PROCEDURE Tracheostomy Cuff and 13 Tube Care

Renee Johnson PURPOSE: Tracheostomy tube care includes care of the tracheal tube cuff, the inner and outer cannulas of the tracheal tube, and the tracheal dressing and ties. Proper care of the tracheostomy tube maintains an adequate airway seal and tracheal tube patency. Proper cuff infl ation may decrease the risk of aspiration of some particles. The tracheal dressing and ties are changed to maintain skin integrity and decrease the risk of infection. Additionally, the tracheal ties help maintain stability of the tracheal tube and prevent tube dislodgement.

PREREQUISITE NURSING identifi ed by the surgeon, and an incision is made below KNOWLEDGE the cricoid cartilage. The isthmus of the thyroid gland is exposed, cross-clamped, and ligated. A Bjork fl ap may be • refers to the surgical procedure in which an created. The fl ap is created when a small portion of the incision is made below the cricoid cartilage through the tracheal cartilage is pulled down and sutured to the skin. second to fourth tracheal rings (Fig. 13-1). Tracheostomy The fl ap helps facilitate reinsertion of the tracheostomy refers to the opening, or the stoma, made by the incision. tube if it is dislodged, especially in patients who may be The tracheostomy tube is the artifi cial airway inserted into obese or have diffi cult anatomy.14 Percutaneous tracheot- the during the tracheotomy ( Fig. 13-2 ). omy has been proven to be a safe alternative to surgical • A tracheotomy is performed as either an elective or emer- tracheostomy on mechanically ventilated patients.8,13 gent procedure for a variety of reasons (Box 13-1). There Unlike surgical tracheotomy, percutaneous tracheotomy is no standard time when a tracheotomy should be per- can be performed without direct visualization of the formed. The decision is based on the projected length of trachea. 14 A bronchoscope may or may not be used to time that or an artifi cial airway is assist with visualization during the procedure. A needle is required to remain in place. A tracheostomy tube is the passed into the trachea. A J-tipped guidewire is placed into preferred method of airway maintenance in patients who the trachea, the incision is then the dilated, and the trache- may require mechanical ventilation for more than 14 to ostomy tube is placed. 21 days. 4-6,20,23,25 Further studies need to be done to help • Tracheostomies are not without complications. Common predict which mechanically ventilated patients may benefi t complications include infection, bleeding, tracheomala- from early tracheostomy. 2,3,11-13 cia, skin breakdown, and transesophageal fi stula. Common • Compared with endotracheal tubes, tracheostomy tubes postoperative tracheostomy emergencies are hemorrhage, provide added benefi ts to patients, including the follow- tube obstruction, and dislodgement. Hemorrhage can ing: prevention of further laryngeal injury from the trans- occur at the stoma site or into the trachea. A small amount ; improved patient comfort, acceptance, and of bleeding is expected postprocedure and is limited to a tolerance; ease of oral care; decreased work of breathing short period of time. Bleeding that continues or is moder- due to decreased airfl ow resistance; facilitation of weaning ate to large in volume could be due to a bleeding vessel from mechanical ventilation; decreased requirements or a tracheoinnominate artery fi stula. Bleeding vessels for ; provision of a speech mechanism which may need to be ligated by a physician. enhances communication; increased patient mobility; • Tracheoinnominate artery fi stula is a rare complication facilitation of removal of secretions; and reduced risk for with high mortality indices. In this complication the unintentional airway loss. innominate artery has eroded into the trachea, which can • Elective tracheotomy is generally performed in the operat- result in exsanguination and is more common when a ing room but may be performed at the bedside; percutane- tracheostomy tube is subject to traction to one side or the ous tracheotomy is commonly performed at the bedside other, away from the midline. Any concerns over bleeding on ventilated patients. Emergent surgical should be reported to the physician immediately. Tube may occur before the patient arrives in the critical care obstruction can occur from occlusion due to secretions or unit or at the bedside (for additional information on from the tracheostomy tube being displaced into the ante- cricothyrotomy refer to Procedure 11 ). rior portion of the trachea within a false passage. If the • Surgical placement is performed under general anesthesia. tube is obstructed from secretions, it should be suctioned. Using an open surgical technique, a stoma is created. The If the tube is felt to be dislodged into a false passage, trachea is visualized by the surgeon. Landmarks are treatment depends on how mature the stoma is. If the

