FOR CLIENTS WHO NEED LONG

TERM AIRWAY SUPPORT

 ACUTE RESPIRATORY DISTRESS due to poor
ventilation

 SEVERE BURNS of head and neck

 Laryngectomy (trach-permanent)
 Types of Tracheostomy Tubes
DOUBLE LUMEN TUBE
 3 major parts:
 Outer cannula—fits into the stoma and keeps the
airway open .
 Inner cannula—fits snugly into the outer cannula;
provides universal adaptor for use with ventilator and
other respiratory equipment
 Obturator—a stylet with a smooth end used to
facilitate the direction of the tube when inserting or
changing a tracheostomy tube; removed immediately
after tube placement ; always kept with the client and
at the bedside
SINGLE-LUMEN TUBE
 (aka “Bull-neck trach”) Long tube used for client with
long or extra thick necks
 More intensive care required because there is NO
INNER CANNULA to ensure patent lumen
 Parts of a Tracheostomy Tube
Single Cannula Silicone Tube
CUFFED TUBE
 When inflated seals the airway; used for
MECHANICAL VENTILATION, preventing aspiration
 Pilot balloon attached to the outside of the tube
indicates the presence or absence of air in the cuff
CUFFLESS TUBE
 Plastic silicone-like (Silastic) or metal tube , usually
with a DOUBLE-LUMEN
 Long-term airway of those who can protect themselves
from aspiration, and who do not require mechanical
ventilation
 CAN SPEAK
 FENESTRATED TUBE
 has pre-cut opening (fenestration) in the upper
posterior wall of the outer cannula
 Used to WEAN by ensuring client can tolerate
breathing through his natural airway before the entire
tube is removed
 Allows the client to speak
 Fenestrated tubes have an opening in the
tube that permits speech through the upper
airway when the external opening is
blocked, even if the tube is too big to allow
airflow around the outer cannula.
Fenestrated tubes are not recommended for
small children, because they can obstruct
the opening with granulation tissue. The
opening of the hole must be at a correct
angle to prevent problems.
CUFFED FENESTRATED TUBE
 Facilitates mech. vent. and speech and often is used for
clients with spinal cord paralysis or neuromuscular
disease who DO NOT REQUIRE VENTILATION at
all times. When not on the ventilator , the client can
have the CUFF DEFLATED and the TUBE capped for
speech.
 Never used in weaning from a tracheostomy, because
the cuff, even fully deflated , may partially obstruct the
airway
METAL TRACHEOSTOMY TUBE
 Used for PERMAMENT tracheostomy
 CUFFLESS DOUBLE-LUMEN tube
 A special adaptor attaches a manual resuscitation bag.
 Popular types are the Jackson and Holinger tubes
TALKING TRACHEOSTOMY
 PROVIDES A MEANS OF COMMUNICATION for a
client using a ventilator for a LONG-TERM basis
 An extra AIR CHANNEL allows air to flow up through
the vocal cords so that the client CAN SPEAK with the
CUFF INFLATED.
 All tracheostomy tubes should be
fitted with a 15-mm universal
adapter to allow for bag ventilation
in an emergency. Metal tubes are
often made without this adapter.
1. Use oxygen before and after each suctioning
2. Humidify oxygen
3. STERILE technique in suctioning; CLEAN
technique at home
4. Cleanse inner cannula as needed—only leave out 5-10
minutes
5. HEMOSTAT handy if OUTER CANNULA is
expelled—have OBTURATOR taped to bed and
another TRACH SET handy
6. CUFF must be DEFLATED periodically to prevent
necrosis of mucosa, unless low pressure cuff used
7.Maintain Semi-Fowler’s to High Fowler’s
8. Monitor for bleeding, difficulty breathing, absence of
breath sounds, and crepitus , which are indications of
hemorrhage, pneumothorax, & SQ emhysema
9. If the client is allowed to eat, sit the client up for meals
and ensure that the cuff is inflated (if the tube is not
capped) for meals and for 1 hour after meals
10. Monitor cuff pressures as prescribed
11. Assess the stoma and secretions for blood or purulent
drainage
12. Follow the MD’s order and agency policy for cleaning
the tracheostomy site and inner cannula; usually, half-
strength hydrogen peroxide is used
 Surgical stoma in the trachea to
provide open airway
 Cuff should be inflated during and
after feeding, doing mouth care,
when patient is not able to handle
oral secretions and during
mechanical ventilation
 Cuff pressure should not exceed 20cm
H20
13. Obtain assistance in changing tracheostomy ties;
after placing the new ties; cut and remove the old ties
themselves holding the old tracheostomy in place
14. Never insert a decannulation plug into a
tracheostomy tube until the cuff is deflated and the
inner cannula is removed; prior insertion prevents
airflow to the client.
15. Keep a resuscitation (Ambu) bag, obturator, clamps,
and a tracheotomy set at the bedside .
 Open the suction catheter – non dominant
 Place a sterile water soluble lubricant on the sterile area-
dominant
 Place a sterile towel on the patient’s chest.- dominant
 Remove the catheter from its wrapper-dominant
 Set the suction machine to its suction pressure according to
hospital policy between 100- 150 mmHg- non dominant
 Disconnect the ventilator- non dominant
 For close tracheal suctioning : insert the suction catheter into the
artificial airway –dominant
 (rotating motion) Apply suction – non dominant, if the client
coughs pause briefly and then resume advancement. APPLY
SUCTION LESSTHEN 10 seconds and NEVER SUCTION WHEN
INSERTING, only when inserted and withdrawal.
 Withdraw the catheter – dominant
 Stabilize the ET or tracheostomy tube – non dominant
 Readjust the ventilator oxygen settings and tidal
volume as orederd. Non dominant
 Assess the need for upper airway suctioning. If
needed suction , make sure that the cuff is inflated.
 Always change the catheter and gloves every shift or as
needed.
 Discard the gloves and catheter in a waterproof
container.
 Wash hands.
 Removing the catheter from its wrapper
 Insertion, suction and withdrawal
COMPLICATIONS OF A
TRACHEOSTOMY

