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              ALGORITHM ONLY TO BE USED FOR PATIENTS DISCHARGED FROM
                                   CRITICAL CARE


                       BLEEDING FROM TRACHEOSTOMY


                                                  TURN O2 UP TO 100%



                                        BRING THE CARDIAC ARREST
                                     TROLLEY TO THE PATIENTS BEDSIDE



                                       IS THE PATIENT UNSTABLE?
                                       OR IS THE BLEEDING COPIOUS?




                       YES                                                                      NO

     CALL THE CARDIAC ARREST TEAM                                         CALL THE WARD PRHO / SHO AND
    AND FAST BLEEP THE ANAESTHETIST                                       ASK THEM TO ATTEND URGENTLY



                                                ASSESS THE SOURCE OF BLEEDING



IS THE BLEEDING FROM THE LUNGS?                              IS THE BLEEDING FROM THE STOMA SITE?



          CONTACT REGISTRAR                                                  APPLY COMPRESSION TO SITE
        AND ASK
        CONTACT THEM TO ATTEND                                                 CONTACT ANAETHETIST
              URGENTLY




                                       Weaning And Decannulation

        Background
        Decannulation is the planned, deliberate and permanent removal of the tracheostomy
        tube. Therefore, the first and main principle is that the condition precipitating the
        need for a tracheostomy has resolved.

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The management of patients discharged from critical care to ordinary wards with a
tracheostomy in situ should be managed by a multi disciplinary team.

Although there does not seem to be a consensus about, or evidence of the best
weaning technique, most authors seem to agree that a standardised systematic
approach improves weaning to decannulation success.


Evidence
As weaning may need the skills of several different practitioners to be achieved
efficiently and safely it would appear intuitive that there should a multidisciplinary
approach which is backed up by Norwood’s study (2004) and Hunt and McGowan
(2005). The suggested participants could include outreach and ward nurses, critical
care medical staff, ENT surgeons, physiotherapy and speech and language
therapists.

A pre-weaning assessment is advocated along with comprehensive criteria including
a strong cough and ability to swallow ones own secretions by Ladyshewsky (1996).
Heffner (1995) also advocates a formalised assessment of airway patency.
Additionally most authors advise the performance of a swallowing assessment.

Thompson Ward (1999) and Le et al (1993) concluded that no method was superior
in assessing a patient’s suitability for decannulation. Ideally objective tests are
required and there does seem to be a degree of consensus over the use of the
following criteria (Hunt 2005):

       An adequate cough with no evidence of upper airway obstruction
       Peak cough flow of 160 litres/min (assessed by electronic peak flow metre
        attached to 15mm connector of tracheostomy tube)

The following test is also recognised as an objective indicator of readiness to
decannulate. However it should only be considered if the patient has a cuffless+/-
fenestrated tube and is in an environment where the staff are experienced in
tracheostomy care and the patient can be closely observed.

       Successful tolerance of capping of the tracheostomy tube for several hours

Recommendations
Each patient should have a documented weaning plan and a multidisciplinary
assessment prior to decannulation.

After decannulation the patient should initially remain in an appropriate place for
close observation for airway compromise, with the emergency equipment kept to
hand (Heffner 1995).

Implementation Date:
August 2007
Review Date:
August 2008



References

Day T, Farnell S, Haynes S, et al (2002) Tracheal suctioning: an exploration of nurses’
knowledge and competence in acute and high dependency ward areas. J of Ad Nursing 39:
35-45.
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Doerksen K, Ladyschewski A, Stansfield K (1994) A comparative study of systemised vs.
random tracheostomy weaning. Axone 16: 5-13.

Heffner JE (1995) The technique of weaning from tracheostomy. The criteria for weaning;
practical measures to prevent failure. J Crit Illn 10: 729-33

Hunt K, McGowan (2005) Tracheostomy management in the neurosciences: A systematic,
multidisciplinary approach. Br J of Neuroscience Nursing 1 (3): 122-25.

