Tracheostomy Nursing Care and Management

Caring for a tracheostomy means maintaining an artificial airway created by a surgical opening in the neck, for patients who need long-term airway support. Your job is to keep the tube patent and prevent infection, since the tracheostomy bypasses the upper airway's natural filtration. Care starts with frequent suctioning and cleaning and tapers as the patient stabilizes.

What is Tracheostomy?

A tracheostomy is a surgical opening into the trachea through the neck, just below the larynx, holding an indwelling tube that creates an artificial airway for clients needing long-term support.

The tube has an outer cannula in 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 then removed; keep it at the bedside in case reinsertion is needed.

See also: Tracheostomy Nursing Care Plans

Tracheostomy care maintains patency and minimizes infection risk, since inhaled air bypasses the upper airway's filtration. Initially, a tracheostomy may need suctioning and cleaning every 1 to 2 hours. Once the initial inflammation subsides, care may be needed only once or twice a day.

Components

• Outer tube: the main part inserted into the trachea.
• Inner tube: fits snugly into the outer tube and removes easily for cleaning.
• Flange: a flat plastic plate on the outer tube that lies flush against the neck.
• 15mm outer diameter termination: fits all ventilator and respiratory equipment.

The rest are optional:

• Cuff: an inflatable air reservoir (high volume, low pressure) that anchors the tube and seals the airway with minimal local compression. Inflated via the:
  • Air inlet valve: a one-way valve preventing air escape.
  • Air inlet line: the route from valve to cuff.
  • Pilot cuff: an indicator of the air in the cuff.
• Fenestration: a hole on the curve of the outer tube to enhance airflow. Single or multiple fenestrations are available.
• Speaking valve, tracheostomy button, or cap: occludes the tube opening. The speaking valve aids speech and swallowing during expiration; the button or cap is used during both inspiration and expiration before decannulation.

Purposes

• Maintain airway patency by removing mucus and encrusted secretions.
• Ensure cleanliness and prevent infection, which can progress to pneumonia.
• Facilitate healing by preventing skin excoriation around the incision.
• Promote comfort during and after care.
• Prevent displacement by securing the tube against dislodgement.

Assessment

• Respiratory status: ease of breathing, rate, rhythm, depth, lung sounds, and oxygen saturation.
• Pulse rate: changes that could signal distress.
• Secretions: character and amount, to detect infection.
• Drainage: on the dressing or ties, indicating infection or improper care.
• Incision appearance: redness, swelling, purulent discharge, or odor.

Equipment

• Sterile disposable tracheostomy cleaning kit or supplies (sterile containers, sterile nylon brush or pipe cleaners, sterile applicators, gauze squares)
• Sterile suction catheter kit (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
• Commercial tracheostomy dressing or sterile 4-in. gauze dressing
• Cotton twill ties
• Clean scissors
• Resuscitation bag (Ambu bag) connected to 100% oxygen
• Sterile towel (optional)
• Suctioning equipment
• Goggles and mask if necessary
• Gown if necessary
• Moisture-resistant bag

Providing Tracheostomy Care

1. Introduce yourself and verify the client's identity per agency protocol. Explain the procedure and how the client can cooperate, using simple signals like eye blinking or raising a finger to indicate pain or distress.

2. Observe infection control, performing hand hygiene.

3. Provide privacy, closing curtains or doors and exposing only what the task needs, keeping the client warm and covered.

4. Prepare the client and equipment. Assist to semi-Fowler's or Fowler's position for lung expansion. Open the kit or sterile basins and pour the soaking solution and sterile normal saline into separate containers.

5. Establish the sterile field, opening other supplies: sterile applicators, suction kit, and 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 sterile gloves on both). Suction the full length of the tube, then rinse the catheter, wrap it around your hand, and peel the glove off so it turns inside out over the catheter.

7. Remove the inner cannula. Unlock it with the gloved hand, pull it out along its curvature, and place it in the soaking solution to loosen secretions.

8. Remove the soiled dressing, placing it in your gloved hand and peeling the glove off inside out over the dressing. Discard both.

