Tracheostomy Management

1. Overview and Anatomy

What is a Tracheostomy?
 The surgical opening of the trachea through the
tissues of the anterior neck
 Made surgically or percutaneusly (see ‘types of
surgery and complications /risks of tracheostomy’
section)
 Involves the placement of a plastic or metal tube
into the trachea to create an airway
 Inserted between the 2nd and 3rd, or the 3rd and
4th tracheal rings, and is therefore below the vocal
cords and above the carina
 A tracheostomy may be temporary or permanent

Indications for insertion/use of Tracheostomy tubes:

 Where there is an obstruction of the upper airway e.g. vocal cord paralysis, tumour,
upper airway oedema or trauma (i.e. to reduce the work of breathing required by the
patient).
 Sputum clearance/removal of secretions via suctioning
 Facilitate weaning from positive pressure ventilation (post acute respiratory failure or
prolonged)
 Airway protection to prevent/minimise aspiration
 To provide adequate oxygenation and ventilation to the lungs.

Type of Surgery:
Percutaneous Tracheostomy
• carried out in ICU by experienced medical officers, to enable removal of ETT and transfer of
mechanical ventilation route
• performed under bronchoscopic guidance, using serial dilators over a guide wire to create a
stoma.
• smaller tracheal stoma formed, therefore will close more quickly, 4-6 hours post
decannulation
• decreases the need to transport critically ill patients out of the ICU to OT for a surgical
tracheostomy
• not performed on patients with anatomical abnormalities of the upper airway, eg enlarged
thyroid or a systemic coagulopathy

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Surgical Tracheostomy

• Performed for patients with unusual neck/laryngeal anatomies or coagulopathy

Cause Examples

Subglottic or upper tracheal stenosis, laryngeal web, laryngeal cysts, tracheo-

Congenital
oesophageal anomalies of the larynx

Infective Acute epiglottitis, laryngo-tracheobronchitis

Malignancy Advanced tumours of the tongue, larynx or upper trachea, presenting with stridor

Trauma Gunshot /knife wounds to neck, inhalation of smoke, swallowing of corrosive fluid

Vocal cord Post-operative complication of thyroidectomy, cardiac or oesophageal surgery,

paralysis bulbar palsy

Foreign body Swallowed or inhaled object lodged in the upper airway causing stridor

Possible Complications and Risks of Tracheostomy

Immediate
• Haemorrhage
• Misplacement
• Pneumothorax
• Subcutaneous emphysema

Delayed
• Mucous plugs
• Wound infection
• Mucosal ulceration
• Aspiration & swallow difficulties
• Chest infection
• Tracheo-oesophageal fistula
• Cuff leakage

Late
• Tracheal scarring and stenosis
• Granuloma – forms in response to an ill-fitting tube or chronic low-grade infection. Occur
most commonly at the stoma, but can also form in the inner lumen of the trachea
• Tracheomalacia

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2. Physiology Changes

The presence of a Tracheostomy tube involves no airflow through the upper airway,
thus leads to:
 Reduced humidification/filtering and warming of air
 Loss of voice (when the cuff is inflated)
 Impaired ability to cough and clear secretions (altered sensation)
 Impaired swallow which may be due to: Reduced mobility of larynx, bypassing
airflow/sensation in upper airway and/or reduced sub-glottic pressure.
 Reduced smell/and taste

Impact on Swallow Function:

A tracheostomy may result in the following structural and physiological changes, which may
impact on swallowing function/oesophageal compression from the inflated cuff. An inflated
cuff isolates the upper airway from the lower airway, thus air cannot flow up through the
upper airway. Likewise the general presence of a trachestomy tube in-situ can also lead to
other changes such as:
• impaired laryngeal elevation as a result of a tethered larynx
• reduction in laryngeal sensitivity subsequent to diverted airflow
• disruption of the normal co-ordination between breathing and swallowing, particularly
prominent in mechanically ventilated patients
• reduced effectiveness of cough to clear secretions from upper airway
• loss or reduction of subglottic positive pressure in the airway, these are important for
coughing and allowing the bolus to pass through the pharynx
• concurrent neurological or mechanical disorders
• post-operative pain and/or oedema
• radiotherapy pain and/or oedema
• excessively dry mouth (xerostomia) – may also be due to side effects of medication

A range of clinical conditions and situations may predispose patients with a tracheostomy to
aspirate. The effect of the tracheostomy on swallowing may be reduced by deflating the cuff
when it is appropriate to do so.

