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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4773_Библиотеки_им_академика_М_И_Перельмана.pdf
‘talk through’ rehearsal between operators before undertaking the
procedure.
Figure 5.22 A bougie inserted into a tracheostomy tube.
Gum-elastic bougies are not primarily designed for tracheostomy tube
exchanges. Several specific airway exchange catheters are available. Some
of these allow connection to standard anaesthetic circuits to allow
oxygenation during the exchange procedure and some have a large enough
internal diameter to allow a fibreoptic scope to be inserted as previously
described. Figure 5.23 shows a Cook Aintree catheter connected to a 15
mm port.
Figure 5.23 A Cook Aintree catheter connected to a 15 mm port.
What to do if the new tube won't go in
Sometimes, new tubes won't insert easily. It is important not to force a
new tube into a stoma. Similarly, blindly attempting to pass a bougie or
introducer into a deep or fresh tracheostomy stoma may lead to the
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creation of a false passage, cause bleeding and delay attempts at more
conventional airway management.
The key principle is to maintain oxygenation by whatever means
necessary. In the elective situation, this may be as simple as reassuring the
patient and awaiting a more experienced practitioner. In the oxygen- or
ventilator-dependent patient, this can be more arduous. All necessary
equipment, drugs and personnel should be on hand to manage this
situation if the patient and clinical area have been adequately prepared.
The commonest solution to this problem is to insert a new tube that is a
size smaller than the tube that has been removed. If necessary, the stoma
can be formally dilated at a later time. If your experience and local
guidelines allow, tracheal dilators (Figure 5.24) may be used to
temporarily dilate the stoma while a new tube is inserted.
Figure 5.24 Tracheal dilators.
If the patient has a patent upper airway, oxygen should be applied to the
face while more invasive attempts at intubating the stoma are made. The
goal is a safely oxygenated patient, and a formal reinsertion of the tube
may need to occur in a planned manner in an operating theatre
environment. If the clinical condition of the patient means that tube
exchange needs to be more urgent, options include:
• identification of the tract and trachea using a fibreoptic scope
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• a scope and airway exchange catheter
• digital manipulation of a bougie into the trachea
14
• blind passage of a bougie or guide wire into the stoma
• formal refashioning of the stoma surgically or percutaneously.
A video demonstrating cannulation of a stoma using an Aintree catheter
and fibreoptic scope is available here.
15
There is more detail on managing
a deteriorating tracheostomy or laryngectomy patient whose airway is
compromised in the emergency management section.
Summary
Table 5.7 summarises key actions related to tube changes and their
rationale (adapted from the NPSA expert working group).
Table 5.7 Tube changes—key actions and their rationale.
Action Rationale
Identify need for tracheostomy tube
change and clarify type of tube to be
inserted
To ensure tube change is necessary
and the correct tube type is selected
for current and ongoing patient care
needs
Patient preparation may include
ensuring ‘nil by mouth’ for 2–6 h
(liquid–solid) and/or aspirate gastric
tube
To limit the risk of aspiration during
tube change procedure
Decide on blind or guided technique and
assemble appropriate equipment
Guided techniques more appropriate
for first or (potentially) difficult
exchanges
Explain the procedure to the patient and
obtain verbal consent if appropriate
To ensure the patient understands the
procedure and improve cooperation
Ensure appropriate staff and equipment
are available
To deal appropriately with additional
measures to secure an airway
Set up bedside suction and oxygen
equipment
To ensure oxygen and suction are
available (when needed)
Prepare, check and lubricate new tube
Remove any inner cannulae from both
old and new tubes
To ensure new tube has no faults and
is prepared for insertion and
application
123
Remove any obstructing clothing or
equipment
To ensure neck area is accessible for
tube change
Position patient for procedure by placing
a roll under the patient's shoulders,
extending the stable neck
Patient may be placed lying down or
sitting upright depending on individual
patient assessment
To bring the trachea closer to the skin
and to stretch stoma opening in order
to aid tube insertion
