Guide to Using Tracheostomy Tubes: Essential Steps for Caregivers and Healthcare Professionals

Tracheostomy tubes are critical tools in medical care, particularly for patients with compromised airways. Understanding their proper use is essential for healthcare professionals and caregivers. This comprehensive guide provides a detailed overview of tracheostomy tubes, from their types and indications to insertion techniques.

Understanding Tracheostomy Tubes

Tracheostomy tubes are crucial artificial airway devices designed to aid in breathing by providing a direct pathway to the trachea. Surgically inserted through a tracheostomy stoma, these tubes play a vital role in patients requiring assistance with ventilation or experiencing respiratory difficulties. They come in different types tailored to diverse medical needs:

• Cuffed Tracheostomy Tubes: Equipped with an inflatable cuff, these tubes create a seal around the trachea, preventing aspiration and facilitating mechanical ventilation. They are commonly used in patients requiring positive pressure ventilation or those at risk of aspiration.
• Uncuffed Tracheostomy Tubes: Unlike cuffed tubes, uncuffed variants lack an inflatable cuff, allowing for continuous airflow around the tube. They are often preferred for patients with a stable airway and adequate swallowing function, minimizing the risk of tracheal damage or pressure injuries.
• Fenestrated Tracheostomy Tubes: These tubes feature a small opening or fenestration in the outer tube near the cuff. This design enables airflow through the upper airway, enabling phonation and easing weaning from mechanical ventilation in select patients.

Indications for tracheostomy tube placement vary widely, encompassing acute respiratory emergencies, chronic respiratory failure, and long-term ventilator dependence. In emergencies, such as upper airway obstruction or respiratory distress, prompt intervention with tracheostomy tube insertion is necessary to maintain adequate oxygenation and ventilation. Conversely, patients requiring prolonged mechanical ventilation or those with compromised airway protection benefit from trach tubes as part of their long-term respiratory support plan.

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How to Choose and Prepare Tracheostomy Tubes?

Choosing the right tracheostomy tube is crucial for patient comfort and safety. Here's how to do it:

1. Consider Patient Age: Pediatric and adult tubes differ in size and design. Pediatric tubes are smaller and often have special features for comfort.
2. Assess Medical Conditions: Some conditions require specific tube features. For instance, patients with tracheal stenosis fenestrated tubes for better airflow.
3. Think about Duration: Decide if the patient needs a temporary or long-term tube. Long-term tubes should be durable and adaptable for patient comfort.

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How to Use Tracheostomy Tubes?

Inserting a tracheostomy tube requires meticulous attention to detail and adherence to established protocols. Here's how to use them safely and effectively:

1. Prepare the Patient

Before beginning the tracheostomy tube insertion, place the patient comfortably, preferably in a semi-upright position, to facilitate breathing and reduce the risk of aspiration. Align the patient's head and neck in a neutral position to facilitate access to the tracheostomy site and ensure proper tube placement.

If the patient is conscious, explain the procedure in clear, reassuring terms, addressing any concerns they have. Reassure them throughout the process to alleviate anxiety and promote cooperation.

2. Gather Necessary Equipment

Having the right equipment readily available is crucial for a successful tracheostomy tube insertion:

• Insertion Kit: Assemble the tools for a sterile environment during insertion, including gloves, sterile drapes to create a sterile field, forceps to handle sterile items, and dilators to aid in tube insertion.
• Suction Devices: Ensure suction equipment is readily available to clear secretions and maintain airway patency during the procedure and afterward.
• Dressing Materials: Prepare gauze pads and transparent dressings to dress the tracheostomy site post-insertion, maintaining cleanliness and preventing infection.
• Tracheostomy Ties: Have tracheostomy ties or securement devices to secure the tube after insertion, preventing accidental displacement.

Keep these supplies organized and easily accessible to streamline the insertion process and respond promptly to any emergent needs.

3.  Insert the Tracheostomy Tube

Inserting the tracheostomy tube requires precision and attention to detail to ensure safe and effective placement:

• Cleanse the area around the tracheostomy site with an antiseptic solution to minimize the risk of infection.
• Don sterile gloves and drape the patient's neck with sterile towels or drapes to maintain a sterile environment during the procedure.
• Use sterile forceps to hold the tracheostomy tube and carefully insert it into the site, ensuring gentle, steady advancement to avoid trauma to surrounding tissues.
• If the tracheostomy tube is cuffed, inflate the cuff using a syringe with air or saline solution, ensuring a secure seal to prevent aspiration while avoiding over-inflation, which leads to tissue damage.

4. Secure the Tube

After inserting the tracheostomy tube, use tracheostomy ties or securement devices to secure the tube firmly around the patient's neck. Ensure the ties are snug enough to keep the tube secure but not excessively tight, as this impedes circulation and causes skin irritation or pressure injuries.

Securing the tube properly minimizes the risk of accidental dislodgement and maintains the integrity of the airway.

5. Confirm Placement

Verifying the correct placement of the tracheostomy tube is crucial to ensure adequate ventilation and prevent complications. To confirm the placement of the tracheostomy tube:

• Listen for bilateral breath sounds using a stethoscope to confirm airflow through both lungs, indicating proper tube placement within the trachea.
• Look for symmetric chest rise and fall, indicating adequate ventilation and tube placement.
• If available, utilize capnography or obtain a chest X-ray to further confirm tube placement and rule out complications such as pneumothorax or malposition.

