Most nurses are not thrilled to learn they will be caring for a patient with a tracheostomy tube on their shift. They are difficult, intensive, and continually require cleaning. Patients with tracheostomy tubes require extra time and nursing care involving humidification, aseptic wound care, suctioning, and removal of secretions.
Most practices do not deal with these patients on a regular basis. However, practices should create a documented set of procedures for veterinary nurses to follow when a patient requires tracheotomy tube care. Outcome of these patients is largely dependent on the care provided by veterinary nurses (Figure 1).
Patients with severe upper respiratory obstruction are potential candidates for tracheostomy tube placement. Causes for such obstruction may include inflammation, laryngeal paralysis, brachycephalic syndrome, or other causes that prevent ventilation and/or endotracheal tube placement.
What is a tracheostomy?
A tracheostomy is a surgical procedure that involves creating an incision through the neck into the trachea. This allows the patient to breathe through a tube and also allows for easy access so that veterinary nurses can provide care and maintain the tube. Brachycephalic breeds, such as English Bulldogs or Boston Terriers, may require tracheostomy tube placement more than other breed types owing to the development of brachycephalic airway obstructive syndrome.
Tracheostomy tubes may be placed in a planned surgical setting, or on an emergency basis. In either case, a surgical wound is created, which allows for the placement of the tube. The tube is placed between the tracheal rings (Tillson, 2008), secured by suturing, and the wound is surgically closed (Figure 2a and Figure 2b).
Once placed by the veterinarian, proper care of the tube and wound must be instituted immediately. Care may be required continuously, every 15 minutes, or every 2–3 hours depending on the patient's needs. Many issues can occur with tracheostomy tubes including obstruction, dislodgement, or occlusion of the tube. Owing to the risks involved with these tubes, these patients require constant observation in addition to systematic care. Goals of managing tracheostomy tubes include:
Veterinary nurses should continually reevaluate the need for changes in frequency or type of care provided. Other care after placement includes suctioning and removal of respiratory secretions (Figure 3).
Humidification
Humidification filters that can be attached to the end of the tube are one of the simplest ways to humidify inspired air for these patients. These are disposable. If the filters are unavailable, there are several alternative techniques which can be employed to provide humidification. One of these is the instillation of sterile isotonic saline (Burkitt Creedon and Davis, 2012). In order to provide proper humidification, 0.5–3 mls of sterile isotonic saline should be instilled into the tracheostomy tube hourly. Prior to instillation, the outside areas of the tracheostomy tube should be cleaned with chlorhexidine solution and sterile gauze. After cleaning and drawing up the sterile saline into a sterile syringe, the needle must be removed quickly and saline should be squirted into the tube without touching the sides. Nebulisation is another alternative method. Nebulising sterile saline for 10–15 minutes every 4–6 hours is effective and preferred to the instillation of saline as described above (Figure 4).
Aseptic wound care
Good wound care is vital for all tracheostomy tube placements, as these sites become prime locations for bacterial growth. Hands should be washed and gloves worn prior to handling the tracheostomy tube or area surrounding it. Sterile gloves should be used when cleaning the wound. The area should be cleaned around the incision and under the tube with chlorhexidine solution-soaked sterile gauze. Chlorhexidine solution should be diluted to 0.05% concentration for cleaning the wound (Burkitt Creedon and Davis, 2012). The gauze must not be dripping as the solution should not be allowed to get inside the incision. The nurse can begin working at the wound edges and work outward, away from the incision. No ointments should be used in the incision and wound area. Sterile cotton-tipped applicators may also be used instead of sterile gauze squares. Dry gauze pads can be placed around the tracheostomy tube after cleaning to aid in the absorption of exudate. The gauze pads should not be cut as the small fibres that will be loosened by the cutting action could be inhaled by the patient. Instead, the gauze should be simply folded as needed to fit around the tube. The tube ties should be checked each time the wound is cleaned, to ensure the tube is secure, and should be changed whenever they become soiled.
Suctioning
Patients with tracheostomy tubes produce various amounts of secretions. Regular suctioning is required but must be done very carefully as complications can occur. The patient should be pre-oxygenated for several minutes prior to suctioning. Aseptic technique must be followed (Fudge, 2009). A sterile, soft, long catheter that is pliable with side fenestrations should be used. Silicone catheters are often preferred, but even a red rubber catheter may be used. The suction unit should not be turned on until the catheter is in place. Suction should be intermittent and light while moving the catheter in a circular motion to withdraw it. This process should take less than 15 seconds. Oxygen should be supplied and the patient given a break before repeating the process. Suctioning should be discontinued if there is a vagal response, cough, gag reflex, or any other adverse effects (Figure 5). This procedure should be practiced in advance of performing it (Figure 6). Veterinary nurses should use an alcohol based hand solution or disinfectant scrub to cleans hands and fingernails prior to the procedure. Ideally gloves should be worn in addition to proper hand sanitisation protocols.
Removal of secretions
The inner cannula of the tracheostomy tube should be removed every 4–6 hours at minimum and replaced with a new sterile inner cannula. The original cannula can then be cleaned and soaked in a chlorhexidine solution to be used for the next exchange. Additional saline may be infused into the outer lumen if copious secretions are noted. If single-lumen tubes are used, the entire tube requires replacement. Care should be taken not to do this too often as it will irritate the wound. Therefore, tubes with inner cannulas are preferred to single-lumen tubes. Coupage and changing the posture of the patient may also facilitate removal of respiratory secretions, especially if done immediately after nebulisation.
While care of a patient with a tracheostomy tube is intensive and involved, when the outcome is a healthy patient returning home, this in itself is a reward. Veterinary nurses must remember to start care immediately once a tube has been placed, and to always be on the watch for complications such as dislodgment, obstruction, or occlusion of the tube. They must also be diligent about preventing secretions from building up and blocking the tube, providing aseptic wound care, and providing humidification of air.
Conclusion
Developing a standard operating procedure (SOP) for all technicians in the hospital to follow when a patient with a tracheostomy tube is in the hospital is beneficial. Providing diligent care as outlined in this article will help to improve the odds of successful outcome in these patients.