Placement of a tracheostomy tube is usually an emergency procedure when there is a physical or functional obstruction of airflow in the upper respiratory tract (Hyndman and Bray, 2017). By bypassing the nares, pharynx, larynx and proximal trachea the obstruction is relieved (Aldridge and O'Dwyer, 2013).
There are three main clinical indications for tracheostomy tube placement:
- To facilitate anaesthesia and/or recovery when airway is compromised
- To allow the patient to be stabilised and allow for management of the airway
- To provide a definitive airway until swelling has resolved.
The most common causes that require tracheostomy tubes are patients in acute respiratory distress associated with laryngeal paralysis, brachycephalic obstructive airway syndrome, or obstructing foreign bodies (bones, tennis balls etc.). Other causes include inflammation, neoplasia, or laryngeal trauma (Hyndman and Bray, 2017). However, it should be noted that placement of a tracheostomy tube in an emergency is only indicated if endotracheal intubation is not possible (Caron, 2016).
Placement
Tube selection
An appropriate size tube needs to be 6 or 7 tracheal rings in length and have a maximum diameter of 50% of the diameter of the tracheal lumen (Caron, 2016). Tubes also come in a variety of different forms as well as a variety of sizes. They can be single or double lumen as well as being cuffed or uncuffed. The type of tracheostomy tube selected depends on the reason for placement of the tracheostomy tube and patient factors such as breed, size and condition (Caron, 2016).
Single-lumen tubes need to be entirely removed and replaced each time they need cleaning whereas double-lumen tubes allow for only the inner lumen to be removed, making removal and replacement easier. Placement of doublelumen tubes in cats and small dogs is not usually possible due to the larger outer diameter required to ensure the inner diameter is the same as a single lumen tube. Cuffed tubes are only used when mechanical ventilation and gaseous anaesthesia are required (Caron, 2016).
Some practices may not keep tracheostomy tubes in stock. In these instances, an appropriate sized, cut down endotracheal tube can be used and maintained in the same way (Hyndman and Bray, 2017).
Equipment
Placement of a tracheostomy tube requires the following equipment:
- Sterile drape and Backhaus towel clamps
- Gauze swabs
- Scalpel handle and size 10/11 blade
- Adson thumb forceps
- Mayo-Hegar needle holders
- Curved mosquito haemostat forceps x2
- Metzenbaum scissors
- Small Gelpi retractors x2
- Non-absorbable suture material (large size)
- Umbilical tape
- Appropriate tracheostomy tube (Hyndman and Bray, 2017).
Patient preparation
The procedure should be performed under general anaesthesia. Once induced the patient should be placed in dorsal recumbency. The neck will need to be extended and a sandbag, foam wedge or rolled up towel placed underneath so the trachea and larynx is raised. The head should be secured, and front legs fixed caudally to ensure the surgical site remains still during the procedure (Hyndman and Bray, 2017). Once appropriately positioned a large area of the ventral cervical region should be clipped and surgically prepared (Figure 1) (King and Waddell, 2007).
Procedure
The following procedure outlines how a tracheostomy tube is placed. The procedure is performed by a veterinary surgeon and is usually carried out with the patient under general anaesthesia. Veterinary nurses are important in assisting with the procedure and the preparation of the patient (Aldridge and O'Dwyer, 2013).
- A ventral cervical midline incision is made from the caudal aspect of the cricoid cartilage to the sixth tracheal ring
- The sternohyoid muscles are separated at the midline and retracted laterally
- The trachea can then be separated from the surrounding structures. A full thickness stab incision is then made between the third and forth tracheal rings through the annular ligament
- The incision can then be extended laterally so that it is around 50–60% of the tracheal circumference
- The appropriately selected tracheal tube is then inserted into the lumen (Figure 2)
- Stay sutures are placed in the rings above and below the tracheostomy site to aid in exposure when placing the tracheostomy tube in the future. Labelling the stay sutures as ‘up’ and ‘down’ will help pull them in the right direction
- The subcutaneous tissues and skin cranial and caudal to stoma site are closed while still allowing a large enough opening for re-intubation if necessary
- The tube can then be secured around the neck using umbilical tape. The tube should be secured tight enough that it will not fall out but if it is too tight it could cause damage to the area around the stoma site or be difficult to remove in an emergency (Figure 3) (King and Waddell, 2007).
