Tracheostomy Guidelines South East Wales Critical Care … Tracheostomy... · SEWCCN Tracheostomy...

SEWCCN Tracheostomy Guidelines May 2009 1

Tracheostomy Guidelines South East Wales Critical Care Network


Contents

1. Introduction

2. Types of tracheostomy

3. Features of tracheostomy tubes

4. Types of tracheostomy tubes

5. Care of a patient with a tracheostomy

Essential equipment

Humidification

Cleaning inner tubes

6. Care of stoma site

7. Suctioning

8. Weaning

9. Speaking valve

10. Decannulation

11.Changing a tube

12. Swallow

13. Communication

14. Emergencies

Appendices

1. Patient information

2. Tracheostomy tube information

3. Emergency algorithms

4. Integrated Care pathway example

5. Tracheostomy observation chart example


Acknowledgements

This work has been informed by all the Hospitals within the South

East Wales Critical Care Network and based on the Intensive Care

Society and NPSA guidelines (with their kind permission)


1. Introduction

This document focuses on the care of adult patients with temporary tracheostomies within the acute in-patient setting. It sets out general guidelines which are intended to support and inform all staff involved in the management of patients with both surgical and percutaneous tracheostomies. These guidelines set out core principles and aim to ensure that there is a consistent approach to the management of tracheostomy patients but the authors acknowledge that there is limited evidence for many of the recommendations. However, this document is for the most part based on the Intensive Care Society (ICS) and National Patient Safety Association (NPSA) guidelines with their kind permission to reproduce.

1.2 Definition A tracheostomy is the formation of an opening through the skin into the trachea. A tracheotomy is the opening created in the trachea itself.

2. Types of tracheostomy 2.1 Surgical tracheostomy The surgical tracheostomy (i.e. the cut into the trachea) may be a vertical slit, fenestration, or may utilise an inferiorly based Bjork flap. The skin edges may then be sutured to the tracheal edge. The procedure may be carried out in the operating theatre, on the ward, or in the intensive care unit. It may be performed under general or local anaesthesia. The tracheostomy may be temporary or long term, and may be formed electively or as an emergency procedure. A temporary tracheostomy can be formed when patients require long term respiratory support or are unable to protect their own airways. A tracheostomy tube will be inserted to maintain the patency of the airway and this can then be removed when the patient recovers. In some circumstances the procedure is elective and patients can be prepared for the potential difficulties. However unconscious patients will not receive preparation and need careful psychological support when they begin to recover. This may also be carried out as an emergency procedure when a patient has an obstructed airway. Among the more common conditions causing obstruction are trauma to the airway or neck, inhalation of foreign objects, poisoning, infection or neoplasms. A temporary tracheostomy may become long term if the patient’s condition requires this. 2.2 Percutaneous Tracheostomy Most patients within critical care will have tracheostomies performed using a percutaneous, dilatational technique. This procedure may require a general anaesthetic, but is usually performed in the intensive care unit by the intensivists. Any patient leaving critical care with this type of tracheostomy should be followed up by the intensivist and the critical care outreach education team. 2.3 Laryngectomy A permanent tracheostomy is created following a total laryngectomy. This involves creating a permanent stoma where the top of the trachea is brought to the surface of the skin and sutured to the neck skin. This stoma is kept open by the rigidity of the tracheal cartilage. The patient will breathe through this stoma for the remainder of his/her life. There is no connection between the oral airway (the mouth and nose) and the trachea, and there may be no connection between the pharynx and the trachea unless one has been specially created. Any ventilation or oxygen support must be via this stoma.


This procedure is elective and the patient will need to be carefully prepared for the consequences of the procedure

3. Features of Tracheostomy Tubes • Single lumen tubes – do not have an inner cannula e.g. some Portex tubes.

• Tubes with inner cannula (also called dual lumen or twin lumen tubes) – these have an outer tube, which is intended to remain in the patient. The inner cannula can be removed for cleaning, and can be changed to a different type to facilitate weaning.

Tracheostomy tubes require different features depending on their intended use. There are a large variety of tubes available which provide some or all of these features.

3.1 Introducers All tracheostomy tubes should be inserted using an introducer (obturator) to prevent damaging the trachea during insertion of the tube. Once the tracheostomy tube has been inserted the introducer should be disposed of. The clear plastic universal cap should also be stored in a safe place and carefully labelled to ensure it is not disposed of.

3.2 Cuffs Some tracheostomy tubes have a cuff which, when inflated, provide an airtight seal which facilitates artificial ventilation including CPAP. It also prevents aspiration of oral secretions, vomit and blood from the upper airways.

3.3 Inner tubes Dual lumen tracheostomy tubes consist of an outer tube, which remains insitu, through which a smaller, inner tube is inserted. The inner tube has an extension at its upper aspect which can be connected to other equipment. It can be removed for cleaning but must be replaced immediately with a spare inner tube which should be at the bedspace.

3.4 Fenestrations Fenestrated tracheostomy tubes are dual lumen tubes which have a fenestration window in the middle of the upper aspect of both of the tubes. If the tracheostomy tube is occluded, this will allow the passage of air and secretions into the mouth and nose in the normal way rather than directing them out via the tracheostomy tube. These tubes will always have an optional non-fenestrated inner tube which must be inserted if the patient requires further respiratory support. A non-fenestrated inner tube should always be inserted prior to performing tracheal suction to ensure the suction catheter does not pass through the fenestration and damage the back wall of the trachea.


4 Tracheostomy tube types and choice There are a variety of different tubes on the market and clinicians must choose the most appropriate tube for their patient. The ICS advise that ‘tracheostomy tubes should be chosen taking account of patient and tube characteristics and not just the ease of insertion’. Factors influencing selection of a temporary tracheostomy tube: from ICS Guidelines July 2008 Factor Notes Respiratory function Most temporary tracheostomies will be inserted whilst

a patient is in an intensive care unit and still requiring some degree of positive pressure ventilation. As a standard, this will require the use of a cuffed tracheostomy tube (although it is recognised that long term mechanical ventilation can be delivered through an uncuffed tube).

Abnormal airway anatomy

Upper airway endoscopy following percutaneous insertion suggests that a standard tracheostomy tube may be anatomically unsuitable in as many as a third of adult patients. Obese patients may require a tube with an extended proximal length, whilst patients with fixed flexion abnormalities may not easily accommodate tubes with a fixed angulation.

Airway pathology Localised airway pathology such as tracheomalacia, granuloma formation etc may on occasion necessitate the use of a tracheostomy tube that has a longer distal length than standard.

Compromised airway protection and weaning problems

Many patients can be weaned to decannulation without any need to change from the cuffed tracheostomy tube that was initially inserted. In problematic cases however, it may be useful to consider options such as downsizing, to an uncuffed or fenestrated tube, or a tube with the option for sub-glottic aspiration of airway secretions. The introduction of a speaking valve may also aid swallowing and secretion control.

Obstructed / absent upper airway

Patients with an obstructed or absent upper airway are at particular risk should a tracheostomy become obstructed or misplaced. This has implications for both the choice of tracheostomy tube as well as the method by which the stoma is fashioned.

Clinical environment

Obstruction of a cuffed tracheostomy tube is a potentially life threatening emergency. Wherever possible a dual cannula tube (i.e. a tube with an inner cannula) should be used, particularly for patients in HDU or ward environments who may not have immediate access to clinicians with emergency airway skills. Ward staff can change inner tubes easily and quickly to relieve obstruction with secretions.


4.1 Characteristics of tubes The characteristics of the tube to be considered when selecting a tracheostomy tube for temporary use include: • construction • dimensions

o internal and outer diameter (ID and OD respectively) o proximal and distal length (i.e. the length of the tube proximal and distal to its

angulation) o shape and angulation

• compatibility with percutaneous insertion kit • presence and nature of tube cuff • presence of inner cannula (dual cannula tracheostomy) • fixed versus adjustable flange • presence of fenestration • specialist features, e.g. low contour on deflation tight to shaft cuffs, subglottic secretion control systems, voice enhancement tubes etc It is essential that the staff caring for a patient with a tracheostomy know the type of tube in place at any time, and this should be clearly documented in the patient’s notes 4.2 Construction • Material Tracheostomy tubes can be constructed of either metal or plastic, and thereby vary considerably in rigidity, durability and kink resistance. This may be clinically relevant. Metal tracheostomy tubes are constructed of either silver or stainless steel, but are seldom used in the critical care environment, and will not be discussed further. Temporary tracheostomies are constructed of polyurethane, polyvinyl chloride or silicone. Products made of polyurethane are more rigid than those constructed of silicone, whilst those of polyvinyl chloride construction are of an intermediate stiffness (although some become softer at body temperature). • Shape Many tubes have an inherent curvature or angulation; others are completely flexible and only assume a correct anatomical alignment through appropriate stabilisation at the stoma and the level of the cuff. Some flexible tubes are reinforced with a spiral wire in order to avoid kinking and airway obstruction. Whilst the design of some tracheostomy tubes has been modified to facilitate percutaneous introduction, others are only appropriate for insertion once a formal track has been formed (either surgically or through the prior placement of an alternative tube). Various aspects of the construction of some commonly used tracheostomy tubes are described in appendix 2. • Dimensions In most circumstances a tracheostomy tube is both described and selected on the basis of its size, or more specifically its diameter. This is simple in theory but may easily be confusing in practice. Most tracheostomy tubes are sized by internal diameter in millimetres, but this may not take account of inner cannula in all cases. See Appendix 1 for dimensions of commonly used tubes Tracheostomy tubes with the same internal diameter (‘size’) may have quite different external diameters and length. 4.3 Choosing the correct size • Diameter When selecting the size of tube for a patient, there is an unavoidable compromise to be made between a desire to maximise the functional internal diameter (and thereby reduce airway resistance and the work of breathing during weaning) and a need to limit the OD to approximately three-quarters of the internal diameter of the trachea (in order to


facilitate airflow through the upper airway when the cuff is deflated). Furthermore, selection of a tube that is too small may result in the need to over-inflate the cuff, thereby increasing the risk of mucosal pressure necrosis, which in turn increases the risk of complications such as tracheal stenosis and tracheo-oesophageal fistula. A need to exceed the quoted nominal cuff volume is often an early indicator that too small a tube has been selected. As a general rule, most adult females can accommodate a tube with an OD of 10mm, whilst a tube with an OD of 11mm is suitable for most adult males. Need for excessive cuff volume or pressure suggests that the tube size may be too small or it may be misplaced. • Length and shape Although a temporary tracheostomy is most commonly selected on the basis of its diameter, there may be situations where the length, angulation or curvature of a tube is of relevance. Thus, whilst many tracheostomy tubes are smoothly curved, others are clearly angulated, thereby allowing a distinction to be made between the proximal (or horizontal) length of a tube (i.e. the distance between the neckplate and the mid-point of the angulation) and the distal length (i.e. the distance from the mid-point of the angulation and the tip). It should be appreciated that these respective lengths are quite short in standard tubes and may be too short even in the patient with apparently normal anatomy. There may be occasions where the proximal length of a standard tube is inadequate (e.g. in the obese, or when cellulitis around a tracheostomy site increases the depth of the anterior cervical tissues after insertion), and leads to the tube tip then abutting against the posterior tracheal wall. This can result in: • obstruction of the tube, and consequent difficulties with ventilation and weaning • injury to the posterior tracheal wall, thereby increasing the risk of tracheo-oesophageal fistula formation • suboptimal positioning of the tube cuff, with the associated risk of aspiration, inadequate ventilation and high cuff pressures There may also be occasions where the proximal length is too long, with the result that the knuckle of the tube abuts against the posterior tracheal wall, whilst the tip is pivoted towards the anterior tracheal wall (the latter increasing the risk of granuloma formation and the development of a tracheal – innominate artery fistula). Less commonly, there may be a need to review the distal length of a temporary tracheostomy. For instance, there may be occasions where there is a need for additional distal length in order to bypass fistulae or obstructing lesions such as tracheomalacia, tracheal stenosis or excessive granuloma formation or tumour. Clinically significant anatomical and pathological variances such as these can be circumvented by using either extended length tracheostomy tubes with an adjustable flange or pre-formed extended tubes which are offered with a range of extended proximal or distal lengths. Extended length adjustable flange tubes are suitable for short term situations but are often difficult to introduce percutaneously and are not currently supplied with an inner cannula. However, the new uniperc is now available and is easy to insert and has an inner cannula. Whilst adjustable flange devices are considered suitable for short terms problems, patients who are likely to need airway access for a considerable length of time may be better served with pre-formed non standard products such as the Shiley® Tracheosoft XLT range or the Portex® Blue Line® Extra Horizontal and Vertical length products. Some manufacturers offer a bespoke service should none of their stock items be suitable. 4.4 Inner cannula (dual cannula tracheostomies) Many tracheostomies are now manufactured with an inner cannula. The design of some makes the use of this optional (e.g. Portex® Blue Line Ultra®), whilst for others it is mandatory, as it is the inner cannulae that has a standard 15mm attachment to connect to the breathing circuit of a mechanical ventilator (e.g. Shiley®, Kapitex Tracoetwist®).


