Tracheostomy Care and Suctioning

Tracheostomy Care and Suctioning
Name of Student
Name of University
12 June 2015
Abstract
The sensory and motor function, as well as sympathetic activity, is rigorously compromised in case of cervical and high thoracic spinal cord injuries (SCIs). The respiratory muscles of quadriplegic patients are weakened, and the respiratory functions are injured due to the interruption in the respiratory pathways of the spinal cord. Mechanical ventilation (MV) is required by patients with severe cervical spinal cord injury because paralysis of the respiratory muscles weakens the vital pulmonary capacity and severely harms the peak cough flow, hence leading to ineffective clearance of tracheobronchial secretions. As a result, endotracheal suctioning is required by all patients having an artificial airway for removing secretions, preventing obstacles in the airway and complications.
Endotracheal suctioning or tracheostomy care and suctioning is a very important process that keeps the airways of patients open by secreting out mucous, as quadriplegic patients cannot cough to take out the mucous in their respiratory tract by themselves. A great impact is observed on the complications and efficiency by the method endotracheal suctioning is performed. According to a report released by the Clinical Excellence Commission, in the year 2009 noticeable harmful events were observed in the patients with a tracheostomy, which was the result of inconsistent knowledge and variation in clinical practice. Hence to prevent complications, nurses performing tracheostomy care and suctioning, no matter they are experts or trainees, must stick to evidence-based guidelines.

Introduction
Tracheostomy Care and Suctioning: Tracheostomy care and tracheal suctioning are procedures of high risk. The procedures have to be conducted very carefully as there are several processes included in it, such as cleaning of stoma and trach tube, cleaning inner and outer cannula, trach site dressing, tube ties and tube change.
Suctioning is performed on patients who cannot clear their airways by themselves. For maintaining the patency and reliability of the airway in patients with a tracheostomy tube, one of the most necessary steps is suctioning. Suctioning must be done only when indicated clinically, and not on a regular basis because there is the whole lot of possibility of harmful effects. According to evidence, the most clinical signs on evaluation were shown by patients who have the largest amount of tracheobronchial secretions, whereas fewer clinical signs thorough assessment were displayed by patients with no secretions, hence thorough examination must be conducted prior taking any decision of suction, every patient has different suctioning requirements (Martinez et al., 2004).
Patients receiving tracheostomy and suctioning are always at high risk of airway obstruction, destructed ventilation, infection, and various other fatal complications, particularly when inconsistency and variation are observed in suctioning techniques.
Background and literature review
Why should the study be done?
The study involves 26 quadriplegic patients who suffer from increasing secretions in airways and because of various problems like artificial airways, non-movement of muscles, and difficulties in respiratory tract have problems to evict these secretions (Zimmer et al., 2007). Thus, these patients require periodical suctioning and since past two years have been receiving tracheostomy care and suctioning. In this study, we are going to conduct research on such 26 quadriplegic patients who are receiving 24*7 nursing care at home.
According to several studies, a patient in each 24 hours requires endotracheal suctioning at least 3 to 24 times. And in case the process is not conducted with suitable method it can lead to various consequences and hazards such as respiratory and cardiac problems, trachea endothelial trauma, bleeding, brain pressure increase, hypoxemia and cardiac arrhythmia. Sometimes it also causes cardiac arrest and ultimately death (Cotton et al., 2005).
Irrespective of the large number of studies, most units do not have the manual of evidence related to tracheal suctioning and the correct technique. Hence, performing suctioning with the observance of such experimental evidence by nurses is questioned. A noticeable gap between knowledge of nurses, the performance of endotracheal suctioning and techniques of suctioning were observed by a study (Golzeles et al., 2004). According to this research, it was found that the nurses’ knowledge and performance related to suctioning techniques varied. Moreover, a study by Kelher and Andrew proposed that during the process of endotracheal suctioning different nurses acted differently and did not follow recommendations of the experiment, hence the nursery care quality was found to be lower (Kelleher and Andrews, 2008).
Where is the gap in knowledge?
Various studies have shown inconsistent level of knowledge and varied techniques in performance of nurses when conducting tracheostomy care and suctioning, for instance a study by Kelher and Andrew, as mentioned above, showed that different nurses responded differently while conducting suctioning process. According to a study conducted in the U.K, a lot of nurses could not even clear a standard level of proficiency; moreover there were few practices that were found to be completely unsafe (Chang et al., 2002). There is even gap observed in performance and knowledge, for instance, a study by Golzeles showed a noticeable gap between knowledge and performance of nurses in endotracheal suctioning. This research showed that though in comparison to their performance their knowledge was much better, yet their performance did not reflect their knowledge (Golzeles et al., 2004).
Aim of the project or study hypotheses
What will be investigated?
In this research, it is proposed to investigate the tracheostomy care and suctioning process used by the nursing staff to take care of 26 quadriplegic patients or patients with spinal cord injury. Moreover, the gaps in knowledge will that leads to inconsistency and variation in the nursing technique will be investigated.
Aims of the study?
In this paper, our aim is to study the process of tracheostomy care and suctioning in these 26 quadriplegic patients who are receiving care at home and to access the gap between the knowledge and performance of nurses’ working in tracheal suctioning.
Hypothesis and research question(s)?
Here in this paper, we would find out answers of certain questions about tracheostomy care and suctioning in case of quadriplegic patients, such as:
What are the suctioning techniques used by nurses?
To understand the knowledge and performance of nurses’ working in tracheal suctioning.
What are the inconsistencies and variations in suctioning techniques that lead to complication in patients?
What can be an evidence-based guidelines that can be used by hospitals and nursing agency that trains and supplies nursing staffs for tracheostomy care and suction?
How frequently should the endotracheal /tracheal suctioning be done?
Which is the best method of suctioning?
Study design or methodological approach
Setting: 24*7 home care
Sample size: 26 quadriplegic patients and 44 nurses
Study design: Cross-sectional study