Nursing care of patients with a tracheostomy tube
Patients that have a tracheostomy tube in situ need continual monitoring 24 hours a day. This high level of monitoring is required as patients are at risk of obstruction, occlusion or tube dislodgement.
There are three main points to consider in tracheostomy tube patients:
- Maintenance of patent airway
- Patient comfort
- Asepsis (O'Dwyer, 2008).
Maintenance of patent airway
Nursing a patient with a tracheostomy tube requires a high-level of nursing care and these patients can be time consuming to nurse. Appropriate management of the tracheostomy tube is important in order to prevent build up of secretions which can occlude the tube (O'Dwyer, 2008). In response to placement of the tube, the body produces an excessive amount of secretion in the airway — this is the body's natural defence system reacting to the tube as a foreign body. In order to remove these secretions and avoid complications, regular, careful suctioning or regular changing of the tube is required (Hyndman and Bray, 2017).
When suctioning or changing the tracheostomy tube each patient must be pre-oxygenated for several minutes prior to starting to reduce the chances of hypoxaemia. Aseptic technique should also be used, including appropriate hand washing and use of gloves (Randels-Thorp, 2015).
Suctioning
A sterile, soft, long catheter that is pliable should be used for suctioning and pre-measured, so the tip of the catheter is not advanced further than the end of the tube to prevent damage to the trachea (Randels-Thorp, 2015). When suctioning, do not turn on the suction machine until the catheter is in place. While suctioning, move the catheter in a circular motion to withdraw it and this should not exceed 15 seconds. Light, intermittent suctioning is required to prevent tracheal damage. If the patient requires repeated suctioning, they should be allowed to rest with the provision of oxygen (Randels-Thorp, 2015).
Changing
Some patients may need their tube completely changing if secretions cannot be removed. Tubes with an inner cannula are preferred as these can be easily removed as required and replaced with a new sterile inner cannula. If no inner lumen is present the umbilical tape needs to be undone so the tracheostomy tube can be carefully removed. Another veterinary nurse can then open the trachea by using the stay sutures. A clean tracheostomy tube can then be inserted (Silver, 2016). The original lumen/tube can then be cleaned and soaked in 0.005% dilute chlorhexidine (Randels-Thorp, 2015) and rinsed with sterile saline before replacement (Silver, 2016). Care should be taken to not insert anything into the lumen of the tube as it can be traumatic and cause abrasions, which will increase the likelihood of mucus sticking to the inside of the tube and causing an obstruction (Gray, 2018). If secretions are very thick and cannot be removed with the use of running water, soaking the tube first can help dislodge the secretions.
Frequency of suctioning/changing depends on each patient, how long the tube has been in situ, and how quickly secretions build up. Typically, patients will require tube care every 4–6 hours, however, it may be required more frequently initially, sometimes up to every 15 minutes (Randels-Thorp, 2015). Harsh respiratory sounds from the tracheostomy tube indicate that suctioning or changing of the tube is required, highlighting the importance for continuous monitoring. Other clinical signs that indicate the tube requires suctioning/changing are:
- Dyspnoea
- Distress
- Coughing
- Discharge from the tube
- Patient discomfort (O'Dwyer, 2008).
It is also crucial to accurately document the procedure and how frequently it needs to be performed. Details to include are the appearance of the secretions, consistency and the volume (Hyndman and Bray, 2017).
Complications
When suctioning a patient's tracheostomy tubes, it is important to be aware of the potential complications that can arise during the procedure. These include vagal response, coughing, or stimulation of the gag reflex. If the patient shows any of these signs, suctioning should be stopped immediately (Randels-Thorp, 2015).
After suctioning or changing the tube it is important to check the patient has airflow through the tube to ensure it has not been dislodged and correctly placed, this can be performed using a capnograph to get an end tidal CO2 reading or holding a microscope slide up and observing for condensation (Hyndman and Bray, 2017). Capnography can also be used to confirm placement when the tube is surgically placed initially. If a cuffed tracheostomy tube is used the cuff will also need to be deflated, repositioned and re-inflated every 4 hours to prevent tissue damage (Sierra, 2012).