89 90 Unit I Pulmonary System

Thyroid stoma is mature the tube should be replaced. If the stoma cartilage is immature—that is, the stoma is less than a week old— mask ventilation should be employed with the cuff defl ated Cricothyroid and an orotracheal tube should be inserted. Once the Cricothyroi- membrane airway is secure the tracheostomy can be revised. 14 The dotomy physician should be notifi ed if the tube becomes obstructed Cricoid and aggressive measures other than routine suctioning are cartilage needed to clear the cannula or secretions of debris. • An initial tracheotomy tube change varies depending Percutaneous Subcricoid on whether the trach was placed via standard surgical dilational space procedure or via percutaneous approach. Currently there tracheostomy is no evidence to justify when the initial or subsequent First tracheal cartilage tracheotomy tubes should be changed; it typically occurs by physician preference. The fi rst tube change most Standard lracheoslomy Second tracheal commonly occurs around day 5 postoperatively. Some sile cartilage reports state that for a percutaneous tracheotomy the initial change should not occur until postoperative day 10 to allow the stoma to mature. After the initial change, the tracheotomy should be changed approximately every 14 days thereafter. The fi rst change is usually done by the Figure 13-1 Sites for tracheostomy insertion. (From Serra A: physician. 12,14 Tracheostomy care, Nurs Stand 14:42,45–52, 2000.) • In all instances, caution should be used to ensure that the tracheostomy tube is not accidentally dislodged or decan- nulated. The stoma takes approximately 1 week to heal posttracheotomy. Dislodgment of the tube in the fi rst week is considered an emergency; the tissue may collapse, and it may not be possible to replace the tracheal tube. Predis- Oral pharynx posing factors to tube dislodgement or decannulation include an underinfl ated cuff, loose ties, neck or airway edema, excessive coughing, agitation or undersedation, Epiglottis morbid obesity, downward traction caused by the weight of the ventilator circuit, and an improperly sized trache- Larynx ostomy tube. Trach ties should be secure. Weight or trac- Vocal cords tion from the ventilator circuit should be minimized; when Thyroid cartilage transporting or mobilizing the patient the tube should Trachea Cricothyroid membrane remain in a neutral midline position. Tube position should be noted before and after the patient is moved to ensure Cricoid cartilage Esophagus safety. Individual institutions usually use protocols to manage new tracheostomy tubes and accidental dislodg- ment to ensure patient safety. 7,12,14,17,31,33 • A tracheostomy tube is shorter than but similar in diameter to an endotracheal tube. Some tracheostomy tubes have both outer and inner cannulas. The outer cannula forms the body of the tracheostomy tube with a cuff. The neck Figure 13-2 A tracheostomy (sometimes called a tracheotomy) fl ange, attached to the outer cannula, assists in stabilizing is created surgically by making an opening through the skin of the the tube in the trachea and provides the small holes neces- neck into the trachea. (From Serra A: Tracheostomy care, Nurs sary for properly securing the tube. Some tracheostomy Stand 14:42,45–52, 2000.) tubes have an inner cannula inserted into the outer cannula. The inner cannula is removable for easy cleaning without airway compromise and may be disposable. The tracheal tube cuff is an infl atable balloon that surrounds the shaft BOX 13-1 Indications for Tracheostomy of the tracheal tube near its distal end. When infl ated, the • Bypass acute upper airway obstruction cuff presses against the tracheal wall to prevent air leakage • Prolonged need for artifi cial airway and pressure loss from the lungs during positive pressure • Prophylaxis for anticipated airway problems ventilation. The tracheal tube cuff is infl ated by injecting • Reduction of anatomical dead space air through a pilot balloon with a one-way infl ation valve. • Prevention of pulmonary aspiration The air in the pilot balloon is used to assess of the amount • Retained tracheobronchial secretions of pressure in the tracheal tube cuff (Fig. 13-3). • Chronic upper airway obstruction • Tracheostomy tubes are available in various materials, sizes, and styles from several manufacturers. It is important 13 Tracheostomy Cuff and Tube Care 91

the inner cannula is removed, the cuff defl ated, and the Outer cannula tracheostomy tube occluded with the plastic plug, the patient can breathe through the fenestration(s) and around Cotton tape the tube, using the normal anatomical airway. When a Flange fenestrated tracheostomy tube is occluded in this manner, Outer the patient can speak, as air is allowed to pass over the Pilot cannula vocal cords. Additional oxygen can be provided to the 8 balloon Cuff patent via nasal cannula if needed. Inflation • Uncuffed tubes are commonly used in children, in patients One-way tube with laryngectomies, and during weaning from the trache- inflation X-ray valve indicator ostomy. Uncuffed tubes may also be used in long-term Inner cannula mechanically ventilated patients who have adequate pul- 15 mm monary compliance and suffi cient oropharanygeal muscle adapter strength for functional swallowing and articulation and Rounded laryngeal strength to achieve glottis closure. 8 tip • Cuffed tubes are generally used in patients requiring Obturator mechanical ventilation. Cuffed tubes allow for airway Figure 13-3 Parts of a tracheostomy tube. (From Eubanks DH, clearance, and the cuff limits aspiration of oral and gastric Bone RC: Comprehensive respiratory care , ed 2. St Louis, 1990, secretions in ventilated patients. Cuffed tubes include Mosby, p. 570.) high-volume, low-pressure cuffs; low-volume, high- pressure cuffs; and foam cuffs ( Fig. 13-4 ). High-volume, low-pressure cuffs are the most desirable. These tubes for the clinician to understand the differences between the allow a large surface area to come into contact with the various tracheostomy tubes to ensure appropriate feature, tracheal wall, distributing the pressure over a much greater fi t, and size for the patient. The tube should be selected with area. This cuff has a relatively larger infl ation volume that the goal of minimizing damage to the tracheal wall, allow- requires lower fi lling pressure to obtain a seal (< 25 mm Hg

