The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [371]
Having emergency equipment readily available is paramount at all times for all types of altered airways (see Preprocedural considerations for equipment required). All staff caring for the patient should also know the type of tube in place at any one time; this and details of all care provided should be clearly documented.
Managing difficult situations with a tracheostomy is stressful for both the patient and staff, so prevention is always better than cure. All procedures should be undertaken only after approved training, supervised practice and competency assessment, and carried out in accordance with local policies and protocols.
Preprocedural considerations
Equipment
The following should always be at the bedside, during transfers or accessible if the patient is self-caring or ambulant.
Operational oxygen with tracheostomy mask available.
Operational suction, checked each shift, with a selection of suction catheters present.
Sterile water (Serra 2000) can be used to help clear suction tubing of secretions after suctioning has been performed.
Non-powdered latex-free gloves, aprons and eye protection (Day et al. 2002).
Two spare cuffed tracheostomy tubes, one the same size as the patient is wearing, the other a size smaller, in case of an emergency tracheostomy tube change (Serra 2000, Tamburri 2000).
One 10 mL syringe to inflate cuff.
Tracheal dilators and artery forceps (ICS 2008) (Figure 10.12).
Spare soft neck ties or tape.
Suture cutter and lubricating gel.
Cuff pressure manometer (Serra 2000) (Figure 10.13).
Readily available rebreathe bag and resuscitation equipment (ICS 2008).
Figure 10.12 Tracheal dilator.
Figure 10.13 Cuff pressure manometer.
It can be useful to have the above equipment in a small ‘tracheostomy box’ that can remain by the patient’s bedside or move with the patient during transfer.
When caring for the patient who has undergone a total laryngectomy, the equipment listed above should always be by the bedside, and in addition the following equipment is recommended.
Tilley’s forceps: these are angled forceps that can be used to remove crusts or plugs of mucus from in and around the stoma.
Pen torch (or access to a light source).
Micropore or Elastoplast tape for those patients with a tracheo-oesophageal puncture, to ensure that the catheter keeping the puncture patent is secured firmly with tape or a suture.
Tracheostomy tubes
Tracheostomy tubes are made of either metal or plastic, and therefore vary considerably in rigidity, durability and kink resistance (ICS 2008). Most tubes manufactured now are dual cannula tracheostomies and are inherently safer and most commonly preferred, particularly for use in acute settings. The outer tube maintains the patency of the airway while the inner tube, which fits snugly inside the outer tube, can be removed for cleaning without disturbing the stoma site. The major advantage of an inner cannula is that it allows immediate relief of life-threatening airway obstruction in the event of blockage of a tracheostomy tube with clots or tenacious secretions. Disposable inner tubes are now available; these single-use items are quicker to use (Dropkin 1996) and minimize cross-infection as no cleaning is required.
The majority of tracheostomy tubes are manufactured from plastics of varying types, some that become softer at body temperature (e.g. polyvinyl chloride construction). Some also have a high-volume, low-pressure cuff which distributes the pressure evenly on the tracheal wall and aims to minimize the risk of tracheal ulceration, necrosis and/or stenosis at the cuff site (ICS 2008, Russell 2004). The cuff when inflated provides a seal between the tube and tracheal wall, enabling effective ventilation and protection of the lower respiratory tract against aspiration (Russell 2004).
Most tubes are sized according to their internal diameter in millimetres, varying also in their length and shape. The size and style of the tube chosen will depend upon the size of the trachea and