Ladyshewsky A, Gousseau A (1996) Successful tracheal weaning. The Canadian Nurse
92(2): 35-8

Le HM, et al (1993) Comparison between conventional cap and one way valve in the
decannulation of patients with long term tracheostomies. Respir. Care 38: 1161-7.

Norwood MG, Spiers P, Bailiss J, Sayers RD. (2004) Evaluation of the role of a specialist
tracheostomy service. From critical to outreach and beyond. Postgrad Med J 80: 478-80.

Russell C, Matta B (2004) Tracheostomy: a Multiprofessional Handbook. London: Greenwich
Medical Media Ltd.

Tanser SJ, Walker MB, Macnaughton PD (1997) Tracheostomy care on the wards – an audit
of nursing knowledge. Clin Int Care 8: 105.

Thompson-Ward E, et al (1999) Evaluating suitability for tracheostomy decannulation: a
critical evaluation of two management protocols. J. Med Speech-Lang Pathol 7: 273-81




                                 Dressing And Stoma Care

Background
Tracheostomy stoma care aims to keep the area clean and dry therefore reducing
the risk of skin irritation and infection. Wetness can lead to excoriation and
maceration and then the increased moisture acts as a medium for bacterial growth.

Evidence
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The evidence available reflects best practice as there are no randomised controlled
trials. There is some confliction on the use of aseptic and clean technique in regard
to changing wound dressings.

The dressing around the tracheostomy should be changed daily or more frequently if
it becomes dirty or stained with secretions (Serra et al 2000). The tapes or tube
holders should also be assessed at least every 24 hours and changed if wet or soiled
(Serra et al 2000, St Georges).

Dressings should be thin and non adherent, pre-cut, preferably hydrophilic polyurethane
foam dressings
e.g., Lyafoam T ‘ Allevyn (St Georges, Morgan et al 1994).

There should be evidence of the use of a wound care chart as early detection and treatment
reduces the
 risk of deterioration of the stoma (Holden et al 2000).


Recommendations
Dressings and tapes should be changed at least every 24 hours or sooner if required. Actual
dressings used should be as per individual trust policy
.

Implementation Date:
August 2007


Review Date:
August 2008



References
Holden J et al (2000) Pressure sore prevention and wound management policy in St Georges’
Healthcare NHS Trust and South West Community NHS Trust

Harkin et al (1998) Trachaeostomy Management Nursing Times 94; 21 56-58

Morgan, D (1994) Formulary of wound management products, sixth edition

Greaves W et al 1980 The problem of Hepatic Whitlow among hospital Personnel Infection Control
1(6)
381- 385

Serra et al (2000) Trachaeostomy care Nursing Standard 14(4)p 45- 52
St George’s Health Care NHS Trust Protocol August 2000




                                                  Suction

Background
Suction is required in those patients who cannot effectively clear their own pulmonary
secretions.
It should only be performed when clinically indicated and not as a matter of routine
(AARC 1993/Wood 1998). There is little grade 1 evidence surrounding this topic and
most comes from practice and expert opinion.
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Evidence
Indications for suction:
     Coarse breath sounds on auscultation
     Deteriorating ABG’s
     Patient attempting to cough spontaneously
     To maintain patency of tracheostomy
     Audible/visible secretions in airway
     Suspected aspiration
     Increased work of breathing
     To obtain a sputum sample

(AARC 1993, Odell 1993, Smith 1993, Carroll 1993, Glass and Grap 1995, Peruzzi and
Smith 1995)

Wash hands and wear gloves and gown (Rossoff et al 1993/ Wood 1998).
When ready to suction use a clean glove on the dominant hand and avoid touching
anything else with it except the sterile catheter (St Georges’ Healthcare NHS Trust
2000). Repeat this process for each suction attempt.

Patients who desaturate during suction may benefit from pre-oxygenation(AARC
1993, Odell 1993). It is accepted that this may not always be possible in emergency
situations.

Catheters should be sterile and not exceed more than half the internal diameter of
the tracheostomy (Odell 1993, Wood 1998).

