Practices regarding the care of tracheostomy tube in the patients with long term tracheostomy

http://doi.org/10.33698/NRF0276-Nupur Chauhan, Meenakshi Agnihotri, Sukhpal Kaur, Naresh K Panda

ABSTRACT

Introduction: Tracheostomy is a common procedure for patients who require prolonged mechanical ventilation, but there is scacity of evidences regarding the practices for performing tracheostomy care amongst the patients with long term tracheostomy. Objective: To assess the practices regarding the care of tracheostomy tube in the patients with long term tracheostomy. Methods: A descriptive study was conducted in ENT, OPD PGIMER, Chandigarh. The Sampling technique was total enumeration. The study includes the participants visiting ENT, OPD PGIMER, Chandigarh during the months Aug-Sept 2018. Total hundred participants were enrolled as per the inclusion criteria. Participants were interviewed by using an interview schedule to know tracheostomy care practices. The tool was validated by experts in the eld of nursing and ENT Department. Each interview took 5- 10 minutes to complete. Most of the participants (84%) had difculty in communication so responses were collected by writing or by pointing. Results: One third (39%) of the participants were in the age group of 40-60years. Majority (82%) of the participants were male. More than half (58%) of the participants were doing stoma care once a day. Nearly half (42%) of the participants were using the antiseptic solution (dettol) for cleaning of stoma. In majority (96%) of the participants secretions were removed through suctioning and only 4% of participants use to cough to remove secretions. Three fourth (72%) of the participants were not using any solution for storage of tracheostomy tube. Majority (92%) of the participants were using a plastic container for storage of tracheostomy tube. Conclusion: The study found that few participants adapt correct practices whereas few adapt wrong practices regarding the care of tracheostomy tube.

Key Words: Tracheostomy care; Long term tracheostomy.

Correspondence address:

Ms. Meenakshi Aghnihotri Tutor

National Institute of Nursing Education PGIMER, Chandigarh

Introduction – A tracheostomy tube is an important aspect for the prevention and management of complications.2 There are two methods for performing tracheostomy i.e open surgical and percutaneous tracheostomy. The choice of technique depends on patient’s  condition  and a s s e s s m e n t . 3 T h e i n d i c a t i o n s o f articial airway inserted into the anterior wall of the trachea inferior to the cricoid cartilage.1  Tracheostomy care is one of the t racheostomy include mechanical obstruction of the upper airway, secretion obstruction, disease of central nervous system, neuromuscular disorder, acute or chronic disease, prophylactically (radical head and neck surgery)4.The indications for permanent tracheostomy include laryngeal paralysis or collapse, radiation therapy of the upper airways or oropharynx, laryngotracheal resections, laryngeal reconstruction, nasal neoplasia, or severe equipment, have been reported.13 Hence a need was felt to assess the practices of tracheostomy care among participants having long term tracheostomy.

Objective: To assess the practice regarding the care of tracheostomy tube in the patients with long term tracheostomy .

Material and methods : A descriptive respiratory disease.5 The most common study was conducted in ENT OPD, indications for tracheostomy was airway obstruction, secondary to trauma and PGIMER, Chandigarh. By using total enumeration Sampling technique, the study laryngeal tumor.6 In the majority of the included participants visiting ENT, OPD cases tracheostomy is done for a longer period of time. Both permanent and temporary tracheostomy is associated with many complications like tube blockage, excessive mucus production, stoma infection, polyp formation around the stoma, and hemorrhage.6-7 Patient requires care for  the  prevention  of  tracheostomy r e l a t e d c o m p l i c a t i o n . R o u t i n e tracheostomy care includes suction, care of inner cannula, stoma site care, and stoma care with changing of the dressing and tie.8