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3. Types of Tracheostomy Tubes used here at GV Health

Cuffed
Cuffed tubes are used for those patients requiring
mechanical ventilation in order to maintain ventilatory
pressures. These tubes are also used for patients with
copious secretions or those who are at risk of aspiration.
Inflation of the cuff may decrease but not prevent aspiration
from the upper airway.

Un-cuffed
Cuff-less tubes are used in the decannulation process once
there is minimal aspiration risk. A deflated cuff or a
cuffless tube provides the opportunity for air to move
through the upper airway.

Double Lumen Tubes (e.g. Shiley

fenestrated with inner cannula)
Some tracheostomy tubes come with an
inner cannula which is removable (double
lumen tubes). The inner cannula can be
removed to clear secretions while the outer
cannula maintains the airway.

Fenestrated (e.g. Portex)

Inner and outer cannulas are available with fenestrations or openings to allow air through the
upper airway when the cuff is inflated. These tubes allow air to be directed upwards through the
vocal cords in order to achieve voice. With some double cannula tubes the inner cannula must be
removed to enable the outer fenestrated tube to function. A possible complication of fenestrated
tubes is the risk of development of granulation tissue within the fenestration. The inner cannula
should be insitu during suctioning to prevent suction catheter from accidentally passing through
the fenestration and causing tracheal trauma.

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Above the Cuff Suction Tracheostomy Tubes

(mostly used in ICU)
Some cuffed tracheostomy tubes may have an
additional suction port to remove secretions above the
cuff. The additional lumen terminates above the cuff in a
rectangular opening 4.8 by 1.5mm allowing subglottic
drainage. The manual aspiration of subglottic secretions
can prevent or delay the onset of ventilator-associated
pneumonia. Aspiration of subglottic secretions is
performed intermittently using a syringe attached to the
proximal end of the suction lumen.

Tracheostomy Tube Sizes

Tracheostomy tube “sizes” are based on internal (airway) diameter of the tube, an internal
diameter of >6mm is sufficient for normal respiration in most adults without increasing the work of
breathing. The ICU stocks tracheostomy tubes in sizes 6, 7, 8 & 9.

4. Humidification Devices

Humidifier set-up
Dual flow connector/regulator (Batman) attached to the water chamber, which can then be
used with a blend of oxygen + air, or with oxygen alone.

Patient Interface
Flow Regulator
Direct Connector Trache shield / mask

The dual flow connector is the preferred gas flow regulation device, as warmer gas, containing
increased water vapour, can be delivered directly onto the respiratory mucosa. Gas flow via a
tracheostomy shield is generally delivered at lower temperatures to ensure patient compliance.
Due to the correlation between temperature and humidity, cooler gases are capable of holding
reduced water vapour levels; hence inhaled air is drier at cooler temperatures. Attempts to deliver
tracheostomy mask oxygen at warmer levels pose a potential risk for maceration of the stoma.

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Alternative Humidification Methods

Over time, the lower respiratory tract may adapt to provide greater
heat and moisture exchange, reducing the need for advanced
supplemental humidification. Therefore, for patients with long term
tracheostomies, alternative humidification methods may be
implemented.

Heat and Moisture Exchanger (HME) e.g.: Swedish Nose act by trapping heat and moisture on
expiration and returning it to the airway on inspiration.

 Suction the patient to ensure a clear airway prior to placing the HME on the hub of the
patient’s tracheostomy tube.
 Monitor patient for increased work of breathing, dyspnoea, fatigue and oxygen
desaturation. If any of these symptoms occur remove the HME and continue using
Fisher Paykel humidification and report to medical staff.
 HME’s are disposable, and should be changed daily or PRN when soiled with
secretions.

A HME may be contraindicated in the following contexts:

 Patients with productive cough or tenacious secretions, acute respiratory tract infection or
blood in their secretions, where the risk of the device becoming blocked is increased
 Patients with a neurological deficit who may be unable to recognise or respond to
respiratory deterioration should the HME become blocked
 During the acute phase of illness or immediately following tracheostomy
insertion.

5. Role of the Speech Pathologist

The Speech Pathologist is responsible for assessing a tracheostomy patient's ability to
manage oral secretions and swallow function, and to identify aspiration risks. They provide
swallow advice including oral versus nil oral; with information on cuff status and dietary
texture also provided if oral intake is to occur. The speech pathologist advises on
communication options and alternatives for consideration such as white boards, Passy Muir
Speaking valves etc. They can also contribute to the process of weaning and decannulation
at some hospitals.