Humidification
In normal circumstances, air is inhaled through the nose and is naturally warmed and humidified. It contains 4–6 times the amount of water vapour content of room air. When a tracheostomy tube is in place this naturally occurring humidification in the upper respiratory tract is by-passed (Silver, 2016). When patients have a tracheostomy tube, they are inhaling cool, dry air with a larger number of particles which can result in irritation, inflammation and cause the mucosa to produce large amounts of thick mucus. In order to reduce these abnormal secretions patient hydration and humidification of the airway are important and enable secretions to be suctioned with ease (Hyndman and Bray, 2017).
There are humidification filters that can be attached to the end of the tube, however not all practices will have these in stock (Randels-Thorp, 2015). Alternative techniques include instilling 0.5–3.0 mls sterile isotonic saline into the tracheostomy tube to loosen and rehydrate dried secretions. This technique however should be used with caution for several reasons. It can induce the patient to cough which could lead to tube dislodgement as well as an increased risk of aspiration pneumonia or small bronchial obstruction (Hyndman and Bray, 2017).
Nebulisation with sterile saline can also be used and incurs fewer associated risks. Nebulisation should be performed for 10 minutes every 2–3 hours (Randels-Throp, 2015).
Following airway humidification walking or gentle coupage should be performed to aid in the elimination of loose secretions. It is also beneficial to suction after humidification and walking (in that order) as secretions will have loosened and become dislodged and will be more productive (Hyndman and Bray, 2017).
Patient comfort and monitoring
It is important to keep stress and excitement to an absolute minimum in patients with a tracheostomy tube. This can be achieved by ensuring they are in a stress-free environment with limited visual triggers. Some patients may need additional medical management to aid in controlling stress and anxiety. Nurses should consult the veterinary surgeon if they are concerned and feel their patient would benefit from medication. Providing appropriate analgesia will also aid in controlling patient comfort. Performing regular pain scoring provides a comparative means of assessing the patient's levels of discomfort (Hyndman and Bray, 2017).
As already mentioned, patients with tracheostomy tubes should be monitored 24 hours a day. Patients should have their respiration rate, respiratory effort and lungs auscultated at least every 2 hours but may need to be more frequent in some patients (Sierra, 2012). Thermoregulation can also be problematic in these patients as the lumen of the tube can become occluded leading to hyperthermia and an obstruction crisis. Patients will require regular temperature checks (if they do not find it too stressful) and may require cooling mechanisms to reduce body temperature (Hyndman and Bray, 2017).
Patients will also often require intravenous fluid therapy to maintain hydration status alongside humidification of the airway as large amounts of water is lost from airway secretions; they will therefore require regular assessments of their hydration status and fluid therapy plan (Hyndman and Bray, 2017).
Patients will also need an intravenous catheter in situ in case of emergencies. It is easier to have a patent catheter already in place as opposed to trying to place one as well as gain an airway if any tube complications arise. This will mean the catheter site will need checking twice daily and flushing at regular intervals to ensure patency (Gray, 2018).
Bedding should be minimal while still providing appropriate comfort (Figure 4) as excessive bedding can occlude the tube. Providing the patient with a mattress can reduce the amount of bedding required while preventing pressure sores. It is also important to keep the kennel clean; tracheostomy tubes can produce large amounts of discharge which can harbour bacteria. Patient hair that is lost in the kennel can also cause problems to the tube if breathed in through the tube so the patient will require regular cleaning of the kennel and bed. Dogs should not be taken for excessively long walks and only walked on a harness; neck leads are to always be avoided.
Occasionally cats may require tracheostomy tubes (Figurte 5). With cats there is a risk that the litter from their tray can occlude the tube and so it should be replaced with shredded paper instead. Feeding and drinking should be supervised. Both cats and dogs should be fed wet food as dry biscuits can be inhaled and become lodged in the tracheostomy tube lumen (O'Dwyer, 2008).
