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Care of the stoma

Infection Control

The presence of the tracheostomy tube, the resultant secretions and stoma site in an already debilitated and possibly immuno-compromised patient all increase the risk of infection. It is therefore important that adequate infection control procedures are in place when caring for these patients.

  • Alcohol gel +/- Handwashing is essential both before and after all procedures.
  • Gloves must be worn and contaminated gloves changed between procedures. For changing the tracheostomy tube or a dressing, these should be sterile. For suctioning these can be clean rather than sterile.
  • Aprons should be worn at all times and changed between procedures.
  • Eye protection should be worn for suctioning, dressing changes and tube changes or where there is any risk a patient may cough secretions towards the carer.
  • Side rooms should be considered for patients with resistant organisms in their sputum (without a closed system suction) or in their stoma site. For further advice contact the infection control team.

Dressings

Secretions that collect above the cuff may ooze out of the stoma site and cause wetness around the tracheostomy site, this can cause irritation leading to skin maceration and excoriation. The site should be assessed at least once in every 24 hours for trauma, infection or inflammation and the findings recorded on the wound assessment chart. The back of the neck should also be inspected for signs of redness/soreness from the holder, to prevent this; a purpose-made broad, soft adjustable holder should be used.

Should the skin around the stoma be wet with secretions or appear irritated a film forming acrylate barrier such as Cavilon™ may be helpful in preventing excoriation and allowing healing. The dressing and tracheostomy holder may need to be changed more frequently if they become soiled. This is a two person technique to prevent dislodgement of the tracheostomy. Red, excoriated or exuding stomas should be swabbed and the doctor informed. Advice should be sought from the wound care team for complicated wounds.

Equipment

Dressing pack
  • Normal saline
  • Pre-cut slim line key hole dressing such as Metalline™ or if large secretions use a more absorbent dressing such as Allevyn™ or Lyofoam™
  • Tracheostomy tube holder
  • Light source such as a pen torch or adjustable procedure light

Procedure

  • This is a sterile non-touch technique
  • Explain/discuss the procedure with the patient and gain consent
  • To reduce the risk of coughing, assess the patients need for suctioning and carry out suctioning if required
  • Wash hands, put on gloves and apron
  • Lay out dressing pack and prepare the normal saline and dressing in a sterile area
  • Two nurses are required: one supports the tube for the duration of the procedure, while the other removes the tapes and removes the soiled dressing
  • Remove soiled gloves, gel hands and replace gloves
  • Observe the condition of the skin and the stoma, swab site if required. Clean around the stoma. If sutures are in place, identify if these are necessary to maintain tube position and remove if not required for security
  • Apply dressing with the opening at the top; this may not be possible if sutures are in situ
  • Secure in place with tracheostomy tube holder allowing for two fingers to fit under the holder, this may not be necessary if sutures are in situ
  • Record assessment and procedure in patients records

Inner cannulae

A study in ventilated patients suggested that routine changes of the inner cannulae were not required to prevent colonisation or obstruction of the inner cannula1. However all the patients in this group were routinely suctioned, which may have prevented tube blockage. Anecdotally it is noted that inner cannulae can collect sputum that may cause tube blockage. Therefore, until further evidence is available we suggest that inner cannulae are regularly inspected, approximately four hourly, to prevent narrowing or ultimately blockage of the tube. It is recommended that this is done at least four hourly but this may be required more or less frequently dependant on the quantity and tenacity of the patients secretions.

Disposable inner cannulae should be discarded if soiled and a new one inserted. Non disposable inner cannulae should be cleaned according to the manufacturers’ instructions or with sterile water and air dried thoroughly before replacing. Due to the risk of damage to the inner surface of the inner cannula we suggest that this should not be cleaned with a brush. No studies could be found that related methods of inner tube decontamination with respiratory tract infection. However, one cross over trial identified that cleansing the inner cannula with detergent is at least as effective as cleansing using an alcoholic chlorhexidine solution in reducing colony counts found on the inner cannula2.

Oral hygiene

Where patients cannot eat and drink they should be encouraged or assisted to maintain their oral hygiene by using a toothbrush and toothpaste and intermittently swilling their mouths with water. It is recommended that patients have regular application of 2% chlorhexidine gel or mouth wash3-5. Patients should have a daily assessment of their buccal mucous membranes to note for bacterial, viral or fungal infections, skin tears or ulceration. A swab should be taken of any suspicious areas, using a viral swab if a virus is suspected i.e. Herpes Simplex.

Sub-glottic secretion drainage and cuff management

There is evidence that the use of an endotracheal tube with sub-glottic secretion drainage and an appropriately inflated cuff reduces the risk of ventilator-associated pneumonia by preventing contaminated oral secretions that accumulate above the tracheal cuff in intubated patients leaking past the cuff into the lungs 6-10. Despite the lack of evidence it is reasonable to assume that sub-glottic secretion removal may also be helpful in mechanically ventilated patients with a tracheostomy, it has yet to be shown whether such a tube is useful outside the setting of a ventilated patient.

Tracheostomy competencies

Health care professionals caring for patients with tracheostomies should have completed their basic tracheostomy competencies (See Appendix 1).

References

  1. Burns S, Spilman M, Wilmoth D, Carpenter R, Turrentine B, Wiley B, Marshall M, Martens S, Burns JE, Truwitt JD,. Are frequent inner cannula changes necessary?: A pilot study. Heart and Lung 1998 Jan-Feb;27(1):58-62
  2. Björling G, Belin AL, Hellström C, Schedin U, Ransjö U, Ålenius M,Johansson U Tracheostomy inner cannula care: A randomised crossover study of two decontamination procedures Am. J. Infection Control 2007 Nov;35(9):600-5
  3. Tantipong H, Morkchareonpong C, Jaiyindee S, Thamlikitkul V,. Randomized controlled trial and meta-analysis of oral decontamination with 2% chlorhexidine solution for the prevention of ventilator-associated pneumonia Infect Control Hosp Epidemiol. 2008 Feb;29(2):131-6
  4. Department of Health The Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance High Impact Interventions (available from http://hcai.dh.gov.uk/files/2011/03/2011-03-14-HII-Ventilator-Associated-Pneumonia-FINAL.pdf) last accessed 27th May 2011
  5. Chan E, Ruest A, O Meade M, Cook D,. Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis British Medical Journal 26th March 2007 doi:10:1136/bmj.39136.528160.BE
  6. Muscedere J, Rewa O, Mckechnie K, Jiang X, Laporta D, Heyland D. Subglottic suction drainage for the prevention of ventilator associated pneumonia: A systematic review and meta-analysis Crit Care Med 2011 39:98 1-6
  7. DezfulianC, Shojania K, Collard H, Myra Kim H, Matthay M, Saint S Subglottic secretion drainage for preventing ventilator-associated pneumonia: a meta-analysis Am J Med (2005) 118 : (1) 11-18
  8. Lorente L, Lecuona M, Jiménez A, Mora M, Sierra A Influence of an Endotracheal Tube with Polyurethane Cuff and Subglottic Drainage on Pneumonia (2007) Am J Respir Crit Care Med 176: 1079-83
  9. Diaz E, Rodriguez AH, Rello J. Ventilator-associated pneumonia: issues related to the artificial airway. Respiratory Care 2005, 50:900–6
  10. Vallés J, Artigas A, Rello J, Bonsoms N, Fontanals D, Blanch L, Fernández R, Baigorri F, Mestre J (1995) Continous Aspiration of Subglottic Secretions in preventing Ventilator-Associated Pneumonia Ann Intern Med 122: 179-86