Physiotherapy EPA3 Tracheostomy Management

The novice physiotherapist will be able to complete a comprehensive assessment of a self-ventilating tracheostomised patients, assess their readiness to commence weaning and as part of the MDT progress them through the following steps:

  • Cuff deflation
  • One way valve use / cap/ Swedish nose (as per trust policy)
  • Decannulation

Limited to tracheostomises inserted for respiratory weans.

Excludes tracheostomises inserted for head and neck cancer and for patients for whom the tracheostomy is expected to be permanent.

Excludes Laryngectomies and mini-tracheostomies.

Print this EPA

You can print this EPA in a completable template by clicking print below.

If you select any prior completed EPAs via the options below the printable form will automatically mark these as "achieved".

EPA overview information
Required knowledge

Competencies Required:

  • C3Framework Shared AHP Competencies
  • C3Framework Core Competencies:
    • Competency 1 Assessment
    • Competency 2 Treatment
    • Competency 3 Tracheostomy management
    • Competency 4 High flow oxygen devices, CPAP and NIV
Required KSA
  • Blocked tracheostomy and emergency algorithm
  • National Tracheostomy Safety Project (NTSP) (2013)
  • Intensive Care Society Tracheostomy Guidance (2020)
  • NCEPOD Report ‘On the Right Trach? A review of the care received by patients who underwent a tracheostomy’ (2014)
Information to assess progression
  • Clinical supervision
  • Nonclinical supervision
  • Notes Audit
Basis for formal entrustment decisions

An entrustment decision should be made by an experienced critical care physiotherapist after observing this EPA completed on more than one patient.

Use the EPA Completion Template (PDF, 88KB) for this.


Previously completed EPAs:
If you have completed any previous EPAs, select them here
to highlight where competencies have already been met.


Shared AHP competencies

Competency description Self assessment Senior assessment

Safety

Infection Prevention and Control:

Able to demonstrate knowledge of general infection control prevention and control including hand hygiene, aprons, masks and aseptic non-touch technique

 
 

Patient Emergency Management:

Has completed Basic Life Support Training as per local trust policy

 
 

Describes how they would summon help in an emergency and locate crash bells

 
 

Describes how to call a medical emergency call via switch

 
 

Describes own role and expected contribution in medical emergency eg. Basic Life Support, providing assistance to MDT as able

 
 

Patient ID:

Demonstrates positive patient identification and awareness of allergies

 
 

Monitoring Vital Signs:

Demonstrates how to monitor vital signs (Temp, HR, SpO2, RR, blood pressure, MAP)

 
 

Interprets observations in an ICU setting, considering trends and normal ranges for all (Temp, HR, SpO2, RR, blood pressure)

 
 

Able to troubleshoot difficulties with taking vital signs eg. poor trace on pulse oximeter, missing ECG leads, positional sensitivity of arterial line

 
 

Awareness of who to escalate concerns to in relation to patient safety with recognition of different levels of urgency and reporting to different staff members dependent on situation

 
 

Orientation:

Can describe the bed numbering, storage location of safety equipment, location of offices and other key areas within the critical care unit

 
 

Can describe the shift patterns and handover process of other MDT members

 
 

Able to identify key MDT members by their role, including critical care nurses, nurse in charge, consultant on call

 
 

Demonstrates how to locate the local protocols and guidelines relevant to own role

 
 

Has an awareness of key ICU meetings relevant to role e.g. MDT meetings, handovers, safety briefings, teaching sessions.

 
 

Can identify standard ICU bedspace equipment and location of equipment necessary for role

 
 

Communication

Communication with patient:

Describe barriers to communication in ICU including those associated with PPE, illness and ICU interventions.

 
 

Awareness of communication aids with patients to overcome communication barriers i.e. PPE + oral intubation

 
 

Communication with family + friends:

Describe the support services available to help liaise with family including family support nurses, PALS, psychology services as appropriate.

 
 

Describe barriers to communication with family and methods to improve this

 
 

Knows importance of confidentiality and consent to share information with friends and family

 
 

Communication with colleagues:

Awareness of peer support and psychological support

 
 

Documentation

Local IT Training:

Demonstrates how to access and document in patient records using local IT systems

 
 

Demonstrates how to view results and imaging on local IT systems

 
 

Moving and Handling

Awareness of Falls prevention and who to escalate to if concerned regarding falls risks

 
 

Compliant with Manual Handling training as per local trust policy.

 
 

Non-technical skills

Teamwork:

Demonstrate working in an MDT by building and maintaining relationships with other professions

 
 

Aware of the roles and responsibilities of other members of the MDT

 
 

Clarifies, accepts and executes tasks delegated by the team leader

 
 

Explains the importance of highlighting safety issues / concerns to a member of your team in a prompt manner

 
 

Uses appropriate level of assertiveness for the clinical situation

 
 

Demonstrates a logical and systematic handover using local format

 
 

Outline how to escalate and to whom if there are patient / safety concerns

 
 

Identify and respond to patient / staff safety issues appropriately

 
 

Clinical Assessment and Basic Life Support

Airway:

Demonstrate ways to open up airway using simple manoeuvres (inc. repositioning, head tilt chin lift, jaw thrust)

 
 

Demonstrates how to deliver manual ventilation using two person bag-valve-mask (BVM) technique

 
 

Recognise and escalate airway compromise in a tracheostomised patient

 
 

Mouth care:

Demonstrates how to perform and document oral hygiene

 
 

Oxygen:

Knows the types of oxygen delivery system and their limitations (including reservoir mask, simple face mask, venturi system and nasal cannulae)

 
 

Demonstrates how to deliver oxygen urgently (including reservoir mask, simple face mask, venturi system and nasal cannulae)

 
 

Describe how to escalate or de-escalate oxygen therapy in a step wise manner eg. nasal cannulae to face mask.

