CARE OF TRACHEOSTOMY TUBES

A newly placed tracheostomy tube should be allowed to heal without manipulation. While guidelines
vary, many practitioners allow 7 days for the stoma to mature before allowing a newly placed tube to
be changed. Tracheostomy tubes changed before the stoma matures are more likely to be misplaced in the
soft tissue of the neck, sometimes with disastrous results . In addition to maintaining the tube without
change, the following care should be given to all newly placed tracheostomy tubes
PRINCIPLES:
1. The surgical site should be inspected daily to be sure that it is clean and dry.
2. Dressings with a 1:1 mix of hydrogen peroxide and sterile saline may be applied as often as 4 to 6
times daily to keep the wound clean in those cases where dressings are soiled; however, the use of
hydrogen peroxide has been abandoned by some institutions in favor of the use of saline alone.
3. If the tube has an inner cannula, it should be removed and cleaned at least daily.
4. If the tube has a cuff, the cuff pressure should be monitored and maintained 20 to 25 mm Hg.
5. The air supplied through a new tracheostomy tube should be heated and humidified.
6. Suctioning should be minimized to limit trauma to the airway and manipulation of the newly placed
tube. However, early postoperative care focuses on keeping the wound clean and free of
accumulating secretions both from the soft tissue wound and from within the airway; therefore,
suctioning frequency will vary from patient-to-patient but should be done only as needed.
7. Many practitioners prefer to secure the tube with foam-padded fabric straps rather than sutures,
which may be more likely to become infected.

TRACHEOSTOMY COMPLICATIONS:
SHORT-TERM COMPLICATIONS
1.

BLEEDING
This is the most common post-tracheostomy complication. A small amount of local bleeding
may occur and can usually be controlled by local care. A large amount of bleeding may require
surgical exploration of the wound. Any bleeding that occurs after 48 hours, especially if it is the first
onset of bleeding, should be investigated immediately as a possible initial sign of a
tracheoinnominate artery fistula.

2.

WOUND INFECTIONS
The tracheostomy site is considered clean-contaminated and is rapidly colonized with
nosocomial organisms, but prophylactic antibiotics are not recommended. Minor wound infections
may occur and can be managed with local care.

3.

PNEUMOTHORAX
Pneumothorax with or without subcutaneous emphysema may occur when air dissects along
tissue planes anterior to the trachea with positive pressure ventilation or coughing. This
complication is usually self-limited; however, tension pneumothorax has been reported, especially
after rupture of the posterior wall of the trachea (more likely in PDTs rather than open surgical
tracheostomies) and may rapidly lead to death.

4.

TUBE OBSTRUCTION
Obstruction of the tracheostomy tube can occur at any time after placement, but is more
likely to occur perioperatively because trauma to the trachea may cause thick secretions and blood
clots to form. In addition, a malpositioned tube that abuts the tracheal wall may compromise the
airway lumen making cough less effective. Suctioning or removal of the inner cannula, if present, is
usually effective in clearing the obstruction. In extreme cases, the entire tube should be changed.

5.

FALSE PASSAGE
A false passage may occur when the tracheostomy tube is accidentally misplaced in the soft
tissue of the neck rather than the trachea. This may occur during a planned tube change or an
accidental decannulation. Inability to replace the tube in the trachea should prompt immediate
orotracheal intubation.

LATE COMPLICATIONS
1.

TRACHEAL STENOSIS
This complication may occur as a consequence of mucosal ischemia from excessive cuff
pressure, infection, or chronic inflammation from the tip of the tube or at the stoma site with
ulceration or granulation tissue formation and fibrosis.
Patients present with cough, difficulty clearing their secretions, and dyspnea. Although it is
more common for symptoms to develop 2 to 6 weeks after airway decannulation, they may
develop while the tracheostomy tube is still in place or have a delayed presentation as late
as 4 months after the tube is removed.
Treatment of tracheal stenosis, when indicated, may involve either laser debridement with
stent placement or surgery to resect the involved segment of the trachea.

2.

