What are the best practices for tracheostomy (trach) care in a patient with a tracheostomy tube?

Tracheostomy Care: A Comprehensive Guide for Providers

Emergency Equipment and Preparedness

Every tracheostomy patient must have an emergency kit at the bedside 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 This kit must accompany the patient wherever they go in the hospital. 2

• All caregivers must be 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
• A tracheostomy tube one size smaller than usual should always be available for emergency use if the same-size tube cannot be inserted after accidental decannulation. 3

Suctioning Technique

Use the "premeasured technique" for all routine suctioning—insert the catheter to a predetermined depth with the distal side holes just exiting the tip of the tracheostomy tube. 3, 1 This prevents epithelial damage that occurs with deep suctioning, which causes denuded epithelium and inflammation. 3

Proper Suctioning Procedure:

• Use premarked catheters to ensure accurate insertion depth and avoid epithelial damage. 1
• Twirl or rotate the catheter between fingers and thumb (not stirring with the entire hand) during insertion to reduce friction and move the side holes in a helix pattern, suctioning secretions from all areas of the tube wall. 3, 1
• For mechanically-ventilated patients, use closed-circuit suctioning systems with inline suction catheters to decrease aerosolization risk. 1

Infection Control and Catheter Care:

• Clean technique is appropriate for home care—thoroughly wash hands before and after each suctioning procedure. 3, 1
• Alcohol or disinfectant foam is acceptable when soap and water are unavailable. 3
• Non-sterile disposable gloves should be worn by non-family caregivers or anyone concerned about infection. 3
• After suctioning, flush the catheter with tap water until secretions are cleared, wipe the outside with alcohol, and allow to air dry. 3, 1
• Use hydrogen peroxide flush when particularly adherent secretions are present. 3
• Individual catheters can be reused as long as they remain intact and allow inspection of removed secretions. 3

Stoma and Skin Care

Keep the peristomal skin clean and dry to prevent infection and pressure necrosis. 1

• Clean the stoma daily with soap and water. 1
• Use 1.5% hydrogen peroxide 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
• Change fixation daily or more often if there is oozing (hemorrhage or pus). 1

Tube Securement

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
• For mechanically-ventilated patients, use a tracheostomy with flexible flanges and secure ventilator tubing to the patient's clothing to minimize suprastomal collapse and accidental decannulation. 3

Tracheostomy Tube Changes

Follow a systematic approach for tube changes: check tube integrity and flexibility before insertion, suction the current tube, position the patient with neck in slight extension using a shoulder roll, remove the old tube in an upward and outward arc, insert the new tube in a downward inward arc, immediately remove the obturator after insertion, secure the ties, and check placement. 1

• Ideally, have two trained adults present for tube changes. 1
• Select a tracheostomy tube of proper diameter, length, and curvature for the individual patient to minimize complications including suprastomal collapse, distal tracheal wall granuloma, and dysphagia from esophageal compression. 3

Cuff Management and Humidification

For patients with cuffed tubes, maintain cuff pressure between 20-30 cmH₂O to prevent tracheal injury while maintaining circuit integrity. 1

• Ensure adequate humidification to prevent secretion thickening and airway dryness. 1
• Use heat moisture exchangers (HMEs) over large-volume humidifiers. 1

Patient Transport

Equip non-ventilated patients with a heat moisture exchanger with viral filter during transport. 1

• For ventilated patients, ensure the cuff is optimally inflated with a closed-circuit to decrease aerosolization. 1
• Wear surgical masks over both the patient's face and the tracheostomy tube during transport. 1

Environmental Safety and Precautions

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

Recognition of Complications

Blood in the tracheal secretions may precede a catastrophic hemorrhage and should trigger immediate evaluation. 3

Common Pitfalls:

• Granulation tissue at the internal stoma may cause few clinical signs of obstruction until the degree becomes critical with increased secretions or mucosal edema from infection. 3
• In children with standard fenestrated tracheostomy tubes, suction catheters may accidentally go through the fenestration—if this happens repeatedly, granulation tissue may develop at this site. 3
• Flexion of the neck to cover the tracheostomy with the chin for vocalization may increase suprastomal collapse—use a speaking valve instead. 3

Emergency Management

If accidental decannulation occurs in the late postoperative period, primary caregivers or emergency response personnel should attempt to replace the tracheostomy with a tube of the same size or one size smaller. 3

• If the patient is capable of being intubated and tube replacement fails, consider oral intubation. 3
• If the patient is stable and tube replacement is unsuccessful, do not attempt further intervention—transport to a tertiary care facility. 3

Multidisciplinary Care and Protocols

Evidence supports the use of tracheostomy bundles, multidisciplinary tracheostomy teams, and weaning/decannulation protocols to improve time to decannulation, decrease length of stay, reduce tracheostomy-related adverse events, and improve outcomes including speaking valve use and oral diet tolerance. 4