TRACHEOSTOMY CARE

____________________

A Written Report Presented to the

Faculty of the Nursing Department
Charmaine Orocio, RN

____________________

In Partial Fulfillment of the

Requirements in NCM 218-RLE
Intensive Care Unit Nursing Rotation

Submitted by:
Vince Lenard F. Mancera, St. N
Charissa Ysabelle B. Maraguinot, St. N
Janielle Christine T. Monsalud, St. N
BSN 4A - Group 4

August 22, 2021

 I. Definition
A tracheostomy is a small surgical opening in the trachea, or windpipe, of the
throat. A tube is put into this hole for a patient's breathing. It keeps the airway open so
oxygen, humidity, or breathing treatments can be given. Mucous can be removed by
suctioning with this tube. A mechanical ventilator is a machine that is used by some
people which will be attached to the tracheostomy tube. Hence, this surgery helps
overcome upper airway blockage, facilitates mechanical ventilator support, and removes
tracheobronchial secretions (“Tracheostomy Care”, 2021).
In addition, this procedure is one of the most common procedures performed on
severely ill patients. A tracheostomy is more likely indicated if a patient requires
mechanical ventilation for an extended period of time. Patients who have had trouble
weaning off a ventilator are the most likely candidates, followed by those who have
sustained trauma or a catastrophic brain insult. In disorders that necessitate a surgical
airway, infectious and neoplastic processes are less common (Lindman, 2018).
In conclusion, tracheostomy care is essential to maintain the cleanliness of the
trach tube. This reduces the risk of infection and prevents a clogged tube.Tracheal care
includes suctioning and cleansing parts of the tube and the skin. After that, the nurse will
show the patient how to properly care for the tracheostomy tube as well as what to do in
the event of an emergency (The Royal Children's Hospital Melbourne, n.d.).

Types of Tracheostomy Tubes

Tracheostomy tubes come in a variety of shapes and sizes, each with its own
set of characteristics to suit its intended use. An obturator, an outer cannula (tube shaft)
with a flange (neck plate), and an inner cannula make up a standard tracheostomy tube.
An obturator is used to insert a tracheostomy tube. It slides into the tube and smooths
off the surface. This makes it easier to install the tracheostomy tube.. The tracheostomy
is held open by the outer cannula, which serves as the outside tube. A neck plate
extends from the outer tube's sides and contains holes for attaching cloth ties or velcro
straps to the neck. Lastly, the inner cannula is designed to fit inside the outer cannula. It
features a lock to prevent it from possibly spitting out due to coughing, and it can be
removed for cleaning.
Tube Indications Recommendations

Single Lumen Tracheostomy Tube

Used for pediatric There is no inner cannula,

patients. resistance may be reduced.

Double Lumen Tracheostomy Tube

Double lumen tubes

are the most
commonly used
tracheostomy tube.

Cuffed Tube with Disposable Inner Cannula

This is used to ● Cuff should be inflated

obtain a closed when using ventilators.
circuit for ventilation. ● Cuff should be inflated just
enough to allow minimal air
leak.
● Cuff should be deflated if
the patient uses a speaking
valve.
● Cuff pressure should be
 checked twice a day.
● The inner cannula is
disposable.

Cuffed Tube with Reusable Inner Cannula

Used to obtain ● Cuff should be inflated

closed circuits for when using ventilators.
ventilation. ● Cuff should be inflated just
enough to allow minimal air
leak.
● Cuff should be deflated if
the patient uses a speaking
valve.
● Cuff pressure should be
checked twice a day.
● The inner cannula is not
disposable. This can be
reused after cleaning it
thoroughly.

Cuffless Tube with Disposable Inner Cannula

● This type of tube ● Save the decannulation

is recommended plug if the patient is close
for patients with to getting decannulated.
tracheal ● The patient may be able to
problems. eat and may be able to talk
● This is also used without a speaking valve.
for patient's who ● The inner cannula is
are ready for disposable.
decannulation.

Cuffless Tube with Reusable Inner Cannula

 ● Used for ● Save the decannulation
patients with plug if the patient is close
tracheal to getting decannulated.
problems. ● The patient may be able to
● Used for eat and may be able to
patients who are speak without a speaking
ready for valve.
decannulation. ● The inner cannula is
disposable. This can be
reused after cleaning it
thoroughly.

