Tracheostomy

Caring for patients with tracheostomy involves maintaining the artificial airway created by a surgical opening in the neck. This procedure supports patients needing long-term airway assistance. Nurses play a vital role in keeping the tracheostomy tube clear and preventing infections, especially since the tracheostomy bypasses the natural airway filtration. Initially, care may include frequent suctioning and cleaning, which decreases as the patient stabilizes. Through skilled and compassionate care, nurses significantly impact the well-being of these patients.

Table of Contents

• What is Tracheostomy?
• Components
• Purposes
• Assessment
• Equipment
• Providing Tracheostomy Care
• Suctioning a Tracheostomy Tube
• Dealing with Emergencies

What is Tracheostomy?

A tracheostomy is a surgical opening into the trachea through the neck, just below the larynx, where an indwelling tube is placed to create an artificial airway. This procedure is for clients needing long-term airway support.

The tracheostomy tube consists of an outer cannula inserted into the trachea and a flange that rests against the neck, secured with tape or ties. An obturator is used to insert the outer cannula and is then removed. The obturator is kept at the client’s bedside in case reinsertion is needed.

See also: Tracheostomy Nursing Care Plans

Nurses provide tracheostomy care to maintain tube patency and minimize infection risk since inhaled air bypasses the upper airway’s natural filtration. Initially, tracheostomies may need suctioning and cleaning every 1 to 2 hours. Once the initial inflammation subsides, care may be required only once or twice a day, depending on the client.

Components

Understanding the components of a tracheostomy tube is essential for effective patient care.

• Outer Tube. The main part of the tracheostomy tube that is inserted into the trachea.
• Inner Tube. Fits snugly into the outer tube and can be easily removed for cleaning.
• Flange. A flat plastic plate attached to the outer tube that lies flush against the patient’s neck.
• 15mm Outer Diameter Termination. Fits all ventilator and respiratory equipment.

All remaining features are optional:

• Cuff. An inflatable air reservoir (high volume, low pressure) that helps anchor the tracheostomy tube in place and provides maximum airway sealing with minimal local compression. To inflate, air is injected via the:
  • Air Inlet Valve. A one-way valve that prevents the spontaneous escape of the injected air.
  • Air Inlet Line. The route for air from the air inlet valve to the cuff.
  • Pilot Cuff. Serves as an indicator of the amount of air in the cuff.
• Fenestration. A 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 or Tracheostomy Button or Cap. Used to occlude the tracheostomy tube opening. The speaking valve facilitates speech and swallowing during expiration, while the tracheostomy button or cap is used during both inspiration and expiration prior to decannulation.

Purposes

Understanding the primary goals of tracheostomy care is essential for providing effective patient care.

• To Maintain Airway Patency. Regular removal of mucus and encrusted encrusted secretions help keep the airway clear and functional.
• To Ensure Cleanliness and Prevent Infection. Keeping the tracheostomy site sterile helps prevent infections, which can lead to serious complications such as pneumonia.
• To Facilitate Healing. Prevent skin excoriation around the incision to promote faster healing and reduce the risk of further issues.
• To Promote Comfort. Ensure the patient’s comfort during and after care, which is crucial for their overall well-being and recovery.
• To Prevent Displacement. Secure the tracheostomy tube properly to prevent it from becoming dislodged, which could compromise the airway.

Assessment

Thorough assessment is critical in tracheostomy care to monitor the patient’s condition and detect any potential problems early.

• Respiratory Status. Regularly check the ease of breathing, rate, rhythm, depth, lung sounds, and oxygen saturation level to ensure adequate respiratory function.
• Pulse Rate. Monitor for changes that could indicate distress or other complications.
• Secretions. Evaluate the character and amount of secretions from the tracheostomy site to detect any signs of infection or other issues.
• Drainage. Inspect tracheostomy dressing or ties for any drainage, which can indicate infection or improper care.
• Incision Appearance. Look for redness, swelling, purulent discharge, or odor around the incision site to identify signs of infection or poor healing.

Equipment

The following equipment are necessary for this procedure:

• 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
• 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

Providing Tracheostomy Care

Caring for a patient with a tracheostomy is a vital nursing responsibility that ensures the patient’s airway remains open and free of infection. Here are the key components of tracheostomy care:

1. Introduce yourself and verify the client’s identity.
Follow agency protocol to confirm the client’s identity. Explain the procedure, its necessity, and how the client can cooperate. Use simple communication methods such as eye blinking or raising a finger to indicate pain or distress.

