Tracheostomy Care - Essay Example

Tracheostomy Care Introduction: Tracheostomy is the most common surgical procedure that is performed on the critically ill. Tracheostomy enabled patients to be taken of mechanical ventilation earlier, leading to their early transfer to general wards. This has enhanced the relevance of tracheostomy care in healthcare environments. Literature Review: Tracheostomy is performed to overcome obstructions in the upper airways or to prolong ventilation in the critically ill patients. Open surgical tracheostomy (ST) and percutaneous dilatational tracheostomy (PT) are the two tracheostomy procedures used. Irrespective of the procedure, outcome of the patients with a tracheostomy is dependent on the care that they receive. The main objectives in tracheostomy care maintaining the patency of the airway and prevention of infection. There are seven elements to tracheostomy care, namely, education and training, communication, swallowing and nutrition, stoma care, tracheostomy tube management, suctioning and humidification. With care of patients the responsibility of the nursing profession, the onus of tracheostomy care in all its requirements becomes that of the nursing profession. This has implications for the nursing profession in terms of education and training to develop skills pertinent to tracheostomy care. Findings: Tracheostomy care is no longer a specialist function only. Tracheostomy care is complex. Nursing professionals have a main role to play in tracheostomy care. This makes education and training to enhance tracheostomy care skills among nursing professionals crucial to the outcome of patients with a tracheostomy. Discussion: Tracheostomy care skills in general ward and primary care nursing professionals need to be enhanced considerably. This means making it a part of the curriculum in nursing schools and also creating education and training programs on tracheostomy care within the health care environment or in more formal environments to meet the requirements of adequate tracheostomy care skills in fresh nursing professionals and the existing nursing professionals. Conclusion: Tracheostomy care is no longer a specialist care function. Introduction: The Best Practice Statement, 2007, of the NHS Scotland on caring for a patient with tracheostomy, defines tracheostomy as “an opening in front of the trachea that can be temporary or permanent”. Tracheostomy has been traditionally employed essentially in emergency situations for the management of upper airway obstructions and managed by skilled professionals. However the use of tracheostomy with has enlarged to include prolonged ventilation, chronic respiratory insufficiency, failure of airway protective reflexes, management of excessive secretions, and obstructive sleep apnoea (Reagan & Hunt, 2008). One of significant reasons for the enhanced use of tracheostomy is the advantages in the form of lower airway resistance smaller dead space, less movement of the tube, greater patient comfort and more efficient suction over endotracheal intubation (Solh & Jafaar, 2007). According to Casserly et al, 2007, tracheostomy has become the most commonly conducted procedure in critically ill patients, where it is performed most often on patients requiring prolonged ventilation, frequent suctioning for broncho-pulmonary toilet or for overcoming obstruction in the upper airways. The indications for the use of tracheostomy have increased as with advances in medical science, the ability to keep alive critically ill patients has increased significantly. This has resulted in about two-thirds of the tracheostomy procedures being performed on critically ill patients managed in the intensive care units (Casserly et al, 2007). However tracheostomy is not without risks. Serious complications that are associated with tracheostomy include tracheal stenosis, bacterial colonization and fatal haemorrhage (Solh & Jafaar, 2007). Besides decannulation and management of acute and life-threatening complications, tracheostomy tube displacement is an issue of serious concern. These factors increase the emphasis on proper tracheostomy care (Casserly et al, 2007). Adequate tracheostomy care becomes even more relevant taking into consideration that the benefits of tracheostomy enable the earlier transfer of patients from critical care environments to the normal wards that may not offer the traditional specialist skills involved in tracheostomy care (Tobin & Santamaria, 2008). Lewis and Oliver, 2005, put this in the right perspective, when they point out that number of patients with tracheostomy under care in normal ward setting has increased in recent times, with intensive care clinicians using tracheostomy as the means for early weaning from mechanical ventilation. This has resulted in ward staff facing the challenges of providing specialist tracheostomy care required by such patients with increasing frequency. Reflecting this concern, The Best Practice Statement, 2007, of the NHS Scotland acknowledges the need for all healthcare workers to take up the professional responsibility