Tube Obstruction: The MD repositions or

replaces the tube
 During 72 hrs. following surgical placement of the
tracheostomy:

 Manually ventilates by using a manual resuscitation

(Ambu) bag while another nurse calls up the
resuscitation team for help.
 EXTEND the client’s neck and open the tissues of the stoma
to secure the airway
 GRASP the retention sutures (if they are present) to spread
openings
 USE a tracheal dilator (curved clamp) to hold the stoma
open
 PREPARE to insert tracheostomy tube; place obturator into
tracheostomy tube, replace the tube, and remove the
obturator
 MAINTAIN ventilation by resuscitation (Ambu) bag.
 ASSESS airflow and bilateral breath sounds
 If unable to secure an airway, CALL the resuscitation team
and the anesthesiologist
 Tracheomalacia: Constant pressure exerted by
the cuff causes tracheal dilation and erosion of
cartilage

 Tracheal Stenosis: narrowed tracheal lumen

is the result of scar formation from irritation of
tracheal mucosa by the cuff
 Tracheoesophageal fistula:

 Excessive cuff pressure causes erosion of the posterior

wall of the trachea. A hole is created between the
trache and the anterior esophagus. The client at
highest risk also has NGT present
Trachea-innominate artery fistula

A malpositioned tube causes its distal tip to push

against the lateral wall of the tracheostomy. Continual
pressure causes necrosis and erosion of the
innominate artery. This is a medical emergency.
 Tracheostomy tubes can be
made of metal, plastic or
silicone. Plastic and silicone
tubes are increasingly popular
because they are lightweight
and there is less crusting of
secretions.
 Initially, the tracheostomy must be suctioned and cleaned as often
as every 1 -2 hours then once or twice a day
Purposes
•To maintain patent airway
•Maintain cleanliness and prevent infection of the
tracheostomy site
•To facilitate healing and prevent skin breakdown around
the incision
•To promote comfort
Cleaning the stoma and the outer cannula
DOMINANT HAND SHOULD BE USE ALL THE TIME
Put on sterile gloves .
Saturate a sterile gauze pad or cotton tipped applicator with the half
strength hydrogen peroxide or cleaning solution. Squeeze excess
fluid to prevent aspiration. Dominant
Wipe the patients neck under the tracheostomy tube.
Saturate a second pad or applicator and wipe until the skin
surrounding the neck is cleaned.
Rinse the debris and peroxide with one or more sterile 4x 4 , and dry
the area with a sterile gauze.
Remove the discard the gloves.
Put on sterile gloves
Using your non dominant hand, remove and discard the patients dressings. With the
same hand disconnect the ventilator or humidification device and unlock the inner
cannula in the tracheostomy tube (counter clockwise).
With ungloved hand, unlock the inner cannula and place in a hydrogen peroxide
solution
Remove the soiled tracheostomy dressing and place it in gloved hand
Clean the inner cannula
Remove the inner cannula from the soaking solution
Clean the lumen and entire inner cannula thoroughly using a pipe cleaner
moistened with sterile normal saline solution
Rinse with sterile NSS and gently tap at the inside edge of sterile saline container