FISTULA FORMATION
TRACHEOINNOMINATE ARTERY FISTULA
This rare (< 0.7%) but deadly complication results from pressure necrosis from the
tracheostomy tube at a low-lying stoma creating a communication between the trachea and
the innominate artery.7 This complication typically occurs within 3 to 4 weeks of tube
placement and may be heralded by sentinel bleeding or a pulsating trachea.
Risk factors include low placement of the tracheostomy tube (below the fourth tracheal
ring), high-pressure cuffs, corticosteroids, malnutrition, sepsis, and excessive head
movement or drag on the tracheostomy tube. It should be suspected if a patient begins to
have bleeding 48 hours after the tube was placed or if a pulsating tube is observed.
In cases of massive hemoptysis, hyperinflation of the cuff of the tube for tamponade or
removal of the tube and insertion of a finger to try to tamponade the bleeding by applying
anterior pressure from within the trachea against the sternum has been reported to
temporize until surgical repair can be performed.
When this diagnosis is suspected, the patient should be taken to the operating room
immediately for evaluation and possible vascular repair rather than delay potentially lifesaving treatment by attempts at diagnostic testing.
TRACHEOESOPHAGEAL FISTULA
This rare complication may be seen in < 1% of patients with tracheostomy tubes and results
from erosion or perforation of the posterior (membranous) wall of the trachea from excessive
cuff pressure, direct inflammation from the tube, or a direct injury from the surgical
procedure itself.
The presence of a nasogastric tube reportedly contributes to the incidence of this
complication. Patients may present with frequent coughing, aspiration of food, dyspnea,
copious secretions, and gastric distention. It is treated by surgical repair.

3. GRANULATION TISSUE
Chronic inflammation, as may be caused by direct mechanical irritation from the
tracheostomy tube, can cause granulation tissue to form. This complication is especially
likely to occur with fenestrated tracheostomy tubes.
Granulation tissue is prone to bleed and, when it occurs at the tip of the tracheostomy tube,
threatens to compromise airway patency and may require laser debridement.
4.

TRACHEOMALACIA
Tracheomalacia is a weakness and resulting luminal narrowing of a segment of the
tracheobronchial tree that is normally supported by cartilage.
The mechanism is uncertain but may include pressure necrosis, impaired blood flow,
recurrent infections, mucosal friction, or mucosal inflammation.
Most patients are asymptomatic, but surgical intervention may be necessary when the
lumen is severely compromised.

5. PERSISTENT STOMA (TRACHEOCUTANEOUS FISTULA)

After decannulation, some patients may have a persistent stoma, especially if the
tracheostomy tube has been in place for a long period of time.
Although the actual defect may be small, it may be disturbing to the patient because it may
leak both secretions and air, especially with coughing. Some patients may be appropriate for
consideration of surgical closure.

PURPOSE:

Clears airway of secretions

Promotes tracheostomy healing
Minimizes tracheal trauma or necrosis

ASSESSMENT

Assess for excess peristomal secretions, excess intra-tracheal secretions, or soiled tracheostomy
dressing and ties.

Assess respiratory status: breath sounds, respiratory rate, skin color, labored breathing, flared nares
or sternal retractions, arterial blood gases.

Identify factors that influence tracheostomy care:

o

Inadequate nutritional status predisposes client to infection, poor healing, and weak cough
reflex.

Respiratory infection: pulmonary secretions increase in amount. Note color, amount, and
odor.

Fluid status: inadequate hydration increases tenaciousness of secretions. Client may have
difficulty coughing up thick secretions.

Humidity: tracheostomy collars deliver humidified air to prevent dry, cracked membranes
and thickened secretions.

Identify type of tracheostomy tube used and if inner cannula is present. Identify if tracheostomy
tube is cuffed and if the cuff is inflated.

Assess client's ability to understand and perform independent tracheostomy care.

