Caring for the patient with a - PowerPoint Presentation

Slide1

Caring for the patient with a Tracheostomy

Mairi Mascarenhas

Clinical Educator ICU

Slide2

ICUMHDUSHDU

7A

It does not relate to care of patients in the ENT or paediatric setting.

This training session relates to the designated areas:

Slide3

The need for education:

Tracheostomies are common procedures in head and

neck surgery and in critical care practice, with over

5000 procedures performed annually.

Increase in patient safety incidents.

Over 1700 incidents (including 32 deaths) reported to

the National Patient Safety Agency between 1

st

Jan

2005 and 31

st

Dec 2008.

Slide4

Problems identified:

Incidents at the time of performing the

tracheostomy

.

Blockage or displacement of the

tracheostomy

after placement.

Equipment incidents.

Competency (skills and knowledge) incidents.

Slide5

A tracheostomy is an opening in the neck

at the front of the windpipe (trachea)

What is a

tracheostomy

?

Slide6

Anatomy

Blood supply to the trachea comes from the branches

of the: Inferior thyroid artery

Innominate

artery

Bronchial artery

Subclavian

artery

Slide7

Innominate artery

Innominate

artery

:

Lies in close proximity to the

tracheostomy

.

Erosion of the anterior tracheal wall can lead to a major life-threatening bleed.

Slide8

Can be done in ICUDilators are used

Neat incision

More cosmetic

Tract takes longer to form

Percutaneous

tracheostomy

Slide9

Surgical tracheostomy

Done in theatre

Surgical incision

Scarring more prominent

Tract takes less time to form

Often have deep ‘stay’ sutures

Slide10

Indications:

The need for prolonged artificial ventilation.

Inability to maintain an airway: reduced cranial nerve function

or damage to the brain stem with poor conscious level.

Bronchial secretions cannot be cleared normally.

Obstructed upper airway: foreign object, oedema of soft tissues,

chemical or inhalation burns.

Undergoing surgery to or around the upper airway:

maxillo

-

facial or ENT/head and neck procedures.

Slide11

Endotracheal tube versus tracheostomy

tube

Slide12

Benefits:

Aids the process of weaning from mechanical ventilation

Reduces the need for sedation and its side effects.

Reduces the work of breathing by shortening the dead space.

Facilitates lip-reading

Slide13

Dual cannula tube

Inner liner or inner tube

Tracoe brand

Tracheostomy

tube:

Slide14

These are used in patients that can protect their own airway by coughing and clearing their own secretions.

Uncuffed

tracheostomy tubes

Slide15

What it looks like

Slide16

Handwashing and application of alcohol gel before and after all procedures.

Clean gloves and apron.

During any disconnection procedures, there is a risk that the patient may cough secretions. Eye protection should be worn to protect carers from any aerosol effects e.g. disconnections for inner tube change, disconnections when changing closed suction catheter, during complete tube changes and

decannulation

procedures.

Infection

control:

Slide17

Safety equipmentHumidification

Suction

Inner tube care

Cuff pressure monitoring

Stoma care and tube security

Communication using speaking valves

Tracheostomy

Care Bundle

Slide18

Safety Equipment

Slide19

Nose and mouth provide warmth, moisture and filtration for inspired air.Tracheostomy

bypasses normal upper airway mechanisms for humidification, filtration and warming of inspired gases.

Risk of increased viscosity of mucous secretions which depresses muco-ciliary

clearance.

Increased risk of infection, impaired secretion removal and

microatelectasis

Humidification

Slide20

Muco-ciliary transport

The purpose of the cilia is to move to and fro in constant motion and direct mucous from the respiratory airways. This helps maintain airway patency and improve lung compliance.

Slide21

Position humidifier away from direct line of draughts, open windows, ceiling vents

Heated humidification must be 37°C

Slide22

Heat Moisture Exchangers (HMEs)

Commonly referred to as “Swedish Noses”

Heated humidification is preferred.

Small device: risk of occlusion by mucous plugs.