2. Observe appropriate infection control procedures.
Perform hand hygiene to prevent infection.

3. Provide for client privacy.
Close curtains or doors to the room, and inform the client and any family members present about the steps you are taking to ensure their privacy. Use a calm and reassuring tone to make the client feel secure and respected. Throughout the procedure, be mindful of exposing only the areas necessary for the task and covering the rest of the client’s body with a sheet or blanket to keep them warm and comfortable.

4. Prepare the client and the equipment.
Assist the client to a semi-Fowler’s or Fowler’s position to promote lung expansion. Open the tracheostomy kit or sterile basins. Pour the soaking solution and sterile normal saline into separate containers.

5. Establish the sterile field.
Open other sterile supplies as needed, including sterile applicators, a suction kit, and a tracheostomy dressing.

6. 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, wrap it around your hand, and peel the glove off so that it turns inside out over the catheter.

7. Remove the inner cannula.
Unlock the inner cannula with the gloved hand. Gently pull it out in line with its curvature and place it in the soaking solution. This moistens and loosens secretions.

8. Remove the soiled dressing.
Place the soiled tracheostomy 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.

9. Put on sterile gloves.
Keep your dominant hand sterile during the procedure. Clean the inner cannula. Remove the inner cannula from the soaking solution.

10. 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, leaving a film of moisture on the outer surface to lubricate the cannula for reinsertion. This removes excess liquid and prevents aspiration.

11. 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) to secure the flange of the inner cannula to the outer cannula.

12. 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 and use each applicator or gauze dressing only once. Hydrogen peroxide may be used (usually in a half-strength solution mixed with sterile normal saline) to remove crusty secretions. Thoroughly rinse the cleaned area using gauze squares moistened with sterile normal saline. This avoids contaminating a clean area and ensures thorough cleaning without irritating the skin.

13. Apply a sterile dressing.
Use a commercially prepared tracheostomy dressing or open and refold a 4×4-inch gauze dressing into a V shape. Place the dressing under the flange of the tracheostomy tube while ensuring the tube is securely supported to avoid irritation from excessive movement.

14. Change the tracheostomy ties.
Change ties as needed to keep the skin clean and dry. Twill tape and Velcro ties are available, with Velcro ties being more comfortable and less likely to cause skin irritation. Follow the two-strip method or one-strip method for securing ties, ensuring they are not too tight and allow for easy access.

Two-Strip Method (Twill Tape)

1. Prepare the Twill Tape. Cut two strips of twill tape: one approximately 25 cm (10 in.) long and the other about 50 cm (20 in.) long. The longer strip allows for fastening at the side of the neck, avoiding pressure on the skin at the back.
2. Create Slits. Fold back about 2.5 cm (1 in.) of each tape end and cut a 1 cm (0.5 in.) slit in the folded edge.
3. Thread the Tape. Leaving the old ties in place, thread the slit end of the shorter tape through the eye of the tracheostomy flange from the bottom, then thread the long end through the slit and pull tight to secure.
4. Replace the Ties. If the old ties are soiled or difficult to work with, have an assistant hold the tracheostomy tube in place with a sterile glove while you replace the ties. This prevents tube displacement.
5. Secure the Second Tie. Repeat the process for the longer tape. Slip it under the client’s neck, place a finger between the tape and the neck, and tie the tapes at the side with a square knot. This prevents tightness that could interfere with breathing or circulation.
6. Final Adjustments. Cut off excess tape, leaving about 1-2 cm (0.5 in.) beyond the knot. Once the new ties are secure, remove and discard the old ties.

One-Strip Method (Twill Tape)

1. Cut the Tape. Cut a length of twill tape 2.5 times the distance around the client’s neck from one flange to the other.
2. Thread the Tape. Thread one end of the tape through the slot on one side of the flange. Bring both ends together and wrap them around the neck, keeping the tape flat and untwisted.
3. Secure the Tape. Thread the end closest to the neck through the slot from back to front.
4. Tie the Tape. Have the client flex their neck. Tie the ends at the side with a square knot, ensuring there is enough slack by placing two fingers under the ties. Cut off any excess length.