of ensuring that they possess knowledge and skills required to provide satisfactory care for patients who have undergone a tracheostomy procedure. It is in this context that this paper briefly evaluates tracheostomy and the care requirements involved in patients with tracheostomy. Literature Review: Tracheostomy: An artificial opening made into the trachea through the neck is known as tracheostomy. A tracheostomy procedure is performed for two reasons. The first reason is to bypass or overcome any possible or actual hindrances to the functioning of the upper airways. Such situations can arise from several causes that include tumour, congenital abnormality, inflammation, trauma that has resulted from an accident or surgical procedure, foreign bodies, and vocal cord paralysis. The second reason for the use of a tracheostomy is to aid and prolong ventilation that may be required due to coma, neurological disorders, chronic pulmonary disease and multiple injuries (South Durham Health Care NHS Trust, 2001). There are two approaches to tracheostomy and the tracheostomy may be of temporary or permanent nature. The first is the older open surgical tracheostomy (ST) procedure that is normally undertaken in the operation room by ear nose and throat surgeons. The more recently developed percutaneous dilatational tracheostomy (PT) is the second approach. PT has found increasing use particularly at the bedside of critically patients in the intensive care units, negating the need for moving the patient to the operation room. Irrespective of the method used there are complications associated with tracheostomy, which calls for understanding the care requirements of patient, who have undergone a tracheostomy procedure (Casserly et al, 2007). There is insufficient data to prove the safety superiority of either of the two approaches. All that can be gleaned from currently available data is that PT may be as safe as ST, when taking into consideration the short-term post-operative complications. Assessment of long-term post-operative complications is again hazy, as there is insufficient data available for comparison (Slushy, 2002) Key areas in the use of tracheostomy are the intensive care units managing the critically ill, as the procedure has evolved as one of the means of keeping many of these patients alive. This has resulted in the intensive care units being the scene of nearly two-thirds of all tracheostomy procedures (Casserly et al, 2007). Tracheostomy also assists the intensive care clinicians to wean the patients from mechanical ventilation earlier and this leads to such patients being transferred to the general ward, away from the specialist tracheostomy care available in the intensive care units. As a consequence ward staff are challenged to take up the specialized care that patients with a tracheostomy need, bringing into focus the requirement for adequate tracheostomy care at the ward level away from where areas, where such specialized care has been made available in a healthcare institution (Lewis & Oliver, 2005). Tracheostomy Care: There are several objectives to tracheostomy care, which are the maintenance of airway patency and through the removal of mucus and encrusted secretions, promoting cleanliness to prevent infection and preventing skin break down at the stoma site (Craven & Himle, 2006). There are several elements involved in tracheostomy care. The guidelines for tracheostomy care of the National Health Service (NHS) categorizes these elements of tracheostomy care into education and training, communication, swallowing and nutrition, stoma care, tracheostomy tube management, suctioning and humidification (NHS, 2007). Education and Training: Education and training needs to be looked at from two perspectives. The first perspective is that the increased number of patients who have undergone a tracheostomy process is on the increase and this calls for health care staff to be adequately educated and trained to meet the needs of these patients. The second perspective is that a tracheostomy may be of permanent nature. In such cases there is the need for patients and their carers to be educated on the implications of tracheostomy on changes in the life conditions of the patient and the support requirements. In addition patients and their carers would have to be trained in tracheostomy care that will have to be provided outside the clinical environment at home after discharge from the hospital environments (NHS 2007). Communication: A tracheostomy leads to communication problems, which is a significant issue in patients with a tracheostomy. The implications of the loss of communication should be taken seriously. Developing an alternate means of communication is a vital element in the care of the patient with a tracheostomy (NHS, 2007). There is evidence to show that several benefits result from overcoming the communication difficulties that these patients face. These benefits include providing a psychological boost to the patient, permits the patient to communicate and interact with the health care staff and may