TRACHEOSTOMY CARE

A 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. It is used for clients needing long-term airway support.
Tracheostomy tubes have an outer cannula that is inserted into the trachea and a flange that rests against the neck and
allows the tube to be secured in place with tape or ties. Tracheostomy tubes also have an obturator which is used to insert the outer
cannula which is then removed afterwards. The obturator is kept at the client’s bedside in case the tube becomes dislodged and
needs to be reinserted.
Nurses provide tracheostomy care for clients with new or recent tracheostomy to maintain patency of the tube and minimize
the risk for infection (since the inhaled air by the client is no longer filtered by the upper airways). Initially a tracheostomy may
need to be suctioned and cleaned as often as every 1 to 2 hours. After the initial inflammatory response subsides, tracheostomy care
may only need to be done once or twice a day, depending on the client.

Definition of Terms
 Decannulation: The process whereby a tracheostomy tube is removed once patient no longer needs it.
 Humidification: The mechanical process of increasing the water vapor content of an inspired gas.
 An opening, either natural or surgically created, which connects a portion of the body cavity to the Stoma: outside
environment (in this case, between the trachea and the anterior surface of the neck).
 Tracheostomy: A surgical procedure to create an opening between 2-3 (3-4) tracheal rings into the trachea below the
larynx.
 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 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.

Components of Tracheostomy Tube

• Outer tube
• Inner tube: Fits snugly into outer tube, can be easily removed for cleaning.
• Flange: Flat plastic plate attached to outer tube – lies flush against the patient’s neck.
• 15mm outer diameter termination: Fits all ventilator and respiratory equipment.

All remaining features are optional

• Cuff: Inflatable air reservoir (high volume, low pressure) – helps anchor the tracheostomy tube in place and provides
maximum airway sealing with the least amount of local compression. To inflate, air is injected via the…
• Air inlet valve: One way valve that prevents spontaneous escape of the injected air.
• Air inlet line: Route for air from air inlet valve to cuff.
• Pilot cuff: Serves as an indicator of the amount of air in the cuff
• Fenestration: Hole situated on the curve of the outer tube – used to enhance airflow in and out of the trachea. Single or
multiple fenestrations are available.
• Speaking valve / tracheostomy button or cap: Used to occlude the tracheostomy tube opening (a) former – during expiration
to facilitate speech and swallow, (b) latter – during both inspiration and expiration prior to decannulation.

Providing Tracheostomy Care

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)

Planning
 Tracheostomy care involves application of scientific knowledge, sterile technique, and problem solving, and therefore
needs to be performed by a nurse or respiratory therapist.
Equipment
 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 non-dominant 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 squares.
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.

Lifespan Considerations

Infant and Child

 An assistant may be necessary during tracheostomy care to prevent active children from dislodging or expelling their
tracheostomy tubes.
 Always make a sterile, packaged tracheostomy available at bedside for emergency purposes.
 Encourage parents to participate with the procedure in an effort to comfort the child and promote client teaching.
 Care for the skin at the tracheostomy site is important especially for the elders whose skin is more fragile and prone to
breakdown.

Home Care Modifications

 Emphasize the importance of handwashing before performing tracheostomy care.
 Describe the function of each part of the tracheostomy tube.
 Explain the proper way on how to remove, change, and replace the inner cannula.
 Clean the inner cannula two or three times a day.
 Check and clean the tracheostomy stoma.
 Suction tracheal secretions if necessary.
 Assess for symptoms of infection (i.e., increased temperature, increased amount of secretions, change in color or odor of
secretions).
 Advise and encourage parents to participate with the procedure in an effort to comfort the child and promote client teaching.
 Provide contact information for emergencies.

Suctioning a Tracheostomy Tube

Suctioning of tracheostomy tube is only done as necessary. Sterile technique must be observed. Nurses should be aware
that there is a frequency for the need of suctioning during immediate postoperative period.

Purposes
 Removes thick mucus and secretions from the trachea and lower airway to maintain patent airway and prevent airway
obstructions
 To promote respiratory function (optimal exchange of oxygen and carbon dioxide into and out of the lungs)
 To prevent pneumonia that may result from accumulated secretions

Assessment
 Assess the client for the presence of congestion on auscultation of the thorax.
 Note the client’s ability or inability to remove the secretions through coughing.

Planning
 Suctioning a tracheostomy or endotracheal tube is a sterile, invasive technique requiring application of scientific knowledge
and problem solving. This skill is performed by a nurse or respiratory therapist and is not delegated to UAP.

