Issaiah Nicolle L.

Cecilia March 19, 2019

1 NRS – 1 Prof. Herman Zoleta

Tracheostomy Care
A tracheostomy is an opening (made by an incision) through the neck into the trachea
(windpipe). A tracheostomy opens the airway and aids breathing. A tracheostomy may be done
in an emergency, at the patient’s bedside or in an operating room. Anesthesia (pain relief
medication) may be used before the procedure. Depending on the person’s condition, the
tracheostomy may be temporary or permanent.

When is a tracheostomy considered?

A tracheostomy may be performed for the following conditions:

 Obstruction of the mouth or throat

 Breathing difficulty caused by edema (swelling), injury or pulmonary (lung) conditions
 Airway reconstruction following tracheal or laryngeal surgery
 Airway protection from secretions or food because of swallowing problems
 Airway protection after head and neck surgery
 Long-term need for ventilator (breathing machine) support

What is a tracheostomy tube?

A tracheostomy (trach) tube is a small tube inserted into the

tracheostomy to keep the stoma (opening) clear.

Tracheostomy tubes are available in several sizes and materials

including semi-flexible plastic, rigid plastic or metal. The tubes are
disposable or reusable. They may have an inner cannula that is either
disposable or reusable. The tracheostomy tube may or may not have a
cuff. Cuffed trach tubes are generally used for patients who have
swallowing difficulties or who are receiving mechanical ventilation.
Non-cuffed trach tubes are used to maintain the patient’s airway when a
ventilator is not needed. The choice of tube is based on your condition,
neck shape and size and purpose of the tracheostomy.

All trach tubes have an outer cannula (main shaft) and a neck-plate
(flange). The flange rests on your neck over the stoma (opening). Holes
on each side of the neck-plate allow you to insert trach tube ties to
secure the trach tube in place.
 How do I take care of my tracheostomy tube?

Your nurse will teach you the proper way to care for your tracheostomy tube before you go
home. Routine tracheostomy care should be done at least once a day after you are discharged
from the hospital.

1. Gather the following supplies:

o Two non-sterile gloves
o A clean basin (or sink)
o Hydrogen peroxide
o Clean 4 x 4 fine mesh gauze pads
o Normal saline or tap water (Use distilled water if you have a septic tank or well
water)
o Clean cotton-tipped swabs
o Clean pipe cleaners or small brush
o Clean washcloth
o Clean towel
o Trach tube ties
o Clean scissors
2. Wash your hands thoroughly with soap and water.
3. Stand or sit in a comfortable position in front of a mirror (in the bathroom over the sink is
a good place to care for your trach tube).
4. Put on the gloves.
5. Suction the trach tube. (Your healthcare provider will give you more information about
the suctioning procedure).
6. If your tube has an inner cannula, remove it. (If the trach tube does not have an inner
cannula, go to step 12.)
7. Hold the inner cannula over the basin and pour the hydrogen peroxide over and into it.
Use as much hydrogen peroxide as you need to clean the inner cannula thoroughly.
8. Clean the inner cannula with pipe cleaners or a small brush.
9. Thoroughly rinse the inner cannula with normal saline, tap water or distilled water (if you
have a septic tank or well water).
10. Dry the inside and outside of the inner cannula completely with a clean 4 x 4 fine mesh
gauze pad.
11. Reinsert the inner cannula and lock it in place.
12. Remove the soiled gauze dressing around your neck and throw it away.
13. Inspect the skin around the stoma for redness, hardness, tenderness, drainage or a foul
smell. If you notice any of these conditions, call your nurse or physician after you finish
routine care.
14. Soak the cotton-tipped swabs in a solution of half hydrogen peroxide and half water. Use
the swabs to clean the exposed parts of the outer cannula and the skin around the stoma.
15. Wet the wash cloth with normal saline, tap water or distilled water. Use the wash cloth to
wipe away the hydrogen peroxide and clean the skin.
16. Dry the exposed outer cannula and the skin around the stoma with a clean towel.
17. Change the trach tube ties.
 o Measure and cut a piece of tie long enough to go around your neck twice. Cut the
tie at an angle (Illustration 17c.) so it is easier to insert the tie into the neck-plate.
o Untie one side of the old tie and remove that side from the neck-plate. Do not
completely remove the old tie until the new one is in place and is securely
fastened.
o Holding the trach tube in place, lace the tie through one hole of the neck-plate,
around the back of your neck, through the other hole of neck-plate, and again
around the back of your neck.
o Pull the tie snugly and tie a square knot on the side of your neck. There should be
enough space for no more than two fingers between the tie and your neck.
(Illustration 17d.)
o Cut, remove and discard the old tie. If you have a cuffed trach tube, be careful not
to cut the cuff balloon when removing the old trach tube tie.
18. Place a fine mesh gauze under the tracheostomy tie and neck-plate by folding
it or cutting a slit in it.
Note: Some brands of mesh gauze are pre-cut.
Important: Do not use 4 x 4 gauze or toppers – they contain cotton fibers
which could clog your airway.
19. Remove your gloves and throw them away.
20. Wash your hands with soap and warm water.
21. Wash the basin and small brush with soap and warm water. Dry them and put
them away.
22. Put the used washcloth and towel in the laundry.
23. Wash your hands again with soap and warm water.

