Tracheotomy

Revised: April 8, 2024

Overview
● Surgical creation of an opening into the trachea—called a tracheostomy—through the neck
and insertion of an indwelling tube into the stoma to maintain airway patency
● Temporary or permanent

Indications
● Route for long-term mechanical ventilation
● Prevention of aspiration in an unconscious or paralyzed patient
● Upper airway obstruction caused by trauma, burns, epiglottitis, tumors, inflammation, a
foreign body that can't be dislodged, vocal cord paralysis, or upper airway surgical
procedures
● Removal of lower tracheobronchial secretions in patients who can't clear them
● Prophylaxis before extensive head and neck surgery
● Severe sleep apnea that has not responded to other treatments

Procedure
● Immediately before starting the procedure, the surgical team takes a time-out to verify the
correct patient, procedure, and site.
● The technique varies with the type of tube and size of the patient. (For example, tracheotomy
in an obese patient requires a special scope to view the airway anatomy.)
● If an endotracheal (ET) tube isn't already in place, the surgeon inserts it with the patient
under general anesthesia. A patient in acute respiratory distress and in need of an acute
intervention may require local anesthesia.

○ For surgical placement, a horizontal incision is made in the skin below the cricoid
cartilage and vertical incisions in the trachea. For percutaneous insertion, a needle
and guidewire are inserted between the second and third tracheal rings.
● The surgeon then places a tracheostomy tube between the second and third tracheal rings.
(See Types of tracheostomy tubes.)
● Retraction sutures are placed in the stomal margins.
● The tube cuff (if present) is inflated.
● Ventilation and suction are performed.
● Oxygen is administered.
● The ET tube is removed, the tracheostomy tube is secured, and a dressing is applied.

Types of tracheostomy tubes

Tracheostomy tubes come in various materials, sizes, and configurations. Tracheostomy tube
selection depends on the patient's condition and the practitioner's preference. Although metal
tracheostomy tubes are available, plastic tubes are more commonly used because they have a
universal adapter for respiratory support equipment. Many plastic tracheostomy tubes have a cuff
that, when inflated, helps prevent tube displacement. A commonly used tracheostomy tube consists
of three parts: an outer cannula with a flange, an inner cannula, and an obturator. The outer
cannula is the outer tube that holds the tracheostomy open. The flange extends from the sides of
the outer tube and has holes to attach cloth ties or Velcro straps for securement around the
patient's neck. The inner cannula fits inside the outer cannula, fastens in place to keep it stable, and
can be removed for cleaning. The obturator helps insert the tracheostomy tube. It fits inside the
tube to provide a smooth surface that guides the tracheostomy tube during insertion.

Cuffed and uncuffed tracheostomy tubes have advantages and disadvantages. A cuffed tube
(shown below) helps seal the area between the tube and trachea, decreasing a patient's risk of
aspiration and, if the patient is ventilated mechanically, preventing air from escaping. In the absence
of regular cuff pressure monitoring, cuffed tubes may erode the patient's trachea. Also, the patient
can't talk with the cuff inflated, necessitating an alternative means of communication.

Uncuffed tubes (shown below) allow a patient to eat and talk. Note that a patient receiving
mechanical ventilation can't use this tube type because delivered volume may escape around the
tube.
Complications
(See Combating complications of tracheotomy.)

● Airway obstruction (from improper tube placement)

● Aspiration of secretions
● Bleeding at the tracheotomy site
● Tube dislodgment
● Tube obstruction
● Edema
● Infection
● Ischemia and mucosal injury
● Hemorrhage due to tracheoarterial fistula
● Perforated esophagus
● Pneumothorax
● Subcutaneous or mediastinal emphysema
● Tracheal necrosis (from cuff pressure)
● Tracheal compression or damage
● Tracheomalacia
● Tracheoarterial or tracheoesophageal fistula
● Hospital-acquired pneumonia
● Reduced phonation
● Dysphagia
● Edema
● Tracheoinnominate fistula
● Airway obstruction
 ● Hypoxia
● Laceration of arteries, veins, and nerves
● Arrhythmias

SCROLL

Combating complications of tracheotomy

COMPLICATION PREVENTION DETECTION TREATMENT

Aspiration ● Evaluate the ● Assess for ● Obtain a

patient's dyspnea, chest X-ray,
ability to tachypnea, if ordered.
swallow. rhonchi, ● Suction
● Elevate the crackles, excessive
patient's excessive secretions.
head a secretions, ● Give
minimum of and fever. antibiotics, if
45 degrees necessary.
for 30
minutes after
eating to
reduce the
risk of
aspiration.
● Inflate the
cuff during
feedings;
keep it
 inflated for
30 minutes
after feeding.

