Tracheostomy Humidification

The nose and mouth provide warmth, moisture and filtration for the air we breathe. Having a tracheostomy tube, however, by-passes these mechanisms so humidification must be provided to keep secretions thin and to avoid mucus plugs. To keep the environment at an optimal humidity level, follow the procedures below.

Equipment

• Air compressor
• Nebulizer bottle
• Aerosol tubing
• Trach mask
• Sterile water
• Saline ampules (“bullets”)
• Heat Moisture Exchanger (HME) Also known by several other terms including: Thermal Humidifying Filters, Swedish nose, Artificial nose, Filter, Thermovent T.
• Room/home humidifiers

Attach a mist collar (trach mask) with aerosol tubing over the trach with the other end of tubing attached to the nebulizer bottle and air compressor. Sterile water goes into the nebulizer bottle (do not overfill, note line guide). Oxygen can also be delivered via the mist collar if needed.

Heated mist may be ordered. Heated mist is accomplished by an electric heating rod that fits into the nebulizer bottle. Extra care should be taken to be sure the bottle does not go dry, which could melt plastic. Many of these heating elements do not have automatic shut-offs and this could be a potential fire hazard. Also, more moisture will accumulate in the aerosol tubing with heated mist. Moisture that accumulates in the aerosol tubing must be removed frequently to prevent occlusion (blocking) of the tube and/or accidental aspiration (inhalation). Disconnect tubing at the trach end, empty into a container and discard. Do not drain fluid into the humidifying unit. Fluid traps (or drainage bags) are helpful in preventing occlusion and aspiration. These collection devices also need to be emptied frequently. Position the air compressor and tubing lower than the patient to help prevent aspiration from moisture in the tubing. A mist collar can also be worn during the day when mucus is thick or blood tinged. Sterile saline drops can be instilled into the trach tube if secretions become thick and difficult to suction. A saline nebulizer treatment is also helpful to loosen secretions if the patient has a nebulizer machine. Additional fluid intake also helps to keep secretions thinner.

Secretions can be kept thin during the day by applying a Heat Moisture Exchanger (HME) to the trach tube. An HME is a humidifying filter that fits onto the end of the trach tube and comes in several shapes and sizes (all styles fit over the standard trach tube opening). There are also HME’s available for portable ventilators. Bedside ventilators have built-in humidifiers. HME’s also help prevent small particles from entering the trach tube. Change HME daily and as needed if soiled or wet.

Source - http://www.hopkinsmedicine.org/tracheostomy

Tracheostomy Equipment

Tracheostomy Supplies

Tracheostomy tubes of the appropriate type and size
Tracheostomy tube (one size smaller)
Trach tube ties or velcro strap
Dressing supplies, gauze
Hydrogen peroxide, sterile water, normal saline
Water soluble lubricant such as Surgilube or KY Jelly
Blunt-end bandage scissors
Tweezers or hemostats
Sterile Q-tips
Trach care kits and/or pipe cleaners (double-cannula trach tubes)
Luer lock syringes for cuffed trach tubes

Suction Equipment

Portable battery-powered suction machine
Suction connecting tubing
Suction catheters
Normal saline solution
Sterile jars with screw tops (sterile specimen containers or sterilized baby food jars work well)
Saline ampules (“bullets“)
Bulb syringe
DeLee suction trap or syringe with catheter
Hand-powered Suction Devices  A simple yet efficient suction unit for first responders, and a reliable backup for emergency healthcare providers.
YanKauer Suction Handle
Sims Connector

Humidification System

Air compressor
Nebulizer bottles
Tracheostomy mask
Aerosol tubing
Water trapHeatMoisture Exchanger  (HME) (If you don't have an HME, use a room humidifier)
Room humidifier
Sterile water
Mist heater (if ordered)
Croup or mist tent (rarely ordered today)
Vapotherm

Other Supplies That You May or May Not Need

Hand washing supplies
Cleaning supplies
Mucus traps for sputum specimens
Sterile or clean paper cups
Tissues
Manual resuscitation (Ambu) bag with mask and trach adapter
Intercom, baby monitor or video monitor
Thermometer
Stethoscope
Disposable Gloves (powder free)
Trach scarf or bib
Rolled-up towel
Other Possible Equipment Needs
Speaking valves
Trach guard
Cardiac/Apnea monitor
CO2 monitor
Pulse oximeter
Oxygen
Oxygen Concentrator
Oxygen Supply tubing
Ventilator
BiPAP
Nebulizer Equipment (Aerosolized medication delivery system)
Dura-neb Portable Compressor/Nebulizer
DeVilbiss® Pulmo-Aide® Compact Compressor/Nebulizer
AeroTrach Plus™
Pressure manometer to check trach cuff pressure on cuffed tubes
Extra smoke detectors and a fire extinguisher suitable for electric as well as regular fires.
Consider an emergency generator if you have frequent power failures.

