TRACHEOSTOMY CARE

PRESENTED BY SITAL B. SHARMA

M Sc Nursing Student
College of Nursing. N.B.M.C.H.
 INTRODUCTION
• A tracheostomy is a surgical procedure in
which an artificial opening is made into the
trachea .The indwelling tube inserted into the
trachea is called a tracheostomy tube. A
tracheostomy may be performed as a
permanent and emergency procedure.
ANATOMICAL SITE OF TRACHEOSTOMY

• A 2 – 3 cm vertical or horizontal skin incision

is made midway between the sternal notch
and thyroid cartilage (approximate level of the
second tracheal ring)
TRACHEOSTOMY
 INDICATION OF TRACHEOSTOMY
• By pass an upper airway obstruction e.g. Cancer
of larynx
• To allow removal of trachea bronchial secretions
• To permit the long term use of mechanical
ventilation
• To prevent aspiration of oral and gastric secretions
in the unconscious or paralized patient ( by closing
of the trachea from the oesophagus )
• To replace an endotracheal tube
TYPES OF TRACHEOSTOMY TUBES
• Plastic or metal
• Cuffed
• Fenestrated
 PARTS OF TRACHEOSTOMY TUBE
• Outer cannula
• Inner cannula: Fits snugly into the outer tube,
can be easily removed for cleaning.
• Obturator
• Flange: Flat plastic plate attached to outer
tube – lies flat against patient’s neck
• 15 mm outer diameter termination: Fits all
ventilator or respiratory equipment.
PARTS OF TRACHEOSTOMY TUBES
 Other parts
• Cuff: Inflatable air reservoir (high volome, low
pressure)- it helps to anchor trachoestomy
tube in place and provides maximum airway
sealing with least amount of local
compression.
• Air inlet valve: One way valve that prevents
spontaneous escape of the injected air.
 ….other parts
• Pilot cuff: Serves as an indicator of the
amount of air in the cuff.

• Fenestration: Hole situated on the curve of

outer tube- used to enhance airflow in and
out of the trachea. Single or multiple
fenestrations are available.
 SPEAKING VALVE
• Speaking valve is used to help patient’s speak
more normally without the need of finger
occluding the tracheostomy opening. When
the patient breathes out, the valve closes and
air flows around the tracheostomy tube, up
through the vocal cords allowing sounds to be
made. The patient breathes out through the
mouth and nose instead of the tracheostomy.
Contraindications of use of speaking valve

• Severe upper airway obstruction

• Tenacious pulmonary secretions
• Cuffed tube
DEFINITION OF TRACHEOSTOMY CARE

• Tracheostomy care involves cleaning around

the tracheostomy incision, suctioning of
tracheobronchial secretions and as well as
replacing the inner cannula of the
tracheostomy tube and is generally done
every eight hours.
 PURPOSE OF TRACHEOSTOMY CARE
• To maintain airway patency by removing mucous
and encrusted secretions ( to prevent tube
blockage)
• 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.
PRINCIPLES OF TRACHEOSTOMY CARE

• Maintaining patient safety

• Facilitating communication

• Preventing complication
 ASSESSMENT
• Respiratory status (ease of breathing, respiratory
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.
• Condition of stoma (Redness, swelling , purulent
discharge or odour)
 ASPECTS OF TRACHEOSTOMY CARE

1. Humidification

2. Care of inner-cannula

3. Stoma care

4. Suctioning
 HUMIDIFICATION
• If patient is on oxygen therapy administration
of moist oxygen is to be done to prevent thick
mucous and crust formation.
• Adequate intake of fluid should be advised to
keep the mucous thin and enhance secretion.
 CARE OF INNER CANNULA
• Strict sterile technique should be followed.
• Care of inner cannula should be done two to
three times a day or more depending on the
need of the patient.
• While removing inner cannula, ensure that
outer cannula is not removed.
 ….care of inner cannula
• Keep the inner cannula in the solution of sodi-
bicarbonate or hydrogen peroxide and then
clean the cannula with a brush. Then wash it
in clean and sterile water.
• Do suction of the outer cannula as well.
• After examining the inner cannula, insert it
again into the outer cannula and clip it
properly.
 SUCTIONING
• 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’s need.
• For wall suction unit a pressure setting of about
100 – 120 mm Hg is normally used for adults and
50 - 95 mm Hg , is used for infants and children.
 ……suctioning