Whilst some inner cannulae are disposable and designed for single use, others can be cleaned and re-used. The principal (and very major) advantage of an inner cannula is that it allows the immediate relief of life-threatening airway obstruction in the event of blockage of a tracheostomy tube with blood clot or encrusted secretions. Whilst traditionally, this has been seen to be particularly advantageous for patients once they have been discharged to a ward environment, it is now recognised that tube obstruction can occur even while the patient is in a critical care facility, and that in such circumstances removal of an obstructed inner cannula may be preferable to removal and repeat tracheal intubation. The principal disadvantage of dual cannula tubes is that the inner cannula may significantly reduce the effective inner diameter of the tracheostomy tube and thereby increase the work of breathing and impair weaning. Failure to properly lock the inner tube in place may also result in disconnection of the breathing circuit in circumstances where it is connected to this rather than the outer cannula. Tracheostomy tubes with an inner cannula are inherently safer and are normally preferred 4.5 Fenestrated tracheostomy tubes Many tracheostomy tubes come with the option of a fenestration in the posterior wall of the intratracheal component of shaft above the cuff. Manufacturers do not recommend the use of such tubes at the time of percutaneous tracheostomy, and generally they should not be used whilst a patient still requires mechanical ventilation because of significant risk of surgical emphysema (even when a non-fenestrated inner cannula is in place). Although a correctly sited fenestrated tube may aid both phonation and weaning (by facilitating the flow of air both through as well as around the tracheostomy tube), in practice the fenestrations are frequently poorly positioned within the trachea, and when abutting against the posterior tracheal wall may increase airway resistance as well as promote the development of granulation tissue in the tracheal mucosa. The design of the fenestrations varies between manufacturers, with some clinicians favouring tubes with multiple smaller openings to a single large one, although both patterns are at risk of blockage by encrusted secretions. If a fenestrated tube is used, it is vital that the position and on-going potency of the fenestration(s) are checked regularly if the patient is to benefit from this option. In practice down sizing or switching to an uncuffed tracheostomy tube is enough to improve flow of air through the upper airway in most patients. Fenestrated tracheostomy tubes should be used with caution in mechanically ventilated patients, and only with patients who are weaning from ventilation. 4.6 Cuffed tracheostomy tubes In the ICU setting, most patients will require an air-filled cuffed tracheostomy tube initially, both to facilitate effective mechanical ventilation and also to protect the lower respiratory tract against aspiration. The cuff should be of a “high volume / low pressure” design, and should effectively seal the trachea at a pressure of no more than 20 – 25 cmH2O in order to minimise the risk of tracheal mucosal ischaemia and subsequent tracheal stenosis. Although many manufacturers offer tracheostomy tubes with suitable cuffs, there is considerable variation between them in the length of the cuff and its precise shape when inflated. Furthermore, there is now considerable evidence to suggest that the current high volume / low pressure design is unable to guarantee isolation of the lower respiratory tract. The intra-cuff pressure should be monitored regularly Causes of excessive cuff pressures include:


• the use of a tube that is too small (an indication for which would be a need to inflate with more than the nominal cuff volume in order to achieve an effective seal)

• poor tube positioning in the trachea • tracheal dilatation • over inflation of the cuff One proposed solution to the problem of cuff-related tracheal mucosal ischaemia is the use of a foam rather than air-filled cuff (Bivona® Adult Fome-Cuf® tracheostomy tube). The cuff is constructed of air-filled polyurethane foam within a silicone envelope that is deflated prior to insertion and then allowed to expand once sited by opening the pilot port to atmosphere. Correct sizing and placement is crucial to their use, which tends to be limited to patients with existing tube related tracheal injury. The prevention of phonation is a further significant drawback to the device. Most patients can wean to decannulation by simply deflating the existing cuff (even though the residual profile of the deflated cuff can still significantly restrict airflow around the tube), or alternatively by changing to a smaller or uncuffed tube. In circumstances where a patient still requires periods of airway protection, but is unable to satisfactorily breathe past a deflated cuff, it may be advantageous to switch to a so-called “tight to shaft” tube in which the deflated cuff makes no distinguishable contribution to the external profile of the tracheostomy tube. 4.7 Percutaneous tracheostomy tubes / kits Several manufacturers have modified aspects of the construction of their standard tracheostomy tubes such as cuff and distal tube profiles in order that they are more easily introduced as part of a percutaneous dilatational technique (e.g. Portex® Per-Fit and Shiley® PERC). Such changes frequently go unnoticed when the tube comes as a component of a percutaneous tracheostomy kit and may have unpredictable functional consequences. Clinicians are advised to carefully evaluate situations where such product consolidation occurs. Specialist functionality Some specialist tracheostomy tubes incorporate a facility for aspiration of sub-glottic secretions (e.g. Portex® Blue Line Ultra® “Suctionaid” tracheostomy tube, Tracoetwist® 306). Initially advocated in the prevention of ventilator-associated pneumonia, they may also benefit patients with poor bulbar function who are unable to effectively clear secretions that accumulate above the tracheostomy tube, although they carry a high risk of significant laryngeal injury if suction is applied continuously. When considering changing to one of these devices clinicians are also advised that in order to accommodate the additional suction channel these tubes may have a wider OD than the standard device that it is replacing. Other options include features that enhance phonation such as the Portex® “Vocalaid” cuffed Blue Line® tracheostomy, in which an external air source is used to deliver gas via a separate pilot channel to the sub-glottic area, or the introduction one-way speaking valves such as the Passy-Muir® valve, the latter also improving swallowing and secretion control. Summary recommendations 1. Critical care clinicians need to be aware of the wide variability in the construction, design and functionality of the tracheostomy tubes that are currently available, and recognise that the anatomical variation of their patients limits the universal applicability of a single tube type. 2. Most adult patients who require a temporary tracheostomy as part of their critical illness will initially need a non-fenestrated semi-soft tube with an air-filled cuff. As a standard, a dual cannula tube (i.e. a tube with an inner cannula) should be used from the outset unless there is a requirement to insert an extended adjustable flange tracheostomy (which currently do not have inner tubes available).


3. Patients with single cannula adjustable flange tracheostomies should not be discharged from a level 3 critical care environment without review of their on-going need for a device that puts them at particular risk of the consequences of tube obstruction. A change to a pre-formed extended tracheostomy with an inner cannula should be considered as soon as the patient is actively weaning from mechanical ventilation and certainly before discharge from critical care. 4. When considering changing an existing tracheostomy to that of another type or manufacturer, clinicians should compare the relative lengths and external diameters of the two tubes, particularly if the proposed new tracheostomy has a wider OD (because the existing stoma may not accommodate it), shorter length (in case cuff related granulation tissue obstructs the tube) or different curvature / angulation. 5. Specialist features such as fenestrations, foam or tight to shaft cuffs or a sub-glottic suction facility may be useful in specific circumstances, although may not recommended as a routine.

5 Caring for a patient with a temporary tracheostomy tube Patients immediately post tracheostomy placement usually return either to a critical care area or a specialist ward environment used to dealing with tracheostomies. Routine care of an established tracheostomy is a basic ward skill, but unfamiliarity with tracheostomies and the simple rules governing their routine care often leads to anxiety for both patient and carer. Good routine care is not difficult and will avoid almost all emergencies, but patients with tracheotomies should only be cared for in areas where staff are competent in such care. Regular review and good communication are the keys to both avoidance of problems, and effective treatment. Consideration should be given to a pathway such as in appendix 4 to ensure that staff are always aware of all relevant information. 5.1 Essential Equipment for ward based patient The following equipment should be immediately available at all times for a patient with a tracheostomy: • Operational suction unit, which should be checked at least daily, with suction tubing

attached and Yankeur sucker (by patient bedside) • Appropriately sized suction catheters (by patient bedside).To calculate size use the

following formula: o size of tracheostomy tube x 3/2

• Appropriate PPE o Non-powdered latex free gloves, aprons and eye protection (by patient

bedside) o Disposagloves or equivalent

• Spare tracheostomy tubes of the same type as inserted: one the same size and one a size smaller (by patient bedside)

• Spare inner cannula (by patient bedside) • 2 bottles of sterile water and receptacle for flushing through tubing and cleaning inner

tubes • Inner cannula cleaning equipment • Tracheal dilators for new surgical tracheostomies only and to be used only by those

competent in doing so • O2 therapy – wall flow meter and tracheostomy mask • Rebreathing/ambu bag and tubing (available for emergency use) • Catheter mount or connection Tracheostomy disconnection wedge


• Tracheostomy tube holder and dressing • 10ml syringe (if tube cuffed) (by patient bedside) One approach is to ensure that all these are in a ‘tracheostomy box’ that goes with the patient from critical care to the ward.

Intervention Rationale The equipment listed above should be at the patients bedside at all times. Each shift the nurse responsible for the patient should check the equipment is present and in working order.

This equipment is the minimum required to care for a patient with a tracheostomy including emergency situations.

For cuffed tracheostomy tubes: assess cuff pressure once each shift as follows: First clear any secretions from the upper airways i.e. above the cuff of the tracheostomy tube. Deflate the amount of air in the cuff by 1-2 mls until air leakage can be heard. Gently reinflate the cuff until the leak stops. Record procedure on patients observation chart.

To ensure the cuff is not over inflated which may cause damage to the trachea but is creating a seal.

The tracheostomy site should be assessed at least each 24 hours and redressed as appropriate - see section 6 on stoma site care

To check for signs of infection. If the site is inflamed take a swab and send to microbiology for M,C&S.

Ensure the tube remains patent by regular tracheal suction and cleaning the inner tube if present - see section 5.5 on inner tube care

Maintain adequate airway

Humidification must be maintained at all times – see section 5.2 - 5.4 on humidification of a tracheostomy

Replace lost natural function of upper airway

Ensure patients have call bell and aids for communication

Patients with cuffed tracheostomies may be unable to speak

Air entry should be assessed on a regular basis - by observing chest movements and listening to air entry. This is especially important for patients with a new tracheostomy or a reduced level of consciousness.

To ensure the tube is patent and in the correct position

Assess the need for mouth care and deliver as necessary

Patients with tracheostomy have altered upper airway function and may have increased mouth care requirements.

Patients may only eat and drink if they have been assessed as able by the Speech and Language Therapist (SLT).

Ensures they are able to swallow safely which will prevent aspiration


5.2 HUMIDIFICATION

After a tracheostomy the patient needs additional humidification, as that provided by the upper respiratory tract is no longer available. Additional humidification aims to prevent secretions becoming viscous and dry leading to consolidation and pneumonia. In turn effective humidification will aid expectoration and suction of secretions, and prevent crust formation. For thick tenacious secretions, heated humidification may be required.

Humidification is essential for patients with temporary tracheostomies

Humidification can be given via:

• Cold water humidification system if receiving oxygen therapy

• Saline nebulisers, every 4 hours or prn. Liaise daily with physio and medical staff

• Heated humidification systems such as Fisher Paykel and Flowgen

Natural humidification can be conserved by:

• A Swedish nose/thermovent over the end of tracheostomy tube. Such devices must be assessed during 2 hourly checks and changed when soiled, or at least every 24 hours.

To prevent clogging up the Swedish nose and therefore interfering with respiration.

• Tracheostomy protectors (Buchanan Protector) may be used for patients who are not oxygen dependent

This acts as a heat moisture exchanger

Humidification and Speaking Valves

• Speaking valves may reduce the effectiveness of humidification. • The valve should be removed for brief periods during the day. • All speaking valves should be removed at night! • When not in use valves should be kept in a dry clean container ready for

further use. • Speaking valves should not be used when nebulisers are in situ as they

reduce efficacy


Indications for humidification Rationale

• Bypassing of mucus membranes

• Long-term use of medical gases

• Tenacious secretions

• Infants and children

Humidification systems are removed or compromised and thus need support

Problems with humidification

Rain out

Tubing may become clogged with water. Use large bore tubing to minimise this

Tracheitis Due to lack of humidity the trachea may become irritated

Over saturation

If the periciliary layer is too deep, the tips of the cilia will not reach the mucus layer and thus will be ineffective

Infection

This was generally a problem with old-fashioned water baths. However to minimise risk regular replacement of disposables as per manufacturers guidelines and infection control advice is recommended.

