Clinical Consensus Statement: Tracheostomy Care
Ron B. Mitchell, MD; Heather M. Hussey, MPH; Gavin Setzen, MD; Ian N. Jacobs, MD; Brian Nussenbaum, MD; Cindy Dawson, MSN, RN, CORLN; Calvin A. Brown III, MD; Cheryl Brandt, MSN, ACNS-BC; Kathleen Deakins, RRT-NPS, FAARC; Christopher J. Hartnick, MD; Albert L. Merati, MDTracheostomy Tracheostomy is one of the oldest and most commonly performed surgical procedures among critically ill patients.1-5 Tracheostomy creates an artificial opening, or stoma, in the trachea to establish an airway through the neck.6 The stoma is usually maintained by inserting a tracheostomy tube through the opening.7,8 Tracheostomy is increasingly performed on adults in intensive care units (ICU) for upper airway obstruction, prolonged endotracheal intubation, and for those requiring bronchial hygiene.9 In adults, the traditional surgical tracheostomy has been accompanied by the emergence of percutaneous dilatational techniques (PDT). Adult tracheostomy can be performed in the operating room or at the bedside in an intensive care unit. In children, other than on rare emergencies, tracheostomy is performed in the operating room with the child intubated under general anesthesia. In children, tracheostomy is most frequently performed in the first year of life due to the increased survival of premature infants requiring prolonged ventilation.10 A review of the literature on the care and management of tracheostomy shows a paucity of both well-controlled studies and high-quality evidence. The majority of publications are book chapters, expert opinion, and small observational studies. There are essentially no controlled studies or peer-reviewed papers to guide care or practice in this field. As evidence-based research is lacking, the current literature does not support the development of a clinical practice guideline, but favors a consensus of expert opinions. Consensus Statement Development A consensus panel was therefore convened by the American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF) to create a clinical consensus statement (CCS). An organized group of multidisciplinary experts was selected to review the literature, synthesize information, and clarify specific areas of controversy or ambiguity regarding the care and management of patients with a tracheostomy. Despite significant differences between pediatric and adult tracheostomy care, the panel concluded there are sufficient similarities to justify a single document for both groups of patients. The findings of this consensus group are stated as opinions or suggestions, not as recommendations. Clinicians should always act and decide in a way they believe will best serve their patients’ interests and needs, regardless of consensus opinions. They must also operate within their scope of practice and according to their training. The consensus panel made suggestions about a large number of statements that dealt with a variety of subjects including the most appropriate tracheostomy tube type, suctioning, humidification, patient and caregiver education, home care, emergency care, decannulation, tube care (including use of cuffs and sutures), as well as overall clinical airway management. The panel also dropped a number of statements on utility of tracheostomy ties or sutures, cleaning methodology, specific circumstances when the tube should be changed, utility of cuffs, and desired frequency of changing the tube. This consensus statement was developed using a modified Delphi method, a systematic approach to achieving consensus among a panel of topic experts. Initially designed by the RAND Corporation to better utilize group information in the 1950s, this methodology has been modified to accommodate advances in technology and is used widely to address evidence gaps in medicine and improve patient care without face-to-face interaction.11,12 Figure 1 provides an overview of the consensus process used to create this CCS. Panel members were asked to complete two surveys utilizing a nine-point Likert scale to measure agreement (see Table 1). An outlier was defined as any rating at least two Likert points away from the mean. Each survey was followed by a conference call during which results were presented and statements discussed. Statements were categorized as follows: Consensus: Statements achieving a mean score of 7.00 or higher and have no more than one outlier. Near consensus: Statements achieving a mean score of 6.50 or higher and have no more than two outliers. No consensus: Statements that did not meet the criteria of consensus or near consensus. Key Consensus Statements Of the 77 statements that achieved consensus, 13 were considered the most important for day-to-day tracheostomy care in adults and children and are presented in Table 2. Research Needs Further research is needed in a number of areas highlighted in this document: To define quality metrics related to tracheostomy care, (optimal tracheostomy tube size, role of tracheostomy tube cuffs, role of sutures and ties in preventing accidental decannulation, cleaning and suctioning techniques, frequency and timing of tracheostomy tube change) that correlate to early hospital discharge. To define important factors in patients with a tracheostomy that may influence the frequency of site infections, accidental tube displacement, emergency room visits, and re-admission to hospital. Important factors may include optimal cleaning and suctioning techniques, patient and caregiver education, frequency of follow up care, training, and competency of home care