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Tracheostomy following discharge from critical care

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					This is an official Northern Trust policy and should not be edited
                             in any way

 Tracheostomy following discharge from
             critical care
Reference Number:

NHSCT/10/329
Target audience:

All staff who manage patients with tracheostomies outside critical care

Sources of advice in relation to this document:

Valerie Jackson, Director Acute Hospital Services
Pauline McGaw, General Manager Anaesthetics

Replaces (if appropriate):

N/A
Type of Document:

Directorate Specific
Approved by:

Policy, Standards and Guidelines Committee
Date Approved:

16 June 2010

Date Issued by Policy Unit:

9 September 2010
                         NHSCT Mission Statement
 To provide for all the quality of services we would expect for our families
                                and ourselves
 Management of patients with a Tracheostomy
        following discharge from critical care


                             Guideline




(Adopted CCaNNI Guideline)
June 2010




                                                 3
Title:
 Management of patients with a tracheostomy following discharge from critical
care




   1. The purpose/objective of the standard/guideline:
         To promote patient safety and minimise potential risk in the context of
         tracheostomy care at the time of discharge from critical care units

   2. Intended target population:
         All staff who manage patients with tracheostomies outside critical care

   3. Time scale for implementation
          Tracheostomies are currently being cared for in general wards, in the
          interested of safety these guidelines should be implemented as soon as
          possible


   4. Resource Implications
         No cost implications as resources required for tracheostomies are already
         present within the system


   5. Financial disclosures/conflicts of interest
         None




                                                                                   4
Contents

1.0   Forward

2.0   Introduction

      2.1   Aim
      2.2   Background
      2.3   What this document adds

3.0   Transfer and Follow Up
      3.1 Location
      3.2 Choice of tube
      3.3 Inner cannula
      3.4 Speaking valves

4.0   Routine Tracheostomy Care
      4.1 Monitoring and cuff management
      4.2 Suctioning
      4.3 Swallowing / feeding
      4.4 Changing the tube

5.0   Management of Complications
      5.1 Tube obstruction
      5.2 Displacement
      5.3 Haemorrhage
      5.4 Other complications

6.0   Decannulation
      6.1 Decision making
      6.2 Downsizing
      6.3 Capping
      6.4 Assessing suitability
      6.5 Procedure
      6.6 Post decannulation observations

7.0   Appendix
      7.1 Swallowing
      7.2 Communications
      7.3 Working Group members




                                            5
1.0   Foreword

This document is the product of a workstream developed within the Critical Care
Network, Northern Ireland (CCaNNI). It was prompted by recognition that most risk in
the context of tracheostomy care of ICU patients is following discharge from the
critical care unit. The remit given to the working group was the development of
standardised guidance relating to the critical care discharge arrangements and
subsequent management of adult patients with a tracheostomy tube within a risk
management framework. It is hoped that this will promote consistency of
tracheostomy advice and support offered to the wards by critical care units in
Northern Ireland.

It is not designed as a detailed ‘how to’ document; local protocols and procedures
should determine this. However, where disparate practices have been identified, an
attempt has been made to establish professional consensus.

The guidance is not intended for patients with laryngectomies/”neck breathers” or
paediatric practice. Responsibility for these groups of patients lies with the relevant
specialty, as does provision of suitable guidance for care of these patients.
Similarly, it does not relate to subsequent management in long term facilities.

2.0   Introduction

2.1 Aim
To promote patient safety and minimise potential risk in the context of tracheostomy
care at the time of discharge from critical care units by setting consistent principles
which reflect current concepts of best practice, particularly around detection and
management of complications.

2.2 Background
The majority of new tracheostomies are performed in patients receiving care within
critical care (intensive care/high dependency) units. Over the last 10-15 years, the
ease of a variety of percutaneous methods has resulted in most tracheostomies
being performed by intensivists/anaesthetists. This document has been developed
with input from those who introduced, and were among the first to implement, the
percutaneous method in Northern Ireland. Intensivists/anaesthetists, critical care
nurses and physiotherapists are the specialists usually looked to for support and
advice in managing tracheostomies at ward level, partly because of the discipline’s
expertise in airway management, but also because of the large numbers of
tracheostomies sited by intensivists. A regional snapshot audit indicated that practice
varied throughout the region in regard to tracheostomy management.

Patients with tracheostomies are transferred both inter- and intra-hospital. Patient
repatriation necessitates that patients may be transferred with tracheostomy tubes in
place. Thus, patients with tracheostomies will continue to require care in general
wards.




                                                                                     6
Concerns about the importance of minimising risk in association with tracheostomies
are not confined to this region. They have prompted publications from the Intensive
Care Society (ICS) and the National Patient Safety Agency (NPSA).

Multiple sources [see bibliography] have been used in order to inform and establish
consensus. Amongst these, the most influential have been the relevant sections of
the ICS Guidance 2008. The ICS document itself acknowledges the paucity and lack
of evidence to support many of its elements of guidance. There are a small number
of key areas where regional consensus expert opinion differs from this guidance.