ing adequate ventilation, and when possible promoting or 34 cm H2 O). The older cuff design (low-volume, high- translaryngeal airfl ow for communication to assist with pressure) may require 40 mm Hg (54.4 cm H2 O) to obtain future rehabilitation and therapy. The American Thoracic an effective seal and is undesirable. Society has published guidelines to guide users in selecting • It is generally accepted that cuff pressure should be 20 to the appropriate tube and size.12,16 Routine patient care and 25 mm Hg to minimize the risk of tracheal wall injury and tube maintenance may be affected based on the tube size, decrease the risk of microaspiration for most tracheos- style, and construction. tomy tubes. 8,26 The amount of pressure and volume neces- • Tracheostomy tubes can be constructed of metal ( or sary to obtain a seal and prevent mucosal damage depends stainless steel) or plastic (polyvinyl chloride or silicone). on tube size and design, cuff confi guration, mode of ven- Metal tubes are rarely used due to cost, rigid construction, tilation, and the patient’ s arterial blood pressure (tracheal lack of cuff, the possibility of damage by cleaning with capillary perfusion pressure is 25 to 35 mm Hg for nor- hydrogen peroxide or enzymatic cleaners, and lack of a motensive patients). Lower cuff pressures are associated 15-mm connector needed to attach the tracheostomy tube with less mucosal damage but are also associated with to a ventilator or bag-valve mask.8,14 Polyvinyl chloride silent aspiration, which has been shown when the cuff softens with the patient ’s body temperature, which helps pressures are less than 20 mm Hg. 8,22,30 the tube conform to the patient’ s anatomy and assists in • Appropriate cuff care helps prevent major pulmonary centering the distal tip in the trachea. Silicone tubes are aspirations; prepares for tracheal extubation; decreases the naturally soft and are not affected by the patient ’ s body risk of inadvertent decannulation; provides a patent airway temperature.8 for oxygenation, ventilation, and removal of secretions; • Tracheostomy tubes may be angled or curved, and come and decreases the risk of hospital-acquired infections. in standard or extra length, fenestrated, and cuffed or • A variety of techniques or devices is available to measure uncuffed. Angled tubes have a straight portion and a cuff pressures, including bedside pressure manometers. curved portion, whereas curved tubes have a uniform Two techniques, minimal leak technique and minimal angle of curvature. Extra length on the tracheostomy tube occlusion volume (MOV), had historically been listed may refer to additional length that is proximal (horizontal in the literature as effective methods to assess proper length) or distal (vertical length). Extra proximal length cuff infl ation. Both of these methods have fallen out may facilitate tracheostomy tube placement in patients of favor due to the risk of aspiration when the cuff is with large necks (for example, obese patients); extra distal defl ated, increasing the incidence of ventilator-associated length may facilitate placement in patients with tracheal pneumonia for some patients. Little research has been anomalies or tracheal malacia.8 conducted regarding the best practices with cuff pressure • Fenestrated tracheostomy tubes are similar to standard assessments.10,15 tracheostomy tubes with an added opening located in the ❖ Measurement of tracheal tube cuff pressures can be posterior portion of the tube above the cuff. Fenestrated achieved through the use of a commercial pressure tubes come with an inner cannula and a plastic plug. When gauge by assembling equipment to assess pressure via 92 Unit I Pulmonary System

Figure 13-4 Cross-sectional view in D-shaped trachea. Effects of soft and hard cuff infl ation on the tracheal wall. (From Kersten LD: Comprehensive respiratory nursing . Philadelphia 1989, Saunders, p. 648.)

