Insertion of (RPA) - Intensive Care & Coordination Monitoring Unit

INTENSIVE CARE SERVICE 

NURSING POLICY & PROCEDURES 

NAME OF POLICY: TRACHEOSTOMY MANAGEMENT: 

Assist with Insertion 

GOAL: TO SAFELY CHANGE A TRACHEOSTOMY TUBE AND 

PROVIDE PATENCY OF CARE WHILE INSITU 

Introduction: 

A tracheostomy may be performed as a surgical procedure under general anaesthetic in the 

operating theatre or as a percutaneous procedure within the intensive care setting. 

A tracheostomy tube provides the best route for long-term airway maintenance and avoids the 

oral, nasal, pharyngeal and laryngeal complications of endotracheal intubation. 

The tube is shorter thus the resistance to airflow is less, and breathing is easier. This may 

facilitate ventilator weaning. Other advantages are increased patient acceptance and comfort, 

reduction in sedation and the possibility of the patient being able to eat and talk. Tracheostomy is 

usually considered if artificial airway is required longer than 10-14 days. Other indications are: 

� Upper airway obstruction or malformation 

� Repeated intubations, presence of complications of endotracheal intubation, glottic 

incompetence, sleep apnoea and chronic inability to clear secretions 

Equipment for insertion of percutaneous tracheostomy 

� Consent and information provided to patient and significant others if applicable 

� Sterile dressing pack, gown/gloves/trolley 

� Disposable dressing pack 

� Percutaneous tracheostomy “Rhinodilator” set 

� Tracheostomy of appropriate size (fenestrated/unfenestrated) 

� Sterile water 

� 1% Lignocaine with adrenaline 

� KY jelly 

� Tracheal dilators (remain at bedside) 

� Syringe 

� Stethoscope 

� Inline tracheostomy suction catheter (appropriate size) 

Pre-Procedure: 

� Check Coagulation and platelet profile 

� Check tracheostomy tube is patent, inflate the cuff and submerge under water, check for 

leaks, deflate and cover with KY jelly (usually done by Medical Officer) 

� Ensure C02 monitoring is insitu (See End Tidal CO2 protocol) 

� Ensure all emergency equipment is ready and in working order 

� Ensure patient is monitored 

� Ensure adequate sedation as ordered 

� Position patient appropriately usually after sedation ( See picture below) 

� Pre-oxygenate with 100% for 3-5 minutes 

© ROYAL PRINCE ALFRED HOSPITAL INTENSIVE CARE SERVICE

Patient’s position for insertion of tracheotomy Anatomy of the neck 

Procedure 

Assist with the procedure but always remain vigilant regarding the patient’s vitals 

� Prepare to inflate cuff when asked (check pressure post insertion) 

� Observe rise and fall of chest 

� Auscultate chest for air entry 

� Secure tracheostomy appropriately with tapes or soft collar 

� Connect patient to ventilator with appropriate mode and alarm settings. 

� Suction as required 

Post-Procedure 

� Xray to confirm placement 

� ABG approximately 30minutes (not always necessary) 

� Ensure key-hole dressing is applied 

� Re-position patient to semi-fowlers 

� Check cuff pressure (18-22mmHg) 

� Ensure tracheostomy of the same size and one smaller with tracheal dilators are at the 

bedside in the event of an emergency 

� Observe for early sign of: 

� Hemorrhage 

� Wound infection 

� Pneumothorax 

� Pneumomediastinum 

If a surgical tracheostomy is performed leave the dressing intact for 24hrs to prevent potential 

bleeding and displacement. A surgical tracheostomy is usually indicated when: 

� Anatomical landmarks are unidentifiable and/or grossly abnormal 

� Difficult Intubation 


Change of tracheostomy 

When a tube is changed, the patient’s artificial airway is temporarily removed. This should be a 

planned procedure, carried out by two competent staff. The procedure can be potentially 

traumatic for the patient, who should be prepared for it. 

A skilled practitioner should perform the first change on day 7. This is because the stoma and 

track to the skin form the patient’s trachea may not be well formed. In addition, if the 

tracheostomy has been performed percutaneously the stoma is likely to be tight. Two 

experienced RN’s may undertake this in conjunction with the Senior Registrar being within 

close proximity for prompt airway intervention if required. 

Equipment 

� Ensure all emergency equipment is working and ready 

� Dressing pack/trolley 

� Suitable size tracheostomy (see types of tubes below) 

� Sterile water 

� 20ml syringe 

� Sterile gloves 

� Keyhole dressing 

� Closed suction catheter (appropriate diameter) or single use “Y” catheters 

� KY jelly 

� “Guide wire” kit if available 

Procedure 

� Inform patient and significant others if applicable 

� Ensure enteral feeds are ceased 6hrs prior to procedure and aspirate NG tube 

� Position patient approximately 30 degree, head moderately extended 

� May enlist physiotherapy treatment prior to procedure but allow at least 20 minutes 

thereafter to prevent potential respiratory embarrassment. 

Prepare tracheostomy tube 

� Inflate cuff and submerge in sterile water to check for leaks, deflate cuff 

� Lubricate cuff with KY jelly (use of obturator is operators preference) 

Prepare Patient 

� Repeat and inform the patient of the procedure 

� Suction lower airway once 

� Perform cuff release on second suction. Briefly deflate and then reinflate cuff as 

requested. 

