Tracheostomy Nursing Care: Educational Presentation
Primary Goals of Tracheostomy Care
The fundamental goals of tracheostomy nursing care are maintaining airway patency through effective secretion management, preventing complications (infection, skin breakdown, tube obstruction), and optimizing patient quality of life through communication and swallowing rehabilitation. 1
Core Nursing Responsibilities
- Airway patency maintenance is the highest priority, requiring continuous assessment and intervention to prevent life-threatening tube obstruction 2
- Complication prevention through meticulous skin care, infection control, and proper humidification reduces morbidity and mortality 1
- Patient safety requires bedside emergency equipment and trained personnel capable of managing tracheostomy emergencies 1, 2
Essential Equipment at Every Bedside
Every tracheostomy patient must have immediately accessible emergency supplies, as tube obstruction can be fatal within minutes. 1, 2
Required Bedside Equipment
- Functional suctioning system with appropriate catheter sizes (premarked to prevent tracheal trauma) 1
- Oxygen source and manual resuscitation bag for emergency ventilation 1
- Complete tracheostomy kit containing the same size tube currently in use plus one size smaller 1, 2
- Emergency supplies must accompany the patient wherever they go in the hospital 2
Humidification: Critical for Secretion Management
Adequate humidification is essential to prevent thick, tenacious secretions that can cause life-threatening tube obstruction, particularly in patients with underlying respiratory conditions like COPD or pneumonia. 1
Humidification Targets and Methods
- Target inspired gas temperature should be 32-34°C with humidity of 36-40 mg/L to replicate normal upper airway conditions 1
- Heat and moisture exchangers (HME) with viral filters are first-line for active patients not using speaking valves 3
- Active heated humidification systems should be used when secretions become thick despite HME use, particularly common in prolonged tracheostomy 3
- Never use routine saline instillation into the tracheostomy tube, as this decreases oxygen saturation, fails to thin mucus, and contaminates lower airways 3
Common Pitfall
Inadequate humidification is indicated by excessive secretions requiring frequent suctioning or secretions becoming thick and difficult to clear 3. This requires immediate adjustment of humidification strategy.
Suctioning Technique: Clean vs. Sterile
Clean technique (non-sterile gloves with clean catheter) is appropriate for chronic tracheostomy patients in home and community settings, while modified clean technique is acceptable in hospital settings. 1
Proper Suctioning Protocol
- Use premarked catheters to prevent insertion beyond the carina, which causes tracheal trauma 1
- Twirl catheter between fingertips during suctioning to prevent mucosal damage 1
- Assess need before suctioning rather than performing routine scheduled suctioning 1
- For mechanically ventilated patients, maintain a closed circuit with in-line suction to minimize aerosolization and infection risk 1, 4
Catheter Cleaning for Reuse (Home Setting)
- Four-step cleaning process: wash with hot soapy water, disinfect in vinegar-water solution or commercial disinfectant, rinse with clean water, air dry 1
- 98% of properly cleaned catheters have sterile exteriors when this protocol is followed 1
Skin Care and Stoma Management
Prevention is the key to skin care—keep the peristomal area clean and dry to avoid pressure necrosis and infection. 1
Daily Skin Care Protocol
- Clean daily with soap and water, inspecting the peristomal area and neck skin carefully 1
- Use 1.5% hydrogen peroxide to remove encrusted secretions, then cleanse with water and dry thoroughly 1
- Products like Duoderm can cushion skin beneath tracheostomy ties to prevent pressure injury 1
- Avoid petroleum-based products and routine use of ointments and creams 1
- Use dressings that promote moisture movement away from skin; if used, they should be loose and non-occlusive 1
High-Risk Populations
- Mechanically ventilated children and infants with short, fat necks require even more meticulous care due to increased risk of infection and pressure necrosis 1
Tracheostomy Tube Changes
Two trained adults should ideally be present for tube changes to manage emergencies effectively. 1
Step-by-Step Tube Change Protocol
- Check tube integrity and flexibility; check cuff integrity if present 1
- Place obturator in new tube (if used) 1
- Suction the current tracheostomy tube 1
- Position child with neck in slight extension using a small roll under shoulders 1
- Deflate cuff (if present) 1
- Cut strings/detach ties 1
- Remove tube in upward and outward arc 1
- Insert new tube in downward, inward arc 1
- Immediately remove obturator (if used) 1
- Reposition to neutral position by removing shoulder roll 1
- Secure ties 1
- Inflate cuff (if used) 1
- Lock inner cannula in place 1
Tracheostomy Tie Management
- Optimal tension: tight enough to slip one finger beneath the tie 1
- Most important aspect is not the material but how well the tie is secured 1
- Soft tracheostomy ties or Velcro may be less irritating than strings, though Velcro poses risk of accidental decannulation in small children 1