Usually the patients are discharged from the hospital along with tracheostomy tube in situ. It is essential that all the caregivers should have comprehensive and thorough training in the proper care of the patient with tracheostomy. Little evidence exists to the best practices for performing tracheostomy care to maintain the airway and promote skin integrity. Few studies have assessed the tracheostomy care PGIMER, Chandigarh during the month of Aug-Sept 2018. Total hundred participants were enrolled as per the inclusion criteria i.e the participants having tracheostomy tube for more than 3 months. Exclusion criteria was patients with mental illness. Ethical clearance was obtained from Institute Ethics Committee. Permission was obtained from the  Head,  Department  of E N T, P G I M E R C h a n d i g a r h . T h e participants were informed about the purpose of the study and written informed consent was taken. The method of data collection was interview. To know Tracheostomy care practices amongst participants they were interviewed by using an interview schedule which was validated by experts in the eld of nursing and ENT Department. The tool consisted of two parts a ) s o c i o d e m o g r a p h i c p r o  l e b ) Tracheostomy care practices. The tracheostomy care practices comprised of practices of caregivers. 9 – 1 2 Limited nine items i.e frequency of stoma care, evidences are available related to tracheostomy care practices amongst the patients and their caregivers. Tracheostomy care using a number of techniques and technique used for stoma care, solution used for stoma care, frequency of suctioning, frequency of change of tracheostomy tube, removal of secretions through suctioning/coughing, solution and place for storage of tracheostomy tube. Each interview took around 20-25 minutes to complete. Most of the participants (84%) had difculty in communication so the participants/caregivers were taught about tracheostomy care in emergency unit and only 8% in the ENT ward.

Table 2: Information about the care of

Variables	f(%)
No. of patients taught about tracheostomy care   Teaching regarding the tracheostomy tube care by Doctors Nurses Place where the teaching about tracheostomy care was provided to the patients/caregivers ENT Ward ENT OPD ICU Emergency unit	94     79 15     08 25 18 43

 

responses were collected by writing or by pointing.

Results : Socio-demographic profile of the participants: One third (39%) of the participants were in the age group of 40-60 yrs. Majority (82%) were male. Three fourth (75%) were Hindu by religion. More than one third (40%) of the participants had education up to primary level.

Table 1: Socio-demographic profile of the participants

the tracheostomy tube

Socio-demographic profile	f(%)
Age (in years )
<20	4
20-40	26
40-60	39
˃ 60	31
Sex
Male	82
Female	18
Religion
Hindu	75
Sikh	19
Muslim	6
Education
Illiterate	23
Primary school	40
Middle school	25
High school and Intermediate	5

 

Information about the care of the tracheostomy tube

Table 2 depicts information about the care of the tracheostomy tube. Majority (94%) of the participants were taught about tracheostomy tube care of which 79% were taught by doctors. Less than half (43%) of

P r a c t i c e s r e g a r d i n g c a r e o f tracheostomy tube

Table 3 depicts the practices regarding care of tracheostomy tube. More than half (58%) of the participants were doing stoma care once a day. Almost half (42%) of the participants were using some antiseptic solution (dettol and savlon) for the care of stoma. In majority of the cases (96%) secretions removed through suctioning and only 4% use to cough to remove secretions. For one-third (31%) of the participants suctioning was done twice a day whereas 30% of the participants suctioning was done once a day. Majority (83%) of the participants’ tracheostomy tube was changed by doctors. For One fourth (24%) of the participants’ tracheostomy tube was changed after every 3 days. Three fourth (72%) of the participants were not using any solution for storage of tracheostomy tube. Majority (92%) of the participants were using a plastic container for storage of tracheostomy tube.

Table 3: Practices regarding care of tracheostomy tube

N =%/100

 

Practices

f (%)

Frequency of stoma care No care Once/day Twice/day Thrice/day Four times/day Technique used for stoma care N=94 Clean Sterile Solution used for stoma care N=94 Antiseptic solution * Plain water Removal of secretions through Suction coughing Frequency of suctioning Once/day Twice/day ˃ Three times a days Change of tracheostomy tube by Doctor Self Frequency of change of TT 1-5days 6-10 days ˃10days Solution for storage of TT Antiseptic solution Plain water No solution Storage of tracheostomy tube Plastic container Any other**

06 58 19 11 06 91 03 42 52 96 04 30 31 36 83 17 83 10 07 26 02 72 92 08

*Antiseptic solution: Dettol, betadine, savlon

**Any other: plastic packet, gauze piece, small cloth, tissue paper

Discussion

Tracheostomy is a common procedure for patients who require prolonged mechanical ventilation. There are very few evidences for best practices of performing tracheostomy care to maintain the airway and promote skin integrity. After tracheostomy, the patients may face many complications and problems. So, to reduce the chances of complications it is important to provide best care and to assess their practices of care for tracheostomy tube at home. Patient were interviewed because they were having low literacy level and were not able to ll questionnaire.