HMEs ideal for short periods e.g. during transfer

Slide23

Suctioning is important as it reduces the risk of respiratory secretions/mucous plugs from blocking the tracheostomy tube.

Helps clear secretions and ease breathing discomfort associated with increasing secretions.

Should be done whenever it is needed.

Suctioning

Slide24

Signs that indicate suctioning:

Secretions may be seen, heard or palpated.

Gurgling or bubbling sounds.

Coughing.

Breathing difficulties/change in respirations.

Colour changes/cyanosis

Desaturation

i.e. Oxygen saturations ≤ 92%

Slide25

Suctioning is needed in the following:

Secretions are seen around the tube opening.

Secretions are audible i.e. gurgling noises.

Vibrations may be palpated on the patient’s chest.

Harsh//noisy decreased breath sounds.

Oxygen saturations are decreased.

The patient is coughing.

The patient requests to be suctioned.

Slide26

Closed suction system:

Slide27

Open suction:

Open suction commonly used in the ENT setting

Slide28

How does suctioning affect the patient?

The procedure can be uncomfortable.

The patient’s colour may change.

Coughing spasms may follow.

Oxygen saturations may decrease.

Heart rate may decrease.

If secretions are excessive repeated suctioning procedures can

lead to exhaustion.

Some patients may feel sick or vomit.

Slide29

Associated problems:

Damage to the tracheal mucosa

Bleeding

Infection

Cardiac arrhythmias

Bradycardia

Desaturation

Slide30

Check suction apparatus is correctly assembled.Check vacuum pressure ≤ 200 mmHg.

Insert catheter to the ideal distance (usually length of the tube plus ¼ inch).

Do not apply suction on the way down.

When withdrawing back the suction catheter - apply suction by depressing thumb control on suction

Suction duration must not exceed 15 seconds.

Suction:

Slide31

Only apply suction when withdrawing the suction catheter.

The suction procedure may need to be repeated.

Important to adequately remove all secretions. No more than 3 suction passes should be made per episode.

Allow the patient to recover between suction passes.

Suction:

Slide32

Inner tube care:

Helps maintain tube patency. The inner tube needs to be changed every 8 hours (or more often) if frequent secretions.

Remove the inner tube and clean it

Slide33

Cleaning the inner tube:

Use cleaning granules dissolved in warm water.

Use trachi

-swabs to clear any debris inside inner tube.

Rinse inner tube in water (to rinse off the cleaning disinfectant

granules)

Shake to remove excess water and then air dry inner tube in its

storage container.

Slide34

The need to monitor the cuff pressure:

Slide35

Cuff pressure assessment should be carried out every 8 hours.Cuff pressure should be

30 cm H2O.

Record the cuff pressure on the tracheostomy care chart.

Under-inflation: risk of aspiration and migration of

subglottic

secretions.

Over-inflation: risk of

tracheo

-oesophageal fistula.

Monitoring the cuff pressure:

Slide36

Signs of cuff leakage:

Audible leak over larynx.

Patient able to vocalise.

Pilot balloon deflated.

Loss of tidal volume in the mechanically ventilated patient.

May need to change the

tracheostomy

tube – inform ICU staff.

Slide37

When should the cuff be deflated?

Prior to removing the tube – referred to as

decannulation.

Prior to connecting the speaking valve.

It may be more comfortable for some patients to eat/drink

when the cuff is deflated.

Slide38

Keep the tracheostomy tube is secure and always check the tapes:

Support the

tracheostomy tube during moving and handling procedures.

Avoid accidental

decannulation

:

ensure the tapes are taut.

One finger should slide snugly under the

tapes at the back of the patient’s neck.

Slide39

Cleaning the stoma or changing the tapes:The

tracheostomy

is at risk of falling out or becoming displaced during this procedure.The procedure is a 2-person task. One person holds the tube. The 2

nd

person cleans around the stoma and secures the tapes.

Stoma care:

Slide40

Change the stoma dressing at least once daily.Frequency of dressing and tapes may need to be undertaken more frequent than once daily – especially if the dressing or tapes become heavily soiled.

Skin integrity – surrounding skin should be dry and intact.