Size 6 tracheostomy Size 10 catheter (max)
Size 7 tracheostomy Size 12 catheter (max)
Size 8 tracheostomy Size 14 catheter (max)

The suction pressure applied should be between 13.5 and 20kPa (Glass and Grap
1995) although this may be increased to 30 kPa if secretions are tenacious
(Carroll1994). A high negative pressure can cause mucosal trauma, subsequently
increasing the risk of infection (Carroll 1994) and may cause atelectasis (Odell 1993).
The suction process should only take between 10 and 15 seconds (AARC 1993,
Knox 1993).

Although evidence is contradictory, practice experience supports the use of a small
amount (2 mls) of sterile normal saline (0.9%) for tenacious secretions or for a
tracheostomy tube at risk of occlusion (St Georges Healthcare Trust 2000).
As evidence is lacking saline should never be used routinely as it may decrease
baseline oxygen saturation (Ackerman 1993).

Recommendations
The need for suction should be assessed regularly by the multidisciplinary team and
should be clearly documented.

Staff should receive training in correct suction technique.

Saline should not be used routinely but following assessment by a specialist
practitioner.

A ticklist to record frequency of suction and description of secretions may be used.


Date    of Please time and tick when suction carried out and describe secretions
Suction
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e.g.                    e.g.
01/03/06                09.45
                        
                        thick
                        and
                        green




Implementation Date:
August 2007


Review Date:
August 2008


References
AARC (1993) Endotracheal suctioning of mechanically ventilated adults and children with
artificial airways. AARC clinical practice guidelines 38 (4) 500 - 504

Ackerman, M.H. (1993). The effect of saline lavage prior to suctioning. American Journal of
Critical Care Vol 2, pp 326-330

Allen D (1988) Making sense of suctioning. Nursing times 84 (10) 46 – 47

Carroll PF (1988) Lowering the risks of endotracheal suctioning. Nursing 88: 46 - 50

Glass CA, Grap MJ (1995) Ten tips for safer suctioning. American Journal Of Nursing.
May 1995 (5): 51 – 53

Knox, A. (1993). Performing endotracheal suction on children: A literature review and
implications for nursing practice. Intensive and Critical Care Nursing Vol: 9, pp 48-54

Odell A, Allder A, Bayne R et al (1993) Endotracheal suction for adult, non head injured
patients. A review of the literature. Intensive and Critical Care Nursing 9 274 – 278

Peruzzi WT, Smith B (1995) Bronchial hygiene therapy. Critical care clinics 11 (1) 79 – 93

Smith SJ (1993) Suctioning the airway. Emergency 25 (3): 41 – 45
St George’s Health Care NHS Trust Protocol August 2000

Wood C (1998) Endotracheal Suctioning; A Literature Review. Intensive And Critical Care
Nursing 14, 124 – 136

                              Tracheostomy Cuff Pressures

Background
The relationship between prolonged tracheal intubation and tracheal mucosal injury
has been well demonstrated. There have been descriptions of the occurrence of
tracheal sequalae secondary to endotracheal tube cuff high pressure since 1950
(Reinaldo J et al). Although there is a general awareness of the dangers of cuff
hyperinflation, more emphasis is put on the risk of air leak and hypoxia than high cuff
pressures. Exposure of the tracheal mucosa to the pressure of the tracheal cuff has
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                                                   17
been implicated as one of the most important predisposing factors for mucosal injury.
Injury includes mucosal necrosis and late stenosis of the trachea.

Measurement of the intracuff pressure represents a simple and reproducible
method of assessing the pressure exerted on the tracheal wall. The
recommended upper and lower limits for cuff pressures are 18 and 25 cmH20.

Evidence
The majority of literature related to measurement of cuff pressure is focused on
endotracheal tubes; however most patients will have been intubated prior to
tracheostomy therefore the literature suggestions that there is a need for precise
measurement of cuff pressure would appear relevant to both groups of patients.

Cuff pressures below 18 cm H2O may lead to longitudinal folds in the cuff promoting
microaspiration of secretions collected above the cuff, thus increasing the risk of
nosocomial pneumonia. Pressures above 25 to 35 cm H2O may exceed capillary
perfusion pressure, thus leading to compression of mucosal capillaries and
promoting mucosal ischemia and tracheal stenosis (Vyas et al 2002).