 Replace the inner cannula, securing it in place
 Clean the incision site and tube flange
Using sterile applicators or gauze dressings moistened with NSS, clean the incision
site
Apply sterile dressing
Use commercially prepared trach dressing or open a 4x4 gauze dressing into a V
shape
 Change the tracheostomy ties
 What is the best position when suctioning the client
with tracheostomy?
 High Fowler’s Position
 Flat in Bed
 Semi-Fowler’s Position
 Trendelenberg Position
 What is the best position when suctioning the client
with tracheostomy?
 High Fowler’s Position
 Flat in Bed
 Semi-Fowler’s Position
 Trendelenberg Position

 Rationale: C – Davis’s NCLEX RN 2007 – Success

Second Edition page 539
What is incorrect when suctioning the patient?
 Apply suction when inserting suction catheter.
 Do not apply suction when inserting suction catheter
 Use strict aseptic technique
 Use clean Gloves
What is incorrect when suctioning the patient?
 Apply suction when inserting suction catheter.
 Do not apply suction when inserting suction catheter
 Use strict aseptic technique
 Use clean Gloves

 Rationale: A – Davis’s NCLEX RN 2007 – Success

Second Edition page 539
 Apply suction intermittently for how long?
 2 – 3 minutes
 4 – 8 minutes
 5 – 10 seconds
 1 – 3 seconds
 Apply suction intermittently for how long?
 2 – 3 minutes
 4 – 8 minutes
 5 – 10 seconds
 1 – 3 seconds

 Rationale: C – Davis’s NCLEX RN – Success Second

Edition 539
 Before suctioning the client with tracheostomy
administer how many % of oxygen?
 90%
 50%
 70%
 100%
 Before suctioning the client with tracheostomy
administer how many % of oxygen?
 90%
 50%
 70%
 100%

 Rationale: D – Davis’s NCLEX RN – Success Second

Edition page 539
 What is the main goal after the patient has under gone
tracheostomy?
 Health teaching
 Maintain patent airway
 Improve nutritional status
 Alleviate apprehension
 What is the main goal after the patient has under gone
tracheostomy?
 Health teaching
 Maintain patent airway
 Improve nutritional status
 Alleviate apprehension

 Rationale: B – Davis’s NCLEX RN – Success Second

Edition page 539
 What is the recommended mm Hg of the cuff
pressure?
 18 mm Hg
 25 mm Hg
 12 mm Hg
 30 mm Hg
 What is the recommended mm Hg of the cuff
pressure?
 18 mm Hg
 25 mm Hg
 12 mm Hg
 30 mm Hg

 Rationale: A – Nurse’s Quick Check Skills 2007 page

484
 What is the incorrect use of a Cuffed Tracheostomy
Tube?
 Provide and maintains a patient airway
 Prevents aspirating food or secretions
 Removal of tracheobronchial secretions
 Don’t use positive pressure ventilation
 What is the incorrect use of a Cuffed Tracheostomy
Tube?
 Provide and maintains a patient airway
 Prevents aspirating food or secretions
 Removal of tracheobronchial secretions
 Don’t use positive pressure ventilation

 Rationale: D – Nurse’s Quick Check Skills 486

 What should you prepare in the clients bed side?
 Suction equipment and a clean obturator
 Sterile tracheostomy and sterile tracheal dilator
 Sterile hemostat
 All of the above
 What should you prepare in the clients bed side?
 Suction equipment and a clean obturator
 Sterile tracheostomy and sterile tracheal dilator
 Sterile hemostat
 All of the above