Metal Tracheostomy Tube

Not used as ● Patients cannot get an

frequently anymore. MRI.
Many of the patients ● One needs to notify the
who received a security personnel at the
tracheostomy years airport prior to metal
ago still choose to detection screening.
continue using the
metal tracheostomy
tubes.

Fenestrated Cuffed Tracheostomy Tube

Used for patients ● There is a high risk for

who are on the granuloma formation at the
ventilator but are not site of the fenestration
able to tolerate a (hole).
speaking valve to ● There is a higher risk for
speak. aspirating secretions.
● It may be difficult to
ventilate the patient
 adequately.

Fenestrated Cuffless Tracheostomy Tube

Used for patients There is a high risk for

who have difficulty granuloma formation at the site
using a speaking of the fenestration (hole).
valve.

PEDIATRIC TUBE

The main indication ● The size of the

for tracheostomy in tracheostomy tube should
the pediatric be selected based on lung
population was for mechanics.
viral and bacterial ● Uncuffed tubes are
infections such as preferred over cuffed
croup, diphtheria, tracheostomy tubes in the
and epiglottitis. pediatric population.
● Some tubes require air to
be inserted, while others
require water.
Manufacturer
recommendations should
be followed.

II. Indications
With the advent of antibiotics and developments in anesthetic, tracheostomy has
become a regular elective treatment. It's worth noting, too, that there are times when
tracheostomy is absolutely necessary. This usually happens to a patient who requires a
surgical airway due to an impending airway obstruction (Lindman, 2018).
Moreover, there are a lot of conditions indicated for a tracheostomy that need the
attention and quality of care from the health team, especially the nurses. The indications
are congenital anomaly such as laryngeal hypoplasia and vascular web; those with
upper airway foreign body that cannot be dislodged with Heimlich and basic cardiac life
support maneuvers; clients with supraglottic or glottic pathologic condition such as
infection, neoplasm, bilateral vocal cord paralysis.
Other conditions that requires tracheostomy are neck trauma that results in
severe injury to the thyroid or cricoid cartilages, hyoid bone, or great vessels;
subcutaneous emphysema; facial fractures that may lead to upper airway obstruction
such as comminuted fractures of the midface and mandible; upper airway edema from
trauma, burns, infection, or anaphylaxis; prophylaxis as preparation for extensive head
and neck procedures and the convalescent period and severe sleep apnea that is not
amenable to continuous positive airway pressure devices or other less invasive surgery.
In addition, in cases of respiratory failure, tracheostomy may also be used to give
a long-term channel for mechanical ventilation or to provide a pulmonary toilet. Some
examples of these are inadequate cough due to chronic pain or weakness and
aspiration and the inability to handle secretions.
Furthermore, for patients who are projected to require mechanical ventilation for
more than seven days, the American College of Chest Physicians' Council on Critical
Care recommends tracheostomy. However, the decision is based on comorbidities and
the patient's current health making it individualized.
Finally, it is also crucial to clearly outline what the procedure will not achieve for
the patient. Tracheostomy, in particular, does not prevent airway or other secretion
aspiration. Botulism, amyotrophic lateral sclerosis, and cervical spine injury are just a
few of the additional illnesses for which tracheostomy is frequently considered early in
the course.

III. Equipments/Materials
For Suctioning:
1. Suction source (wall or portable)
2. Sterile aspirating catheter
● Infants: Fr. 6 to 8
● Children: Fr. 8 to 10
● Adults: Fr. 12 to 16
 3. Sterile container
4. Sterile gloves
5. Sterile NSS or sterile water
6. Clean towel or waterproof pad
7. Sterile 2-10 ml. Syringe (optional)
8. Mask

For Cleaning Inner Cannula/Incision Site

● Small brush or pipe cleaners
● Half-strength solution of hydrogen peroxide (1/2 water, 1/2 hydrogen peroxide)
● Saline or homemade sterile salt water
● Two small bowls
● Tracheostomy dressing or sterile gauze dressing

For Changing Tracheostomy Ties:

● Tracheostomy kit
● Two equal lengths of cotton ties (approximately 40cm) or
● Velcro ties (for patients older than 6 years)

IV. Procedure with Rationale

Suctioning the Tracheostomy

Tracheostomy suctioning is the removal of secretions from the trachea or bronchi
by means of a suction catheter inserted into the tracheostomy tube. Tracheal suction is
an essential component of managing secretions, maintaining respiratory function and a
patent airway.