EQUIPMENT:
-

Tracheostomy Care Kit:

Sterile bowls
Cotton tipped swabs
Pipe cleaners
Nonabrasive cleaning brush
Tracheostomy ties
Gauze pads
Normal Saline ( 500 ml bottle)
Hydrogen Peroxide
Suction Machine or wall suction setup
Suction catheter (size should be half of the lumen of the trachea; adult, 14 to 16 French)
Pair of nonsterile gloves
Pair of sterile gloves (often in suction catheter kit)
Towel of waterproof drape
Goggles or protective glasses
Gown or protective apron (optional)
Hemostat

PROCEDURE:
1. Verify the physician order and identify the client.
Rationale: Prevents potential errors.
2. Wash your hands and don gloves.
Rationale: Handwashing and gloves reduce transmission of microorganisms.
3. Explain procedure to client. Place the client in semi- to high Fowler's position (Fig. 1).
Rationale: Teaching decreases client anxiety and increases compliance.

Fig. 1: Greet client and explain procedure.

4. Suction tracheostomy tube. Before discarding gloves, remove soiled tracheostomy dressing
and discard with catheter inside glove. When suctioning through a tracheostomy tube, insert
catheter about 10 to 12 cm (in an adult).
Rationale: Removing secretions maintains a patent airway while doing tracheostomy cleaning.
5. Replace oxygen or humidification source and encourage client to deep-breathe as you prepare
sterile supplies. Do not snap in place.
Rationale: Maintain good oxygenation status. Promotes easy removal prior to sterile procedure.
6. Open sterile tracheostomy kit
Rationale: Preparing equipment allows for smooth, organized performance of tracheostomy care.
Fig. 2: Open sterile tracheostomy kit.

Fig. 3: Pour sterile hydrogen peroxide into basin.

Fig. 4: Don sterile gloves.

Fig. 5: Place items on sterile field.

7. Remove oxygen source (Fig. 6). The hand that touches the oxygen source is no longer sterile.
Note: For tracheostomy tube with inner cannula, complete Steps 7 to 25. For tracheostomy
tube without inner cannula or plugged with a button, complete Steps 14 to 25.
Rationale: Prevents contamination of sterile gloves.

Fig. 6: Remove oxygen source.

8. Unlock inner cannula by turning counterclockwise. Remove inner cannula (Fig. 7).

Fig. 7: Unlock inner cannula by turning counter-clockwise.

9. Place inner cannula in basin with hydrogen peroxide (Fig. 8).
Rationale: Hydrogen peroxide loosens and removes secretions from inner cannula.

Fig. 8: Place inner cannula into basin with hydrogen peroxide.

10. Replace oxygen source over or near outer cannula.
Rationale: Maintain a constant supply of oxygen to prevent respiratory or cardiac distress. Note:
Not all clients require a constant oxygen supply during tracheostomy care.
11. Clean lumen and sides of inner cannula using pipe cleaners or sterile brush (Fig. 9).
Rationale: Mechanical force and friction are needed to remove thick or dried secretions.

Fig. 9: Clean inner cannula with brush.

12. Rinse inner cannula thoroughly by agitating in normal saline for several seconds (Fig. 10).
Rationale: Rinsing and agitation remove secretions and water from cannula and provide
lubrication for easy reinsertion.

Fig. 10: Rinse inner cannula in normal saline.

13. Remove oxygen source and replace inner cannula into outer cannula. "Lock" by turning clockwise
until the two blue dots align (Fig. 11). Replace oxygen or humidity source.
Rationale: Oxygen is reestablished to a secured inner cannula.

Fig. 11: Replace inner cannula, then lock into place.

14. Remove tracheostomy dressing from under faceplate (Fig. 12).

Fig. 12: Remove soiled tracheostomy dressing.

15. Clean stoma under faceplate with circular motion using hydrogen peroxide-soaked cotton
applicators. Clean dried secretions from all exposed outer cannula surfaces (Fig. 13).
Rationale: Dried secretions are a good medium for bacterial growth.

Fig. 13: Clean secretions from tracheostomy site with cotton applicator.
16. Remove foaming secretions using normal saline-soaked, cotton-tipped applicators.
Rationale: Hydrogen peroxide can be irritating to the skin.
17. Pat moist surfaces dry with 4" 4" gauze.
Rationale: Moist surfaces support growth of microorganisms and skin excoriation.
18. Place dry, sterile, precut tracheostomy dressing around tracheostomy stoma and under
faceplate (Fig. 14). Do not use cut 4" 4" gauze.
Rationale: Frayed cotton fibers from cut gauze could be aspirated into the trachea.

