What are the management steps for secretions at the side of a tracheostomy tube?

Management of Secretions at the Side of a Tracheostomy Tube

The management of secretions at the side of a tracheostomy tube requires immediate assessment of tube patency, removal of any external attachments, and proper suctioning technique using an appropriately sized catheter. 1

Initial Assessment and Emergency Response

• Remove any external attachments from the tracheostomy tube including heat and moisture exchange (HME) filters, speaking valves, decannulation caps, or humidifying devices which can become blocked with secretions 1, 2
• If an inner cannula is present, remove it to assess for blockage and clean thoroughly 1, 2
• Use a suction catheter to assess tube patency - it should pass easily beyond the tracheostomy tube tip and into the trachea 1
• Never use rigid devices like bougies to assess tube patency as they may create a false passage if the tube is partially displaced 1
• Summon appropriate help according to local protocols if respiratory distress is evident 1

Suctioning Technique

• Use the largest size catheter that will fit inside the tracheostomy tube to efficiently remove secretions 1
• Apply suction both while inserting and removing the catheter with adequate pressure to efficiently clear secretions 1
• Complete the suctioning procedure rapidly (less than 5 seconds) to prevent atelectasis 1
• For visible secretions at the side of the tube, make an initial pass of the catheter to quickly clear the tube before any hyperinflation or hyperoxygenation 1
• Do not instill normal saline routinely as it does not effectively thin mucus and may decrease oxygen saturation 1

Managing Obstruction

• If suctioning fails to clear the obstruction and the suction catheter cannot pass to the predetermined depth, the tracheostomy tube may be blocked or displaced 1
• In case of obstruction, an emergency tracheostomy tube change may be necessary 1, 2
• Ensure proper equipment is readily available at the bedside, including a functional suctioning system, oxygen source, manual resuscitation bag, and complete tracheostomy kit 3

Prevention of Secretion-Related Complications

• Ensure proper humidification to prevent thickening of secretions 2
• Use Heat Moisture Exchanger (HME) devices when possible 2
• Keep the skin around the stoma clean and dry to prevent infection, which can worsen secretion management 2
• For patients with thick secretions, consider using disposable inner cannulas to reduce tube blockage risk 2, 4
• Regular monitoring of patients with tracheostomies is essential as they exhibit a higher risk of colonization of the lower respiratory tract, which can lead to increased secretions 5

Special Considerations

• Patients with neurological injuries or certain respiratory conditions often have unusually thick and tenacious secretions that predispose to tracheostomy tube occlusions 2
• If the patient is receiving mechanical ventilation, ensure the ventilator circuit is functioning properly and not contributing to secretion issues 6, 7
• Waveform capnography can be invaluable when managing airways and should be used during assessment if available 1