Tracheostomy Care

What is a Tracheostomy?

A tracheostomy, commonly called a trach, refers to a surgically created hole that

extends from the neck skin into the windpipe or trachea. This operation is performed for
a number of reasons. Some persons have tracheostomy to bypass obstructions in their
airway from injuries, scarring, or tumors. Some patients have a tracheostomy for the
treatment of sleep disorders, such as obstructive sleep apnea. Many patients have a
tracheostomy for improvement of breathing and for suctioning secretions from the lungs
that are unable to clear with coughing. In most patients the tracheostomy enables a
person to function more normally and continue to breathe, despite significant medical
problems. For this reason this artificial airway needs to be maintained in order to
prevent serious or life-threatening problems. These problems are frequently related to
blockage of the tracheostomy tube.

Procedure:

1. Explain procedure to client.

Rationale: Explanation facilitates cooperation and provides reassurance for
patient.
2. If tracheostomy tube has just been suctioned, remove soiled dressing from
around tube and discard with gloves when they are removed.
Rationale: Suctioning prevents secretions from accumulating in inner cannula
and occluding airway.
3. Perform hand hygiene and open necessary supplies.
Rationale: Hand hygiene deters the spread of microorganisms.
Cleaning a Nondisposable Inner cannula
4. Prepare supplies before cleaning inner cannula.
a. Open tracheostomy care kit and separate basins, touching only the edges.
If kit is not available, open two saline basins.
Rationale: Basins are sterile receptacles for cleaning solutions.
b. Fill one basin 0.5” (1.25 cm) deep with hydrogen peroxide).
Rationale: Hydrogen peroxide helps remove dry, encrusted secretions.
c. Fill other basin 0.5” (1.25 cm) deep with saline.
Rationale: Saline rinses and removes hydrogen peroxide and lubricates the
outer surface of the inner cannula for easier reinsertion.
 d. Open sterile brush or pipe cleaners if they are not already available in
cleaning kit. Open additional sterile gauze pad.
Rationale: Sterile brush or pipe cleaner provides friction to clean inner surface
of cannula.
5. Don disposable gloves.
Rationale: Gloves protect against exposure to blood and body substances.
6. Remove the oxygen source if one is present. Rotate the lock on the inner
cannula in a counterclockwise motion to release it.
Rationale: Releasing the lock permits removal of the inner cannula.
7. Gently remove the inner cannula and carefully drop it in the basin with hydrogen
peroxide. Remove gloves and discard.
Rationale: Soaking in hydrogen peroxide loosens dry, hardened secretions.
8. Clean the inner cannula.
a. Donsterile gloves.
Rationale: Sterile gloves maintain surgical asepsis.
b. Remove inner cannula from soaking solution. Moisten brush or pipe
cleaners in saline and insert into tube, using back – and – forth motion.
Rationale: Movement of brush creates friction and helps remove accumulated
secretions.
c. Agitate cannula in saline solution. Remove and tap against inner surface
of basin.
Rationale: Saline rinses inner cannula. Tapping tube against basin removes
excess saline in inner tube.
d. Place on sterile gauze pad.
Rationale: Placing on sterile gauze maintains sterility and frees both hands for
suctioning.
9. Suction outer cannula using sterile technique if necessary.
Rationale: Suctioning removes any remaining secretions.
10. Replace inner cannula into outer cannula. Turn lock clockwise and check that
inner cannula is secure. Reapply oxygen source if needed.
Rationale: Clockwise motion secures inner cannula in place.
Replacing a Disposable Inner Cannula
11. Release lock. Gently remove inner cannula and place in disposal bag. Discard
gloves and don sterile ones to insert new cannula. Replace with appropriately
sized new cannula. Engage lock on inner cannula.
Rationale: Disposable cannulas, although more costly, ensure that airways is clean
and patent.
Applying Clean Dressing and Tape
12. Dip cotton-tipped applicator in sterile saline and clean stoma under faceplate.
Use each applicator only once, moving from stoma site outward.
Rationale: Saline is nonirritating to tissue. Cleansing from the stoma outward and
using each applicator only once promotes aseptic technique.
13. If secretions prove difficult to remove, apply diluted ½ strength hydrogen
peroxide to area around stoma, faceplate, and outer cannula. Rinse area with
saline.
Rationale: Hydrogen peroxide may cause tissue damage and needs to be removed
from skin and surrounding area.
14. Pat skin gently with dry 4”x4” gauze.
Rationale: Gauze removes excess moisture.
15. Slide commercially prepared tracheostomy dressing or prefolded non-cotton filled
4”x4” dressing under faceplate.
Rationale: Lint or fiber from cotton-filled gauze pad can be aspirated into the trachea
and cause irritation.
16. Change the tracheostomy tape:
a. Leave soiled tape in place until new one is applied
Rationale: Leaving tape in place ensures that tracheostomy will not be
expelled if patient coughs or moves.
b. Cut piece of tape that is twice the neck circumference plus 4” (10cm). Trim
ends of tape on the diagonal.
Rationale: This action provides for secure attachments with knot in front at
neckplate. Diagonal cut facilitates insertion of tape into openings on faceplate.
c. Insert one end of tape through faceplate opening alongside old tape. Pull
through until both ends are even.
Rationale: Doing so provides attachment for one side of faceplate.
d. Slide both tapes under patient’s neck and insert one end through
remaining opening on other side of faceplate. Pull snugly and tie ends in
double square knot. Check that patient can flex neck comfortably.
Rationale: A secure tape prevents accidental expulsion of the tracheostomy
tube. Allowing one finger breadth under tape permits neck flexion that is
comfortable and ensure that tape will not compromise circulation to the area.
e. Carefully remove old tape. Reapply oxygen source if necessary.
Rationale: New tape provides for secure attachment.
17. Remove gloves and discard. Perform hand hygiene. Assess patient’s
respirations. Document assessments and completion of procedure.
 Rationale: Assessment and accurate documentation provide for
comprehensive care.

Nursing Considerations:
1. Assess insertion site for any redness or purulent drainage; if present, these may
signify an infection.
2. Assess patient for pain.
3. Assess lung sounds and oxygen saturation levels.
4. If tracheostomy is fresh, pain medication may be needed before performing
tracheostomy care.
5. If mucus is plugging the tracheostomy tube, first irrigate and suction. If this is not
successful, remove the inner cannula and repeat the irrigation and suction. If
there is still obstruction, there may be mucus plugging the outer cannula and it
should be replaced.