1. Obtain baseline vital signs.

R: An immediate baseline data serves as an index for needing suctioning as well
as a basis for evaluating its effectiveness.
2. Prepare equipment at the bedside.
 R: Preparation of equipment allows smooth performance of the procedure without
interruption.
3. Explain the procedure to the client.
R: An explanation relieves apprehension and facilitates cooperation.
4. Wash hands with bactericidal soap and water or apply bactericidal alcohol hand
rub, put on disposable plastic apron, disposable gloves and eye protection
R: To minimize the risk of cross infection

5. Assist the client to a semi–Fowler’s position if conscious. An unconscious client

should be placed in the lateral position facing you.
R: A sitting position helps the client to cough and breathe more easily. This
position also uses gravity to aid in the insertion of the catheter. A lateral position
prevents the airway from becoming obstructed and promotes drainage of
secretions.
6. Place a towel or waterproof pad across the client’s chest.
R: Absorbent material protects the client and bed linen.
7. Turn the suction on to the appropriate pressure:
a. Wall unit:
● Adult: 110 – 150 mmHg
● Child: 95 – 110 mmHg
● Infant: 50 – 95 mmHg
b. Portable unit:
● Adult : 10 – 15 mmHg
● Child : 5 – 10 mmHg
● Infant : 2 – 5 mmHg
R: Proper suction pressure provides safe negative pressure according to the
client’s age. Excessive negative pressure can precipitate a pneumothorax.
8. Open the sterile container and place it on the bedside table or overbed table
without contaminating the inner surface.
R: The chambers within the container maintain the sterility of items that will be in
direct contact with the client’s airway.
9. Pour sterile saline or water into the container.
R: Sterile solution is needed to lubricate the catheter to decrease friction and
promote smooth passage of the catheter.
10. Hyperoxygenate the client for 1 to 3 minutes by using the manual resuscitation
bag.
R: To prevent acute hypoxia during suctioning.
11. Apply a sterile glove to your dominant hand. Remove wrapper around the
catheter with the non–dominant unsterile hand and discard.
R: The sterile glove reduces the risk of infection.
12. Holding the sterile suction catheter with the gloved hand, connect it to the suction
tubing that is held with the unsterile hand.
R: Sterile technique prevents introducing organisms into the respiratory tract.
13. Moisten the catheter by dipping it into the container of sterile saline. Occlude the
suction control port to check suction.
R: Lubricating the inside of the catheter with saline helps move secretions
through the catheter. Occluding the suction control port while the catheter is in the
sterile solution ensures that suction equipment is functioning well before insertion.
14. Remove the oxygen administration equipment with the unsterile hand.
R: Removing the oxygen allows access to the tracheostomy tube.
15. Using your nondominant hand and a manual resuscitation bag, hyperventilate
the patient, delivering 3 to 6 breaths.
R: Hyperoxygenation and hyperventilation aid in preventing hypoxia during
suctioning.
16. Using the sterile hand, gently but quickly insert the catheter into the trachea
about one third of its length or approximately 10 -15 cm or until the client coughs
if resistance is felt, withdraw the catheter about 1 cm before applying suction by
placing the thumb over the port control and slowly withdraw the remainder of the
catheter.
R: Using the suction while inserting the catheter can cause trauma to the tracheal
mucosa and respiratory infection; Catheter should not go further than the carina
to prevent trauma; Catheter inserted with suction off can reduce trauma.
17. Apply suction by occluding the suction control port with the thumb of the unsterile
hand. Gently rotate the catheter with the thumb and index finger of the gloved
hand as you withdraw it. Limit suctioning to 10 seconds duration only for adults;
newborn 5-8 sec, children 5-10 seC, at 30 seconds – 1 minute interval.
R: Occlusion of suction control port activates suction pressure. Rotation removes
secretions from all surfaces of the airway and prevents trauma from suction
pressure on one area of the airway; Prolonged suctioning may result in acute
hypoxia, cardiac arrhythmia (Day et al 2002), mucosal trauma, infection and the
patient experiencing a feeling of choking.
18. Encourage the client to cough during suctioning.
R: Coughing helps loosen and move secretions to the area of the catheter.
19. Using your nondominant hand and a manual resuscitation bag, hyperventilate the
patient, delivering 3 to 6 breaths .
R: Hyperoxygenation and hyperventilation aid in preventing hypoxemia during
suctioning.
20. Attach the oxygen administration equipment with the unsterile hand.
R: This prevents hypoxemia
21. Flush the catheter with saline and assess the need to repeat suctioning. Allow the
client to rest at least 3 – 5 minutes between suctioning. Readminister oxygen
between suctioning efforts and when suctioning is completed.
R: Flushing cleanses the catheter and lubricates it for the next insertion. Allowing
a time interval and replacing the oxygen help compensate for hypoxia induced by
the previous suctioning.
22. When the procedure is completed, turn off the suction and disconnect the
catheter from the suction tubing. Remove the sterile glove inside out and dispose
of the gloves, catheter and container in a waste receptacle. Wash hands.
R: Keeping contaminated articles confined to certain areas limits the transmission
of microorganisms. Handwashing deters the spreads of microorganisms by direct
contact.
23. Keeping contaminated articles confined to certain areas limits the transmission of
microorganisms. Handwashing deters the spreads of microorganisms by direct
 contact.
R: Respiratory secretions that accumulate in the mouth are irritating to the
mucous membranes and unpleasant for the patient. Reassessment helps
evaluate the effect of suctioning. Breathing should be relatively effortless and
quiet.
24. Reassess the patient’s respiratory status, including respiratory rate, effort, oxygen
saturation and lung sounds.
R: This assesses the effectiveness of suctioning and presence of complications.
25. Record the time of the suctioning and the nature and amount of secretions. Also
note the character of the client’s respirations before and after suctioning.
R: A written summary provides accurate documentation of comprehensive care.

