Level 3 Award in Tracheostomy Care

Level 3 Award in Tracheostomy Care

1. 1
Tracheostomy Care
Level3 Award
Advantage Accreditation / Version No. V.9.1.G

2. Aim
Care staff will be have an
understanding of what a
tracheostomy is and how to
safely care for a patient who
has one

3. 01
Demonstrate how to do a single
lumen tube change
List reasons why a
tracheostomy may be needed
Learning
Outcomes
02
05
Demonstratehowtochangean
innercannulaandhowtocleanan
innercannula
Demonstratehowtocomplete
tape/tiechanges03
06
State what a tracheostomy
Demonstrate how to clean the
stoma and list signs of infection04
Explain actions to take in an
emergency07

4. A tracheostomy is an opening created at the front of the neck
so a tube can be inserted into the windpipe (trachea).
The purpose of tracheostomy tube is to keep airway patent
Can be required short term or permanent, dependanton indication
What is a tracheostomy?

5. What is a tracheostomy?
Allow you to breathe if your throat is blocked –for example, by a swelling, tumouror
foreign object lodged in the throat
Deliver oxygen to the lungs if you're unable to breathe normally after an injury
or accident, or because your muscles are very weak
Reduce the risk of food or fluid entering the lungs (aspiration) if you find
coughing difficult
It may be carried out to:

6. Tracheostomy v Tracheotomy
VSTracheostomy
Breathing is done through the
tracheostomy tube rather than
through the nose and mouth
The term “tracheotomy” refers to
the incision into the trachea (windpipe)
that forms a temporary or permanent
opening, which is called a “tracheostomy,”
Tracheotomy

7. Respiratory
System
Upper Respiratory Tract
Lower Respiratory Tract

8. Function of the respiratory
system –understanding how
normal respiration occurs

9. Upper respiratory tract:
Composed of the nose, the pharynx, and the larynx, the organs
of the upper respiratory tract are located outside the chest
cavity.
01
Nasal cavity: Inside the nose, the sticky mucous membrane lining the nasal cavity traps
dust particles, and tiny hairs called cilia help move them to the nose to be sneezed or blown out.
02
Sinuses: These air-filled spaces along side the nose help make the skull lighter.
Pharynx: Both food and air pass through the pharynx before reaching their appropriate destinations.
The pharynx also plays a role in speech.
Larynx: The larynx is essential to human speech.
03
04

10. Lower respiratory tract:
Composed of the trachea, the lungs, and all segments of the
bronchial tree (including the alveoli), the organs of the lower
respiratory tract are located inside the chest cavity.
01
Trachea: Located just below the larynx, the trachea is the main airway to the lungs.
02
Lungs: Together the lungs form one of the body’s largest organs. They’re responsible for providing
oxygen to capillaries and exhaling carbon dioxide.
Bronchi: The bronchi branch from the trachea into each lung and create the network of
intricate passages that supply the lungs with air.
Diaphragm: The diaphragm is the main respiratory muscle that contracts and relaxes to
allow air into the lungs.
03
04

11. Position of the
tracheostomy tube
Usually placed between the 2
nd
and 4
th
tracheal ring

12. Indications for
tracheostomy

13. c
Conditions that can lead to respiratory failure egcoma, severe head injury,
Stroke, Pneumonia, Cystic Fibrosis, Motor Neuronedisease, Guillain-Barre syndrome
To bypass a blocked airway caused by egburns, anaphylaxis, swelling post surgery or trauma,
accidental swallowing of object which gets stuck in trachea, cancerous tumours
To remove fluid build up eginability to cough effectively due to muscle weakness or paralysis,
lungs clogged with fluid egpneumonia, lungs and/or airways filled with blood as a result of
injury/ trauma
Indications

14. Procedure
Surgical v
Percutaneous

15. c
Surgical dissection down to trachea, creation of window in trachea with insertion of
tracheostomy tube for ventilation
Benefits include dissection under direct vision, better for difficult cases, time honored,
best control of the airway, lower complication rate
Disadvantages include transport required, more bleeding, higher risk of tracheal stenosis
(narrowing), 9% complication rate
Surgical

16. c
Refers to a number of different techniques to insert a tracheostomy;
the most popular technique today is described by Ciagliain 1985.
This technique uses serial dilators over a guide wire and is usually done at the bedside in the
intensive care unit under bronchoscopicguidance. Ciaglialater introduced a single tapered
dilator to replace the serial dilators, further simplifying the technique. In experienced hands,
percutaneous tracheostomy can be done in five to 10 minutes and will rarely require more than 15 minutes.
Benefits include no transport needed, decreased local infection, less bleeding,
less cosmetic deformity, quicker, less planning and logistic, less expensive and better
resource utilisation, tighter fit, can be performed earlier
Disadvantages include tissues traversed no visualised, requires bronchoscopy,
risk of bronchoscope damage, no improvement in pneumothorax risk,
8% complication rate, occlusion by posterior tracheal membrane
Percutaneous