High gas flow An efficient humidification system is required to cope with an increased flow rate

Bronchoconstriction

Inhalation of cold mist or water may cause bronchoconstriction in patients with hyper reactive airways

5.3 To set up cold water humidification

Equipment needed

• Air or oxygen supply • Gas flow meter • Elephant tubing • Humidification set – e.g. aquapak / inspiron • Tracheostomy mask

Action Rationale Explain the procedure to the patient To gain co-operation and consent

Assemble equipment and label with date set up

Provides information about when to change equipment – see local policy

Turn on oxygen/air flow to prescribed concentration. Ensure flow to mask

Provide appropriate gas delivery

Check at least 2 hourly that there is adequate water supply and that the humidification is working and empty water that may have collected in the tubing and water traps

To ensure gas supply is maintained and water supply replaced when necessary

Secure tracheostomy mask over the tracheostomy

To humidify the airway

Change the mask and tubing at least weekly or if they become soiled

To prevent the introduction of infection – local policy

Document all interventions in patient notes

For ongoing evaluation


5.4 To set up heated humidification

Equipment needed

• As above • Replace humidification set with heated

humidification set.

Action

As per cold water humidification plus:

Rationale

Set up heater unit according to manufacturers guidelines

Safe and comfortable system

Check at least 2 hourly that there is adequate water supply and that the humidification is working and is not too hot and empty water that may have collected in the tubing and water traps

To ensure gas supply and temperature are maintained and water supply replaced when necessary

Secure tracheostomy mask over the tracheostomy

To humidify the airway

Change the mask and tubing at least weekly or if they become soiled

To prevent the introduction of infection – local policy

Document all interventions in patient notes For ongoing evaluation

5.5 CLEANING TRACHEOSTOMY INNER TUBES The inner tube should be checked every two hours and cleaned as required, minimally once per nursing shift i.e. 3 times in 24 hours. Within critical care, ventilated patients may have a longer period between inner tube checks as recurrent disconnection from ventilation may be detrimental to overall management of the patient.

Remember! An inner tube narrows the lumen of the tracheostomy tube. The lumen may therefore become easily blocked by secretions within the internal diameter of the inner cannula:

Equipment

• I bowl / disposable kidney dish

• Protective clothing

• A clean inner tube

• Sterile water: The bottle should be dated, labelled and renewed every 24 hours

• Tracheostomy cleaning swabs

• Gauze squares


Action Rationale

Explain the procedure to the patient and sit patient up to 45-70 degrees, as their condition allows.

To gain informed consent and allow easy access to tracheostomy.

Wash hands, put on non-sterile gloves. Reduces risk of infection

Hold tracheostomy flange with one hand; hold inner tube with the other.

To secure the outer tracheostomy tube

Shiley tubes – Turn the inner tube anti-clockwise to unlock it and remove it from the outer tracheostomy tube, placing it in a bowl ready for cleaning at end of procedure.

Portex ultraline tubes – hold ring pull of inner tube and pull out and down to remove. Place inner cannula in a bowl ready for cleaning at end of procedure.

Replace immediately with clean inner tube

Shiley tubes – Twist new inner tube clockwise until it clicks into place (when 2 blue dots are in line), continuing to stabilise the tracheostomy flange.

Portex ultraline tubes – slide inner tube into place until a gentle click is felt. The tracheostomy phlange should be stabilised throughout procedure

Reduces risk of outer tube blocking

To ensure inner tube secure and prevent displacement

Place soiled inner tube in bowl of sterile water (Choate and Barbetti 2003)

To loosen secretions which may be attached to it. Tap water is an infection risk and has been shown to increase incidence of nosocomial pneumonia. Due to infection control risks, do not leave inner tubes to soak in water.

Clean soiled inner tube with tracheostomy cleaning swabs – see ordering information

Tracheostomy cleaning swabs will not affect the surface of the inner tube.

Due to infection control risks, do not use brushes supplied with tracheostomy tubes.

Shake off all excess water, dry with gauze squares and store in a dry container with a lid at the patient’s bedside.

A clean inner tube should always be available to use urgently

Clear away equipment as per the clinical waste disposal guidelines; remove gloves and wash hands.

For infection control purposes.

Document care Professional responsibility and to ensure effective multi-disciplinary communication

Never leave a double lumen tracheostomy tube without an inner tube in situ


6 CHANGING TRACHEOSTOMY TIES & DRESSING and CARE OF TRACHEOSTOMY SITE: ASEPTIC PROCEDURE

This procedure should be carried out at least daily and more frequently if required with two staff present. Equipment Needed: • Sterile dressing pack (including gloves), trolley, clinical waste bag

• PPE including apron and visor

• Tracheostomy dressing

• Vaseline or Cavilon lollipop sticks as appropriate

• Cleaning solution, 0.9% sodium chloride

• Tracheostomy velcro tracheostomy holder

CHECK ALL EMERGENCY EQUIPMENT IS IN WORKING ORDER AND WITHIN EASY REACH

Action Rationale

Explain and discuss procedure with patient Allows for co-operation, patient reassurance and to gain informed consent from patient.

Two person procedure, one of whom must be qualified (lead) and an assisting member of staff (who may be unqualified).

To maintain safety and limit cross infection.

Screen area and assist patient to comfortable position, with neck extended (if patients condition allows)

Ensures privacy, patient comfort and allows easy access to stoma.

Lead person – assess if suction is required. (Refer to suction guidelines)

To clear secretions and minimise patient coughing and potential tube displacement during procedure. Promote patient comfort.

Assistant – prepare the dressing trolley items with the lead.

For ready use

Both staff wash hands and put on gloves

(lead should wear sterile gloves)

Reduces risk of infection

Aseptic technique

Assistant – loosen tracheostomy velcro neck tapes and hold the tracheostomy tube securely in place, preferably by the outer tube.

To stabilise the tracheostomy tube and reduce the risk of displacement.

Lead - remove soiled dressing and clean around the tracheostomy site with normal saline and sterile gauze, using an aseptic technique. Dry thoroughly.

Removes secretions and prevents infection from any crusting which may have formed. Normal saline is non-irritant


Lead - observe tracheostomy site for

• Infection • Pressure damage • Bleeding • Overgranulation

Apply skin protection if excessive secretions or if the stoma site is red/inflamed.

Early detection and prompt treatment of complications Barrier cream can protect skin from tracheal secretions and encourage wound healing as appropriate Many organisations recommend Cavilon lollipop sticks

If the stoma is not intact or the area is becoming excoriated, the senior nurse and medical staff on the ward should be notified

Communication if there is a change in site status is important as a photograph may be necessary to monitor progress

Apply clean tracheostomy dressing, starting from below the tracheostomy tube.

To absorb any discharge from around tracheostomy site and to avoid pressure from the tube, promoting patient comfort.

Refer to manufacturers advice for individual dressings

Secure the tracheostomy tube in position with a Velcro tracheostomy tube holder. Ensure that it is possible to allow two fingers to pass between the tracheostomy holder and the neck

To prevent displacement and pressure damage to skin

Clear away equipment as per the clinical waste disposal guidelines, remove gloves and wash hands

Adhering to Health and Safety and Infection Control Policies

Document the procedure Professional responsibility and to ensure effective multi-disciplinary communication

S EWCCN Tracheostomy Guidelines May 2009 19

7 SUCTIONING A TRACHEOSTOMY 7.1 Introduction Suction should not be routinely carried out on a patient with a tracheostomy. Suctioning should only be carried out following an assessment of need.

Clearing secretions with suction will: - • Maintain a patent airway

• Prevent lung collapse due to small airways blocked by secretions

The frequency of suction varies widely between patients. Each must be individually assessed. Factors which should be considered are;

• Patients ability to cough and clear own secretions

• Amount and consistency of secretions

• Oxygen saturation/arterial blood gases

• Presence of infection

As with all techniques, you should only carry out suctioning if it is within your own scope of practice

7.2 Equipment Needed

• Catheters

o Suction catheters with porthole suction

o Size 10 FG-12 FG (French gauge), depending on the size of the

tracheostomy tube – the catheters should be < 50% diameter of the tube

o Generally the equation tube size x 3/2 is used to select a catheter of the

correct size

• Suction Machine

o Vacuum 100-150 mmHg or up to 20 KPa

o Use the lowest pressure possible to remove secretions

• Eye Protector and apron

• Gloves

o 1 Pair of non-sterile disposable gloves to be worn throughout procedure

o Over these place clean disposal glove on dominant hand - this hand should

only touch the catheter (see below)

• Oxygen To preoxygenate patient as necessary to prevent adverse effects

• Yankeur - for oral and external use

• Sputum specimen trap– if required for sample

• Yellow bag - for waste disposal

• One litre bottle of sterile water – to clean suction tubing. The bottle should be

dated, labelled and renewed every 24 hours


7.3 Procedure

Action Rationale

Explain procedure to patient To reassure patient

Wash hands, put on gloves, apron and visor and change inner cannula if necessary as directed above.

To prevent cross-infection and protect against contact with body substances.

If patient is receiving oxygen therapy preoxygenation may be required by increasing oxygen to 100% for 1 minute prior to suctioning

Suctioning may frequently lead to hypoxaemia. In order to prevent this, preoxygenation is recommended prior to suctioning. Pre oxygenation will also reduce the likelihood of any cardiac arrhythmias

Check suction pressure is within previously stated parameters and that you have the correct size of suction catheter

To ensure appropriate pressure is applied for the procedure and that the catheter is of an appropriate size for the patient.

Open outer package of sterile catheter and peel back the adapter end of the catheter package. With catheter in package, attach adapter to suction tubing. Do not touch the body of catheter.

To keep the catheter as clean as possible allowing for a clean technique

Put clean glove on dominant hand without touching its outer surface.

Gloves minimise the risk of infection transfer to the catheter.

Take package off the catheter. With the dominant hand hold the catheter, ensuring the glove only touches the catheter and nothing else. Insert the catheter gently into the tracheostomy tube without applying suction.

Gentleness is essential: damage to the tracheal mucosa can lead to trauma and respiratory infection. Saline bolus prior to suctioning is not recommended – it has been shown to increase rate of nosocomial infection

Insert catheter gently until resistance is felt, withdraw catheter 1 cm, then apply continuous suction withdrawing the catheter smoothly at all times.

OR Insert catheter until cough is stimulated; stop and apply continuous suction withdrawing the catheter smoothly at all times. There is no need to rotate catheter.

To prevent the catheter from adhering to the tracheal mucosa, negative pressure should only be applied during withdrawal.


If resistance is present continue procedure and check inner tube patency.

Check that you are using the correct catheter size. Resistance may indicate that the inner cannula is blocked with secretions and needs to be changed and cleaned. If problems persist after cleaning, inform nurse in charge and Physio during the day. Overnight contact the Hospital at Night Team.

Suction should not exceed 10 seconds at a time

Prolonged suction will result in hypoxaemia and trauma

Replace tracheostomy mask and return oxygen supply to prescribed percentage. If further suctioning is indicated pre-oxygenate as per 3.

In order to minimise the risk of hypoxaemia

Dispose of catheter and glove as per infection control policy

Infection control

Repeat suction process as necessary (but no more than 3 suction passes should be made during any one suction episode) using a new catheter and sterile/clean gloves each time.

Catheters are used only once to reduce the risk of introducing infection. The number of suction passes may contribute to the occurrence of complications

Assess the patients respiratory status following suctioning. This should include assessing the rate, depth and pattern of respiration and by using a pulse oximeter.

To reassess efficacy of suction

After the final suction, flush through suction tubing with sterile water.

To loosen secretions that have adhered to the inside of the tube.

Note colour, quantity and tenacity of secretions. Record in patient’s records.

For effective communication of information.

Clean suction equipment should be replaced every 24 hours or as necessary.

Infection control

7.4 Closed Suction Technique

This technique is only suitable for ventilated patients. The inner cannula should not be fenestrated for ventilation and therefore will not need to be changed for suctioning purposes. It will still require a 2 hourly check as per guidelines on tracheostomy tube care. Indications for a closed suction system include

• PEEP dependence • Oxygen dependence • Immunosuppressed patients • Patients that are a potential infection risk to staff • Blood on suction • High Frequency Oscillator Ventilation (HFOV)


As with all techniques, you should only carry out closed system

suctioning if it is within your own scope of practice

Action Rationale

Explain procedure to patient To reassure patient

Wash hands, put on gloves and apron and change

To prevent cross-infection and protect against contact with body substances

If patient is receiving oxygen therapy ensure preoxygenation by increasing % of oxygen to 100% for 1 minute prior to suctioning

Suctioning may frequently lead to hypoxaemia. In order to prevent this, preoxygenation is recommended prior to suctioning

Check suction pressure is within previously stated parameters and that you have the correct size of catheter attached to endotracheal tube

To ensure appropriate pressure is applied for the procedure and that the catheter is of an appropriate size for the patient.

