What are the guidelines for proper tracheostomy care?

Guidelines for Proper Tracheostomy Care

Proper tracheostomy care requires a systematic approach focusing on infection prevention, equipment management, and emergency preparedness to minimize complications and optimize patient outcomes.

Essential Equipment for Tracheostomy Care

Bedside Equipment

• Humidification equipment
• Suction with appropriate catheters
• Spare tracheostomy tubes (one same size, one smaller size)
• Clean container for spare inner cannula
• Sterile water for cleaning
• Scissors (and stitch cutter if tube is sutured)
• Water-soluble lubricating jelly
• Sterile dressing pack and tracheostomy dressings
• Tracheostomy tapes/ties
• Personal protective equipment (gloves, aprons, eye protection)
• Communication aids 1

Emergency Equipment

• Manual resuscitation bag of appropriate size
• Oxygen source
• Suction catheters and DeLee suction traps
• Extra tracheostomy tubes with ties in place
• Shoulder roll
• 15-mm adapter (for metal tubes)
• Scissors
• Emergency phone numbers
• Brief medical history description 1
• Waveform capnography (critical for monitoring tube placement) 1

Routine Tracheostomy Care Procedures

Suctioning Technique

1. Assess need for suctioning (increased respiratory effort, visible secretions)
2. Use proper hand hygiene and PPE
3. Use pre-marked catheters
4. Twirl catheter between fingertips during suctioning
5. Limit suction time to prevent hypoxia
6. Clean suction equipment after use 1

Skin Care

• Keep skin clean and dry to avoid pressure necrosis
• Perform daily cleansing with soap and water
• Use 1.5% hydrogen peroxide for encrusted secretions, followed by water rinse
• Inspect peristomal area and neck skin daily
• Avoid routine use of ointments and creams
• Petroleum-based products are contraindicated
• Consider products like Duoderm to cushion skin beneath ties 1

Tube Change Procedure

1. Check tube integrity and flexibility; check cuff integrity
2. Place obturator in new tube
3. Suction current tracheostomy tube
4. Position with neck in slight extension using shoulder roll
5. Deflate cuff
6. Cut strings/detach ties
7. Remove tube in upward and outward arc
8. Insert new tube in downward, inward arc
9. Immediately remove obturator
10. Reposition to neutral position
11. Secure ties
12. Inflate cuff if present
13. Lock inner cannula in place 1, 2

Safety Measures and Precautions

• Avoid dust, smoke, lint, pet hair, powder, sprays, small toys
• No fuzzy toys, clothes, or bedding
• No contact sports or water sports
• Bathing permitted in 1-2 inches of water with trained caretaker present
• Showers may be permissible for older children 1
• Use waveform capnography to confirm tube placement 1
• Maintain closed circuit for ventilated patients 2

Emergency Management

Signs of Tracheostomy Emergency

• Absence/change of capnograph waveform
• Absence/change of chest wall movement
• Increasing airway pressure
• Reducing tidal volume
• Inability to pass suction catheter
• Obvious air leak
• Vocalization with inflated cuffed tube
• Surgical emphysema 1

Emergency Response

1. Call for help immediately (follow bedhead instructions)
2. Apply high-flow oxygen to face and tracheostomy
3. Remove any attachments from tracheostomy tube
4. Remove inner cannula if present
5. Attempt to pass suction catheter to assess patency
6. If obstruction suspected, change tracheostomy tube
7. Use waveform capnography to confirm placement 1

Common Complications and Prevention

• Tube obstruction: Most common cause of respiratory distress - maintain regular suctioning and inner cannula cleaning 1
• Accidental decannulation: Secure ties properly, have emergency equipment ready 1
• Infection: Use proper hand hygiene, clean technique, regular stoma care 1
• Skin breakdown: Perform meticulous skin care, avoid pressure 1
• Tracheomalacia/stenosis: Monitor for signs during follow-up 1

Special Considerations

COVID-19 Precautions

• Use appropriate PPE based on risk assessment
• Consider closed suction systems
• Use HME filters
• Test patients with existing tracheostomies for SARS-CoV-2 1

Multidisciplinary Approach

• Ensure staff training in tracheostomy care
• Implement standardized protocols
• Conduct regular multidisciplinary rounds
• Use bedhead signs with key information
• Ensure emergency equipment availability 2

Pitfalls to Avoid

• Never use petroleum-based products around tracheostomy
• Avoid using rigid devices (bougies) to assess tube patency
• Don't delay tube change if obstruction is suspected
• Never attempt tracheostomy tube changes without proper training
• Don't forget to remove obturator immediately after tube insertion
• Avoid inadequate humidification 1

By following these comprehensive guidelines for tracheostomy care, healthcare providers can significantly reduce complications and improve patient outcomes.