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Respiratory – Aspiration Precautions SECTION: 9.01 Strength of Evidence Level: 3

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Respiratory – Aspiration Precautions SECTION: 9.01 Strength of Evidence Level: 3 Respiratory – Aspiration Precautions SECTION: 9.01 Strength of Evidence Level: 3 PURPOSE: 4. Consult speech therapist for patients with Implement and educate patient/caregiver on precautions dysphagia, as needed, and as ordered by that prevent aspiration. healthcare provider. 5. Consult dietitian for diet evaluation, as needed CONSIDERATIONS: (requires physician’s order). 6. If patient receiving enteral feedings, See Digestive - 1. Precautions should be taken with all patients who Gastrostomy or Jejunostomy Tube Feeding. are unable to protect their airway to prevent the 7. Monitor patient when eating/drinking: involuntary inhalation of foreign substances, such a. Instruct family or caregiver to do the same. as gastric contents, oropharyngeal secretions, b. Observe adequacy of swallowing. food or fluids, into the tracheobronchial passages. c. SN: order ST eval for tube fed patients for 2. Patients at particular risk for aspiration include those swallow eval as appropriate. whose normal protective mechanisms are impaired. 8. Maintain calm environment when the patient is 3. Major risk factors include: eating or drinking. a. Decreased level of consciousness (confusion, 9. If patient is unable to manage own oral secretions, coma, sedation). nasopharyngeal suctioning may be indicated, b. Documented previous episode of aspiration. consult with healthcare provider and refer to c. Neuromuscular disease and structural nasopharyngeal suctioning policy as needed. abnormalities of the aerodigestive tract. 10. Keep wire cutters at HOB of patient with wired jaws d. Depressed protective reflexes (cough or gag). and instruct patient and caregiver in use. e. Presence of an endotracheal tube. 11. Notify healthcare provider immediately for any signs f. Persistently high gastric residual volumes. or symptoms of aspiration such as tachypnea, g. Vomiting. cough, crackles, cyanosis, wheezing, fever or apnea h. Need for prolonged supine position. as these will usually develop within two hours of the i. Diagnosis of dysphagia. aspiration. 4. Additional risk factors: a. Poor oral care. AFTER CARE: b. Malpositioned feeding tube. c. Presence of a large-bore naso-enteric tube. 1. Document in patient’s record: d. Non-continuous or intermittent tube feeding. a. Maintenance of aspiration precautions. e. Delayed gastric emptying. b. Respiratory rate, effort and quality. f. Oral surgery or trauma. c. Patient’s response to eating/drinking and g. Abdominal/thoracic surgery or trauma. adequacy of swallowing. h. Transport. d. Instructions to patient/caregivers or family. 5. Potential outcomes from aspiration include: airway obstruction and asphyxiation, chemical pneumonia, REFERENCES bacterial pneumonia and/or death. Goodwin, R.S. (2009). Prevention of aspiration pneumonia: a research-based protocol. Retrieved March EQUIPMENT: 4, 2009, from None http://www.pspinformation.com/disease/aspiration/pneu. shtml PROCEDURE: 1. Keep head of bed (HOB) elevated 30-45 degrees at all times unless medically contraindicated. If HOB cannot be raised, position patient in reverse Trendelenberg at 30-45 degrees unless medically contraindicated. 2. Perform mouth care every 4 hours and as needed. Avoid triggering the gag reflex when performing care activities, especially mouth care. 3. Monitor respiratory status and level of consciousness as follows when taking vital signs: a. Auscultate breath sounds. Vesicular (normal) breath sounds should be heard over the distal lung field. b. Observe respiratory efforts. c. Determine ability to effectively manage secretions. Tracheostomy Care SECTION: 9.02 Strength of Evidence Level: Blank PURPOSE: 3.0 PROCEDURE To ensure the proper and safe procedure when 3.1 Wash your hands. performing tracheostomy care by keeping the airway 3.2 Explain the procedure in a way appropriate for a child’s open, prevention of aspiration, atelectasis and infection age or an adult to understand. control. 3.3 Assemble equipment at the bedside. Place a drape absorption pad on the table. POLICY: 3.4 Assure the suction apparatus is working at proper Tracheostomy care procedures for a patient with a settings. trach with or without an inner cannula, suctioning, and 3.5 Lay the adult or child in a comfortable position on his/her tracheostomy maintenance. back with a small blanket or towel roll under his/her Suctioning is the mechanical removal of secretions shoulders to extend the neck and allow easier visualization from airway to maintain an obstructed airway, allow for and trach care. adequate air exchange, and prevent airway infection. 3.6 Don clean gloves. 