3/15/2017 Tracheostomy care: An evidence-based guide to suctioning and dressing changes - American Nurse Today

Tracheostomy care: An evidence-based guide to suctioning

and dressing changes
July 2011 Vol. 6 No. 7
Author: Betty Nance-Floyd, MSN/Ed, RN, CNE

TRACHEOSTOMY CARE and tracheal suctioning are high-risk procedures. To avoid poor
outcomes, nurses who perform them—whether they’re seasoned veterans or novices—
must adhere to evidence-based guidelines. In fact, experienced nurses may
overestimate their own trach care competence. Tracheostomy patients aren’t seen only
in intensive care units. As patients with more complex conditions are admitted to
hospitals, an increasing number are being housed on general nursing units. Trach
patients are at high risk for airway obstruction, impaired ventilation, and infection as
well as other lethal complications. Skilled bedside nursing care can prevent these
complications. This article describes evidence-based guidelines for tracheostomy care,
focusing on open and closed suctioning and site care.

Suctioning a trach tube

A trach tube may have a single or double lumen; it may be cu ed or uncu ed,
fenestrated (allowing speech) or unfenestrated. Each variation requires speci c
management. For instance, before suctioning a fenestrated tube, you must insert
a plain inner tube, because a suction catheter may puncture the small opening of the
fenestrated tube. (See Trach tube positioning by clicking the PDF icon above.)
Regardless of the type of tube used, suctioning always involves:
assessment
oxygenation management
use of correct suction pressure
liquefying secretions
using the proper-size suction catheter and insertion distance
appropriate patient positioning
evaluation.
Also, be sure to keep emergency equipment nearby. (See Be prepared for trach
emergencies by clicking the PDF icon above.)

When to suction
Suctioning is done only for patients who can’t clear their own airways. Its timing should
be tailored to each patient rather than performed on a set schedule. Start with a
complete assessment. Findings that suggest the need for suctioning include increased
work of breathing, changes in respiratory rate, decreased oxygen saturation, copious
secretions, wheezing, and the patient’s unsuccessful attempts to clear secretions.
According to one researcher, ne crackles in the lung bases indicate excessive uid in
the lungs, and wheezing patients should be assessed for a history of asthma and
allergies.
Suctioning technique
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Suctioning technique
Before suctioning, hyperoxygenate the patient. Ask a spontaneously breathing patient
to take two to three deep breaths; then administer four to six compressions with
a manual ventilator bag. With a ventilator patient, activate the
hyperoxygenation button. Experts recommend using suction pressure of up to 120 mm
Hg for open-system suctioning and up to 160 mm Hg for closed-system suctioning. For
each session, limit suctioning to a maximum of three catheter passes. During catheter
extraction, suctioning can last up to 10 seconds; allow 20 to 30 seconds between
passes. For open-system suctioning, catheter size shouldn’t exceed half the inner
diameter of the internal trach tube. To determine the appropriate-size French catheter,
divide the internal trach tube size by two and multiply this number by three. A #12
French catheter is routinely used for closed suctioning. Premeasure the distance
needed for insertion. Experts suggest 0.5 to 1 cm past the distal end of the tube for an
open system, and 1 to 2 cm past the distal end for a closed system.

Liquefying secretions
The best ways to liquefy secretions are to humidify secretions and hydrate the patient.
Do not use normal saline solution (NSS) or normal saline bullets routinely to
loosen tracheal secretions because this practice:

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may reach only limited areas

may ush particles into the lower respiratory tract
may lead to decreased postsuctioning oxygen saturation
increases bacterial colonization
damages bronchial surfactant.
Despite the potential harm caused by NSS use, one survey found that 33% of nurses
and respiratory therapists still use NSS before suctioning. Other researchers have
found that inhalation of nebulized uid also is ine ective in liquefying secretions.

Evaluation
When evaluating the patient after suctioning, assess and document physiologic and
psychological responses to the procedure. Convey your ndings verbally during nurse-
to-nurse shift report and to the interdisciplinary team during daily rounds.