If the stoma site appears red or there is

exudate

: obtain surface swab and send to microbiology for ‘M, C + S’.

Report any signs of swelling: there should be no local swelling or

crepitations

i.e. subcutaneous emphysema.

Decannulated

patients: use either gauze and

tegaderm

dressing to cover the stoma or 4” x 4”

allevyn

dressing.

Stoma assessment:

Slide41

Always ensure patient has access to call bell.

Remember the patient cannot call for help (unless speaking valve is in situ)

Pen and paper, “magic slates”, electronic devices e.g. typing message in mobile phone/iPad

.

Non-verbal cues.

Speaking valves.

Communication:

Slide42

Speaking valves are not without risk especially on cuffed tubes:

The cuff must always be fully deflated

before attaching the speaking valve.

Attach the aqua coloured warning tag to the cuff pilot line.

Speaking valves:

Slide43

The speaking valve must be removed in the following situations:

If the patient suddenly develops breathing problems.

During cardiac arrest.

If the patient requires “hand-bagging” (

ambu

bag).

If the patient requires nebuliser treatment.

Prior to patient settling to sleep overnight.

Slide44

Not all patients with tracheostomies will have swallowing

problems.

Speech and Language Therapists are involved in assessment and management of tracheostomised

patients with swallowing or specific communication difficulties.

An assessment of swallowing function is usually required prior to the commencement of oral feeding in patients particularly in patients identified as being at risk of

dysphagia

.

This is required to reduce the risk of aspiration which may lead to aspiration pneumonia.

Patients in the ICU usually undergo swallowing assessment using the blue dye test protocol.

Swallowing, eating and drinking:

Slide45

Must not be used on cuffed

tracheostomy

tubes (relates to Safety Action Notice 1988)

Tracheostomy

Masks:

Slide46

Usually changed every 28 days.30 days to comply with EU regulations.

Tube change can only be undertaken by a person specifically trained in the procedure.

Risk of false passage.

Changing

tracheostomy

tubes:

Slide47

Tube displacement can lead to subcutaneous emphysema and may be fatal

False passage:

Slide48

Emergency Guidelines:

Suspected Tube Blockage.

Tube displacement or Accidental

decannulation

.

Major bleeding.

Slide49

Can’t pass suction catheter?Tube blockage must be suspected.

Remove the inner tube (as it may be blocked) and replace with spare bedside inner tube.

Still can’t pass suction catheter?

Call for help and dial 2222

Proceed to removing the

tracheostomy

tube.

Suspected Tube Blockage:

- usually assessed on ability to pass suction catheter

Slide50

If unable to pass suction catheter the tube must be removed.Most ICU patients will be able to maintain their airway.

Apply

O2 mask and remove the tapes securing the tube.

Open

trachi

-case and use 10ml syringe to fully deflate the

tracheostomy

cuff.

Remove the

tracheostomy

tube.

Use the

yankaeur

suction catheter to remove secretions

peri

-stoma.

Cover stoma with gauze and secure gauze with air-tight dressing e.g.

Tegaderm

.

Removing the

tracheostomy

tube

:

Slide51

Emergency guidelines will be attached to the

trachi

-case

Slide52

Accidental decannulation

or tube dislodgement:

Treat as medical emergency.

Call for urgent bedside assistance and dial 2222.

Apply O2 facemask.

Most ICU patients will be able to maintain their airway.

Open

trachi

-case and use

yankaeur

suction catheter to

remove any secretions/mucous plugs around the stoma site.

Apply gauze dressing over stoma and secure with

tegaderm

.

Await arrival of emergency team.

Slide53

Patient looks like this after accidental decannulation

:

Slide54

Major bleeding – act quickly!

Increase oxygen to maximum flow rate.

Fast bleep the Registrar (medical or surgical as appropriate)

and the Anaesthetic Registrar.

Apply compression to any obvious bleeding point.

Keep suctioning the

tracheostomy

tube and repeat as

necessary until the emergency team arrive.

Immediate transfer to theatre likely.

ENT surgeon – Vascular Surgeon – Anaesthetist