assist in the patient recovering the ability to smell and taste. Hence several methods have been developed to facilitate speech in such patients and based on the assessment of the individual patient, the most suitable method be employed (Reagan & Hunt, 2008). For a patient with a tracheostomy to attempt speech, the patient should be capable of tolerating periods of cuff deflation without the problem of respiratory compromise and without the risk of gross aspiration. In such a patient that is spontaneously breathing, the simplest means to aid communication is through cuff deflation, which allows air to pass around the tracheostomy and through the vocal cord apparatus. A fenestered tracheostomy tube permits the maximum flow of air and should the tube be too big, the possibility of reducing the size the tube needs to be considered. Another option is to employ a one-way speaking valve with the tracheostomy tube to maximize the possibility of speech ability of the patient (Reagan & Hunt, 2008). In encouraging patients with a tracheostomy to overcome speech difficulties the speech and language therapist has a key role to play (NHS, 2007). Swallowing and Nutrition: According to Russell, 2005, the presence of the tracheostomy tube in a tracheostomy is the main reason that makes it difficult for the patient to swallow. This impediment in swallowing has a detrimental effect on the patient’s ability for oral feeding with the patient showing reluctance to consume food, thereby affecting the nutritional requirements of the patient negatively. Tracheosotomy care includes monitoring the oral intake of food and assessing whether the nutritional requirement of the patient is being met and taking the necessary steps to provide adequate nutrient intake. These measures include nutrients being provided intravenously, when there is an elevated requirement of respiratory support (Russell, 2005). The difficulty caused by the tracheostomy tube in swallowing arises from two reasons. The first reason is the weight of the tracheostomy tube restricting laryngeal elevation during swallowing and the second reason is that the cuff may protrude into the oesophagus. Evidence is lacking on the appropriate regimen to be applied for initiating trial feeding. However, at many of the health care centres the practice is to initiate trial feeding regimens even when the tracheostomy tubes are present, provided the patient has low oxygen and respiratory support requirements and is found not to drool (Reagan & Hunt, 2008). The NHS guidelines on swallowing and nutritional support for patients with a tracheostomy include a nursing assessment of the swallowing function in the patient and deciding when to involve the assistance of a language and speech therapist and a dietician, based on knowledge and experience derived from training. The role played by the language and speech therapist is to assess swallowing based on the history of the patient from nursing records of the function and physical examination of the swallowing function. The role of the dietician is to assess the nutritional needs of the patient (NHS, 2007). Stoma Care: The objective in care of the stoma is to facilitate healing at the earliest by providing a clean and dry stoma site. Keeping the stoma site clean and dry involves the requires ensuring that any secretions are removed regularly in keeping with individual patient situations, so that these secretions do not lie close to the skin and cause excoriation, which provides a focal point for infection to set in (South Durham Health Care NHS Trust, 2001). Critical elements of stoma care that need to be kept in mind are that patients with a tracheostomy have an elevated risk of infection. Effective management of the stoma assists in preventing peristomal infection and irritation. The normal time taken for the formation of a clearly defined tracheal tract is five to seven days after the tracheostomy procedure. Removal of any sutures present is after seven to ten days after the procedure and varies according to the nature of the procedure. Should radiotherapy be a part of the treatment procedure there probability of the skin integrity being compromised is high calls for even more skilled assessment and evaluation of the stoma site. Specialist assistance will be required in these cases to provide adequate assessment and evaluation of the stoma site. The frequency of stoma care of patients with a tracheostomy is based on individual patient requirements. Stoma care in the intensive care environment and ward environment differ from the community environment after the discharge of the patient and healthcare staff providing stoma care and discharge education to the patients and their cares should be aware of this (NHS, 2007). Tracheostomy Tube Management: The tracheostomy tube is the tube that is inserted to keep the tracheostomy. The material used in tracheostomy tubes is either plastic or silver. Tracheostomy tubes come in different categories and are used selectively in tracheostomy based on the requirements and the patient. The different categories of