Trach site care and dressing changes

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Trach site care and dressing changes

Tracheostomy dressing changes promote skin integrity and help prevent infection at
the stoma site and in the respiratory system. Typically, healthcare facilities have both
formal and informal policies that address dressing changes, although no
evidence suggests a particular schedule of dressing changes or speci c supplies for
secretion absorption must be used. On the other hand, the evidence does show that:
secretions can cause maceration and excoriation at the site
the site should be cleaned with NSS
a skin barrier should be applied to the site after cleaning
loose bers increase the infection risk
the trach tube should be secured at all times to prevent accidental dislodgment,
using the two-person securing technique described below under “Securing the
trach tube.”
Start by assessing the stoma for infection and skin breakdown caused by ange
pressure. Then clean the stoma with a gauze square or other nonfraying
material moistened with NSS. Start at the 12 o’clock position of the stoma and wipe
toward the 3 o’clock position. Begin again with a new gauze square at 12 o’clock
and clean toward 9 o’clock. To clean the lower half of the site, start at the 3 o’clock
position and clean toward 6 o’clock; then wipe from 9 o’clock to 6 o’clock, using a clean
moistened gauze square for each wipe. Continue this pattern on the surrounding
skin and tube ange. Avoid using a hydrogen peroxide mixture unless the site is
infected, as it can impair healing. If using it on an infected site, be sure to
rinse afterward with NSS.

Dressing the site

At least once per shift, apply a new dressing to the stoma site to absorb secretions and
insulate the skin. After applying a skin barrier, apply either a split-drain or a foam
dressing. Change a wet dressing immediately.

Securing the trach tube

Use cotton string ties or a Velcro holder to secure the trach tube. Velcro tends to be
more comfortable than ties, which may cut into the patient’s neck; also, it’s easier to
apply. The literature overwhelmingly recommends a two person technique when
changing the securing device to prevent tube dislodgment. In the two-person
technique, one person holds the trach tube in place while the other changes the
securing device.

Review trach tube policy and procedures

To achieve positive outcomes in patients with trach tubes, keep abreast of best
practices and develop and maintain the necessary skills. Every nurse who
performs trach care needs to be familiar with facility policy and procedure on trach
tube care. If your facility’s current policy and procedures don’t support

evidencebased practice, consider urging colleagues and managers to conduct a

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evidencebased practice, consider urging colleagues and managers to conduct a

patient-care study comparing di erent approaches to suctioning. Then follow
the evidence by advocating for changes if necessary.
Selected references
Chulay M. Suctioning: endotracheal or tracheostomy tube. In: Wiegand DJ, Carlson KK,
eds. AACN Procedure Manual for Critical Care. 6th ed. Philadelphia, PA: Elsevier
Saunders; 2010:62-70.
Dennis-Rouse MD, Davidson JE. An evidence-based evaluation of tracheostomy care
practices. Crit Care Nurs Q. 2008;31(2):150-160.
Edgtton-Winn M, Wright K. Tracheostomy: a guide to nursing care. Aust Nurs J.
2005;13(5):1-4.
Harkreader H, Hogan MA, Thobaben M. Fundamentals of Nursing: Caring and Clinical
Judgment. 3rd ed. Philadelphia, PA: Saunders; 2007.
Klockare M, Dufva A, Danielsson AM, et al. Comparison between direct humidi cation
and nebulization of the respiratory tract at mechanical ventilation: distribution of saline
solution studied by gamma camera. J Clin Nurs. 2006;15(3):301-307.
Kuriakose A. Using the Synergy Model as best practice in endotracheal tube suctioning
of critically ill patients. Dimens Crit Care Nurs. 2008;27(1):10-15.
Lewis SL, Dirksen SR, Heitkemper MM, Bucher L, Camera I. Medical-Surgical Nursing:
Assessment and Management of Clinical Problems. 8th ed. St. Louis, MO: Mosby; 2010.
Smith-Miller C. Graduate nurses’ comfort and knowledge level regarding tracheostomy
care. J Nurses Sta Dev. 2006;22(5):222-229.
Wiegand DJ, Carlson KK, eds. AACN Procedure Manual for Critical Care. 6th ed.
Philadelphia, PA: Elsevier Sauders; 2010.
Betty Nance-Floyd is a clinical assistant professor at the University of North
Carolina at Chapel Hill School of Nursing.

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