Removal & Insertion of tracheostomy 

� Remove old tracheostomy dressing 

� Pre-oxygenate with 100% for 3-5 minutes 


Method 1 

� Deflate old tracheostomy and remove the tube 

� Rapidly insert new tube angled at 90 degrees to the trachea, rotate to a downward 

position. (may feel some resistance, especially if it is a percutaneous stoma) 

� Inflate the cuff (18-22mmHg) 

� Remove obturator and insert inner unfenestrated cannula 

� Attach to ventilator, check mode and alarm parameters 

� Auscultate chest for air entry and observe chest movement 

� Secure tracheostomy and dress appropriately 

� Follow up chest Xray if applicable 

Method 2 (obturator not required) 

� A single Y-suction catheter is required for this method or a guidewire kit if available 

� After suctioning leave the “Y” suction catheter in situ and cut off the end as this will keep 

the pathway (a guidewire is used in the same way) 

� Deflate cuff and remove old tracheostomy over the catheter or guidewire 

� Guide the new tracheostomy tube over the catheter or guidewire until correct position is 

attained, remove catheter or guidewire and inflate the cuff 

� Follow all other procedures as for Method 1 

Blueline Ultra fenestrated tube with obturator and guidewire insitu 


Care of the Tracheostomy 

� Monitor cuff pressure every 8hrs, maintain between 18-22mmHg, greater pressure may 

decrease blood flow to capillaries in the tracheal wall. Lesser pressure increases the risk of 

aspiration. 

� Suction with “tracheostomy” closed suction system insitu PRN 

� When performing suctioning with a fenestrated tracheostomy ensure the unfenestrated 

inner cannular is insitu prior to suctioning, if balloon is down, reinflate. 

� Humidification is required as the tracheostomy tube by passes the natural humidifying 

passages. When changing to a humidified circuit the ventilator tubing requires checking 

for air leaks. 

� When using “Swedish nose” the inner coil acts as the humidifier (change regularly) 

� Change stoma dressing and tapes ensuring integrity of skin remains intact. Use sterile 

water to clean stoma area. Observe for signs of complications mentioned above. 

� To prevent undue weight and movement of the ventilator tubing, support as necessary 

� Inner cannular should be changed every shift and PRN, soak in sodium chloride 

solution 

TYPES OF TRACHEOSTOMIES 

“Portex Blue Line Ultra” A thermosensitive tube moulds to the patient’s trachea and it has a 

soft seal cuff to minimise patient trauma. It comes cuffed and uncuffed with or without 

fenestration. The sizes are 6-10mm. Corks and speaking valves plus separate fenestrated and 

unfenestrated inner cannula are available. These tubes can be left insitu up to 3 months. 

Fenestrated tracheostomy tube has one large or several small elliptical holes located on its 

outer curve. These tubes are often used to wean patients from mechanical ventilation. An 

unfenestrated inner cannula must be insitu, when the patient is being mechanically 

ventilated. This closes off the fenestrae so the tube serves as a regular tracheostomy tube. 

Ensure the cuff is inflated. 

Blueline Ultra unfenestrated tube with cuff Blueline Ultra fenestrated tube with 

and inner unfenestrated cannular cuff, obturator insitu 

When weaning from a tracheostomy the patient should be spontansouly breathing through the 

tracheotomy. The inner cannula is changed to a fenestrated cannula with the cuff remaining 

inflated, to prevent aspiration. The patient will be able to spontaneously breath through the 

fenestrae. The cuff may be deflated as ordered by the Intensivist, allowing the patient to 

spontaneously breath around the tube. A Swedish nose provides oxygen and humidification. 


Separate inner fenestrated cannular 

Corking or plugging the tube lets the patient directly exhale air through the upper trachea and 

past the vocal cords of the larynx; the cuff must be deflated for phonation to take place. If the 

tube is plugged while the cuff is inflated or the inner cannula is in place, the patient won’t be 

able to breathe except through the fenestrae, which can result in respiratory distress 

“Shiley” tracheostomies are a low pressure cuffed with fenestration. They are available in four 

sizes 4,6,8 &10. They are not equivalent to Portex size. 

The Shiley contains the obturator to facilitate insertion and two translucent inner cannulas 

with twist-lock connectors, one fenestrated to assist with weaning and phonation; the other 

unfenestrated (inner cannula to the hard outer fenestrated tube) provides for mechanical 

ventilation; when this tube is insitu it should never be corked. The Shiley outer tube may stay in 

situ for up to 3 months. The Shiley swivel neck allows conformity to individual neck anatomies. 

The “red” cork and “green” twist-lock cannular are not pictured below. 


“Portex Tracheostomy with adjustable flange” These are specifically designed for patients 

who have deep set tracheas, such as those that are obese or have distorted anatomy within the 

neck due to inflammation and oedema. The adjustable flange means that the tracheostomy tube 

can be manipulated to the desired length. Used inplace of the Rusch tracheostomy tube 

“Portex Minitrach” Is used for the prevention of sputum retention. This tube is very small in 

diameter and is performed through the cricothyroidectomy membrane. 

“Quicktrach” Is usually used in an emergency situation where an emergency cricothyrotomy is 

required for life threatening airway obstruction and the delivery of oxygen. The “quicktrach” 

pack contains a metal tipped needle and syringe for immediate cannulation of the cricothyroid 

membrane. Not suitable for patients who require long term ventilation 

REFERENCES: 

Quintel, M. & Roth, H. (1999). Tracheostomy in the critically ill: clinical impact of new procedures. 

Intensive Care Medicine. 25:326-328. 

Thelan, L. A. et al (1998) Critical Care Nursing: Diagnosis and Management. Mosby St Louis 

Occupational Health and Safety: Universal precautions taken in the preparation, administration of drug and 

disposal of equipment and sharps. 

Cross Referenced: RPAH Occ. Health & Safety Manual and Infection Control Manual 

NSW Infection Control Policy 98/99 

Revised by: Frankie Hopkins (ACNC) and Suzy Dimovski (CNS) February 2002 

Authorised and assisted by: Dr. Clive Woolfe February 2002 

Revision February 2004

Insertion of (RPA) - Intensive Care & Coordination Monitoring Unit

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