The Speech Pathologist's role also encompasses participation in "trouble shooting"

discussions regarding tracheostomy tube status. They are involved in education,
communication and advocacy when considering options for patient transfer and follow up.

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Swallowing Assessment
NB: medical permission must be given before considering cuff deflation/swallowing
assessment.

Important factors to be considered under direction of medical/nursing staff and physiotherapist to

determine if a patient is appropriate for oral trials are:
 Respiratory rate: including set numbers of breath per minute from the ventilator (if
ventilated) and the patients own respiratory effort
 Oxygenation levels and requirements i.e. SpO2 and FiO2
 Weaning process e.g. time off/on ventilator
 Level of consciousness

The tracheostomy cuff is inflated at all times for ventilation purposes as determined by medical
staff. However, at least partial cuff deflation during the swallow assessment is required to assess
swallowing function. Cuff deflation can only be performed where the patient is breathing
spontaneously. Feeding a patient with an inflated cuff poses risks and limitations on the
assessment process (Dikeman & Kazandjian, 2003). A patient who is unable to tolerate a period
of cuff deflation is “unlikely to be a candidate for significant oral intake” (Dikeman & Kazandjian,
2003, p292).

Patients who are considered short term ventilator dependent will not undergo dysphagia
assessment until they can tolerate cuff deflation for the amount of time taken to complete an
entire dysphagia assessment. This is consistent with best evidence and practice in this area
(Dikeman & Kazandjian, 2003; Speech Pathology Australia, 2005).

Patients therefore need to be able to tolerate periods of cuff deflation for the swallowing
assessment to proceed. Once this has been established. the speech pathologist may then begin
oral trials as appropriate. A nurse or physiotherapist must always be present to assist in
suctioning and cuff deflation and inflation. This is a 2 person task.

Preparation to Swallow

 Discuss with patient the process for cuff deflation and assessment
 Perform oro-motor examination as per dysphagia assessment and assess the patient’s
management of oral secretions
 Nursing or physiotherapist will suction above cuff and note secretions (type and quantity)

Aspirated material in the

larynx sitting above the cuff
(needs to be suctioned prior to
deflation)

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 Speech pathologist, nurse or physiotherapist will deflate cuff

 Monitor tolerance. If patient is tolerating cuff deflation, commence swallowing assessment.
If patient is not tolerating cuff deflation, re-inflate the cuff and trial again at a later time or
day.
 Occlude lumen of tracheostomy tube with gloved finger on expiration to clear secretions
pooled in the oropharynx, check vocal fold function and establish upper airway patency. If
this is adequate, the clinician may choose to connect a speaking valve and ask patient to
phonate.

Swallow Trial:
 Cuff remains deflated
 Trial with appropriate texture/consistency.
 Throughout assessment, intermittently check the voice quality and cough by occluding the
tracheostomy tube or by using speaking valve and ask the patient to phonate.
 Make note of patient’s swallowing function as per standard dysphagia assessment and
record on MR5M form.

Cease oral intake trial or do not commence trial if:

 patients condition deteriorates
 patient becomes fatigued
 voice is sounding wet
 persistent cough in association with eating and drinking
 signs of aspiration on tracheal suction
 respiratory changes (decreased O2 saturation) or increase respiratory rate

Post Swallow
 Assess and note the presence/absence of overt aspiration and aspiration risk
 Ask nursing/physiotherapist to suction if required and note quantity and quality of material
 If swallow is competent, the recommendation is to commence oral intake of the appropriate
texture/consistency with the cuff deflated, as per speech pathology medical record
entry
 If swallow is not competent, re-evaluation of swallowing function is indicated.
 Nursing staff or physiotherapist will reinflate cuff if necessary at the completion of the
assessment.

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Cuff Deflation and Decannulation

When a speech pathologist is determining appropriateness of cuff deflation to undertake
swallowing and communication assessment, the following indicators must be considered and
discussed with the treating team.

