Tracheostomy care bundle
Reasons for Tracheostomy in critical care
- facilitation of weaning from mechanical ventilation
- airway protection and maintenance
- secretion management
In terms of weaning from ventilator support, there is currently no strong evidence to indicate the optimal timing for insertion of a tracheostomy tube.
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
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.
Tracheostomy dressings are also advised to be changed at least once daily.
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.
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:
- cuff deflation trials (variable durations)
- downsizing or change to a fenestrated tube
- use of a speaking valve
- periods of tube occlusion via a cap (variable durations)
- rapid decannulation without any of the above
An MDT approach to weaning has been demonstrated to reduce tracheostomy cannulation times. General information regards weaning can be found here
Once the original reason for tracheostomy has resolved, suggested criteria to meet prior to decannulation are:
- Self-ventilating off of mechanical ventilation
- Minimal secretions, suctioning needs < 2 hourly, with an effective cough
- FiO2 ≤ 0.35
- CVS stable
- Consistent GCS, not drowsy
- No signs of bronchopulmonary infection
- Any head and neck oedema considered minor
- Absence of significant gastro-oesophageal reflux
- Able to manage oral secretions (by expectoration, Yankauer suction or swallow)
- Demonstration of upper airway patency in tolerating at least 60 seconds of tracheostomy tube occlusion without signs of stridor, respiratory distress or significant oxygen desaturation
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”).