• Lubricate the suction catheter before use with

normal saline or sterile water.
• Apply suction for 5 to 10 seconds by placing
the non dominant thumb over the thumb
port. 
• Do not apply suction while inserting the
suction catheter.
 …..suctioning
• Rotate the catheter by rolling it between your
thumb and forefinger while slowing
withdrawing it.
• Withdraw the catheter completely, and
release the suction. 
• Hyperventilate the client.  
• Suction again, if needed.
 CARE OF STOMA
• Clean the exposed surfaces of outer cannula
and peristomal site with gauge soaked in
normal saline, in circular pattern from stoma
site outward.
• Observing for any abnormal condition of the
peristomal region.
• Lightly padding dry exposed surface of outer
cannula and skin with 4”x 4’’ gauge.
 ….care of stoma
• Changing the soiled twill tape that secures the
tracheostomy tube.
• Keeping the old twill tape in place until new
tape is applied and secured.
• Ensuring attachments of tape and verifying if
there is enough slack to slip two fingers under
the neck strap.
 ARTICLES REQUIRED
• Personal protective equipments
• Face mask
• Cap and Gown
• Sterile gloves
 …articles required
A sterile tray containing the following equipments
for suctioning:
 
• Sterile gauge pieces
• Sterile Q- tips
• Sterile sheet
• A small bowl with normal saline
• Artery forcep, ( To hold the gauge if needed)
 …Articles required
…a sterile tray containing
• Suction catheter
• Type of prescribed tracheostomy tube if tube
is to be replaced
• Twill tapes
• Sterile Kidney dish
….equipments needed for tracheostomy

• A clean tray containing

• Normal saline bottle
• Betadine
• Scissors
 ….other articles
Other equipments that must be ready are
• Resuscitation bag connected to 100 % oxygen.
• Equipment for suctioning (Suction Apparatus
or wall suction )
 STEPS OF TRACHEOSTOMY CARE
• Determining the need for tracheostomy care.
• Assessing the patient’s pain and administer pain
medication if indicated. Also being aware of the
side effects like respiratory depression.
• Explaining the procedure to the patient.
• Performing hand hygiene
• Performing full respiratory assessment including
auscultation of lung sounds, vital signs and pulse
oxygenation.
• Placing patient in a semi-fowler to high fowler
position
• Adjusting the bed to a comfortable working
position
• Lowering side rails closer to nurse.
• Ensuring good light, ventilation and enough
space to work.
• Considering patient’s privacy
 preparation of articles
• Arranging all the necessary articles
• Checking equipments like suction machine,
oxygen delivering system
 ….steps
• Performing thorough hand wash again.
• Hyper oxygenating the patient ( turn oxygen to
100%) for few minutes
• Turning on suction
• Performing hand rub with alcohol
• Applying sterile gloves
• Applying sterile sheet to chest
• Attaching suction tubing to sterile catheter
• Keeping dominant hand and suction catheter
sterile
• Lubricating the suction catheter in normal
saline before inserting it into the cannula.
• Asking the patient to inhale during insertion.
• Avoiding to suction while inserting the suction
tube.
• Rotating the catheter while taking out
• Applying intermittent suctions for not more
than 10 seconds
• Waiting for one minute before repeating
suction
• Keeping dominant hand and suction catheter
sterile
• Returning oxygen flow to previous setting, if
patient is on oxygen.
• Turning off suction
• Cleaning the exposed surfaces of outer cannula
and peristomal site with gauge soaked in normal
saline, in circular pattern from stoma site
outward.
• Observing for any abnormal condition of the
peristomal region.
• Lightly padding dry exposed surface of outer
cannula and skin with 4”x 4’’ gauge.
• Changing the soiled twill tape that secures the
tracheostomy tube
• Keeping the old twill tape in place until new tape is
applied and secured.
• Ensuring attachments of tape and verifying if there is
enough slack to slip two fingers under the neck strap
• Removing gloves and performing hand hygiene
• Termination of used supplies and articles and
documentation of procedure
 DEALING WITH EMERGENCIES
If the tracheostomy tube falls out
• Not to 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.
 ….dealing with emergencies
• 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.
 ….if patient is having acute dyspnoea