Suctioning
The upper airway warms, cleans and moistens the air we breathe. The trach tube
bypasses these mechanisms, so that the air moving through the tube is cooler, dryer
and not as clean. In response to these changes, the body produces more mucus.
Suctioning clears mucus from the tracheostomy tube and is essential for proper
breathing. Also, secretions left in the tube could become contaminated and a chest
infection could develop. Avoid suctioning too frequently as this could lead to more
secretion build up.

Removing mucus from trach tube without suctioning

1. Bend forward and cough. Catch the mucus from the tube, not from the nose and mouth.

2. Squirt sterile normal saline solutions (approximately 5cc) into the trach tube to help clear
the mucus and cough again.
3. Remove the inner tube (cannula).

4. Suction.

5. Call 911 if breathing is still not normal after doing all of the above steps.
6. Remove the entire trach tube and try to place the spare tube.

7. Continue trying to cough, instill saline, and suction until breathing is normal or help
arrives.

When to suction
Suctioning is important to prevent a mucus plug from blocking the tube and stopping the
patient's breathing.  Suctioning should be considered

 Any time the patient feels or hears mucus rattling in the tube or airway
 In the morning when the patient first wakes up
 When there is an increased respiratory rate (working hard to breathe)
 Before meals
 Before going outdoors
 Before going to sleep
The secretions should be white or clear. If they start to change color, (e.g. yellow, brown or
green) this may be a sign of infection. If the changed color persists for more than three days or if
it is difficult to keep the tracheostomy tube intact, call your surgeon's office. If there is blood in
the secretions (it may look more pink than red), you should initially increase humidity and
suction more gently. A Swedish or artificial nose (HME), which is a cap that can be attached to
the tracheostomy tube, may help to maintain humidity. The cap contains a filter to prevent
particles from entering the airway and maintains the patient's own humidity. Putting the patient
in the bathroom with the door closed and shower on will increase the humidity immediately. If
the patient coughs up or has bright red blood mucus suctioned, or if the patient develops a fever,
call your surgeon's office immediately.

How to suction
Equipment
Clean suction catheter (Make sure you have the correct size)
Distilled or sterile water
Normal saline
Suction machine in working order
Suction connection tubing
Jar to soak inner cannula (if applicable)
Tracheostomy brushes (to clean tracheostomy tube)
Extra tracheostomy tube
1. Wash your hands.

2. Turn on the suction machine and connect the suction connection tubing to the machine.
3. Use a clean suction catheter when suctioning the patient. Whenever the suction catheter is
to be reused, place the catheter in a container of distilled/sterile water and apply suction for
approximately 30 seconds to clear secretions from the inside. Next, rinse the catheter with
running water for a few minutes then soak in a solution of one part vinegar and one part
distilled/sterile water for 15 minutes. Stir the solution frequently. Rinse the catheters in cool
water and air-dry. Allow the catheters to dry in a clear container. Do not reuse catheters if they
become stiff or cracked.

4. Connect the catheter to the suction connection tubing.

5. Lay the patient flat on his/her back with a small towel/blanket rolled under the shoulders.
Some patients may prefer a sitting position which can also be tried.

