What are the recommended care and maintenance procedures for a tracheostomy (trach) tube?

Tracheostomy Tube Care and Maintenance

Proper tracheostomy tube care requires meticulous attention to suctioning technique, skin care, and regular tube maintenance to prevent complications and ensure patient safety. 1

Essential Tracheostomy Care Components

Emergency Preparedness

• Always maintain an emergency kit containing: manual resuscitation bag, suction source, suction catheters, replacement tracheostomy tubes (current size and one size smaller), extra ties, shoulder roll, scissors, and emergency contact information 1
• Ensure caregivers are trained in CPR specific to tracheostomy patients, including bag-to-tracheostomy ventilation 1
• For patients with patent upper airways, training should include mouth-to-mouth ventilation with stoma occlusion 1

Suctioning Technique

• Use the "premeasured technique" for routine suctioning, inserting the catheter to a predetermined depth with the distal side holes just exiting the tip of the tracheostomy tube 1
• Twirl or rotate the catheter between fingers during insertion to reduce friction and effectively clear secretions from all areas of the tube wall 1
• Use premarked catheters to ensure proper insertion depth and avoid epithelial damage 1
• Clean technique is appropriate for home care with thorough handwashing before and after each suctioning procedure 1
• After suctioning, flush the catheter with tap water until secretions are cleared, wipe the outside with alcohol, and allow to air dry 1
• For mechanically-ventilated patients, use closed-circuit suctioning systems with inline suction catheters to decrease aerosolization risk 1

Tube Securement and Skin Care

• Secure the tube with ties tight enough to prevent dislodgement but loose enough to allow one finger to slip beneath the tie 1
• Foam straps place minimal stress on the skin compared to twill ties and decrease risk of skin breakdown 1
• Keep the peristomal skin clean and dry to prevent infection and pressure necrosis 1
• Clean the stoma daily with soap and water; 1.5% hydrogen peroxide can be used to remove encrusted secretions, followed by thorough rinsing and drying 1
• Avoid routine use of ointments and creams; petroleum-based products are contraindicated 1
• If dressings are used, they should promote moisture movement away from the skin and be loose and nonocclusive 1

Tube Changes and Maintenance

• Follow a systematic approach for tube changes:
  1. Check tube integrity and flexibility before insertion 1
  2. Suction the current tube 1
  3. Position the patient with neck in slight extension using a shoulder roll 1
  4. Remove the old tube in an upward and outward arc 1
  5. Insert the new tube in a downward, inward arc 1
  6. Immediately remove the obturator after insertion 1
  7. Secure the ties and check placement 1
• Ideally, have two trained adults present for tube changes 1
• For patients with cuffed tubes, maintain cuff pressure between 20-30 cmH2O to prevent tracheal injury while maintaining circuit integrity 2

Humidification

• Ensure adequate humidification to prevent secretion thickening and airway dryness 2
• Heat moisture exchangers (HMEs) are preferred over large-volume humidifiers 2

Special Considerations

Infection Prevention

• Decontaminate hands before and after contact with the tracheostomy tube or any respiratory device 2
• Wear gloves when handling respiratory secretions or contaminated objects 2
• Change the fixation daily or more often if there is oozing (hemorrhage or pus) 1

Patient Transport

• During transport, equip non-ventilated patients with a heat moisture exchanger with viral filter 1
• For ventilated patients, ensure the cuff is optimally inflated with a closed-circuit to decrease aerosolization 1
• Surgical masks should be worn over both the patient's face and the tracheostomy tube during transport 1

Environmental Safety

• Avoid exposure to dust, smoke, lint, pet hair, powder, sprays, and small objects 1
• Restrict contact with fuzzy toys, clothes, or bedding 1
• Limit water exposure; bathing should be supervised with water level no higher than 1-2 inches 1

Common Complications and Management

• Tube obstruction: Often caused by mucus plugging, requiring immediate suctioning to prevent respiratory distress 3
• Skin breakdown: Prevent by proper skin care and appropriate tube securement 1
• Tube dislodgement: Requires immediate replacement using the emergency kit supplies 3
• Infection: Minimize risk through proper cleaning techniques and hand hygiene 4

By following these comprehensive care guidelines, healthcare providers and caregivers can significantly reduce tracheostomy-related complications and improve patient outcomes 5.