Tracheostomy Cuff and Tube Care

0022-ch0013-9780323376624.inddTracheostomy Cuff and Tube Care Renee Johnson
PURPOSE: Tracheostomy tube care includes care of the tracheal tube cuff, the inner and outer cannulas of the tracheal tube, and the tracheal dressing and ties. Proper care of the tracheostomy tube maintains an adequate airway seal and tracheal tube patency. Proper cuff infl ation may decrease the risk of aspiration of some particles. The tracheal dressing and ties are changed to maintain skin integrity and decrease the risk of infection. Additionally, the tracheal ties help maintain stability of the tracheal tube and prevent tube dislodgement.
PREREQUISITE NURSING KNOWLEDGE • Tracheotomy refers to the surgical procedure in which an
incision is made below the cricoid cartilage through the second to fourth tracheal rings ( Fig. 13-1 ). Tracheostomy refers to the opening, or the stoma, made by the incision. The tracheostomy tube is the artifi cial airway inserted into the trachea during the tracheotomy ( Fig. 13-2 ).
• A tracheotomy is performed as either an elective or emer- gent procedure for a variety of reasons ( Box 13-1 ). There is no standard time when a tracheotomy should be per- formed. The decision is based on the projected length of time that mechanical ventilation or an artifi cial airway is required to remain in place. A tracheostomy tube is the preferred method of airway maintenance in patients who may require mechanical ventilation for more than 14 to 21 days. 4-6,20,23,25 Further studies need to be done to help predict which mechanically ventilated patients may benefi t from early tracheostomy. 2,3,11-13
• Compared with endotracheal tubes, tracheostomy tubes provide added benefi ts to patients, including the follow- ing: prevention of further laryngeal injury from the trans- laryngeal tube; improved patient comfort, acceptance, and tolerance; ease of oral care; decreased work of breathing due to decreased airfl ow resistance; facilitation of weaning from mechanical ventilation; decreased requirements for sedation; provision of a speech mechanism which enhances communication; increased patient mobility; facilitation of removal of secretions; and reduced risk for unintentional airway loss.
• Elective tracheotomy is generally performed in the operat- ing room but may be performed at the bedside; percutane- ous tracheotomy is commonly performed at the bedside on ventilated patients. Emergent surgical cricothyrotomy may occur before the patient arrives in the critical care unit or at the bedside (for additional information on cricothyrotomy refer to Procedure 11 ).
• Surgical placement is performed under general anesthesia. Using an open surgical technique, a stoma is created. The trachea is visualized by the surgeon. Landmarks are
identifi ed by the surgeon, and an incision is made below the cricoid cartilage. The isthmus of the thyroid gland is exposed, cross-clamped, and ligated. A Bjork fl ap may be created. The fl ap is created when a small portion of the tracheal cartilage is pulled down and sutured to the skin. The fl ap helps facilitate reinsertion of the tracheostomy tube if it is dislodged, especially in patients who may be obese or have diffi cult anatomy. 14 Percutaneous tracheot- omy has been proven to be a safe alternative to surgical tracheostomy on mechanically ventilated patients. 8,13 Unlike surgical tracheotomy, percutaneous tracheotomy can be performed without direct visualization of the trachea. 14 A bronchoscope may or may not be used to assist with visualization during the procedure. A needle is passed into the trachea. A J-tipped guidewire is placed into the trachea, the incision is then the dilated, and the trache- ostomy tube is placed.
• Tracheostomies are not without complications. Common complications include infection, bleeding, tracheomala- cia, skin breakdown, and transesophageal fi stula. Common postoperative tracheostomy emergencies are hemorrhage, tube obstruction, and dislodgement. Hemorrhage can occur at the stoma site or into the trachea. A small amount of bleeding is expected postprocedure and is limited to a short period of time. Bleeding that continues or is moder- ate to large in volume could be due to a bleeding vessel or a tracheoinnominate artery fi stula. Bleeding vessels may need to be ligated by a physician.
• Tracheoinnominate artery fi stula is a rare complication with high mortality indices. In this complication the innominate artery has eroded into the trachea, which can result in exsanguination and is more common when a tracheostomy tube is subject to traction to one side or the other, away from the midline. Any concerns over bleeding should be reported to the physician immediately. Tube obstruction can occur from occlusion due to secretions or from the tracheostomy tube being displaced into the ante- rior portion of the trachea within a false passage. If the tube is obstructed from secretions, it should be suctioned. If the tube is felt to be dislodged into a false passage, treatment depends on how mature the stoma is. If the
90 Unit I Pulmonary System
stoma is mature the tube should be replaced. If the stoma is immature—that is, the stoma is less than a week old— mask ventilation should be employed with the cuff defl ated and an orotracheal tube should be inserted. Once the airway is secure the tracheostomy can be revised. 14 The physician should be notifi ed if the tube becomes obstructed and aggressive measures other than routine suctioning are needed to clear the cannula or secretions of debris.