17. Surgical video
Mayo Clinic Published on Mar 28, 2019, Open Tracheostomy
https://www.youtube.com/watch?v=77Wi5Z3FOGk
https://rb.gy/9c5f4
Please see the video link below

18. Percutaneous video
Dr.MuraliChand NallamothuPublished on Nov 17, Percutaneous Tracheostomy
https:/zLhdZqy8wDY/www.youtube.com/watch?v=
https://rb.gy/vxvw1
Please see the video link below

19. 01
Bleeding
Infection
Blockages
Stoma site failure to heal
Dislodgement
Accidental injury
Complications
02
03
04
05
06
Pneumothorax (collapsed lung)
caused by air collecting around the lung07

20. Types of tracheostomy tubes
Many different types, vary in certain features for different purposes
Can be made from soft plastic, hard plastic or metal

21. Types of tubes

22. Dual lumen –consists of 3 parts: outer cannula with flange, inner cannula & introducer
Types of tracheostomy tubes
Single lumen –consists of 2 parts: cannula with flange (neck plate) & introducer (obturator)
Cuffed –used to obtain a closed circuit for ventilation, can have either disposable or
reusable inner cannulas, should be inflated when using with ventilators, should be inflated
just enough to allow minimal air leak, should be deflated if using a speaking valve
Additional video
Tracheostomy cuff explanation
National Tracheostomy Safety Project
Published on Dec 9, 2011
https://www.youtube.com/watch?v=_TGwkxbhGcU
–tend to be changed weekly
–tend to be changed every 28 days
Always refer to care plan

23. Fenestrated (holes) Cuffed –used for patients on ventilators but who are NOT able to tolerate
a speaking valve, high risk of granuloma (mass of granulation tissue),
high risk of aspirating secretions, difficult to achieve adequate ventilation due to leaks
Types of tracheostomy tubes
Cuffless–can have either disposable or reusable cannula, used if patient is ready for decannulation
(removal of tracheostomy tube), may be able to eat or speak WITHOUT a speaking valve

24. Adjustable flange / fixed flange
Types of tracheostomy tubes
Fenestrated Cuffless–for patients who have difficulty tolerating a speaking valve,
high risk of granuloma formation
Metal –not widely used now, however still very well tolerated, cannot have MRI with
metal tube in situ
Additional video

25. The normal function of the nose and upper airway is to warm, moisten and filter inspired air. The viscosity of
secretions is partly dependanton the humidity of inspired air or gases. Patients with a tracheostomy tube in situ
bypass normal mechanisms and require adjuncts to facilitate humidification
Humidification
Humidification is very important for thinning secretions so they do not block the tracheostomy tube
Humidification is needed even in very damp climates, at least at first
Humidity in the lungs helps to protect the lining of the lung and keep secretions thin
Humidifier –normally used at night and periodically through the day if required
HME –heat moisture exchange -‘Swedish nose’

26. Suctioning should be done whenever it is needed. Signs that suctioning is required include: gurgling or bubbly
sounds, coughing, trouble breathing or increased RR
Suction
How often you needs to be suctioned depends on age, how much mucus is produced, and how well the patient is
breathing. A baby or toddler may need to be suctioned more often because of crying, a less efficient cough, and
more frequent colds. An older child may need suctioning only occasionally when they are healthy and more often
when he or she is sick. The best advice, especially for babies, is to first attend to what is making them upset, calm
them, and then decide if they need to be suctioned. Frequently, you will find that after your child is quieted, the
tube is quite clear.
Remember, secretions and saliva are always being produced. This is fluid that the body naturally recycles. If you
suction too much, you may not have a reserve of moisture for longer periods of time wearing the HME

27. c
Suction pressures…The pressure setting for tracheal suctioning is 80-120mmHg (10-16kpa).
To avoid tracheal damage the suction pressure setting should not exceed 150mmHg/20kpa.
It is recommended that the episode of suctioning (including passing the catheter and suctioning
the tracheostomy tube) is completed within 5-10 seconds
Suction Machine, Pressures and
Suction Catheters
The importance of precise suctioning cannot be underestimated in paediatrictracheostomy care.
If the suction length is too short, the patient is at risk of tube blockage, yet if the suction length is
too long it may lead to tracheal trauma and can result in distal soft tissue trauma and overgrowth.

