TRACHEOSTOMY

CARE
TRACHEOSTOMY

is an opening into the trachea through

the neck just below the larynx through
which an indwelling tube is placed and
thus an artificial airway is created.
TRACHEOSTOMY TUBE
 A curved hollow tube of rubber or plastic inserted into
the tracheostomy stoma (the hole made in the neck
and windpipe (Trachea)) to relieve airway obstruction,
facilitate mechanical ventilation or the removal of
tracheal secretions.
PARTS OF TRACHEOSTOMY
TUBE
PURPOSES
• To maintain airway patency by removing mucus and
encrusted secretions.
• To maintain cleanliness and prevent infection at the
tracheostomy site
• To facilitate healing and prevent skin excoriation around
the tracheostomy incision
• To promote comfort
• To prevent displacement
ASSESSMENT
• Respiratory status (ease of breathing, rate, rhythm, depth,
lung sounds, and oxygen saturation level)
• Pulse rate
• Secretions from the tracheostomy site (character and
amount)
• Presence of drainage on tracheostomy dressing or ties
• Appearance of incision (redness, swelling, purulent
discharge, or odor)
EQUIPMENTS

• Sterile disposable tracheostomy cleaning kit or supplies (sterile containers,

sterile nylon brush or pipe cleaners, sterile applicators, gauze squares)
• Sterile suction catheter kit (suction catheter and sterile container for
solution)
• Sterile normal saline (Check agency protocol for soaking solution)
• Sterile gloves (2 pairs)
• Clean gloves
• Towel or drape to protect bed linens
• Moisture-proof bag
• Commercially available tracheostomy dressing or sterile 4-in. x -in. gauze
dressing
• Cotton twill ties
• Clean scissors
PROCEDURE

1. Introduce self and verify the client’s identity using agency protocol. Explain
to the client
everything that you need to do, why it is necessary, and how can he cooperate. Eye
blinking, raising a finger can be a means of communication to indicate pain or
distress.
2. Observe appropriate infection control procedures such as hand hygiene.
3. Provide for client privacy.
4. Prepare the client and the equipment.
• To promote lung expansion, assist the client to semi-Fowler’s or Fowler’s
position.
• Open the tracheostomy kit or sterile basins. Pour the soaking solution and
sterile normal saline into separate containers.
• Establish the sterile field.
• Open other sterile supplies as needed including sterile applicators, suction kit,
and tracheostomy dressing.
5. Suction the tracheostomy tube, if necessary.
• Put a clean glove on your nondominant hand and a sterile glove on
your dominant hand (or put on a pair of sterile gloves).
• Suction the full length of the tracheostomy tube to remove
secretions and ensure a patent airway.
• Rinse the suction catheter and wrap the catheter around your hand,
and peel the glove off so that it turns inside out over the catheter.
• Unlock the inner cannula with the gloved hand. Remove it by gently
pulling it out toward you in line with its curvature. Place it in the
soaking solution. Rationale: This moistens and loosens secretions.
• Remove the soiled tracheostomy dressing. Place the soiled dressing
in your gloved hand and peel the glove off so that it turns inside out
over the dressing. Discard the glove and the dressing.
• Put on sterile gloves. Keep your dominant hand sterile during the
procedure.
6. Clean the inner cannula.
• Remove the inner cannula from the soaking solution.
• Clean the lumen and entire inner cannula thoroughly using the brush
or pipe cleaners moistened with sterile normal saline. Inspect the
cannula for cleanliness by holding it at eye level and looking through it
into the light.
• Rinse the inner cannula thoroughly in the sterile normal saline.
• 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.
7. Replace the inner cannula, securing it in place.
• Insert the inner cannula by grasping the
outer flange and inserting the cannula in the
direction of its curvature.
• 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.
8. Clean the incision site and tube flange.
• Using sterile applicators or gauze dressings moistened with normal
saline, clean the incision site. 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.
• Hydrogen peroxide may be used (usually in a half-strength solution
mixed with sterile normal saline; use a separate sterile container if
this is necessary) to remove crusty secretions. Check agency
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.
• Clean the flange of the tube in the same manner.
• Thoroughly dry the client’s skin and tube flanges with dry gauze
9. Apply a sterile dressing
• Use a commercially prepared tracheostomy dressing of
non- raveling material or 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.
• Place the dressing under the flange of the tracheostomy
tube.
• While applying the dressing, ensure that the
tracheostomy tube is securely supported. Rationale:
Excessive movement of the tracheostomy tube irritates
the trachea.
10. Change the tracheostomy ties.
• Change as needed to keep the skin clean and dry.
• Twill tape and specially manufactured Velcro ties
are available. Twill tape is inexpensive and readily
available; however, it is easily soiled and can trap
moisture that leads to irritation of the skin of the
neck. Velcro ties are becoming more commonly
used. They are wider, more comfortable, and cause
less skin abrasion.
• Tracheal Suctioning
 A means of clearing thick mucus and secretions from the
trachea and lower airway through the application of
negative pressure via a suction catheter.
Tracheostomy care video
Tracheostomy Tube
Cuff
PURPOSE
• The purpose of the inflated tracheostomy tube cuff is to
direct airflow through the tracheostomy tube. This is
typically during mechanical ventilation when the ventilator
circuit must be closed to control and monitor ventilation for
the ventilator patient, who frequently has a more seriously
compromised system than patients not on a ventilator.
• The inflated cuff also may be important in cases of gross
emesis or reflux when gross aspiration is present, to limit
the penetration of aspirated material into the lower airway.
Inflated Cuff Considerations
The inflated cuff should be avoided whenever possible
because it has the potential to cause multiple complications,
such as:
1. Increased risk of tracheal injury, including mucosal
injury, stenosis, granulomas, and more;
2. Diminished ability to use the upper airway, leading to
disuse atrophy over time; and
3. Restriction of laryngeal movement (laryngeal tethering)
which may impact swallowing negatively.
Cuff Deflation