nurses. Determine whether trained Advanced Practice Providers (APPs) are able to perform initial tracheostomy changes with similar or fewer complication rates compared to experienced physicians. More Information This article is freely available to AAO-HNS members and the public at Otolaryngology—Head and Neck Surgery, visit http://oto.sagepub.com. References Hameed AA, Mohamed H, Al-Ansari M. Experience with 224 percutaneous dilatational tracheostomies at an adult intensive care unit in Bahrain: a descriptive study. Ann Thorac Med. Jan 2008;3(1):18-22. Al-Ansari MA, Hijazi MH. Clinical review: percutaneous dilatational tracheostomy. Crit Care. Feb 2006;10(1):202. Freeman BD, Isabella K, Lin N, Buchman TG. A meta-analysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients. Chest. Nov 2000;118(5):1412-1418. Delaney A, Bagshaw SM, Nalos M. Percutaneous dilatational tracheostomy versus surgical tracheostomy in critically ill patients: a systematic review and meta-analysis. Crit Care. 2006;10(2):R55. Griffiths J, Barber VS, Morgan L, Young JD. Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation. BMJ. May 28 2005;330(7502):1243. ANZICS. Percutaneous Dilational Tracheostomy Consensus Statement 2010. MOH. Nursing Management of Adult Patients with Tracheostomy. Singapore: Ministry of Health; 2010. Woodrow P. Managing patients with a tracheostomy in acute care. Nurs Stand. Jul 17-23 2002;16(44):39-46; quiz 47-38. Durbin CG, Jr. Tracheostomy: why, when, and how? Respir Care. Aug 2010;55(8):1056-1068. Pereira KD, MacGregor AR, Mitchell RB. Complications of neonatal tracheostomy: a 5-year review. Otolaryngol Head Neck Surg. Dec 2004;131(6):810-813. Vonk Noordegraaf A, Huirne JA, Brolmann HA, van Mechelen W, Anema JR. Multidisciplinary convalescence recommendations after gynaecological surgery: a modified Delphi method among experts. BJOG. Dec 2011;118(13):1557-1567. Dalkey NC. The Delphi Method: An Experimental Study of Group Opinion. Santa Monica: RAND Corporation;1969. RM-5888-PR. Figure 1. Modified Delphi method for achieving consensus Select Multidisciplinary Panel Eight to 10 panel members Conference Call 1 Develop scope Identify evidence gaps in literature Qualitative Survey Develop series of open-ended questions Distribute to panel for completion Conference Call 2 Discuss results from qualitative survey Delphi Survey 1 Chair and staff liaison develop statements Distribute to panel for completion Conference Call 3 Discuss results achieving near or no consensus from Delphi survey 1 Delphi Survey 2 Revise statements and add new statements (if applicable) Distribute to panel for completion Conference Call 4 Discuss survey results and revise statements if necessary Table 1. Likert scale used to measure level of agreement among respondents for both Delphi surveys. Strongly Disagree Disagree Neutral Agree Strongly Agree 1 2 3 4 5 6 7 8 9 Table 2. Key statements achieving consensus. # Statement Mean Median Mode IQR Range 1 The purpose of this consensus statement is to improve care among pediatric and adult patients with a tracheostomy. 8.56 9 9 1 8-9 2 Patient and caregiver education should be provided prior to performing an elective tracheostomy. 8.22 9 9 2 7-9 3 A communication assessment should begin prior to the procedure when non-emergent tracheostomy is planned. 7.67 7 7 2 7-9 4 All supplies to replace a tracheostomy tube should be at bedside or within reach. 8.78 9 9 0 7-9 5 An initial tracheostomy tube change should normally be performed by an experienced physician with the assistance of nursing staff, a respiratory therapist, medical assistant, or assistance of another physician. 8.22 8 9 1.5 7-9 6 In the absence of aspiration, tracheostomy tube cuffs should be deflated when a patient no longer requires mechanical ventilation. 8.22 9 9 2 7-9 7 In children, prior to decannulation, a discussion with family regarding care needs and preparation for decannulation should take place. 8.67 9 9 1 8-9 8 Utilization of a defined tracheostomy care protocol for patient and caregiver education prior to discharge will improve patient outcomes and decrease complications related to their tracheostomy tube. 8.11 8 9 2 7-9 9 Patients and their caregivers should receive a checklist of emergency supplies prior to discharge that should remain with the patient at all times. 8.89 9 9 0 8-9 10 All patients and their caregivers should be evaluated prior to discharge to asses competency of tracheostomy care procedures. 8.89 9 9 0 8-9 11 Patients and their caregivers should be informed of what to do in an emergency situation prior to discharge. 8.89 9 9 0 8-9 12 In an emergency, a dislodged, mature tracheostomy should be replaced with the same size or a size smaller tube or an endotracheal tube through the trach wound. 8.44 9 9 2.5 7-9 13 In an emergency, patients with a dislodged tracheostomy that cannot be re-inserted should be intubated (when able to intubate orally) if the patient is either failing to oxygenate, ventilate, or there is fear the airway will be lost without intubation. 8.11 9 9 2.5 5-9
Ron B. Mitchell, MD; Heather M. Hussey, MPH; Gavin Setzen, MD; Ian N. Jacobs, MD; Brian Nussenbaum, MD; Cindy Dawson, MSN, RN, CORLN; Calvin A. Brown III, MD; Cheryl Brandt, MSN, ACNS-BC; Kathleen Deakins, RRT-NPS, FAARC; Christopher J. Hartnick, MD; Albert L. Merati, MDTracheostomy
Tracheostomy is one of the oldest and most commonly performed surgical procedures among critically ill patients.1-5 Tracheostomy creates an artificial opening, or stoma, in the trachea to establish an airway through the neck.6 The stoma is usually maintained by inserting a tracheostomy tube through the opening.7,8