Positive Indicators Negative Indicators

Adequate level of alertness Reduced/fluctuating level of alertness
Does not require frequent oral or Frequent oral/tracheal suctioning
Tracheal suctioning > 1 per hour that is > I per hour
Clear chest Poor chest condition
Spontaneous swallow present Reduced/absent spontaneous
swallow. Secretions pooling in oral
cavity.
Effective cough Ineffective cough
 If all indicators are positive, then commence cuff deflation.
 If there are any negative indicators, DO NOT undertake cuff deflation. Consider re-trialling
at a later time or day.
 It is nursing staff’s responsibility to record how long the patient is tolerating cuff deflation.

Communication Assessment

NB: medical permission must be given before considering cuff deflation/communication

assessment.

Patients are often unable to create voice while a tracheostomy tube is in place. This is because
there is no longer enough air to pass through the vocal folds to produce voice. This can affect
psychosocial status and increased anxiety in the patient.

Vocalisation depends on several factors such as:

 Severity of airway obstruction.

 Extent of vocal cord function.
 The size and type of the tracheostomy tube.
 Respiratory muscle strength.

For new patients with tracheostomies, a referral to a speech pathologist for a thorough
communication assessment is a necessity. The Speech Pathologist will be able to determine
which verbal or non-verbal communication methods are best suited to that individual patient.

Non-verbal Communication Methods

 Pen and paper/whiteboard.
 Facial Expression and Gesture
o Concentrate on facial and body expressions which will add extra information to the
patient’s “mouthed” words.
 Alphabet board, picture board and phrase books.

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o Alphabet boards or simple pictures depicting basic activities e.g. toilet, pain are easy
methods of communication when the patient is unable to voice (available in different
languages by Speech Pathology).
 Electronic Communication Aids
o Rarely used in the acute setting. Requires full assessment by Speech Pathology to
assess the appropriateness of the device and educate patient/family/staff on its use.

Verbal Communication Methods

 Cuff deflation
o Deflation of the cuff of the tracheostomy tube will allow air to pass into the upper
airway and voice expiration. Phonation will be achieved as air is directed into the
larynx, however the strength of the voice will be weaker as some air will pass out of
the open tracheostomy.
 Manipulation of the Tracheotomy Tube
o Voice production may be achieved in patients with a tracheostomy tube by using cuff
deflation and intermittent finger occlusion.
 Speaking Valves
o Speaking valves are placed on the end of the tracheostomy tube allowing air to enter
the tracheostomy tube on inspiration.

There are various types of speaking valves available. However the commonly used speaking
valve that a patient might have post transfer from a metropolitan hospital is the Passy-Muir™
one-way speaking valves. One-way speaking valves close on exhalation thus directing air up
through the trachea, larynx and upper airway to allow voice.

One-way Speaking Valves-

CAN ONLY BE USED WITH PATIENTS WHO HAVE A PATENT
UPPER AIRWAY AND ABLE TO TOLERATE CUFF DEFLATION
A one-way speaking valve has a one-way mechanism that allows air
to be entrained via the tube opening on inhalation, but not exhaled
through this route. Exhaled air is redirected either through the
fenestrations or up around the sides of the tube into the larynx,
permitting vocalisation.

Speaking valves may be used to facilitate swallowing and airway protection with this group as
research indicates that placement of a one way speaking valve increases subglottic pressure
which aids in re-establishing normal swallowing pressures (e.g. Suiter, 2003), therefore assisting
in normalising the swallowing process. For ventilator dependent patients, consider using the
Passy-Muir valve which assists with communication. This is specifically designed for use with a
ventilator.

NB: A speaking valve or finger occlusion must NEVER be placed on a non-fenestrated

tube when the cuff is inflated as patient will not be able to exhale.

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This eliminates the need for finger occlusion.

The patient must be assessed as a suitable candidate prior to use of the PMV (i.e. the speech
pathologist must assess airway protection (swallowing), upper airway patency and voice quality).

Patients MUST be referred to Speech Pathology before placement of a speaking valve. This is to
ensure safe placement of the valve, avoid unnecessary wastage of expensive valves and to
determine patent airway e.g. able to tolerate cuff deflation, managing secretions.

Precautions with speaking valves

 A cuffed tube must be deflated before attaching the speaking valve.
 If the patient has severe upper airway obstruction the speaking valve should not be used.
 The patient should always be supervised when wearing the speaking valve.
 The speaking valve should not be worn when the patient is sleeping.
 If the patient has thick or copious secretions the speaking valve may not be suitable.

If the speaking valve is not functioning properly or the patient shows signs of respiratory
distress/discomfort, then remove the valve immediately.