bedside manometer. An advantage to direct cuff pres- mechanisms are mainly responsible for airway damage: sure monitoring is that there is no need to defl ate then tube movement and pressure. Duration of intubation reinfl ate the cuff, thus decreasing the potential risk for also plays a signifi cant role.16,28 aspiration. Disadvantages are that these devices are ❖ Routine cuff defl ation is unnecessary and is no longer designed for high-volume, low-pressure cuffs that recommended.17 are air fi lled. Saline-fi lled cuffs would damage the • Consideration should be given to obtaining assistance device.24 with tracheostomy care, especially when tracheal ties are ❖ The MOV consists of injection of air into the cuff until changed or when the patient is agitated. An assistant can no leak is heard, then withdrawal of the air until a minimize risk for accidental dislodgement. small leak is heard on inspiration, and then addition of more air until no leak is heard on inspiration. 1,10,17,25,30 EQUIPMENT The main advantages of this method are that it is easy to perform and that there is little additional equip- • Specially designed manometer to measure cuff pressures ment needed to perform the MOV. The main disadvan- • Stethoscope tage is that by withdrawing air from the cuff, a leak is • Self-infl ating manual resuscitation bag-valve device created, thus increasing the patient’ s potential risk for • Oxygen source and tubing aspiration. • Suction supplies (see Procedure 12 ) ❖ Although rare since the use of high-volume, low- • Personal protective equipment pressure devices became common, the adverse effects • Sterile normal saline solution or sterile water of tracheal tube cuff infl ation include tracheal stenosis, • Two to three sterile containers to place supplies (cotton necrosis, tracheoesophageal fi stulas, and tracheomala- swabs, normal saline) cia. These complications may be more likely to occur • Sterile cotton balls and/or cotton-tipped applicators in conditions that adversely affect tissue response to • Sterile nylon brush mucosal injury, such as hypotension. Two major • Sterile 4 × 4 gauze 13 Tracheostomy Cuff and Tube Care 93

• Commercial tracheostomy tube holder patient with mechanical ventilation. Rationale: An ade- • Sterile precut tracheostomy dressing or dressing used by quate seal of the cuff to the tracheal wall does not permit institutional preference air to fl ow past the cuff. • If inner cannula is disposable, new sterile disposable inner • Assess signs and symptoms of inadequate ventilation, cannula of the same size including rising arterial tension, chest- • Extra sterile tracheostomy kit at bedside and obturator abdominal dyssynchrony, patient-ventilator dyssynchrony, Additional equipment, to have available as needed, includes dyspnea, headache, restlessness, confusion, lethargy, the following: increasing (early sign) or decreasing (late sign) arterial • Scissors blood pressure, and activation of expiratory or inspiratory • 10-mL syringe volume alarms on mechanical ventilator. Rationale: This • Three-way stopcock guides needed interventions. • Padded hemostats • Assess the amount of air or pressure currently or previously • Short 18-gauge or 23-gauge blunt needle used to infl ate the cuff. Rationale: The amount of air previ- • Tongue depressor ously used to infl ate the cuff can be used as a guideline to • Tape (1 inch wide) determine changes in volume or pressure or both. • Reintubation equipment, in case of accidental extubation • Assess the size of the tracheal tube and the size of the patient. Rationale: The volume and pressure of air needed PATIENT AND FAMILY EDUCATION to seal the airway depends on the relationship between the tracheal tube and the diameter of the trachea. • Explain the procedure and the reason for tracheal tube cuff • Assess the amount of secretions. Rationale: This may care, tracheal tube care, and/or tracheostomy dressing increase the frequency of suctioning and tube care. change. Rationale: This communication identifi es patient • Assess for the presence of cutaneous tracheal sutures. and family knowledge defi cits concerning the patient’ s Rationale: After 7 days (when the trach is mature), condition, procedure, expected benefi ts, and potential the sutures may no longer be required. If they remain risks, and allows time for questions to clarify information in place, notify the physician and query for removal. and voice concerns. Explanations decrease patient anxiety The sutures increase the risk of decanulation due to and enhance cooperation. diffi culty with maneuvering to care for the site and dress- • Explain the patient ’ s role in assisting cuff care. Rationale: ing. Prolonged suture retention may also promote skin This information elicits patient cooperation. breakdown. • Explain that the procedure may cause the patient to cough. Rationale: This explanation prepares the patient for what Patient Preparation to expect. • Ensure that the patient and family understand preprocedural teachings. Answer questions as they arise, and reinforce information as needed. Rationale: This communication PATIENT ASSESSMENT AND evaluates and reinforces understanding of previously taught PREPARATION information. • Verify that the patient is the correct patient using two Patient Assessment identifi ers. Rationale: Before performing a procedure, the • Assess the presence of bilateral breath sounds. Rationale: nurse should ensure the correct identifi cation of the patient This assessment provides baseline data. for the intended intervention. • Assess signs and symptoms of cuff leakage, including • Consider placing the patient in semi-Fowler ’ s position. audible or auscultated inspiratory leak over larynx, audible Rationale: This positioning promotes general relaxation, patient vocalizations, infl ation (pilot) valve balloon defl a- oxygenation, and ventilation. It also reduces stimulation tion, and loss of inspiratory and expiratory volume on of the gag refl ex and risk of aspiration. 94 Unit I Pulmonary System

