What are the guidelines for using a T-piece (tracheostomy tube attachment) at night for tracheostomy patients?

Guidelines for T-Piece Use in Tracheostomy Patients at Night

For patients requiring nocturnal ventilation, a cuffed tracheostomy tube with the cuff inflated at night for ventilation and deflated during the day to facilitate speech is recommended. 1

Tracheostomy Tube Selection for Nocturnal Use

• Cuffed tracheostomy tubes should be used for patients requiring nocturnal ventilation, with the cuff inflated at night and deflated during the day to allow speech and breathing around the tube 1
• When using cuffed tubes, maintain cuff pressures below 20 cm H2O to preserve airway epithelium perfusion and prevent tracheal injury 1
• For patients with high-pressure ventilation needs, use low-pressure/high-volume cuffs rather than low-volume/high-pressure cuffs to minimize tracheal wall damage 1
• Uncuffed tracheostomy tubes are generally preferred when mechanical ventilation is not required 1

T-Piece Setup for Nocturnal Use

• A T-piece with an expiratory filter should be used for spontaneously breathing tracheostomy patients to reduce environmental aerosol dispersion 1
• When disconnecting from closed-circuit systems, immediately place a heat moisture exchanger (HME) with viral filter to minimize aerosolization 1
• Use HMEs with filtration efficiency >99.9% and bidirectional design for optimal humidification and protection 1
• Avoid using masks placed over the tracheostomy tube as they do not adequately prevent aerosol escape 1

Cuff Management During Nocturnal Use

• For mechanically ventilated patients, maintain cuff pressure between 20-30 cmH2O for air-filled cuffs to prevent tracheal injury while maintaining circuit integrity 1
• Avoid hyperinflation of cuffs as this increases risk of tracheal injury 1
• For water-filled cuffs, fill with sterile water until air leak is not appreciated 1
• Monitor cuff pressure regularly to ensure optimal volume and maintenance of closed-circuit ventilation 1

Suctioning Protocols for Overnight Management

• Use closed-circuit suctioning systems with inline suction catheters to decrease aerosolization risk 1
• For non-ventilated patients, use a T-connector or Kelley Circuit with an inline suction catheter 1
• Avoid instillation of saline before suctioning as it increases risk of coughing and aerosolization 1
• Use only sterile fluid to remove secretions from suction catheters if they will be re-entered into the patient's respiratory tract 1

Humidification Considerations

• Heat moisture exchangers (HMEs) are strongly preferred over large-volume humidifiers to prevent airway dryness and secretion thickening 1
• If using HMEs, ensure they are changed when soiled to maintain effectiveness 1
• If HMEs are unavailable and there is high risk of mucus plugging, consider scheduled suctioning to reduce mucus buildup 1
• Avoid large-volume room-air humidifiers that create aerosols unless they can be sterilized daily and filled only with sterile water 2

Infection Prevention During Nocturnal Care

• Decontaminate hands before and after contact with the tracheostomy tube or any respiratory device 1, 2
• Wear gloves when handling respiratory secretions or objects contaminated with respiratory secretions 1, 2
• Change gloves and decontaminate hands between contacts with different patients or after handling respiratory secretions 1
• When soiling with respiratory secretions is anticipated, wear a gown and change it after soiling occurs 1

Common Pitfalls and Complications to Avoid

• Mucus plugging is one of the most common reasons for airway emergencies, particularly at night when monitoring may be reduced 3
• Accidental decannulation occurs more frequently during night shifts and with patients experiencing mental status changes 4
• Inadequate humidification can lead to thickened secretions and tube obstruction 5
• Improper cuff inflation can cause tracheal injury if too high or ventilation leaks if too low 1

Special Considerations for Weaning

• Pressure support mode with an inflated cuff is preferred over spontaneous breathing trials using T-piece to avoid aerosol generation during weaning 1
• High-flow therapy via tracheostomy tube connected with a one-way valve (HFT-T-OWV) may facilitate extended use without dry airway mucosa and thickened secretions 5
• Once the patient tolerates cuff deflation or a cuffless tracheostomy tube, one-way speaking valves or capping may be considered to facilitate speech and promote weaning 1