N.B. the cuff must always be deflated when a speaking valve is used or the patient will
asphyxiate.

Patient Selection Criteria: Candidates for speaking valves should demonstrate the following:

1. Alert, responsive and able to make basic attempts at communication (e.g. mouthing, effort
at voicing around the tracheostomy)
2. Ability to generate at least minimal phonation upon brief tracheal occlusion with finger upon
cuff deflation
3. Ability to tolerate cuff deflation without risk of gross aspiration of patient’s own secretions
4. Generally stable medical status and vital signs, no current chest infections

Patient Exclusion Criteria- DO NOT place the valve on under any circumstances

1. Inability to tolerate cuff deflation

2. Upper airway obstruction
3. Unstable medical/pulmonary status
4. Severe anxiety/cognitive dysfunction
5. Anarthria
6. Severe tracheal/laryngeal stenosis
7. Excessive secretions

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Procedure for using speaking valves: Nursing or physiotherapist must be present to assist in
trial

 Patient be alert and upright

 O2 saturation levels monitored using a pulse oximeter
 Explanation of the procedure is provided to the patient- including reinforcing education
about how to use the speaking valve, including contraindications, cautions and warnings
 Before applying the PMSV, slowly deflate the cuff of the tracheostomy tube. Simultaneously
ask the Nurse/Physiotherapist to suction the patient during cuff deflation to remove
secretions that were present above the cuff.
 If humidified O2 or air is required, this can be placed over the speaking valve as per
nursing/physiotherapy guidelines
 Trial momentary finger occlusion with gloved finger and ask patient to phonate
 Place speaking valve to tracheotomy with twisting motion (quarter clockwise turn).
 Begin trials of phonation by asking patient to count, sustained phonation of “ah” etc.
 Closely monitor whilst speaking valve is in-situ:
- oxygen saturation
- respiratory rate
- colour of skin
- anxiety levels
 Remove speaking valve immediately if any of the above signs occur and re-inflate cuff if
necessary

NB: Always remove the speaking valve if patient is distressed.

Remove valve prior to sleeping.

Finger Occlusion/use of gauze etc-

CAN ONLY BE USED WITH PATIENTS WHO HAVE A PATENT
UPPER AIRWAY AND ABLE TO TOLERATE CUFF DEFLATION

 The patient is suctioned via the tracheostomy tube

 A gloved finger is placed over the hub of the TT
 The patient may be able to clear his/her throat, cough or voice
 Remove the finger to allow the patient to breath

NB: A speaking valve or finger occlusion must NEVER be placed on a non-fenestrated

tube when the cuff is inflated as patient will not be able to exhale.

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Emergency Management
A medical emergency (CODE BLUE) must be called at GV Health if there is respiratory distress
or the following occurs:

 There is partial or total decannulation;

 Tracheal occlusion is suspected;
 Patient experiences respiratory distress/tachypnoea (>28 breaths/min)
 Increased work of breathing/stridor is noted
 Tracheal tug is present (i.e. a downward pull of the trachea and the larynx, apparent by a
downward movement of the thyroid cartilage). Please refer to picture on right-hand side.
 Unexplained surgical emphysema around face or neck.

Recognising Respiratory Distress

 difficult, laboured or noisy breathing
 absence of respiration
 use of accessory muscles
 pale or cyanosed skin colour
 anxiety/agitation
 increased heart rate
 increased respiratory rate
 clammy / diaphoretic skin

The primary life threatening complications associated with a tracheostomy are blockage,
accidental decannulation and bleeding. It is imperative that staff can recognise and respond
to these emergencies.

BLOCKED TRACHEOSTOMY TUBE

A tracheostomy tube may become blocked with thick tracheal secretions, blood or foreign bodies.
The patient may present with increasing respiratory distress over a few hours, or with a much
more rapid deterioration. In either context a blocked tracheostomy tube is an emergency situation
during which the patient’s life is at risk if not rapidly resolved.