Tool: An observational checklist was maintained for recording the steps of the procedure and the knowledge assessed by using questionnaire
Significance of the project:
How and why is this study important?
Tracheostomy care and tracheal suctioning are procedures of high-risk, particularly when quadriplegic patients or patients with spinal cord injury (SCI) are involved who need intensive care because of their complex and massive requirements also when much various and inconsistency has been observed in the nurses knowledge of tracheal suctioning that leads to lot of complications (Celik and Elbas, 2000). In the study proposed 26 quadriplegic patients are on mechanical ventilation and have been receiving tracheostomy since past two years or more and now are receiving 24*7 nursing care at home, hence nurses play very important role in taking care of these patients, Hence, this project becomes very significant as we would discuss what are the suctioning techniques that can be used by the nurses to avoid complications, which generally occurs due to inconsistent level of knowledge and variations in suctioning techniques (Pedersen et al., 2009).
Endotracheal suctioning is a frequently performed procedure, which contains several related threats and complications. This study is designed for examining to what degree the knowledge and practice of endotracheal suctioning are based on research evidence, and to find out the relationships between knowledge and performance.
Method
How will the study be done?
In order to conduct the research, a sectional cross-study will be done where all nurses appointed to take care of these 26 quadriplegic patients will be observed, and also their method of performing suctioning techniques, gap in knowledge etc.
Sites, sampling, procedure for recruitment
Site: Individual home of patients
Sampling: capitation technique will be used for sampling and also the 26 patients, and all 44 nurses taking will be included in the sample.
Procedure for recruitment: The inclusion criteria for this research are- i) possessing a BS degree and ii) having working experience of at least one month, that too in intensive care units.
What data will be collected and how?
Data stating about the performance and knowledge in endotracheal suctioning and tracheostomy in nurses will be collected.
A questionnaire containing two parts will be prepared for the research, where the first part would gather data related to basic and demographical factors, for example, age, sex, working experience, and the process of their recruitment to the job (Hadain et al., 2010). Their level of knowledge about endotracheal suctioning will be assessed in the second part.
There will be 26 questions in this second part that will try to seek information on various features of nurses’ knowledge, basically in three areas of preceding, during and post endotracheal suctioning. The score of one will be given for each right answer, whereas each wrong answer will get the score of zero. So each nurse will be obtaining the score of zero to twenty-six and for analyzing the nurses’ knowledge level their raw score will be used (Thompson, 2000).
Even the checklist for observation of performing standards of endotracheal suctioning by nurses includes 26 questions that concerns about nurses’ performance in suctioning in three areas of earlier, during and post endotracheal suctioning. Each right function would give the score of one whereas and each wrong one will lead to a score of zero. To observe the performance of each nurse, their performance will be observed thrice, and the average of three scores for each nurse will be taken as their final score.
The questionnaire and checklist that will be used for examination purpose will contain, 8 items in the area of earlier suctioning, such as listening to, and examination of respiratory sounds, explanation and assuring the patient, hyperoxygenation, hyperinflation, to wash the hands, to wear gloves, to wear gown, and application of glasses.
There will be 10 items in the area of during suctioning, such as application of proper size catheter, alteration and using new catheter, suitable negative pressure, suitable depth and timing to enter the catheter, number of times to enter the catheter, no application of normal saline, technique to entering the catheter, attention to the heart rhythm and the heartbeat, attention to saturation of oxygen (Scoble et al., 2001).
The area of post suctioning also contains 8 items such as quick connection to the ventilator, patient’s hyperoxygenation, patient reassurance, to listen to the lungs, investigating the rhythm and heartbeat, investigating features of secretions’, hand wash and noting the observations (Day et al., 2002).
What approach will be used for analysis?
In this cross-sectional research, knowledge and performance of 44 nurses appointed to take of these 26 quadriplegic patients will be examined. A kruskalwallis test, Spearman correlation coefficient, and SPSS14 software will be used for analyzing the data that will be collected through questionnaire and checklist.
The questionnaire and checklist will be prepared using bibliographical studies and revision of books and earlier studies on the issue.
Credible scientific resources and articles will be collected for preparing the questionnaire and check list, prepare standard suggestions and protocols related to endotracheal suctioning.
After finishing the observations, the questionnaire was filled out by the nurses in the presence of the researcher. In the analysis of the data, non-parametrical tests of kruskal-wallis and Spearman correlation coefficient was used in SPSS14 software (Ania et al., 2004).
Ethical or resource implications
What are sources of potential harm or disruption to people or services and what measures will be taken to avoid this harm?
As the research will be limited to only 44 nurses and 26 patients who all quadriplegic, the study will be limited in its findings as endotracheal suctioning is required by lot of patients under mechanical ventilation suffering from various problems other than spinal cord injury.
The questionnaires of knowledge will be asked filled out in the presence of the researcher, but still there will be chance of passing information among nurses as it will not be possible for the researcher to make the assessment of all nurses at the same time. Thus, there will be chances of wrong and mislead information.