Tracheostomy is increasingly performed on adults in intensive care units (ICU) for upper airway obstruction, prolonged endotracheal intubation, and for those requiring bronchial hygiene.9 In adults, the traditional surgical tracheostomy has been accompanied by the emergence of percutaneous dilatational techniques (PDT). Adult tracheostomy can be performed in the operating room or at the bedside in an intensive care unit. In children, other than on rare emergencies, tracheostomy is performed in the operating room with the child intubated under general anesthesia. In children, tracheostomy is most frequently performed in the first year of life due to the increased survival of premature infants requiring prolonged ventilation.10
A review of the literature on the care and management of tracheostomy shows a paucity of both well-controlled studies and high-quality evidence. The majority of publications are book chapters, expert opinion, and small observational studies. There are essentially no controlled studies or peer-reviewed papers to guide care or practice in this field. As evidence-based research is lacking, the current literature does not support the development of a clinical practice guideline, but favors a consensus of expert opinions.
Consensus Statement Development
A consensus panel was therefore convened by the American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF) to create a clinical consensus statement (CCS). An organized group of multidisciplinary experts was selected to review the literature, synthesize information, and clarify specific areas of controversy or ambiguity regarding the care and management of patients with a tracheostomy. Despite significant differences between pediatric and adult tracheostomy care, the panel concluded there are sufficient similarities to justify a single document for both groups of patients.
The findings of this consensus group are stated as opinions or suggestions, not as recommendations. Clinicians should always act and decide in a way they believe will best serve their patients’ interests and needs, regardless of consensus opinions. They must also operate within their scope of practice and according to their training. The consensus panel made suggestions about a large number of statements that dealt with a variety of subjects including the most appropriate tracheostomy tube type, suctioning, humidification, patient and caregiver education, home care, emergency care, decannulation, tube care (including use of cuffs and sutures), as well as overall clinical airway management. The panel also dropped a number of statements on utility of tracheostomy ties or sutures, cleaning methodology, specific circumstances when the tube should be changed, utility of cuffs, and desired frequency of changing the tube.
This consensus statement was developed using a modified Delphi method, a systematic approach to achieving consensus among a panel of topic experts. Initially designed by the RAND Corporation to better utilize group information in the 1950s, this methodology has been modified to accommodate advances in technology and is used widely to address evidence gaps in medicine and improve patient care without face-to-face interaction.11,12 Figure 1 provides an overview of the consensus process used to create this CCS.
Panel members were asked to complete two surveys utilizing a nine-point Likert scale to measure agreement (see Table 1). An outlier was defined as any rating at least two Likert points away from the mean.
Each survey was followed by a conference call during which results were presented and statements discussed. Statements were categorized as follows:
- Consensus: Statements achieving a mean score of 7.00 or higher and have no more than one outlier.
- Near consensus: Statements achieving a mean score of 6.50 or higher and have no more than two outliers.
- No consensus: Statements that did not meet the criteria of consensus or near consensus.
Key Consensus Statements
Of the 77 statements that achieved consensus, 13 were considered the most important for day-to-day tracheostomy care in adults and children and are presented in Table 2.
Research Needs
Further research is needed in a number of areas highlighted in this document:
- To define quality metrics related to tracheostomy care, (optimal tracheostomy tube size, role of tracheostomy tube cuffs, role of sutures and ties in preventing accidental decannulation, cleaning and suctioning techniques, frequency and timing of tracheostomy tube change) that correlate to early hospital discharge.
- To define important factors in patients with a tracheostomy that may influence the frequency of site infections, accidental tube displacement, emergency room visits, and re-admission to hospital. Important factors may include optimal cleaning and suctioning techniques, patient and caregiver education, frequency of follow up care, training, and competency of home care nurses.
- Determine whether trained Advanced Practice Providers (APPs) are able to perform initial tracheostomy changes with similar or fewer complication rates compared to experienced physicians.
More Information
This article is freely available to AAO-HNS members and the public at Otolaryngology—Head and Neck Surgery, visit http://oto.sagepub.com.
References
- Hameed AA, Mohamed H, Al-Ansari M. Experience with 224 percutaneous dilatational tracheostomies at an adult intensive care unit in Bahrain: a descriptive study. Ann Thorac Med. Jan 2008;3(1):18-22.
