Tracheostomy Humidification

The nose and mouth provide warmth, moisture and filtration for the air we breathe. Having a tracheostomy tube, however, by-passes these mechanisms so humidification must be provided to keep secretions thin and to avoid mucus plugs. To keep the environment at an optimal humidity level, follow the procedures below.

Equipment

• Air compressor
• Nebulizer bottle
• Aerosol tubing
• Trach mask
• Sterile water
• Saline ampules (“bullets”)
• Heat Moisture Exchanger (HME) Also known by several other terms including: Thermal Humidifying Filters, Swedish nose, Artificial nose, Filter, Thermovent T.
• Room/home humidifiers

Attach a mist collar (trach mask) with aerosol tubing over the trach with the other end of tubing attached to the nebulizer bottle and air compressor. Sterile water goes into the nebulizer bottle (do not overfill, note line guide). Oxygen can also be delivered via the mist collar if needed.

Heated mist may be ordered. Heated mist is accomplished by an electric heating rod that fits into the nebulizer bottle. Extra care should be taken to be sure the bottle does not go dry, which could melt plastic. Many of these heating elements do not have automatic shut-offs and this could be a potential fire hazard. Also, more moisture will accumulate in the aerosol tubing with heated mist. Moisture that accumulates in the aerosol tubing must be removed frequently to prevent occlusion (blocking) of the tube and/or accidental aspiration (inhalation). Disconnect tubing at the trach end, empty into a container and discard. Do not drain fluid into the humidifying unit. Fluid traps (or drainage bags) are helpful in preventing occlusion and aspiration. These collection devices also need to be emptied frequently. Position the air compressor and tubing lower than the patient to help prevent aspiration from moisture in the tubing. A mist collar can also be worn during the day when mucus is thick or blood tinged. Sterile saline drops can be instilled into the trach tube if secretions become thick and difficult to suction. A saline nebulizer treatment is also helpful to loosen secretions if the patient has a nebulizer machine. Additional fluid intake also helps to keep secretions thinner.

Secretions can be kept thin during the day by applying a Heat Moisture Exchanger (HME) to the trach tube. An HME is a humidifying filter that fits onto the end of the trach tube and comes in several shapes and sizes (all styles fit over the standard trach tube opening). There are also HME’s available for portable ventilators. Bedside ventilators have built-in humidifiers. HME’s also help prevent small particles from entering the trach tube. Change HME daily and as needed if soiled or wet.

Source - http://www.hopkinsmedicine.org/tracheostomy

Tracheostomy Equipment

Tracheostomy Supplies

Tracheostomy tubes of the appropriate type and size
Tracheostomy tube (one size smaller)
Trach tube ties or velcro strap
Dressing supplies, gauze
Hydrogen peroxide, sterile water, normal saline
Water soluble lubricant such as Surgilube or KY Jelly
Blunt-end bandage scissors
Tweezers or hemostats
Sterile Q-tips
Trach care kits and/or pipe cleaners (double-cannula trach tubes)
Luer lock syringes for cuffed trach tubes

Suction Equipment

Portable battery-powered suction machine
Suction connecting tubing
Suction catheters
Normal saline solution
Sterile jars with screw tops (sterile specimen containers or sterilized baby food jars work well)
Saline ampules (“bullets“)
Bulb syringe
DeLee suction trap or syringe with catheter
Hand-powered Suction Devices  A simple yet efficient suction unit for first responders, and a reliable backup for emergency healthcare providers.
YanKauer Suction Handle
Sims Connector

Humidification System

Air compressor
Nebulizer bottles
Tracheostomy mask
Aerosol tubing
Water trapHeatMoisture Exchanger  (HME) (If you don't have an HME, use a room humidifier)
Room humidifier
Sterile water
Mist heater (if ordered)
Croup or mist tent (rarely ordered today)
Vapotherm