15. Tape and pad the tie knot.
Place a folded 4×4-inch gauze square under the tie knot and apply tape over the knot. This reduces skin irritation and prevents confusion with other ties.

16. Check the tightness of the ties.
Frequently check the tightness of the tracheostomy ties and the position of the tracheostomy tube. Swelling of the neck may cause ties to become too tight, and ties can loosen in restless clients, potentially dislodging the tube.

17. Document all relevant information.
Record suctioning, tracheostomy care, and dressing changes, noting your assessments.

When using a disposable inner cannula

18. Check policy for frequency of changing the inner cannula.
Standards vary among institutions. Open a new cannula package. Using a gloved hand, unlock the current inner cannula and remove it gently, checking for the amount and type of secretions. Discard properly.

19. Insert the new inner cannula.
Pick up the new inner cannula, touching only the outer locking portion. Insert it into the tracheostomy and lock it in place.

Lifespan considerations

• For infants and children. An assistant may be necessary to prevent active children from dislodging or expelling their tracheostomy tubes. Always have a sterile, packaged tracheostomy available at the bedside for emergencies. Encourage parents to participate in the procedure to comfort the child and promote client teaching.
• Elderly. Care for the skin at the tracheostomy site is particularly important for elders whose skin is more fragile and prone to breakdown.

Home care considerations

• Handwashing. Emphasize the importance of handwashing before performing tracheostomy care.
• Tube Care. Describe the function of each part of the tracheostomy tube. Explain the proper way 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.
• Infection Monitoring. Assess for symptoms of infection, such as increased temperature, increased amount of secretions, and changes in color or odor of secretions.
• Parental Involvement. Advise and encourage parents to participate in the procedure 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.

1. Introduce Yourself and Verify Identity.
Follow agency protocol to confirm the client’s identity.

2. Review procedure
Explain the procedure, its necessity, and how the client can cooperate. Inform the client that suctioning usually causes intermittent coughing, which helps in removing secretions. 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

3. Perform Hand Hygiene.
Follow infection control procedures, including using gloves and goggles.

4. Provide Client Privacy
Ensure privacy by closing curtains or doors and covering the client appropriately.

5. Prepare the client.
Place the client in a semi-Fowler’s position, if not contraindicated, to promote deep breathing, maximum lung expansion, and productive coughing. Provide analgesia before suctioning if necessary, especially for clients with thoracic or abdominal surgery or traumatic injuries.

6. Prepare the Equipment
Attach the resuscitation apparatus to the oxygen source and adjust the flow to 100%. Open sterile supplies, including the suction catheter, and place a sterile towel across the client’s chest. Turn on the suction and set the pressure according to agency policy (100-120 mm Hg for adults, 50-95 mm Hg for infants and children). Put on goggles, a mask, and a gown if necessary. Put on sterile gloves, or a sterile glove on the dominant hand and an unsterile glove on the nondominant hand. Attach the suction catheter to the suction tubing.

8. Flush and Lubricate the Catheter.
Using the dominant hand, place the catheter tip in sterile saline solution. Occlude the thumb control with the nondominant hand and suction a small amount of the solution through the catheter to ensure the suction equipment is working and to lubricate the catheter.

9. Hyperventilate the Lungs (if necessary).
If the client does not have copious secretions, use a resuscitation bag to hyperventilate the lungs before suctioning. Have an assistant help if available. Turn on the oxygen to 12-15 L/min. Disconnect the oxygen source from the tracheostomy tube, attach the resuscitator, and compress the Ambu bag 3-5 times while observing chest rise and fall. For clients on a ventilator, use the ventilator’s hyperventilation and hyperoxygenation settings.

10. Adjust Oxygen Delivery (if necessary)
For clients with copious secretions, keep the regular oxygen delivery device on and increase the flow or adjust FiO2 to 100% for several breaths before suctioning.

11. Insert the Catheter
Without applying suction, quickly and gently insert the catheter into the trachea through the tracheostomy tube. Insert the catheter about 12.5 cm (5 in.) for adults or until resistance is felt or the client coughs. Withdraw the catheter 1-2 cm before applying suction to prevent mucous membrane damage.

12. Perform Suctioning
Apply suction for 5-10 seconds by placing the nondominant thumb over the thumb port. Rotate the catheter while withdrawing it to minimize tissue trauma. Withdraw the catheter completely and release the suction.