2.3 What this document adds.

The purpose of this document is not to replicate existing guidance described above.
It should be seen as complementary, with:

    •   A particular focus on the process of preparing a patient for discharge from
        critical care to a general ward, whether the tracheostomy has been
        established percutaneously or surgically

    •   The establishment and documentation of consensus across the region, in
        terms of risk management of tracheostomy following ICU care.

It should help in standardising the advice offered to wards. This should also assist
nursing staff, physiotherapy staff, allied health professionals and trainee doctors as
they move between HSC Trusts in Northern Ireland.




                                                                                         7
3.0       Transfer arrangement and Follow Up
At the time of transfer out of a critical care unit, including intra-hospital
transfer, it must be clear, and documented in patient’s notes, which team will
be responsible for care of the tracheostomy, and which person or team is
responsible for decision-making in relation to the tracheostomy, especially if that
team/person is not the specialty with primary responsibility for the patient’s care.

With regard to interhospital transfer between acute hospital sites, it is the
responsibility of the transferring/discharging hospitals/units to ensure that the
patient transfer is communicated to the relevant team (e.g. critical care or
surgical team) within the receiving Trust. Adult patients with tracheostomies should
only be transferred to hospital sites where there is twenty four hour availability of an
appropriately skilled discipline e.g. ENT/critical care.

3.1       Location

      •   Patients must be transferred to a ward where staff possess the skills
          and knowledge to care for the patient with a tracheostomy. Trusts must
          ensure local arrangements are in place to facilitate this. The receiving staff
          should possess competency-based training.
      •   As a general rule the patient should be nursed in an open observation area,
          rather than a side room (unless continuous 1:1 staffing is provided).
          Discussion with infection control teams should take place as close
          observation for airway compromise is likely to take priority over use of a side-
          room for infection control purposes.

3.2       Choice of Tube

      •   The choice of tracheostomy tube should take account of the patient’s
          condition, requirements, ongoing management and tube characteristics.
          Similarly, the type of tube suitable for an individual patient may change with
          time and the patient’s clinical condition.
      •   Professional opinion regionally from Critical Care Consultants is that there is
          practical need to retain individualisation by Consultant in respect of each
          patient’s perceived needs.
      •   Many patients can be weaned to decannulation without need to change from
          the original tube inserted at time of procedure. However options such as
          downsizing to an un-cuffed tube may be considered.
      •   It should be noted that standard tubes may be too short even in the patient
          with apparent normal anatomy, and the use of adjustable flange tube should
          be considered when (i) there is an anatomical problem to which an adjustable
          flange tube is better suited and (ii) when the chosen standard tube does not
          seem to be securely and appropriately placed.
      •   The type of tube that is in place should be clearly documented in the
          patient’s notes and any transfer documentation




                                                                                        8
3.3       Inner Cannulae

      •   A tube with a removable inner cannula is preferable for ward management,
          where possible, unless deemed inappropriate for that patient. An inner tube
          may help ward staff clear blockages.
      •   The risk of change of tube to one with an inner cannula, prior to discharge
          from the critical care unit, must be weighed against the potential benefit. Risk
          may outweigh benefit e.g. if the tracheostomy has been recently created or
          was difficult to site.
      •   It should be noted that the presence of inner cannula may reduce the internal
          diameter of the tracheostomy tube and thus may increase the work of
          breathing for a spontaneously breathing patient1. Furthermore, some patients
          may require a type of tracheostomy tube which is incompatible with an inner
          cannula.
      •   The inner cannula, if present, must be removed and cleaned regularly. The
          frequency of cleaning depends on individual patient assessment but should
          be a minimum of once daily.

3.4       Speaking valves (see Appendix 2 for further guidance)

Speaking valves can improve communication and patient mood but may block and
occlude the airway. Speaking valves, if used, should only be used with an un-cuffed
tube, or a cuffed tube with the cuff deflated. Used in combination with cuffed tubes,
speaking valves increases risk even with guidance for the cuff to be deflated. If
speaking valves are used on the general wards, staff must be familiar with them, the
risk of blockage, and know how to remove them.
Trusts should be clear in their local policy/practice/guideline regarding the use
(or not) of speaking valves outside critical care units.

3.5       Humidification

Humidification is essential whether the tracheostomy is open to atmosphere or
connected to an oxygen supply. Humidification method should be considered
according to patient needs and risk assessment.

      •   Heated/cold water humidification system. If heated, the heater should be set
          at 37oC to optimise mucosal function and maximise sputum clearance.
          Heated systems are encouraged in general. In patients with a particular risk or
          history of tube blockage, heated humidification should be utilised.
      •   Heat Moisture Exchange Devices (HMEs) – there may be a higher risk of
          tracheostomy blockage with HME use and HMEs may occlude the airway if
          secretions are copious. Alternative forms of humidification are encouraged to
          reduce risk but should not be used in combination with HMEs.
      •   Saline nebulizers (being intermittent) are inferior to continuous humidification.
          If optimal humidification is present they are redundant.