Decannulation of Tracheostomy

Definition:
The process whereby a tracheostomy tube is removed once patient no longer needs it.

Indication:
When the initial indication for a tracheostomy no longer exists.

Requirements:

A patient is considered a candidate for decannulation once the following conditions are met.

1.     Patient is alert and oriented and responsive to commands.

2.     Patient is no longer dependent on a ventilator for assisted breathing.

3.     The frequency requirement for tracheal suctioning is less than once a day. (This is not always the case. Check with your physician)

4.     Patient has met the criteria for decannulation outlined below.

Criteria for decannulation

1.     Patient should not be dependent on a ventilator.

2.     Patient’s mental status should be to the level of alert and responsive and should be able to manage their oral secretions without a risk of aspiration.

3.     Should not require frequent suctioning for tracheal secretions.

4.     Patient should be able to cough and clean his/ her tracheal secretions.

5.     The patient should have their tracheostomy tube downsized to a size 4 Shiley or similar tracheostomy tube and they should not have breathing difficulty in the presence of this tube.

6.     The size 4 Shiley or similar tube should be occluded (with a trach plug/ cork) for twelve hours during the day with close monitoring by the nursing staff  with no evidence of respiratory difficulty or requiring of suctioning of the trach tube.

7.     Once the patient is seen to tolerate the steps in item # 6 above, their trach is plugged for twenty four hours and they are monitored for respiratory difficulty or suction requirement.

Decannulation:

Once all of the above criteria are met, the patient is informed that their trach tube is going to be removed. They are instructed that they may experience a sensation of shortness of breath for a few minutes once they are decannulated.

Arrangements should be made for back-up personnel (RT or RN) to be available in case of emergency. Decannulation is usually not done at home.

The patient is placed supine (flat) on their bed, the tube is removed and the opening into the neck is covered with sterile gauze and a tape is placed over the gauze.

The patient is instructed to occlude the gauze with their finger tip every time they cough or speak so that air does not leak. They should change the gauze and the tape at least once a day (more often as needed) until the hole in the neck heals itself closed over the next few days to weeks. In a minority of patients (<10 %), the opening into the neck skin has to be surgically closed.

Making sterile salt water (saline) for home suctioning/use

Making sterile salt water (saline) for home suctioning/use

Start with clean hands, pans, containers and spoon

1.     Put saline storage jar and lid in one pan and cover with tap water.

2.     Put 4 ¼ cups of tap water in a second pan.

3.     Boil both pans for ten minutes.

4.     Add two level teaspoons of table salt to plain boiled tap water and stir to dissolve.  Cool both pans to room temperature.

5.     Remove storage jar and lid touching only the outside.

6.     Pour cooled salt water directly into storage jar.  Place lid tightly on jar.  Store in refrigerator.

7.     Pour off the amount needed for each cleaning or suctioning session into a smaller container.  Do not dip anything into the large supply of saline.

8.     Make a new batch every day.

Tracheostomy Stoma Care

Tracheostomy Stoma Care

The buildup of mucus and the rubbing of the tracheostomy tube can irritate the skin around the stoma. The skin around the stoma should be cleaned at least twice a day to prevent odor, irritation and infection. If the area appears red, tender or smells badly, stoma cleaning should be performed more frequently. Call your surgeon’s office if a rash, unusual odor, and/or yellowish-green drainage appears around the stoma.

Equipment:

• Face cloth
• Cotton-tipped applicators
• Hydrogen peroxide (1/2 strength - equal parts peroxide and water)
• Normal saline
• Vaseline guaze 2x2 dressing (optional)

1.     Wash your hands.

2.     Remove any dressing around the tracheostomy (if applicable). The tube should not have to be removed to clean the stoma.