28. Hypoxia
Suction is associated with potential
complications & is only recommended when
airway patency or ventilation is
compromised
Formation of distal granulation tissue/ulceration
Cardiovascular changes
Pneumothorax
Atelectasis
Bacterial infection
Intracranial changes
Suction Machine, Pressures
and Suction Catheters
Potential complications include:

29. Lorem ipsum dolor sit amet, consectetur
Suction catheters Suction machines; care of & cleaning
Suction Machine, Pressures and
Suction Catheters

30. Speaking valve
It's usually difficult to speak if you have a tracheostomy.
Speech is generated when air passes over the vocal cords at the back of the throat.
But after a tracheostomy most of the air you breathe out will pass through
your tracheostomy tube rather than over your vocal cords.
A speaking valve is an attachment that sits at the end of the tracheostomy tube
and is designed to temporarily close every time you breathe out.
This prevents the air leaking out of the tube and allows you to speak.
It can take a while to get used to speaking with the valve
SALT team involved

31. Speech & Swallow Valve Videos
National Tracheostomy Safety Project Published on Apr 15, 2019
The Benefits of a Speaking Valve
https://www.youtube.com/watch?v=Qbtz4crBb-8

32. Speech & Swallow Valve Videos
National Tracheostomy Safety Project Published on Apr 15,
Speaking Valve Trial in PaediatricPatient
https://www.youtube.com/watch?v=vD6CapvP2Y8

33. Most people will eventually be able to eat
normally with a tracheostomy, although
swallowing can be difficult at first.
While in hospital, you may start by taking small
sips of water before gradually moving on to soft
foods, followed by regular food.
If you have swallowing difficulties, a speech and
language therapist can teach you some
techniques that may help
Eating

34. Management of a
tracheostomy
Developed to highlight the 6 main areas related to trachycares
T
Tapes
Resus
Care of the site
Humidity
R
A
C
Airway Clear
H
E
Emergency Box

35. c
Suction unit, tubing and yankauersucker,
humidifier, nebulisermask & tubing,AMBUbag
Equipment
Sterile water, sterile bowl for suctioning
Sterile /non-sterile gloves, aprons, eye/face
protection ( Universal precautions)
2 spare sterile tracheostomy tubes
(one should be the same type as the one
inserted and the other one –a size smaller).
Tracheostomy securing tapes/ribbon
Tracheostomy mask
Normal saline
Oxygen cylinder; if prescribed home O2
Dressing
Essential equipment always required to maintain safety of patients with
tracheostomy
Clinical waste bag (orange)

36. Recommended practice is to review the stoma site, assess the skin of the
neck and clean the area around the tracheostomy tube THOROUGHLY
DAILY
Care of the stoma
Practical session –how to clean the stoma site

37. Document in daily notes
Thin and flexible hydrocolloid dressings are preferred due to their excellent skin
protection and their limited impact on the positioning of the tracheostomy tube.
Bulkier dressings have the potential to alter the angle of the tracheostomy affecting
the stoma as well as abrading the tracheal wall
Check for redness, swelling, oozing, offensive smells, over-granulation
Care of the stoma

38. c
Appropriate emergency equipment
Equipment
Personal Protective Equipment (PPE)
Protective eye wear, gloves, face mask and apron
2 packs of sterile gauze swabs and saline
sachet/ampoules
Tracheostomy dressing, if req
Tracheostomy tapes or ties, if risk assessed
A blanket to swaddle a baby or
uncooperative toddler; age appropriate
Round ended scissors to cut ties
A rolled up towel/blanket; age appropriate
Suction equipment available
Planned tracheostomy tape change –equipment
required:

39. 01
Perform a hand wash; put on PPE
Ensure emergency equipment is readily
available
Prepare gauze and saline
Ensure patient is in good position to allow
the head to be extended and gives good
visibility of the stomal area
Cut tapes to desired length OR
prepare velcroties
Assistant should hold tube in position using
either their thumb and index finger, or index
and middle finger; Avoid undue pressure on
the neck.
Tape Changes
02
03
04
05
06
Assistant to hold the tube until the stoma
has been cleaned and the new tapes attached
and secured
07
Planned tracheostomy tape changes -this is a
two-person procedure

40. 08
Tape changer should cut the tapes between
the knot and the flange and remove old
tapes and dressing
Once the skin is dry, place the Trachi-Dress
under the tracheostomy tube, shiny side to
the skin (and any other dressings/ creams
they may be using)
The stoma and neck are to be thoroughly
washed and dried in 5 areas: above, below the
stomal opening, under each flange, always
wipe away from the stomal edges and finally
sit the patient forward, and clean around the
back of the neck
Thread the new tape through the flange on the
side furthest away. Tie the tapes using a bow
ensuring the tape is flat to the skin to minimize
excoriation
As you dry the back of the neck,
place the new tapes behind the neck
Pick up the tension and pull the tapes tight.
Thread the tape through near side flange,
and make a bow (bows are easier to re-adjust
if they are tight/loose)
Tape Changes
09
10
11
12
13
DO NOT knot at this stage14
Check tape tension; 1 finger width full
circumference of neck 15