1
   The relationship between the inner diameter with an inner cannula in situ and outer
diameter/nominal tracheostomy tube size varies between manufacturers/tubes.


                                                                                         9
4.0 Routine tracheostomy care

      •   Essential equipment must be readily available at the bed space [Table 1]. This
          should be checked regularly, documented and signed.
      •   The tracheostomy tube should be secured with a collar or tapes. Changing
          collar/tapes is a two person procedure.
      •   A Tracheostomy Care Bundle is recommended, example Table 2.

Table 1          Essential equipment to be kept at bed space on general ward

Suction equipment
Appropriate suction catheters – size and length
Spare inner cannulae, if used
Spare tracheostomy tubes -same size and one size smaller
Resuscitation bag & mask
Trache collar or tapes
10 ml syringe
Hand held pressure manometer
A fully equipped resuscitation trolley should be available

                         Tracheostomy dilators are not recommended2


4.1       Monitoring and Managing Cuffs (if present)3,4

•     Cuffs should be high volume/low pressure and provide an effective seal
•     If and when the cuff is to be inflated, use only sufficient air in the cuff to abolish
      leak
•     Fingertip pressure on the external pilot balloon is not an accurate method of
      measuring cuff pressure
•     The cuff pressure should be maintained at less than 25 cm H2 O. The cuff
      pressure should be measured and documented 8 hourly, using a pressure
      manometer.




2
  This is a departure from ICS guidance. There is a strong view amongst regional experts (informed
by the literature) that, in the setting of difficulty with reinserting a trache tube, repeated attempts
should be avoided. Use of dilators in inexperienced hands is considered to increase risk rather than
reduce it. If there is any difficulty reinserting a tracheostomy tube, immediate assistance should be
sought from staff with advanced airway skills e.g. the on-call anaesthetist.
3
  This guidance is aimed at by far the most commonly used cuffed tracheostomy tubes, which have an
air-filled cuff which must be inflated by injection of air into the pilot tube. In a small number of patients,
a foam cuff (e.g. Fomecuff®) may be used. In these the cuff, constructed of air filled polyurethane
foam within an envelope, is deflated prior to insertion and then is allowed to expand passively once in
situ by opening the pilot port to atmosphere (ie a syringe is not used for injection of air). In such cases
the above guidance does not apply. Management of a foam cuff involves ensuring that the port
remains open to atmosphere.
4
   It is recognised that some individual manufacturers recommend specific volume rather than
pressure. However, this is difficult to incorporate in standardised guidance, aimed at covering a
variety of tubes and manufacturers.


                                                                                                          10
Table 2        Tracheostomy Care Bundle
 Routine care                       Suction (see 4.2)
 Cleanse site daily & PRN - Use     Suction when clinically indicated:
 normal saline and aseptic             • Audible secretions
 technique                             • Palpable secretions
                                       • Respiratory distress
 Check dressing if used PRN and
 change as necessary – use          Patients with copious secretions need frequent
 stoma dressing. Avoid using        suction
 dressing if stoma dry and clean
                                    Use closed/open system according to local
 Look for and report any evidence policy. With closed suction system, keep
 of infection                       continuous periods of suctioning to less than 5
                                    seconds. After a few seconds break, suctioning
 Check and clean inner cannula      can be repeated if necessary
 daily and PRN if this type of tube
 is used                            Use the correct length and size of catheter

 Check trache collar/tape is Use low vacuum (-100 to -150mmHg) routinely
 secure but not too tight. Tapes, if
 used, should be tied with a knot Clean catheter after suctioning with closed
 and not a bow and secured firmly system; discard single use catheter after use

                                    Change suction tubing every 24 hours or
                                    sooner if visibly soiled following adequate
                                    flushing
                                    Change suction bottle every 24 hours

 Humidification (see section 3.5)   Safety
 Check system at least 2 hourly     1. Check at start of each shift:
       Type                         • All beside equipment relating to trache care
       Temperature                      is available
       Water level                  • Cuff inflated or deflated – document
       Inspired oxygen              • If inflated, record cuff pressure and ensure it
       concentration                    is within recommended limits (see text).
       Empty ‘rain-out’             • Communication appropriate for patient
       (water/condensate) in the        o Call bell, paper and pen, alphabet board
       oxygen tubing if present         o Speaking valve, if permitted and
                                            appropriate (see main text)
                                    • Location remains appropriate for patient
                                    2. Regularly ensure tracheostomy tube is
                                    secured (see main text). Oxygen tubing must
                                    not drag on the trache tube
                                    3. One person must take responsibility for
                                    airway management whilst moving patient
                                    4. Note any respiratory distress




                                                                                   11
4.2    Suctioning5
Suctioning of secretions to prevent occlusion of a tracheostomy should be an aseptic
procedure and should be carried out when clinically indicated and not just on a
routine, timed basis.