Asepsis
Aseptic wound care in patients with tracheostomy tubes is vital as the stoma site is the perfect location for bacterial growth. As well as keeping the tube clean, it is important to keep the skin around the tube clean and dry. The stoma site should be monitored at least every 4 hours for signs of inflammation, pain, discharge or subcutaneous emphysema. Cleaning can be performed with 0.05% diluted chlorhexidine and gauze swabs (Sierra, 2012). Materials where small fibres can break off should not be used as they can be inhaled by the patient. The wound should be cleaned from the incision site outwards, taking care to not let any solution enter the wound (Randels-Thorp, 2015). Petroleum jelly around the tube can be applied to prevent rubbing of the surrounding tissue or a sterile dressing can be applied (O'Dwyer, 2008).
Non-sterile gloves should always be worn when handling a tracheostomy tube. Sterile gloves should be worn if the inner cannula is going to be touched directly, when performing suctioning or when cleaning the stoma site (Gray, 2018).
Tube ties should also be checked at the same time and changed if they become soiled (Randels-Thorp, 2015). Ensuring they are also secure enough to prevent the tube from becoming dislodged without being too tight and easily removed in an emergency.
Emergency kit
When there is a hospitalised patient with a tracheostomy tube it is important to be prepared in case an emergency arises; having suction apparatus and appropriately sized suction catheters on standby close to the patient's accommodation is useful, as well as having facilities to provide oxygen therapy close by. Also an emergency kit containing the following items is useful:
- Spare tracheostomy tubes (same size and size below)
- Induction agent, flush, syringe and needle
- Scissors/blade
- Sterile gloves (Figure 6).
Having an electrocardiograph and pulse oximetry nearby might also be beneficial as well as a crash cart with emergency drugs (Hyndman and Bray, 2017). Having the equipment ready ensures intervention is as quick as possible and reduces stress to everyone involved (Sierra, 2012).
Removal and nursing care
Removal of the tube occurs once the patient's underlying condition does not require its use and can vary from days to weeks depending on the primary condition. When deciding if the tube can be removed or not the tube can be partially or completely occluded to assess the patient's ability to breathe adequately. However, as the tube occupies a large proportion of the tracheal lumen proper assessment of the patient's normal respiration will be compromised. It will still be a good indicator of the patient's ability to breathe without the use of the tracheostomy tube if they do not experience too much compromise (Caron, 2016). Complications that can arise post tube removal that nurses need to be aware of are infection, tracheal stenosis and inefficient respiration (Hyndman and Bray, 2017).
Once patients have their tube removed, they should be closely monitored for several hours and will still require regular monitoring until discharge. The emergency tray as previously discussed should still be avaliable. It is also advisable to leave the stay sutures in place for 24 hours post tube removal (Figure 7) (Hyndman and Bray, 2017). The stoma site is left to heal by second intention which usually takes 7–10 days. Stoma site care should continue throughout this period (Hyndman and Bray, 2017).
Contraindications for use
Tracheostomy tubes can be of great benefit to patients, however in some circumstances placement can be contraindicated. It is important to be aware of the reasons why a tracheostomy tube should not be placed to ensure they are being appropriately used. These include:
- Patients with coagulopathies and thrombocytopenia
- Mass or tracheal obstruction distal to the site of tracheostomy tube placement
- Tracheal collapse distal to the tracheal tube site or previous tracheal stents
- Increased intracranial pressure or an unstable cervical spine (Silver, 2016).
Conclusion
Tracheostomy tubes provide an essential lifeline to patients where there is no alternative, for example where the airway is compromised and needs to be carefully managed in emergency situations.
Tracheostomy tube patients, although time consuming, can be very rewarding patients to nurse. It is important that nurses know how to appropriately nurse and manage tracheostomy tubes to ensure complications do not arise, especially with the rise of brachycephalic breeds being seen in veterinary practice.
KEY POINTS
- Patients with a tracheostomy tube or that have had one removed need continuous monitoring throughout their hospitalisation.
- Maintenance of the patient's airway can be time-consuming but is essential to the patient's survival.
- Having all the equipment ready for an emergency is important.
- Asepsis is crucial in tracheostomy tube patients to prevent further complications arising.