• An initial tracheotomy tube change varies depending on whether the trach was placed via standard surgical procedure or via percutaneous approach. Currently there is no evidence to justify when the initial or subsequent tracheotomy tubes should be changed; it typically occurs by physician preference. The fi rst tube change most commonly occurs around day 5 postoperatively. Some reports state that for a percutaneous tracheotomy the initial change should not occur until postoperative day 10 to allow the stoma to mature. After the initial change, the tracheotomy should be changed approximately every 14 days thereafter. The fi rst change is usually done by the physician. 12,14
• In all instances, caution should be used to ensure that the tracheostomy tube is not accidentally dislodged or decan- nulated. The stoma takes approximately 1 week to heal posttracheotomy. Dislodgment of the tube in the fi rst week is considered an emergency; the tissue may collapse, and it may not be possible to replace the tracheal tube. Predis- posing factors to tube dislodgement or decannulation include an underinfl ated cuff, loose ties, neck or airway edema, excessive coughing, agitation or undersedation, morbid obesity, downward traction caused by the weight of the ventilator circuit, and an improperly sized trache- ostomy tube. Trach ties should be secure. Weight or trac- tion from the ventilator circuit should be minimized; when transporting or mobilizing the patient the tube should remain in a neutral midline position. Tube position should be noted before and after the patient is moved to ensure safety. Individual institutions usually use protocols to manage new tracheostomy tubes and accidental dislodg- ment to ensure patient safety. 7,12,14,17,31,33
• A tracheostomy tube is shorter than but similar in diameter to an endotracheal tube. Some tracheostomy tubes have both outer and inner cannulas. The outer cannula forms the body of the tracheostomy tube with a cuff. The neck fl ange, attached to the outer cannula, assists in stabilizing the tube in the trachea and provides the small holes neces- sary for properly securing the tube. Some tracheostomy tubes have an inner cannula inserted into the outer cannula. The inner cannula is removable for easy cleaning without airway compromise and may be disposable. The tracheal tube cuff is an infl atable balloon that surrounds the shaft of the tracheal tube near its distal end. When infl ated, the cuff presses against the tracheal wall to prevent air leakage and pressure loss from the lungs during positive pressure ventilation. The tracheal tube cuff is infl ated by injecting air through a pilot balloon with a one-way infl ation valve. The air in the pilot balloon is used to assess of the amount of pressure in the tracheal tube cuff ( Fig. 13-3 ).
• Tracheostomy tubes are available in various materials, sizes, and styles from several manufacturers. It is important
Figure 13-1 Sites for tracheostomy insertion. (From Serra A: Tracheostomy care, Nurs Stand 14:42,45–52, 2000.)
Thyroid cartilage
Cricoid cartilage
Subcricoid space
Cricothyroid membrane
Figure 13-2 A tracheostomy (sometimes called a tracheotomy) is created surgically by making an opening through the skin of the neck into the trachea. (From Serra A: Tracheostomy care, Nurs Stand 14:42,45–52, 2000.)
Esophagus
• Bypass acute upper airway obstruction • Prolonged need for artifi cial airway • Prophylaxis for anticipated airway problems • Reduction of anatomical dead space • Prevention of pulmonary aspiration • Retained tracheobronchial secretions • Chronic upper airway obstruction
13 Tracheostomy Cuff and Tube Care 91
the inner cannula is removed, the cuff defl ated, and the tracheostomy tube occluded with the plastic plug, the patient can breathe through the fenestration(s) and around the tube, using the normal anatomical airway. When a fenestrated tracheostomy tube is occluded in this manner, the patient can speak, as air is allowed to pass over the vocal cords. Additional oxygen can be provided to the patent via nasal cannula if needed. 8
• Uncuffed tubes are commonly used in children, in patients with laryngectomies, and during weaning from the trache- ostomy. Uncuffed tubes may also be used in long-term mechanically ventilated patients who have adequate pul- monary compliance and suffi cient oropharanygeal muscle strength for functional swallowing and articulation and laryngeal strength to achieve glottis closure. 8
• Cuffed tubes are generally used in patients requiring mechanical ventilation. Cuffed tubes allow for airway clearance, and the cuff limits aspiration of oral and gastric secretions in ventilated patients. Cuffed tubes include high-volume, low-pressure cuffs; low-volume, high- pressure cuffs; and foam cuffs ( Fig. 13-4 ). High-volume, low-pressure cuffs are the most desirable. These tubes allow a large surface area to come into contact with the tracheal wall, distributing the pressure over a much greater area. This cuff has a relatively larger infl ation volume that requires lower fi lling pressure to obtain a seal ( < 25 mm Hg or 34 cm H 2 O). The older cuff design (low-volume, high- pressure) may require 40 mm Hg (54.4 cm H 2 O) to obtain an effective seal and is undesirable.