•     Staff should be trained in the correct suction technique.
•     Adverse haemodynamic effects, patient discomfort and potential for hypoxia
      should be minimised.
•     Although evidence is contradictory, experience supports the installation of small
      aliquots of normal saline (0.9%)/single use sterile pods, if necessary, during
      physiotherapy to loosen thick tenacious secretions. As evidence is lacking saline
      should not be used routinely as it may decrease the baseline oxygen saturation.
•     The use of adequate humidification should reduce the requirement for saline
      irrigation.

4.3      Swallowing/feeding

•     The presence of a tracheostomy tube (whether with cuff inflated or deflated)
      interferes with swallowing. Although an inflated cuff may make swallowing worse,
      it offers some protection from aspiration.
•     Deflation of the cuff to facilitate establishment of an oral diet may be necessary
      and is best conducted by appropriately experienced staff with the patient being
      observed closely for any signs of aspiration.
•     Speech and Language Therapist (SALT) assessment may be valuable in a ward
      setting. For further guidance see Appendix 1.

4.4      Changing the Tracheostomy Tube

Recommendations for a prescribed frequency of tube change are inconsistent and
unsupported by evidence. In practice the frequency with which the tube requires
changing will be affected by the individual patient’s condition and type of tube used.
Assessment with a bronchoscope, if necessary, is preferable to routinely changing
the tube after a prescribed period.

•     A decision to change the tube must be made in conjunction with medical
      staff competent in the management of tracheostomies. Only those deemed
      competent to do so should change tracheostomy tubes.

•     Ongoing risk assessment and management of patient at ward level should inform
      the clinical decision to change the tube type at any given time.

•     Changing the tracheostomy tube is a two-person procedure. One of the two
      individuals should be either:
      o Medical staff with appropriate, advanced airway skills or
      o An alternative competent skilled practitioner e.g. specialist nurse or specialist
          physiotherapist


5
   Infection control procedures, here and elsewhere in this document should be consistent
with/determined by local infection control policy.


                                                                                      12
•   Tube change should be avoided within the first 72 hours unless absolutely
    essential.
•   In the case of percutaneous tracheostomy, it is preferable to defer tube change
    until at least 5-7 days, to allow the track (between the stoma and trachea) to
    become established.
•   Medical staff with advanced airway skills should perform/directly supervise
    the first tracheostomy tube change.
•   Subsequent changes, if required, can be undertaken by experienced staff trained
    and competent in tracheostomy tube changes.
•   All staff changing tracheostomy tubes electively must be aware of the risk
    of para-tracheal tube placement and be able to recognise the clinical
    features of failure to re-cannulate the trachea.
•   Resuscitation equipment must be readily available prior to tracheostomy
    tube change, along with all the items listed in Table 1.




                                                                                13
5.0       Management of Complications
The main life-threatening complications associated with a tracheostomy are
blockage, dislodgement and bleeding. These will normally present with respiratory
difficulty or distress. Bleeding from the stoma is relatively uncommon outside the
early period following its creation. If bleeding does occur, blood clots can block the
tracheostomy tube. All three complications can present with similar symptoms, and
all require restoration of airway patency.

If a patient with a tracheostomy develops any breathing difficulty, problems
with the tracheostomy should be excluded first.

Key points
  • Tube dislodgement, occlusion or bleeding is an emergency situation which
     may be life threatening if not rapidly diagnosed and resolved

      •   Help from senior medical staff with experience in airway and tracheostomy
          management should be sought early

      •   Early intubation to secure the airway may be the immediate priority if
          respiratory and/or cardiovascular compromise occurs.


5.1       Tube Obstruction / Occlusion (Table 3)

Recognition
The patient may present with increasing respiratory distress over a few hours or
deterioration maybe more rapid. In such circumstances:

                Do not panic,
                Reassure patient
                Call for expert help

1. Assess whether the tracheostomy is patent by:
    • Checking for air movement through tube during expiration (look, listen and
      feel)
    • Asking the patient to cough
    • Attempting to pass a suction catheter (with vacuum attached) via the trache
      tube

2. Determine if patient is breathing through mouth and nose




                                                                                    14
 Table 3 Management of a Blocked Tracheostomy tube (excluding
 laryngectomy)


        Commence oxygen via whichever route there is air movement

                      Check if tube is single or dual cannula
                    If dual cannula remove the inner cannula

            Assess for subsequent patient improvement/air movement
                 Inspect lumen of inner cannula for debris/plug.