13. Reassess and Repeat as Necessary
Observe the client’s respirations, skin color, and pulse if needed. Encourage deep breathing and coughing between suctions. Allow 2-3 minutes with oxygen between suctions for reoxygenation. Flush the catheter and repeat suctioning until the airway is clear.

14. Dispose of Equipment
Flush the catheter and suction tubing. Turn off the suction and disconnect the catheter. Wrap the catheter around your sterile hand and peel off the glove over the catheter. Discard appropriately. Replenish sterile fluid and supplies to ensure readiness for future use.

15. Ensure Client Comfort and Safety
Assist the client to a comfortable, safe position that aids breathing. Use semi-Fowler’s for conscious clients and Sims’ position for unconscious clients to aid secretion drainage.

16. Document Relevant Data.
Record the suctioning procedure, including the amount and description of secretions and relevant assessments.

17. When using Closed Airway/Tracheal Suction System (In-Line Catheter)
If a catheter is not attached, aseptically open a new closed catheter set and attach it to the ventilator tubing and endotracheal tube or tracheostomy. Attach the suction connecting tubing to the suction device. Turn on the suction and set it to the appropriate level. Use the ventilator to hyperoxygenate and hyperinflate the client’s lungs. Unlock the suction control mechanism, if required. Advance the suction catheter enclosed in its plastic sheath, apply suction, and withdraw the catheter. Flush the catheter with normal saline until clear, then close the irrigation port and suction valve.

18. For infants and children.
Restrain the child gently with an assistant’s help and keep the head in the midline position. Perform a thorough lung assessment before and after the procedure.

Home care considerations

• Encourage Coughing. Encourage the client to clear the airway by coughing. If they cannot cough effectively, suction their secretions.
• Use Clean Gloves and Observe Proper Hand Hygiene. Advise using clean gloves for the procedure and teach caregivers to recognize the need for suctioning.
• Hydration. Emphasize adequate hydration to thin secretions, aiding their removal by coughing or suctioning.

Dealing with Emergencies

Emergencies involving a tracheostomy can be alarming, but understanding the steps to take can ensure quick and effective responses, maintaining patient safety and comfort.

If the tracheostomy tube falls out:

• Stay Calm. The tract will not close suddenly if the tube has been in place for about five days.
• Reassure the Patient. Keep them calm and encourage them to breathe normally through their stoma while waiting for medical assistance.
• Call for Medical Help. Immediately seek assistance.
• Use Stay Sutures or Tracheal Dilator. If available, use these to keep the stoma open if necessary.
• Stay with the Patient. Never leave the patient alone.
• Prepare for New Tube Insertion. Once the new tracheostomy tube is inserted, secure it with ties, ensuring there is one finger-space between the ties and the patient’s neck.
• Check Tube Position. Ask the patient to inhale deeply—they should do so easily and comfortably. Hold a piece of tissue in front of the opening—it should move during exhalation.

If the patient is having acute dyspnea:

Acute dyspnea in tracheostomy patients is usually caused by partial or complete blockage of the tracheostomy tube due to retained secretions. To unblock the tracheostomy tube:

• Ask the Patient to Cough. A strong cough may expel the secretions.
• Remove the Inner Cannula. If secretions are stuck, they will be removed when the inner cannula is taken out, allowing the patient to breathe freely. Clean and replace the inner cannula.
• Suction. If coughing or removing the inner cannula does not work, use a suction machine to remove secretions lower in the airway.
• Seek help. If these measures fail, commence low-concentration oxygen therapy via a tracheostomy mask and call for medical assistance. It is possible the tracheostomy tube has become displaced. Stay with the patient until help arrives and prepare for a possible tube change.

If the patient needs cardiopulmonary resuscitation:

In the event of cardiopulmonary arrest, treat tracheostomy patients as you would others.

• Expose the Neck. Remove any clothing covering the tracheostomy tube and neck area. Do not remove the tracheostomy tube.
• Check Patency of the Inner Cannula. Wearing a non-sterile glove, remove the inner cannula. If it is clean, reinsert and lock it into place. If soiled, replace it and continue resuscitation.
• Ventilate. Use an Ambu-bag directly on the t-tube. If unable to ventilate, suction to remove or clear any secretions blocking the tube. If still unable to ventilate, the tube may be displaced. A doctor may need to change the tube or intubate orally.