Equipment
 Resuscitation bag (Ambu bag) connected to 100% oxygen
 Sterile towel (optional)
 Equipment for suctioning
 Goggles and mask if necessary
 Gown (if necessary) as Sterile gloves
 Moisture-resistant bag

Preparation
 Determine if the client has been suctioned previously and, if so, review the documentation of the procedure. This
information can be very helpful in preparing the nurse for both the physiologic and psychologic impact of suctioning on
the client.

Procedure
1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. Explain to the client
what you are going to do, why it is necessary, and how he or she can cooperate. Inform the client that suctioning usually
causes some intermittent coughing and-that this assists in removing the secretions.
2. Perform hand hygiene and observe other appropriate infection control procedures (e.g., gloves, goggles).
3. Provide for client privacy.
4. Prepare the client.
  If not contraindicated because of health, place the client in the semi-Fowler’s position to promote deep breathing,
maximum lung expansion, and productive coughing. Rationale: Deep breathing oxygenates the lungs,
counteracts the hypoxic effects of suctioning, and may induce coughing. Coughing helps to loosen and move
secretions.
 If necessary, provide analgesia before suctioning. Endotracheal suctioning stimulates the cough reflex, which can
cause pain for clients who have had thoracic or abdominal surgery or who have experienced traumatic injury.
Rationale: Premedication can increase the client’s comfort during the suctioning procedure.
5. Prepare the equipment.
 Attach the resuscitation apparatus to the oxygen source.
 Adjust the oxygen flow to 100%.
 Open the sterile supplies in readiness for use.
 Place the sterile towel, if used, across the client’s chest below the tracheostomy.
 Turn on the suction, and set the pressure in accordance with agency policy. For a wall unit, a pressure setting of
about 100 to 120 mm Hg is normally used for adults, 50 to 95 mm Hg for infants and children.
 Put on goggles, mask, and gown if necessary.
 Put on sterile gloves. Some agencies recommend putting a sterile glove on the dominant hand and an unsterile
glove on the non-dominant hand to protect the nurse.
 Holding the catheter in the dominant hand and the connector in the non-dominant hand, attach the suction catheter
to the suction tubing
6. Flush and lubricate the catheter.
 Using the dominant hand, place the catheter tip in the sterile saline solution.
 Using the thumb of the non-dominant hand, occlude the thumb control and suction a small amount of the sterile
solution through the catheter. Rationale: This determines that the suction equipment is working properly and
lubricates the outside and the lumen of the catheter. Lubrication eases insertion and reduces tissue trauma during
insertion. Lubricating the lumen also helps prevent secretions from sticking to the inside of the catheter.
7. If the client does not have copious secretions, hyperventilate the lungs with a resuscitation bag before suctioning.
 Summon an assistant, if one is available, for this step.
 Using your non-dominant hand, turn on the oxygen to 12 to 15 L/min.
 If the client is receiving oxygen, disconnect the oxygen source from the tracheostomy tube using your non-
dominant hand.
 Attach the resuscitator to the tracheostomy or endotracheal tube.
 Compress the Ambu bag three to five times, as the client inhales. This is best done by a second person who can
use both hands to compress the bag, thus, providing a greater inflation volume.
 Observe the rise and fall of the client’s chest to assess the adequacy of each ventilation.
 Remove the resuscitation device and place it on the bed or the client’s chest with the connector facing up.
Variation: Using a Ventilator to Provide Hyperventilation
 If the client is on a ventilator, use the ventilator for hyperventilation and hyper-oxygenation. Newer models have
a mode that provides 100 % oxygen for 2 minutes and then switches back to the previous oxygen setting as well
as a manual breath or sigh button. Rationale: The use of ventilator settings provides more consistent delivery of
oxygenation and hyperinflation than a resuscitation device.
8. If the client has copious secretions, do not hyperventilate with a resuscitator. Instead:
 Keep the regular oxygen delivery device on and increase the liter flow or adjust the Fi02 to 100% for several
breaths before suctioning. Rationale: Hyperventilating a client who has copious secretions can force the
secretions deeper into the respiratory tract.
9. Quickly but gently insert the catheter without applying any suction.
 With your non-dominant thumb off the suction port, quickly but gently insert the catheter into the trachea through
the tracheostomy tube. Rationale: To prevent tissue trauma and oxygen loss, suction is not applied during
insertion of the catheter.
 Insert the catheter about 12.5 cm (5 in.) for adults, less for children, or until the client coughs or you feel resistance.
Rationale: Resistance usually means that the catheter tip has reached the bifurcation of the trachea. To prevent
damaging the mucous membranes at the bifurcation, withdraw the catheter about 1 to 2 cm (0.4 to 0.8 in.) before
applying suction.
10. Perform suctioning.
 Apply suction for 5 to 10 seconds by placing the non-dominant thumb over the thumb port. Rationale: Suction
time is restricted to 10 seconds or less to minimize oxygen loss.
 Rotate the catheter by rolling it between your thumb and forefinger while slowly withdrawing it. Rationale: This
prevents tissue trauma by minimizing the suction time against any part of the trachea.
 Withdraw the catheter completely, and release the suction.
 Hyperventilate the client.
 Suction again, if needed.
11. Reassess the client’s oxygenation status and repeat suctioning.
 Observe the client’s respirations and skin color. Check the client’s pulse if necessary, using your non-dominant
hand.
 Encourage the client to breathe deeply and to cough between suctions.
 Allow 2 to 3 minutes with oxygen, as appropriate between suctions when possible. Rationale: This provides an
opportunity for re-oxygenation of the lungs.
  Flush the catheter and repeat suctioning until the air passage is clear and the breathing is relatively effortless and
quiet.
 After each suction, pick up the resuscitation bag with your non-dominant hand and ventilate the client with no
more than three breaths.
12. Dispose of equipment and ensure availability for the next suction.
 Flush the catheter and suction tubing.
 Turn off the suction and disconnect the catheter from the suction tubing.
 Wrap the catheter around your sterile hand and peel the glove off so that it turns inside out over the catheter.
 Discard the glove and the catheter in the moisture-resistant bag.
 Replenish the sterile fluid and supplies so that the suction is ready for use again. Rationale: Clients who require
suctioning often require it quickly, so it is essential to leave the equipment at the bedside ready for use.
 Be sure that the ventilator and oxygen settings are returned to pre suctioning settings. Rationale: On some
ventilators this is automatic, but always check. It is very dangerous for clients to be left on 100% oxygen.
13. Provide for client comfort and safety.
 Assist the client to a comfortable, safe position that aids breathing. If the person is conscious, a semi-Fowler’s
position is frequently indicated. If the person is unconscious, Sims’ position aids in the drainage of secretions
from the mouth.
14. Document relevant data.
 Record the suctioning, including the amount and description of suction returns and any other relevant assessments.