Signs of a Completely Blocked Tube

 absent air entry
 oxygen desaturation
 inability to pass a suction catheter
 increased work of breathing
 acute patient distress
 cyanosis
 use of accessory muscles
 diaphoretic

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 tachycardia / bradycardia
 cardiorespiratory arrest

Signs of a Partially Blocked Tube

 decreased air entry
 oxygen desaturation or fluctuations in oxygen saturations
 inability to pass a suction catheter
 increased work of breathing
 acute patient distress and use of accessory muscles
 cyanosis
 diaphoretic
 tachycardia

Prevention is better than cure:

 Patients with tracheostomies must always receive adequate humidification to lessen the
risk of tube blockage.
 A double lumen tube will promote tube patency. The inner cannula must be cleaned
regularly to prevent the build-up of secretions. The specific frequency will depend on
individual risk assessment.
 Certain specialist tracheostomy tubes (e.g. adjustable length or custom-made long tubes)
may not have an inner cannula. Extra vigilance is needed in these patients to minimise the
risk of blockage.

IF TUBE IS COMPLETELY BLOCKED

 Follow emergency algorithm in GV Health Clinical Practice Guideline- Tracheostomy
Management, 2015 (GVH0000237). Deflate the cuff, remove inner cannula if present and
call a Code Blue in inpatient units or Ambulance (000) for emergency assistance in the
community.

IF THE TUBE IS PARTIALLY BLOCKED

 Call a Code Blue to seek assistance. In the community call an ambulance (000).
 Follow emergency algorithm in GV Health Clinical Practice Guideline- Tracheostomy
Management, 2015 (GVH0000237). Deflate the cuff, remove inner cannula if present and
call a Code Blue in inpatient units or Ambulance (000) for emergency assistance in the
community.

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ACCIDENTAL DECANNULATION

Tracheostomy tubes may become dislodged or displaced for a number of reasons. It is important
to ensure that the tracheostomy tube holder is adjusted regularly so that the tube is fixed in a
secure, comfortable position at all times. Tracheostomy tubes may become dislodged when a
patient is turned, or moved from their bed to a trolley. Restless or agitated patients may pull at
their tracheostomy tubes, or tubing attached to the tracheostomy. A partly dislodged
tracheostomy tube is just as dangerous, if not more dangerous, as a completely removed
tracheostomy tube. As with any emergency situation, it is important to adopt a systematic
approach to assess and troubleshoot the problem.

Assess the patient

Airway: is the airway at least partially patent?

 If the tube is displaced, the patient may be breathing through their nose or mouth. The
patient may be safe in the short term, requiring urgent but not emergency action. Only
experienced staff should try to replace the tube under such circumstances. If in doubt it will
usually be safer to remove a partly dislodged tube, although a suction catheter or airway
exchange catheter may be first advanced through it to allow oxygen administration. The
airway should be maintained by other methods until experienced help arrives.
 If tube is partially occluded, the patient may still be able to breathe through it, but with
difficulty. The inner cannula should be removed and changed. If the tube does not have an
inner cannula, but a suction catheter can be passed down the tracheostomy tube, then it
must be at least partially patent. It may be possible to change the tube over a catheter or
other airway exchange device.

References:
St George’s Healthcare NHS Trust (2012) Guidelines for the care of patients with tracheostomy
tubes. Smiths Medical International Ltd
Sherlock Z, Wilson J and Exley C (2009) Tracheostomy in the acute setting: patient experience
and information needs. Journal of Critical Care 24: 501-507
Muscedere J et al (2011) Subglottic suction drainage for the prevention of ventilator associated
pneumonia: A systematic review and meta-analysis Crit care Med 39 (98) 1-6
Intensive Care Society. (2008). Standards for the care of adult patients with a temporary
tracheostomy. Council of the Intensive Care Society

Prigent H et al (2012) Effect of a Tracheostomy Speaking Valve on the Breathing-Swallowing

Interaction. Intensive care Medicine 38: 85-90

Romero C et al (2010) Swallowing Dysfunction in Non-Neurological Critically Ill Patients who

Require Percutaneous Dilational Tracheostomy. Chest 137: 1278-1282

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Ding R & Logermann J (2005) Swallow physiology in patients with tracheostomy cuff inflated and
deflated: A retrospective study. Head and Neck. Sep 809- 813

The Joanna Briggs Institute (2006) Tracheostomy: Routine care evidence summary (16th Sept
2006)

Russell, C., Matta, B. (2006). Tracheostomy: a multi-professional handbook. Cambridge

University Press

Speech Pathology Australia (2005). Tracheostomy tube management: Position Paper.

Melbourne, Australia.

Speech Pathology Australia (2011). Competency-Based Occupational Standards for Speech

Pathologists Entry Level – Revised. Melbourne, Australia.

GV Health Clinical Practice Guideline- Tracheostomy Management, 2015 (GVH0000237).

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