 Rationale: D. All – Nurse’s Quick Check Skills 487

 In re-inserting the tracheostomy tube what is to be
avoided?
 Tracheal trauma
 Perforation
 Asphyxiation
 all
 In re-inserting the tracheostomy tube what is to be
avoided?
 Tracheal trauma
 Perforation
 Asphyxiation
 all

 Rationale: D – Nurse’s Quick Check Skills 487

The nurse is teaching the client about the proper
tracheostomy care at home except:
 For tracheostomies older than 2 months, clean
technique can be used for tracheostomy care
 Tap water can be used for rinsing the inner cannula
 Stress the importance of good hand washing
technique
 Inform the client/relatives of the signs and symptoms
that may indicate an infection to the stoma site or
lower airway
The nurse is teaching the client about the proper
tracheostomy care at home except:
 For tracheostomies older than 2 months, clean
technique can be used for tracheostomy care
 Tap water can be used for rinsing the inner cannula
 Stress the importance of good hand washing
technique
 Inform the client/relatives of the signs and symptoms
that may indicate an infection to the stoma site or
lower airway
 Answer: A - You can use clean technique as early
as 1 month --- Fundamentals of Nursing 7th Ed.
Pg.1318
A client is allowed to eat with a tracheostomy. What
should the nurse do first?
 Place the client in fowler’s position
 Place the client in sitting position
 Ensure that the cuff is deflated, if the tube is not
capped
 Ensure that the cuff is inflated, if the tube is capped
A client is allowed to eat with a tracheostomy. What
should the nurse do first?
 Place the client in fowler’s position
 Place the client in sitting position
 Ensure that the cuff is deflated, if the tube is not
capped
 Ensure that the cuff is inflated, if the tube is capped

 Answer: B - The client is place on a sitting position

and the cuff should be INFLATED if the tube is
NOT capped --- Saunders 4th Edition pg.259
In cleaning the tracheostomy site and inner cannula this
is used:
 Normal Saline Solution
 Half-strength hydrogen peroxide
 Alcohol
 Tap Water
In cleaning the tracheostomy site and inner cannula this
is used:
 Normal Saline Solution
 Half-strength hydrogen peroxide
 Alcohol
 Tap Water

 Answer: B - Following the physician’s orders and

agency policy for cleaning the tracheostomy site
and inner cannula, half-strength hydrogen
peroxide is used --- Saunders 4th Edition pg.259
 To provide means of communication for a client with a
tracheostomy, the nurse should not:
 Use Magic Slate
 Give paper and pencil to the client
 Keep the call light within the client’s reach
 Talk loud and clear in front of the client
 To provide means of communication for a client with a
tracheostomy, the nurse should not:
 Use Magic Slate
 Give paper and pencil to the client
 Keep the call light within the client’s reach
 Talk loud and clear in front of the client

 Answer: D - Major objectives of nursing care are to

alleviate apprehension and to provide means of
COMMUNICATION --- Brunner & Suddarth’s
Medical Surgical Nursing 10th Ed. Pg.612-613
While teaching the family of the client about how to
suction his tracheostomy at home, the nurse should
not include which of the following procedure?
 Encourage the client to clear airway by coughing
 Stress importance of adequate hydration
 Instruct on how to determine the need for suctioning
 Sterile gloves are used when suctioning
While teaching the family of the client about how to
suction his tracheostomy at home, the nurse should
not include which of the following procedure?
 Encourage the client to clear airway by coughing
 Stress importance of adequate hydration
 Instruct on how to determine the need for suctioning
 Sterile gloves are used when suctioning

 Answer: D - Clean gloves should be used when

endotracheal suctioning is performed in the
home environment [ARRC, 1999] ---
Fundamentals of Nursing 7th Ed. Pg.1325
Which of the following action/s is/ are incorrect in
tracheal suctioning?
 Insert the catheter about 5 inches
 Insert the catheter about 12.5cm
 Apply intermittent suction for 5-10 seconds while
withdrawing the catheter
 Allow 5-10 minutes between suctions
Which of the following action/s is/ are incorrect in
tracheal suctioning?
 Insert the catheter about 5 inches
 Insert the catheter about 12.5cm
 Apply intermittent suction for 5-10 seconds while
withdrawing the catheter
 Allow 5-10 minutes between suctions