Insert catheter gently until resistance is felt, withdraw catheter 2 cm, then apply continuous suction withdrawing the catheter smoothly at all times.

OR Insert catheter until cough is stimulated; stop and apply continuous suction withdrawing the catheter smoothly at all times There is no need to rotate catheter

To prevent the catheter from adhering to the tracheal mucosa, negative pressure should only be applied during withdrawal

If resistance is present continue procedure and check inner tube patency.

Check that you are using the correct catheter size. Resistance may indicate that the inner cannula is blocked with secretions and needs to be changed and cleaned. If problems persist after cleaning, inform nurse in charge and liaise with medical colleagues

Suction should not exceed 10 seconds at a time

Prolonged suction will result in hypoxaemia and trauma

Return oxygen supply to prescribed percentage. If further suctioning is indicated preoxygenate as per 3.

In order to minimise the risk of hypoxaemia


Repeat suction process as necessary (but no more than 3 suction passes should be made during any one suction episode) using a new catheter and sterile/clean gloves each time.

Catheters are used only once to reduce the risk of introducing infection. The number of suction passes may contribute to the occurrence of complications

Assess the patients respiratory status following suctioning. This should include using a pulse oximeter.

To reassess efficacy of suction

Note colour, quantity and tenacity of secretions. Record in patient’s tracheostomy record.

For effective communication of information.

Clean suction equipment should be replaced every 24 hours or as necessary.

Infection control

8 WEANING AND DECANNULATION FROM A TRACHEOSTOMY It is important that each individual case is carefully discussed and a clear plan made prior to the weaning process commencing. This must be continuously evaluated. These guidelines are intended to assist in the decision making and timing of each stage of the weaning process. There is evidence from the literature, which highlights that although tracheostomy weaning needs to be individualised, a standard procedure is essential to decrease anxiety and facilitate success.

8.1 Preparation for Weaning The decision to wean a patient should be taken by the multidisciplinary team. The patient must be involved in this discussion if possible. The process usually consists of the following stages.

Tracheostomy

Cuff deflation

Fenestrated tube

Swallow assessment

Speaking valve

Downsizing of tube

Capping off

Decannulation

It may not be appropriate to proceed to full decannulation for some patients and the process may take a number of weeks or longer and vary at different stages. It should also be noted that this is not a linear process and that patients may go backwards as well as forwards. In some instances some steps in the process may be omitted. Any decisions should always be dictated by patient needs.


8.2 Pre-Weaning Criteria

Original indication for tracheostomy is resolving Spontaneously breathing with a regular respiratory

pattern and rate less than 30 breaths per minute On oxygen dependency less than 35% with adequate

saturations Strong cough – able to clear to the top of the

tracheostomy tube Clear chest Adequate nutrition Patient needs to be seen to be coping with their own

saliva and where appropriate assessed by a Speech and Language Therapist or a competent Healthcare Practitioner.

Multidisciplinary team in agreement

8.3 Contraindications to weaning

Tumour Upper airway oedema Absent or inadequate cough or gag reflex Persistent dysphagia and compromised airway

protection Reduced ability to clear secretions

8.3.1 Considerations for Cuff Deflation

To maximise success, cuff deflation should be considered only if the pre-weaning criteria are met. 8.4 Cuff Deflation Assessment

Action Rationale

Explain procedure to the patient

To gain patient consent and minimise anxiety

Sit patient upright To optimise lung expansion

Assess patients’ respiratory status i.e. rate, depth and pattern

Ensures that the patient remains stable

Suction on deflation of cuff or encourage active cough

To clear any loose secretions that may have pooled above the cuff and may be colonised by bacteria

Deflate cuff slowly and note reaction to cuff deflation

Allows the patient to adjust to changes in airflow

Monitor • Respiratory rate and effort • Any spontaneous swallow attempts • Additional wheezes/stridor • Any voicing • Monitor oxygen saturation • Observe for signs of fatigue • Ability to deal with oral secretions

To assess patients ability to tolerate cuff deflation and detect any difficulties


8.4.1 Indications that a patient is coping safely with cuff deflation are: • If spontaneous swallows are noted • If the patient manages to swallow oral secretions • If the patient maintains O2 saturations • If the patient is able to cough at least into tracheostomy tube • If respiratory/cardiovascular systems are stable 8.4.2 Do not continue with cuff deflation if any of the following occur: • Constant oral drooling • No swallows observed • Respiratory or cardiovascular distress • Fatigues quickly • Fails to protect airway e.g. audible pooled “wet” pharyngeal secretions • Desaturation • REINFLATE the cuff and reassess when appropriate The multidisciplinary team should agree and determine the length of time the patient is able to tolerate cuff deflation. This may vary from a few minutes to permanent cuff deflation and depends on the individual patients’ abilities. Careful respiratory monitoring during the process of weaning and decannulation is essential. Many patients will require the cuff deflated in incremental periods. 8.5 Cuffless Tubes If a patient tolerates cuff deflation well but is likely to require a tracheostomy for a further period a cuffless tube should be considered at the earliest opportunity. Even a deflated cuff in the airway has been shown to increase work of breathing 8.6 Cuff Management The tracheostomy cuff provides a seal to enable positive pressure ventilation and also provides some protection against aspiration of secretions. Cuff pressure should be monitored at least once a shift using a cuff manometer with pressure between 16-24mmHg. Constant unchecked high pressure in a cuff may lead to mucosal necrosis, stenosis or fistula formation between the trachea and oesophagus. • Cuff pressure should not exceed 25 cm H2O. • If an air leak occurs with the cuff pressure at the maximum recommended,

the tracheostomy may have become displaced or may require changing: medical or other professionals who are competent in tracheostomy management should review the patient.

Finger tip pressure on the external pilot balloon is not an accurate method of measuring cuff pressure! The cuff should be deflated to remove the tube, to allow the patient to eat or drink and when a speaking valve or decannulation cap is secured to the tube. • Failure to deflate the cuff when the speaking valve or decannulation cap is

secured to the tube will result in a total occlusion of the patient’s airway and potentially catastrophic results.

8.7 Fenestrated Tubes Tracheostomy tubes can also be fenestrated: i.e. a window in the outer tube, which is patent if an inner fenestrated tube is also sited. This allows for use of the native airway. With a fenestrated inner tube in situ using digital occlusion or a speaking valve, a voice may be elicited – see assessment of phonation using a speaking valve. There is little literature as to when they should be used and generally this is left to clinical judgement. Fenestrated tubes are often used when there is an extended weaning period. They have been shown to reduce the work of breathing. Fenestrated tubes always


come with a non-fenestrated inner cannula that can be inserted for suctioning or respiratory support. Suction should never be performed with a fenestrated inner tube in situ – this will cause damage to the trachea.

9 Speaking valve Patients who are able to take oral nutrition should be assessed as safe to do so by a Speech and Language Therapist or a competent Healthcare Practitioner. This is particularly important as tracheostomised patients have a high incidence of aspiration (See Swallow Assessment Procedure) 9.1 Assessment of Phonation and Use of a Speaking Valve The speaking valve can be used as an aid to communication. It may also improve the biomechanics of swallow. See also Communication Issues

THE CUFF MUST BE FULLY DEFLATED IN ORDER TO USE A SPEAKING VALVE! (OTHERWISE THE PATIENT WILL BE

UNABLE TO EXHALE) 9.2 Contraindications to the use of a speaking valve

Severe tracheal/laryngeal stenosis Airway obstruction Inability to tolerate cuff deflation End stage pulmonary disease Unstable medical/pulmonary status Anarthria Laryngectomy Severe anxiety or severe cognitive dysfunction

9.3 Use of Speaking Valve - Procedure

Action Rationale

Explain procedure to the patient

Gain consent and reduce anxiety

Ensure cuff is fully deflated To ensure that the patient is able to exhale

If the outer tube is fenestrated, insert the fenestrated inner tube

This allows passage of air through the native airway.

On expiration, lightly occlude the tracheostomy with your finger and ask the patient to breathe onto your forearm/hand to assess for expiration from mouth

This is a simple assessment of whether the patient will tolerate tube occlusion

Ask the patient to say “aah” and listen to the quality and ease of voice production

To assess the patients ability to vocalise


Be aware that a valve is not suitable for someone who has no or very minimal tongue function

These patients should be discussed with and assessed by the speech and language therapist

If voice is clear and effortless, try with a speaking valve

This ensures optimal chance of success

If this is tolerated set an individualised speaking valve regime. The time the speaking valve is applied should be clearly documented and a time for removal stated on the tracheostomy observation chart.

Patient regime should be reviewed daily and adapted as status dictates [Patient will tire with a speaking valve insitu so should wear it for a short time initially and gradually increase use over time]

If the patient’s voice is gurgly ask the patient to cough and clear secretions

To ensure that the patient is able to clear the airway independently

The patient should be monitored closely as the patient may fatigue quickly. They should have a call bell within easy reach

To ensure maximum observation of the patient. The patient is able to summon help immediately if distressed

The speaking valve should not be worn at night

Due to increased resistance produced the patient may struggle if secretions build up behind the valve

If voice is consistently hoarse or weak, a referral to ENT may be indicated

ENT specialist will be able to assess the larynx directly

9.3.1 Indications that a patient is coping safely with use of the speaking valve

If respiratory/cardiovascular systems are stable If voice is clear If maintains O2 saturations If patient is comfortable

Do not continue with the procedure if any of the following occur

Constant oral drooling Increased work of breathing Desaturation Respiratory or cardiovascular distress Fatigues quickly Change of facial colour Stridor Voice is gurgly and wet and unable to be cleared

REMOVE the speaking valve and reassess when appropriate


9.4 Use of a speaking valve with a ventilated Patient In this situation only the turquoise Passy Muir valve can be used within a ventilator circuit. Only staff competent in its use (or supervised by staff experienced in its use) should attempt to fit a speaking valve into a ventilator circuit. Action Rationale

Explain procedure to the patient Gain consent and reduce anxiety


If the outer tube is fenestrated, insert the fenestrated inner tube

This allows passage of air through the native airway

Adjust the alarm settings on the ventilator

To allow the speaking valve to be inserted without continually setting off alarms

Try the Passy Muir valve in the ventilator circuit

Fit according to Passy Muir recommendations

Ask the patient to say “aah” and listen to the quality and ease of voice production

To assess the patients ability to vocalise

If the patient’s voice is gurgly ask the patient to cough and clear secretions

To ensure that the patient is able to clear the airway independently

The patient should be monitored closely as the patient may fatigue quickly. They should not be left unsupervised

To ensure maximum observation of the patient. The patient is able to summon help immediately if distressed

A short trial period is recommended with time using the Passy Muir valve increased according to the patients ability to tolerate it in the ventilation circuit

Build up tolerance slowly. This may be difficult if the tracheostomy tube is relatively large and downsizing of the tube may be required before speaking valve use is tolerated

9.5 Downsizing of Tubes

It may be necessary to downsize the tracheostomy tube in order to tolerate a speaking valve and continue the weaning process. In some patients a large tracheostomy tube will not allow enough airflow around the tube to elicit phonation. Larger tubes have also been shown to increase work of breathing.


9.6 Capping off Tracheostomy Tube

THE CUFF MUST BE FULLY DEFLATED WHEN CAPPING OFF (OTHERWISE THE PATIENT

WILL BE UNABLE TO BREATHE)

9.6.1 Procedure for Capping Off Action Rationale

Discuss aims and explain procedure to the patient

Gain consent and reduce anxiety


The patient must be able to swallow his or her own secretions safely

To ensure that the patient is able to protect their airway

Place cap over end of tracheostomy tube

To stop air entering the tracheostomy and thus making the patient breathe via upper airway

Apply facial oxygen if required via a face mask and encourage the patient to take deep breaths

Provide supplementary oxygen and to help them begin to feel the change in breathing

Ensure that the patient is able to obtain adequate breath via upper airway

Tracheostomy tube may be too large to allow the patient to breathe around it. (Remove cap and discuss need for smaller tube with tracheostomy team)

Stay with the patient until they are settled and feel comfortable

The patient may become anxious or is genuinely unable to breathe requiring immediate assistance

Agree with the multi-disciplinary team or the tracheostomy team the period for capping off

This should be an individualised regime that is reviewed daily

Do not continue with the procedure if any of the following occur:

Increased work of breathing Oxygen desaturation Respiratory or cardiovascular distress Fatigues quickly Change of facial colour Stridor

9.6.1 Indications that the patient is coping safely with use of the cap are:

If respiratory/cardiovascular systems are stable If voice remains clear If maintains O2 saturations If patient is comfortable

Within current literature, time for capping off varies from 6 – 48 hours. There is the greatest consensus that a patient should be able to tolerate at least 24 hours capped off prior to decannulation. However, this should be based on individual assessment.


