What are the best practices for caring for a patient with a tracheostomy?

Tracheostomy Care: Best Practices

Core Principle

Keep the skin clean and dry, maintain proper humidification, suction only when needed using proper technique, and always have emergency equipment at the bedside—these fundamentals prevent the majority of tracheostomy complications and reduce mortality risk. 1, 2

Emergency Equipment (Must Be at Bedside at All Times)

Every tracheostomy patient requires immediate access to: 2

• Manual resuscitation bag
• Functional suction source with catheters
• Two replacement tracheostomy tubes (current size AND one size smaller)
• Extra ties/straps
• Shoulder roll for positioning
• Scissors
• Emergency contact information

This equipment must accompany the patient everywhere in the hospital. 2, 3

Suctioning Technique

When to Suction

Assess the need for suctioning rather than performing it on a schedule—only suction when clinically indicated by visible secretions, audible sounds, or respiratory distress. 1

Proper Technique

• Use premarked catheters to ensure consistent depth and avoid epithelial damage 1, 2
• Insert to a predetermined depth where distal side holes just exit the tube tip (the "premeasured technique") 2
• Twirl or rotate the catheter between fingertips during insertion and withdrawal to reduce friction and clear secretions from all tube wall areas 1, 2
• For home care, clean technique with thorough handwashing is appropriate 2
• After suctioning, flush catheter with tap water until clear, wipe outside with alcohol, and air dry 2

Infection Control During Suctioning

• Decontaminate hands before and after contact with the tracheostomy tube or respiratory devices 1, 2
• Wear gloves when handling respiratory secretions or contaminated objects 1, 2
• For mechanically-ventilated patients, use closed-circuit suctioning systems with inline catheters to decrease aerosolization 2, 4
• Use only sterile fluid to remove secretions if the catheter will re-enter the lower respiratory tract 1

Skin and Stoma Care

Daily Cleaning Protocol

• Clean the peristomal area daily with soap and water 1, 2
• For encrusted secretions, use 1.5% hydrogen peroxide followed by thorough rinsing with water and complete drying 1, 2
• Inspect the peristomal area and neck skin carefully every day 1

Critical Restrictions

• Avoid routine use of ointments and creams 1, 2
• Petroleum-based products are contraindicated 1, 2
• If dressings are used, they must promote moisture movement away from skin and be loose and nonocclusive 1, 2
• Products like Duoderm can cushion skin beneath tracheostomy ties 1

High-Risk Populations

Children on mechanical ventilation and infants with short, fat necks require even more meticulous care due to increased risk of infection and pressure necrosis. 1

Tube Securement

• Secure ties tight enough to prevent dislodgement but loose enough to allow one finger beneath the tie 2
• Foam straps are preferred over twill ties as they place minimal stress on skin and decrease breakdown risk 2
• Change ties every 8 hours to daily, or more frequently if there is oozing, hemorrhage, or pus 1, 2

Tracheostomy Tube Changes

Systematic Approach (13-Step Protocol)

1, 2

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

Ideally, two trained adults should be present for tube changes. 1, 2

Sterile Technique Requirements

• Perform tracheostomy placement under sterile conditions 1
• When changing tubes, use aseptic technique and replace with a tube that has undergone sterilization or high-level disinfection 1

Humidification

• Ensure adequate humidification to prevent secretion thickening and airway dryness 2
• Heat moisture exchangers (HMEs) are strongly preferred over large-volume humidifiers 2, 4
• For transport, equip non-ventilated patients with HME with viral filter 2

Cuff Management (For Cuffed Tubes)

• Maintain cuff pressure between 20-30 cmH2O to prevent tracheal injury while maintaining circuit integrity 2, 4
• Check cuff pressure every 8 hours to daily 1
• Never hyperinflate cuffs as this increases tracheal injury risk 4

Environmental Safety Measures

Strict avoidance of: 1, 2

• Dust, smoke, lint, pet hair, powder, and sprays
• Fuzzy toys, clothes, or bedding
• Small toys and objects
• Contact sports and water sports

Water Exposure

• Bathing permitted in only 1-2 inches of water with trained caretaker present 1, 2
• Showers may be permissible in older children only 1

Inner Cannula Care

• Check and clean inner cannula every 8 hours to daily 1
• A cleaning regimen performed every 4 hours reduces risk of blocked cannula, complete tube occlusion, and respiratory arrest 5

Emergency Management

Accidental Decannulation

• Attempt to replace with same size tube or one size smaller 1
• If unable to replace and patient can be intubated, consider oral/nasal intubation 1
• If patient is stable, do not attempt intervention—transport to tertiary care facility 1

Warning Signs

• Blood in tracheal secretions may precede catastrophic hemorrhage and requires immediate evaluation 1

Common Pitfalls to Avoid

• Never perform tracheostomy care without emergency equipment at bedside—tube obstruction and decannulation can occur suddenly and are life-threatening 2, 3, 6
• Never use petroleum-based products on peristomal skin—they are contraindicated 1, 2
• Never suction deeper than the premeasured depth—this causes epithelial damage and bleeding 1, 2
• Never allow cuff pressures to exceed 30 cmH2O—this causes tracheal ischemia and stenosis 2, 4
• Never leave a tracheostomy patient unattended during bathing—aspiration risk is significant 1, 2