 
 

Lines and attachments:

Recognise different lines and their location relevant to local population (eg arterial lines, central line, vas-cath)

 
 

Nutrition:

Identify enteral feeding tube in situ, whether it is connected to feed and whether the feed pump is running

 
 

Knows to discuss plans with nursing staff prior to moving or reposition a patient with NG feed running

 
 

Aware of events which can displace feeding tubes and to escalate accordingly

 
 

Describes how to check enteral feeding length and escalates if tube length has changed

 
 

Describe how to recognise dysphagia and an escalation plan including referral to SLT

 
 

Demonstrates how to assist patients with eating and drinking

 
 

Have an awareness of modified diets or thickened fluids in line with SLT recommendations

 
 

Delirium:

Demonstrate how to categorise neurological status using the AVPU scoring

 
 

Describe factors that may cause or contribute to delirium

 
 

Describes how to recognise delirium

 
 

Demonstrates how to complete a CAM-ICU score

 
 

Demonstrates an understanding of non-pharmacological management of delirium

 
 

Demonstrates knowledge of the Mental Capacity Act, when capacity assessment is indicated, how to assess capacity and when specialist communication support is required eg. referral to SLT

 
 

Pain:

Demonstrates how to use pain faces or a similar visual analog scale

 
 

Demonstrates an understanding on the impact of pain on patient presentation eg. agitation

 
 

Demonstrates an understanding of the impact of pain medication on patient presentation eg. sedative effect

 
 

Sedation:

Demonstrates an understanding of RASS (or alternative sedation) scoring system

 
 

Able to access and read using ICU drug charts

 
 

Demonstrates an awareness of common ICU sedative medications

 
 

Demonstrates a basic knowledge of common ICU medications and their role e.g. sedatives, vasopressors, inotropes

 
 

Core competencies

Competency description Self assessment Senior assessment

Assessment

Explains physiotherapy role to patients and family

 
 

Acquires consent for assessment and treatment or understands when to “treat in best interest”

 
 

Ascertains the presenting condition and relevant medical and social history to inform assessment and goal setting

 
 

Ascertains limitations of treatment (e.g. resuscitation status, End of life pathway)

 
 

A - AIRWAY:

Identifies type of airway, airway adjuncts and patency

  • Own
  • Naso Pharyngeal (NP)
  • Endo tracheal tube (ETT)
  • Tracheostomy
 
 

Awareness of grades of Intubation and measures taken to secure ETT

 
 

B - BREATHING:

Identifies the oxygen delivery device, flow rate and FiO2

 
 

Ability to interpret vital signs from bedside monitoring equipment including respiratory rate, and saturations

 
 

Auscultates patient and describes breath sounds and added sounds

 
 

Observes and describes breathing pattern and chest wall movement

 
 

Assesses cough and describes effectiveness

 
 

Interprets a CXRAY, completing a systematic assessment identifying volume loss, consolidation, pneumothorax, pleural effusions and pulmonary oedema.

 
 

Interprets blood gases demonstrating knowledge of parameters appropriate for the patient

 
 

Able to identify mucolytics, bronchodilators and antibiotics within a prescription chart

 
 

Mechanically Ventilated Patients:

 
 

Identifies the mode of ventilation and can interpret set parameters including PEEP, inspiratory support, I to E ratio and fio2

 
 

Awareness of spontaneous modes, controlled modes and mixed modes of ventilation.

 
 

Able to identify tidal volumes, peak airway pressures and aware of safe limits

 
 

C - CIRCULATION:

Interprets vital signs from bedside monitoring including heart rate and rhythm.

 
 

Identifies systolic and diastolic pressure and recognise a poor arterial trace

 
 

Interprets cardiac monitoring demonstrating knowledge of parameters appropriate for the patient.

 
 

Able to identify commonly used cardiac drugs within a prescription chart

 
 

D - DISABILITY:

Able to complete an accurate assessment of level of consciousness using AVPU or GCS

 
 

Able to understand the RASS scoring system in the sedated patient

 
 

Recognises Delirium scoring system and can describe methods to reduce delirium

 
 

Able to identify commonly used medications to reduce agitation and ones that may affect level of consciousness

 
 

E - EXPOSURE:

Identifies and explain the indication for Chest drains and comment on their status (swinging/bubbling/on suction)

 
 

Identifies and explain the indication for a PCA (Patient controlled analgesic)

 
 

Identifies the urinary catheter or filter for Renal replacement therapy

 
 

F - FLUIDS:

Identifies and explain rationale for NG tube and completes the 4 checks for safety

 
 

H- HAEMOTOLOGY:

Identifies abnormal blood results and describes their potential impact on physiotherapy treatment.