Cleaning the inner cannula

The tracheostomy inner cannula tube should be cleaned two to three times per
day or more as needed. Please note that this only applies to reusable inner cannulas.
Cleaning is needed more immediately after surgery and when there is a lot of mucus
buildup.
1. Wash the hands.
2. Place 1/2 strength peroxide solution in one bowl and sterile salt water in the
second bowl.
3. Remove the inner cannula while holding the neck plate of the trach still.
4. Place inner cannula in peroxide solution and soak until crusts are softened or
removed.
5. Use the brush or pipe cleaner to clean the inside, outside and creases of the
tube.
6. Do not use scouring powder or Brillo pads.
7. Look inside the inner cannula to make sure it is clean and clear of mucus.
8. Rinse the tube in saline or sterile salt water.
9. After rinsing, gently tap the cannula against the inside edge of the sterile saline
container. Use a pipe cleaner folded in half to dry only the inside of the cannula;
do not dry the outside.
 Rationale: This removes excess liquid from the cannula and prevents possible
aspiration by the client, while leaving a film of moisture on the outer surface to
lubricate the cannula for reinsertion.
10. Re-insert it while holding the neck plate of the trach still.
11. Insert the inner cannula by grasping the outer flange and inserting the cannula
in the direction of its curvature.
12. Lock the cannula in place by turning the lock (if present) into position to secure
the flange of the inner cannula to the outer cannula.

Cleaning the incision site as well as the tube flange

1. Clean the incision site using sterile applicators or gauze dressings that have been
moistened with normal saline.Handle the sterile supplies with your dominant
hand. Use each applicator or gauze dressing only once and then discard.
Rationale: This avoids contaminating a clean area with a soiled gauze dressing
or applicator.
2. Hydrogen peroxide can typically be used in a half-strength solution—mix it with
sterile normal saline—in order to remove crusty secretions (check hospital policy).
Thoroughly rinse the cleaned area using gauze squares moistened with sterile
normal saline.
Rationale: Hydrogen peroxide can be irritating to the skin and inhibit healing if
not thoroughly removed
3. Clean the flange of the tube in the same manner.
4. Thoroughly dry the patient’s skin and tube flanges with dry gauze squares.