Bleeding at the ● Don't pull on ● Check the ● Keep the cuff

tracheotomy site the dressing inflated to
tracheostom regularly; prevent
y tube, and slight edema and
don't allow bleeding is blood
the ventilator normal, aspiration.
tubing to do especially if Give
so. the patient humidified
● If the has a oxygen.
dressing bleeding ● Document
adheres to disorder. bleeding
the wound, characteristic
wet it with s.
hydrogen ● Check for
peroxide and prolonged
gently clotting time.
remove it. ● As ordered,
assist with
Gelfoam
application or
ligation of a
small
bleeder.

Infection at the ● Always use ● Check for ● As ordered,

tracheotomy site strict sterile purulent, obtain
technique. foul-smelling culture
● Thoroughly drainage specimens
clean the from the and
tubing. stoma.
 ● Change the ● Be alert for administer
nebulizer or other signs antibiotics.
humidifier jar and ● Inflate the
and tubing symptoms of tracheostom
daily. infection, y cuff to
● Collect such as prevent
sputum and fever, aspiration.
wound malaise, ● Suction the
drainage increased patient
specimens white blood frequently;
for culture. cell count, avoid
and local cross-conta
pain. mination.
● Change the
dressing
whenever it
becomes
soiled.

Pneumothorax ● Assess the ● Auscultate ● If ordered,

patient for for prepare for
subcutaneou decreased or chest tube
s absent insertion.
emphysema, breath ● Obtain chest
which may sounds. X-rays, as
indicate ● Check for ordered, to
pneumothora tachypnea, evaluate for
x. Notify the pain, and pneumothora
practitioner if subcutaneou x or to check
it occurs. s the
emphysema. placement of
the chest
tube.
 Subcutaneous ● Ensure that ● This occurs ● Inflate the
emphysema the cuffed most cuff correctly
tube is commonly in or use a
patent and mechanically larger tube.
properly ventilated ● Suction the
inflated. patients. patient and
● Avoid ● Palpate the clean the
displacement neck for tube to
by securing crepitus, remove
ties and listen for air blockage.
using leakage ● Document
lightweight around the the extent of
ventilator cuff, and crepitus.
tubing and check the
swivel site for
valves. unusual
swelling.

Tracheal malacia ● Avoid ● Note a dry, ● Minimize

excessive hacking trauma from
cuff cough and tube
pressures. blood-streak movement.
● Avoid ed sputum ● Keep the cuff
suctioning when pressure
beyond the manipulating below 18 mm
end of the the tube. Hg.
tube.

Pretreatment Care
● Collaborate with the patient to determine an appropriate communication system for after the
procedure.
● Verify that the patient has signed an appropriate informed consent form and that the signed
form is in the patient's medical record.
● Explain preoperative and postoperative procedures and equipment to the patient and family.
 ● Discuss postoperative analgesia and encourage the patient to report pain. Instruct the
patient in using a facility-approved pain scale.
● If the procedure isn't an emergency, confirm the patient's nothing-by-mouth status before the
procedure; minimum fasting recommendations are 2 hours for clear liquids, 6 hours for a
light meal or nonhuman milk, and 8 hours for fried or fatty foods or meat.
● Verify that the patient has not taken any blood thinners, aspirin, or other nonsteroidal
anti-inflammatory drugs in the last week. Notify the surgeon if there's a history of bleeding
disorders or if the patient is taking anticoagulants, anti-inflammatories, aspirin, or other
medications, herbal supplements, or vitamins that may affect blood clotting.
● Conduct a preprocedural verification to make sure that all relevant documentation, related
information, and equipment are available and correctly identified to the patient's identifiers.
● Perform a complete preoperative assessment, noting any allergies; obtain vital signs.
● Verify that laboratory studies, including arterial blood gas (ABG) analysis, and imaging
studies are complete, as ordered, and that the results are in the patient's medical record.
Notify the practitioner of any unexpected results.
● Administer preoperative medications, as ordered.
● Initiate IV therapy, as prescribed.
● Screen for and assess the patient's pain using a validated, appropriate, facility-approved
pain assessment tool.
● Treat the patient's pain, as needed and ordered, using nonpharmacologic, pharmacologic, or
a combination of approaches. Base the treatment plan on evidence-based practices and the
patient's clinical condition, past medical history, and pain management goals.