 Answer: D - Allow 2-3 minutes between suctions

to provide an opportunity for reoxygenation of
the lungs---Fundamentals of Nursing 7th Ed.
Pg.1324
While changing the tapes on the tracheostomy tube, the
client coughs and the tube is dislodged. The initial
nursing action is:
 Grasp the retention sutures to spread the opening
 Call the physician
 Cover the tracheostomy site
 Apply pressure on the tracheostomy site
While changing the tapes on the tracheostomy tube, the
client coughs and the tube is dislodged. The initial
nursing action is:
 Grasp the retention sutures to spread the opening
 Call the physician
 Cover the tracheostomy site
 Apply pressure on the tracheostomy site

 Answer: A - A dislodged tracheostomy tube is

difficult to reinsert, and respiratory distress may
occur --- Brunner & Suddarth’s Medical Surgical
Nursing 10th Ed. Pg.614
a) Only as necessary
b) Every 2-4 hours
c) Once a day
d) Never- do not remove the inner cannula for any
reasons
a) Only as necessary
b) Every 2-4 hours
c) Once a day
d) Never- do not remove the inner cannula for any
reasons
 Rationale
 Once a day cleansing ensures a decrease in growth of
microorganisms and prevents infection
 Saunders and Kozier
a) Administering oxygen to the patient before
beginning suctioning
b) Applying suction for 20 to 30 seconds; then suction
again if no sample is obtained
c) Advance the catheter into the trachea, touching the
larynx to stimulate cough reflex
d) Disconnecting the in-line trap from the suction
tubing after suctioning and obtaining the specimen
a) Administering oxygen to the patient before
beginning suctioning
b) Applying suction for 20 to 30 seconds; then
suction again if no sample is obtained
c) Advance the catheter into the trachea, touching the
larynx to stimulate cough reflex
d) Disconnecting the in-line trap from the suction
tubing after suctioning and obtaining the specimen
 Rationale
 Applying suction for 20 to 30 seconds is too long; then
suction again if no sample is obtained may cause vagal
stimulation that can lead to cardiac dysrythmia
a) Use of cuffed tracheostomy tube
b) Notify the physician because the child cannot be
inserted with tracheostomy tube
c) Use of uncuffed tracheostomy tube
d) Keep in mind that tracheostomy will only be use on a
shot term basis
a) Change tie tapes every 24 hours
b) Change tracheostomy tie tapes before suctioning
secretions
c) Put on face shields and clean gloves when cleaning
d) Cleaning of the fresh stoma and suctioning should
be performed every 4 hours
a) Change tie tapes every 24 hours
b) Change tracheostomy tie tapes before suctioning
secretions
c) Put on face shields and clean gloves when cleaning
d) Cleaning of the fresh stoma and suctioning should
be performed every 4 hours
 Rationale

 In performing tracheostomy care trachea and pharynx

should be suctioned first before tracheostomy care.
Sterile Gloves and cleaning of the fresh stoma should be
done every 8 hours , cleaning the inner cannula is 24
hours and suction as needed. Change ties once a day or
24 hours.Lippincott manual of nursing 7th edition page
218-220
a) Respiratory rate and breathe sounds
b) Amount of oxygen ordered to be delivered
c) How long ago client received any pain medication
d) Status of tracheostomy dressing
a) Respiratory rate and breathe sounds
b) Amount of oxygen ordered to be delivered
c) How long ago client received any pain medication
d) Status of tracheostomy dressing
 Rationale

 Assessment first the only objective data that peratins

to effectiveness of tracheostomy care the respiratory
rate and breathe sounds. Subjective measures are
unreliable eventhough the patient is stating it.
a) Call the doctor immediately
b) Suction the stoma to remove residual secretions and
prepare new tracheostomy set
c) Attempt to reinsert a new tracheostomy tube.
d) Grasp and spread the retention sutures to open the
stoma
a) Call the doctor immediately
b) Suction the stoma to remove residual secretions and
prepare new tracheostomy set
c) Attempt to reinsert a new tracheostomy tube.
d) Grasp and spread the retention sutures to open
the stoma
 Rationale