• It is generally accepted that cuff pressure should be 20 to 25 mm Hg to minimize the risk of tracheal wall injury and decrease the risk of microaspiration for most tracheos- tomy tubes. 8,26 The amount of pressure and volume neces- sary to obtain a seal and prevent mucosal damage depends on tube size and design, cuff confi guration, mode of ven- tilation, and the patient ’ s arterial blood pressure (tracheal capillary perfusion pressure is 25 to 35 mm Hg for nor- motensive patients). Lower cuff pressures are associated with less mucosal damage but are also associated with silent aspiration, which has been shown when the cuff pressures are less than 20 mm Hg. 8,22,30
• Appropriate cuff care helps prevent major pulmonary aspirations; prepares for tracheal extubation; decreases the risk of inadvertent decannulation; provides a patent airway for oxygenation, ventilation, and removal of secretions; and decreases the risk of hospital-acquired infections.
• A variety of techniques or devices is available to measure cuff pressures, including bedside pressure manometers. Two techniques, minimal leak technique and minimal occlusion volume (MOV), had historically been listed in the literature as effective methods to assess proper cuff infl ation. Both of these methods have fallen out of favor due to the risk of aspiration when the cuff is defl ated, increasing the incidence of ventilator-associated pneumonia for some patients. Little research has been conducted regarding the best practices with cuff pressure assessments. 10,15 Measurement of tracheal tube cuff pressures can be
achieved through the use of a commercial pressure gauge by assembling equipment to assess pressure via
for the clinician to understand the differences between the various tracheostomy tubes to ensure appropriate feature, fi t, and size for the patient. The tube should be selected with the goal of minimizing damage to the tracheal wall, allow- ing adequate ventilation, and when possible promoting translaryngeal airfl ow for communication to assist with future rehabilitation and therapy. The American Thoracic Society has published guidelines to guide users in selecting the appropriate tube and size. 12,16 Routine patient care and tube maintenance may be affected based on the tube size, style, and construction.
• Tracheostomy tubes can be constructed of metal (silver or stainless steel) or plastic (polyvinyl chloride or silicone). Metal tubes are rarely used due to cost, rigid construction, lack of cuff, the possibility of damage by cleaning with hydrogen peroxide or enzymatic cleaners, and lack of a 15-mm connector needed to attach the tracheostomy tube to a ventilator or bag-valve mask. 8,14 Polyvinyl chloride softens with the patient ’ s body temperature, which helps the tube conform to the patient ’ s anatomy and assists in centering the distal tip in the trachea. Silicone tubes are naturally soft and are not affected by the patient ’ s body temperature. 8
• Tracheostomy tubes may be angled or curved, and come in standard or extra length, fenestrated, and cuffed or uncuffed. Angled tubes have a straight portion and a curved portion, whereas curved tubes have a uniform angle of curvature. Extra length on the tracheostomy tube may refer to additional length that is proximal (horizontal length) or distal (vertical length). Extra proximal length may facilitate tracheostomy tube placement in patients with large necks (for example, obese patients); extra distal length may facilitate placement in patients with tracheal anomalies or tracheal malacia. 8
• Fenestrated tracheostomy tubes are similar to standard tracheostomy tubes with an added opening located in the posterior portion of the tube above the cuff. Fenestrated tubes come with an inner cannula and a plastic plug. When
Figure 13-3 Parts of a tracheostomy tube. (From Eubanks DH, Bone RC: Comprehensive respiratory care , ed 2. St Louis, 1990, Mosby, p. 570.)
Outer cannula
Cotton tape
Pilot balloon
Rounded tip
92 Unit I Pulmonary System
Figure 13-4 Cross-sectional view in D-shaped trachea. Effects of soft and hard cuff infl ation on the tracheal wall. (From Kersten LD: Comprehensive respiratory nursing . Philadelphia 1989, Saunders, p. 648.)
bedside manometer. An advantage to direct cuff pres- sure monitoring is that there is no need to defl ate then reinfl ate the cuff, thus decreasing the potential risk for aspiration. Disadvantages are that these devices are designed for high-volume, low-pressure cuffs that are air fi lled. Saline-fi lled cuffs would damage the device. 24
The MOV consists of injection of air into the cuff until no leak is heard, then withdrawal of the air until a small leak is heard on inspiration, and then addition of more air until no leak is heard on inspiration. 1,10,17,25,30 The main advantages of this method are that it is easy to perform and that there is little additional equip- ment needed to perform the MOV. The main disadvan- tage is that by withdrawing air from the cuff, a leak is created, thus increasing the patient ’ s potential risk for aspiration.