3.7 Open suction kit. SCOPE OF RESPONSIBILITY: 3.8 Open Q-tips, trach gauze and regular gauze. Can be performed by an RN, LPN/LPN/Licensed 3.9 Cut the trach ties to appropriate length (if trach ties are to Respiratory Care Practitioner. be changed). PRINCIPLE: 3.10 Pour ½ strength hydrogen peroxide into one cup and sterile water into the other. Tracheostomy care is a series of standardized 3.10.1 Clean the skin around the trach tube with Q-tips procedures used for the care and suctioning with soaked in ½ strength hydrogen peroxide. Using a rolling a patient and performing dressing changes that motion, work from the center outward, using 4 swabs, one for will prevent irritation, infection around the stoma each quarter around the stoma and under the flange of the site and prevent aspiration of secretions into the tube. Do not allow any liquid to get into the trach tube or lung. stoma area under the tube. PROCEDURE: 3.11 Note: Check with patient’s MD to determine what 1.0 General Information solution they would recommend for use around the site. 1. Ensure not to rub around the trach tube and Some doctors recommend cleaning with just soap and water secretions, because they can irritate the skin in home care, using hydrogen peroxide only to remove around the stoma site. Daily care of the trach encrusted secretions, because daily use of hydrogen site is needed to prevent infection and skin peroxide might irritate the skin of some children and adults. breakdown under the tracheostomy tube and 3.12 Rinse the area with Q-tip soaked in sterile water. ties. 3.13 Pat dry with gauze pad or dry Q-tips. 2. Care should be done at least once a day; 3.14 Change the trach ties if needed. more if needed. 3.15 Check the skin under the trach ties. 3. Children with new trachs or children on 3.16 Tuck pre-cut trach gauze around and under the trach ventilators may need trach care more often. tube flush to skin. Do not cut the gauze or use gauze 4. Tracheostomy dressings are used if there is containing cotton because the patient may inhale small drainage from the tracheostomy site or irritation particles. from the tube rubbing on the skin. 3.16.1 Use pre-cut tracheostomy gauze or unfilled gauze opened full length and folded into a U shape or use two 2.0 Equipment gauze pads, one placed under each wing of the tube. • The following are the items needed prior to 3.16.2 Be sure the trach dressing does not fold over and performing the procedure: cover the trach tube opening. • Sterile cotton tipped applicators (Q-tips)•Trach 3.16.3 Change the dressing when moist, to prevent skin gauze and “unfilled” gauze irritation. • Sterile water Tracheostomy dressings may not be needed for older • Hydrogen peroxide (1/2 strength with sterile tracheostomies when the skin is in good condition and water) the stoma is completely healed and free from rash or • Trach ties and scissors (if ties are to be redness. changed) 3.16.4 For tracheostomy tubes with cuffs, check with • Two sterile cups or clean disposable paper cups your doctor for specific cuff orders. • Small blanket or towel roll 3.16.5 Check cuff pressures every 4 hours (usual • Suction catheter kit or in-line dose suction kit pressure 15 – 20 mm Hg). In general, the cuff pressure • Suction unit should be as low as possible while still maintaining an • Connecting tubing adequate seal for ventilation. • Suction liner 3.16.6 Monitor skin for signs of infection. IF the stoma • Oxygen source becomes red, swollen, inflamed, warm to touch or has a • 5cc sterile saline for irrigational/lavage foul odor, call your doctor. • Sterile lubricating gel (for NT suction) 3.16.7 Check with the doctor before applying any salves • PPE (if indicated) or ointments near the trach. • Ambu bag (if indicated) 3.16.8 If an antibiotic or antifungal ointment is ordered by • Yankauer (if needed) the doctor, apply the ointment lightly with a cotton swab • Nasal trumpet (if indicated) Q-tip in the direction away from the trach stoma. • Trach kit 3.17 Wash your hands after trach care. Tracheostomy Care SECTION: 9.03.1 Strength of Evidence Level: Blank 4.0 CARE OF THE INNER CANNULA 6.0 CUFF DEFLATION TECHNIQUES: 4.0.1 Some older children and teens have trachs with 6.0.0 Minimal Occluding Volume Technique: an inner cannula. Some inner cannulas are 6.0.1 Deflate the cuff, then slowly begin re-injecting air disposable (DIC: Disposable Inner Cannula). These (or sterile water depending on the type of tube) with a luer should be changed daily, discarding the old cannula. lock syringe. 4.0.2 Check with Haven DME department regarding 6.0.2 Place a stethoscope to the side of the child’s neck disposable cannulas and provide equipment vendor near the trach tube. information so they can be re-ordered. 6.0.3 Inject air into the pilot line until you can no longer 4.0.3 For the reusable cannulas, the cannula should hear air going past the cuff. be cleaned 1 to 3 times a day and more often if 6.0.4 This means the airway is sealed. For children that needed. are totally ventilation dependent, provide breaths with 4.0.4 Do NOT leave the inner cannula out for more manual resuscitator.
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