 
 

HB, Platelets, INR, APTT, K+, CRP, WCC, NA, Urea, Creatinine and Albumin

 
 

Clinical Reasoning:

Forms a problem list informed by the holistic patient assessment with and understanding of which problems are amenable to physiotherapy intervention

 
 

Treatment

Risk assessment:

Identifies the manual handling risks to the MDT associated with providing care to this patient

 
 

Positioning and Postural drainage:

Identifies positions that can reduce the work of breathing

 
 

Explains ventilation and perfusion in the spontaneously breathing and ventilated patient and identifies positions to optimise gas exchange

 
 

Identifies postural drainage positions to optimise secretion clearance

 
 

ACBT:

Explains how to instruct the patient in ACBT

 
 

Supported cough:

Explains the benefits of a supported cough and how to instruct the patient to complete one.

 
 

IPPB:

Explains how to set up IPPB and can recommend treatment pressures

 
 

Aware of local guidelines for its use and can safely assemble equipment required

 
 

Can discuss the risks and benefits associated with use and how to monitor effectiveness

 
 

Cough Augmentation device:

Explains how to set up cough augmentation device and can recommend treatment pressures

 
 

Aware of local guidelines for its use and can safely assemble equipment required

 
 

Can discuss the risks and benefits associated with use and how to monitor effectiveness

 
 

Nasal airway:

Explains how to size for and insert a nasal airway.

 
 

Aware of local guidelines for insertion and frequency of change

 
 

Can discuss the risks and benefits associated with its use and how to monitor effectiveness

 
 

Manual Techniques:

Explains manual techniques (including percussion and vibrations) and their role in sputum clearance.

 
 

Can discuss the risks and benefits associated with its use and how to monitor effectiveness

 
 

Suction via an artificial airway:

Explains aseptic technique and the importance of this

 
 

Aware of local guidelines and safe suction pressures

 
 

Can discuss the risks and benefits associated with its use and how to monitor effectiveness

 
 

Manually assisted Cough:

Explains the indications for Manual assisted cough (MAC) and it use in cough augmentation

 
 

Can discuss the risks and benefits associated with its use and how to monitor effectiveness

 
 

Manual Hyperinflation (MHI):

Explains manual hyperinflation and its role in secretion clearance and volume loss

 
 

Aware of local guidelines for its use and can safely assemble equipment required (including pressure manometer)

 
 

Can discuss the risks and benefits associated with use and how to monitor effectiveness

 
 

Can discuss the use of MHI vs VHI

 
 

Ventilator hyperinflation (VHI):

Explains Ventilator hyperinflation and its role in secretion clearance and volume loss.

 
 

Aware of local guidelines for its use.

 
 

Describes mandatory modes of ventilation and suggests alterations to optimise sputum clearance and volume loss

 
 

Can discuss the risks and benefits associated with its use and how to monitor effectiveness

 
 

Tracheostomy Management

Subjective assessment:

Able to demonstrate a basic understanding of the anatomy and physiology of the respiratory system

 
 

Objective assessment:

Identifies type of tracheostomy (single or double lumen/cuffed or uncuffed, fenestrated or unfenestrated

 
 

Identifies surgical or percutaneous

 
 

Identifies presence of stitches

 
 

Identifies which oxygen delivery system is in use and how humidification is being delivered

 
 

Can establish cuff status (up or down)

 
 

Can state appropriate safe cuff pressure with cuff pressure manometer

 
 

Can describe when we would consider deflating the cuff and what physiological parameters to use to assess tolerance of this

 
 

Can describe the rationale for use of a one way valve.

 
 

Can explain the role of SALT in tracheostomy weaning and when to refer.

 
 

Suction:

Can perform open suction using a sterile technique

 
 

Can change an inner cannuale and store this safety

 
 

Awareness of emergency tracheostomy algorithm

 
 

Awareness of contents of emergency tracheostomy box

 
 

Decannulation:

Can state local requirements for decannulation including any objective measures and requirements

 
 

High Flow Oxygen, CPAP and NIV

High Flow Oxygen Devices:

Can discuss the indications for initiation of high flow oxygen therapy and is aware of the precautions

 
 

Can explain how to adjust and modify the therapy (flow rate and oxygen) to optimise the patient’s condition

 
 

Can recommend next steps if set parameters are not being achieved

 
 

Continuous Positive Airway Pressure:

Can discuss the indications for initiation of CPAP and is aware of the precautions

 
 

Can explain how to adjust and modify the therapy (PEEP and oxygen) to optimise the patient’s condition

 
 

Can recommend next steps if set parameters are not being achieved

 
 

Non Invasive Ventilation (NIV):

Can discuss the indications for initiation of NIV and is aware of the precautions

 
 

Can explain how to adjust and modify the therapy (PEEP, oxygen and Inspiratory Pressure) to optimise the patient’s condition

 
 

Can recommend next steps If set parameters are not being achieved