Dealing with Emergencies: “If the tracheostomy tube falls out”

 DON’T PANIC!
 Once the tracheostomy tube has been in place for about 5 days the tract is well formed and will not suddenly close.
 Reassure the patient
 Call for medical help.
 Ask the patient to breathe normally via their stoma while waiting for the doctor.
 The stay suture (if present) or tracheal dilator may be used to help keep the stoma open if necessary.
 Stay with patient.
 Prepare for insertion of the new tracheostomy tube
 Once replaced, tie the tube securely, leaving one finger-space between ties and the patient’s neck.
 Check tube position by (a) asking the patient to inhale deeply – they should be able to do so easily and comfortably, and
(b) hold a piece of tissue in front of the opening – it should be “blown” during patient’s exhalation.

Patient is having Acute Dyspnea

Acute dyspnea for patient with tracheostomy is most commonly caused by partial or complete blockage of the tracheostomy
tube retained secretions. To unblock the tracheostomy tube:
 ASK THE PATIENT TO COUGH: A strong cough may be all that is needed to expectorate secretions.
 REMOVE THE INNER CANNULA: If there are secretions stuck in the tube, they will automatically be removed when
you take out the inner cannula. The outer tube – which does not have secretions in it – will allow the patient to breath
freely. Clean and replace the inner cannula.
 SUCTION: If coughing or removing the inner cannula do not work, it may be that secretions are lower down the patients
airway. Use the suction machine to remove secretions.
 If these measures fail – commence low concentration oxygen therapy via a tracheostomy mask, and call for medical
assistance.
“It is possible that the tracheostomy may have become displaced. Stay with the patient until assistance arrives. Prepare for
change of tracheostomy tube.”

Patient needing Cardiopulmonary Resuscitation

In the event of cardiopulmonary arrest, treat tracheostomy patients as other patients:
 Step 1: Expose the patient’s neck. Remove any clothing covering the tracheostomy tube and the neck area. Do
not remove tracheostomy.
 Step 2: Check the patency of the inner cannula. To check inner cannula: Wearing a non-sterile glove, remove
inner cannula. If clean, reinsert and lock into place. If soiled – replace. Continue resuscitation.
 Step 3: Ventilate. Use the ambu-bag directly to the t-tube.
 If unable to ventilate:
• Try to suction. To remove or clear the secretions blocking the tube.
• If still unable to ventilate. The tube may be displaced and the doctor may:
 Change the tube
 Intubate orally