Identify the roles of any stay sutures Elevate and open the stoma
If the tracheostomy tube is sutured in
situ, remove all sutures; skin sutures
may be considered for removal if
appropriate
To allow tube removal and to prevent
sutures becoming embedded or an
infection risk
Pharyngeal and sub-glottic suction
orally or via dedicated port on tube
Reduces the risk of aspirating
collections above the cuff
Deflate cuff (if present), simultaneously
suctioning
To enable existing tube to be removed
and for secretions to be cleared
Untie tapes and remove dressing while
tube is held firmly in place
To remove old dressings and tapes
Insert guide via old tube (if used) Maintains patency of stoma
Remove existing tube with a firm out
and downwards movement as patient
breathes out
To reduce patient coughing
Observe stoma site and tracheal opening To identify signs of infection,
granulation tissue and/or bleeding
Holding the introducer (obturator) in
place, insert new tube directly into
stoma or using the guide, railroad the
new tube
To pass tube along contour of tract
Remove introducer/guide To allow patient to breathe and to
allow confirmation of correct tube
position
Check correct positioning:
• Ask patient to breathe out, air
should be felt through end of
tracheostomy
• Auscultate
Evidence of airflow exiting the tube
will confirm correct placement within
the airway
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• Bilateral chest movement
• Suction below the end of the
tracheostomy to confirm
placement within trachea
• Capnography
a
• Fibreoptic endoscopy
Following successful exchange:
Re-attach any oxygen or ventilation
needs
Inflate cuff and check cuff pressure (as
per guidelines)
Apply tapes and dressing (as per
guidelines)
To recommence respiratory
requirements and secure tube position
Reposition patient as to patient
requirements and comfort
To maintain patient comfort
a
Capnography and endoscopy should be immediately available for
difficult cases.
Weaning, downsizing and
planning for decannulation
Tracheostomies may be only a short-term requirement for patients and
should be removed as soon as they are no longer needed. Judging the
timing of removal of the tube (decannulation) can be difficult, and the
patient may need to spend several days, or even weeks, progressing
towards this step. The best way to reduce complications from having a
tracheostomy tube in situ is often to remove the tube as soon as it is safe to
do so.
The term ‘weaning’ can mean either a reduction in support from
mechanical ventilation (or assisted spontaneous breathing modes), a
generic term for the period of time as the patient progresses towards
decannulation, or the term is sometimes applied to a reduction in the size
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of the tracheostomy tubes. The latter term is referred to as ‘downsizing’ in
this manual.
Within the hospital setting, patients will be in one of three different
categories with their tracheostomy: permanent tracheostomy
(non-weanable), long-term (weanable with difficult or under specialist
supervision) or temporary (weanable). Tracheostomy tubes may cause
permanent anatomical or physiological damage to the airway and related
structures and therefore timely weaning, where indicated, is advantageous.
Prior to the removal of a temporary tracheostomy tube, there must be
MDT agreement that the indication for the tracheostomy has been
resolved sufficiently. The weaning process must be clearly led by
individuals who are competent to do so, as the process is not without risk.
This same team should remain the main point of contact for at least 48-h
post decannulation. If patient location prevents this being a viable option,
care should be formally handed over to someone able to provide adequate
advice and interventions.
A tracheostomy MDT will regularly include:
• ward nurse
• physiotherapist
• SALT
• specialist nurse [Tracheostomy, ENT or Critical Care, for example,
Outreach]
• respiratory physician
• head and neck surgeon
• anaesthetist or intensivist
• the patient and/or their carer may be valuable team members with
considerable knowledge; the patient will be included in any
relevant discussions if possible.
The team must have a thorough knowledge of the individual patient's
condition including indication for tracheostomy, established indicators for
decannulation and plan of further future assessments or interventions.
Practitioners caring for the patient through the decannulation process must
have a sound understanding of the signs of deterioration during or post
decannulation and must be able to take necessary actions in the event of
an emergency.