3.     Dip the cotton tip applicators in the hydrogen peroxide (saline can be used if the peroxide is too irritating) and use it to clean around the stoma site. Start as close as possible to the tracheostomy tube then work away from it.

4.     Repeat the process until debris and/or mucus is removed.

5.     Use a dry cotton tip applicator or face cloth to dry the skin.

6.     No gauze should be placed under the trach tube unless recommended by the treating physician.  A dry dressing is helpful if the patient has areas of skin irritation or secretions. 

Daily Care

Rubbing of the trach tube and secretions can irritate the skin around the stoma. Daily care of the trach site is needed to prevent infection and skin breakdown under the tracheostomy tube and ties. Care should be done at least once a day; more often if needed. Patients with new trachs or on ventilators may need trach care more often. Tracheostomy dressings are used if there is drainage from the tracheostomy site or irritation from the tube rubbing on the skin.

It may be helpful to set up a designated spot in the home for equipment and routine tracheostomy care.

Equipment

• Sterile cotton tipped applicators (Q-tips) 
• Trach gauze
• Sterile water
• Hydrogen peroxide (1/2 strength with sterile water)
• Trach ties and scissors (if ties are to be changed) 
• Two sterile cups or clean disposable paper cups
• Small blanket or towel roll

Procedure

1.     Wash your hands. 

2.     Make sure the patient is laying in a comfortable position on his/her back with a small blanket or towel roll under his/her shoulders to extend the neck and allow easier visualization and trach care.

3.     Open sterile cotton, trach gauze and regular gauze.

4.     Cut the trach ties to appropriate length (if trach ties are to be changed).

5.     Pour 1/2 strength hydrogen peroxide into one cup and sterile water into the other.

6.     Clean the skin around the trach tube with sterile cotton soaked in 1/2 strength hydrogen peroxide. Using a rolling motion, work from the center outward using 4 swabs, one for each quarter around the stoma and under the flange of the tube. Do not allow any liquid to get into trach tube or stoma area under the tube.  Note: We recommend cleaning with just soap and water in home care, using hydrogen peroxide only to remove encrusted secretions. This is because daily use of hydrogen peroxide might irritate the skin, especially in cases with small children.

7.     Rinse the area with cotton soaked in sterile water.

8.     Pat dry with gauze pad or dry sterile cotton.

9.     Change the trach ties if needed.

10.   Check the skin under the trach ties.

11.   For tracheostomy tubes with cuffs, check with your surgeon’s office for specific cuff orders. Check cuff pressure every 4 hours (usual pressure 15 - 20 mm Hg). In general, the cuff pressure should be as low as possible while still maintaining an adequate seal for ventilation.

12.   Monitor skin for signs of infection. If the stoma area becomes red, swollen, inflamed, warm to touch or has a foul odor, or if the patient develops a fever, call your surgeon’s office.

13.   Check with the doctor before applying any salves or ointments near the trach. If an antibiotic or antifungal ointment is ordered by one of our doctors, apply the ointment lightly with a cotton swab in the direction away from the trach stoma.

14.   Wash your hands after each trach care.

Tracheostomy Suctioning

The upper airway warms, cleans and moistens the air we breathe. The trach tube bypasses these mechanisms, so that the air moving through the tube is cooler, dryer and not as clean.  In response to these changes, the body produces more mucus.  Suctioning clears mucus from the  tracheostomy tube and is essential for proper breathing. Also, secretions left in the tube could become contaminated and a chest infection could develop.  Avoid suctioning too frequently as this could lead to more secretion buildup.

Removing mucus from trach tube without suctioning

1.     Bend forward and cough. Catch the mucus from the tube, not from the nose and mouth.

2.     Squirt sterile normal saline solutions (approximately 5cc) into the trach tube to help clear the mucus and cough again.