tracheostomy tubes include single and double cannula tubes, fenestered and unfenestered tubes and adjustable tracheostomy tubes. An understanding of the different kinds of tracheostomy rubes is necessary for proper tracheostomy tube management (Reagan & Hunt, 2008). Tracheostomy tubes need to be changed as they may get blocked with debris like mucus and blood. The objective of the tracheostomy tube change is to maintain a clear airway through changing the tracheostomy tube that is blocked by debris. The frequency of changing of the tube varies based on the kind of secretion and its quantity. Good knowledge and skills are required for satisfactory changing of tracheostomy tubes and hence only trained and competent healthcare personnel are involved in tracheostomy tube change (South Durham Health Care NHS Trust, 2001). There is a dearth of evidence to provide clear guidance on the periodicity for changing the tracheostomy tube (Reagan & Hunt, 2008). The NHS guidelines on best practices have however set certain parameters for tracheostomy tube change based on the material of the tracheostomy tube used and the type of procedure. The initial tube change is highly risky requiring the involvement of highly skilled healthcare personnel under medical direction. The initial tube change, where necessary, is done only after three to seven days in the case of the ST and only after a minimum period of seven days in the case of PT, when a tracheostomy tube with no inner cannula is used. However, the recommendation is to use double cannulated tubes in all possible patients with the exception of patients with a minitracheostomy and in paediatric patients, thereby reducing the complications that are likely to accompany an early initial tracheostomy tube change (NHS, 2007). Normally the insertion tract remains poorly formed for approximately a week after the tracheostomy procedure and changing the tracheostomy tube before this period of time would lead to encountering difficulties. Subsequently changing of tracheostomy tubes is less demanding and medical direction may be superfluous (Reagan & Hunt, 2008). It is advisable to have the patient to have a spare tracheostomy tube readily available for changing of the tracheostomy tube. Tracheostomy tubes with inner cannulae need to be changed only after 29-31 days based on the instructions of the manufacturer. Cleaning and changing of tracheostomy tubes are guided by the manufacturer instructions and the infection prevention policy followed by the individual healthcare institutions. In cleaning the plastic tracheostomy tubes brushes are not to be used unless advised by the manufacturer. The inner cannula tube is cleaned using warm water and air-dried in keeping with the need to prevent infection. All patients with a tracheostomy using inner cannulae have to be assessed on an individual basis to decide on the inner cannula tube care requirements. In the case of silver tracheostomy tubes, which do not have an inner cannula the tube needs to be changed once in five to seven days (NHS, 2007). The inner cannula tube will have to be cleaned at a minimum of four times a day normally in the morning after waking, at lunchtime, at tea time and prior to going to sleep at night. The frequency may increase based on the individual assessment of the patient in terms of excessive secretion and formation of crusts (South Durham Health Care NHS Trust, 2001). There is the requirement for all cuffed tracheostomy to have their pressure checked twice daily using a manometer. The pressure of the cuff needs to be maintained between 15 -30 cm of H2O, measured by the manometer (NHS, 2007). Equipment that is used for tracheostomy tube cleaning or replacement has to be readily available for satisfactory tracheostomy care and include sterile dressing pack, tracheostomy dressing, clean tape, normal saline, lubricating jelly, disposable plastic apron, sterile gloves, medicated hand wash, clinical waste bag, tracheal oxygen suction equipment, and spare tracheostomy dilators. (South Durham Health Care NHS Trust, 2001). In addition to these standard equipment required for tracheostomy tube cleaning and replacement, additional equipment that needs to be readily accessible include a cuffed and uncuffed tracheostomy tube of the same size as used by the patient and a tracheostomy tube a size smaller than the one used by the patient, stitch cutters and a10 ml syringe (NHS, 2007). Suctioning: The objective of suctioning is to ensure that tracheal secretions are removed. Removal of tracheal secretions maintains a patent airway, making sure that adequate oxygenation and ventilation of the patient occurs. An additional objective of suctioning is to prevent infection. There is hardly any benefit in routine suctioning (South Durham Health Care NHS Trust, 2001). This means that the frequency of suctioning is based on individual patient assessment for the requirement of functioning. Suctioning is employed only when a patient with a tracheostomy is unable to clear their own airway effectively. The emphasis during suctioning should be to