Studies reveal that undesirable side effects of endotracheal suctioning can be reduced by the correct performance of nurses. Nurses can, Application of scientific recommendations will help nurses to improve their performance, and improve the quality of this care. The following are some strategies that can be used by nurses in case of complications that would help to enhance their performance and lessen the gap of knowledge:
There is the risk of trach tubes to be accidentally displaced while a patient is being suctioned or as trach care is being performed. In case this occurs, immediately the trach has to be replaced. The following action must be taken for keeping the airway of patients open:
A new sterile trach tube must be used to replace the trach tube, or
The original trach tube must be reinserted, or
For ventilating the patient at 8-16 breaths per minute rate, the stoma can be occluded, and an ambu bag and mask can be used until EMS arrives.

No longer than 30 seconds time should be taken for reinserting the trach tube. In cases, there is a problem in a swollen airway there should be at least one trach tube, which is one size smaller than the tube that the patient has been using. Insertion becomes easier by this process.

For protecting the patients and nursing staff, strict adherence to infection control policies is essential. However, all patients might not need a strictly sterile suctioning technique.
For effective removal of secretions, the suction pressure should be high enough. However, it must not be so high that it leads to damage of the mucosa or loss of lung volume.

Any injury to the mucosa can be reduced or minimized by selecting the correct size catheter, using shallow suctioning process and by keeping each event of suctioning as short as possible.
Nursing strategies
To prevent complications in tracheostomies patients and to identify problems prior the complications become emergencies, a very crucial role is played by the nurses who take care of these patients 24*7. The following are few strategies that nurses followed during this study:
The most important tool is a suction catheter. The proper position of the tube is ensured by passing a suction catheter beyond the length of the tube. Secretions are removed by suctioning, and a strong cough is stimulated, which mobilizes more secretions.

