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Tracheostomy care bundle

Reasons for Tracheostomy in critical care

In terms of weaning from ventilator support, there is currently no strong evidence to indicate the optimal timing for insertion of a tracheostomy tube.

Tracheostomy care
Although a range of tube types and sizes exist, and different approaches to tracheostomy insertion may be adopted, all tracheostomy patients should have standard emergency bedside equipment. The regular completion, 2-4 hourly of tracheostomy care bundles can also optimise patient management.

Example - Tracheostomy care bundle - The Hillingdon Hospital

Example - Tracheostomy care proforma - NWLHT

Included in care proformas is ensuring a clean inner tube to maintain tube patency for double lumen tubes. Suctioning should be performed when clinically indicated.

Example - Suctioning guidance

Tracheostomy dressings are also advised to be changed at least once daily.

Example - Tracheostomy dressing guidance

For the patient with an inflated cuff, cuff pressure should be checked with a manometer every 6-8 hours. An optimal cuff pressure should be within 15-25 cmH2O to minimise risk of damage to the tracheal wall.
In bypassing the efficient heating and humidification system of the upper airway, all patients breathing via a tracheostomy tube should have some form of humidification. Heated humidification should ideally be applied, or a heat and moisture exchanger (e.g. Swedish nose, Buchanan bib) may be used for those patients requiring minimal or no supplemental oxygen in the absence of thick tenacious airway secretions.

Transfer out of Critical Care
If a patient with a tracheostomy is to be transferred from critical care, they should be transferred to a location where staff are adequately trained to manage tracheostomy tubes. A proficient handover of the patient should be given and preferentially the patient should be changed to a double lumen tube if necessary prior to transfer to the ward. This will optimise patient safety in case of tube obstruction. The National Tracheostomy Safety Project has developed an algorithm for emergency tracheostomy management which ward staff should be familiar with.

Example - Transfer information sheet for tracheostomy patients

Tracheostomy tube changes
Most tracheostomy tubes are advised to be in situ no longer than 28 days. Only trained individuals should perform tracheostomy tube changes.There is currently no consensus of the optimal tracheostomy weaning strategy. Multiple approaches are described in the literature, including:

An MDT approach to weaning has been demonstrated to reduce tracheostomy cannulation times. General information regards weaning can be found here

Decannulation
Once the original reason for tracheostomy has resolved, suggested criteria to meet prior to decannulation are:

Example - Decannulation guidance

Decannulation should be performed by trained individuals only, and outside of critical care ideally should be performed in the morning and not on weekends (link to “Procedure for Tracheostomy Decannulation”).

North West London Critical Care Network,     Network Office,     15 Marylebone Road,     London,     NW1 5JD

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