maximize removal of secretions and minimize damaging any tissues and hypoxia. Prior to initiating suctioning proper hand wash hygiene routine needs to be followed and personal protective equipment must be worn during suctioning. These steps are necessary as infection prevention precautions. Suctioning equipment must be positioned for easy accessibility and checked regularly for proper functioning. Patients with a tracheostomy demonstrating difficulty in clearing their own secretions could be helped through a referral to a physiotherapist (NHS, 2007). Suctioning should not exceed ten second at a time. The recommended suction pressure is no less than 120 mmHg and should not exceed 200 mmHg. The upper limit is meant only for adults and to be used only if necessary. As far as possible the lowest effective pressure should be used for suctioning, which can be ascertained through individual patient assessment (NHS, 2007). Even lower suction pressures are recommended for use in children based on evidence suggested from research In the case of adolescents the recommended suction pressure is between 80-120mmHg. For children these recommendations are between 80-100 mmHg, while in the case of neonates the suction pressure ranges are 60-80 mmHg (Ireton, 2007). Humidification: A tracheostomy by passes the breathing processes of the upper airway, whereby natural humidification of the air takes place. This has negative consequences for the patient. Breathing of dry gases could lead to the damage of the respiratory cilia and epithelium. In addition there is the possibility of secretions drying out and blocking the tracheostomy lumen. To prevent these negative implications it is essential that patients with a tracheostomy are given humidified and preferably heated gases if they are being provided supplemental oxygen. When such patients are breathing room air suitable nose devices that have a heat and moisture exchanger can be used (Reagan & Hunt, 2008). Extra care needs to be taken when a cuffed tracheostomy tube has been used for the patient. In such patients the additional risk of airway obstruction necessitates the placing of a T-piece during delivery of nebulised drugs or humidified gas. It must be remembered that humidification systems used are a potential reservoir for infection. In addition the humidification system used or a patient with a tracheostomy is based on the appropriate choice for each individual patient, subsequent to risk assessment and managed in the right manner based on the protocols and the infection control policies of the health care institution. Patients discharged with a tracheostomy will need to continue humidification at home. A range of products are available for this purpose and it may be necessary for guiding the patient and the family in making the appropriate choice and using the equipment correctly (NHS, 2007). Tracheostomy Care Implications for Nursing: Tracheostomy care is no longer a specialized nursing care function. Such a contention arises from the increased number of patients with a tracheostomy and the intensive care clinicians employing this practice to assist in the early weaning of patients from mechanical ventilation, leading to many of such patients with a tracheostomy requiring tracheostomy care in the wards, with their transfer from the intensive care units to the wards. Ward nurses thus become associated with tracheostomy care and these nursing professionals are now required to perform a function that was essentially a specialist function formerly (Lewis & Oliver, 2005). Caring for a patient with a tracheostomy is demanding as it is multi-dimensional. To understand the impact of the tracheostomy on the respiratory system it requires a thorough knowledge of respiration, methods of humidification and suctioning techniques. The tracheostomy has a negative impact on the several normal body functions like swallowing and communication. This means besides knowledge of the anatomy and physiology of the respiratory system and humidification, suctioning and tracheostomy tube changing techniques, the nursing professional needs an understanding of the impact of tracheostomy from a larger perspective. This brings into relevance the requirement of adequate education and training for nursing professionals to equip them with the appropriate knowledge and skills that will be required to support the unique needs of patients with a tracheostomy to provide better outcomes for these patients (Russell, 2005). Tracheostomy care is a complex activity of the nursing professionals. There is evidence that tracheostomy care occurs without uniformity and with a certain amount of confusion among the nursing professionals on the correct techniques to be employed in tracheostomy care, particularly in environments outside specialist nursing care. Such a situation may be because some of the evidence on the correct techniques to be used for tracheostomy care may be contradictory, leading to the nursing professionals relying on their individual judgements on the correct procedures to be used in tracheostomy care. Nurses