10 Decannulation The decision to decannulate should be agreed by the multidisciplinary team. The capping off period having been individually determined based on patient status. The patient should be aware of the procedure and be able to get help immediately if distressed. The planned decannulation of a tracheostomy tube should be carried out during normal weekday working hours. During these times, there is greater staff availability should a patient develop problems.

10.1 Procedure for Decannulation

Action Rationale

Discuss aims and explain procedure to the patient

To gain consent and avoid undue anxiety

Check that all emergency equipment is at the bedside

To ensure appropriate equipment is available if the patient has difficulties post decannulation

Ensure that the patient is sitting in an upright position

To optimise lung expansion

Universal precautions should be adhered to

To reduce the risk of infection

Ensure the cuff is deflated; remove the tracheostomy tapes and dressing. Remove the tracheostomy tube in a gentle outward and downward movement

The tracheostomy tube will follow the anatomical formation of the tract. Rapid jerking or pulling the tube upwards will cause trauma to the trachea and acute discomfort to the patient

Following decannulation the stoma should be cleaned; dried; dressed and covered with an occlusive dressing

This will absorb any bronchial secretions whilst occluding the stoma opening to aid healing and communication. Although most UK papers recommend an occlusive dressing, there is no consensus on which type is most appropriate

Assess the dressing at least once a shift and change as indicated. Dressings should be changed at least daily. Observe stoma for signs of infection on dressing changes

This is to reduce the risk of pooled secretions that may delay wound healing and cause maceration increasing risk of infection

The patient should be encouraged to apply overpressure on the stoma dressing on speech and coughing

It is suggested that this will minimise any leak from the stoma site, produce a more effective cough and encourage stoma closure


10.2 Following decannulation, the following signs may indicate that an immediate anaesthetic or ENT opinion is required:

Problems Actions in all circumstances

Stridor Persistently decreased

oxygenation Increased respiratory rate Increased heart rate Sweatiness Agitation Cyanosis Loss of consciousness

• Position patient in a sitting/high side lying

• Check tracheostomy dressing for leakage

• Encourage deep breathing • Clear secretions via active

cough / suction if necessary • Give oxygen via face mask • Ready emergency trolley • Monitor oxygen saturations via

pulse oximeter continuously

If you have any queries with regard to the weaning process or any difficulties with tracheostomy care please contact the relevant multidisciplinary team member. If urgent assistance is needed contact a member of the tracheostomy team, the head and neck ward or critical care unit. There should be clear guidance to staff to observe for complications, clear criteria for review and point of contact to obtain urgent review by tracheostomy team, anaesthetic, intensive care or surgical staff. A tracheostomy should be removed as soon as it is no longer required. Care of patients with tracheostomies will be multidisciplinary, but it must be clear who is responsible, particularly when patients are not under the direct care of the critical care team. Every Trust should have an explicit policy on this. It must be clear which person or team is responsible for management of the tracheostomy, especially if it is not the specialty with primary responsibility for the patient’s care.

11 CHANGING A TRACHEOSTOMY TUBE Changing a tracheostomy tube is potentially hazardous, but so is failure to do so. Unfortunately, recommendations for the frequency of changing tracheostomy tubes are inconsistent and unsupported by evidence. Basic principles guiding replacement of a tracheostomy tube are listed in the box below.

Tracheostomy tubes should only be changed by staff who are competent to do so. Most will be doctors, but there are specialist non-medical practitioners who have the necessary skills. Doctors who have not had relevant training will not have competency in this area, and should not undertake the procedure unsupervised.

Basic principles for changing a tracheostomy tube • Tracheostomy tubes without an inner cannula should be changed every 7-

14 days, the frequency then decreasing once the patient is free of pulmonary secretions and has a well formed clean stoma

• A European Economic Community Directive (1993) states that tracheostomy tubes with an inner cannula can remain in place for a maximum of thirty days.

• The first tracheostomy tube change: o Should not be performed within 72 hours following a surgical

tracheostomy and not before 3 – 5 (and ideally 7 – 10) days after a percutaneous tracheostomy to allow the stoma to become established.

o The decision to change the tube must be made in conjunction with a medical practitioner competent in the care of tracheostomies.

o Must be carried out by either: a medical practitioner with appropriate, advanced airway

skills, or Another suitably skilled practitioner.

• Subsequent changes can be made by experienced personnel trained in tracheostomy tube changes (e.g. specialist tracheostomy nurse)

• In practice, the frequency with which the tube needs to be changed will be affected by the individual patient’s condition and the type of tube used. Elective changes are inherently safer than those done in a crisis.



11.1 The first tube change Changes within the first 72 hours should be avoided unless absolutely essential and should only be performed in an environment in which trans-laryngeal intubation can immediately be established. Although the risk of stomal closure lessens somewhat thereafter, the first change remains hazardous, particularly following a percutaneous procedure, and exchange over a bougie or an airway exchange catheter that allows the continued insufflation of oxygen such as the Frova catheter or Cook TM airway exchange catheter should be considered. Whilst problems can occur in any patient, they are particularly likely in the obese, those with a deep trachea, other anatomical difficulties. 11.2 Second and subsequent changes A standard procedure for subsequent changes of a tracheostomy tube is described in appendix 4. It is reasonable to expect that two skilled practitioners should be present when changing the tube, particularly when a previous change has been difficult. Resuscitation equipment must be readily available, as should a smaller tube. If a patient has a smooth long term stoma and has regular tracheostomy changes, it is reasonable to introduce the new tube using the tracheostomy introducer rather than an airway exchange device. The practitioner must however be aware of the risk of paratracheal tube placement with any blind technique and be able to recognise the clinical features of failure to re-cannulate the trachea. It is essential that if the new tube cannot be inserted or is misplaced, there is an agreed procedure for handling the situation.

Following tracheostomy tube change patients should be monitored for difficulties

11.3 Signs that a patient may have difficulties

• Respiratory or cardiovascular distress • Cyanosis • Desaturation • Increased work of breathing • Stridor • Change of facial colour • Sweatiness • Agitation • Loss of consciousness

IF REINSERTION OF THE TRACHEOSTOMY TUBE FAILS, CALL THE ARREST TEAM AND BE FAMILIAR WITH THE EMERGENCY ALGORITHMS

12 SWALLOWING The presence of a tracheostomy tube can adversely affect swallowing in patients who previously had no swallowing difficulties.

Swallowing assessment should only be undertaken by an appropriately trained professional. The speech and language therapist is most commonly and appropriately the team member who carries out dysphagia (swallowing) assessment and intervention. As in other aspects of care a team approach is optimal and assessment and management decisions should be shared.


12.1 Indications for a swallowing assessment

1. Patients with neurological involvement e.g. CVA, Head Injury, post neurosurgery, Guillian Barre, progressive neurology and A.I.D.S.

2. Patients post oral or head and neck surgery/radiotherapy, oesophageal or pharyngeal stricture, voice problems and acute/chronic chest difficulties.

3. Patients with evidence of aspiration of food/ fluid/ oral secretions on tracheal suctioning.

4. Patients who present with persistent wet or weak voice when cuff is deflated and speaking valve or decannulation cap in place.

12.2 Procedure for oral intake in Tracheostomised Patients.

Action Rationale

The patient should meet pre-weaning criteria and tolerate cuff deflation.

To optimise success in weaning

Discuss aims with patient and explain procedure to patient

To gain consent and minimise anxiety

Sit the patient upright in the bed or a chair with the chin flexed slightly towards the chest.

This position may improve reduced laryngeal closure and delays in the swallowing reflex.

Suction via the tracheostomy tube and oropharynx after cuff deflation.

Secretions may pool above the inflated cuff. When cuff is deflated these secretions may enter the lungs

Deflate the cuff fully for ALL ORAL INTAKE, if it is agreed that the patient can tolerate this. However, in special circumstances e.g. quality of life issues, a team decision for small amounts of oral intake, with partial cuff deflation may be indicated.

Tracheostomy tube cuffs only reduce the risk of aspiration not prevent it

An inflated cuff may contribute to silent aspiration and reduce effectiveness of a cough

It can contribute to swallowing problems and loss of protective reflexes. A deflated cuff it better for oral communication and swallowing as it allows laryngeal and upper airway resistance. Oral intake should be deferred until at least partial cuff deflation is achieved

If the team will not permit cuff deflation it is up to the individual SLT to explain the risks of a swallowing assessment in the presence of an inflated cuff and a team discussion on the management of the individual case should follow.

If the patient is aspirating, it is vital to know immediately so that suctioning can be carried out and management planned. With an inflated cuff such information is delayed

If neurogenic dysphagia is suspected or patient has undergone head and neck surgery, a full bedside evaluation of swallowing should be undertaken by a proficient SLT.

For full swallowing assessment, see South Wales Speech and Language Therapy Tracheostomy Working Group document March 2002.

Eye protection should be worn by staff working with these patients and universal precautions adhered to.

Infection control

Regular suctioning should be available To ensure a clear airway.


throughout the swallowing assessment by nursing or physiotherapy staff. They must therefore remain in attendance at all times. Ensure unfenestrated inner cannula is replaced prior to suctioning.

If the patient has a fenestrated tracheostomy tube, ensure the inner cannula is replaced by a fenestrated inner cannula if available. Finger occlusion or speaking valves can be used at this stage if tolerated.

This allows laryngeal examination e.g. voice quality and cough and helps normalise the pressures thus improving the swallow function.

Occlusion of the tracheostomy tube may reduce or eliminate aspiration.

An individual assessment is necessary. A Passy-Muir speaking valve may help to reduce, though not eliminate aspiration

Encourage the patient to clear the throat and expectorate secretions. Intermittently check the voice quality and cough by occluding the tracheostomy tube (with a gloved finger) or by using a speaking valve and ask the patients to say 'ah' or count aloud. If voice quality deteriorates and sounds wet, encourage the patient to clear any secretions by coughing and re-swallowing.

The competent practitioner/SLT will progress the patient to trial swallows if indicated.

A gurgly/wet voice may indicate laryngeal penetration. A weak cough may increase the risk of aspiration

The Modified Evans Blue Dye Test (MBDT) should be carried out by the SLT or other competent practitioner.

For competencies regarding MEBDT see Tippett 2000 p168-171.

This test should be used by professionals trained in the assessment of dysphagia THIS TEST SHOULD BE INTERPRETED CONSERVATIVELY and monitored very carefully

The test is initially carried out with sterile water and the blue dye. If a different consistency is needed to be trialled, the blue dye can be mixed with pudding or thickened fluids.

The appropriate consistency is dependent on the underlying impairment/aspiration risk

Nursing and physiotherapy staff are asked to monitor the tracheostomy secretions using a tracking chart.

Blue dye on suctioning indicates aspiration. This needs to be monitored as secretions can be discoloured for up to 72 hours.

The SLT's recommendations such as patient positioning, swallowing manoeuvres and modified textured diets will be clearly documented in the medical notes and discussed with the relevant staff.

The Dietitian will also be notified.

Professional responsibility to ensure effective multidisciplinary communication


13 COMMUNICATION The ability to communicate is affected by the presence of a tracheostomy tube. The patient will be unable to talk and produce voice in the normal way since no air will pass through the vocal cords unless the patient is able to benefit from a fenestrated tube, a speaking valve or in some cases leakage of air around the tube. [N.B. This will not be the case where the patient has undergone a laryngectomy.] All other systems required to enable the patient to communicate will be intact unless there is a co-existing neurological impairment with possible muscular weakness, impaired sensory function, language and cognitive deficits. The patient’s general medical condition may result in fatigue, reduced alertness, behavioural influences, reduced motivation all of which may impede communication.

13.1 Process for establishing good communication with the patient

Action

Rationale

If possible ascertain whether the patient had communication or literacy difficulties pre-tracheostomy.

To obtain a baseline of the patients ability.

Explain to the patient /relative why they are having communication problems [when appropriate the patient/family should be warned pre-tracheostomy placement regarding the effect on communication.]