Deflating the tracheostomy tube cuff, when appropriate, has

been shown to have multiple patient benefits, including:
1. Reducing the risk of potential tracheal mucosal damage;
2. Returning the patient to a more normal physiology, including
closing the system through the use of a bias-closed position, noleak Valve;
3. Restoring speech and improving communication;
4. Allowing for the possible improvement of the swallow;
5. Potentially lowering the risk of aspiration;
6. Allowing rehabilitation to begin as early as possible; and
7. Decreasing the time to decannulation.
• Decannulation
 The process whereby a tracheostomy tube is removed once patient
no longer needs it.
• Humidification
 The mechanical process of increasing the water vapour content of an
inspired gas.
• Stoma
 An opening, either natural or surgically created, which connects a
portion of the body cavity to the outside environment (in this case,
between the trachea and the anterior surface of the neck).
OROPHARYGEAL and
NASOPHARYNGEAL
SUCTIONING
• OROPHARYGEAL SUCTIONING

Extends from the lips to the pharynx.

Requires the insertion of a suction catheter
through the mouth to the pharynx.

• NASOPHARYNGEAL SUCTIONING

Extends from the tip of the nose to the pharynx.

 The suction catheter is inserted through the
nostrils in to the pharynx.
INDICATIONS
• Suction is indicated for visible or audible airway
secretions, signs of airway obstruction or signs
of oxygen deficit that persist in spite of the
patient's best cough effort.
INDICATIONS
• Patient feels/ indicates the presence of secretions in his /
her airway
• Deteriorating arterial blood gas values
• Altered chest movements
• Restlessness
• Decreased oxygen saturation levels
• Diminished air entry
• Change of colour
• Tachypnoea
CAUTION
 Suspected epiglottitis
 Occluded nasal passages
 Nasal Bleeding
 Acute head, facial, or neck injury(nasopharyngeal suctioning
not advisable with basal skull fractures
 Coagulopathy or bleeding disorder
 Laryngospasm
 Irritable airway
 Tracheal surgery
 Gastric surgery with high anastomosis
COMPLICATIONS

Suctioning is not a benign procedure and adverse physiological

effects directly attributed to oral or
nasopharyngeal suctioning are well documented e.g.:
 Hypoxia
 Atelectasis
 Cardiovascular changes
 Intra cranial pressure alterations
 Pneumothorax
 Bacterial infection

Discomfort/pain
 Hypo/hypertension
 Overstimulation of secretions
 Laryngospasm
 Sepsis
 Gagging/vomiting
 Nosocomial infection
SAFETY CONSIDERATIONS

