Due to the current COVID-19 pandemic, the number of patients requiring intensive care stay, and therefore the frequency of tracheostomy insertions, is on the rise. These patients are likely to arrive on COVID-19 wards for weaning, and teams on the wards might not be familiar with caring for a patient with a tracheostomy.

The All-Wales TRACHES checklist (linked below) provides a simple, step-by-step guide to safely care for a patient with a tracheostomy:

Tapes and dressings

• The tapes secure the tracheostomy in place and prevent it becoming dislodged.
• The dressing protects the skin around the tracheostomy and prevent it becoming irritated or macerated.
• The tapes and dressings should be changed once a day in hospital or as required (becomes soiled or dislodged).
• Ensure the tapes are not too loose or too tight; you should be able to pass two fingers between the tapes and the patient’s neck.

Red flags

• Red flags are the often-detectable warning signs that occur before an emergency.
• Common red flags include increased frequency to change inner tube, increased need to re-inflate the cuff, and ability to vocalise when the cuff is supposed to be inflated.
• Knowing what to look out for will allow early trouble shooting and stop minor problems escalating.

Assessment of the inner tube

• The inner tube is a safety feature that sits inside the outer tube of the tracheostomy, and reduces the potential for blockage of the tracheostomy tube.
• The inner tube can be easily removed and cleaned, while the outer tube remains in place to keep the airway open.
• The inner tube must be present at all times; it may not be possible to provide resuscitation to the patient if the inner tube is absent.
• The inner tube should be checked every two hours and cleaned as required.

Cuff pressure

• The tracheostomy cuff (when present) provides a seal to enable mechanical ventilation.
• It also provides some protection against aspiration of secretions from the upper airway.
• The pressure within the cuff should be checked once a shift or as required with a hand-held pressure manometer and should be maintained between 20 – 25cmH₂O.

Humidification and oxygen therapy

• A tracheostomy bypasses the normal upper airway mechanisms for humidification, filtration and warming of inspired gases.
• Without supplementary humidification, secretions in the airways get thick and sticky, and may block the tracheostomy tube or cause infection.
• There are various methods to provide supplementary humidification, and these can be tailored to the patient’s needs.

Emergency management

• There are several scenarios that can lead to a tracheostomy emergency. The most common are a dislodged or displaced tracheostomy, a blocked tracheostomy tube, and a bleeding tracheostomy site.
• During a tracheostomy emergency, the Tracheostomy emergency algorithm should be followed (linked below). Each step of the emergency tracheostomy algorithm is to assess and achieve patient stability until expert airway help arrives.

Suction

• Assess the need for suction at least 2 hourly. Suction should not be performed routinely, but only when the patient requires it.
• The frequency of suction varies widely between patients. Providing suction uses an aseptic non-touch technique and the suction pressure ideally less than 20cmH₂O.
• Suction may need to be applied to two sites: the lumen of the tracheostomy tube where secretions may gather in the trachea, and above the cuff of a tracheostomy tube where secretions may build up from the upper airway.

Please note, the demonstrations of each step in the video below were filmed before the COVID-19 pandemic, and therefore the PPE worn by the healthcare team is not appropriate for the management of a patient on a COVID-19 ward with a tracheostomy. Please review up-to-date guidance on PPE in COVID-19.

For more information about managing a patient with a tracheostomy, as well as a whole series of videos on each of the seven steps, locate the ‘All-Wales TRACHES Checklist – Education package‘ below.

Get Wales TRACHES ready