Procedure for Tracheostomy Cuff and Tube Care Steps Rationale Special Considerations Measurement of Cuff Pressure 1 . HH 2 . PE 3. Hyperoxygenate and suction Clears secretions above the trach If an open suction system is used, a tracheobronchial tree and pharynx cuff and in the lower airway and fresh sterile is needed for before cuff defl ation. Special care decreases incidence of suctioning the tracheobronchial should be untaken with subglottic aspiration. tree. When suctioning of the suctioning 16 (see Procedure 12 ). tracheobronchial tree is complete, ( Level D* ) the same catheter may be used to suction the pharynx. If a closed suction system is used in suctioning the tracheobronchial tree, a fresh sterile catheter is needed for suctioning the pharynx. 4. Attach a commercial pressure gauge Allows for measurement of the to the tracheal cuff.18 cuff pressure. 5. Read the measurement. Intracuff pressure measurement Most cuffs are suffi ciently infl ated provides an approximation of with < 10 mL of air. cuff-to-tracheal wall pressure.17 6. If the cuff pressure is > 25 cm H2 O, Provides optimal pressure to seal Hazards of cuff infl ation include cuff press the pressure-release button on the cuff without causing overinfl ation, distention, and the pressure gauge until the pressure excessive tracheal pressure. rupture. The patient who is alert and

reaches 20–25 cm H2 O. If the cooperative may be asked to speak. pressure is < 20 cm H2 O, add air by If the trachea is sealed, vocalization squeezing the bulb to increase is not possible. pressure.8,28 ( Level D ) 7. If unable to maintain appropriate Elevated cuff pressures have been pressures, notify the physician or associated with tracheal stenosis advance practice nurse. and necrosis. Inadequate cuff pressures may lead to impaired ability to provide ventilation and increase the risk for aspiration.28 8. Dispose of used supplies and equipment and remove PE . 9 . HH Troubleshooting Tracheal Cuff Problems Faulty Infl ation Valve 1 . HH 2 . PE 3. Identify the faulty infl ation valve by Determines need for repair. If the infl ation valve becomes faulty determining that the cuff continually and reintubation is undesirable, defl ates, despite the addition of air to consider instituting an emergency the cuff ( Fig. 13-5 ). cuff-infl ation technique. There are commercial cuff infl ation-valve repair kits available. Follow institutional standards regarding who is responsible for repairing a faculty infl ation valve. 4. Clamp the infl ation tube with the Prevents further air loss through padded hemostat. the faulty infl ation valve. 5. Insert a three-way stopcock into the Provides access to the cuff. infl ation valve. 6 . I n fl ate the cuff with the MOV Allows for cuff infl ation; restores technique. tracheal wall and cuff seal.

* Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommen dations. 13 Tracheostomy Cuff and Tube Care 95

Figure 13-5 Attachments for emergency cuff infl ation for a faulty infl ation line. (From Sills J: An emergency cuff infl ation technique, Respir Care 31:200, 1986.)

Procedure for Tracheostomy Cuff and Tube Care—Continued Steps Rationale Special Considerations 7. Turn the stopcock off to the infl ation Temporarily maintains cuff valve and leave it in place; remove pressure. the hemostat. 8. Discard used supplies and remove PE . 9 . HH Faulty Infl ation Tube 1 . HH 2 . PE 3. Identify malfunctioning of the Determines need for and method There are commercial infl ation tube infl ation tube by determining that an of repair. repair kits available. air leak is present in the tube (see Follow institutional standards Fig. 13-5 ). regarding who is responsible for repairing a faculty infl ation tube. Collaborate with respiratory therapy, the advanced practice nurse, and the physician. 4. Clamp the infl ation tube, below the Prevents further air loss through The placement of the padded hemostat leak with the padded hemostat. the faulty infl ation line. should allow adequate infl ation tube length to accept the blunt needle. 5. Cut the infl ation line above the Allows introduction of the blunt padded hemostat but below the needle for repair. identifi ed leak. 6. Insert a short 18-gauge to 23-gauge Provides infl ation access. Maintain care to avoid puncture or blunt needle into the infl ation tube. severing of infl ation line or clinician ’ s skin. 7. Attach a three-way stopcock to a Provides control of airfl ow in and blunt needle, “Off” to the infl ation out of the infl ation tube. tube. 8. With a 10-mL syringe, infl ate the Allows cuff infl ation; restores cuff with air using the MOV tracheal wall and cuff seal. technique. 9. Turn the stopcock off to the Provides for temporary use of the infl ation tube. tracheal tube while maintaining cuff pressure. 10. Secure the assembled device with Provides for stabilization and tape to a tongue depressor. protection. 11. Assemble equipment for tracheal Prepares for tracheal tube Make plans to change the tube as a tube replacement. replacement. more permanent solution. 12. Discard used supplies and remove Reduces transmission of PE . microorganisms and body secretions; Standard Precautions. 13. HH Procedure continues on following page 96 Unit I Pulmonary System