    Ensure there is no kinking or compression of tube or oxygen supply

                             Stop NG feed if in progress

                         Is the airway stoma still blocked?
                   Yes                                         No

1. Call ICU/Anaesthetics for urgent help.     Clean and replace inner cannula.

2. In meantime deflate cuff to allow Assess patient’s breathing: Is the
patient to breathe around the tube patient still distressed?
through nose and mouth. If a speaking
valve is present, remove it.              Consider seeking advice re need or
                                          otherwise for semi-elective tube
3. Give high flow oxygen via face mask if change.
spontaneously breathing through mouth.
                                          Ensure adequate humidification.
4. If not breathing use bag and mask
resuscitation and monitor oxygen Consider              alternative causes of
saturation. Check pulse.                  respiratory distress.

5. Does the patient require endotracheal
intubation?

6. If airway obstruction is not reversed by
removal of inner cannula and deflation of
cuff, remove entire tracheostomy tube,
and reassess for air movement through
stoma/mouth and improvement of
symptoms – administer oxygen via
whichever route there is air movement.
Proceed as per management of
dislodged tracheostomy tube.




                                                                                 15
5.2 Displaced Tracheostomy Tube (Table 4)


Recognition
Tube dislodgement may be partial or complete. This may not be obvious initially as
the patient may be able to breathe through his/her mouth and nose.

Tube displacement is a possible cause of cardio-respiratory arrest. Appropriate
management of cardiac arrest in a patient with a tracheostomy includes ensuring
adequate airway management – see local Trust policy.

1. The tracheostomy should be inspected. Any one of the following indicates
possible dislodgement:
    • Ongoing blockage (lack of air movement, inability to pass suction catheter)
      despite manoeuvres described in Tube Occlusion
    • Obvious outward displacement of the tube from its previous position
    • Noisy breathing (may indicate partial dislodgement)
    • Patient able to speak audibly past an inflated tracheostomy cuff (where
      present).

2. Following removal of an inner cannula (if present), inability to pass a suction
catheter easily via the tracheostomy tube into the trachea should be regarded
as confirming tracheostomy tube dislodgement.6

3. A tube which is too small may be inappropriately sited. It may lie partially in the
trachea or against tracheal wall. This may present as partial dislodgement.




6
  Ability to pass a suction catheter successfully through the lumen of the tube does not guarantee that
it is not partially obstructed. Viscous secretions/mucosal hypertrophy can cause a ball-valve effect
which may allow the passage of the catheter.




                                                                                                   16
  Table 4 Management of Dislodged / Displaced Tracheostomy Tube

                                     Do not panic
                                  Reassure patient
                           Call for ICU/Anaesthetic help


                                  In meantime
                            Assess state of patient:
                                 Conscious level
                           Degree of respiratory distress
                                Oxygen saturation

             Assess whether dislodgment is partial or complete:
            Presence of some air movement via trache tube suggests
                          dislodgement may be partial

               If dislodgement is partial, deflate cuff (if present)
                      and assess briefly for any improvement

   Administer high flow oxygen by whatever route there is air movement



Ongoing management depends on the state of the patient:

   1. If in respiratory distress and suction catheter cannot be passed,
      remove entire tracheostomy tube (following cuff deflation).
   2. Occlude stoma externally and assess if patient can breathe through nose
      and mouth. If this does not rapidly relieve distress, orotracheal intubation
      may be necessary. Bag and mask resuscitation may be required in the
      interim.
   3. If distress is not present, or is relieved by removal of the tube, an attempt to
      replace the previous trache tube with a new one may be appropriate.
      There should not be repeated attempts to replace a trache tube in a
      ward environment.
   4. If trache tube replacement proves difficult, consider transfer to an area with
      more trained staff and equipment e.g. theatre.
   5. If distress is not present but concern remains, bronchoscopic assessment
      of the tube should be considered.


  If the above measures address tracheostomy position and patency, and
  respiratory distress is still present, consider alternative reasons.




                                                                                         17
5.3      Haemorrhage (Table 5)

Moderate blood staining of tracheal secretions is often due to bronchial epithelial
trauma from the suction catheter and requires no specific treatment. However,
erosion of the innominate artery by pressure from the tracheostomy tube or the tube
cuff is rare but may cause catastrophic blood loss. There may be apparently
insignificant sentinel bleeding a number of hours beforehand.

Bleeding several days or weeks after creation of the tracheostomy usually
occurs due to erosion of blood vessels in/around the stoma site. It may settle with
conservative management.

