Overview

• A tracheostomy is a surgically made opening into the trachea (windpipe) held open by a tracheostomy tube. 
• A commonly used tracheostomy tube consists of three parts: 
  • outer cannula with flange (neck plate), - the outer tube that holds the tracheostomy open. A neck plate extends from the sides of the outer tube and has holes to attach cloth ties or Velcro straps around the neck. 
  • inner cannula - fits inside the outer cannula and has a lock to keep it from being coughed out. It is removed for cleaning, and an 
  • obturator that fits inside the tracheostomy tube to provide a guide for the tracheostomy tube when it is being inserted. 
• A tracheostomy helps a person breathe more easily as air goes in and out through the tracheostomy tube, bypassing their nose and mouth. 
• A tracheostomy can be temporary, long term or permanent, depending on the client's medical condition.
• There are many different reasons why a tracheostomy may be needed. One of the most common reasons is prolonged mechanical ventilation. 
• The main reasons are when a person:
  • has breathing problems (respiratory failure) such as: 
    • being unconscious or in a coma as a result of a severe head injury or stroke
    • when a condition damages the lungs
    • when a condition damages the nervous system
    • paralysis as a result of spinal cord injury
  •  has blockages: 
    • when an injury, infection, burn or severe allergic reaction (anaphylaxis) has swollen or narrowed the throat 
    • caused by a cancerous tumour in the throat or thyroid 
    • as a result of birth defects
  • has fluid in their lungs: 
    • during a serious lung infection
    • when chronic pain, muscle weakness or paralysis impedes coughing—the body’s way to get rid of foreign particles, irritants, microbes and mucus from the airways.
• The correct care of someone with a tracheostomy is important as there is a greater risk of death or harm if inappropriate or inadequate care is provided. 
• Key managers must ensure that carers follow this policy and that clients have person-centred tracheostomy management plans.

• As part of the service entry process, a detailed assessment is required for a client with a tracheostomy. Family presence is recommended for the assessment meeting for additional information and support. This is especially true when verbal communication is impossible for clients with an inflate tracheostomy cuff (unless a specialised cuff is used, i.e. one-way speaking valves).
• It is essential to determine the level of care required for care and maintenance of the tracheostomy. 
  • Close liaison should also be maintained with the multidisciplinary team, including specialised nurses, physiotherapists, speech therapists and doctors. 
  • A coordinated team approach is the best practice for this specialised care area.
• A documented assessment, management and review plan is required for each client with a tracheostomy. 
  • The type of detail to evaluate at the initial assessment includes, but is not limited to:
    • client history—the level of self-care management the client can perform:
      • can they change their tube? 
      • how well are they able to clear their secretions by coughing?
      • can they swallow? 
    • when was tracheostomy surgery performed? 
      • do they have a larynx? or 
      • do they have a connection between the oral airway and lungs?
    • record baseline weight and oxygen saturation
    • communication strategy, e.g. verbal, non-verbal, pen and paper, communication board or voice synthesiser
    • oxygen dependence
    • type and size of tracheostomy tube—cuffed or non-cuffed tubes, cuff pressure requirements
    • when is a routine change of tube required—every 4-6 weeks is normal
    • how often is suction required? This will depend on whether they are mechanically ventilated or non-ventilated
    • routine observations.

• The risks and complications for a person with a tracheostomy include:
  • respiratory distress (cyanotic, tachypnoea, stridor, gurgling breath sounds, oxygen desaturation)
  • dislodged tracheostomy tube
  • obstruction
  • cuff leak
  • faulty oxygen delivery or ventilation device
  • ineffective humidification
  • bleeding and damage to the throat
  • blockage of the tube with secretions, which can be breathed into the lungs, causing aspiration pneumonia
  • infection
  • tube displacement
  • scar formation
  • dehydration
  • cardiac or respiratory arrest (stop breathing).
• The risks associated with tracheostomies are greater with":
  • children
  • the elderly
  • smokers
  • alcoholics
  • diabetics
  • persons with impaired immune systems
  • persons with chronic diseases or respiratory infections
  • persons taking steroids or cortisone.

• People with tracheostomies who rely on ventilators for breathing are often monitored. Monitoring devices include:
  • a pulse oximeter (measures oxygen level and heart rate) or 
  • apnea monitor (measures heart rate and breathing rate). 
• The person’s medical practitioner will determine the need for monitoring.

• when clients are supported with a tracheostomy
• to all HWH employees and key managers supporting clients with a tracheostomy

• Tracheostomy Prima

Policy

• all carers supporting clients with a tracheostomy must adhere to the best evidence-based practice in monitoring the safety of those clients 
• assessing the need for additional support services is ongoing, e.g. allied health services such as speech therapy
• A qualified health professional makes a decision to remove or change a tracheostomy tube permanently.

• A medical practitioner sets ventilator settings, they should not be changed by anyone else.

• Responsibilities of key managers is to:
  • ensure carers have current knowledge and a training plan to learn the standards of care for clients with tracheostomies
  • provide carers' education to provide excellent, confident care
  • ensure carers are following the Manage Tracheostomy process
  • ensure carers know when and how to activate emergency support
  • ensure emergency airway equipment is available at all times, including resuscitation bags and airway equipment
  • ensure supervisors have accreditation in Basic Life Support
  • regularly audit safe tracheostomy management practises
  • ensure carers comply with the Manage Tracheostomy process
  • document all tracheostomy interventions, assessments and care provided in an observation chart, including any abnormal findings.

• Clients that rely on a tracheostomy are at greater risk of pneumonia (chest infection). 
• We are responsible for caring for and ensuring our clients are safe. 
• This includes carers to:
  • work within their scope of practice and qualifications
  • possess competent problem-solving skills and suctioning skills
  • carers need to be able to assess signs and symptoms of upper and lower airway obstruction and the immediate need for suction—this might include: 
    • increased respiratory rate 
    • persistent coughing 
    • nasal secretions 
    • anxiety or agitation 
    • decreased ability to concentrate 
    • fatigue 
    • dizziness 
    • irritability
    • increased blood pressure 
    • pallor 
    • hypoxia 
    • irregular heartbeat 
  • adhere to hand hygiene and infection control policies
  • physically examine the tracheostomy flange and the skin condition around the stoma site
  • if ever in doubt about an intervention, seek assistance from supervisors or key managers
  • report incidents via the incident report and not on the shift notes.
• Clients with tracheostomy airways no longer have normal humidification of the tracheal mucosa—ensuring humidity is supplied to the airway through nebulisation or with an oxygen delivery system is vital (4 hourly saline nebulisation or as needed).
• The risk of respiratory impairment is greater for those with illness or injury that restricts mobility—frequent changes of position reduce the risks of stasis of pulmonary secretions and decreased chest wall expansion.