Although rare since the use of high-volume, low- pressure devices became common, the adverse effects of tracheal tube cuff infl ation include tracheal stenosis, necrosis, tracheoesophageal fi stulas, and tracheomala- cia. These complications may be more likely to occur in conditions that adversely affect tissue response to mucosal injury, such as hypotension. Two major
mechanisms are mainly responsible for airway damage: tube movement and pressure. Duration of intubation also plays a signifi cant role. 16,28
Routine cuff defl ation is unnecessary and is no longer recommended. 17
• Consideration should be given to obtaining assistance with tracheostomy care, especially when tracheal ties are changed or when the patient is agitated. An assistant can minimize risk for accidental dislodgement.
EQUIPMENT
• Specially designed manometer to measure cuff pressures • Stethoscope • Self-infl ating manual resuscitation bag-valve device • Oxygen source and tubing • Suction supplies (see Procedure 12 ) • Personal protective equipment • Sterile normal saline solution or sterile water • Two to three sterile containers to place supplies (cotton
swabs, normal saline) • Sterile cotton balls and/or cotton-tipped applicators • Sterile nylon brush • Sterile 4 × 4 gauze
13 Tracheostomy Cuff and Tube Care 93
patient with mechanical ventilation. Rationale: An ade- quate seal of the cuff to the tracheal wall does not permit air to fl ow past the cuff.
• Assess signs and symptoms of inadequate ventilation, including rising arterial carbon dioxide tension, chest- abdominal dyssynchrony, patient-ventilator dyssynchrony, dyspnea, headache, restlessness, confusion, lethargy, increasing (early sign) or decreasing (late sign) arterial blood pressure, and activation of expiratory or inspiratory volume alarms on mechanical ventilator. Rationale: This guides needed interventions.
• Assess the amount of air or pressure currently or previously used to infl ate the cuff. Rationale: The amount of air previ- ously used to infl ate the cuff can be used as a guideline to determine changes in volume or pressure or both.
• Assess the size of the tracheal tube and the size of the patient. Rationale: The volume and pressure of air needed to seal the airway depends on the relationship between the tracheal tube and the diameter of the trachea.
• Assess the amount of secretions. Rationale: This may increase the frequency of suctioning and tube care.
• Assess for the presence of cutaneous tracheal sutures. Rationale: After 7 days (when the trach is mature), the sutures may no longer be required. If they remain in place, notify the physician and query for removal. The sutures increase the risk of decanulation due to diffi culty with maneuvering to care for the site and dress- ing. Prolonged suture retention may also promote skin breakdown.
Patient Preparation • Ensure that the patient and family understand preprocedural
teachings. Answer questions as they arise, and reinforce information as needed. Rationale: This communication evaluates and reinforces understanding of previously taught information.
• Verify that the patient is the correct patient using two identifi ers. Rationale: Before performing a procedure, the nurse should ensure the correct identifi cation of the patient for the intended intervention.
• Consider placing the patient in semi-Fowler ’ s position. Rationale: This positioning promotes general relaxation, oxygenation, and ventilation. It also reduces stimulation of the gag refl ex and risk of aspiration.
• Commercial tracheostomy tube holder • Sterile precut tracheostomy dressing or dressing used by
institutional preference • If inner cannula is disposable, new sterile disposable inner
cannula of the same size • Extra sterile tracheostomy kit at bedside and obturator Additional equipment, to have available as needed, includes the following: • Scissors • 10-mL syringe • Three-way stopcock • Padded hemostats • Short 18-gauge or 23-gauge blunt needle • Tongue depressor • Tape (1 inch wide) • Reintubation equipment, in case of accidental extubation
PATIENT AND FAMILY EDUCATION
• Explain the procedure and the reason for tracheal tube cuff care, tracheal tube care, and/or tracheostomy dressing change. Rationale: This communication identifi es patient and family knowledge defi cits concerning the patient ’ s condition, procedure, expected benefi ts, and potential risks, and allows time for questions to clarify information and voice concerns. Explanations decrease patient anxiety and enhance cooperation.
• Explain the patient ’ s role in assisting cuff care. Rationale: This information elicits patient cooperation.
• Explain that the procedure may cause the patient to cough. Rationale: This explanation prepares the patient for what to expect.
PATIENT ASSESSMENT AND PREPARATION Patient Assessment • Assess the presence of bilateral breath sounds. Rationale:
This assessment provides baseline data. • Assess signs and symptoms of cuff leakage,…