To provide reassurance.

Check if the patient can see, hear, understand, use facial expression such as smile/ blink, write.

To review available options

When appropriate provide the patient with a means of attracting attention e.g. buzzer/call button.

To facilitate basic communication.

Establish a method for the patient to indicate YES /NO. Ensure everyone who comes in contact with the patient is aware of what method is being used.

Enables the patient to respond to simple questions.

If a coded eye blink is the only means available instruct the patient to blink once for yes and twice for no in response to a question.

Ensures the same system is always used.

If the patient can mouth then to aid lip reading ask the patient to exaggerate their lip movement and to speak in short but complete sentences.

To facilitate oral communication.

If a patient is able to have an uncuffed or deflated cuff tube then trial of a speaking valve may be appropriate. [Please refer to the section on speaking valves.]

To facilitate oral communication.

Where more specific communication To reduce frustration and enable the


problems exist please refer to the Speech & Language Therapy department who will assess and provide other options for alternative communication e.g. picture/ word boards, electronic communication aids etc.

patient to express his/her needs more fully.

14 Emergencies, Common Complications and their Management The main life threatening complications associated with a tracheostomy are blockage, dislodgement and bleeding. 14.1 Blockage and displacement A blocked or displaced tracheostomy tube generally presents with respiratory difficulty. The nature of the problem will often be obvious, but if not, it is important to adopt a systematic approach and be aware that acutely ill patients may have other cardio-respiratory reasons for difficulty in breathing. Every hospital must have a procedure for managing patients whose tracheostomy is blocked or displaced. Staff must be aware of this and receive appropriate training to manage the problem. Tracheostomy tubes may become dislodged or displaced for a number of reasons. This can be a stressful event for both patients and staff, and prevention is better than cure. It is important to ensure that the tracheostomy tube holder is adjusted regularly so that the tube is fixed in a secure, comfortable position all times. Tracheostomy tubes may become dislodged when a ventilated patient is turned, or moved from their bed to a trolley. Restless or agitated patients may pull at their tracheostomy tubes, or ventilator tubing attached to the tracheostomy. A partly dislodged tracheostomy tube is just as dangerous, if not more dangerous, as a completely removed tracheostomy tube. Airway: is the airway (at least partially) patent? • If the tube is displaced, the patient may be breathing through their nose or mouth.

The patient may be safe in the short term, requiring urgent but not emergency action. Only experienced staff should try to replace the tube under such circumstances. If in doubt it will usually be safer to remove a partly dislodged tube, although a suction catheter or airway exchange catheter may be first advanced through it to allow oxygen administration. The airway should be maintained by other methods until experienced help arrives.

• If tube is partially occluded, the patient may still be able to breathe through it, but with difficulty. If the tube has an inner cannula, this should be removed and changed. If the tube does not have an inner cannula, but a suction catheter can be passed down the tracheostomy tube, then it must be at least partially patent. It may be possible to change the tube over a catheter or other airway exchange device.


Staff treating patients with a tracheostomy in an emergency situation need to be aware that ‘bag and mask’ ventilation via the mouth is not possible with a cuffed tracheostomy tube in situ. Individual hospitals are advised to develop their own specific guidelines with bleep numbers, taking account of available staff and recognising this may happen day or night. Chest X rays do not give useful information about the position of the tube in this situation. Fibreoptic bronchoscopy may be useful if it is immediately available, but this should not delay treatment. Displaced tracheostomy tube This guidance is appropriate for patients capable of spontaneous respiration. In a patient who is fully ventilated, critically ventilator dependent or paralysed, prompt replacement or removal and replacement by a tracheal tube will be required. Such a situation is only likely to arise in a level 3 area, but can also occur in a cardio-respiratory arrest elsewhere. Remember tube displacement as a possible cause of cardio-respiratory arrest.

DON’T PANIC! 1. Call for help – senior medical and nursing staff, other AHPs with tracheostomy

care skills (e.g. physiotherapist). If in doubt, call for anaesthetic assistance 2. Reassure patient. 3. Assess patency of airway (A) and patient’s breathing (B). Is air passing through

the tracheostomy tube or stoma? Is the patient breathing via mouth or nose? Check oxygen saturation with a pulse oximeter.

4. If airway is not patent, it must be cleared immediately.

• ONLY SENIOR STAFF WITH APPROPRIATE EXPERIENCE OF TRACHEOSTOMY MANAGEMENT SHOULD ATTEMPT TO RE-INSERT DISLODGED OR DISPLACED TRACHEOSTOMY.

• ANY SUCH ATTEMPT SHOULD BE QUICKLY ABANDONED IF UNSUCCESSFUL.

• MULTIPLE ATTEMPTS SHOULD NOT BE MADE. • IF IN ANY DOUBT, REMOVE TRACHEOSTOMY TUBE AND ALLOW

BREATHING THROUGH THE STOMA OR THE MOUTH/NOSE. • APPLY OXYGEN MASK OVER ONE OR BOTH SITES OF AIR ENTRY. Appropriately experienced staff may attempt to re-insert a tracheostomy tube in a patient with a well-formed track from skin to the tracheal stoma. Typically, this would be more than 72 hours following surgical tracheostomy or more than 7 days after percutaneous tracheostomy. It is advisable to attempt any such re-insertion using a gum elastic bougie or, if time permits, a fibre-optic bronchoscope. 5. Re-establish the airway in the usual fashion – tilt the head back to extend the

head on the neck, perform a jaw thrust. If necessary insert an oral airway (Guedel). Note that if ‘bag and mask’ ventilation is attempted, air will escape through the stoma. In this situation, get a colleague to occlude the stoma by applying pressure over it with gauze swabs or a pad.

6. Tracheal intubation may be needed – this should only be performed by a doctor competent in tracheal intubation. This is not the time to “have a go”. It may be necessary to push the tracheal tube distal to the stoma. (Use an ‘uncut’ tube.)

7. If the patient is breathing adequately at this point, there may be no need to artificially assist ventilation. Check the oxygen saturation with a pulse oximeter and administer oxygen as equired via a facemask or resuscitation bag with an oxygen reservoir.

8. If artificial ventilation is needed, use a resuscitation bag and mask in the standard fashion. aintain occlusion of the stoma as above to prevent an air leak. If the patient has been intubated, the person controlling the airway (usually an anaesthetist or intensivist) will ventilate with the resuscitation bag. Measurement of oxygen saturation with a pulse oximeter will confirm adequacy of oxygenation.

9. At this point the patient is safe, with a patent airway and adequate respiration. Do not panic or rush. Take time to think about what the patient needs at this time.

10. A decision must now be reached about re-insertion of the tracheostomy tube. This decision should only be made an experienced anaesthetist, intensivist, or ENT surgeon. The ecision will be depend on the ability of the patient to maintain a patent airway without the racheostomy tube, and to maintain oxygenation, cough and clear respiratory tract secretions without artificial assistance. If there is any doubt, the correct decision is to reinsert the tracheostomy tube.

11. Re-insertion of the tracheostomy tube can now take place in a controlled manner. It may be possible to do this in the ward, providing the stoma has a well-established track (at least 7 days old). Relevant equipment should be available at the bedside in the patient’s tracheostomy box or from the cardiac arrest trolley (e.g. tracheal dilator forceps). If in doubt arrange to move the patient to a critical care area, ENT ward, or operating theatre. Another option for an experienced practitioner is to pass a tracheal tube via the tracheostomy stoma, which may be easier to advance than a tracheotomy tube.


14.2 BLOCKED TRACHEOSTOMY TUBE A tracheostomy tube may become blocked with thick tracheal secretions, blood or foreign bodies. The patient may present with increasing respiratory distress over a few hours, or with a much more rapid deterioration. In either case, a blocked tracheostomy tube is an emergency situation in which the patient’s life is at risk if it is not rapidly resolved. Prevention is better than cure: • Patients with tracheostomies must always receive adequate humidification of their inspired gas to lessen the risk of tube blockage. • The risk of tube blockage is reduced by the use of a tracheostomy tube with an inner cannula. Such tubes should have their inner cannula cleaned regularly to prevent the buildup of secretions. The precise frequency will depend on individual risk assessment. • Certain specialist tracheostomy tubes (e.g. adjustable length or custom-made long tubes) may not have an inner cannula. Extra vigilance is needed in these patients to minimise the risk of tube blockage. If a blocked tracheostomy tube is suspected, rapid diagnosis will enable prompt treatment. YOU NEED TO KNOW IF THE TRACHEOSTOMY TUBE HAS AN INNER CANNULA

DON’T PANIC! 1. Call for help: senior medical and nursing staff, other AHPs with tracheostomy

care skills (e.g. physiotherapist). 2. Reassure patient. 3. Assess patency of airway (A) and patient’s breathing (B). Is air passing through

the tracheostomy tube or stoma? Is the patient breathing via the mouth or nose? Check the oxygen saturation with a pulse oximeter.

4. If the airway is not patent, this must be dealt with first. 5. If the patient is awake, breathing spontaneously and co-operative, encourage

the patient to give a vigorous cough – this may be sufficient to relieve the obstruction by shifting a plug of thick secretions.

6. If the tracheostomy tube has an inner cannula, remove it. 7. Attempt tracheal suction with a suction catheter – this alone may be sufficient

to remove a thick plug of secretions. 8. If the obstruction is not relieved, then deflate the tracheostomy tube cuff.

Administer oxygen via a facemask if the patient is breathing spontaneously. If the patient is not breathing spontaneously, it will be necessary to ventilate the patient with a resuscitation bag and mask – an oral airway (Guedel) may be necessary. Monitor the oxygen saturation with a pulse oximeter.

9. If it is not possible to achieve adequate oxygenation, then remove the tracheostomy tube and suction and proceed as per dislodged tracheostomy tube protocol. Consider passing Yankeur or other large bore suction catheters directly into the trachea via stoma to remove thick secretions or blood clot. Suction applied directly via the tracheostomy tube or translaryngeal tube may also be required to remove big clots, or large mucus plugs (as in neonates for meconium aspiration).

10. If the patient is now adequately oxygenated, then it is now safe to consider changing the tracheostomy tube. This is not necessary if removal of the inner cannula has relieved the obstruction.


14.3 BLEEDING FROM A TRACHEOSTOMY Bleeding is the most common complication of tracheostomy. Bleeding may occur early (within 48 hours of formation of the tracheostomy) or late (several days afterwards). It may be minor (settles with simple conservative management) or major (requiring transfusion of blood and/or blood products) and surgical exploration may be needed to identify and deal with the source of bleeding. The management of bleeding from a tracheostomy therefore depends upon the context in which the bleeding occurs. 14.4 Early minor bleeding Oozing from the stoma site is the most common type of bleeding seen following formation of a tracheostomy. Most commonly, this is the result of the effects of the vasoconstrictor used to infiltrate the incision site wearing off. Blood staining of the dressings may be noted, or there may be blood staining of tracheal secretions. Large volumes of fresh blood represent significant bleeding, which may require surgical exploration.

DON’T PANIC! 1. Call for help– senior medical and nursing staff, other AHPs with

tracheostomy care skills (e.g. physiotherapist). 2. Reassure patient. 3. Whilst maintaining control of the tracheostomy tube, remove the

tracheostomy tube holder and dressing. 4. Clean stoma site with sterile saline. 5. Inspect stoma site, looking for any obvious bleeding point. 6. Apply manual pressure to any obvious bleeding point – this may be

sufficient to stop minor oozing. Suturing locally may also be effective. 7. If still bleeding, infiltrate any obvious bleeding point with dilute

adrenaline (1:80,000 to 1:200,000). If no obvious bleeding point, infiltrate the stoma margins with dilute adrenaline.

8. If still oozing, apply Kaltostat packing to stoma to promote local clot formation. The Kaltostat may also be soaked in dilute adrenaline.

9. 1Check full blood count and a coagulation screen. Correct any abnormalities in the standard fashion.

10. If bleeding is not stopped by these measures, refer to ENT or other appropriate surgeon for surgical exploration.

Then seek surgical haemostasis in theatres with appropriate senior surgeon. Junior surgeons should not explore such wounds alone as major vessel bleeding and a compromised airway will require senior ENT, cardiothoracic or vascular expertise.