Table 5        Management of bleeding from a Tracheostomy

                                  Do not panic
                                Reassure patient
                                   Call for help
                                  Give oxygen
                             Remove dressing if in place

                Minor bleeding                              Major bleeding

•     Request surgical, and/or anaesthetic       •   Call for urgent anaesthetic/ICU
      review                                         help
•     Check stoma site for obvious bleeding      •   If cuffed tracheostomy tube in
      point – ward staff should not remove           place insert additional air to cuff
      tracheostomy tube in this situation,           maximum total of 20ml in attempt
      unless in line with blocked/dislodged          to protect maximum airway
      guidance                                       protection +/-tamponade bleeding
•     Clean site with normal saline              •   If the airway is not protected by a
•     Apply digital pressure to any obvious          cuffed tracheostomy tube, an
      bleeding site                                  orotracheal tube should be sited
•     Suturing locally may also help                 with the cuff below the bleeding
•     If bleeding persists soak gauze with           point.     This      will   require
      dilute adrenaline 1:80,000-1:200,000 and       experienced anaesthetic input
      apply to bleeding site using digital       •   In massive arterial bleeding, it
      pressure                                       may be necessary to insert a
•     If still oozing applying Kaltostat to          gloved finger into the stoma in an
      promote local clot formation may be an         attempt to compress the bleeding
      option                                         artery against the posterior
•     Check full blood count and coagulation         portion of the sternum
      screen                                     •   Emergency referral must be
•     Continuous observation of patient is           made for surgical/bronchoscopic
      essential even if bleeding stopped. Look       intervention (ENT).
      for and report any evidence of neck
      swelling
•     Minor bleeding may progress to major
      bleeding.




                                                                                      18
5.4       Other complications

      •   Surgical emphysema is a potentially life threatening complication. Inform
          anaesthetic staff/ICU team immediately.             There is a risk of
          pneumomediastinum if positive pressure ventilation is applied, and this could
          make intubation more difficult.
      •   Pneumothorax may occur as a complication at the time of the creation of the
          tracheostomy. However, it may also occur later - particularly if the lower
          airway has been instrumented e.g. use of a bougie during change of
          tracheostomy tube. Contact ICU or surgical staff.



6.0       Decannulation (Planned removal of tracheostomy tube)
6.1       Decision-making

Decisions to decannulate electively a patient with a tracheostomy should only be
made by a healthcare professional with appropriate training and competency.

6.2       Down-sizing

Opinion and practice vary with respect to down-sizing tracheostomy tubes. Trusts
should be clear what their local policy/usual practice is on down-sizing. It is
important to recognise that reduction in the internal diameter of a tube with a fixed
bend may result in a tube that is too short or does not lie appropriately within the
trachea, or dislodges easily, each producing a risk of airway obstruction. An uncuffed
Mini-tracheostomy tube (e.g. 6mm) should not cause this effect, and may help
maintain good tracheal toilet when a patient no longer requires a full size
tracheostomy. Mini-tracheostomy tubes should be capped when not in use so that
unhumidified air is not entrained into the lower airway.


6.3      Capping
Capping uncuffed tracheostomy tubes (or cuffed tubes with cuff deflated), often in
conjunction with downsizing,7 is controversial as a means to “wean” patients from a
tracheostomy. Tracheostomy tubes must NEVER be capped without:
    (i)    deflation of the cuff (if present), and
    (ii)   an assessment that the patient is able to breathe around the tube through
           the mouth and nose. Crusted secretions may be present on the outer
           aspect of the portion of the tube within the trachea (hence not evident) and
           obstruct breathing around the tube.

Trusts should be clear what their local policy /usual practice is on capping
tracheostomy tubes.




7
 Capping in the absence of downsizing risks increased work of breathing and possible airway
obstruction.


                                                                                              19
6.4       Assessment of suitability for decannulation

The first requirement for decannulation is the determination that the indication
for tracheostomy is no longer present. This may be indicated, e.g. by return of a
strong cough/improved muscle power, reduction of secretion load, or improved
protective airway reflexes.

Prior to elective removal of a tracheostomy, the following questions should be
considered:
    • Is the patient is able to cough and swallow effectively, and protect their
       airway?
    • Is ventilatory reserve adequate? (decannulation increases anatomical dead
       space and may increase the work of breathing)
    • Is bronchopulmonary infection or other pathology resolving?
    • Is the patient likely to be able to cope with the volume and viscosity of
       pulmonary secretions present?
    • Does the patient have adequate nutritional status?
    • Is the patient comfortable with the cuff deflated?
    • Is the airway patent above the level of the stoma?

6.5       Procedure

Decannulation (except in extreme emergencies involving a blocked airway)
should be performed only by those trained and experienced in the procedure.

      •   Suction the mouth and pharynx to remove any pooled secretions
      •   Assess the patient’s ability to breathe around the trache tube. With the cuff
          deflated (if present), the end of the tracheostomy tube should be occluded
          briefly with a clean, gloved finger to check for airflow around the tube.

[If capping is in line with local Trust practice/policy, it can be used at this point
provided:

      (i) it is ONLY used in conjunction with uncuffed tracheostomy tubes, or with
           tubes whose cuff is, and will remain, deflated
      (ii) the patient will remain under continuous close observation while the tube is
           capped
      • Suction via the tracheostomy tube immediately prior to decannulation
      • Remove the tracheostomy tube
      • After decannulation, cover the stoma with a dressing, in accordance with local
           policy
      • Remain with the patient until observations are satisfactory
      • The patient should remain in an open observation area for at least 24 hours
           following decannulation.