Procedure for Tracheostomy Cuff and Tube Care—Continued Steps Rationale Special Considerations Tracheostomy Tube Care 1 . HH 2 . PE Protective eyewear or a face mask should be worn.22 3. Hyperoxygenate and suction the Reduces the risk of hypoxemia and Saline solution fl ushes to assist with trachea and pharynx as needed (see arrhythmias; removes secretions secretion removal are not Procedure 12 ). and diminishes the patient ’ s need recommended. These fl ushes do not to cough during the procedure. loosen secretions, but they potentiate infections. (Level D * ) 4. Remove and discard soiled Provides access and visibility of tracheostomy dressing and PE . the tracheostomy site. 5 . HH 6. For disposable inner cannula: Replaces the inner cannula. A. Open prepackaged inner cannula. B. Apply clean gloves. C. Remove soiled inner cannula. D. Replace with prepackaged cannula. 7. For nondisposable inner cannula Prepares for cleaning the Only sterile normal saline should be (open prepackaged commercial tracheostomy. used for cleaning tracheostomy tracheostomy care kit): tubes. Hydrogen peroxide may A. Prepare sterile saline or sterile cause pitting of metal inner water on a sterile fi eld. 22,31,32 cannula. 25 B. Apply sterile gloves. C. Remove oxygen source and then inner cannula, placing it in sterile saline or sterile water. 8. Place tracheostomy collar, T tube, or Maintains oxygen supply. If the patient cannot tolerate ventilator oxygen source over or disconnection from a ventilator for near the outer cannula. the time needed to clean the inner cannula, replace the existing inner cannula with a clean one and reattach the ventilator. Then, clean the cannula just removed from the patient and store it in a sterile container for the next inner cannula change. 29 9. Clean the inner cannula with a small Assists in the removal of debris brush. and thick secretions. 10. Rinse inner cannula by pouring Removes any remaining debris normal saline over the cannula. from the cannula. Excess Remove excess solution by tapping solution left on the inside of the on the inside edge of the sterile inner cannula may lead to container. Do not dry the outside aspiration. Solution on the portion of the inner cannula. outside portion of the inner cannula may help act as a lubricant for insertion.29 11. Remove the oxygen source from Allows access to the opening of over the outer cannula. the outer cannula. 12. Insert the inner cannula and lock it Secures the inner cannula. into place. 13. Reapply the oxygen source to the Reestablishes oxygen supply. inner cannula hub.

*Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommendations. 13 Tracheostomy Cuff and Tube Care 97

Procedure for Tracheostomy Cuff and Tube Care—Continued Steps Rationale Special Considerations 14. Moisten 4 × 4 gauze pads with Removes debris and secretions sterile normal saline or sterile water from the stoma area. and clean the stoma site, outer cannula, and neck plate surface by wiping with cotton-tipped swabs and 4 × 4 gauze. 15. Dry the skin around the stoma by Decreases the likelihood of gently patting it dry. microorganism growth and skin breakdown. 16. If needed, prepare to attach a new Ties may need to be replaced if Review individual institutional polices tracheostomy tube holder or twill they are soiled. regarding the use of twill tape or tape tie. commercial trach tie devices. Institutions may prohibit tracheostomy tube holders from being changed for up to 72 hours after tracheostomy tube placement due to the risk of dislodgement. Have an assistant hold the neck plate securely if this procedure is performed. 17. Remove the current tracheostomy Prepares for replacement. Make certain an assistant securely tube holder or twill tape. holds the tracheostomy in place. 18. Tracheostomy tube holder: Connect Removes soiled holder or tape. A variety of commercial tracheostomy one side of the neck plate to the tube holders is available. In some new tracheostomy tube holder, then instances a newly placed connect the other side of the neck tracheostomy tube may be sutured plate and tighten the tube holder, into place and no holder or ties are allowing one fi nger under the holder used (i.e. for patients with a new to ensure it is secure. laryngectomy and fl ap). If this Twill tape: Cut a length long enough to occurs, the physician should write encircle the patient’ s neck two clear orders if a tracheostomy times. Cut ends diagonally. Insert holder or twill tape should not be one end through the faceplate eyelet used. and pull the ends even. Pass both ends of the tie around the patient’ s neck and insert one end through the faceplate ’ s second eyelet. Pull snugly to allow space for one fi nger between tie and the patient ’ s neck and tie the ends securely with a double square knot so that the knot rests on the side of the patient’ s neck ( Fig. 13-6 ). 19. Apply a clean, precut tracheostomy Provides a dressing between the Any precut surgical gauze is dressing under the neck plate. tracheostomy and the neck plate. suffi cient. Never cut a 4 × 4 gauze pad because cut edges fray and provide a potential source for infection. 22,25 (Level D * ) 20. Provide oral care (see Procedure 4 ). Increases patient comfort. 21. Discard used supplies and remove PE . 22. HH

*Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommendations.