9. Put on sterile gloves, keeping the dominant hand sterile, and remove the inner cannula from the soaking solution.

10. Clean the lumen and entire inner cannula with the brush or pipe cleaners moistened with sterile normal saline. Inspect it at eye level against the light. Rinse thoroughly in sterile normal saline, tap it against the inside edge of the container, and use a pipe cleaner folded in half to dry only the inside, leaving a film of moisture on the outer surface to lubricate reinsertion and prevent aspiration.

11. Replace the inner cannula, grasping the outer flange and inserting along its curvature. Lock it by turning the lock (if present) to secure the inner flange to the outer cannula.

12. Clean the incision site and tube flange with sterile applicators or gauze moistened with normal saline, using each one once. Hydrogen peroxide may be used (usually half-strength, mixed with sterile normal saline) to remove crusty secretions. Rinse thoroughly with gauze squares moistened with sterile normal saline.

13. Apply a sterile dressing, using a commercial tracheostomy dressing or a 4×4-inch gauze dressing refolded into a V shape. Place it under the flange while supporting the tube to avoid irritation.

14. Change the tracheostomy ties as needed. Twill tape and Velcro ties are available, with Velcro more comfortable and less irritating. Use the two-strip or one-strip method, not too tight.

Two-Strip Method (Twill Tape)

1. Prepare the twill tape. Cut two strips: one approximately 25 cm (10 in.) long, the other about 50 cm (20 in.) long. The longer strip fastens at the side of the neck, avoiding pressure at the back.
2. Create slits. Fold back about 2.5 cm (1 in.) of each 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 flange eye from the bottom, then thread the long end through the slit and pull tight.
4. Replace the ties. If the old ties are soiled or hard to work with, have an assistant hold the tube with a sterile glove while you replace them, to prevent displacement.
5. Secure the second tie. Repeat for the longer tape: slip it under the neck, place a finger between tape and neck, and tie at the side with a square knot to prevent tightness.
6. Final adjustments. Cut off excess, leaving about 1-2 cm (0.5 in.) beyond the knot, then remove and discard the old ties.

One-Strip Method (Twill Tape)

1. Cut the tape to 2.5 times the distance around the neck from one flange to the other.
2. Thread the tape through the slot on one side of the flange. Bring both ends together and wrap around the neck, keeping the tape flat and untwisted.
3. Secure the tape, threading the end closest to the neck through the slot from back to front.
4. Tie the tape. Have the client flex the neck, tie at the side with a square knot, leaving slack for two fingers under the ties, and cut off excess.

15. Tape and pad the tie knot. Place a folded 4×4-inch gauze square under the knot and tape over it to reduce irritation.

16. Check the tightness of the ties and the tube position frequently. Neck swelling can tighten ties, and ties can loosen in restless clients, risking dislodgement.

17. Document suctioning, care, and dressing changes, with your assessments.

When using a disposable inner cannula

18. Check policy for the frequency of changing the inner cannula. Open a new cannula package. With a gloved hand, unlock and gently remove the current cannula, noting secretions, and discard it properly.

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

Lifespan considerations

• Infants and children. An assistant may be needed to prevent active children from dislodging the tube. Keep a sterile, packaged tracheostomy at the bedside for emergencies, and involve parents to comfort the child and support teaching.
• Elderly. Skin care at the site is especially important, since older skin is fragile and prone to breakdown.

Home care considerations

• Handwashing before tracheostomy care.
• Tube care. Explain each part's function and how to remove, change, and replace the inner cannula. Clean it two or three times a day, check and clean the stoma, and suction secretions if needed.
• Infection monitoring for increased temperature, more secretions, and changes in color or odor.
• Parental involvement to comfort the child and support teaching, with emergency contact information.

Suctioning a Tracheostomy Tube

Suction only as necessary, with sterile technique. Expect frequent need in the immediate postoperative period.

1. Introduce yourself and verify identity per agency protocol.

2. Review the procedure, explaining it and how the client can cooperate. Note that suctioning causes intermittent coughing, which helps remove secretions. Check whether the client has been suctioned before and review the documentation, which helps you prepare for the physiologic and psychologic impact.

3. Perform hand hygiene, following infection control with gloves and goggles.

4. Provide privacy, closing curtains or doors and covering the client.

5. Prepare the client in semi-Fowler's position, if not contraindicated, for deep breathing, lung expansion, and productive coughing. Give analgesia before suctioning if needed, especially after thoracic or abdominal surgery or trauma.

