Managing a Tracheostomy/Endotracheal Tube Cuff

Nursing Procedure 6.12

Managing a Tracheostomy/Endotracheal Tube Cuff

Maintains minimum amount of air in cuff to ensure adequate ventilation without trauma to trachea
Prevents aspiration

10-mL syringe
Blood pressure sphygmomanometer
Three-way stopcock
Mouth-care swabs, moistener, and mouthwash
Suctioning equipment
Nonsterile gloves
Pen

Assessment should focus on the following:

Size of cuff
Maximum cuff inflation pressure (check cuff box)
Bronchial breath sounds
Respiratory rate and character
Agency policy or doctor's orders regarding cuff care

Nursing diagnoses may include the following:

Ineffective airway clearance related to thick secretions
Risk for aspiration related to use of tracheostomy tube

Outcome Identification and Planning

Desired Outcomes

Sample desired outcomes include the following:

The client's respirations are 14 to 20 breaths/min, of normal depth, smooth, and symmetric.
The client's lung fields are clear.
Minimum occlusive pressure is maintained while cuff is inflated.
The client experiences no undetected tracheal damage.
The client does not demonstrate any signs of aspiration.

Special Considerations in Planning and Implementation

General

Some cuffs are low-pressure cuffs and require minimum manipulation, but the client should still be monitored periodically to ensure proper cuff function.

Pediatric

Tracheal tissue is extremely sensitive in children. Smaller cuffs require lower inflation pressures: Be very careful not to overinflate them.

Home Health

Clients with permanent tracheostomies typically have a cuffless tracheostomy for home use.

Delegation

Management of cuff pressure should not be delegated to unlicensed assistive personnel. Respiratory therapy personnel often manage endotracheal and tracheal cuff pressure.

[Outline]

Desired Outcomes
Special Considerations in Planning and Implementation

Action		Rationale
1	Perform hand hygiene, don gloves, and organize equipment.	Reduces microorganism transfer; prevents contamination of hands; reduces risk of infection transmission; promotes efficiency
2	Check cuff balloon for inflation by compressing between thumb and finger (should feel resistance).	Indicates cuff is inflated
3	Attach 10-mL syringe to one end of three-way stopcock. Attach manometer to another stopcock port. Close remaining stopcock port.	Establishes connection between syringe and manometer
4	Attach pilot balloon port to closed port of three-way stopcock (Fig. 6.21).	Places balloon for use
5	Instill air from syringe into manometer until 10 mm Hg reading is obtained.	Prevents rapid loss of air from cuff
6	Auscultate tracheal breath sounds, noting presence of smooth breath sounds or gurgling (cuff leak).	Determines if cuff leak is present (evidenced by gurgling)
7	If smooth breath sounds are noted
	Turn stopcock off to manometer.
	Withdraw air from cuff until gurgling is noted with respirations.
	Once gurgling breath sounds are noted, insert air into cuff until gurgling is noted only on inspiration.	Provides minimum leak and minimizes pressure on trachea (airway is larger on inspiration)
8	Turn stopcock off to syringe.	Reestablishes a closed system
9	Note manometer reading as client exhales. Record reading (note if pressure exceeds recommended volume; do not exceed 20 mm Hg). Notify doctor if excessive leak persists or if excess pressure is needed to inflate cuff.	Allows reading of pressure in cuff; indicates expiratory cuff pressure identifying minimum occlusive volume (cuff pressure on tracheal wall)
10	Turn stopcock off to pilot balloon and disconnect. If doctor orders intermittent cuff inflation, proceed to Step 11. If not, proceed to Step 12.	Disconnects from system
11	To perform intermittent cuff inflation
	Auscultate tracheal breath sounds, noting presence of smooth breath sounds (cuff inflated) or vocalization/hiss (cuff deflated).	Determines cuff inflation
	If smooth breath sounds are noted, withdraw air from cuff until faint gurgling is noted with respirations. If vocalization or hiss is noted, insert air into cuff until faint gurgling is noted with respirations.	Prevents injury
	Once gurgling breath sounds are noted, insert air into cuff until gurgling is noted only on inspiration.	Provides minimum leak and minimizes pressure on trachea (airway is larger on aspiration)
	Monitor breath sounds every 2 hr until cuff is deflated.	Determines that minimum leak remains present
12	To maintain cuff	Determines if minimum or excessive cuff leak is present
	Every 2–4 hr, check tracheal breath sounds (more frequently if indicated) and note pressure of pilot balloon between fingers.
	Every 8–12 hr, or as per agency policy, check cuff pressure and note if minimum occlusive volume increases or decreases.	Indicates if tracheal tissue damage or softening is occurring or if tracheal swelling is present
	If oral or tube feedings are being given, assess secretions for tube feeding or food particles.	Indicates possible tracheoesophageal fistula
13	To perform cuff deflation	Prepares for removal of secretions pooled on top of cuff; facilitates oxygenation
	Obtain and set up suctioning equipment.	Promotes efficiency
	Enlist assistance and perform oral or nasopharyngeal suctioning (see Nursing Procedure 6.9).	Removes secretions pooled in pharyngeal area
	Set up Ambu bag (if client is not on ventilator and long-term cuff inflation has been used).	Provides for deep ventilations to remove secretions
	Have assistant initiate deep sigh with ventilator, or administer deep ventilation with Ambu bag as you remove air from cuff with syringe.	Pushes pooled secretions into oral cavity as cuff is deflated
	Suction pharynx and oral cavity again.	Removes remaining secretions
14	Perform mouth care with swabs and mouthwash.	Promotes client comfort
15	Apply lubricant to client’s lips.	Promotes comfort
16	Restore or discard all equipment appropriately.	Reduces transfer of microorganisms among clients; prepares equipment for future use
17	Remove and discard gloves and perform hand hygiene.	Reduces microorganism transfer
18	Position client for comfort and place call light within reach.	Promotes comfort and safety; facilitates communication

Were desired outcomes achieved? Examples of evaluation include

Desired outcome met: Client's respirations are 14 to 20 breaths/min, of normal depth, smooth, and symmetric.
Desired outcome met: Client's lung fields are clear.
Desired outcome met: Tracheal tube cuff with 15 mm Hg minimum occlusive pressure.
Desired outcome met: Client experiences no undetected tracheal damage.
Desired outcome met: Client does not demonstrate any signs of aspiration.

The following should be noted in the client's record:

Cuff pressures and tracheal breath sounds
Suctioning performed and nature of secretions
Tolerance to procedure (changes in respiratory status and vital signs)
Cuff deflation and inflation

section name header

Purpose ⬇

Equipment ⬆ ⬇

Assessment ⬆ ⬇

Nursing Diagnoses ⬆ ⬇

Outcome Id ⬆ ⬇

Implementation ⬆ ⬇

Evaluation ⬆ ⬇

Documentation ⬆