14.5 Major early bleeding Proceed as minor bleeding guideline. Note that large volumes of blood in the trachea may cause respiratory embarrassment – the patient may need further respiratory support in a critical care area. Beware of the risk of the tracheostomy tube becoming occluded by blood clot. If this occurs, proceed as per blocked tracheostomy tube guideline. If airway obstruction occurs due to blood clot in the airway (look with a laryngoscope) then direct suction on the tracheal tube with suction tubing may be required to remove it. Large clots will not pass through a suction catheter or a fibreoptic bronchoscope suction channel. 1Lsswmbio(TiTrftins

S

DON’T PANIC! 1. In most situations of significant bleeding, secure the airway by

translaryngeal intubation with the cuff below the stoma so the airway is protected from blood entering the trachea from the stoma. Then temporary haemostasis of the stoma can be achieved by digital pressure, packing the wound with gauze or deep tension sutures.

2. Early referral to an appropriate SENIOR surgeon (e.g. ENT, cardiothoracic, vascular expertise) for urgent surgical exploration is necessary.

3. Ensure that cross-matched blood is made available. 4. Check full blood count and a coagulation screen. Correct any

abnormalities in the standard fashion.

4.6 Late bleeding ate bleeding may occur because of erosion of blood vessels in and around the stoma ite. This is more likely if there has been infection of the stoma site. Such bleeding may ettle with conservative management, as described in the early bleed guideline. More orryingly, however, is the prospect of such bleeding being the result of erosion of a ajor artery in the root of the neck where there has een pressure from the tracheostomy tube itself or the cuff tube (another reason why it

s important to ensure that the tracheostomy tube cuff pressure is monitored to avoid ver-inflation). Most commonly, this erosion occurs into the right brachio-cephalic artery also known as the innominate artery), resulting in a tracheo-innominate artery fistula. his situation may be heralded in the preceding hours by a small, apparently nsignificant, sentinel bleed. Bleeding from such a fistula will be massive. THIS IS A LIFE-HREATENING EMERGENCY and so decisions need to be rapidly made. It is well ecognised that fatalities occur in this situation, and that this may be the mode of death or some patients with head and neck cancers. The appropriate management may, herefore, be palliation. Such a decision should, ideally, have been made in advance and n discussion with the patient and family, clearly documented in the patient’s medical otes and communicated to the nursing staff (who will undoubtedly have to deal with this ituation). If active treatment is still the plan, proceed as below:

EWCCN Tracheostomy Guidelines May 2009 42

DON’T PANIC! 1. Call for help– senior medical and nursing staff, other AHPs with

tracheostomy care skills (e.g. physiotherapist). 2. Reassure the patient. 3. Proceed as described in the major early bleeding guideline. 4. Bleeding may be temporarily reduced or stopped by applying finger

pressure to the root of the neck in the sternal notch, or by inflating the tracheostomy tube cuff (if present) with a 50ml syringe of air. This inflation should be done slowly and steadily to inflate the balloon to a maximum volume without bursting it. Depending on the type and size of the tracheostomy tube this may be anywhere between 10 and 35 ml.

5. Urgent referral for surgical exploration must now be made, if not already done so. In addition to an ENT or maxillofacial surgeon, it may be necessary to get help from a vascular surgeon. Sometimes, the damage can only be repaired utilising cardio-pulmonary bypass, and so a cardiothoracic surgeon may also be needed to help. The operating theatres must be informed that this is an NCEPOD Category One emergency, as any delay will increase the risk of death significantly.



Appendices 1. Patient information

2. Tracheostomy tube information

3. Emergency algorithms

4. Integrated Care pathway example

5. Tracheostomy observation chart example

Appendix 1 Tracheostomy on the Intensive Care Unit

Information for patients and their relatives Many patients on the Intensive Care Unit (ICU) need help with their breathing as a result of their illness. This may be achieved by attaching the patient to a ventilator (breathing machine). In order to attach the patient to the ventilator, they need a plastic tube that goes through the patient's mouth (or, occasionally, nose) into the trachea (windpipe). When the patient has recovered from their illness and no longer requires the ventilator, this tube will be removed. It is perfectly safe to leave the tube in place for several days. If a patient needs a breathing machine for a long period of time a tube in the mouth or nose can be very uncomfortable and medicines may be needed to allow the patient to put up with the tube. A tracheostomy can help reduce this discomfort and in some cases will allow us to wake the patient up and get them off a breathing machine faster. What is a Tracheostomy? A tracheostomy is a hole in the front of the neck into the trachea (windpipe). A tube can then be inserted through this hole into the trachea in order to allow the patient to be connected to a ventilator and to allow access for suction (clearing phlegm off the lungs). The pictures below show where the tube is placed and some of the commonly seen tracheostomy tubes that are used in Wales:

Figure 1 - The position of the tracheostomy tube in the trachea.

Figure 2 – Some common tracheostomy tubes

Benefits of a tracheostomy • A tracheostomy is more comfortable than a breathing tube in the mouth. • It allows us to clean the mouth and lip read more easily. • A tube in the mouth or nose can damage the delicate tissues in the mouth and throat.

A tracheostomy reduces this risk. • If a patient has lots of phlegm (sputum / secretions) a tracheostomy allows staff to

suck them out easily even if they do not have a very strong cough.



Is it safe? Are there any risks? A tracheostomy is generally a very safe procedure. However, like any procedure there are some risks and complications associated with it. A tracheostomy is only performed when the benefits are greater than the risks. Most of the complications are minor and of no great significance. However, very occasionally, a severe complication may arise which may call for intervention. The risks associated with the procedure are: - • Bleeding • Infection • Damage to other structures in the neck Fortunately, complications are extremely rare. These are the most serious risks from having a tracheostomy, as the patient may experience severe difficulty with breathing. There have very rarely been deaths recorded in the medical literature due to this procedure. How is a Tracheostomy done? A tracheostomy can be done in the intensive care unit by the intensive care senior doctors and consultants (this is called a percutaneous tracheostomy) OR by an Ear Nose and Throat (ENT) surgeon in theatre (this is a surgical tracheostomy). Which ever way it is done the patient is put to sleep (has an anaesthetic) which means they will not be aware of what is happening and will not feel any pain. The procedure itself takes less than half an hour. How long does a tracheostomy stay in place? It is perfectly safe to leave a tracheostomy tube in place for a prolonged period of time. However, in the type of patient we most commonly see on the ICU, we would expect to be able to remove the tracheostomy tube when the patient is judged as no longer requiring it. This time period will vary depending on the needs of the individual - for some this may be a few days for others it could be a few weeks. Tracheostomies may be removed on ICU but patients can also go to the ward with one in place. Before a tracheostomy is taken out patients have to undergo a weaning process to assess that it is safe to remove. This is broken down into stages which allow staff to see how a person is coping. This process is different for each person and staff will be able to discuss with you how you / your relative is doing. When the tube does come out a dressing pad is applied to the hole and secured with tape. The hole usually closes fairly quickly within a week to ten days after removal, the hole will have sealed off, leaving only a small scar. The scar from a percutaneous tracheostomy is less than a centimetre (1/2 inch), with a surgical tracheostomy it is 11/2 centimetres (3/4 inch). Communication A tracheostomy tube it bypasses the larynx (voicebox) and therefore you will not be able to speak. However staff can be very good at lip reading and can provide pen and paper, symbols charts or communication aids to help. You may also be referred to a speech and language therapist to help you. As part of the weaning process a speaking valve can sometimes be attached, allowing a patient to speak with the tracheostomy tube still in place. Staff will be able to advise you if and when this may be appropriate. Eating and Drinking A tracheostomy tube can make it more effortful to swallow and some patients have problems with aspiration (food / drink going down the wrong way). This can be assessed by staff and if possible you will be allowed to eat and drink. If you have continued problems with aspiration you will be seen by a speech and language therapist. Are there any long-term problems? Occasionally patients may develop narrowing of the trachea. This is called stenosis. Often this is not problematic but if this narrowing causes noisy breathing your General Practitioner (GP) is advised to refer you to an ENT surgeon for investigation and treatment. In our experience, it is very rare for this to occur. Some useful websites


The links below you may find of some use: - http://www.tracheostomy-uk.com http://www.tracheostomy.com although this site is about children it has some useful information http://www.ics.ac.uk/patrel/patrel.asp provides general information on critical care Acknowledgements Thanks to the Intensive Care Society (ICS) for use of their resources.


Appendix 2

Tracheostomy Tubes The table below gives the dimensions of dual cannula Portex® Blue Line Ultra® tracheostomy tube (ICS guidelines 2008)

Equivalent Jackson size

(approx.)

ID without inner cannula

(mm)

ID with inner cannula (mm)

OD (mm) Length (mm)

5 6.0 5.0 9.2 64.5 6 7.0 5.5 10.5 70.0 7 7.5 6.0 11.3 73.0 8 8.0 6.5 11.9 75.5 - 8.5 7.0 12.6 78.0 - 9.0 7.5 13.3 81.0

10 10.0 8.5 14.0 87.5 The table below gives dimensions of dual cannula Shiley® tracheostomy tubes Jackson size ID without

inner cannula (mm)

ID with inner cannula (mm)

OD (mm) Length (mm)*

4 6.7 5.0 9.4 62-65 6 8.1 6.4 10.8 74-76 8 9.1 7.6 12.2 79-81 10 10.7 8.9 13.8 79-81 * varying according to precise model selected The table below is a comparison of ID and OD tracheostomy tubes with and without inner cannulae

Portex® Blue Line® Portex® Blue Line Ultra®

Shiley® Dual Cannula Tube

Kapitex® Tracoetwist®

ID with

(mm)

ID without (mm)

OD (mm)

ID with

(mm)

ID without (mm)

OD (mm)

ID with

(mm)

ID without (mm)

OD (mm)

ID with

(mm)

ID without (mm)

OD (mm)

4.0 5.8 7.2 5.0 7.0 8.6 n/a 6.0 8.3 5.0 6.0 9.2 5.0 6.7 9.4 6.0 8.1 9.2 5.0 7.0 9.7 5.5 7.0 10.5 7.0 8.9 10.4 6.0 7.5 11.3 8.0 11.0 6.5 8.0 11.9 6.4 8.1 10.8 8.0 10.1 11.4 7.0 8.5 12.6 7.0 9.0 12.4 7.5 9.0 13.3 7.6 9.1 12.2 9.0 10.8 12.5 n/a 10.0 13.8 8.5 10.0 14.0 8.9 10.7 13.8 10.0 11.9 13.8 Bold type indicates the dimension used to describe the tube commercially. Data for the Shiley® dual cannula tube refers to Jackson sizes 4,6,8 & 10 respectively


Physical characteristics of some tracheostomy tubes Tube Material Stiffness Curvature

or angulation

Angle° Notes

Mallinckrodt armoured adjustable flange

Soft 100 Spiral wire reinforced wall

Shiley Semi-rigid Curved 90 Shiley® Tracheosoft XLT

Angulated 90

Mallinckrodt PERC

Designed for se with the Cook® percutaneous tracheostomy kit

Portex® Blue Line®

PVC Medium Curved 90 ?105

Portex® Blue Line Ultra®

PVC Medium Curved 90 ?105

Portex® adjustable flange

PVC Medium Angulated 110

Portex® Per- Fit®

PVC Medium Curved

Portex ® Blue Line Ultra® Suctionaid

PVC Medium Curved 105

Thermo labile PVC allows tube to soften in vivo. Portex® Blue Line®, Blue Line Ultra® and PERC® are compatible with a customised percutaneous tracheostomy kit.

Bivona® Aire- Cuf® adjustable flange

Silicone Soft n/a n/a Wire reinforced for kink resistance

Bivona® Aire- Cuf® adjustable flange

Silicone Medium Curved 90

Kapitex® Tracoetwist®

Polyurethane Semi-rigid 90

Kapitex® Tracoevario®

Soft Option for spiral wire reinforcement available


Extended length adjustable flange tracheostomy tubes ID

(mm) OD (mm)

Length (mm)

Portex® adjustable flange

6.0 8.2

7.0 9.6 91 8.0 10.9 104 9.0 12.3 119 10.0 13.7

Semi-rigid pre-formed tube with total length of 100 mm. Distinct angulation limiting maximum proximal length to 40mm. Constructed using thermosensitive polyvinylchloride that softens at body temperature. No inner cannula. Not specifically designed for compatibility with percutaneous introducer kits.

Bivona® Mid-range Aire- Cuf®

6.0 8.7 110

7.0 10.0 120 8.0 11.0 130 9.0 12.3 140

Flexible spiral wire-reinforced silicone shaft. No angulation and seamless variability in position of flange and the resulting proximal and distal lengths. No inner cannula. Not specifically designed for compatibility with percutaneous introducer kits.