3.     Remove the inner tube (cannula).

4.     Suction.

5.   If still the breathing is not adequate

6.     Remove the entire trach tube and try to place the spare tube.

7.     Continue trying to cough, instill saline, and suction until breathing is normal or help arrives.

When to suction

Suctioning is important to prevent a mucus plug from blocking the tube and stopping the patient's breathing.  Suctioning should be considered

• Any time the patient feels or hears mucus rattling in the tube or airway
• In the morning when the patient first wakes up
• When there is an increased respiratory rate (working hard to breathe)
• Before meals
• Before going outdoors
• Before going to sleep

The secretions should be white or clear. If they start to change color, (e.g. yellow, brown or green) this may be a sign of infection. If the changed color persists for more than three days or if it is difficult to keep the tracheostomy tube intact, call your surgeon's office. If there is blood in the secretions (it may look more pink than red), you should initially increase humidity and suction more gently. A Artificail humidifier, which is a cap that can be attached to the tracheostomy tube, may help to maintain humidity. The cap contains a filter to prevent particles from entering the airway and maintains the patient's own humidity. Putting the patient in the bathroom with the door closed and shower on will increase the humidity immediately. If the patient coughs up or has bright red blood mucus suctioned, or if the patient develops a fever, call your surgeon's office immediately.

How to suction

Equipment
Clean suction catheter (Make sure you have the correct size)
Distilled or sterile water
Normal saline
Suction machine in working order
Suction connection tubing
Jar to soak inner cannula (if applicable)
Tracheostomy brushes (to clean tracheostomy tube)
Extra tracheostomy tube

1.     Wash your hands.

2.     Turn on the suction machine and connect the suction connection tubing to the machine.

3.     Use a clean suction catheter when suctioning the patient. Whenever the suction catheter is to be reused, place the catheter in a container of distilled/sterile water and apply suction for approximately 30 seconds to clear secretions from the inside. Next, rinse the catheter with running water for a few minutes then soak in a solution of one part vinegar and one part distilled/sterile water for 15 minutes. Stir the solution frequently. Rinse the catheters in cool water and air-dry. Allow the catheters to dry in a clear container. Do not reuse catheters if they become stiff or cracked.

4.     Connect the catheter to the suction connection tubing.

5.     Lay the patient flat on his/her back with a small towel/blanket rolled under the shoulders. Some patients may prefer a sitting position which can also be tried.

6.     Wet the catheter with sterile/distilled water for lubrication and to test the suction machine and circuit.

7.     Remove the inner cannula from the tracheostomy tube (if applicable). The patient may not have an inner cannula. If that is the case, skip this step and go to number 8.

a. There are different types of inner cannulas, so caregivers will need to learn the specific manner to remove their patient's. Usually rotating the inner cannula in a specific direction will remove it.

b. Be careful not to accidentally remove the entire tracheostomy tube while removing the inner cannula. Often by securing one hand on the tracheostomy tube?s flange (neck plate) one can/ will prevent?accidental removal.

c. Place the inner cannula in a jar for soaking (if it is disposable, then throw it out).

8.     Carefully insert the catheter into the tracheostomy tube. Allow the catheter to follow the natural curvature of the tracheostomy tube. The distance to the location of catheter becomes easier to determine with experience. The least traumatic technique is to pre-measure the length of the tracheostomy tube then introduce the catheter only to that length. For example if the patient?s tracheostomy tube is 4 cm long, place the catheter 4 cm into the tracheostomy tube. Often, there will be instances when this technique of suctioning (called tip suctioning) will not clear the patient?s secretions. For those situations, the catheter may need to be inserted several mm beyond the end of the tracheostomy tube (called deep suctioning). With experience, caregivers will be able to judge the distance to insert the tracheostomy tube without measuring.

9.     Place your thumb over the suction vent (side of the catheter) intermittently while you remove the catheter. Do not leave the catheter in the tracheostomy tube for more than 5-10 seconds since the patient will not be able to breathe well with the catheter in place.

10.   Allow the patient to recover from the suctioning and to catch his/her breath. Wait for at least 10 seconds.

11.   Suction a small amount of distilled/sterile water with the suction catheter to clear any residual debris/secretions.

12.   Insert the inner cannula from extra tracheostomy tube (if applicable).

13.   Turn off suction machine and discard catheter (clean according to step 3 if to be reused).

14.   Clean inner cannula (if applicable).

Cleaning and Caring for Tracheostomy Equipment

Cleaning suction catheters at home

Suction catheters must be cleaned after each session of suctioning. This helps prevent infection as well as helps cut down costs by reusing the same catheter for one week.

After suctioning the trach tube:

1.     Pour a few ounces of hydrogen peroxide into a small clean container.

2.     Suction hydrogen peroxide through the catheter until it is free of mucus. Wipe the outside of the catheter with a cloth or gauze wet with peroxide.

