Background

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 cuffs.
• 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.

(NSW DoH 2015; Dawson 2014; Craig Hospital 2014; CCAM 2016)

Airway Profile

All children in Western Australia with a tracheostomy will have an Airway Profile. The Airway Profile will outline:

• Tracheostomy tube type (cuffed /uncuffed), size and the appropriate smaller size tube
• Suction depth
• Patient-specific airway information
• Ventilator settings, if applicable
• If patient has a speaking valve, whether it is drilled / undrilled and if used throughout the day

Complications

Tracheostomy airway impairment may occur due to:

• Partially blocked tube
• Completely blocked tube
• Accidental decannulation or dislodgement of the tube.

Emphasis is on early recognition of any change in the patient’s respiratory status and tube patency to avoid an emergency event. Late signs of impending respiratory collapse include cyanosis, bradycardia and apnoea – do not wait for these to develop before intervening.

Officers should familiarise themselves with the Tracheostomy / Laryngectomy Airway Emergencies Clinical Practice Guideline, and Suction - Tracheostomy Clinical Skill to manage these complications.

Management

• Position & reassure
• Inform family

1. The tracheostomy tube is in place and patent:
   • Commence respiratory support by connecting bag-valve mask to the tracheostomy tube and commence bagging. Be mindful of ventilation rate and tidal volume, being cautious not to hyperventilate or over-inflate.
2. The tracheostomy tube is not in place:
   • Request caregiver to re-insert tracheostomy tube.
   • If successful, follow instructions above.
3. Unable to ventilate, follow instructions below.
• SJA personnel may assist, but are discouraged from performing this procedure independently (as this skill is deemed a competency).
• All children carry an emergency management kit equipped with a same size tracheostomy tube and a size smaller tracheostomy tube.
• Attempt to reinsert same size tracheostomy tube with lubricant prior to providing bag valve mask ventilation.
• If unable: size smaller tube with lubricant
• If caregiver unable to reinsert tracheostomy tube, provide bag valve mask ventilation per the instructions below.
The patient has a patent upper airway:
• Dry the stoma area
• Cover stoma with an air tight dressing e.g. Tegaderm®
• Use bag valve mask (with appropriate sized face mask), covering the mouth and nose and commence ventilation as per clinical skill
• Apply gentle pressure over stoma, if required
The patient has a non-patent upper airway:
• Position to optimise airway and breathing
• Use a bag valve mask (with neonatal mask) to cover the stoma and attempt to ventilate.
  (Note: bag valve mask via nose/mouth are likely to be ineffective)

Suction should maximise removal of secretions while minimising tissue damage and hypoxia in order to maintain a patent airway and allow effective ventilation.

The routine suction depth will be recorded on the patient’s Airway Profile. Deep suctioning is not to be performed.

• If the patient is able to cough up their own secretions this should be encouraged.
• Suction can raise intracranial pressure and should be used with caution in patients with a head injury and conditions related to raised blood or intracranial pressure.
• The patients caregiver should be able to provide additional suction catheters if those provided are not suitable; they may also be able to provide a suction unit if there are incompatibilities with SJA carried equipment.
• Routine suction depth is 0.5cm beyond the tip of the tracheostomy tube. The suction depth on the Airway Profile already includes this 0.5cm.

Procedure

• Position the patient, allowing access to the tracheostomy tube
  • The patient can remain in a wheelchair in a reclined position with shoulder roll
  • A young patient may be placed in a semi-recumbent position exposing the tracheostomy tube
  • An older patient may prefer to sit
• Attach the suction catheter to suction tubing, remove packaging and turn on the suction
  • The LCSU4 suction unit has a pressure gauge and variable suction dial; set to between 80-120mmHg/10-16kpa by occluding the suction catheter and rotating the dial on the side of the unit until the LED indicators increase/decrease to the desired setting
  
  • If you are not equipped with an LCSU4 unit (and are still using the ComWeld StatVac II unit in the Ferno Oxygen Bag), check with the parent/caregiver if they have a variable suction unit available.
  • Note: Higher pressure may cause alveolar collapse, mucosal damage or catheter collapse, whilst inadequate suction pressure may not remove enough secretions resulting in increased number of catheter passes.
• Observe the patient during the procedure for signs of respiratory and cardiovascular instability and discomfort.
  • If this occurs suction will need to be discontinued.
• Insert catheter into tracheostomy tube to the predetermined depth as specified on the patient’s Airway Profile.
  • Protect the catheter tip from coming into contact with surfaces, hands and clothing – discard if contaminated and use a new catheter.
  • If the catheter does not pass easily into the tracheostomy tube do not force, suspect a blocked or partially obstructed tube.
  • The suction depth on the Airway Profile already includes the 0.5cm below the end of the tracheostomy tube.
  • Suction should be applied on withdrawal of the suction catheter to minimise mucosal damage in the respiratory tract.
  • It is not necessary to rotate the catheter as the multiple eyelet catheters will remove secretions effectively.
• Assess the patient and the effectiveness of secretion clearance.
• Repeat the procedure if necessary.
  • Do not contaminate the catheter tip between passes.
  • If the suction catheter is not contaminated between suction passes it can be reused for multiple passes then discarded.
• Re-assess the patient, in terms of respiratory effort, adventitious lung sounds & colour
  
• Dispose of suction catheter. Suction tap water through the suction tubing to clear it of secretions.
• Discuss with the caregiver reattaching any external devices (e.g. Swedish nose, speaking valve) which were removed prior to starting procedure; these may stay disconnected in case the patient requires suctioning during ambulance transport.
  

References

• Tracheostomy Management.
• Royal Children’s Hospital. Tracheostomy Management. In: Clinical Nursing Guidelines, editor. Melbourne Australia: The Royal Children's Hospital Melbourne; 2018.
• Perth Children's Hospital. Tracheostomy Management Guideline. In: Clinical Practice Manual, editor. Perth: Child and Adolescent Health Services; 2018.
• Perth Children's Hospital. Tracheostomy Resuscitation Procedure. Clinical Practice Manual. Perth: Child and Adolescent Health Services; 2017.4.
• Credland N. How to suction via a tracheostomy. Nurs Stand. 2016;30(28):36-8