Estimation of cuff pressures by palpation of the external inflation bulb is unreliable as
a substitute for cuff pressure measurements. Cuff pressures are most accurately
measured using a manometer directly connected to the cuff tubing by a stopcock.
The stopcock assembly must communicate simultaneously with the inflation syringe,
the manometer, and the cuff to achieve real-time pressure monitoring during cuff
inflation.

Recommendations
Cuff pressure should be checked and documented each shift as well as whenever air
is removed from or added to it. This assessment should only be made by staff who
are competent and confident to do so

There is a need to monitor, measure and adjust the cuff pressure, with a simple,
reliable and safe device.

When checked the amount of air should be documented in the patients’ notes
(Woodrow 2002).

Implementation Date:
August 2007
Review Date:
August 2008




References
D Vyas, K. Inweregbu and A Pittard. Measurement of tracheal tube cuff pressure in critical
care. Anaesthesia 2002 Volume 57. 275

Reinaldo J, Braz C, Navarro L, Takata I, Nascimento P, 1999        Endotracheal tube cuff
pressure:need for precise measurement. Sao Paulo Med J. Vol117

Woodrow P. 2002 Managing patients with a tracheostomy in acute care. Nursing Standard Vol
16(44)39-48
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                 Single –v- Double Cannula Tracheostomy Tubes

Background
Tracheostomy tubes are available in a variety of styles and sizes from several
manufacturers. It is important for clinicians to understand these differences and then
select a tube that appropriately fits the patient (Hess 2005).


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Some tracheostomy tubes have a double cannula-the inner cannula sits inside the
outer cannula and may be disposable or reusable, allowing for cleaning and
replacement (Hess, 2005).

Over a prolonged period of time, secretions may adhere to the internal lumen of a
tracheostomy and progressively reduce the lumen size, leading to obstruction of the
patient’s airway. In order to reduce this risk, the tracheostomy tube should be
changed frequently (if single-cannula), or a tracheostomy with an inner cannula
inside an outer cannula should be used (St George’s Healthcare NHS Trust, 2000).

Tracheostomy tubes may be fenestrated in order to allow the patient to vocalise.
These tubes have a small hole in both the inner and the outer tube to allow air to
pass through into the larynx. Some inner tubes will need to be removed and
replaced with a plain inner cannula during suction to prevent trauma as per
manufacturer’s guidelines. A plain inner tube must be used if ventilation of the
patient via the tracheostomy is required.

Evidence
 It has been suggested that the presence of an inner cannula may reduce the
possibility of progressive occlusion as they can be removed and cleaned regularly
(Heffner 2001, Krishnan et al 2005)

The use of an inner cannula to prevent occlusion will therefore also reduce the need
for frequent tube changes, which is especially important within the ward setting
where the risks associated with this procedure may be increased (Krishnan et al
2005).

The inner cannula can also be easily removed in an emergency situation, leaving the
outer cannula in situ, and therefore restoring the patient’s airway, in case of blockage
(Hess 2005).

However, it should be noted that the presence of an inner cannula will reduce the
internal diameter of the tracheostomy, and therefore may increase the work of
breathing for a spontaneously breathing patient (Cowan et al 2001).

Recommendations
Patients should have a double-cannula tracheostomy tube, unless deemed
inappropriate for that individual.

The inner cannula must be removed and inspected for secretions regularly (as per
individual trust policy).

The inner cannula should be cleaned or disposed of as per individual trust policy.

The manufacturers instructions should always be read and followed prior to use.




Implementation Date:
August 2007


Review Date:
August 2008


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                                                   20
References
Cowan T, Op’t Holt T, Gegenheimer C, Izenberg S, Kulkarni P. Effect of Inner Cannula
Removal on the Work of Breathing Imposed by Tracheostomy Tubes: A Bench Study. Respir
Care 2001; 46(5):
460-465

Hess D. Tracheostomy Tubes and Related Appliances. Respir Care 2005; 50(4): 497-510

Heffner JE. The Role of Tracheotomy in Weaning. Chest 2001; 120: 477-481

Krishnan K, Elliot SC, Mallick A. The current practice of tracheostomy in the United Kingdom:
a postal survey. Anaesthesia 2005; 60: 360-364

St George’s Health Care NHS Trust Protocol August 2000. Appendix 1. Data collection
proforma.