Fig. 14: Replace new precut tracheostomy dressing.

19. If tracheostomy ties are to be changed, have an assistant don a sterile glove and hold the
tracheostomy tube in place.
Rationale: This action prevents accidental displacement of the tracheostomy tube if the client
moves or coughs when the ties are not secure.
For Tracheostomy Ties, Follow Steps 20-24
20. Cut a 12-inch slit approximately 1 inch from one end of both clean tracheostomy ties. This is
easily done by folding back on itself 1 inch of the tie and cutting a small slit in the middle.
21. Remove and discard soiled tracheostomy ties.
22. Thread end of tie through cut slit in tie. Pull tight.
Rationale: The tie is secured to the faceplate without using knots. Knots are difficult to undo
when ties become crusted with secretions.
23. Repeat Step 21 with the second tie.
24. Bring both ties together at one side of the client's neck. Assess that ties are only tight enough
to allow one finger between tie and neck. Use two square knots to secure the ties. Trim excess
tie length. Note: Assess tautness of tracheostomy ties frequently in clients whose neck may
swell from trauma or surgery.
Rationale: Ties must be taut enough to prevent accidental dislodging of tracheostomy tube
but loose enough not to cause choking or pressure on the jugular veins. Ties at side of neck
are more comfortable for the client.
For Tracheostomy Collar, Follow Steps 25-27.
25. While an assisting nurse holds the faceplate, gently pull the Velcro tab and remove the collar
on one side. Insert the new collar into the opening on the faceplate and secure the Velcro tab.
(Figs. 15 and 16).

Fig. 15: Insert new collar into opening on faceplate.

Fig. 16: Secure Velcro tab.

26. Hold faceplate in place as the assisting nurse repeats step on the second side (Fig. 17).
27. Remove the old collar and ensure that the new collar is securely in place (Fig. 18).

Fig. 17: Insert new collar on second side and secure Velcro tab.

Fig. 18: Discard soiled collar, ensure new collar is securely in place.
28. Remove gloves and discard disposable equipment. Label with date and time, and store
reusable supplies.
Rationale: Opened normal saline is considered sterile for 24 hours.
29. Assist client to comfortable position and offer oral hygiene.
Rationale: Promotes client comfort.
30. Wash your hands.
Rationale: Maintains infection control and communicates with other healthcare team
members.

DOCUMENTATION:
The following should be noted on the clients chart:
Breath sounds before and after suctioning
Number of times suctioned
Character of respirations
Status of tracheostomy site
Size of trach cannula
Cleaning provided and dressing change
Significant changes in vital signs
Color, amount, and consistency of secretions
Tolerance to treatment (i.e. state of incisions, drains)
Replacement of oxygen equipment after treatment
Sample Documentation
12/05/1
0900
P: Impaired airway clearance.
0
I: Trach care - large amount of thick secretions cleansed from inner
cannula, skin around trach is intact but slightly red. Client is able to
expectorate secretions when encouraged to do so. Mist collar in place to
maintain humidification.
E: Increase fluids and encourage pulmonary hygiene and mobility to
decreased pooling of secretions.
S. Roberts, RN

LIFESPAN CONSIDERATIONS
Infant and Child
Additional assistants may be necessary during tracheostomy care to prevent active children from
dislodging or expelling their tracheostomy tubes.
Encourage parents to participate with the procedure in an effort to comfort the child and promote
client teaching.
Home Care Modifications
Teach the client or caregiver the following:
o Hand washing is the most important step before touching the tracheostomy.
o The function of each part of the tracheostomy tube.
o To remove, change, and replace the inner cannula.
o To clean the inner cannula two or three times a day.
o To clean the tracheostomy stoma.
o To suction tracheal secretions.
o To assess for symptoms of infection (i.e., increased temperature, increased amount of
secretions, change in color or odor of secretions).
o To use a mirror for better visualization.
Encourage parents to participate with the procedure in an effort to comfort the child and promote
client teaching.
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