 Grasp and spread the retention sutures to open the

stoma this technique will ensure that the stoma won’t
close. Other measures stated are done by the physician.
 Saunders page 241
a) Change the tracheostomy tube
b) Suction the tracheostomy tube
c) Obtain an Arterial Blood Gas(ABG) level
d) Increase the oxygen flow rate
a) Change the tracheostomy tube
b) Suction the tracheostomy tube
c) Obtain an Arterial Blood Gas(ABG) level
d) Increase the oxygen flow rate
 Rationale

 Suction the tracheostomy tube is the best intervention

because the patient manifests poor oxygenation which
might be cause by pool of secretions. Changing the trach
set won’t relieve anything. There is already vital
information of the O2 sat and pulse. ABG and increase
of oxygenation requires physicians order.
a) Suction less than 10 seconds at a time
b) Regulate the suction machine at 300 cm suction
c) Apply suction to the catheter during insertion only
d) Pass the suction catheter into the opening of the
tracheostomy tube 2 to 3 cm
a) Suction less than 10 seconds at a time
b) Regulate the suction machine at 300 cm suction
c) Apply suction to the catheter during insertion only
d) Pass the suction catheter into the opening of the
tracheostomy tube 2 to 3 cm
• Ideal span of time for suctioning is from 10 to 15 seconds
more than this may interfere with ventilation of the client.
Other choices have no basis
a) Change the disposable inner cannula touching the
external portion only
b) Use your non-dominant hand when changing the
dressing
c) Ties should be changed every 24 hours and cleaning
the stoma should be every 8 hours
d) Tie the tapes at the sides of the neck in a square
knot, suction every shift
a) Change the disposable inner cannula touching the
external portion only
b) Use your non-dominant hand when changing the
dressing
c) Ties should be changed every 24 hours and cleaning
the stoma should be every 8 hours
d) Tie the tapes at the sides of the neck in a square
knot, suction every shift
 Rationale

 Tie the tapes at the sides of the neck in a square knot,

suction every shift. Tying the tapes into square ensures
smooth fastening and removal of the tie. Suction should
be every shift or as the condition necessitates.
Which among the following is a corrrect technique
in tracheostomy care?
a. Inserting a decannulation plug into a tracheostomy
tube until cuff is deflated and the inner cannula is
removed.
b. Tying two ends using a square knot with two fingers
inserted as the knot is tied.
c. If client is allowed to eat, ensure the cuff is deflated if
the tube is not capped.
d. . Cleanse the skin under the neck plate of tube with
cotton applicator moistened with saline water.
Which among the following is a corrrect technique
in tracheostomy care?
a. Inserting a decannulation plug into a tracheostomy
tube until cuff is inflated and the inner cannula is
removed.
b. Tying two ends using a square knot with two
fingers inserted as the knot is tied.
c. If client is allowed to eat, ensure the cuff is deflated if
the tube is not capped.
d. . Cleanse the skin under the neck plate of tube with
cotton applicator moistened with saline water.
 Rationale: B. Never insert a decannulation plug into a
tracheostomy tube until cuff is deflated and the inner
cannula is removed, and cuff should be inflated if the
tube is not capped to prevent aspiration..(Saunders,
p.221)
 Skin under the neck plate should be cleansed with
hydrogen peroxide and rinse with sterile or saline
water. (Delmar’s Fundamentals of Nursing, p. 1007)
A client with neck cancer has a permanent
tracheostomy. The nurse should primarily
emphasize to the family the following as part of
the long-term intervention
A. Supporting psychosocial issues of the patient
B. Using humidifiers to prevent thick, tenacious
secretions
C. Providing tracheostomy site care
D. Observing early signs and symptoms of skin
breakdown in the tracheostomy site
A client with neck cancer has a permanent
tracheostomy. The nurse should primarily emphasize
to the family the following as part of the long-term
intervention
A. Supporting psychosocial issues of the patient
B. Using humidifiers to prevent thick, tenacious
secretions
C. Providing tracheostomy site care
D. Observing early signs and symptoms of skin breakdown
in the tracheostomy site
Rationale: B. Providing adequate humidification to the
client with tracheostomy is essential because the client no
longer has the function of the nose for warming,
moistening, or filtering the air when breathing to the site.