6. Provide Ongoing Care

After successfully inserting and confirming the placement of the tracheostomy tube,  regularly monitor the patient's respiratory status, including respiratory rate, oxygen saturation, and breath sounds, to detect any signs of respiratory distress or tube dysfunction promptly. Keep the tracheostomy site clean and dry by changing dressings regularly and performing routine hygiene measures to prevent infection and skin breakdown. Suction devices should clear secretions from the tracheostomy tube and airway, maintaining patency and optimizing respiratory function.

Be prepared to promptly address common issues such as tube dislodgement, blockage, or infection. Have established protocols in place for managing emergent situations, including securing the airway, providing oxygenation and ventilation support, and summoning additional assistance as needed.

Considerations in Pediatric Tracheostomy Management

In recent years, pediatric tracheostomy procedures have become more common due to improvements in neonatal and pediatric ICU care, with many children now relying on tracheostomy for long-term survival. While tracheostomy is less frequent in pediatric ICUs compared to adult ICUs, it remains predominantly a surgical procedure, with percutaneous methods considered feasible only in older children. There is a lack of consensus on the optimal timing for tracheostomy placement and decannulation protocols, with various approaches utilized. Children with tracheostomy face increased risks of adverse events and mortality, often related to underlying comorbidities. However, many tracheostomy-related events are preventable, emphasizing the need for enhanced coordination and quality improvement initiatives in pediatric tracheostomy care, such as those facilitated by the Global Tracheostomy Collaborative.

How do you manage eating with a tracheostomy tube?

Individuals with a tracheostomy tube eat, but modifications in food consistency and swallowing techniques are necessary to prevent aspiration. Managing eating with a tracheostomy tube involves careful steps to ensure safe swallowing and proper nutrition:

1. Assess swallowing ability with a healthcare professional.
2. Consult the healthcare team for a personalized eating plan.
3. Modify food and liquid consistency as needed.
4. Position the patient upright for meals.
5. Offer small, frequent meals to prevent fatigue.
6. Monitor for signs of aspiration during feeding.
7. Provide thorough oral care after eating.
8. Encourage hydration with appropriate fluids.
9. Follow dietary recommendations from the healthcare team.
10. Educate patients and caregivers on safe eating practices.

Consultation with a speech therapist or swallowing specialist guides safe eating practices.

What to Do If Tracheostomy Tube Comes Out at Home?

If a tracheostomy tube becomes dislodged at home, it's essential to stay calm, apply gentle pressure to control any bleeding and attempt to reinsert the tube if possible. If reinsertion is unsuccessful or there are any signs of respiratory distress, seek immediate medical attention.

Can You Talk with a Tracheostomy Tube?

Yes, individuals with a tracheostomy tube communicate, although speaking requires adjustments due to changes in airflow. Speech therapy and speaking valves help improve vocalization while ensuring the tube remains in place securely.

How Long Is a Tracheostomy Tube?

Tracheostomy tubes come in various lengths, depending on the patient's anatomy and the manufacturer's specifications. Standard lengths for adult tubes typically range from 55mm to 85mm, but lengths vary based on individual needs.

How Often Should Tracheostomy Tube Be Changed?

According to a study published on PubMed, tracheostomy tubes should typically be changed every 1-2 weeks after the initial placement. Subsequent changes become less risky over time as the tracheo-cutaneous tract matures. Malpositioned tubes must be promptly corrected to prevent patient distress and complications. The timing of routine tube changes should be determined based on clinical judgment and patient-specific factors.

How to Change Tracheostomy Tube?

To change a tracheostomy tube, healthcare professionals must prepare the necessary equipment, carefully remove the old tube, insert the new one, and ensure it is secured properly. Skilled healthcare providers should perform this procedure to minimize the risk of complications.

Can a Nurse Replace a Tracheostomy Tube?

Nurses with proper training and competency in tracheostomy care are authorized to replace tracheostomy tubes. However, this procedure is typically performed by experienced healthcare providers to ensure safety and prevent potential complications.

Obtain Certification and Further Education

Enrolling in Basic Life Support (BLS) and Advanced Cardiovascular Life Support (ACLS) courses will enhance your lifesaving skills. BLS training equips individuals with fundamental techniques for immediate care in cardiac emergencies, including cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use. ACLS builds upon BLS principles, offering advanced interventions and algorithms for managing cardiac arrest, stroke, and other life-threatening conditions. These courses provide hands-on training, scenario-based simulations, and certification upon completion, empowering healthcare professionals and lay rescuers alike to respond confidently and effectively in emergencies. Invest in your education and join the ranks of skilled responders dedicated to saving lives.

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Sources:

• Tracheostomy Update: When and How 2017 Apr;33(2):311-322. doi: 10.1016/j.ccc.2016.12.007.
• Tracheostomy in Infants and Children 2017 Jun;62(6):799-825. doi: 10.4187/respcare.05366.
• Tracheostomy Tube Placement: Early and Late Complications 2015 Oct;22(4):357-64. doi: 10.1097/LBR.0000000000000177.
• When to change a tracheostomy tube 2010 Aug;55(8):1069-75.

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