What is the proper management and care for a patient undergoing a tracheostomy?

Tracheostomy Management and Care

Essential Bedside Equipment

Every tracheostomy patient must have a dedicated emergency box at the bedside containing specific equipment to prevent life-threatening complications. 1

Required Bedside Supplies:

• Humidification equipment with Heat Moisture Exchangers (HMEs) with viral filters (>99.9% filtration efficiency) 2
• Suction system with appropriate catheters and closed-circuit inline suction capability 2, 3
• Two spare tracheostomy tubes: one same size and one size smaller 1
• Clean pot for spare inner cannula 1
• Sterile water for cleaning suction tubes 1
• Scissors and stitch cutter (if tube is sutured) 1
• Water-soluble lubricating jelly 1
• Tracheostomy dressings and tapes 1
• Personal protective equipment (gloves, aprons, eye protection) 1
• Nurse call bell (patient may be unable to call verbally) 1
• Communication aids 1

Emergency Equipment (Must Be Available Within Minutes):

• Waveform capnography - invaluable for airway assessment and must be immediately available 1
• Fiberoptic scope suitable for immediate use 1
• Basic airway equipment: oxygen masks, self-inflating bags, oral/nasal airways 1
• Advanced airway equipment: laryngeal mask airways and laryngoscopes with tubes 1
• Bougies 1
• Tracheal dilators (based on local protocol and patient characteristics) 1

Daily Routine Care

Secretion Management:

• Use closed-circuit suctioning with inline suction catheters to minimize aerosolization risk 2
• Never instill saline before suctioning - this increases coughing risk and aerosolization without benefit 2
• Remove and clean inner cannula regularly to prevent tube occlusion from secretions 1, 2
• Inspect HME filters daily and whenever ventilation deteriorates 2

Humidification Protocol:

• Prefer HMEs with viral filters over heated humidification to reduce coughing and secretion buildup 2
• Use bidirectional HME filters with >99.9% filtration efficiency 2
• For thick secretions, maintain HME use but monitor closely 2

Cuff Management:

• Maintain cuff pressure at 20-30 cmH2O for air-filled cuffs to ensure ventilation system integrity while preventing tracheal injury 2

Emergency Management Algorithm

Initial Response to Deterioration:

1. Call for help immediately - specific contacts should be displayed on bed-head sign 1
2. Apply high-flow oxygen to BOTH face and tracheostomy - requires two oxygen sources 1
3. Attach waveform capnography immediately for airway assessment 1
4. If apneic or no signs of life: check pulse and begin CPR per standard guidelines 1

Assessment of Tracheostomy Patency (ABCDE Approach):

• Remove ALL attachments immediately: speaking valves, caps, obturators, humidifying devices - these have caused significant mortality 1
• Remove inner tube - this alone may resolve obstruction 1
• If no improvement with above steps, remove the entire tracheostomy tube - a non-functioning tube offers no benefit and considerable harm 1

Critical caveat: The only exception to immediate tube removal is when fiberoptic equipment and expertise are immediately available AND the patient is clinically stable, allowing inspection before removal 1. This should never delay removal in a deteriorating patient 1.

Emergency Oxygenation After Tube Removal:

• Primary approach: Ventilate via mouth/nose while occluding the tracheal stoma 1
• Alternative: Apply pediatric facemask or LMA directly to the stoma while occluding nose and mouth if large leak present 1
• Goal is oxygenation, not necessarily intubation 1

Secondary Emergency Oxygenation (If Primary Fails):

• Oral intubation with long uncut tube advanced beyond stoma to bypass anterior tracheal wall 1
• Stoma intubation: Insert smaller tracheostomy or endotracheal tube 1
• Use fiberoptic scope when available to guide placement of airway catheter, bougie, or tube 1
• Confirm placement with waveform capnography 1

Communication and Swallowing Management

Speech Pathology Consultation:

• Refer ALL tracheostomy patients to speech pathology regardless of diagnosis, age, or expected duration 1
• Consult before tracheostomy surgery when possible 1

Speaking Valve Criteria:

• Tracheostomy tube size must not exceed two-thirds of tracheal lumen (unless fenestrated) 1
• Medical stability present 1
• Ability to deflate cuff without aspiration 1
• Some vocalization ability with tube occluded 1
• Patent airway above tracheostomy 1
• Secretions not excessively thick 1

Swallowing Assessment:

• Perform bedside evaluation with methylene blue dye mixed with food 1
• Any blue-tinged mucus over several hours indicates aspiration 1
• Perform videofluoroscopy if bedside exam shows disordered swallow 1
• Test with cuff both inflated and deflated (if cuffed tube present) 1
• Test with and without speaking valve to note changes 1

Pain and Cough Management

Procedural Pain Control:

• Spray airways with 4% lidocaine before tube changes to decrease coughing, with careful attention to dosing in pediatric patients 2

For Persistent Cough:

• Optimize humidification with HMEs 2
• Use closed-circuit suctioning 2
• Avoid saline instillation 2
• For neuromuscular disease with ineffective cough: use mechanical insufflation-exsufflation in addition to standard physiotherapy 2

COVID-19 Specific Modifications

Timing Considerations:

• Tracheostomy is an aerosol-generating procedure with increased risk during positive-pressure ventilation 1
• Delaying tracheostomy reduces healthcare worker risk but exposes patients to prolonged intubation complications 1
• Negative SARS-CoV-2 test is NOT required before tracheostomy 1
• Pre-procedural apnea test can assess physiological stability 1

Technique Modifications:

• Open surgical procedures are preferred but percutaneous not contraindicated 1
• Maintain neuromuscular blockade throughout procedure with monitoring 1
• Planning, rehearsal, and communication are critical 1

Post-Procedural Care:

• Minimize airway procedures and aerosol-generating procedures 1
• Review humidification needs 1
• Specify suction frequency 1
• Perform daily inner tube care 1
• Discontinue positive pressure ventilation during circuit disconnection whenever possible 1

Common Pitfalls to Avoid

• Never delay removing a blocked tracheostomy tube in a deteriorating patient, even if the upper airway is known to be difficult 1
• Never attempt blind manipulation of the stoma when not required - this has caused harm 1
• Never use speaking valves with an inflated cuffed tube - this can cause obstruction 1
• Never forget to occlude the stoma when attempting oral/nasal ventilation 1
• Never send tracheostomy patients anywhere in the hospital without their complete emergency kit 3