• 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 and prepare for the change of
tracxheostomy tube.
 Patient needing CPR

• 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.
 …patient needing CPR
• 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
 NURSING POINTS
• The patient requires continuous monitoring and
assessment.
• The newly made opening must be kept patent by proper
suctioning of secretions.
• After vital signs are stable the patient is placed in semi
fowlers position to facilitate ventilation, promote drainage,
minimize edema and prevent strain on the suture lines.
• Analgesia and sedative agents must be administered with
caution because of the risk of suppressing the cough
reflex.
 ….nursing points
• Always sterile tracheostomy set must be kept
ready at hand to meet any emergency.
• A new tracheostomy pack of the required size
should be kept intact and readily available at
bedside to manage any sudden emergency.
• Always ensure that the equipments like
suction machine, oxygen cylinder are in
proper working condition.
 ….nursing points
• Major objectives of patient care is to alleviate
the patients apprehension and to pencil, magic
slate and call light within the patients reach at
all times to ensure a means of communication.
• The patient should be given food and fluids
intravenously and not by mouth, soon after
tracheostomy operation.
• Some patients are fed through the nasogastric
tube.
 ….nursing points
• After tracheostomy, patient is allowed fluid slowly
through mouth. If the patient feels no difficulty, a light
diet is allowed and in due time a normal diet is
started.
• The nurse should be with the patient unless the
patients morale is boosted
• Hygiene of the mouth is must. It does away with the
possibility of infection.
• It is recommended that the mouth should be cleaned
once every two hours.
 PATIENT TEACHING
• If the tracheostomy is permanent, the patient
should be taught how to take care of the tube
• Emphasize the importance of hand washing.
• 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.
 …..patient teaching
• Also, teach the patients relatives about
necessary precautions and care.
• Give them essential facts related to the usage
of equipment and its upkeep.
• Use suction in front of the patient keeping a
mirror
• Teaching patient the importance of oral
hygiene.
 ….patient teaching
• Tell the patient as how to protect hair, cotton
bandages from getting wet during the bath.
• Swimmimg is prohibited for such a patient.
• Precautions should be taken during shower.
• Keep away visitors with high infectivity.
• After some time the patient should visit the
out -patient department and get his tube
changed.
 ….patient teaching
• The patient and family members should be
taught to assess for symptoms of infection
(i.e., increased temperature, increased
amount of secretions, change in colour or
odour of secretions).
• Provide contact information for emergencies.
 SPECIAL PRECAUTIONS
• Tracheostomy is an emergency operation. Time
plays an important role in it. A slight delay results in
the death of the patient.
• The outer cannula should never be removed.
• The patient should be kept under close observation.
Monitor the patient for sign and symptoms of
aspiration.
• We must ensure that the inner cannula and the
obturator properly get fitted into the outer cannula.
 ….precautions
• Always maintain aseptic technique during the
operation because infection in the respiratory
tract causes death of the patient.
• Inner cannula should be always locked when it is
being changed.
• If the outer cannula is removed by the patient
take the help of physician.
• Suction should be never be done for more than
10 secs , as this may cause hypoxemia
 ….precautions
• The tape should be tied properly in a square knot so
that the outer cannula may not slip.
• Dressing of the tracheostomy wound should not be
done with cotton threads and powder should not be
used. Otherwise , when the sweat comes in contact