are responsible and accountable for the care provided to patients with a tracheostomy and this makes it essential that the nursing professionals on relevant aspects of tracheostomy care including assessment of patients individual requirements, tracheal suctioning, suction pressure, suction catheters and humidity (Buglass, 1999). Evaluation of competency of nursing care in patients with a tracheostomy even in an intensive care unit show discrepancies in the practices employed without any significant difference in competencies with several years of experience in the intensive care units. This highlights the need for specific training in tracheostomy care procedures (Gonzalvez et al, 2004). Tracheostomy care is a multi-disciplinary exercise. A key role performed in tracheostomy care by nursing professionals in the multi-disciplinary approach, is the coordination of the various disciplines involved in providing care to patients with a tracheostomy. In addition it is the general ward nursing professionals that are most involved in educating patients prior to discharge. There is disparity among nursing professionals with regard to their comfort, willingness and knowledge of outpatient tracheostomy care (Garner, Shoemaker-Moyle & Franzese, 2007). Within the acute care and general ward settings discharges of patients with a tracheostomy are delayed due to the lack of knowledge and confidence in caring for patients with a tracheostomy. In the primary care setting the issue lies with the lack of support for patients, carers and health care staff. Nursing professionals across the acute care, general ward and primary care settings require taking advantage of the training sessions on tracheostomy care provided to ensure early discharge of patients with a tracheostomy (Strategic Health Authority, 2005). Methodology: The methods involved in sourcing the relevant articles included searching the local libraries for books and articles that provided information on the topic and using the Internet subsequently to provide more articles on the subject. The Internet was used to access the medical databases of Medscape, Medline, PubMed and BioMed and the Google search engine was used to access available guidelines on tracheostomy care. Search terms included “tracheostomy”, “tracheostomy care”, “implications of tracheostomy care on nursing”, “guidelines on tracheostomy care” “NHS guidelines on tracheostomy care”, DOH guidelines on tracheostomy care”, ‘royal college of nursing guidelines on tracheostomy care and NICE guidelines on tracheostomy care. Several books and articles were found and the articles were screened to provide fifteen articles suitable for the topic. To keep the information found from the articles as relevant to the current state of tracheostomy care, it was decided to include only books and articles published not later than ten years back. Hence all books and articles published prior to 1999 were excluded and only suitable articles published from 1999 onwards were included. Findings: Tracheostomy is performed to overcome obstructions in the upper airway or to aid and prolong ventilation in certain patient conditions (South Durham Health Care NHS Trust, 2001). Irrespective of the method used a patient with a tracheostomy needs to be cared for to prevent complications (Casserly et al, 2007). Maintenance of airway patency and prevention of infection air the main objectives in tracheostomy care (Craven & Himle, 2006). Sufficient evidence is not available on some the appropriate procedure to adopt in some aspects of tracheostomy care (Reagan & Hunt, 2008). However, the NHS has laid down guidelines for best practice in tracheostomy care (NHS, 2007). Tracheostomy care is a complex process that consists of several elements requiring high training and skill in the procedures involved. (NHS, 2007). Care of patients with a tracheostomy is not restricted to the acute care environments, where specialist care is available, but is gradually becoming a frequent occurrence in the general wards, which offers a challenge to the general ward staff (Lewis & Oliver, 2005). Nursing plays a critical role in tracheostomy care, which involves several aspects of it. This includes assessment of the individual needs of a patient with tracheostomy, (NHS, 2007), skilled in the several aspects of tracheostomy care (Buglass, 1999), coordination of the several disciplines involved in the care of a tracheostomy patient, and educating the patient and the family on the tracheostomy care that needs to be provided at home on discharge of a patient with a tracheostomy (Garner, Shoemaker-Moyle & Franzese, 2007). Yet, there is a deficiency in the competence and confidence among nursing professionals in tracheostomy care (Gonzalvez et al, 2004). These factors emphasize the requirement for enhanced education and training for the nursing professionals on tracheostomy care (Russell, 2005). Nursing professionals across the acute care, general ward and primary care settings require taking advantage of the training sessions on tracheostomy care that is being provided (Strategic Health Authority, 2005). Discussion: With the onus of tracheostomy care become more relevant to general wards, tracheostomy care is no longer a specialist care responsibility only. This means that general ward staff need to be equipped with the knowledge of the various aspects of tracheostomy and the provided with training to be skilled in providing satisfactory care to patients with a tracheostomy in all aspects, so that patients can be assessed for their individual tracheostomy care needs and provided with the same, improving the outcomes for these patients. In addition the general ward staff there is also the requirement to enhance the knowledge and skill levels of the community care staff on tracheostomy care, as it is their support that will be essential for the care of patients with a tracheostomy on their discharge from the hospital environment, irrespective of the education and training that will be provided by the general ward staff at the time of discharge. Meeting the education and training needs of these healthcare professionals will need to be wide ranged in making it a part of the curriculum of these staff, so that the fresh health care personnel become more proficient in tracheostomy care requirements. For existing health care staff it will be necessary to create facilities whereby the existing are provided with education and training within the health care environment that they work in or outside in more formal environments and the health care staff should be encouraged to participate in such education and training programs or courses. Guidelines for tracheostomy care have been created and the health care personnel need to be made aware of these guidelines. There is a lack of clarity in some areas of tracheostomy care and studies to produce evidence that brings clarity need to be encouraged. Conclusion: Tracheostomy care is no longer an area of health care that is in the realm of the specialists, but has enlarged to become a part of the general ward responsibilities.. General ward and primary care health care personnel have to be made adept at tracheostomy care for better outcomes for patients with a tracheostomy. Literary References Buglass, E.1999, ‘Tracheostomy care: tracheal suctioning and humidification’, British Journal of Nursing, vol.8, no.8, pp. 500-504. Casserly, P., Lang, E., Fenton, J. E. & Walsh, M. 2007, ‘Assessment of Healthcare Professionals Knowledge of Managing Emergency Complications in Patients With a Tracheostomy’, British Journal of Anaesthesia, vol.99, no.3, pp.384-388. Craven, F. R. & Himle, J. C. ‘Fundamentals of Nursing’, Fifth Edition, Lippincott, Williams & Wilkins, Philadelphia. Garner, J. M., Shoemaker-Moyle, M. & Franzese, C. B. 2007, ‘Adult outpatient tracheostomy care: practices and perspectives’, Otolaryngology and head and neck surgery, vol.136, no.2, pp.301-306. Gonzalez, A. N., Mingo, M. A., Sagardoy, E. M., Coscojuela, M. M. A. & Erro, A. M. C. 2004, ‘Assessment of practice competence and scientific knowledge of ICU nurses in the tracheal suctioning’, Enfermeria intensive, vol.15, no.3, pp.101-111. Ireton, J. 2007, ‘Tracheostomy suction: a protocol for practice’, Paediatric nursing, vol.19, no.10, pp.14-28. Lewis, T. & Oliver, G. 2005, ‘Improving tracheostomy care for ward patients’, Nursing standard, vol.19, no.19, pp.33-37. NHS Scotland. 2007. ‘Best Practice Statement – Caring for the patient with a tracheostomy’, [Online] Available at: http://www.nhshealthquality.org/nhsqis/files/TRACHEOREV_BPS_MAR07.pdf (Accessed August 3, 2008). Reagan, K. & Hunt, K. 2008, ‘Tracheostomy Management’, Continuing Education in Anaesthesia, Critical Care & Pain, vol.8, no.1, pp.31-35. Russell, C. 2005, ‘Providing the nurse with a guide to tracheostomy care and management’. British Journal of Nursing, vol.14, no.8, pp.428-433. Slutsky, S. A. 2002, ‘Does Tracheostomy Improve Outcomes in Critical Care Patients? Medscape Today, [Online] Available at: http://www.medscape.com/viewarticle/443572 Solh, E. A. A. & Jafaar, W. 2007, ‘A Comparative Study of the Complications of Surgical Tracheostomy in Morbidly Obese Critically Ill Patients’, Critical Care, Vol.11, no.1, Biomed Central Ltd., Medscape Today [Online] Available at: http://www.medscape.com/viewarticle/554054 (Accessed August 3, 2008). South Durham Health Care NHS Trust. 2001, ‘Tracheostomy Care’, [Online] Available at: http://www.ndhc.nhs.uk/foi/content/parttwo/class08/docs/ClinGuide/MANAGEMENT%20OF%20A%20PATIENT%20WITH%20A%20TRACHEOSTOMY.pdf (Accessed August 3, 2008). Strategic Health Authority. 2005, ‘Multidisciplinary Teaching around Tracheostomy Care’, NHS, [Online] Available at: http://www.nscsha.nhs.uk/directorates/workforce/projects/critcare/projects/mutlidisc_tracheo.html (Accessed August 3, 2008). Tobin, E. A. & Santamaria, D. J. 2008, ‘An Intensivist-led Tracheostomy Review Team is Associated With Shorter Decannulation Time and Length of Stay: A Prospective Cohort Study’, Critical Care, Vol.12, no.2, Biomed Central Ltd., Medscape Today [Online] Available at: http://www.medscape.com/viewarticle/575833 Read More