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By Root 2011 0

7 for information regarding mobilization of the patient with a tracheostomy), humidification techniques and general care for tracheostomies. Patients may have difficulty with an altered body image and need psychological support not only from the team closely involved in their care but also potentially from a formal psychological support team. Other key support teams include rehabilitation teams (for rehabilitation, relaxation and occupational therapy), critical care outreach teams (particularly for newly formed stomas in the ward environment and/or the deteriorating patient with airway difficulties), anaesthetists in the event of an airway emergency, discharge co-ordinators and community teams for patients with airways who are going home.

Humidification

Constant humidification is required while a new stoma adapts to the outside environment. Humidification also prevents the formation of crusts which are liable to obstruct the airway.

Humidification can be provided for patients requiring low rate (1–5 L/min) oxygen therapy by using a disposable nebulizer set with sterile 0.9% sodium chloride (approximately 5 mL), attached to the oxygen supply and setting the gas rate for the liquid to form into humidification droplets. The nebulizer is administered using a specific tracheostomy mask (Figure 10.22) rather than via the nose and mouth, as is usual practice. Local policy will determine frequency which may need to be every 4–6 hours or more frequently in patients with more tenacious secretions. 0.9% sodium chloride nebulizers can also be given using air instead of oxygen if the patient is not on oxygen therapy. Patients requiring continual high concentrations of oxygen (≥28%) require humidification via a heated circuit where possible or a cold water Venturi humidified system at all other times (see Figure 10.10). Patients no longer requiring oxygen therapy can receive humidification in the form of a HME and a patient with a laryngectomy stoma can effectively humidify using laryngeal stoma protectors that combine protection along with humidification, for example: Laryngofoam, Buchanan bib, Romet.

Figure 10.22 Tracheostomy mask.

Humidification of a tracheostomy is important to prevent drying of the airway which impairs mucus and cilia function resulting in thickened airway secretions. Devices such as HME filters or a Trachphone (Figure 10.23), which also has an integral speaking valve and oxygen port, may be used for tracheostomy patients (Woodrow 2002).

Figure 10.23 Trachphone.

Education

Patient education is paramount to providing quality care. In the initial postoperative/postprocedural phase, this may be purely to aid comfort and relaxation, explaining and stressing the rationale and importance of suctioning, positioning and how to strengthen cough. This will involve a multidisciplinary approach with all members of the team educating, supporting and providing comfort throughout all interventions.

For patients with long-term tracheostomy needs, early education is vital. Supporting an individual with a tracheostomy of any type requires an understanding of the impact the tracheostomy tube has on the patient’s airway and knowing how to manage potential complications (Serra 2000). In order to support and teach the patient and/or their carer, staff must confirm whether the tube serves as the primary airway (i.e. a permanent stoma) or if the patient has a functioning upper airway (Bowers and Scase 2007).

Patient education will come from various sources but primarily the clinical nurse specialists, nursing staff, physiotherapists and community nursing teams will play pivotal roles. Education will be both practical (i.e. through demonstration with their own tracheostomy, possibly utilizing mirrors) or through the use of posters and pictures. Practical tracheal suctioning on a specialized mannequin and examining the tracheostomy tubes can also be beneficial (Woodrow 2002).

Tracheostomy: dressing change

Evidence-based approaches

A tracheostomy is a surgical opening into the trachea and hence a potential route of infection,