Guillaume Buiret1*, Laura Gautheron2 and Hélène Labrosse-Canat2
1ENT department and head and neck Surgery, Association Francophone des Soins Oncologiques de Support, Hospital of Valence, 179 Boulevard du Maréchal Juin, 26953 Valencia, France
2Regional Network of Cancer, Association Francophone des Soins Oncologiques de Support, Bio Park / Adenine, 60 Avenue Rockefeller, 69373 Lyon Cedex 08, France
Received: 01 November, 2016; Accepted: 08 November, 2016; Published: 09 November, 2016
Guillaume Buiret, ENT Department, Valencia Hospital, 195 Boulevard Marécal June, 26953 Valencia, France, Tel: +33475757575; Fax: +33475757110: E-mail:
Buiret G, Gautheron L, Labrosse-Canat H (2016) Tracheotomy/Tracheostomy Management at Home and in Care Centers. Arch Otolaryngol Rhinol 2(1): 061-069. DOI: 10.17352/2455-1759.000027
© 2016 Buiret G, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Tracheotomy; Tracheostomy; Care management; Supportive care
Aim and objectives: Formalize a consensus about patient’s care management (nursing techniques, management of complications) with tracheotomy or tracheostomy at home and in care center.
Background: Tracheotomy and tracheostomy are medical devices used for many years thus inspiring fear mainly by their symbolic impacts and the lack of training of health professionals.
Design: This study is a mixed research with a qualitative methodology including iterative focus groups.
Methods: A national call for project was performed on Internet to recruit multi-professional volunteers early 2015, anyone was accepted. Seven phone call with focus groups, each 2 hours, were set during 2015. Finally the project was presented and validated in “Guidelines and French Oncology Networks” J2R congress in Nantes, France in December 2015 and published on the web.
Results: Definitions, anatomic and physiologic notions, then the different types of cannulas are presented in the document. The management of tracheotomy/tracheostomy daily cares with protocols and videos, of the complications (infections, bleeding …), of functional sequelae (phonation, swallowing) at home and in care centers is then explained and demonstrated.
Conclusions: Finally, this work has led to a national consensus on the management, at home and in care centers, of tracheotomy and tracheostomy management and their potential complications.
Relevance to clinical practice: Such a work has never been done before. It aims to be comprehensive and didactic by means of figures and decision trees. This study will be useful and could be implemented despite local habits.
Tracheotomy and tracheostomy are medical devices used for many years. This technique was first described during the second century AD by Galien and Aretaeus of Cappadocia . Even though a tracheostomy is performed only in an oncological purpose, there are many reasons of performing a tracheotomy (oncological or neurological fields, after a prolonged intubation in Intensive Care Units…). However those devices are still inspiring fear which is mainly caused by their symbolic impacts (speech, swallowing, breathing, appearance) and the lack of training of healthcare professionals in use of such devices. After leaving their specialized center (surgery or rehabilitation center), patients and their caregivers are forced to fend for themselves or under care of inadequately trained medical and paramedical professionals. This means a lot of distress on the patient’s side but also on the health professional’s side and a frequent refusal of care.
Very little objective data concerning the care management of patients suffering from local habits are reported in the specialized literature.
The aim of this national working group was to formalize a consensus on care management (nursing techniques, management of complications) of patients with tracheotomy or tracheostomy at patients’ home and in care centers, whatever the cause of tracheotomy / tracheostomy is, benign or malignant.
This study is a mixed research  combining both quantitative and qualitative researches. Furthermore, the methodology of a qualitative research with iterative focus groups was applied and the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist is reported in Table 1.
Setting / Participants
The group was supported by the French Association for Supportive Care in Oncology (AFSOS) and the Regional Oncology Network of Rhone Alps, Lyon, France. A national call for project was performed on Internet to recruit multi-professional volunteers at the beginning of 2015, anyone was accepted.
The multi-professional group includes two nurses in primary care centers, six nurses in tertiary centers, one ENT surgeon in secondary center, two ENT surgeons in tertiary centers, one oncologist in tertiary center, one General Practitioner in primary center, one resuscitator in tertiary center, one pharmacist, and one dietician.
Seven phone call with focus groups, each 2 hours, were set during 2015. Minutes performed during each meeting to modify the text which has been send by email to each participant before the next meeting.
Approval by every member of the focus group, another national call for the project was performed to recruit new readers to improve its quality. Then interregional guidelines have been reworked by new experts, submitted and approved during the “Guidelines and French Oncology Networks” congress in Nantes, France in December 2015. Finally they were published on AFSOS and regional oncology networks websites.
Definitions, anatomic and physiologic notions: They are presented in Table 2.
Different types of cannulas: Many types of cannulas exist. Eight different types can be described according to three options: with vs without (disposable or reusable) inner cannula (IC), cuffed vs cuffless and fenestrated vs non-fenestrated. For instance a cuffed fenestrated with an IC can be found, as well as a cuffless non-fenestrated without IC.
- Cannulas with and without IC
IC allows easy cleaning of sputum without removing the outer cannula (OC). It is therefore recommended to use IC for daily use.
Cannula without IC are common in intensive care units for sedated patients and when the caregivers are aware of the suction process and cleaning cares.
Shapers, with a wide collar and without IC, are used after total (pharyngo) laryngectomy to avoid tracheostomy stenosis.
- Cuffed and cuffless cannulas
A cuff protects the lungs from fluid leakage. Therefore it is recommended if there is a risk of bleeding (just after the operation for instance), of swallowing disorder (after head and neck surgery or neurological diseases) or of major gastroesophageal reflux.
The cuff can be inflated temporarily in risk situations (swallowing for example) and deflated the rest of the day. When the cuff is inflated and unless the cannula is fenestrated a valve must not be absolutely used (risk of asphyxia).
The gold-standard method of cuff-inflation is a manometer control: the cuff must be 20 to 25-cmH2O air-inflated. Under than 20cmH2O, cuff is not sealed; over than 25cmH2O, i.e. more than capillary pressure, mucosal necrosis then stenosis are possible. When there is no manometer available (especially at the patient’s home), the necessary air volume of air is a necessary parameter which must be transmitted from the health institution nurse to the home nurse. Alternatively the cuff can be air-inflated while the patient is speaking. When the patient is not able to speak, the cuff is filled-in enough. Very anecdotally (hyperbaric chamber) the cuff can be inflated with sterile water (volume determined by the ENT surgeon). A special attention must be paid in case of accidental cuff rupture due to the risk of aspiration.
Cuffless cannulas are more lightweight, allow speaking and must preferably be used when there is no risk of aspiration.
- Fenestrated and non-fenestrated cannulas
A fenestrated cannula has a window top-directed, facilitating the path of the airflow through the larynx (Figure 1C). The main convenient cannula for that purpose is a cuffed fenestrated with IC system with patient who swallows the wrong way. Two IC are provided: a fenestrated one and a non-fenestrated one. When the patient wants to speak, even if the cuff is filled-in, the fenestrated IC must be used. When the patient wants to eat, the non-fenestrated IC avoids aspiration.