Posttreatment Care
● Turn the patient every 2 hours, and provide chest physiotherapy, as ordered.
● Provide oxygen and humidification, as ordered. Monitor ABG values and oxygen saturation
using pulse oximetry.
● Suction the airway, as indicated, and monitor the amount, color, and consistency of
secretions.
● Perform tracheostomy tube and insertion site care. If using a cuffed tracheostomy tube,
monitor cuff pressure every 4 hours and as needed after any procedure that may cause the
tracheostomy tube to move.
● Ensure that you place little or no pressure on the tracheostomy tube and that attached tubing
is lightweight and freely movable.
● If the patient is conscious and allowed oral feedings, ensure that you inflate the
tracheostomy cuff to prevent aspiration during feedings and for 30 minutes after feedings. If
the patient isn't receiving mechanical ventilation and is alert and able to protect the airway,
you can allow oral intake with the cuff deflated.
● Elevate the head of the bed at least 45 degrees to minimize the risk of aspiration.
● Provide frequent oral care.
● Provide comfort measures. Use pillows for support.
● Perform incision site care and dressing changes, and monitor the site for infection or
inflammation.
● Keep a sterile tracheostomy tube with obturator (including a tube one size smaller) at the
bedside.
● Monitor the patient's vital signs, reporting any fever.
 ● Assess intake and output.
● Monitor the patient's respiratory status and assess breath sounds; note changes, such as a
decrease in or absence of breath sounds, and report this to the practitioner.
● Observe for abnormal bleeding and other complications. Keep emergency equipment at the
patient's bedside.
● Assess for peritracheal edema and subcutaneous emphysema.
● Make sure that the patient has an appropriate method of communicating needs; enlist the aid
of a speech therapist, as appropriate.

WARNING!

Limit tracheostomy tube cuff pressure to 25

mm Hg to prevent ischemia and mucosal
injury.

Patient Teaching
Teaching should be family-centered. Be sure to include the family or caregiver, when appropriate.
● Review with the patient the prescribed medications, such as antibiotics to prevent infection;
review their safe use and their possible adverse effects.
● Teach the patient how to care for the tracheostomy site and tube. (See Caring for your
tracheostomy tube.)

Patient-Teaching Aid: Caring for your

tracheostomy tube

Dear Patient:

A tracheostomy—a small opening, or

stoma—has been created in your throat.

Inserting a tube into the tracheostomy makes

breathing easier because the tube keeps your
windpipe open. A tracheostomy tube—a “trach”
(rhymes with “cake”) tube, for short—features
three parts:
 ● An inner cannula (either reusable or
disposable)
● An outer cannula
● An obturator

The inner cannula fits inside the outer cannula,

which you insert with the obturator.

HOW TO CLEAN THE INNER CANNULA

To prevent infection, remove and clean the inner

cannula regularly (or replace the disposable tube
according to your physician's orders). Follow
these steps:

1. Gather your equipment near a sink: a small

basin, a small brush, mild liquid dish detergent, a
4" × 4" gauze bib or two 4" × 4" gauze pads,
scissors, and clean trach ties (twill tape). Or open
a prepackaged kit that contains the equipment
you need. Prepare trach ties by knotting the end
of each clean tracheostomy tie to prevent fraying,
and then cut a half-inch (1.3-cm) slit in each tie.

2. Wash your hands thoroughly.

3. Position a mirror so that you can see your face

and throat clearly.

4. Unlock the inner cannula: stabilize the outer

cannula with one hand and remove the inner
cannula by pulling steadily outward and
downward with the other hand, as shown. (Some
cannulas must be turned counterclockwise to
unlock them.)
5. Prepare to clean the soiled cannula
immediately for reinsertion, or put the soiled
cannula aside and slip a clean inner cannula
inside the outer cannula.

6. If you start to cough, cover your stoma with a

tissue, bend forward, and relax until the coughing
stops.

7. Next, clean the soiled cannula. Here's how:

Soak the cannula in mild liquid dish detergent
and water (never use alcohol or bleach). Then
clean it with a small brush. If your cannula is
heavily soiled, try soaking it in a basin of
hydrogen peroxide solution. You'll see foaming
as the solution reacts with the secretions coating
the cannula. When the foaming stops, clean the
cannula with the brush.

You can obtain a special tracheostomy tube

brush at a medical supply company or pharmacy.
However, the small brushes used to clean coffee
pots work just as well; they're inexpensive and
available at hardware stores. Just be sure to use
the brush only for your tracheostomy tube and
only when the inner cannula is not in your
tracheostomy.

8. Rinse the inner cannula under running water.

Be sure to remove all of the cleaning solution.
Shake off the excess water and reinsert the
clean, moist inner cannula immediately if you
haven't already inserted a new, clean inner
cannula. Don't dry it; the water drops remaining
help lubricate the cannula, making reinsertion
easier.