 Hand hygiene
 Review all safety considerations for oral suctioning.
 The mouth and pharynx contain bacteria that can potentially contaminate the
trachea. If necessary, suction the mouth with a different suction catheter /
yankauer prior to beginning this procedure. Perform regular good mouth
care.
 Monitor the client throughout the procedure, and stop suctioning if the client
experiences rapid changes in status.
 Suctioning can cause increased intracranial pressure in patients with head
injury. The nurse can reduce this risk by hyper-oxygenating the patient before
suctioning and/or limit the number of times a suction catheter is inserted into
the trachea.
 Use sterile technique for oropharyngeal suctioning.
PROCEDURE

STEPS

1. Assess the need for suctioning including respiratory

assessment, signs of hypoxia, inability to clear own
secretions adequately, alterations in oxygenation levels

ADDITIONAL INFORMATION
Perform baseline respiratory assessment including
SpO2.
Assess for additional factors that might influence
procedure, i.e., recent surgery; head, chest, or neck
tumors; facial or nasal trauma; and neuromuscular
diseases.
Determine if the patient is on any medications that
increase risk of bleeding

2. Explain the procedure in calm reassuring manner

explaining the benefits to remove secretions to make
breathing easier.

Procedure can cause patient anxiety. This is part of the

consent procedure. Allow the patient an opportunity to
ask questions.

3. Position the patient in semi to high Fowler’s – unless

contraindicated. Drape chest with towel or disposable
pad.

Promotes lung expansion and promotes secretion

clearance.
STEPS

ADDITIONAL INFORMATION

4. Perform hand hygiene. Gather equipment.

Ensure suction set up is working

Suction machine (portable or wall); canister &

liner; connective tubing (2), suction catheter,
lubricant, sterile saline or water (acts as
lubricant), PPE (sterile gloves, face shield and / or
gown), pulse oximeter.

5. Administer oxygen if needed

Hyper-oxygenating might be necessary if the

patient is hypoxic or at risk of hypoxia during
procedure.

6. Estimate the appropriate suctioning depth by

measuring the catheter from the tip of the
patient’s nose to the angle of the mandible or to
the earlobe

This is done with the suction catheter still in the

sterile package. Ensures that the catheter
remains sterile and at minimum reaches the
pharynx.
STEPS
7. Turn the suction device on, and set the
vacuum regulator to the appropriate
negative pressure. Set suction levels to
medium / moderate.
Attach the suction catheter to the tubing
whilst remaining in the sterile package.
Open the sterile water / saline.

ADDITIONAL INFORMATION
It is the tip of the catheter that you try to
keep sterile.
Suction setting:
Adult 80 to 100 mmHg
Children 60 to 80 mmHg
*Not to exceed 150 mmgHg (AARC 2004)

If using lubricant, squeeze water soluble

lubricant onto sterile surface.
8. Hand hygiene & Donne PPE

At minimum PPE should include: sterile

gloves & face shield.
Sterile gloves reduce risk of transmitting
microorganisms into the lungs.
STEPS
9. Apply sterile gloves. With the non-dominant hand,
pick up the packaged connecting tubing.
Expose the suction catheter enough to allow the
dominant hand to grab the sterile catheter.
Wrap the sterile catheter around the dominant hand.
Suction a small amount of sterile NS / water.
Apply lubricant if necessary (to 10 cm of catheter tip)
10. Insert suction catheter via route of choice (oral /
nasal) until you feel that you are in the pharynx or until
you feel resistance:
Oral (last resort)
Nasal

ADDITIONAL INFORMATION
You can also apply a non sterile glove to the non
dominant hand and a sterile glove to the dominant
hand.
There is more than one way to remove the sterile
suction catheter from the package: the principle is keep
the dominant hand & the suction catheter tip sterile.
Suctioning sterile NS/ water ensures properly
functioning equipment.
The route chosen will depend on the urgency of the
situation and presence of tubes and the skill level of the
nurse. Each route comes with inherit risks:
Oral (increases risk of respiratory infection by
introduction of oral bacteria to the trachea). This route
should be used as a last resort
Nasal (increases risk of nasal trauma – chose a nare
with least resistance). Can also be done through a nasal
airway
All: increased risk of vasovagal response laryngospasm
( which could lead to airway obstruction / hypoxia)
STEPS

ADDITIONAL INFORMATION
Important for this patient population is frequent and
adequate mouth care and collaboration with
respiratory therapy and physiotherapy
Introduction of the catheter sometimes stimulates a
cough response.
Suction applied during insertion increases risk of
mucosal damage and increases risk of hypoxia

11. Apply intermittent suction as the catheter is

withdrawn. This means occluding and releasing the
catheter vent with the non-dominant thumb. Some
sources suggest twisting catheter back and forth
as the catheter is withdrawn. Always encourage
the patient to cough.

