Due to the current COVID-19 pandemic, the number of patients requiring intensive care stay, and therefore the frequency of tracheostomy insertions, is on the rise. These patients are likely to arrive on COVID-19 wards for weaning, and teams on the wards might not be familiar with caring for a patient with a tracheostomy.
The All-Wales TRACHES checklist (linked below) provides a simple, step-by-step guide to safely care for a patient with a tracheostomy:
Tapes and dressings
- The tapes secure the tracheostomy in place and prevent it becoming dislodged.
- The dressing protects the skin around the tracheostomy and prevent it becoming irritated or macerated.
- The tapes and dressings should be changed once a day in hospital or as required (becomes soiled or dislodged).
- Ensure the tapes are not too loose or too tight; you should be able to pass two fingers between the tapes and the patient’s neck.
- Red flags are the often-detectable warning signs that occur before an emergency.
- Common red flags include increased frequency to change inner tube, increased need to re-inflate the cuff, and ability to vocalise when the cuff is supposed to be inflated.
- Knowing what to look out for will allow early trouble shooting and stop minor problems escalating.
Assessment of the inner tube
- The inner tube is a safety feature that sits inside the outer tube of the tracheostomy, and reduces the potential for blockage of the tracheostomy tube.
- The inner tube can be easily removed and cleaned, while the outer tube remains in place to keep the airway open.
- The inner tube must be present at all times; it may not be possible to provide resuscitation to the patient if the inner tube is absent.
- The inner tube should be checked every two hours and cleaned as required.
- The tracheostomy cuff (when present) provides a seal to enable mechanical ventilation.
- It also provides some protection against aspiration of secretions from the upper airway.
- The pressure within the cuff should be checked once a shift or as required with a hand-held pressure manometer and should be maintained between 20 – 25cmH2O.
Humidification and oxygen therapy
- A tracheostomy bypasses the normal upper airway mechanisms for humidification, filtration and warming of inspired gases.
- Without supplementary humidification, secretions in the airways get thick and sticky, and may block the tracheostomy tube or cause infection.
- There are various methods to provide supplementary humidification, and these can be tailored to the patient’s needs.
- There are several scenarios that can lead to a tracheostomy emergency. The most common are a dislodged or displaced tracheostomy, a blocked tracheostomy tube, and a bleeding tracheostomy site.
- During a tracheostomy emergency, the Tracheostomy emergency algorithm should be followed (linked below). Each step of the emergency tracheostomy algorithm is to assess and achieve patient stability until expert airway help arrives.
- Assess the need for suction at least 2 hourly. Suction should not be performed routinely, but only when the patient requires it.
- The frequency of suction varies widely between patients. Providing suction uses an aseptic non-touch technique and the suction pressure ideally less than 20cmH2O.
- Suction may need to be applied to two sites: the lumen of the tracheostomy tube where secretions may gather in the trachea, and above the cuff of a tracheostomy tube where secretions may build up from the upper airway.
Please note, the demonstrations of each step in the video below were filmed before the COVID-19 pandemic, and therefore the PPE worn by the healthcare team is not appropriate for the management of a patient on a COVID-19 ward with a tracheostomy. Please review up-to-date guidance on PPE in COVID-19.
For more information about managing a patient with a tracheostomy, as well as a whole series of videos on each of the seven steps, locate the ‘All-Wales TRACHES Checklist – Education package‘ below.
Get Wales TRACHES ready