                                                                                    20
6.6       Post Decannulation Observations

The patient should be observed for signs of respiratory compromise including:
   • Dyspnoea
   • Laboured or noisy respiration, stridor
   • Increased respiratory rate and heart rate
   • Increased use of accessory muscles
   • Diaphragmatic respiration (see-saw pattern)
   • Agitation
   • Oxygen desaturation.

In the event of a failed decannulation, maintaining the airway is the priority.

      •   Management should be as for a dislodged tracheostomy tube

      •   A decision to reinsert the tracheostomy tube depends on:
             (i) Clinical condition of the patient and skills of the staff
             (ii) Access to intubation and resuscitation equipment, anaesthetic and
                  emergency drugs. Urgent transfer of the patient to a suitable area
                  where the above is available, such as theatre/ICU, may be necessary.


Equality, Human Rights and DDA

This policy is purely clinical/technical in nature and will have no bearing in terms of
its likely impact on equality of opportunity or good relations for people within the
equality and good relations categories.

Alternative formats

This document can be made available on request on disc, larger font, Braille, audio-
cassette and in other minority languages to meet the needs of those who are not
fluent in English.


Sources of Advice in relation to this document

The Policy Author, responsible Assistant Director or Director as detailed on the
policy title page should be contacted with regard to any queries on the content of this
policy.




                                                                                          21
Appendix 1

SWALLOWING

A tracheostomy tube may cause swallowing impairment in patients who have
previously had no difficulty swallowing and may cause further difficulty for those
patients who previously presented with dysphagia.

There are several suggested mechanisms which predispose patients with a
tracheostomy to swallowing difficulty and possible aspiration:
    • Compression of the oesophagus from inflated tracheostomy tube cuff
    • Impaired laryngeal elevation as a result of laryngeal tethering due to the
      presence of a tracheostomy tube
    • Reduction in laryngeal sensitivity as a result of diverted airflow
    • Disruption of normal co-ordination between breathing and swallowing,
      particularly in ventilated patients
    • Reduced effectiveness of cough to clear secretions from the upper airway
    • Loss of subglottic positive pressure.

By deflating the cuff, the adverse effect of the tracheostomy on the normal
swallowing mechanism may be reduced.


Swallowing may also be affected by:
  •   Neurological or mechanical disorders
  •   Post-operative pain and/or oedema
  •   Radiotherapy pain and/or oedema
  •   Excessively dry mouth (xerostomia) may be due to side effects of medication.

Patients with tracheostomy may also experience loss of appetite due to the altered
airway, which causes a reduction in the ability to smell. Patients undergoing
radiotherapy may experience altered taste sensations and/or a painful, ulcerated
mouth.

However, not all patients with tracheostomy will have swallowing problems. Ideally
oral intake is deferred until at least partial cuff deflation has been achieved.
However, in special circumstances (e.g. quality of life issues) a team decision for
small amounts of oral intake with cuff inflated or with partial cuff deflation may be
indicated. The SLT/competent practitioner should ensure that the potential risks for
                                                                      s
secondary complications are made clear to all involved in the patient' care.

When to consider referral to Speech and Language Therapy for Swallowing
Assessment of patients with Tracheostomy in situ:
  •  Concomitant neurological disorders e.g. Stroke, bulbar palsy
  •  Concomitant head and neck surgery
  •  Evidence of aspiration of enteral feed or oral secretions on tracheal
     suctioning, or recurrent unexplained chest infection
  •  Increased secretions when cuff is deflated
  •  Persistent wet/weak voice when cuff is deflated and speaking valve or de-
     cannulation cap in place.
  •  Coughing and/or de-saturation following oral intake
  •  Disuse atrophy
  •  Patient anxiety or distress during oral intake


                                                                                  22
Appendix 1


Oral Intake for Patients with Tracheostomy following Head and Neck Surgery
It is recommended that the SLT perform a detailed assessment of this patient group,
ideally at the pre-operative stage.

Speech and Language Therapists are only involved in the assessment and
management of those patients who present with swallowing or specific
communication problems.




                                                                                23
Appendix 2

COMMUNICATION

The impact of the loss of normal voice following tracheostomy should not be
underestimated and, whenever possible, patients and their families should be
prepared for this with explanation and written information.

Developing alternative means of communication, including the use of a speaking
valve is a vital part of care.

Patients should have a means of summoning support and advice particularly
during emergency situations (See Safety Section of Routine Care)

The Speech and Language Therapist (SLT) has an important role in the care of
patients with a tracheostomy when there are communication difficulties.

Following SLT assessment, a communication care plan specific to the individual
needs should be completed.

All those involved in supporting the patient should follow an agreed protocol to
facilitate communication

Methods of Communication

The Speech and Language Therapist can advise patients, family and staff on the
most effective way to communicate.

Non-verbal Communication – Methods to Consider

Writing

Lip Reading – ensure dentures are in place if appropriate. Ask the patient to
exaggerate their lip movements. Encourage use of short sentences. Look for key
words to aid your understanding.