Procedure continues on following page 98 Unit I Pulmonary System

A B

C Figure 13-6 Placement of tracheostomy twill tape. A, Faceplate with threading of twill tape (for prevention of decannulation, an additional person needs to stabilize faceplate). B, Advancing of the twill tape around the back of the neck and looping through the other side of the faceplate. C, Doubling of the twill tape and securing it in a knot.

Expected Outcomes Unexpected Outcomes • Tracheal tube remains in correct position • Decannulation or tube dislodgment • Cuff pressure is kept at a level to maintain a seal • Tracheal mucosal ischemia from cuff overinfl ation between cuff and tracheal wall (usually between 20 • Faulty infl ation valve or tube and 25 mm Hg) • Cuff overinfl ation and distention over the end of the • Cuff remains intact tube • Airway remains patent • Cuff rupture • Stoma site is infection free • Prolonger apnea, increasing hypoxemia, or cardiopulmonary arrest • Hemorrhage • Interstitial air: , pneumothorax, pneumopericardium, pneumomediastinum • Thyroid gland injury • Cardiac dysrhythmias • Tube tip erosion into the innominate artery • Skin breakdown, pressure areas, stomatitis • Signs of stoma infection • Bronchopulmonary infection • Displacement or dislodgement out of trachea • Excessive cuff pressure • Leaking airway cuff • Airway obstruction from misalignment, cuff overinfl ation, or dried or excessive secretion • Tracheal stenosis, malacia, or tracheoesophageal fi stula 13 Tracheostomy Cuff and Tube Care 99

Patient Monitoring and Care Steps Rationale Reportable Conditions These conditions should be reported if they persist despite nursing interventions. 1. Assess respiratory status Inadequate interface between tracheal cuff and • Rising arterial carbon dioxide for optimal ventilation. tracheobronchial mucosa decreases inspiratory tension fl ow. • Chest-abdominal dyssynchrony • Patient-ventilator dyssynchrony • Dyspnea • Headache • Restlessness • Confusion • Lethargy • Increasing (early sign) or decreasing (late sign) arterial blood pressure • Activation of expiratory or inspiratory volume alarms on the mechanical ventilator 2. Measure cuff pressure Prevents tracheal injury and aspiration. Excessive • Cuff pressure < 20 mm Hg or every 8 hours, cuff pressure is cited as the most frequent > 25 mm Hg or per institutional problem of and the best • Inability to maintain cuff requirements, predictor of tracheolaryngeal injury.8,10 pressure maintaining cuff If the volume (milliliters) needed to seal the airway pressure between increases, evaluate the patient for tracheal 20 and 25 mm Hg.31 dilation with chest radiography of cuff diameter/ (Level D * ) tracheal diameter ratio. Increasing volumes also may indicate a leak in the cuff, infl ation valve, or tube. 3. Maintain tracheal tube Manipulation of the tracheal tube increases the • Inability to maintain cuff cuff integrity. likelihood of cuff disruption. Cuff leak or rupture infl ation is evident when the pressure on the manometer • Audible air through the continues to decrease. patient ’ s nose or mouth • Low-pressure or low-volume alarm sounds on the mechanical ventilator • Audible or auscultated inspiratory leak over larynx • Patient able to vocalize audibly • Pilot balloon defl ation • Loss of inspiratory and expiratory volume on patients with mechanical ventilation 4. Hyperoxygenate and Removal of secretions reduces chance for partial or suction patient based on complete airway obstruction. assessment (see Procedure 12 ).

*Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommendations.