Rusch® UltrTracheoflx®

7.0 10.8 82 Siliconised PVC construction with kink resistant spiral steel wire reinforcement. Preformed angulation with distal length ranging from 45 to 62mm. Long low pressure high volume cuff. No inner cannula. Not specifically designed for compatibility with percutaneous introducer kits

Extra-length pre-formed Portex® Blue Line® tracheostomy tubes Extra Horizontal Length ID (mm) OD (mm) Horizontal length

(mm) Total length (mm)

7.0 9.7 18 84 8.0 11.0 22 95 9.0 12.4 28 106

Currently only available in North America. Thermosensitive siliconised PVC construction. No inner cannula

Extra Vertical Length with Double Cuff ID (mm) OD (mm) Vertical length

(mm) Total length (mm)

7.0 9.7 41 83 8.0 11.0 45 93 9.0 12.4 48 103 10.0 13.8 52 113

Thermosensitive siliconised PVC construction. No inner cannula. Constructed with two independently inflatable cuffs.

Shiley® TracheoSoft® XLT Extended Length tracheostomy tubes Proximal extension ID (mm) OD (mm) Total length Proximal Radial Distal length


(mm) length (mm)

length (mm)

(mm)

5.0 9.6 90 20 37 33 6.0 11.0 95 23 38 34 7.0 12.3 100 27 39 34 8.0 13.3 105 30 40 35 Distal extension

5.0 9.6 90 5.0 37 48 6.0 11.0 95 8.0 38 48 7.0 12.3 100 12.0 39 49 8.0 13.3 105 15.0 40 50 Provided with disposable inner cannula with integral 15mm twist lock connector. Available with or without high volume/low pressure cuff.

Appendix 3

YES

NO

NO YES

NO

YES

DISLODGED/DISPLACED TRACHEOSTOMY TUBE

General Ward Setting

DON’T PANIC!

Call for help

Assess Airway Patency (A) and Breathing (B).

Is the airway patent?

Reassure Patient

Patient is safe.

Re-establish airway. Tilt head back. Use jaw thrust. Insert oral (Guedel) airway. Occlude stoma site with pad. Consider endotracheal intubation (anaesthetist or intensivist only).

Is the patient breathing or can the patient be ventilated?

Administer oxygen by available route. Monitor oxygen saturation (pulse

oximeter).

Only senior staff with appropriate experience of tracheostomy management (e.g. ENT surgeon or Intensivist) should ever attempt to re-insert a dislodged or displaced tracheostomy. Any such attempt should be quickly abandoned if unsuccessful. Multiple attempts should not be made. If in any doubt, remove tracheostomy tube.

Does the patient need the tracheostomy tube to be replaced? Decision to be made by experienced ENT or Intensive Care doctor (usually in discussion with physiotherapist).

Proceed to Re-insertion

flowchart

Apply dressing. Monitor for signs of breathing difficulties. If in doubt, obtain chest X-ray.


YES

NO

YES

YES

DISLODGED/DISPLACED TRACHEOSTOMY TUBE – Critical Care Setting

NO YES

DON’T PANIC!

Call for help

Assess Airway Patency (A) and Breathing (B).


Reassure Patient

Re-establish airway. Tilt head back. Use jaw thrust. Insert oral (Guedel) airway. Occlude stoma site with pad. Consider endotracheal intubation.

Is the patient breathing or can the patient be ventilated?

Identify if percutaneous or surgical tracheostomy?

Percutaneous more than 7 days old? OR

Surgical more than 72 hours old?

Consider attempting re-insertion using gum-elastic bougie and/or fibre-optic bronchoscope.

Patient is safe.

Only senior staff with appropriate experience of tracheostomy management (e.g. ENT surgeon or Intensivist) should ever attempt to re-insert a dislodged or displaced tracheostomy. Any such attempt should be quickly abandoned if unsuccessful. Multiple attempts should not be made. If in any doubt, remove tracheostomy tube.

Administer oxygen by available route. Monitor oxygen saturation (pulse

oximeter).

Proceed to Re-insertion

flowchart Does the patient need the tracheostomy tube to be replaced? Decision to be made by experienced ENT or Intensive Care doctor (usually in discussion with physiotherapist).

Apply dressing. Monitor for signs of breathing difficulties. If in doubt, obtain chest X-ray.

YES

NO


-RE INSERTION OF TRACHEOSTOMY TUBE


NO

NO

NO

YES

Patient has continuing need for tracheostomy tube?(Decision made by experienced Intensive Care doctor or by experienced ENT surgeon)

YES

Apply dressing. Monitor for signs of breathing difficulties. If in doubt , obtain

chest X-ray.

Is the tracheostomy stoma well -formed?(More than 7 d ays for a percutaneoustracheostomy or more than 72 hours for a surgical tracheostomy

Consider moving patient to a critical care area, ENT ward or an operating theatre area. If in doubt, refer toexperienced Intensive Care doctor or ENT surgeon

)

YES If in doubt, return to dislodged /displaced tracheostomy tube Assemble necessaryflowchartequipment. Must include

tracheostomy tube of same sizeas previously and one sizesmaller. Open sterile dressing

Remove pack onto trolley. Check tracheostomy tube.tracheostomy tube cuff (if

present).

Is the patient breathing or can Position patient sitting up at 30 – 45 degrees. the patient be ventilated?Remove pillow to extend neck. Consider placing

pillow or sandbag behind shoulders to optimiseposition

Check tracheostomy tube. Clean stomasite with sterile saline. Lubricate tracheostomy tube with water-based jelly(e.g. K-Y jelly or aqua gel)

Insert new tracheostomy tube. Remove obturator. Inflate cuff (if present)

BLOCKED TRACHEOSTOMY TUBE


NO

YES

YES

NO

NO

YES

YES

NO

NO YES

NO

YES

YES

NO

NO

NO

Patient with tracheostomy in s itu develops respiratory embarrassment or distress

DON’T PANIC!

Call for help -Re establish airway. Deflate

tracheostomy tube cuff (if present). Remove tracheostomy inner cannula

Assess Airway Patency (A) andBreathing (B).


and replace with clean inner . Tilt head back. Use jaw thrust. Insert

oral (Guedel) airway if needed.

Is the patient awake and able to co-operate?

Remove tracheostomyinner cannula (if present). Encouragepatient to give a strong

Obstruction relieved?

Is the patient breathing?

Attempt trachealsuction (NO MORE

THAN TWICE)

Can the patient be ventilated by hand?

Remove tracheostomy tube.

Ensure inner tube is completely clean beforereplacing. Depending on type of tube, a new innercannula may be indicated, or a new tracheostomy tube may be needed. Decision should be made byexperienced Intensive Care or ENT doctor.

Proceed as per dislodged/ displaced tracheostomy tube flowchart

Obstruction relieved?

New tracheostomy tube needed?

Apply new dressing and tube holder

-Proceed as per reinsertion of

tracheostomy tube flowchart

NO YES

YES NO

NO

YES

BLEEDING TRACHEOSTOMY Blood oozing from stoma site, staining dressings and/or blood

found on tracheal suctioning

Is the tracheostomy less than 7 days old?

Consider possibility of tracheo-innominate artery fistula

A SMALL BLEED MAY HERALD THE ONSET OF MAJOR

HAEMORRHAGE. SEEK URGENT EXPERT HELP.

Remove dressing and tracheostomy tube holder.

Clean site with sterile saline

DON’T PANIC!

Call for help

Check observations – pulse, BP, respiratory rate. Establish IV

access

Look for obvious bleeding point. Apply pressure if

Is the bleeding controlled by pressure?

If still bleeding when pressure removed, infiltrate bleeding point and/or stoma edges with dilute adrenaline. Apply Kaltostat dressing if necessary

Is the bleeding now controlled?

MAJOR BLEED LIKELY!Check observations. Take blood for FBC, coagulation screen and cross-match 4 units of blood.

Apply dressing. Monitor for further bleeding.

Refer to ENT surgeon for urgent exploration

Apply finger pressure to sternal notch. Using 50ml

syringe, carefully hyper-inflate tube cuff (if present).



Appendix 4

INTEGRATED CARE PATHWAY For patients with percutaneous tracheostomies

CONSULTANT: ____________________________________________

DATE PATHWAY COMMENCED: _____________________________

DATE PATHWAY COMPLETED: ______________________________

• This Integrated Care Pathway (ICP) is a multidisciplinary document and replaces all other documentation relating to this episode of care; it thus forms the patient’s sole record of care.

• It is intended as a guide to good practice and is evidence based. • The ICP is not a rigid document and clinicians are free to use their own professional judgement as

appropriate, recording as a Variance any alterations to the practice outlined, or any deviation from the expected plan of treatment. It is set out in chronological order to enable the patient's progress to be monitored.

• All sections should be fully completed. Please follow all instructions. • It is essential that all entries are signed and dated as indicated. Sign only for care that YOU have carried out. • Use black ink only. Any variation from the expected plan of care: anything that happens that is not expected is recorded as a VARIANCE. In recording variances, please give as much information as possible. Please ensure your details are included in the initials box below –

• This pathway should be commenced when patients with a percutaneous

tracheostomy no longer require mechanical ventilation

Initials

Print Name

Signature

Designation

Tracheostomy Study Day Completed

Post Study Day Competencies Completed

Patient Addressograph

Guidelines for completing the pathway


Met this indicates that an activity has been completed, you tick the appropriate box and initial the corresponding shift

Unmet this indicates that you have been unable to complete a specific activity and you need to complete the variance table for that day writing the activity code, a description of why the activity could not be completed and the action taken

Not Applicable only to be used if the activity is not required for the patient Date of discharge to ward_______________ Time ________________ Ward________________________________

Contents of blue box checked and correct Signature ____________________ Print name____________________ Rationale for percutanous tracheostomy insertion

Prolonged airway protection

Prolonged ventilator requirements

To aid weaning Details __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Appendix 5

TRACHEOSTOMY OBSERVATION CHART

Ward:

Tube type: ________________________________ Tube size: _________________________________

Suction catheter size required: _______________

X3 size of tracheostomy tube divided by 2 e.g. size 7 tracheostomy = 7X3=21 divided by 2=10.5 so use a size 10 suction catheter. The catheters should be <50 % diameter of the tube (Glass and Grap 1995, Wood 1998)

Tracheostomy size=suction catheter Size 6 tube=suction catheter size 8 often a 10 is used and this fits with the alternate equation of double and minus 2 personally would not recommend an 8 for a size 6 tube as does not clear and not readily stocked on the weards Size 7 tube=suction catheter size 10

SALT ASSEMENT (refer to page 25) Date ____________________ Details

Date of initial tracheostomy: _______________________ Date of last tracheostomy change: __________________ Date of next recommended change: _________________

Date of decannulation: ___________________


Aim of the integrated care Pathway Anticipated outcomes To care appropriately for tracheostomy. To support weaning from tracheostomy as tolerated and safe To prevent secondary complications.

SEWCCN Tracheostomy Group May 09

Day 1 Date______________ Bedside equipment check Early Late Night Blue box and contents checked Suction working effectively Does Suction liner requires changing Appropriate sized suction catheters Oxygen working if required Spare inner tube available Please initial appropriate shift ACTIVITY

CODE DAY 1 - ACTIVITY TIME (2 HOURLY)

Clinical Assessments

1.0 Competent Health care professional to check oxygen percentage 2 hourly

1.1

Competent Health care professional to check adequate humidification 2 hourly � Aquapak � Swedish nose � Other

1.2

Competent Health care professional to record S =speaking valve attached N= speaking valve not attached ensure cuff deflation if speaking valve is attached

1.3 Please remove speaking valve when patient is asleep if appropriate

1.4

Competent Health care professional to assess need for suction 2 hourly If suction is required pre oxygenate patient to 100 % oxygen for 1 minute prior to commencing procedure and return to prior oxygen setting on completion of suction.

1.5

Competent Health care professional to record quantity and type of secretions when tracheal suction has been performed 1=scanty, 2= moderate, 3=profuse M=mucoid B=blood stained, P=purulent

1.6

Competent Health care professional to clean inner tube 2 hourly With sterile water and Kapitex swabs (refer to guidelines p 26 )

1.7 2 health care professionals to change dressing and tapes as required or at least every 24 hours

1.8

Competent Health care professional to check tracheal cuff pressure with cuff pressure manometer and adjust to 16-24 cms h20

Met Unmet Not Applicable

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SEWCCN Tracheostomy Group May 09

ACTIVITY CODE

DAY 1 - ACTIVITY TIME (2 HOURLY)

record cuff pressure if cuff inflated

1.9 Competent Health care professional to check if tapes are secure and stoma site condition

1.91 Record I if cuff inflated and D if cuff deflated

Please initial appropriate Time Day 1 variance table Activity code

description of variance action taken initials

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