Facial Expression and Gestures – concentrate on facial and body expressions
which will add “extra” information to the patient’s words.

Coded Eye Blink or Hand Gesture = Instruct the patient to blink once for “yes” and
twice for “no. Alternatively consider thumbs up for “yes” and down for “no”. Ensure
staff use the agreed system consistently to minimise patient fatigue and confusion.

Alphabet Board, Picture Board and Phrase Books
Laminate A4 sheets displaying the alphabet in large letters or simple picture
depicting basic activities. These systems can be supplemented by a list or book of
useful phrases for the patient. Communication boards can be individualised for each
patient by the Speech and Language Therapist.

Electronic Larynx and Electronic Communication Aids – It is necessary for the
Speech and Language Therapist to assess the patient for the use of one of these
aids and then if appropriate advise the patient, family and staff in their use.



                                                                                24
Appendix 2

Verbal Communication – Methods to Consider

Voice production may be achieved in patients with a tracheostomy tube by using a
variety of techniques under the guidance of a competent practitioner. e.g. cuff
deflation, intermittent finger occlusion and one-way speaking valves.

Cuff Deflation – deflation of the cuff of the tracheostomy tube will allow the air to
pass into the upper airway on expiration. Voice will be achieved as air is directed into
the larynx, however the strength of the voice will be weaker as some air will pass out
of the open tracheostomy. Trusts should be clear what their local policy/usual
practice is on cuff deflation.

Downsizing of Tracheostomy Tube – use of a smaller tube will allow increased
passage of air between the tube and the tracheal walls on expiration. Trusts should
be clear what their local policy/usual practice is on down-sizing. Refer to main text.

Intermittent Finger Occlusion – intermittently occluding the tracheostomy tube with
a gloved finger will allow for effective voicing in patients. This technique should only
be introduced by a competent practitioner and must only be used if the cuff is
deflated.

One way speaking valve e.g. Passey Muir Valve
This type of speaking valve has a one-way mechanism that allows air to be entrained
via the tube opening on inhalation but not exhaled through this route. Airflow is then
redirected back down the tube tip and up into the larynx on exhalation, allowing
voicing.

The Speech and Language Therapist can provide advice on the introduction and
management of speaking valves. However if used on general wards, all staff
must be familiar with them, the risk of blockage, and know how to remove
them.

Warning – A speaking valve should only be used if the cuff is deflated or with
an uncuffed tube. The combination of speaking valve and a trache tube with
the cuff deflated can be risky.
Trusts should be explicit in their local policy/practice for use of speaking valve
outside critical care units.

The Speech and Language Therapist will be able to provide information and advice
on achieving the most appropriate communication system for the individual patient.




                                                                                     25
Appendix 3

CCaNNI TRACHEOSTOMY WORKING GROUP MEMBERS

Mary Lennon, Nurse Clinical Specialist ICU, Southern HSC Trust (Chair)

Ana Marie Magorrian, Principal SLT Manager for Acute Adult SLT Services,
Belfast HSC Trust

Dr Charles McAllister, Consultant, Intensive Care Medicine & Anaesthesia,
Southern HSC Trust

Kate McCusker, ICU Sister, Northern HSC Trust

Sally Murphy, Physiotherapist, Belfast HSC Trust

Dr John Trinder, Consultant, Intensive Care Medicine & Anaesthesia, South
Eastern HSC Trust




                                                                            26
BIBLIOGRAPHY

DHSSPS (2009) Best practice Circular - Reducing The Risks Associated With The
Management of a Patient with a Tracheostomy

Dikeman K.J. and Kazandjian M.S. (2003) communication and swallowing
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California Singular Publishing Group

Donizelli J, Brady S, Wesling Theisen M (2005) Effects of the removal of the
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Leder SB, Tarro JM Burrell MI, 1996, Effect of Occlusion of a Tracheostomy Tube on
Aspiration, Dysphagia, 11 (4) 254-258.

Leder SB (1999) Effect of One Way Tracheostomy Speaking Valve on the Incidence
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Leder SB & Ross DA (2000) Investigation of the causal relationship between
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Logemann JA (1998) Evaluation and Treatment of Swallowing Disorders, Texas Pro-
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Mackenzie et al (2008) Standards for the care of adult patients with a temporary
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Murray J (1999) Manual of Dysphagia Assessment in Adults, San Diego California
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McClave SA, DeMea MT, DeLegge MS, North American Summit on Aspiration in the
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Nutrition (2002) 26 (6): S80 – 86.

National Patient Safety Agency (NPSA) (2005) Management of patients with a
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NHS Quality Improvement Scotland, Best Practice Statement,( 2007) Caring for the
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          s
St George' Healthcare NHS Trust (2000) Guidelines for the care of patients with
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West Yorkshire Critical Care Network, Tracheostomy care bundle.




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