Temporary tracheal airway patency and tube care

This blog post covers temporary tracheostomy placement, and transmyelohyoid oral tracheal intubation, as well as aftercare.

1 - Temporary tracheostomy

This is a link to a video I made on the procedure to place a temporary tracheostomy. Always take a lateral radiograph at the completion of the procedure to check where the tube lies in the trachea.

https://www.youtube.com/watch?v=68aENXAiDdI

This is the video that outlines how to make a temporary tracheostomy tube from a sterile endotracheal tube

https://www.youtube.com/watch?v=yeGVUkXNbvU

For sizing length from the cable tie to tip, the following guide can be used (courtesy of Hayley Strain of PetICU, Underwood)

ET SIZE Length

3.5 6-8cm

4,4.5 7-10cm

5,5.5 9-11cm

6 - 7.5 10-12cm

larger 10-14cm

Most British bulldogs need around 10cm of length to get adequate purchase in the trachea.

Care of a Temporary Tracheostomy Tube

Equipment to Keep at the Cage Side:

• Gloves

• Sterile tracheostomy tube (appropriate size)

• Suction machine (with dog urinary catheter, adapter, and suction tip)

• Cotton buds

• Swabs

• Sterile saline (NaCl 0.9%) for cleaning

• Water for injection (WFI)

• Nebuliser

• Adrenaline 1:1000 vials

• Sedation protocol (as directed by the anaesthesia team)

Emergency Trolley Equipment:

• ET tubes and replacement tracheostomy tubes

• Induction agent drawn up and ready

• Needle and syringe

• Cuff syringe for inflating cuff on temporary tracheostomy tube if needed

• Knit-fix tie replacement, for holding the tube in place around the neck

• Swabs

• Laryngoscope

• Oxygen supply

• NaCl flush

Tracheostomy ongoing care:

Glove Use: Always wear gloves when handling tracheostomy tubes.

Nebulisation: Nebulise the tracheostomy tube site with sterile water for injection for 10 minutes every hour (or as directed by the clinician) to humidify the airways.

Adrenaline (0.5ml of 1:1000 with 4.5ml WFI) may be added as per the anaesthetist’s or surgeon's instructions.

Cleaning the Tube: Moisten cotton buds with NaCl 0.9% and gently clean the inside of the tracheostomy tube. Take care not to obstruct the airway for too long, and remove any secretions.

Tracheostomy Site Care: Clean the skin around the tracheostomy site with sterile NaCl 0.9%, then gently dry. This should be done every 2 hours initially, and every 4-6 hours later, depending on the amount of secretions.

Wipe: Wipe the area around the tracheostomy with a diluted solution of chlorhexidine, then dry thoroughly.

Barrier Cream: Apply barrier cream around the tracheostomy site, if recommended by the clinician.

Continuous Monitoring: Continuously monitor the patient, as the tracheostomy tube can become obstructed or dislodged unexpectedly.

Emergency Tube Availability: Keep a sterile tracheostomy tube readily available in case of obstruction or dislodgement that requires immediate replacement.

Routine Tube Replacement: Replace the tracheostomy tube every 12-24 hours, or as directed by the clinician, in collaboration with the surgeon.

Securing the Tube: Ensure the tracheostomy tube is securely fastened behind the neck. The securing material should be changed if it becomes soiled.

Aseptic Technique: Maintain strict aseptic technique when replacing the tracheostomy tube.

Oxygen Support: Keep flow-by oxygen available at 5 L/min at all times.

Suctioning: Periodically suction the airways as needed to remove secretions, but only when there is clinical evidence of airway obstruction or some clinicians prefer every 4 hours. Prolonged suctioning can cause mucosal injury. A urinary catheter may be attached to the suction tube with a Christmas-tree adapter. Limit suctioning to 10-15 seconds to prevent hypoxia and use a clean catheter each time. Have an approximate idea from the radiographs, how far the carina/bifurcation is from the trachy entry and do not suction beyond this level (usually around 10-15cm). Suction on withdrawal.

Positioning: Ensure recumbent patients are positioned to allow unobstructed airflow through the tracheostomy tube. Protect the tube from blankets etc that can also obstruct.

Stomach: Ideally ensure there is no significant ileus or delayed gastric emptying, and consider the placement of a feeding tube to empty stomach as required.

Documentation: Record all observations and procedures on the hospital sheet.

Tips:

• Positioning Support: Pillows and blankets may be necessary to help patients with tracheostomy tubes rest comfortably, as they may be reluctant to lie flat. However, need to be particularly careful bedding does NOT obstruct the tube.