Usually the patients are discharged from the hospital along with tracheostomy tube (TT) in situ. It is essential that all the caregivers should have comprehensive and thorough training regarding proper care of the patients with tracheostomy. A study was conducted to develop the skills regarding TT suction with a foot-operated suction machine among the caregivers of the patients who were going to be discharged with tracheostomy tube in situ.14 Nagi et al recommends that the caregivers should be properly trained regarding changing the TT in order to prevent any complication while performing the procedure. The caregivers need to learn the technique of change of TT at home.15 In the present study majority of the tracheostomy care was performed by the patient’s caregivers at home. Majority of the participants (94%) were taught about the tracheostomy care and nearly 80% were taught by the doctors.

Currently, no empirical evidence indicates a standardized time for changing a tracheostomy tube. White et al suggest that indications for changing a tracheostomy tube include the need for a different size tube, tube malfunction, need for a different type of tube, and routine changes for ongoing a i rway management and prevention of infection. They suggest that a tracheostomy tube should be changed every 7 to 14 days after initial insertion, but they acknowledge that no evidence supports that recommendation. 1 6 . Mitchell et al r e c o m m e n d r e p l a c i n g t h e i n i t i a l tracheostomy tube within 10 to 14 days after placement of a percutaneous procedure was used to establish the tracheostomy and within 3 to 7 days if a surgical procedure was used.17 Yaremchuk found that routine tube changes in every 2 weeks decreased the formation of granulation tissue.12 In the present study, for 83% of the participants tube was changed within 1-5 days, for 10% of the participants tube was changed within 06-10 days and for 7% of the participants tube was changed after more than 10 days.

In literature it was suggested that suctioning should be undertaken only when excessive secretions are present.18-19 In the present study, for 31% of the participants suctioning was done twice a day and for 30% of the participants suctioning was done once a day whereas 36% of the participants required suctioning more than 3 times a day as per the need of the participants.

Tracheostomy tubes can be of either metalic or plastic material. Metal tubes are not used commonly because of their high cost, their rigid construction, lack of a cuff plastic tracheostomy tubes should be cleaned with a solution of full- or half- strength hydrogen peroxide and sterile water21-22 but some other study recommend only saline alone for cleaning purpose.23 Silicone tubes and metal tubes got damaged by using hydrogen peroxide. These tubes should be cleaned by soaking in warm water with mild dishwashing liquid to soften secretions and then a tracheal brush should be used to clean it.24 In the present study three fourth (72%) of the participants were not using any solution for cleaning of tracheostomy tube, 26% of the participants were using dettol and savlon and only 2% were using plain water. Antiseptic solution should not be use for cleaning of tube because during insertion of tube the solution may cause irritation around the skin of stoma.

The literature suggests that stoma should be cleaned every 4 to 8 hours. The skin should be inspected for any irritation or infection, such as erythema, pain, or dried secretions etc. Erythema often occurs because of the continued presence of moisture at the skin. Patients with copious secretions often require frequent dressing changes to keep the skin dry and prevent maceration of tissue and skin breakdown.23 Dried secretions can be loosened with diluted hydrogen peroxide and then rinsed and lack of a connector (15 mm) to attach away with saline.25 In the present study, with ventilator. Plastic tubes are commonly used because they are exible and easily inserted.20 In the present study, only plastic tracheostomy tubes were used by the participants.

In literature it was suggested that more than half (58%) of the participants were doing stoma care once a day and around half (42%) of the participants using the antiseptic solution (dettol and savlon) for the cleaning of stoma. Antiseptic solution (dettol and savlon) should not be use for cleaning of stoma because it may cause irritation around the skin of stoma.

Carpen et al suggested that the spare tracheostomy tube should be store in close for the discharge home of the child on long term assisted ventilation in the United Kingdom.UK Working Party jar for next use.26 In the present study, on pediatric long term ventilation. majority of the participants (94%) were using a  plastic  container  for  storage  of  t racheostomy tube and 8 % of the participants uses plastic packet, gauze piece, small cloth and tissue paper for storage of tracheostomy tube.

It was concluded that most of the participants performed right practices for care of tracheostomy tube. These practices include cleaning of stoma, suctioning, changing of tracheostomy tube and storage of tracheostomy tube. Some of the participants performed wrong practices for care of tracheostomy tube which included use of antiseptic solution for cleaning of stoma, changing of tracheostomy tube after 10 or 15 days, using no solution and no container for the storage of tracheostomy tube. Hence, this is recommended that nurses and doctors should properly assess the tracheostomy care practices and teach the right practices to the patients and caregiver at the time of discharge from the health care settings.

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