Do not apply suction for longer than 10 to 15

seconds. Suction removes oxygen and increases
risk of hypoxia as oxygen is sucked out.
The need to rotate the catheter is questioned in the
literature because modern suction catheters have
multiple eyes / holes (Moore, 2003).
Encourage patient to cough to promote secretion
clearance.
STEPS

ADDITIONAL INFORMATION

12. Replace the oxygen delivery device, if

applicable, and instruct the patient to take deep
breaths to encourage oxygenation.

Reapply oxygen delivery device, if applicable

13. Clear secretions from the suction catheter by

suctioning sterile water / saline to clear tubing of
secretions.

Clears tubing of secretions to maintain patency

STEPS
14. Assess the need to repeat the procedure.

ADDITIONAL INFORMATION
Observe for changes to cardiopulmonary status.
Can often be done through observation of
breathing pattern including HR and SpO2.
If stethoscope is needed, hand hygiene and
reapplication of sterile gloves is necessary if you
are going to repeat the procedure.
When possible, provide recovery time (at least 1
minute) between suction passes to allow for
ventilation and oxygenation to occur.

15. Discard suction catheter, sterile saline / water,

lubricant, sterile gloves. Turn off suction. Remove
gloves. Perform hand hygiene. Ensure the patient
is comfortable and the call bell within reach.
16. Document the procedure in the patient’s
record.

Open suctioning method requires new suction

catheter after each round of suctioning. Reuse
may introduce microorganisms into the patient’s
respiratory tract increasing risk of infection
Oropharyngeal Suctioning Video
Nasotracheal Suctioning Video
NEBULIZATION
THERAPY
NEBULIZATION
is the process of medication administration
via inhalation. It utilizes a nebulizer which
transports medications to the lungs by
means of mist inhalation.
INDICATION

Nebulization therapy is used to deliver medications along the

respiratory tract and is indicated to various respiratory
problems and diseases such as:
Bronchospasms
Chest tightness
Excessive and thick mucus secretions
Respiratory congestions
Pneumonia
Atelectasis
Asthma
CONTRAINDICATION
In some cases, nebulization is restricted or avoided due to possible
untoward results or rather decreased effectiveness such as:

 Patients with unstable and increased blood pressure

 Individuals with cardiac irritability (may result to dysrhythmias)
 Persons with increased pulses
 Unconscious patients (inhalation may be done via mask but the
therapeutic effect may be significantly low)
EQUIPMENTS:
Nebulizer and nebulizer connecting tubes
Compressor oxygen tank
Mouthpiece/mask
Respiratory medication to be administered
Normal saline solution
NEBULIZER
MAS
K

MOUTH PIE
CE
PROCEDURE
1. Position the patient appropriately, allowing optimal
ventilation.
2. Assess and record breath sounds, respiratory status,
pulse rate and other significant respiratory functions.
3. Teach patient the proper way of inhalation:
 Slow inhalation through the mouth via the mouthpiece
 Short pause after the inspiration
 Slow and complete exhalation
 Some resting breaths before another deep inhalation
4. Prepare equipments at hand
5. Check doctor’s orders for the medication, prepare
thereafter
6. Place the medication in the nebulizer while adding the
amount of saline solution ordered.
7. Attach the nebulizer to the compressed gas source
8. Attach the connecting tubes and mouthpiece to the nebulizer
9. Turn the machine on (notice the mist produced by the
nebulizer)
10. Offer the nebulizer to the patient, offer assistance until he
is able to perform proper inhalation (if unable to hold the
nebulizer [pediatric/geriatric/special cases], replace the
mouthpiece with mask
11. Continue until medication is consumed
12. Reassess patient status from breath sounds, respiratory
status, pulse rate and other significant respiratory functions
needed. Compare and record significant changes and
improvement. Refer if necessary
13.Attend to possible side effects and inhalation reactions
NURSING RESPONSIBILITY
• As nurses, it is important that we teach the patients
the proper way of doing the therapy to facilitate
effective results and prevent complications
(demonstration is very useful). Emphasize
compliance to therapy and to report untoward
symptoms immediately for apposite intervention.
Nebulization Therapy Video
THANK YOU