3.     Suction sterile salt water through the catheter until it is free of peroxide.

4.     Suction air until the catheter is free of water.

5.     Remove the catheter from the connecting tubing and let it air dry.

6.     Wrap it in a clean dry towel.

7.     Use it as needed with this cleaning process each time for up to 8 hours, then THROW IT AWAY.

8.     Follow manufacturer's instruction for cleaning and disinfecting your suction machine and humidifier. Do not allow water to stand in your humidifier when not in use.

Cleaning the tracheostomy inner cannula tube (for reusable inner cannulas only)

The tracheostomy inner cannula tube should be cleaned two to three times per day or more as needed. Please note that this only applies to reusable inner cannulas.Cleaning is needed more immediately after surgery and when there is a lot of mucus buildup.

Equipment

• Small brush or pipe cleaners
• Half-strength solution of hydrogen peroxide (1/2 water, 1/2 hydrogen peroxide)
• Saline or homemade sterile salt water
• Two small bowls

Procedure

1.     Wash your hands.

2.     Place 1/2 strength peroxide solution in one bowl and sterile salt water in second bowl.

3.     Remove the inner cannula while holding the neck plate of the trach still.

4.     Place inner cannula in peroxide solution and soak until crusts are softened or removed.

5.     Use the brush or pipe cleaner to clean the inside, outside and creases of the tube.

6.     Do not use scouring powder or Brillo pads.

7.     Look inside the inner cannula to make sure it is clean and clear of mucus.

8.     Rinse tube in saline or sterile salt water.

9.     Re-insert it while holding the neck plate of the trach still.

10.   Turn the inner cannula until it locks into position.

11.   Double check the locking pulling forward gently on the inner cannula.

Tracheostomy Complications

The surgeon will perform the first tracheostomy tube change to ensure that the stoma and tracheostomy site heal properly.  If the stoma is ready (usually 1-2 weeks after surgery), the otolaryngology team will teach the caregivers how perform a tube change.  It is important that caregivers feel confident and competent in tube changing before leaving the hospital in case an emergency tube change is needed.  The procedure is not without risks and in order to be as safe as possible, it is important to have two people present.  

Secretions from the lungs coat the inside of the tracheostomy tube requiring the tube to be changed once a week, although some patients may be fitted with a different tube that can be left in longer. The tube may have to be changed more often if secretions become very dry or if the patient has a chest infection and is producing more and thicker secretions. Always change the trach tube before a feeding or wait for at least two hours after a feeding to avoid vomiting and resulting spillage of vomitus into the windpipe.

Instructions for tube changing

1.     Prepare equipment:
- Suction catheter and suction machine in working order
- two lengths of 1/4 inch cotton tapes or Velcro strap
- new tube - check correct size and that the tube is intact and in good order
- a smaller sized tube (one incremental size smaller) in case the usual one will not go in
- water-based lubricant to prevent the tube sticking to the skin as it is inserted
- round-ended scissors

2.     Wash your hands.

3.     Prepare tube - take out of wrapping and hold by the flanges. Put in introducer (if applicable). Carefully apply a small amount of lubricant to the outer side of the end of the tube, ensuring no lubricant gets into the ends of the tube. Place the ties or strap on the new tube. Place the tube on the wrapper.

4.     Have all equipment within easy reach.

5.     Suction if necessary.

6.     Position the patient as you do for tape changing.

7.     Have one person hold the tube while the other cuts and remove the dirty tapes and place clean tapes behind the patient’s neck.

8.     The tube should continue to be held while the other person holds the new tube by the flanges and positions the tip near the patient’s neck.

9.     Gently remove the old tube following the curve of the tube.

10.   Firmly and gently slide in the new tube, again following the curve of the tube so as not to damage the trachea. Remove introducer if this has been used.

11.   Hold the new tube securely in place - changing the tube may cause the patient to cough, which could dislodge it.

12.   Allow the coughing to settle. Check air flow through the tracheostomy tube by feeling the air flow onto your hands and the patient’s breathing pattern and color. Suction if necessary.

13.   Clean and observe the skin around the tube.

14.   Tie the tapes.

15.   Do not let go of the tube until the tapes are secure.

Source:http://www.hopkinsmedicine.org/tracheostomy