- Al-Ansari MA, Hijazi MH. Clinical review: percutaneous dilatational tracheostomy. Crit Care. Feb 2006;10(1):202.
- Freeman BD, Isabella K, Lin N, Buchman TG. A meta-analysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients. Chest. Nov 2000;118(5):1412-1418.
- Delaney A, Bagshaw SM, Nalos M. Percutaneous dilatational tracheostomy versus surgical tracheostomy in critically ill patients: a systematic review and meta-analysis. Crit Care. 2006;10(2):R55.
- Griffiths J, Barber VS, Morgan L, Young JD. Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation. BMJ. May 28 2005;330(7502):1243.
- ANZICS. Percutaneous Dilational Tracheostomy Consensus Statement 2010.
- MOH. Nursing Management of Adult Patients with Tracheostomy. Singapore: Ministry of Health; 2010.
- Woodrow P. Managing patients with a tracheostomy in acute care. Nurs Stand. Jul 17-23 2002;16(44):39-46; quiz 47-38.
- Durbin CG, Jr. Tracheostomy: why, when, and how? Respir Care. Aug 2010;55(8):1056-1068.
- Pereira KD, MacGregor AR, Mitchell RB. Complications of neonatal tracheostomy: a 5-year review. Otolaryngol Head Neck Surg. Dec 2004;131(6):810-813.
- Vonk Noordegraaf A, Huirne JA, Brolmann HA, van Mechelen W, Anema JR. Multidisciplinary convalescence recommendations after gynaecological surgery: a modified Delphi method among experts. BJOG. Dec 2011;118(13):1557-1567.
- Dalkey NC. The Delphi Method: An Experimental Study of Group Opinion. Santa Monica: RAND Corporation;1969. RM-5888-PR.
Figure 1. Modified Delphi method for achieving consensus
Select Multidisciplinary Panel |
|
Conference Call 1 |
|
Qualitative Survey |
|
Conference Call 2 |
|
Delphi Survey 1 |
|
Conference Call 3 |
|
Delphi Survey 2 |
|
Conference Call 4 |
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Table 1. Likert scale used to measure level of agreement among respondents for both Delphi surveys.
Strongly Disagree | Disagree | Neutral | Agree | Strongly Agree | ||||
1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 |
Table 2. Key statements achieving consensus.
# | Statement | Mean | Median | Mode | IQR | Range |
1 | The purpose of this consensus statement is to improve care among pediatric and adult patients with a tracheostomy. | 8.56 | 9 | 9 | 1 | 8-9 |
2 | Patient and caregiver education should be provided prior to performing an elective tracheostomy. | 8.22 | 9 | 9 | 2 | 7-9 |
3 | A communication assessment should begin prior to the procedure when non-emergent tracheostomy is planned. | 7.67 | 7 | 7 | 2 | 7-9 |
4 | All supplies to replace a tracheostomy tube should be at bedside or within reach. | 8.78 | 9 | 9 | 0 | 7-9 |
5 | An initial tracheostomy tube change should normally be performed by an experienced physician with the assistance of nursing staff, a respiratory therapist, medical assistant, or assistance of another physician. | 8.22 | 8 | 9 | 1.5 | 7-9 |
6 | In the absence of aspiration, tracheostomy tube cuffs should be deflated when a patient no longer requires mechanical ventilation. | 8.22 | 9 | 9 | 2 | 7-9 |
7 | In children, prior to decannulation, a discussion with family regarding care needs and preparation for decannulation should take place. | 8.67 | 9 | 9 | 1 | 8-9 |
8 | Utilization of a defined tracheostomy care protocol for patient and caregiver education prior to discharge will improve patient outcomes and decrease complications related to their tracheostomy tube. | 8.11 | 8 | 9 | 2 | 7-9 |
9 | Patients and their caregivers should receive a checklist of emergency supplies prior to discharge that should remain with the patient at all times. | 8.89 | 9 | 9 | 0 | 8-9 |
10 | All patients and their caregivers should be evaluated prior to discharge to asses competency of tracheostomy care procedures. | 8.89 | 9 | 9 | 0 | 8-9 |
11 | Patients and their caregivers should be informed of what to do in an emergency situation prior to discharge. | 8.89 | 9 | 9 | 0 | 8-9 |
12 | In an emergency, a dislodged, mature tracheostomy should be replaced with the same size or a size smaller tube or an endotracheal tube through the trach wound. | 8.44 | 9 | 9 | 2.5 | 7-9 |
13 | In an emergency, patients with a dislodged tracheostomy that cannot be re-inserted should be intubated (when able to intubate orally) if the patient is either failing to oxygenate, ventilate, or there is fear the airway will be lost without intubation. | 8.11 | 9 | 9 | 2.5 | 5-9 |