• Infection Monitoring: Watch for signs of infection, such as inflammation or purulent discharge, around the tracheostomy site.

• Tracheal Injury: Be alert for signs of emphysema, which could indicate a tracheal tear.

• Respiratory Monitoring: Continuously monitor for signs of respiratory distress or abnormal effort.

• Emergency Equipment: Ensure suction and oxygen are readily available near the patient at all times.

• In our experience, the use of an ET tube fashioned into a temporary tracheostomy tube has the advantage of being less prone to blockage, is longer (so better for thick necks), and is a better shape versus commercial tubes.

2 - Transmylohyoid Orotracheal Intubation:

Potential advantages

- Less risk of SQ emphysema

- Less secretions, and therefore less risk of blockage/infection

- Potentially lower risk of aspiration pneumonia

- Less tracheal damage to already damaged hypoplastic or collapsing tracheal

cartilage.

- Safer to place

Potential disadvantages

- Need to clean with flexible brush

- The larynx is held open in a fixed position, therefore could aspirate with

eating.

- Tube ends at a less secure height, therefore care needed to prevent

obstruction (food/water/blanket)

Surgical technique (attached paper), but summary below

- Patient is intubated

Technique (I'm in the process of creating a video)

- Incision made inside mandible. Clamp then used to pull reinforced ET tube

into mouth (grasping the cuffed end). Then once tube is into the oral cavity,

extubate patient and intubate with the spiral tube until cuff is caudal to larynx.

Do not inflate the cuff. Secure with finger trap suture.

- Aim for a slightly loose ET tube, potentially down 1 size from being ‘tight’. Not

too small or increases risk of obstruction

Equipment to Keep at the Cage Side:

• Gloves

• Sterile reenforced endotracheal tube (appropriate size)

• Suction machine (with dog urinary catheter, adapter, and suction tip)

• Cotton buds

• Swabs

• Sterile saline (NaCl 0.9%) for cleaning

• Water for injection (WFI)

• Nebuliser

• Adrenaline 1:1000 vials

• Sedation and anaesthetic protocol (as directed by the anaesthesia team)

• Brush (like a straw cleaner) to clean the tube

Emergency Trolley Equipment:

• ET tubes and replacement reenforced ET tube

• Induction agent drawn up and ready

• Needle and syringe

• Swabs

• Laryngoscope

• Oxygen supply

• NaCl flush

Oral Tube Care:

Fasting: Fast the patient while these tubes are in place. The larynx is open. For the same reason, there needs to be care with regurgitation and suction any regurgitated contents.

Nebulisation: Nebulise the tube with sterile water for injection for 10 minutes every hour (or as directed by the clinician) to humidify the airways.

Adrenaline (0.5ml of 1:1000 with 4.5ml WFI) may be added as per the anaesthetist’s or surgeon's instructions.

Suction and cleaning:

-Must suction the tube every 1 hour. Limit suctioning to 10-15 seconds to prevent hypoxia and use a clean catheter each time. Suction to the same distance as the end of the tube (use equivalent tube length to measure).

- Every 2 hours use a brush/straw cleaner to clean the tube. Flush with 1ml saline and aspirate quickly with suction prior to the brush. Take care not to obstruct the airway for too long!

- They are not replaced unless they clog, however if use the brush frequently they

won’t clog.

Continuous Monitoring: Continuously monitor the patient, as the tube can become obstructed or dislodged unexpectedly.

Emergency Tube Availability: Keep another ET tube readily available to intubate patient in emergency.

Oxygen Support: Keep flow-by oxygen available at 5 L/min at all times.

Positioning: Ensure recumbent patients are positioned to allow unobstructed airflow through the tube. Protect the tube from blankets etc that can also obstruct.

Stomach: Ideally ensure there is no significant ileus or delayed gastric emptying, and consider the placement of a feeding tube to empty stomach as required.

Documentation: Record all observations and procedures on the hospital sheet.

- At removal, must be ready to re-GA and put back in. The general recommendation is that if they are in for swelling, then leave for 48 hours, for suspected laryngospasm then 8 hours only.

- Sometimes you can hear the patient breathing next to the tube, and this is a possible

indication that can remove earlier

Tips:

• Positioning Support: Pillows and blankets may be necessary to help patients with tubes rest comfortably, as they may be reluctant to lie flat. However, need to be particularly careful bedding does NOT obstruct the tube.

• Respiratory Monitoring: Continuously monitor for signs of respiratory distress or abnormal effort.

• Emergency Equipment: Ensure suction and oxygen are readily available near the patient at all times.