The Importance of Tracheostomy Progression in the Intensive Care Unit

Abstract

T racheostomy is now considered a common procedure, 1 and so it is important for nurses to become knowledgeable about tracheostomy progression, beginning immediately postoperatively and continuing through long-term care. Most tracheostomies placed in patients in intensive care units (ICUs) are done in order to facilitate weaning from mechanical ventilation. After the patient has been liberated from mechanical ventilation and the need for the tracheostomy is resolved, there should be a plan to progress toward decannulation. Daily evaluation of the progress toward decannulation can reduce length of stay, infection rates, and overall health care costs. [2][3][4][5] In this article, we review a systematic method for tracheostomy progression and describe how critical care nurses can facilitate this process. FeatureA plan to progress a tracheostomy toward decannulation should be initiated unless the tracheostomy has been placed for irreversible conditions. In most cases, tracheostomy progression can begin once a patient is free from ventilator dependence. Progression often begins with cuff deflation, which frequently results in the patient's ability to phonate. A systematic approach to tracheostomy progression involves assessing (1) hemodynamic stability, (2) whether the patient has been free from ventilator support for at least 24 hours, (3) swallowing, cough strength, and aspiration risk, (4) management of secretions, and (5) toleration of cuff deflation, followed by (6) changing to a cuffless tube, (7) capping trials, (8) functional decannulation trials, (9) measuring cough strength, and (10) decannulation. Critical care nurses can facilitate the process and avoid unnecessary delays and complications. (Critical Care Nurse. 2014;34[1]:40-50) This article has been designated for CNE credit. A closed-book, multiple-choice examination follows this article, which tests your knowledge of the following objectives:1. Discuss a systematic method for tracheostomy progression 2. Describe how critical care nurses can facilitate the process of decannulation 3. List outcomes achieved with a standardized clinical practice guideline for tracheostomy patients

Restoring Speech to Tracheostomy Patients

“…12,13 If respiratory distress, dyspnea, or shortness of breath occurs with cuff defl ation, the cuff should be reinfl ated, and cuff defl ation trials can be repeated at another time. Working side by side with speech language pathologists and respiratory therapists can ensure patients' comfort, tolerability of cuff defl ation trials, and quality outcomes.…”

“…With 2 exceptions, cuffed tracheostomy tubes with defl ated cuffs should never be capped. 8,13 The bulk of the defl ated cuff on most tracheostomy tubes creates a great deal of resistance around the tube, potentially interfering with optimal ventilation. The only cuffed tracheostomy tubes that can be safely capped when defl ated are a properly fi t fenestrated tube or a tight-to-shaft (TTS) tracheostomy tube ( Figure 3).…”

“…With the TTS tube, the defl ated cuff fl attens completely against the shaft of the tube and mimics a cuffl ess tracheostomy tube. 8,13 The safety implications of both types of tubes are discussed later in this article.…”

“…Because the patient is breathing around the tube when it is capped, oxygen should be provided as needed by nasal cannula or face mask. 8,13 These potential complications reinforce the need to adequately assess a patient's cognitive status in order for the nurse to detect respiratory distress quickly.…”

“…Patients can be evaluated for use of a smaller tube or decannulation when they can tolerate continuous capping for at least 24 to 48 hours and achieve an acceptable cough strength so that they are able to cough out all their secretions. 8,13 Alternative Methods of Phonation. Two other methods of phonation in spontaneously breathing patients may be used by long-term tracheostomy patients in subacute care, home, or rehabilitation settings: the tracheostomy button and the Speak EZ tracheal cannula.…”