What are the best practices for caring for an adult patient with a tracheostomy in the ICU or long‑term care setting?

Tracheostomy Care in Adult ICU and Long-Term Care Settings

All ICU staff caring for tracheostomy patients must receive comprehensive training in prevention, detection, and management of tracheostomy emergencies, with continuous waveform capnography as the single most critical monitoring tool to prevent mortality from tube displacement or blockage. 1

Essential Monitoring and Equipment

Mandatory Bedside Equipment

• Functional suction system with oxygen source must be present at every bedside and accompany the patient throughout the hospital. 2
• Complete tracheostomy kit including a tube one size smaller than current tube 2
• Manual resuscitation bag 2
• Waveform capnography is mandatory for all tracheostomy patients, as it detects 95% of critical incidents and is the single most important intervention to prevent airway-related deaths. 3

Critical Airway Red Flags Requiring Immediate Action

Monitor continuously for these warning signs 1, 3:

• Absence or change of capnograph waveform with ventilation
• Absence or change of chest wall movement with ventilation
• Increasing airway pressure
• Reducing tidal volume
• Inability to pass a suction catheter
• Obvious air leak
• Vocalization with a cuffed tube in place and inflated
• Apparent deflation or need for regular re-inflation of the pilot balloon
• Discrepancy between actual and recorded tube insertion depth
• Surgical emphysema

Daily Care Protocol

Suctioning Management

• Assess need for suctioning based on clinical indicators rather than routine timing: monitor capnograph waveform changes, reduced chest movement, increasing airway pressures, or inability to pass catheter. 3
• Use premarked catheters and twirl catheter between fingertips during suctioning 1
• Provide hyperoxygenation with 100% FiO₂ for 30-60 seconds before and after each suction pass to prevent desaturation. 3
• Do not routinely instill normal saline before suctioning, as this causes adverse effects on oxygen saturation and cardiovascular stability without consistent benefit for secretion removal. 3
• Either open or closed suction systems are acceptable, though closed systems may be preferred in high-risk situations 3

Cuff Management

• Maintain cuff pressure at 20-30 cm H₂O and verify each shift to prevent both microaspiration and tracheal mucosal injury. 3
• Check cuff integrity regularly 1
• Avoid aggressive over-inflation, which significantly increases mucosal injury risk 4

Skin and Stoma Care

• Keep peristomal skin clean and dry to prevent infection and pressure necrosis. 1
• Perform daily cleansing with soap and water 1
• Use 1.5% hydrogen peroxide to remove encrusted secretions, followed by water cleansing and thorough drying 1
• Inspect peristomal area and neck skin carefully daily 1
• Products like Duoderm can cushion skin beneath tracheostomy ties 1
• Soft tracheostomy ties may be less irritating than strings 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 skin and be loose and nonocclusive 1

Tube Position and Documentation

• Document tracheal tube insertion depth on bedside chart and verify each shift or with any respiratory deterioration. 3
• Display relevant information on bedhead signs identifying tube type, size, and emergency management plan 1

Tube Exchange Considerations

Critical Timing for Stoma Maturation

• Percutaneous tracheostomy stomas are not mature enough for safe tube exchange until 7-10 days post-insertion. 1, 4
• During the first 7-10 days, management of tube blockage or displacement must focus on securing the native upper airway rather than attempting tube replacement. 1, 4

Tube Change Procedure (After Stoma Maturation)

When performing elective tube changes 1:

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

Two trained adults should ideally be present for tube changes. 1

Emergency Management

Displacement or Blockage Protocol

• In tracheostomy-dependent patients, displacement or blockage may be rapidly fatal; waveform capnography is critical for recognition and management. 1
• Follow UK National Tracheostomy Safety Project algorithms for emergency management 1
• In the first 7-10 days post-insertion, secure the native upper airway rather than attempting tube replacement. 1
• Approximately 26-30% of ICU tracheostomy patients have difficult native airway management, often compounded by obesity 1

Common Pitfalls

• 50% of ICU tracheostomy incidents in NAP4 were complications occurring after insertion, primarily due to displacement, with fewer episodes of blockage or hemorrhage. 1
• Common themes in adverse incidents include lack of staff training, lack of capnography and basic bedside equipment, inadequate environments and support mechanisms, and poorly considered care pathways 1

Multidisciplinary Team Approach

Organizational Structure

• Improvements in quality and safety are demonstrated through comprehensive staff education, multidisciplinary oversight, multidisciplinary ward rounds, bedhead signs, and ensuring equipment and infrastructure availability. 1
• Evidence supports addition of a multidisciplinary tracheostomy team to improve time to decannulation, length of stay, tracheostomy-related adverse events, and increased speaking valve use. 5
• Evidence supports use of tracheostomy bundles evaluated by experienced teams to decrease time to decannulation and tracheostomy-related adverse events. 5
• Evidence supports use of weaning/decannulation protocols to guide removal and improve time to decannulation. 5

Long-Term Monitoring

Complications Surveillance

• Monitor for subglottic or tracheal stenosis at ICU follow-up, as prolonged intubation or tracheostomy may cause stenosis requiring surgical intervention. 1, 4
• 94% of patients intubated for more than 4 days develop laryngeal injury including edema and ulceration of vocal folds. 4
• Patients with diabetes and ischemic disease have increased risk of laryngeal injury 4
• Watch for infection, tracheomalacia, skin breakdown, and tracheoesophageal fistula 2

Communication and Documentation

• When future airway management is anticipated to be difficult, complete an airway alert and communicate information to patient, family, and physician with proper coding (e.g., SNOMED CT 718447001) to ensure information remains in electronic patient record. 1