9. After you lock the clean inner cannula in place,

replace the soiled tracheostomy ties that secure
the tracheostomy plate. To do so, hold your trach
in place with one hand, and with your other hand
use scissors to carefully clip and remove one of
the tracheostomy ties. Thread the unknotted end
of the new tie through the opening on the
tracheostomy plate. Then feed the end through
the slit, as shown below, and gently pull the tie
taut. Do the same for the other tie.
10. Secure the ties at the side of your neck with a
square knot. Leave enough room so that you can
breathe comfortably. You should be able to slip
two fingers between the side of your neck and
the knot.

11. Place a 4" × 4" gauze bib behind the tube to

protect your neck.
12. Carefully insert the gauze bib under the
tracheostomy plate. If you have heavy discharge
draining from the stoma, you can insert the
gauze bib from below. If you don't have a precut
bib, fold two 4" × 4" gauze pads into triangles
and place one on each side of the tube.

HOW TO REINSERT YOUR TRACHEOSTOMY

TUBE

If you accidentally cough out your tracheostomy

tube, don't panic. Follow these simple steps to
reinsert it:

1. Remove the inner cannula from the dislodged

tracheostomy tube. Then, if you're using a cuffed
tube, be sure to deflate the cuff on the outer
cannula.

2. Insert the obturator into the outer cannula.

Then use the obturator to reinsert the
tracheostomy tube into your stoma.
 3. Hold the tracheostomy plate in place and
immediately remove the obturator, as shown.

WARNING!

Remove the obturator

immediately so that
you don't block your
airway.

4. Insert the inner cannula into the tracheostomy

tube. Next, turn the inner cannula clockwise until
it locks in place. You'll likely cough or gag while
doing this, so be sure to hold onto the
tracheostomy plate securely.

If you're using a cuffed tube, you'll also need to

follow these steps:

1. Insert the tip of a syringe into the tube's pillow

port. Inflate the cuff, as directed. The inflated cuff
will help prevent the tube from accidentally
dislodging again.

2. After inflating the cuff, secure the

tracheostomy ties and tuck a gauze pad under
the tracheostomy plate.

This patient-teaching aid may be reproduced by

office copier for distribution. © 2024 Wolters
Kluwer.

● Reinforce the teaching of the speech therapist on how to swallow. (See Learning a new way
to swallow.)
● Remind the patient to protect the stoma from water.
● Tell the patient to use a foam filter over the stoma during winter.
 ● Review with the patient the signs and symptoms of infection and the proper disposal of
expelled secretions.
● Review possible complications. Urge the patient to notify the practitioner of any drainage
from the tracheostomy site, changes in the color or characteristics of secretions, fever, or
difficulty breathing.
● As necessary, arrange for home health care services, which may include respiratory therapy.
● Advise the patient as to when to follow up with the practitioner.
● Advise the patient that the tracheostomy tube is routinely changed by the practitioner 7 to 14
days after insertion and then every 60 to 90 days.
● Advise the patient that a speaking valve may be used to help with communication.

Patient-Teaching Aid: Learning a new way to swallow

Dear Patient:

After surgery, you'll need to learn a new way to

swallow to prevent food and fluids from flowing
the wrong way and entering your trachea
(windpipe) and lungs. The nurse or speech
therapist will show you how before surgery so
that you can start practicing. The steps will be
reviewed with you after surgery, when you're
ready for your first meal.

PRACTICE STEPS

1. To begin, place a small amount of food at the

back of your throat.

2. Take a deep breath and hold it. Doing so

pulls your vocal cords together and closes the
entrance to your trachea.
3. Use a gulping motion to swallow, and then
cough. Repeat this step once or twice to
prevent any food left in your throat from entering
your trachea.

AFTER SURGERY

You'll have your first meal after your

tracheostomy has matured. The meal will
consist of soft, easy-to-swallow foods such as
mashed potatoes. As you get better at
swallowing, you'll progress to foods that are
more difficult to swallow until you can swallow
liquids.

SWALLOWING TIPS

Here are some tips to help you swallow

comfortably:

● Eat slowly. It's the best way to avoid

choking.
● Lean forward slightly as you eat. This
position helps prevent food from
entering your trachea.
● Stay calm. If some food does enter your
trachea, the nurse will remove it
immediately by suctioning it through
your tracheostomy tube.

This patient-teaching aid may be reproduced by

office copier for distribution. © 2024 Wolters
Kluwer.