Apply Sterile Dressing:

5. Use a commercially prepared tracheostomy dressing of non-raveling material.

Alternatively, you can open and refold a 4-in. x 4-in. gauze dressing into a V
shape. Avoid using cotton-filled gauze squares or cutting the 4-in. x 4-in. gauze.

Rationale: Cotton lint or gauze fibers can be aspirated by the client, potentially
creating a tracheal abscess.

6. Place the dressing under the flange of the tracheostomy tube.

 7. While applying the dressing, make sure that the tracheostomy tube is firmly
supported.

Rationale: Excessive movement of the tracheostomy tube irritates the trachea.

Changing Tracheostomy Ties

The bands that go around the neck are known as trach ties. The trach tube is
held in position by them. Trach ties come in a variety of materials. A soft cloth with
Velcro is frequently used. The trach tie could be made using a single piece of material.

Procedure (Cotton Ties):

1. Explain to the patient and their family about the procedure.
2. Apply eye protection.
3. Perform hand hygiene, then don working gloves.
4. Prepare two equal lengths of ties long enough to go around the patient’s neck.
5. Position the patient; the patient may lie down with the neck gently extended by a
small rolled towel placed under the shoulders. If tolerated, the patient may like to
sit up in a bed or chair.
6. Insert a clean tie into the holes on each side of the flange.
7. On each side tie a single loop approximately 0.5cm from the flange on the
tracheostomy tube.
8. Then tie both sides together in a bow to secure.
9. Check the tension of the ties.
10. Allow one finger to fit snugly between the skin and the ties.
11. Re-tie into a double (reef) knot to secure.
12. Cut off excess length of ties leaving approximately 3cm.
13. Using scissors remove old ties and recheck tension of new ties.
14. Dispose of waste, remove gloves, and perform hand hygiene.
15. Observe around the patient’s neck to check skin integrity.

Procedure (Velcro Ties):

1. Changing Velcro ties is a two person procedure. Check the Velcro on the
 tracheostomy ties prior to each use to ensure adhesiveness. If not adherent,
discard and replace.
2. Apply eye protection.
3. Perform hand hygiene, don working gloves.
4. The other person holds the tracheostomy tube securely in place. So, the second
person removes the existing Velcro ties and then inserts the clean Velcro ties
through one side of the flange, passing the tie around the back of the patient's
neck and inserting the Velcro tie through the other side of the flange.
5. Adjust the ties to allow one finger to fit snugly between the skin and the ties.
6. Check to ensure the Velcro is securely fastened
7. Dispose of waste, remove gloves, and perform hand hygiene.
8. Observe the patient's neck to check skin integrity.
9. Wash Velcro ties daily in warm, soapy water, rinse and allow to dry completely
before reusing.

V. Nursing Responsibilities
1. The student nurse or nurse should explain the procedure to the patient.
2. Emphasize the importance of handwashing before and after performing the
tracheostomy care.
3. The student nurse or nurse should know the proper way on how to remove,
change, and replace the inner cannula.
4. Observe the patient for signs of hypoxia, infection, and pain.
5. Examine the trach tube, any tubing and equipment connected to it, as well as the
stoma site. Observe redness, purulent drainage, and abnormal bleeding around
the stoma. Note the amount, color, consistency, and odor of secretions.
6. Auscultate to breath sounds with a stethoscope. Before beginning any care,
ensure that the appropriate emergency trach replacement tubes and CPR
equipment is at the bedside.
7. The student nurse or nurse should change the tracheostomy dressing every 8
hours or when the dressing gets soiled.
8. Tracheostomy tubes may come with disposable inner cannula or without the inner
 cannula. If a disposable inner cannula is present, replace the one that is currently
inside with a new one.
9. If a single lumen tube is used, suction the tracheostomy tube and clean the neck
plate as well as the tracheostomy site.
10. Check and clean the tracheostomy stoma.
11. Older adult skin is fragile and prone to breakdown. Care of the skin at the
tracheostomy stoma is essential.
12. Assess for signs and symptoms that may indicate an infection of the stoma site or
lower airway.

