The management of home tracheostomy patients is complex and is not backed by much published literature. Caregivers must use limited data, consensus statements, and common sense
Modern health care practice now encompasses the management of medicallyfragile and technology-dependent patients in a variety of nonacute settings, including and specifically the home. This new population of stable but chronically ill and technology-dependent patients includes those with a tracheostomy.
In the United States, economic factors are often drivers of health care practice and the supporting standards of care. This is especially true in the home care setting, where insurance coverage rules often dictate a de facto standard of practice. Additional factors supporting the growth of technology dependency in the home may include a growing social acceptance of persons with disabilities, and technological advances, which may empower nonprofessional caregivers to manage patients in the home.
The underlying medical conditions contributing to the growing number of long-term tracheostomy patients in the home are quite diverse. Diagnoses can include but are not limited to patients with upper airway deformity or obstruction requiring improved airway management, patients requiring prolonged invasive ventilatory support, and patients with other diseases compromising the integrity of the upper airway. There is no central data collection or tracking of medically complex patients in the home. As a result, no accurate data exist regarding the number and type of patients with a tracheostomy in the home.
Scientific Foundation for Chronic Tracheostomy Care Outside of the Hospital
Much like many other parts of the home care environment, there are essentially no controlled studies or significant peer-reviewed research papers to guide the care of tracheostomy patients in the home. As a result, many of the home tracheostomy care standards are based on some form of extrapolation of the tracheostomy care performed in local hospitals. Other factors might include local physician prescribing standards, anecdotal clinical data, and, of course, insurance payment rules.
In the area of pediatrics, the consensus statement prepared by the American Thoracic Society (ATS) entitled “Care of the Child with a Chronic Tracheostomy” is a very complete set of recommendations derived from a review of the available and relevant published data, along with the consensus of a panel of experts.1
A more specific and procedure-focused consensus guideline is the American Association for Respiratory Care (AARC) Clinical Practice Guideline (CPG) governing suctioning of the patient in the home.2 The current AARC-CPG, although well referenced, is specific to suctioning only and provides little additional guidance regarding the overall and long-term management of tracheostomy patients in the home.
The April 2006 issue of Respiratory Care includes a comprehensive series of New Horizon Symposium papers on tracheostomy care.3 One of these is a review of literature and practice surrounding long-term care of the tracheostomy patient in the home or alternate site.4
Components of Tracheostomy Care in the Home
As technology-dependent patients transition from the comfort and protection of the controlled institutional setting to the home, there are a number of important factors that must be evaluated and controlled. Even with the recent growth and improvement of home medical and respiratory technologies, creating a subacute or intensive care-like environment in the home can be difficult. The home is not piped with an unlimited supply of high-flow oxygen, suction is not available on the wall next to the bed, and experienced clinicians are not often immediately accessible. In many cases, the home medical equipment (HME) provider has to work hard to piece together various devices to create an environment appropriate for the safe and effective management of a patient with a tracheostomy in the home. These include oxygen devices, high-pressure/flow air compressors, AC and DC powered suction machines, heated humidification devices, tracheostomy tubes, suction catheters, tracheostomy care supplies, gloves, etc. The list can become quite comprehensive and somewhat expensive. To help narrow the focus, the following is a list of the key elements of any home tracheostomy management program:
1. Patient and caregiver training
2. Airway management/ventilation considerations
3. Tracheostomy tube selection and management
Patient and Caregiver Training
Training should begin as early as possible to allow the patient and caregiver adequate time to understand the information and practice techniques with the equipment. The more complex the case, the earlier the training should begin. The details of appropriate patient training extend well beyond the scope of this article but at a minimum should include basic airway anatomy, medical justification for the tracheostomy, tube description and operation, signs and symptoms of respiratory and upper airway distress, signs and symptoms of aspiration, suctioning technique, tracheostomy tube cleaning and maintenance, stoma site assessment and cleaning, cardiopulmonary resuscitation, emergency decannulation and reinsertion procedures, tube change procedure, equipment and supply use and ordering procedures, and a scheduled follow-up plan with the attending physician.5
Airway Management/Ventilation Considerations
The patient’s ventilatory and oxygenation needs play a major role in the types and complexity of the care equipment needed in the home. The needs of a patient breathing spontaneously vary greatly from one needing ventilatory support. The same applies to oxygen. A major challenge for HME providers is meeting the needs of tracheostomy patients with modest to high flow and/or Fio2 needs. While typically easy to accomplish in the hospital, high oxygen flows for tracheostomy patients, especially when accommodating ambulation, are often quite difficult to duplicate and provide in the home. Such requirements often place HME providers in the position of using devices “off label,” creating some potential liability risks for the provider and the physician. When possible, oxygen should be weaned to the lowest flow/Fio2 or discontinued prior to discharge to home.
Tracheostomy Tube Selection and Management
Tracheostomy tube selection is commonly the responsibility of the medical facility and physician performing the initial surgical procedure. There is no specific research available documenting the optimal choices in tracheostomy tube selection (ie, brand, style). As a result, local practice standards and facility device preferences play a major role in the actual tube choice, and often the HME provider has little influence over this process. There is little research or published consensus in regard to long-term tracheostomy tube and stoma care. The frequency of tracheostomy tube changes varies widely and is often driven by local practice. A common practice in pediatrics is weekly tracheostomy tube changes. There is essentially no published or recommended standard for adult tracheostomy tube changes.