41. 16
If the tension is correct, change the two
bows into knots by pulling the loops of
the bow through to create a second knot.
If you pull the strands of the bow by accident,
redo the bow and re-check the tension
Assistant may release tube
ONLY when told to do so
Tie one further knot to secure the ties
(do this to both sides) Cut off excess tape
to leave ½ inch remaining
Ensure patient is made comfortable
Clear away equipment according to the
Waste Management Policy
Tape Changes
17
18
19
20
21
Wash hands
22
Record the tape change in the patients health
care records
23
Check all equipment is replaced and restocked
as necessary

42. Planned tracheostomy tube
changes
Single lumen tube

43. c
Emergency equipment, oxygen and suction
Equipment
A tracheostomy tube of the same size the
patient is currently using
A tracheostomy tube that is half a size smaller
A water-based lubricant such as Aqualube®
or KY jelly®
Gauze swabs/ Tracheostomy dressing /other
dressings and creams that are being used
Round ended scissors
Saline sachets
Marpaccotton tape
A rolled up towel
Planned tracheostomy tube changes –Single lumen tube
Personal Protective Equipment (PPE)
Two syringes may be required if the patient
has a cuffed tube

44. 01
Wash hands & put on appropriate PPE
Have the spare smaller tube available,
in case the tube fails to go in
Lubricate new tube with a “dot” of
water-based lubricant on the outside
bend of the tube only
Position the rolled up towel under the
shoulders; age appropriate
Measure the length of the tube for suction
distance. Insert obturator. If the tube has a
cuff inflate and check it works-
deflate before insertion
Assistant should hold the tube in position
Tape Changes
02
03
04
05
06
Tube changer should cut the ties between
knot and flange 07
Remove the old ties and dressing08

45. 09
Gently remove the tube from the stoma with a
curved action & quickly insert new tube with a
curved action into the stoma
The stomal area and back of the neck
should be cleaned and dried and tube
secured as described in the tape changing
procedure above
Remove obturator quickly as the patient cannot
breathe with this in place
The assistant should take over and hold
the tube in position
Tape Changes
10
11
12

46. c
Should be removed & inspected at least once in 8hr shift, more frequently if signs of respiratory distress
Management of the inner cannula
Can be cleaned with tap water, sterile water or sterile saline –follow local policies
Cleaned to remove debris & to reduce the numbers of microbes present
Should be left to air dry in clean container

47. Cleaning or changing inner cannula
National Tracheostomy Safety Project. Published on Nov 6, 2017
Cleaning or changing inner cannula
https://www.youtube.com/watch?v=TFFl7pU51yI

48. Suction catheters
Tracheostomy emergency
kit contents
Spare trachytubes
Scissors or stitch cutter
Lubricating jelly
Tapes

49. Resus
Basic Life
Support & CPR
NationalTracheostomySafetyProject,DevelopedwithResuscitationCouncilUK–trainingand
guidancedocumentation

50. c
Presence of respiratory distress
Tracheostomy Tube
Emergencies
Increased respiratory rate
Increasing MEWS
Increasing oxygen requirements
Decreased SaO2
Decreased level of consciousness
Hypotension
Tachycardia
Noisy breathing
Care should be focused on minimisingthe risk to the patient. Early intervention and
management may prevent a clinical emergency occurring
Difficulty removing secretions either by
suctioning or asking the patient to expectorate
Patient complains of shortness of breath
Ongoing concern or unresolved issues relating
to the airway

51. Clinical assessment should include but not be limited to the identification of
the following:
Is the tracheostomy tube patent?
If patent, give the patient high flow oxygen via the tracheostomy tube
Is the patient appropriately monitored ?
Is help coming ?
If oxygen is prescribed at home
Look for the cause of the problem and where possible resolve these

52. Tracheostomy tube emergency
change Practical demo

53. Emergency Tube Change
National Tracheostomy Safety Project. Published on Apr 15,
Emergency Tracheostomy Tube Change
https://www.youtube.com/watch?v=ep2MM2CcMhI

54. 01
Demonstrate how to do a single
lumen tube change
List reasons why a
tracheostomy may be needed
Learning
Outcomes
02
05
Demonstratehowtochangean
innercannulaandhowtocleanan
innercannula
Demonstratehowtocomplete
tape/tiechanges03
06
State what a tracheostomy
Demonstrate how to clean the
stoma and list signs of infection04
Explain actions to take in an
emergency situation07