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For some short-term conditions requiring a tracheostomy (e.g. facilitating
a straightforward wean from mechanical ventilation or covering extensive
oral surgery), the original tracheostomy tube may suffice for the whole
weaning process, prior to removal. In more complex situations, a smaller
tube, a different type of tube (e.g. minitrach), a fenestrated tube or a
variety of speaking valves or decannulation caps may be required. Figure
5.25 demonstrates expected airflows with cuffed, uncuffed and uncuffed,
fenestrated tubes.
Figure 5.25 Expected airflows with cuffed tube (a), uncuffed tube (b) and
an uncuffed, fenestrated tube (c).
Reproduced with permission of HEE eLfH.
Patient assessment
In assessing whether a patient is a suitable candidate to attempt weaning
with an aim of decannulation, it must first be clarified whether the reason
for the tracheostomy has been resolved. This may require assessment by
endoscopy to assess patency of upper airway and movement of vocal
cords. This can be carried out by anyone competent to do so, but may
involve head and neck surgical teams, anaesthetists, intensivists or SALT
teams who are usually more experienced with endoscopy. A more general
assessment of the patient is also required to ascertain whether the patient
is well enough to endure the removal of the tracheostomy within the
coming days.
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A checklist to use prior to commencing weaning should ascertain these
aspects.
• Is the upper airway patent? (This may require endoscopic
assessment.)
• Can patients maintain and protect their airway spontaneously?
• Are they free from ventilatory support?
16
• Are they haemodynamically stable?
• Are they free of fever or active infection?
• Are the patients consistently alert?
• Do they have a strong consistent cough (able to cough into mouth)?
• Do they have control of saliva + /− a competent swallow?
• Are there any planned procedures requiring anaesthesia within next
7–10 days?
• Is this patient causing concern?
• Can we safely support the weaning process in the patient's current
clinical environment?
The principles of weaning involve gradually returning the airflow patterns
in the upper airways back towards ‘normal’, thus restoring normal
physiological functions. This process will only succeed if the
tracheostomy tube in situ is of an appropriate size to allow sufficient
airflow around and/or through the tube to the upper airways.
The process
There are many variations on decannulation protocols described in the
literature. It is not clear which of these is ‘the best’ or whether some work
better in certain situations. If your institution has a protocol which works
for your patients, then you are probably just as well continuing to work
with it. We have attempted to explain here the principles behind the
various strategies that may be employed.
The first step after determining suitability is to deflate a tracheostomy tube
cuff, if present. This is in order to ensure the patency of the upper airway
and to ensure that the patient can manage the upper airway secretions.
Deflation of a cuff is explained in detail elsewhere in this manual. In
summary, it involves prior sub-glottic and pharyngeal suctioning (or
suction of a dedicated sub-glottic suction port) prior to cuff deflation with
simultaneous suctioning.
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If a patient has had a cuffed tracheostomy tube in situ for some time, then
deflation and the subsequent flow of air through the upper airways (Figure
5.26) can cause some initial coughing or distress. The cuff may have to be
deflated on a number of occasions for increasing time periods. If the
patient is breathing significantly through the upper airways, then
consideration should be given to the inspired oxygen concentration. Room
air (21% oxygen) will be mixed with the concentration inspired via the
tracheostomy and the oxygen concentration delivered to the lungs will be
lower than that delivered. If the patient is oxygen dependent, this could
lead to hypoxaemia. The oxygen concentration delivered to the
tracheostomy can be increased, supplemental oxygen may need to be
given by facemask or the cuff may need to be reinflated. Hypoxia usually
indicates that the patient is not ready to proceed beyond short trials of cuff
deflation.
Figure 5.26 Potential air flow with a partially deflated cuff.
Reproduced with permission of HEE eLfH.
Figure 5.27 Varying tube size and the level of cuff inflation during
weaning.
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Reproduced with permission of HEE eLfH.
Figure 5.28 A selection of speaking valves and caps.
Figure 5.29 A speaking cap should never be attached to a cuffed tube
when the cuff is fully inflated, as shown here, as the patient will suffocate.
Reproduced with permission of HEE eLfH.
130