Communication and Swallowing Management
All patients with a tracheostomy should be referred to speech pathology services regardless of diagnosis, age, or expected duration of tracheostomy. 1
Speaking Valve Use
- One-way speaking valves (Passy-Muir, Shirley, Montgomery) are more effective than finger occlusion for speech 1
- Criteria for speaking valve use: tracheostomy tube size should not exceed two-thirds of tracheal lumen (unless fenestrated), medical stability, ability to deflate cuff without aspiration, some vocalization ability with tube occluded, patent upper airway, and secretions not thick 1
- Speaking valves optimize swallowing safety by allowing air through vocal cords during exhalation, creating positive subglottic pressure that clears residual material from the larynx 3
Swallowing Assessment Protocol
- Deflate cuff or transition to cuffless tube before initiating swallowing trials, as inflated cuff prevents translaryngeal airflow and increases aspiration risk 3
- Cuff deflation should only occur when patient is low-risk for requiring mechanical ventilation 3
- For low-risk dysphagia patients, perform blue dye test rather than FEES to minimize aerosol generation 3
- For high-risk patients, instrumental evaluation (FEES or VFSS) is necessary 3
- Do not advance to oral intake if patient cannot manage their own oral secretions, even with cuff deflation, as this predicts aspiration 3
Oral Care Protocol
Implement an 8-hourly oral care protocol to prevent aspiration pneumonia and maintain oral hygiene. 3
Essential Components Every 8 Hours
- Tooth brushing with toothpaste to mechanically remove bacterial colonization 3
- Chlorhexidine gluconate 0.12% solution application 3
- Saliva replacement gel application to maintain mucosal integrity and prevent xerostomia 3
Red Flags
- Inability to manage oral secretions indicates unsafe swallowing and potential upper airway pathology requiring immediate multidisciplinary evaluation 3
Mucolytic Therapy for COPD Patients
High-dose N-acetylcysteine (600 mg twice daily orally) reduces COPD exacerbation rates and is recommended for patients with moderate to severe COPD and history of two or more exacerbations in the previous 2 years. 4
Mechanism and Safety
- Acetylcysteine cleaves disulfide bonds in mucoproteins, reducing viscosity and making thick secretions easier to clear 4
- Generally well tolerated with rare adverse gastrointestinal effects 4
- No evidence of increased adverse events compared to placebo 4
Emergency Management
Tracheostomy emergencies include hemorrhage, tube dislodgement/loss of airway, and tube obstruction—all are managed more effectively when supplies are readily available. 2
Emergency Response Protocol
- For tube obstruction: attempt suctioning first; if unsuccessful, remove inner cannula; if still obstructed, remove entire tube and replace 2
- For accidental decannulation: attempt immediate reinsertion with same size tube; if unsuccessful, use one size smaller; if still unsuccessful, maintain airway with bag-mask ventilation and call for help 1
- For hemorrhage: assess severity, apply pressure if external bleeding, suction if airway bleeding, notify physician immediately 1
CPR Considerations
- Instruction in CPR should include bag-to-tracheostomy ventilation, as well as mouth-to-mouth with stoma occlusion in a child with patent upper airway 1
Safety Measures and Environmental Precautions
Avoid all dust, smoke, lint, pet hair, powder, sprays, small toys, and objects that could enter or obstruct the tracheostomy. 1
Activity Restrictions
- Contact sports and water sports are not permitted 1
- Bathing in 1-2 inches of water with trained caretaker in attendance is acceptable 1
- Showers may be permissible in older children with appropriate precautions 1
- Child should not be in contact with fuzzy toys, clothes, or bedding 1
Multidisciplinary Team Approach
Tracheostomy care requires coordination among critical care teams, respiratory therapists, speech-language pathologists, nursing staff, and physicians, with daily discussion at every shift change. 1, 3
Team Responsibilities
- Daily assessment of nutrition adequacy, swallowing efficiency, signs of aspiration, and oral secretion management 3
- Multidisciplinary teams have demonstrated marked decrease in major complications (from 25.4% to 4.9%) and reduction in wait time for procedures 1
- Patient and family education is crucial, as 34% of patients discharged with tracheostomy are readmitted due to pneumonia/secretions, hypoxia, or other complications 1
Discharge Planning and Home Care
Comprehensive caregiver education must be completed before discharge to prevent readmissions. 1
Required Caregiver Competencies
- Demonstrate CPR including bag-to-tracheostomy ventilation 1
- State type and size of tracheostomy tube, name parts and purpose of each 1
- Demonstrate proper suctioning technique, cleaning inner cannula, and equipment care 1
- Perform complete tracheostomy tube change independently 1
- Implement skin care principles and safety measures 1
- Understand humidification importance and demonstrate equipment care 1
- Know emergency contact information and ensure local emergency services are notified 1