A patient who requires prolonged mechanical ventilation, is experiencing upper airway obstruction or needs assistance with chronic airway secretions may undergo a tracheostomy (Doyle & Scales 2015).
What is a Tracheostomy?
A tracheostomy is a surgical procedure that involves making an incision (stoma) into the trachea through the front of the neck. A tube is then inserted into the incision, creating an air passage that allows the patient to breathe directly through their trachea while avoiding their upper airway. This may be a temporary or permanent intervention (Healthdirect 2018; Mayo Clinic 2019).
It is vital to ensure you care for a tracheostomy carefully and thoroughly, as an adverse event such as respiratory distress may develop if the tracheostomy is not managed properly.
Indications for a Tracheostomy
The most common reasons for undergoing a tracheostomy are:
Managing an upper-airway obstruction (caused by a tumour, surgery, foreign body or infection)
Preventing damage to the larynx and upper airways after prolonged trans-laryngeal intubation
Providing easy access to the lower airway for suctioning and the removal of secretion
Providing a stable airway for a patient who requires prolonged mechanical ventilation or oxygenation support.
Conditions that may lead to a tracheostomy being required include:
When an endotracheal tube has been in situ for more than seven days, a tracheostomy may be considered.
Types of Tracheostomy Tubes
There are a variety of tracheostomy tubes available with some or all of the following features, depending on what the patient requires:
An inner cannula is a small tube inserted into the larger outer tube. It can be removed for cleaning while the outer tube stays in situ, helping to prevent mucus build-up.
A cuff is a balloon on the outside of the tube, which inflates and creates an airtight seal against the airway walls. It prevents air from escaping through the nose and mouth and can also prevent the aspiration of saliva. Mechanically ventilated patients with tracheostomies require cuff inflation.
An obturator/introducer attaches to the tracheostomy tube, creating a smooth, round tip. It is only used during the insertion of a tube to prevent damage to the trachea. It should be removed and discarded after tube insertion.
Fenestrations are small holes on the upper surface of the tube that allow air and secretions to pass into the upper airways. Fenestrations help to facilitate speech, however, care should be taken to ensure they do not become blocked by downward-passing secretions.
Sub-glottic suction ports facilitate suctioning above the cuff to prevent secretions from accumulating and going into the patient’s airway.
Ensuring there is a tracheostomy emergency kit available in the patient’s room at all times and the equipment inside is checked on the commencement of each shift. Follow local policy and procedures. This is essential
Monitoring the patient’s skin condition, maintaining the cleanliness of the incision (stoma) area and changing dressings
Performing routine suctioning to ensure the patient’s airways remain patent;
Monitoring and reporting abnormal secretions
Donning appropriate PPE (googles, gown, gloves, mask) when caring and suctioning the patient
Cleaning and maintaining suctioning equipment
Supporting routine tube tie changes
Keeping appropriate charts and records
Identifying and responding to the signs of airway obstruction
Implementing emergency procedures related to patient deterioration or infection
Adequately humidifying the trachea to prevent thick mucus and tube blockage
Cuff management and cuff pressure monitoring
Oral hygiene assessments
Maintaining the cleanliness and patency of the inner cannula
Establishing a non-verbal communication system for patients who are not able to achieve verbal speech
Monitoring and assisting with swallowing
Preparing the patient for and performing weaning and decannulation from the tracheostomy
Assisting the medical and/or surgical team with tube changing
Ensuring the patient has cooling devices (e.g. cold wet face washer on the forehead, light bed linen, frequent washes), as the humidification attached to the tracheostomy can make them feel hot.
Although complications during placement are uncommon, they can be serious (Fernandez-Bussy et al. 2015).
Early complications are defined as those that occur within the first postoperative week (RCHM 2018). They include:
Respiratory or cardiac arrest
Infection of the stoma
Injury to the posterior tracheal wall
Build up of sputum, which could create a blockage.
(Fernandez-Bussy et al. 2015; Doyle & McCutcheon 2015)
Late complications become more likely the longer the tube is kept in situ and are estimated to affect about 65% of patients. Patients who are critically ill or have comorbidities are more at risk (Fernandez-Bussy et al. 2015). These complications include:
Tracheal damage or erosion
Formation of stomal or tracheal granulation tissue.
(Doyle & McCutcheon 2015; RCHM 2018)
Tracheostomy Emergency Management
Being able to identify the following signs of respiratory distress is crucial in promptly and appropriately addressing an emergency situation.
Signs of Respiratory Distress
Possible Causes of Respiratory Distress
Increased work of breathing
Decreased or gurgling breath sounds
High inspiratory airway pressure (or low tidal volume if the patient is mechanically ventilated)
Lack of breath sounds when auscultating the lung fields
Inability to pass the suction catheter or inner cannula
Cyanosis (turning blue due to decreased oxygen supply)
Partial or complete airway obstruction due to blockage
Tracheostomy tube dislodgement
Persistent cuff leak
Faulty oxygen source or ventilation device
Tracheostomy in a false passage
Other causes (non-tracheostomy related)
(Adapted from NSW DoH 2015)
In the case of respiratory distress, you should take these immediate steps:
Call for assistance.
Provide oxygen via tracheostomy or face mask. Manually ventilate if required with a bag- valve mask (BVM) apparatus.
Check the oxygen source and connections, cuff inflation and humidifier.
If an inner cannula is in situ, check to see if there is a blockage and change it if required.
Conduct a head-to-toe assessment. Reassure the patient.
Check the positioning of the patient’s head/neck and the tracheostomy tube. If required, realign the tube to the midline.
If the tube is dislodged, maintain a patent airway (through head/neck positioning, jaw thrust and/or artificial oropharyngeal airway). Only an appropriately trained staff member may insert a new tube.
If the tube is still in situ but obstruction is suspected:
Pass a suction catheter and apply suction.
Change the inner cannula if present (ideally with a non-fenestrated one).
If the tube is obstructed, deflate the cuff if one is present.
Monitor the patency of the tube, the presence of any secretions and whether the patient is responding to suction.
If the patient’s respiratory distress reduces, assess if airflow is present and unobstructed and whether oxygen is adequate. A clinical assessment should be performed to identify the cause of the distress.
Perform chest auscultation assessment to ensure there is equal air entry to both sides of the lungs.
If there is no airflow through or around the tube:
Insert tracheal dilators around the tube into the stoma.
Remove the tube.
Insert a bougie or suction catheter. This must only be performed by an expert clinician with relevant experience.
Maintain an oropharyngeal airway to achieve oxygenation.
If a laryngectomy patient, focus on clearing the stoma and trachea.
(NSW DoH 2015)
Emergency Bedside Equipment
All tracheostomy patients should have the following equipment accessible by their bedside at all times in the event of an emergency:
Humidifier (set at 37 degrees)
Bag mask valve apparatus (with tracheostomy connecter and face mask)
Spare tracheostomy tubes (one the same size as the tube in situ and another that is one size smaller)
Water (for cleaning suction tubing)
Waste disposal bag
Suction canister, tubing and suction device
(Austin Health 2016)
Tracheostomies can be both temporary and permanent and may appear in a variety of care and clinical settings. Being able to thoroughly monitor and care for tracheostomies is essential in preventing complications.
Note: This article is intended as a refresher and should not replace best-practice care. Always refer to your facility's policy on tracheostomy care and emergency management.