Other Supplies That You May or May Not Need

Hand washing supplies
Cleaning supplies
Mucus traps for sputum specimens
Sterile or clean paper cups
Tissues
Manual resuscitation (Ambu) bag with mask and trach adapter
Intercom, baby monitor or video monitor
Thermometer
Stethoscope
Disposable Gloves (powder free)
Trach scarf or bib
Rolled-up towel
Other Possible Equipment Needs
Speaking valves
Trach guard
Cardiac/Apnea monitor
CO2 monitor
Pulse oximeter
Oxygen
Oxygen Concentrator
Oxygen Supply tubing
Ventilator
BiPAP
Nebulizer Equipment (Aerosolized medication delivery system)
Dura-neb Portable Compressor/Nebulizer
DeVilbiss® Pulmo-Aide® Compact Compressor/Nebulizer
AeroTrach Plus™
Pressure manometer to check trach cuff pressure on cuffed tubes
Extra smoke detectors and a fire extinguisher suitable for electric as well as regular fires.
Consider an emergency generator if you have frequent power failures.

Decannulation of Tracheostomy

Definition:
The process whereby a tracheostomy tube is removed once patient no longer needs it.

Indication:
When the initial indication for a tracheostomy no longer exists.

Requirements:

A patient is considered a candidate for decannulation once the following conditions are met.

1.     Patient is alert and oriented and responsive to commands.

2.     Patient is no longer dependent on a ventilator for assisted breathing.

3.     The frequency requirement for tracheal suctioning is less than once a day. (This is not always the case. Check with your physician)

4.     Patient has met the criteria for decannulation outlined below.

Criteria for decannulation

1.     Patient should not be dependent on a ventilator.

2.     Patient’s mental status should be to the level of alert and responsive and should be able to manage their oral secretions without a risk of aspiration.

3.     Should not require frequent suctioning for tracheal secretions.

4.     Patient should be able to cough and clean his/ her tracheal secretions.

5.     The patient should have their tracheostomy tube downsized to a size 4 Shiley or similar tracheostomy tube and they should not have breathing difficulty in the presence of this tube.

6.     The size 4 Shiley or similar tube should be occluded (with a trach plug/ cork) for twelve hours during the day with close monitoring by the nursing staff  with no evidence of respiratory difficulty or requiring of suctioning of the trach tube.

7.     Once the patient is seen to tolerate the steps in item # 6 above, their trach is plugged for twenty four hours and they are monitored for respiratory difficulty or suction requirement.

Decannulation:

Once all of the above criteria are met, the patient is informed that their trach tube is going to be removed. They are instructed that they may experience a sensation of shortness of breath for a few minutes once they are decannulated.

Arrangements should be made for back-up personnel (RT or RN) to be available in case of emergency. Decannulation is usually not done at home.

The patient is placed supine (flat) on their bed, the tube is removed and the opening into the neck is covered with sterile gauze and a tape is placed over the gauze.

The patient is instructed to occlude the gauze with their finger tip every time they cough or speak so that air does not leak. They should change the gauze and the tape at least once a day (more often as needed) until the hole in the neck heals itself closed over the next few days to weeks. In a minority of patients (<10 %), the opening into the neck skin has to be surgically closed.

Making sterile salt water (saline) for home suctioning/use

Making sterile salt water (saline) for home suctioning/use

Start with clean hands, pans, containers and spoon

1.     Put saline storage jar and lid in one pan and cover with tap water.

2.     Put 4 ¼ cups of tap water in a second pan.

3.     Boil both pans for ten minutes.

4.     Add two level teaspoons of table salt to plain boiled tap water and stir to dissolve.  Cool both pans to room temperature.

5.     Remove storage jar and lid touching only the outside.

6.     Pour cooled salt water directly into storage jar.  Place lid tightly on jar.  Store in refrigerator.

7.     Pour off the amount needed for each cleaning or suctioning session into a smaller container.  Do not dip anything into the large supply of saline.

8.     Make a new batch every day.