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

7. Flush and lubricate the catheter. With the dominant hand, place the tip in sterile saline, occlude the thumb control with the nondominant hand, and suction a small amount through to confirm the equipment works and lubricate the catheter.

8. Hyperventilate the lungs if necessary. If secretions are not copious, use a resuscitation bag before suctioning, with an assistant if available. Turn oxygen to 12-15 L/min, disconnect the oxygen source from the tube, attach the resuscitator, and compress the Ambu bag 3-5 times while watching chest rise and fall. For ventilated clients, use the ventilator's hyperventilation and hyperoxygenation settings.

9. Adjust oxygen delivery if necessary. For copious secretions, keep the regular device on and increase flow or set FiO2 to 100% for several breaths before suctioning.

10. Insert the catheter without applying suction, quickly and gently into the trachea through the tube, 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.

11. Perform suctioning for 5-10 seconds with the nondominant thumb over the port, rotating the catheter while withdrawing to minimize trauma. Withdraw completely and release suction.

12. Reassess and repeat as necessary. Observe respirations, skin color, and pulse. Encourage deep breathing and coughing between suctions, and allow 2-3 minutes with oxygen between suctions for reoxygenation. Flush the catheter and repeat until the airway is clear.

13. Dispose of equipment. Flush the catheter and tubing, turn off suction, disconnect the catheter, wrap it around your sterile hand, and peel off the glove over it. Discard properly and replenish sterile supplies.

14. Ensure comfort and safety. Position the client to aid breathing: semi-Fowler's for conscious clients, Sims' for unconscious clients to aid drainage.

15. Document the procedure, including the amount and description of secretions and relevant assessments.

16. When using a closed airway/tracheal suction system (in-line catheter): if no catheter is attached, aseptically open a new closed catheter set and attach it to the ventilator tubing and the endotracheal or tracheostomy tube. Attach the connecting tubing to the suction device, turn it on, and set the level. Use the ventilator to hyperoxygenate and hyperinflate the lungs. Unlock the suction control if required, advance the catheter in its sheath, apply suction, and withdraw. Flush with normal saline until clear, then close the irrigation port and suction valve.

17. For infants and children, restrain the child gently with an assistant, keeping the head midline, and do a thorough lung assessment before and after.

Home care considerations

• Encourage coughing to clear the airway; suction if the client cannot cough effectively.
• Use clean gloves and hand hygiene, and teach caregivers to recognize the need to suction.
• Hydration to thin secretions for easier removal.

Dealing with Emergencies

If the tracheostomy tube falls out:

• Stay calm. The tract will not close suddenly if the tube has been in place about five days.
• Reassure the patient and encourage normal breathing through the stoma while waiting for help.
• Call for medical help immediately.
• Use stay sutures or a tracheal dilator, if available, to keep the stoma open.
• Stay with the patient.
• Prepare for new tube insertion. Once the new tube is in, secure it with ties, leaving one finger-space between the ties and the neck.
• Check tube position. Have the patient inhale deeply; it should be easy and comfortable. Hold tissue in front of the opening; it should move on exhalation.

If the patient has acute dyspnea:

Acute dyspnea in tracheostomy patients usually comes from partial or complete blockage by retained secretions. To unblock:

• Ask the patient to cough, which may expel the secretions.
• Remove the inner cannula. Stuck secretions come out with it, letting the patient breathe; clean and replace it.
• Suction if coughing and cannula removal fail, to clear secretions lower in the airway.
• Seek help. If these fail, start low-concentration oxygen via a tracheostomy mask and call for help. The tube may be displaced; stay with the patient and prepare for a tube change.

If the patient needs cardiopulmonary resuscitation:

Treat tracheostomy patients as you would others.

• Expose the neck, removing clothing over the tube and neck. Do not remove the tracheostomy tube.
• Check the inner cannula's patency. With a non-sterile glove, remove it; if clean, reinsert and lock it, if soiled, replace it, and continue resuscitation.
• Ventilate with an Ambu bag directly on the t-tube. If you cannot ventilate, suction to clear secretions. If still unable, the tube may be displaced and a doctor may need to change it or intubate orally.