Most tracheostomy problems can be prevented by good basic nursing and medical care, provided that essential emergency equipment is with the patient at all times - in the ward, ICU or nursing home, and whenever the patient moves between locations, e.g. to X-ray departments. A small emergency ‘lunchbox’ is ideal for the emergency equipment.

Some of this equipment may be available routinely at the bed space or on the cardiac arrest trolley:

Basic airway equipment

Oxygen masks for the face and the tracheostomy require two oxygen supplies. Critical Care and some specialist areas usually have two supplies, but if not, think what you need and plan where to get it from, before an emergency occurs.

Laryngeal mask airways and paediatric facemasks can be used to oxygenate and ventilate via the stoma and should be available for all tracheostomy patients.

Oral and nasal airways should be available, along with other basic airway kit.

Advanced airway equipment

Standard Supraglottic Airway Devices (such as laryngeal mask airways), laryngoscopes and a range of endotracheal tubes should be available on the arrest trolley.

If the patient has a known, particularly difficult airway, this should be recorded on the bedhead sign and the equipment used to manage the airway should be immediately available.

A small size 6.0 endotracheal tube should be available as this can be inserted into the stoma if necessary.

Spare tracheostomy tubes

As a minimum, one spare tube of the same size and one tube one size below that currently in situ in the patient should be at the bedside.

Spare inner cannuale are useful because they can be lost or become damaged.

Some tubes have an inner cannula, which needs to be in place to connect the patient to a breathing circuit, and in this case a spare cannula is essential.

Tracheal dilators

Tracheal dilators are seen as essential by some and potentially harmful by others. However, they may have a role in keeping a stoma open or allowing enable someone who is experienced in their use to manipulate a tube into a tracheostomy stoma.

Whether to stock dilators is a local decision.

Bougies

Bougies can help with upper airway management but they can cause problems with tracheostomies. Because a bougie is stiff, blindly inserting a bougie into a tracheostomy stoma may result in a false passage being formed, if the bougie doesn’t enter the trachea. This is a particular problem with recent tracheostomies or if the neck anatomy is complicated.

It is safer to use either an endoscope or a hollow bougie loaded onto a 'scope for this purpose (such as an 'Aintree catheter'). Blind insertion of a bougie should be avoided if at all possible.

During an elective, uneventful tracheostomy tube change, the tube starts in the trachea and you can be fairly confident that if you use a bougie as a guide, the bougie will remain in the trachea as it is inserted.

Click here to watch a video showing the use of a bougie during a tracheostomy tube replacement.

Suction

A range of suction catheters must be available.

Inner diameter of tracheostomy tube

(NB: see manufacturers' details to confirm)

Suction catheter

FG

mm

10 mm

14

4.5

9 mm

12

4

8 mm

12

4

7 mm

12

4

6 mm

10

3.3

5 mm

8

2.6

Miscellaneous equipment:

Scissors (and stitch cutters if the tracheostomy is sutured in place) are required to remove dressings and ties rapidly in an emergency.

The use of a bougie during a tracheostomy tube replacement.

Endoscope

An endoscope should be available in any area caring for patients with tracheostomies. Immediate availability is required for critical care and other specialist areas, where endoscopes can be used to inspect tubes suspected of being displaced, or to guide the insertion of bougies or tubes into stomas.
Disposable, single-use endoscopes are now available to complement traditional re-useable endoscopes.

Personal protective equipment

Care must be taken to protect staff. Gloves must be worn and, ideally, eye protection should be worn, sometimes with an apron, depending on the patient’s infection status and location.