VI. Special Considerations

1. For tracheostomies older than 1 month, clean technique rather than sterile
technique is used for tracheostomy care.
2. Tap water may be used for rinsing the inner cannula.

Special considerations for Suctioning

1. Suctioning can cause nosocomial infections, hypoxia, injury to the airway, and
cardiac dysrhythmias. Follow agency policy on suction to prevent these
complications.
2. Hyperoxygenate the patient according to agency policy.
3. If a sterile sputum sample is required, follow agency policy for specific directions
related to type of equipment in the agency.
Lifespan considerations for Infants and Children
1. An assistant should always be present while performing the tracheostomy care.
2. Always keep a sterile, packaged tracheostomy tube taped to the child’s bed so
that if there is dislodgement in the tube, a new one is available for immediate
reintubation.

Health Teachings
● Clean the trach equipment as directed. Use clean or sterile trach care methods to
clean the equipment.
 ● Clean the area around the trach as directed. The area around the trach is called
the stoma.
● Use a trach cover as directed. Do not use a trach cover unless the doctor says it is
okay. A trach cover sits over the opening to the trach tube. It prevents dirt and
other foreign bodies from getting into the airway.
● Keep the mouth clean. Saliva and mucus contain germs that cause infection if they
enter the airway. Brush the teeth twice a day. Suction the mouth as needed. Use
a mouthwash twice a day or as directed.
● Take deep breaths and cough 10 times each hour. This will decrease the risk for a
lung infection. Encourage the patient to take a deep breath and hold it for as long
as he or she can. Let the air out and then cough strongly. Deep breaths help
open the airway. The patient may be given an incentive spirometer to help take
deep breaths. Put the plastic piece in the mouth and take a slow, deep breath,
then let the air out and cough. Repeat these steps 10 times every hour.

VII. References
Boshoff, E. L. D., & Nakawunde, H. (2016, December 21). Tracheostomy.
Nurseslabs. Retrieved on August 20, 2021 from https://nurseslabs.com/
tracheostomy-nursing-management/.

John Hopkins Medicine. (N.D). Cleaning and Caring for Tracheostomy

Equipment. Retrieved on August 19, 2021 from
https://www.hopkinsmedicine.org/tracheostomy/living/equipment_clean
ing.html
John Hopkins Medicine. (N.D). Complications and Risks of Tracheostomy.
Retrieved on August 19, 2021 from https://www.hopkinsmedicine.org/
tracheostomy/about /complications.html
Lindman, J.P. (2018). Tracheostomy. Medscape. Retrieved on August 19, 2021
from https://emedicine.medscape.com/article/865068-overview#a1-a2
Mathew, T. (2018, December 11). Tracheostomy care. Retrieved on August 21,
2021, from https://www.slideshare.net/thanuja01/tracheostomy-care-
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Molnar, H. (2017, June 21). Types of TRACHEOSTOMY TUBES. Retrieved
August 19, 2021, from https://www.hopkinsmedicine.org/tracheostomy/
about/types.html
Ng, J. (2021, March 01). Tracheostomy tube Change. Retrieved August 19,
2021, from https://www.ncbi.nlm.nih.gov/books/NBK555919/
Parker, L. ( 2014). Tracheostomy care : Nursing2020 critical care. Retrieved
August 19, 2021, from https://journals.lww.com/nursingcriticalcare/
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Support, S. E. (2017, May 18). Cleaning and caring for tracheostomy equipment.
Johns Hopkins Medicine, based in Baltimore, Maryland. Retrieved on August
20, 2021 from https://www.hopkinsmedicine.org/tracheostomy/living/
equipment_cleaning.html.
Support, S. (2017, June 12). Stoma care. Retrieved August 19, 2021, from
https://www.hopkinsmedicine.org/tracheostomy/living/stoma.html
Unitek College. (2021, March 22). Step-by-step master's guide to tracheostomy
care. Unitek College. Retrieved on August 20, 2021 from https://
www.unitekcollege.edu/blog/a-step-by-step-guide-to-tracheostomy-care/.