For preventing breakdown of skin, the stoma must be kept clean and dry. The stoma present behind the neck flange must be cleaned by cotton-tipped swabs.
The tracheostomy tube must be placed neutrally.
The most important task for a nurse is to identify the potential problems prior to an emergency occurs.
Information relevant to the tracheostomy is noted down each time by the nurses for further reference.
Moreover, along with nurses the caretakers such as family members and relatives must be well aware of techniques for preventing several complications that are associated with this condition, it is very important that caregivers must be properly educated about technique on care of the tracheostomy tube and stoma. The basic care of the tracheostomy, which includes changing the tracheotomy tube as, planned, cleaning of the inner cannula, stoma cleansing, and changing the tracheostomy ties must be taught to the caregivers of the patient that can be nurse or family member.
A checklist of supplies that are required to be with the patient at all times must be handed over to the patients and the caregiver. Patients and caregivers must have adequate knowledge about what to do during an emergency. They should be informed of the type, size, and length of the tracheostomy tube, they must have knowledge regarding how and when to use suctioning, the cleaning procedure of the stoma and the tube, changing ties. They also need to have adequate information about the signs and symptoms of infection, skin breakdown and other emergencies and complication related to quadriplegic patients receiving tracheostomy care. Lastly, patients and caregivers must have accessibility to a home care instruction manual (Day et al. 2002).
Studies show that the correct performance of nurses in endotracheal suctioning can minimize undesirable side effects of it on the patients. Nurses can, by utilizing scientific recommendations in their performance, improve the quality of this care and decrease the period of hospitalization and patients’ expenses. So a quality nurse care can be effective on prevention of unnecessary deaths as well as medical interventions (Bighamian et al., 2004).
Budget
What items need to be considered in the budget?
It is important to consider several techniques that will be used in the research in order to consider the budget of the research, moreover tools and equipment required to conduct tracheostomy care and to suction also needs to be taken into account.

Approximate cost of tracheostomy supplies
Item Cost in $
Tracheostomy tubes:
Plastic tubes
Silicone tubes
Stainless steel tubes
Silver tubes
Custom tubes 40-500
80-500
80-300
300-2000
500-5000
Disposable inner cannulas (plastic) 3-5
Tracheostomy ties
3-5
Speaking valves
60-150
Suction catheters
60-150
Drain sponges
0.25
Tracheostomy care kits 2-12
Timeline

How long will the project take?
To conduct this cross-sectional study a minimum of one year time will be required as all the 26 quadriplegic patient’s suctioning techniques have to be observed, for answering the questionnaire and checklist prepared. Moreover, several related books and article have to be referred and reviewed carefully.
References
Zimmer MB, Nantwi K, Goshgarian HG. ( 2007). Effect of spinal cord injury on the respiratory system: basic research and current clinical treatment options. J Spinal Cord.
Cotton BA, Pryor JP, Chinwalla I, Wiebe DJ, Reilly PM, Schwab CW (2005) Respiratorycomplications and mortality risk associated with a thoracic spine injury. J Trauma.
Day T, Farnell S. Wilson-Barnett J. ( 2002). Suctioning: a review of current research recommendations. Intensive Critical Care Nursing.
Day T, Wainwright SP, Wilson-Barnett J. (2001). An evaluation of a teaching intervention to improve the practice of endotracheal suctioning in intensive care units. J Clin Nurs.
Zolfaghari M, Nikbakht Nasabadi AR, Karimi Rezveh A, Haghani H. ( 2008). Effect of open and closed system endotracheal suctioning on vital signs of ICU patients. Hayat.
Chang BL, Lee JL, Pearson ML, Kahn KL, Elliott MN. Rubenstein LL. (2002). Evaluatingquality of nursing care: The gap between theory and practice. J Nurs Adm.
Kelleher S, Andrews T.( 2008). An observational study on the open system endotracheal suctioning practices of critical care nurses. J Clin Nurs.
Bighamian B, Zarkeshan R, Rafieeano M. (2004). The effect of nursing education inendotracheal tube suctioning. Iranian Journal of Nursing and Midwifery Research.
Thompson L. Suctioning adults with an artificial airway (2000). Systematic Review #9.
Scoble MK, Copnell B, Taylor A, Kinney S. Shann F. (2001). Effect of reusing suction catheterson the occurrence of pneumonia in children. Heart Lung.
Ania Gonzalez N, Martinez Mingo A, Eseberri Sagardoy M, Margall Coscojuela Ma, Asiain Erro Mc. (2004). Assessment of practice competence and scientific knowledge of ICU nurses in the tracheal suctioning. Enferm Intensive.

Celik SS, and Elbas NO (2000). The standard of suction for patients undergoing endotracheal intubation. Intensive Crit Care Nurs.
Pedersen CM, Rosendahl-Nielsen M, Hjermind J, Egerod I. (2009). Endotracheal suctioning ofthe adult intubated patient–what is the evidence? Intensive Crit Care Nurs.
Day T, Farnell S, Haynes S, Wainwright S. Wilson- Barnett J. (2002). Tracheal suctioning: an exploration of nurses’ knowledge and competence in acute and high dependency wardareas. J Adv Nurs.
Hadian Shirazi Z, Kargar M, Edraki M, Ghaem H.vPishva N. (2010). The effect of instructing the principles of endotracheal tube suctioning on knowledge and performance of nursing staff working in the neonatal intensive care unit in shiraz university of medical sciences. Iranian J Med Edu.