with these things, this may cause hindrance.
• A bell and a writing material should be kept within
the easy reach of patient, so that he may use them
in case of emergency.
 Complications
Early complications-
• Bleeding
• Pneumothorax
• Air embolism
• Aspiration
• Subcutaneous and mediastinal emphysema
• Recurrent laryngeal nerve damage.
• Posterior tracheal wall penetration
 ….Complications
Long term complications:
• Airway obstruction from accumulation of secretions.
• Protusion of cuff over the opening of tube.
• Infection
• Rupture of innominate artery.
• Tracheoesophageal fistula.
• Tracheal dilatation, tracheal ischemia and necrosis.
• Tracheal stenosis may develop after the tube is
removed.
 DECANNULATION
• DECANNULATION: It is the permanent
removal of tracheostomy tube with intent for
tracheostomy site to close.
• The patient’s airway is routinely visualized before
decannulating a patient.
• A trial of successful corking or occluding the
tracheostomy tube is done for a specified period of
time to ensure the safety of removal of tracheostomy
tube.
• Downsizing of the tracheostomy tube is done and
patient should not have breathing difficulty with the
smaller sized tracheostomy tube.
• Once the patients tolerates the previous steps, the
tracheostomy tube is removed for 24 hours and they
are monitored for respiratory difficulty of suction
requirement.
• After patient passes in the previous
assessments the planning for tracheostomy
tube removal is done final.
• Patients should be instructed that they may
experience shortness of breath for few minutes
after they are decannulated.
• The patient is placed in supine position and the
tube is removed and the opening of the neck is
covered with a sterile gauge and taped.
• The patient is instructed to support the gauge
when they cough or speak so that air does not
leak.
• The patient should be instructed to change
the gauge atleast once a day until the hole in
the neck heals itself.
• In some patients( < 10%), the opening of the
neck skin is surgically closed.
 PREOPERATIVE NURSING DIAGNOSIS
• Impaired gaseous exchange related to partial or complete
obstruction of airway as evidenced by respiratory distress.
– Assess respiratory rate, heart rate, oxygen saturation, patient’s
level of consciousness.
– Administer moist oxygen therapy , nebulization as supportive
measures.
– Inform the on duty doctor as early as possible.
– Ensure that equipments like suction machine, are in order.
– Ensure availabilty of tracheostomy set, tracheostomy tubes,
suction catheters and all necessary articles are at hand.
 …cont
• Anxiety related to lack of knowledge of
impending surgery and implication of
condition on life style.
POST OPERATIVE NURSING DIAGNOSIS
• Risk for ineffective airway clearance related to
increased secretions secondary to
tracheostomy.
• Impaired verbal communication related to
inability to produce speech secondary to
tracheostomy.
• Risk of infection related to excessive pooling of
secretions and by passing of upper respiratory
defences.
POST OPERATIVE NURSING DIAGNOSIS

• Imbalance nutrition less than body

requirements related to post operative NPO
status, dysphagia, odynophagia, anorexia and
aspiration.
• Low self esteem related to disturbed body
image as evidenced by verbalization.
POST OPERATIVE NURSING DIAGNOSIS

• High risk for ineffective management of

therapeutic regimen related to insufficient
knowledge of tracheostomy care, precautions,
sign and symptoms of complications,
emergency care and follow up.
 Conclusion
• Nurses play a vital role in providing care of patients
with tracheostomy tube, patient teaching for home
care management and follow up. Maintaining a
patent airway, as in case of patient with
tracheostomy ,is achieved through meticulous
airway management. Thus the professional nurse
should be competent enough to give routine
tracheostomy care as well as to monitor and
manage any danger sign in patients with
tracheostomy.
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