Tracheostomy-site care also varies greatly, and there is no recognized or literature-based standard of care for the home. Care standards often evolve from the availability of reimbursed resources, such as tracheostomy care cleaning supplies. Insurance coverage policies often dictate home care practice by limiting the type and quantity of tracheostomy supplies that will be paid for.
Simply put, suctioning is the mechanical aspiration of secretion from the airway. It is a necessary part of routine care of the patient with a tracheostomy. For adults, many patients can be taught self-suctioning technique and most of the procedures for safe home tracheostomy care. If the patient is capable, training at least one additional caregiver is recommended. If the patient cannot participate in their care, at least two caregivers should be trained. For pediatric patients, it is recommended that at least two caregivers be trained. As noted earlier, the AARC suctioning CPG is an excellent resource and reference. Key elements from the CPG include self-suctioning training, guidelines for preoxygenation or hyperinflation, acceptance and promotion of clean technique, suction catheter size selection, suction catheter insertion depth, frequency of suctioning, reuse of suction catheters, and consensus opposing the routine use of saline lavage.2
The use of supplemental heat and humidity systems in conjunction with long-term tracheostomy patients in the home varies greatly and is again more often based on local practice than on objective scientific evidence. This is also one of the more challenging home care procedures, since there are very few devices and systems specifically designed to provide heat and humidity to tracheostomy patients in the home.
The technology of delivering humidification varies but typically includes large-volume air compressors for flow generation, some form of heated passive humidifiers, both heated and nonheated jet nebulizers, and disposable heat-moisture exchangers. The use of heat and humidification systems with adult long-term tracheostomy patients is often based solely on local clinical practice—there is little science and no consensus in this area. Stable adult patients with adequate systemic hydration often tolerate little or no supplemental humidity and/or heat, as is often evidenced from clinical practice.
There is general consensus supporting supplemental heat and humidification in the home for pediatric tracheostomy patients. The goal of supplemental heat and humidity in pediatric long-term tracheostomy patients is to target the normal physiology, which includes a temperature at the carina of approximately 32º to 34º C and approximately 100% relative humidity. The reality and challenges of home care, including insurance coverage guidelines, environmental obstacles, technology obstacles, and cost constraints, will likely prevent many pediatric patients from achieving such idealistic and sometimes unrealistic clinical goals, however. Ensuring airway patency, effective secretion management, and patient comfort may prove to be more practical, achievable, and realistic clinical goals.
Communication is one of the most important considerations associated with the long-term management of patients with a tracheostomy, yet it is often overlooked by many providers. The entire discharge process and transition to home are quite overwhelming for most people. Imagine the added anxiety if you could not communicate effectively. The loss of speech can isolate adult patients and inhibit normal social and communication development in children. There are a number of tracheostomy adjuncts to promote speech, including cuffless tracheostomy tubes, fenestrated tracheostomy tubes, and one-way speaking valves. In my opinion, all home tracheostomy patients should be referred for speech therapy.
Decannulation of long-term tracheostomy patients can be divided into two categories: (1) planned decannulation and (2) accidental decannulation. A common planned decannulation process involves the sequential downsizing of the tube. This process can take several days or weeks and is often dependent on patient stability and tolerance of the procedures. Another planned decannulation is referred to as the one-step method. This method is more comprehensive and includes endoscopic evaluation of the airway and, if clinically indicated, the subsequent removal of the tube. The one-step procedure is considered more intensive and is often performed in the acute care setting followed by 24 to 48 hours of decannulation monitoring. There are no scientific data supporting one method over the other.
Accidental decannulation is simply any unplanned removal of the tracheostomy tube. Such unplanned decannulations can be uneventful or produce a life-threatening situation. There are no published data on the frequency at which this occurs in the home, but common practice is to provide all long-term tracheostomy patients with backup tubes, including tubes that are one to two sizes smaller to be used in the event the primary tube cannot be quickly reinserted.
The management of medically complex and technology-dependent patients in the home will likely continue to increase as health care costs continue to rise. It is clear that, in the absence of high-quality, published science that supports and directs the care of tracheostomy patients in the home, we must rely on the limited data that does exist, along with the consensus statements of the experts, the local practice standards, and, of course, some common sense.
Joseph Lewarski, RRT, FAARC, is vice president of clinical affairs, Inogen Inc, Goleta, Calif.
1. Sherman JM, Davis S, Albamonte-Petrick S, et al. Care of the child with a chronic tracheostomy. this official statement of the American Thoracic Society was adopted by the ATS Board of Directors, July 1999. Am J Respir Crit Care Med. 2000;161:297-308.
2. Respiratory Home Care Working Group. AARC Clinical Practice Guideline. Suctioning of the patient in the home. Respir Care. 1999;44:99-104.
3. Pierson DJ, Epstein SK, Durbin CG Jr, et al. 20th Annual New Horizons Symposium: tracheostomy from A to Z. Respir Care. 2005;50:473-549.
4. Lewarski JS. Long-term care of the patient with a tracheostomy. Respir Care. 2005;5:534-7.
5. Ronczy NM, Lichtenstein MA. Preparing the family for home tracheostomy care. Clin Issues Crit Care (now Advanced Critical Care). 1990;1:367.