What airway clearance measures are recommended for a patient with a tracheostomy who is not on mechanical ventilation (using only a tracheostomy shield)?

Airway Clearance for Tracheostomy Patients Not on Mechanical Ventilation

For patients with a tracheostomy shield (not on mechanical ventilation), implement regular suctioning as-needed based on clinical indicators, ensure adequate humidification, remove and clean inner cannulas regularly, and apply high-flow oxygen to both the tracheostomy and face when needed. 1

Essential Bedside Equipment

Your bedside setup must include 1:

• Humidification equipment (critical to prevent secretion plugging)
• Suction with appropriate catheters
• Spare tracheostomy tubes (same size and one size smaller)
• Scissors and water-soluble lubricant
• Personal protective equipment

Airway Clearance Strategy

When to Suction

Suction only when clinically indicated, not on a scheduled basis 2:

• Visible secretions in the airway
• Audible breath sounds suggesting secretions
• Increased work of breathing
• Patient distress or desaturation

Avoid routine scheduled suctioning - this is unnecessary and increases complications 2.

How to Suction Properly

Use sterile technique during open suctioning 2:

• Suction catheter should occlude <50% of the tube lumen in adults
• Keep suction pressure below -200 mm Hg in adults
• Apply suction for maximum 15 seconds per attempt
• Use shallow suctioning unless deep suctioning is specifically needed for retained secretions 2

Preoxygenate before suctioning to prevent desaturation 2.

Critical: Inner Cannula Management

Remove the inner cannula first if secretions are suspected - this single action may resolve tube obstruction without further intervention 1. Inner cannulas significantly reduce occlusion risk when properly maintained 1.

Clean or replace inner cannulas regularly. Some designs require a dedicated inner cannula for connection to resuscitation equipment 1.

Humidification is Non-Negotiable

Patients with tracheostomy shields require continuous humidification 1. Small humidifying devices (Swedish noses/HME filters) can become blocked with secretions and must be monitored closely 1.

Common pitfall: HME filters becoming wet and blocked, which can be mistaken for patient deterioration 3. Check and replace these regularly.

Assessment of Tube Patency

When concerned about tube obstruction 1:

1. Pass a soft suction catheter through the tube - it should advance easily beyond the tube tip into the trachea
2. Never use rigid bougies for patency testing - they can create false passages if the tube is displaced 1
3. If the suction catheter passes easily, the tube is patent
4. If it won't pass, consider tube blockage or displacement

Emergency Algorithm for Deterioration

If your patient deteriorates 1:

1. Call for help immediately and apply high-flow oxygen to both face and tracheostomy
2. Remove inner cannula if present
3. Pass suction catheter to assess patency
4. If catheter won't pass and patient continues to deteriorate: Remove the tracheostomy tube
5. After removal, apply oxygen to both face and stoma, reassess both airways

Critical point: A blocked or displaced tracheostomy tube offers no benefit and considerable harm. Don't hesitate to remove it in a deteriorating patient 1.

Pulmonary Rehabilitation

For non-ventilated tracheostomy patients, pulmonary rehabilitation training significantly improves outcomes 4:

• Respiratory muscle training
• Diaphragmatic mobility exercises
• Chest physiotherapy
• These interventions shorten hospital stays, improve muscle strength, and increase successful decannulation rates 4

Avoid These Mistakes

• Don't instill normal saline during suctioning - this should generally be avoided 2
• Don't attempt vigorous hand ventilation through a potentially displaced tube - this causes surgical emphysema and worsens the situation 1
• Don't obtain routine surveillance cultures - only culture when there's concern for acute lower respiratory tract infection 5
• Don't use scheduled suctioning protocols - suction only when clinically indicated 2

Communication and Monitoring

Patients with tracheostomy shields may have difficulty calling for help verbally. Ensure nurse call bells are accessible and consider communication aids 1.

Monitor for signs requiring intervention: increased secretions, respiratory distress, desaturation, or visible secretions in the tube.