What are the indications and care requirements for a tracheostomy?

Tracheostomy Indications and Care Requirements

Tracheostomy is primarily indicated for facilitating and weaning from prolonged mechanical ventilation, managing actual or anticipated airway obstruction, addressing inadequate laryngeal reflexes, and providing invasive pulmonary hygiene in patients unable to clear respiratory secretions. 1

Indications for Tracheostomy

Primary Indications

• Prolonged mechanical ventilation (most common indication)
• Actual or anticipated airway obstruction
• Inadequate laryngeal reflexes
• Need for invasive pulmonary hygiene in patients unable to clear secretions 1

Timing Considerations

• For COVID-19 patients, tracheostomy should be delayed until at least day 10 of mechanical ventilation and only considered when patients show signs of clinical improvement 1
• For non-COVID patients requiring prolonged intubation, tracheostomy should be considered as soon as the need for prolonged intubation (longer than 14 days) is identified 2

Essential Tracheostomy Care Requirements

Equipment Needs

• Each bedside should be equipped with:
  • Functional suctioning system
  • Oxygen source
  • Manual resuscitation bag
  • Complete tracheostomy kit (should accompany patients wherever they go in hospital) 3

Infection Control Measures

• Decontaminate hands before and after patient contact
• Wear gloves when handling respiratory secretions
• Use eye protection for all tracheostomy care
• Change gloves and decontaminate hands between contacts with different patients
• Wear a gown when soiling with respiratory secretions is anticipated 4

Tracheostomy Tube Care

1. Suctioning:

   • Assess need for suctioning
   • Use proper technique with premarked catheters
   • Twirl catheter between fingertips during suctioning
   • Use sterile, single-use catheters for open-system suction 1, 4

2. Tube Changes:

   • Check tube integrity and flexibility before insertion
   • Check cuff integrity if present
   • Position patient with neck in slight extension using small roll under shoulders
   • Remove tube in upward and outward arc
   • Insert new tube in downward, inward arc
   • Immediately remove obturator if used
   • Secure ties and inflate cuff if used 1

3. Skin Care:

   • Keep skin clean and dry to avoid pressure necrosis
   • Perform regular daily cleansing with soap and water
   • Use 1.5% hydrogen peroxide to remove encrusted secretions (followed by water cleansing)
   • Inspect peristomal area and neck skin daily
   • Avoid routine use of ointments and creams
   • Petroleum-based products are contraindicated 1

Safety Measures

• Avoid dust, smoke, lint, pet hair, powder, sprays, small toys
• Avoid contact with fuzzy toys, clothes, or bedding
• Contact sports and water sports are not permitted
• Bathing permitted in 1-2 inches of water with trained caretaker present
• Showers may be permissible for older children 1

Emergency Management

Emergency Supplies

• Replacement tracheostomy tube (same size)
• Replacement tube one size smaller
• Suction equipment
• Oxygen source 1, 3

Emergency Protocols

• For accidental decannulation:
  • Replace tracheostomy with tube of same size or one size smaller
  • If unable to replace, consider endotracheal intubation if patient is stable
  • If patient is stable and tube cannot be replaced, transport to tertiary care facility 1

Special Considerations

COVID-19 Patients

• Use enhanced PPE for aerosol-generating procedures
• Consider closed-circuit suction system with expiratory viral filter
• Patients with deflated cuffs should wear fluid-resistant surgical masks 1

Discharge Planning

• Begin discharge planning before insertion of tracheostomy tube
• Caregivers must demonstrate proficiency in routine and emergent care
• Ensure availability of necessary equipment and supplies
• Establish clear plans for daily care, PPE requirements, review and decannulation 1

Decannulation

• Consider decannulation when:
  1. Original need for tracheostomy is no longer present
  2. Patient can maintain safe and adequate airway independently 1
• Decannulation should be managed by a multidisciplinary tracheostomy team 1

Monitoring for Complications

• Infection
• Tracheomalacia
• Skin breakdown
• Tracheoesophageal fistula
• Hemorrhage (blood in tracheal secretions may precede catastrophic hemorrhage)
• Tube dislodgement
• Tube obstruction 1, 3

Proper tracheostomy care requires meticulous attention to detail, appropriate equipment, and trained caregivers to minimize complications and optimize patient outcomes. A multidisciplinary approach with clear protocols for insertion, care, and decannulation is essential for safe management.