What is the management and care of a patient with a tracheostomy?

Management and Care of Patients with Tracheostomy

Comprehensive tracheostomy care requires a multidisciplinary approach focused on maintaining airway patency, preventing complications, and optimizing communication and swallowing to reduce morbidity and mortality. 1

Emergency Equipment and Bedside Preparation

Every patient with a tracheostomy must have the following equipment at their bedside:

• Humidification equipment
• Suction with appropriate catheters
• Spare tracheostomy tubes (one same size, one smaller)
• Clean pot for spare inner cannula
• Sterile water for cleaning
• Scissors and stitch cutter (if tube is sutured)
• Water-soluble lubricating jelly
• Sterile dressing supplies
• Tracheostomy tapes
• Personal protective equipment 1

Emergency Equipment Must Include:

• Basic airway equipment (oxygen masks, self-inflating bags, oral/nasal airways)
• Advanced airway equipment (laryngeal mask airways, laryngoscopes)
• Waveform capnography
• Fibreoptic scope
• Tracheal dilators
• Bougies 1

Routine Tracheostomy Care

Daily Care:

• Inner cannula inspection and cleaning/replacement
• Stoma site cleaning with sterile technique
• Humidification assessment and management
• Cuff pressure monitoring (if cuffed tube present)
• Tracheostomy tape/holder security check without excessive tension
• Secretion assessment and suctioning as needed

Suctioning Technique:

1. Use aseptic technique
2. Pre-oxygenate before suctioning
3. Insert catheter without suction to appropriate depth
4. Apply suction only during withdrawal
5. Limit suction duration to <15 seconds
6. Allow recovery between attempts 2

Communication Management

Speech and communication are critical for quality of life in tracheostomy patients. Management includes:

1. Speech pathologist consultation before or immediately after tracheostomy placement 1
2. Speaking valve assessment for appropriate candidates
3. Criteria for speaking valve use:
   • Tracheostomy tube size not exceeding 2/3 of tracheal lumen
   • Medical stability
   • Ability to have cuff deflated without aspiration
   • Some ability to vocalize with occluded tracheostomy
   • Patent upper airway
   • Manageable secretions 1

Swallowing Management

1. Bedside swallowing evaluation with respiratory therapist/nurse present for suctioning
2. Methylene blue dye testing with physician order
3. Videofluoroscopy for definitive assessment if swallowing disorder suspected
4. Evaluation with cuff both inflated and deflated to determine optimal swallowing conditions
5. Speaking valve assessment during swallowing to determine if it improves function 1

Emergency Management

Immediate Actions for Respiratory Distress:

1. Call for help per local protocol
2. Apply high-flow oxygen to both face and tracheostomy
3. Use waveform capnography to assess ventilation
4. Assess tracheostomy patency with gentle suction 1

If Obstruction Suspected:

1. Remove inner cannula if present and replace with clean one
2. Attempt gentle suction
3. If still obstructed, remove tracheostomy tube
4. Oxygenate via stoma and/or upper airway
5. Re-establish airway with new tracheostomy tube or endotracheal tube 1

Decannulation Considerations

Decannulation should be considered when:

1. The original indication for tracheostomy has resolved
2. The patient has adequate respiratory function
3. The upper airway is patent
4. The patient can effectively clear secretions
5. The patient has successfully tolerated capping trials 1

Special Considerations

COVID-19 Patients:

• Enhanced PPE required for all tracheostomy care
• Minimize aerosol-generating procedures
• Use closed suction systems when possible
• Consider delayed timing of tracheostomy 1

Monitoring for Complications:

• Infection (most common complication - 43% of all complications)
• Bleeding/hemorrhage (may precede catastrophic hemorrhage)
• Tube displacement
• Tube obstruction
• Tracheomalacia
• Skin breakdown
• Tracheoesophageal fistula 1, 3

Caregiver Education

Before discharge, caregivers must demonstrate competency in:

• Routine tracheostomy care
• Suctioning technique
• Emergency tube replacement
• Signs of respiratory distress
• Emergency protocols
• Equipment management 1

Proper tracheostomy management requires vigilant care, appropriate equipment, and a multidisciplinary approach to minimize complications and optimize patient outcomes.