6. Wet the catheter with sterile/distilled water for lubrication and to test the suction machine
and circuit.

7. Remove the inner cannula from the tracheostomy tube (if applicable). The patient may
not have an inner cannula. If that is the case, skip this step and go to number 8.

a. There are different types of inner cannulas, so caregivers will need to learn the specific
manner to remove their patient's. Usually rotating the inner cannula in a specific direction will
remove it.

b. Be careful not to accidentally remove the entire tracheostomy tube while removing the inner
cannula. Often by securing one hand on the tracheostomy tube’s flange (neck plate) one can/ will
prevent accidental removal.

c. Place the inner cannula in a jar for soaking (if it is disposable, then throw it out).
8. Carefully insert the catheter into the tracheostomy tube. Allow the catheter to follow the
natural curvature of the tracheostomy tube. The distance to the location of catheter becomes
easier to determine with experience. The least traumatic technique is to pre-measure the length of
the tracheostomy tube then introduce the catheter only to that length. For example if the patient?s
tracheostomy tube is 4 cm long, place the catheter 4 cm into the tracheostomy tube. Often, there
will be instances when this technique of suctioning (called tip suctioning) will not clear the
patient’s secretions. For those situations, the catheter may need to be inserted several mm beyond
the end of the tracheostomy tube (called deep suctioning). With experience, caregivers will be
able to judge the distance to insert the tracheostomy tube without measuring.

9. Place your thumb over the suction vent (side of the catheter) intermittently while you
remove the catheter. Do not leave the catheter in the tracheostomy tube for more than 5-10
seconds since the patient will not be able to breathe well with the catheter in place.

10. Allow the patient to recover from the suctioning and to catch his/her breathe. Wait for at
least 10 seconds.
11. Suction a small amount of distilled/sterile water with the suction catheter to clear any
residual debris/secretions.

12. Insert the inner cannula from extra tracheostomy tube (if applicable).

13. Turn off suction machine and discard catheter (clean according to step 3 if to be reused).

14. Clean inner cannula (if applicable).

How you can tell whether you have a bacterial infection or a viral infection

White blood cells serve the sole job of killing infections (not a bad gig if you can get it). A
normal white blood cell count is in the range of 4,000 to 11,000 cells per liter of blood. If you
have an elevated white blood cell count (anything above 11,000), it’s a good bet you have an
infection. The next step is to determine what type of infection you have: bacterial or viral (no
guessing allowed).

A simple and very informative test is the white blood cell “differential”, which is run as part of a
Complete Blood Count. The white blood cell “differential” will usually tell you whether you
have a bacterial infection or a viral infection.

This is how the white blood cell differential works: there are different types of white blood cells
in your body. The five types of white blood cells, also called leukocytes, appear in the blood:
Neutrophils, Lymphocytes (B cells and T cells), Monocytes, Eosinophils, and Basophils. The
white blood cell differential shows if the number of cells are in proper proportion to one another,
and if there is more or less of one cell type. A computer counts the number of each type of cell.

Neutrophils are by far the most common form of white blood cell that you have in your body
(pus is simply dead neutrophils). Neutrophils are infection fighters that increase during bacterial
infections (neutrophils are also known as granulocytes (grans), polys, PMNs, or segs).
Lymphocytes, on the other hand, can increase in cases of viral infections.

The normal results of a white blood cell differential are: Neutrophils 40% to 60%; Lymphocytes:
20% to 40%; Monocytes: 2% to 8%; Eosinophils: 1% to 4%; Basophils; 0.5% to 1%; Band
(young neutrophil): 0% to 3%.

An increase on one type of white blood cell can cause a decrease in other types of white blood
cells. For example, if you have a bacterial infection, you will have an increase neutrophils and a
decrease in lymphocytes. Conversely, if you have a viral infection, you will have a decrease in
neutrophils and an increase in lymphocytes.

Let’s say you have abnormally elevated levels of neutrophils (e.g., 80%) and low levels of
lymphocytes (e.g., 10%), this is a strong indication that you have a bacterial infection. On the
other hand, if you have low levels of neutrophils (30%) and high levels of lymphocytes (60%),
this is a sign that you have a viral infection. You should ask your doctor about your white blood
cell differential, as it may tell you whether you have a bacterial infection or a viral infection.