Procedure continues on following page 100 Unit I Pulmonary System

Patient Monitoring and Care —Continued Steps Rationale Reportable Conditions 5. Compare patient ’ s Identifi es the effects of tracheal tube cuff care on • Decreased arterial oxygen cardiopulmonary status the cardiovascular system. saturation before and after tracheal • Cardiac dysrhythmias tube cuff care. • • Respiratory distress • Cyanosis • Increased blood pressure or intracranial pressure • Anxiety, agitation, or changes in level of consciousness 6. Reassess cuff pressure Changes in altitude may change the volume of gas and volume when in the cuff; volume and pressure need to be transporting the patient reevaluated during and after transport. from one altitude to another (i.e., air transport) or during hyperbaric therapy without environmental pressurization. 7. Provide continuous Artifi cial airways bypass the nose and mouth, humidifi ed air or preventing normal warming, humidifi cation, and oxygen. Warm or cool fi ltering.4,22 as appropriate.21,25,29 (Level D * ) 8. Maintain the Traction on the tracheostomy from ventilator • Sutures that prevent adequate tracheostomy tube in a circuits, oxygen, or suction tubing may cause the stoma care neutral position, midline tip of the tracheostomy tube to erode through the with the patient’ s body. trachea and, potentially, into the innominate artery. 9. Auscultate lung sounds Improper placement may lead to inadequate • Decreased chest wall motion to check proper ventilation and complications. An extra sterile • Unilateral breath sounds placement of tracheostomy kit should be kept at the bedside at • Audible expiratory wheeze tracheostomy tube and all times. Displacement into the subcutaneous • Bilateral decreased breath ensure tracheostomy tissue can occur. How emergent the situation is sounds tube is securely in depends on whether the upper airway is • Oxygen desaturation place. obstructed. Decannulation inadvertently occurs • Dyspnea and respiratory from lack of tracheotomy securement. If distress decannulation occurs and if retention sutures are • Stridor present, pull them apart to lift the trachea up and • Ventilator alarms hold the tracheal stoma open. Do not cross tracheal sutures because this action will close the airway. When help arrives, a second person should reinsert the tracheostomy tube as per individual facility policy.23 If the patient does not have retention sutures, open a new tracheostomy tube set, remove the inner cannula, insert the obturator into the outer cannula, and slide it into place. 14 10. Inspect and palpate for Air may escape into the incision, causing • Subcutaneous emphysema air under the skin. subcutaneous emphysema. Special note: Subcutaneous emphysema does not injure the patient with an artifi cial airway in place. However, puffi ness of the soft tissue may result and, if signifi cant, can change the patient ’ s appearance, alarming the patient and family.

*Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommendations. 13 Tracheostomy Cuff and Tube Care 101

Patient Monitoring and Care —Continued Steps Rationale Reportable Conditions 11. Assess for bleeding or a Surgical procedures increase the risk of potential • Frank bleeding or constant constant ooze of blood. injury to adjacent tissue or structures. Stoma oozing of blood placement below the second and third cartilaginous rings results in an increased incidence of innominate artery erosion. 12. Gently palpate the tube Pulsation felt on the tracheal tube is suggestive of • Pulsation of the tracheal tube for pulsation. potential erosion of major blood vessels. 13. Follow institutional Identifi es pain and need for appropriate • Continued pain despite standards for assessing interventions. interventions pain and administering analgesia as prescribed. 14. Tracheostomy care Keeps tube free of secretions, mucus, and plugs • Frequent plugs should be performed that may impede airway patency. • Copious drainage every 4–8 hours and as • Change in color, odor, or needed or per tenacity of secretions institutional policy depending on the type and volume of secretions produced.13,19,20,23,27 (Level E * ) 15. Assess stoma for signs Skin irritation or breakdown may occur from the • Elevated temperature of infection, neck plate, tracheostomy tube holder, or sutures, • Swelling infl ammation, or if present. • Excoriated or open areas pressure from tension • Redness by trach ties or equipment. 16. Monitor secretions for Change in secretion characteristic may indicate • Purulent drainage color, consistency, odor, infection or inadequate hydration. • Excessively thick secretions and amount. • Copious or purulent secretions 17. Maintain the head of the Promotes oropharyngeal and nasopharyngeal bed at 30–45 degrees drainage and minimizes the risk of aspiration. and during enteral Prevents ventilator-associated or hospital- feedings. 24 (Level D * ) acquired pneumonia.9 Withholding enteral feedings when gastric residuals are high is also important in the prevention if regurgitation and pulmonary aspiration. 18. Perform oral care every Prevents bacterial overgrowth and promotes patient 2–4 hours (see comfort. Procedure 4 ). 19. Tracheostomy tube care Prevents bacterial overgrowth and promotes patient should be completed comfort. every 4–8 hours and as needed, or as institutional policy dictates. 21,25,29 ( Level D ) 20. Promote effective The patient cannot talk, which may result in fear patient-provider and anxiety. Patients need an established communication (paper communication mechanism. and pencil, letter or A speaking valve may be used to facilitate speech. word boards, one-way speaking valves, if appropriate).

* Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommen dations. * Level E: Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to support recommendations.

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Documentation Documentation should include the following: • Patient and family education and comprehension • Cuff infl ation volume and cuff pressure • Vital signs assessed before and after the procedure • Patient ’ s tolerance of the procedure. • Date, time, and frequency of tracheostomy care • Condition of stoma, including infl ammation and • Type and size of tracheostomy tube, changing of inner secretions cannula, replacement of tracheostomy tube holder, and • Expected and unexpected outcomes general condition of stoma and surrounding skin • Type and amount of secretions, frequency of • Nursing interventions in response to assessed suctioning complications • Performance of oral care • Patient and family education • Pain-assessment interventions, and effectiveness • Cardiopulmonary and vital sign assessment before and • Evidence that the securing device is adequate without after procedure being excessively tight (2-fi nger technique) • Method of cuff infl ation

References and Additional Readings For a complete list of references and additional readings for this procedure, scan this QR code with any freely available smartphone code reader app, or visit http://booksite.elsevier.com/9780323376624 .