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                                                   21
CHESHIRE & MERSEY CRITICAL CARE NETWORK
AUDIT OF TRACHEOSTOMY CARE BUNDLES


Trust………………………………                                              Hospital…………………………...
Lead Contact……………………..                                         Email:
Telephone:

Patient number:
Location (please circle):          HDU               ICU            Ward patient

                                     Day       Day       Day      Day   Day    Day   Day
                                     1         2         3        4     5      6     7
Heated humidified O2
Bedside safety equipment
Emergency         algorithm
available
Weaning       plan      and
assessment
Dressings changed daily
Need for suction assessed
Training in correct suction
procedure
Cuff pressures checked
each        shift       and
documented
Double               lumen
tracheostomy tubes

                                     Day       Day       Day      Day   Day    Day   Day
                                     8         9         10       11    12     13    14
Heated humidified O2
Bedside safety equipment
Emergency         algorithm
available
Weaning       plan      and
assessment
Dressings changed daily
Need for suction assessed
Training in correct suction
procedure
Cuff pressures checked
each        shift       and
documented
Double               lumen
tracheostomy tubes

Data Collected by:




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                                                   22
Tracheostomy Care Bundle Audit Form

 HOSPITAL ……………………….                                                                       DATE ………………



                                     Bed          1   2   3   4   5   6   7   8   9   10   11   12   13   14   15
   O2 therapy and




                                        Yes
                    humidification




                                           No

                                     Exclusions




                                        Yes
   Equipment
     Safety




                                           No

                                     Exclusions




                                        Yes
   Algorithms




                                           No

                                     Exclusions
   Decannulation
   Weaning and




                                        Yes

                                           No


                                     Exclusions
   Dressings and




                                        Yes
    Stoma Care




                                           No

                                     Exclusions




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                                                   23
                    Bed           1    2   3   4    5   6   7    8   9   10   11    12    13   14   15




                       Yes
   Suction




                          No

                    Exclusions
   Cuff Pressures




                       Yes

                          No

                    Exclusions




                       Yes
   Double tubes
   Single v




                          No

                    Exclusions




                       Yes

                          No


                    Exclusions




                       Yes

                          No

                    Exclusions




                           NB. If an ‘exclusion’ applies then ‘yes’ may also be ticked.




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                                                   24
           Element                             Criteria                    Exclusions
                                                                     


       O2 therapy and
       humidification


                                                                     


     Safety Equipment


                                                                     


         Algorithms


                                                                     


       Weaning and
       Decannulation


                                                                     


Dressings and Stoma Care


                                                                     


           Suction


                                                                     


       Cuff Pressures


                                                                     


   Single v Double tubes




Construct a table condensing all the criteria and exclusion as identified for each element. This

                  information is then printed on the reverse of the Audit Form.




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                                                   25
Acknowledgements
This document was brought together by a multi-professional group, whose main
participants were:

Peter Goman               East Cheshire Hospital
Laura Vincent             Royal Liverpool and Broadgreen University Hospital
Ian Tweedie               Walton Centre for Neurology and Neurosurgery
Anne Trafford             Walton Centre for Neurology and Neurosurgery
June Carr                 Aintree Hospitals
Joanne Oldroyd            Wirral Hospitals
James Mangam              The Cardiothoracic Centre
Helen Hagan               Mid Cheshire Hospital
Kathy Hodgson             Aintree Hospital
Sian Axon                 Cheshire and Mersey Critical Care Network
Francis Andrews           Whiston Hospital
John Gannon               Arrowe Park Hospital
Andrea Fazackerly         Royal Liverpool and Broadgreen University Hospital
Pat Crofton               Walton Centre for Neurology and Neurosurgery
Kathy McDermott           Whiston Hospital
Rosemary Gilbert




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                                                   26

				
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