Placement

1. Head and Neck Surgery (HNS) performs tracheostomy on patients with H & N pathology, all pediatric patients, and morbidly obese patients with thick necks where special long tube may be required.
2. General surgery performs the "routine trach's" in adult patients (in appropriate circumstances, qualified intensivists may place percutaneous trach's in the ICU setting if they are privileged to do so by the medical center).
3. The initial decision to request a trach on medical patients will be made by the attending physician, intensivist, or pulmonary consultant.
4. The patient will be pre-op'ed (CBC, coagulation parameters checked; blood type and screened; NPO after midnight; procedure discussed with the patient and family) by the attending physician.
5. The SOD will be contacted in the morning that the trach is required. HNS will be consulted in the special circumstances listed above.
6. The SOD will review the case as necessary and obtain formal consent from the patient and family.
7. Tracheostomy will be performed on that day whenever operating schedule permits.
8. A Shiley #8 cuffed trach tube with disposable inner cannula (blue box) will be placed in most patients. If a smaller trach tube is placed, higher cuff pressure is needed to obtain an adequate seal and it is not possible to perform a bronchoscopy through the tube. Fenestrated tubes are not recommended, particularly as the initial trach tube.

Post-Op Care

1. After a tracheostomy, the patient will be managed in the ICU or DOU for the first 24 hours.
2. A spare Shiley #8 cuffed trach tube will be kept at the patient's bedside at all times.
3. If the tube becomes dislodged (unable to ventilate through the trach or prominent subcutaneous air seen):
   a. And the patient has RESPIRATORY DISTRESS, the following should be paged STAT.:
   - anesthesiologist should be paged STAT by contacting the OR duty desk (x4305)
   - CRNA (beeper 9758) should be paged
   - patient's primary hospital physician (or the physician covering, i.e. the medical consult or SOD).
   - The anesthesiologist and/or the critical care physician will manage the airway acutely. The trach will be replaced into the trachea, using bronchoscopy as needed. The patient will be intubated orally to temporize as needed
   b.  But the patient is stable (no respiratory distress, O2 sat normal),
   the surgeon or the SOD should be contacted. For ICU patients, the critical care physician should be paged if he or she is in the hospital.
   · If the anesthesiologist or the critical care physician is unable to replace the trach, the surgeon or the SOD will be called after securing an airway.
4. The surgeon will assess the patient and the tracheostomy the day following the procedure and document the post-op check. The surgeon will provide subsequent follow up care as needed.
5. It should be noted that a fair amount of inflammatory changes and exudate around the trach is common for several days.
6. At approximately 7 days post-op, the first trach change and suture removal should be performed. This can be done by a qualified respiratory therapist, or the pulmonary/critical care physician if he or she is involved in the patient's care. If not, the surgeon who performed the trach should be contacted to do this. If the trach needs to be changed prior to 7 days (usually for a cuff leak), the surgeon or SOD should be contacted.
7. The patient should be observed in the hospital for several days (to allow the stoma to mature) prior to discharging the patient to an ECF or home.

Problems with Chronic Trach

1. If a chronic trach needs to be replaced (either because it's time or cuff leak), a qualified respiratory therapist will change the trach (same type and size will be placed).
2. Other problems should be referred either to pulmonary or HNS, depending on which service was involved with placing the trach. If neither pulmonary nor HNS is on the case, problems should be referred to the hospitalist physician. The hospitalist physician will consult HNS as needed.

Trach Tube Removal

1. The pulmonologist on-call should be consulted about removal of tracheostomy tube (HNS should be consulted if HNS performed the trach).
2. There are many options for the approach to trach decannulation. The following is one option that might be followed.
   • · If it is felt that trach is no longer needed and will not be needed in the foreseeable future, a trial of breathing with the trach cuff deflated will be undertaken. If this is tolerated, the current trach tube may remain in place with the cuff deflated, or a qualified RT or the pulmonologist will change the trach to a cuffless #6 Shiley tube . The trach tube may then be plugged with the plug (with a red button) provided with the trach tube at the pulmonologist's discretion.
   • · If the patient is stable for 24 - 48 h with the trach plugged, a qualified RT of the pulmonologist will remove the trach, and the stoma will be allowed to close.
   • · If upper airway pathology such as tracheal stenosis is suspected, the pulmonologist will perform a flexible bronchoscopy prior to decannulation.
   • · If the patient is stable for 24 - 48 hours with the trach cuff deflated or with a cuffless tube in place, the patient may be discharged to an ECF or home at the attending physicians discretion.

- If the patient is discharged home, the patient should follow up with either pulmonary or HNS for subsequent trach care and possible decannulation.

- If the patient is transferred to an ECF, the ECF physician may decannulate the trach when appropriate in consultation with a pulmonary or HNS physician.

· For awake patients who are tolerating a cuffless trach or a deflated trach cuff, a Passey-Muir (speaking) valve may be ordered by the attending physician or pulmonologist. A qualified respiratory therapist can apply the speaking valve and instruct the patient in it's use. When necessary, speech therapy should be consulted to help the patient phonate correctly with the speaking valve.

· In situations where we want to keep the stoma open for longer periods, an Olympic Trach-Button (From Olympic Medical 800 426-0353) will be placed by the pulmonologist. This needs to be special ordered through distribution.

BK 10-19-1999

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