Step-by-Step Guide to Tracheostomy Care

Learn the procedures, steps, risks, and requirements for providing tracheostomy care.

Tracheostomies are a potentially life-saving procedure that can be temporary or permanent. A tracheostomy may be performed during an emergency if a person’s airway is blocked. It may also be performed due to a disease, injury, or health condition that restricts the airway.

This article focuses on the art and science of tracheostomy care, one of the most vital tasks for nurses and other medical staff. Healthcare professionals who master this skill can help save lives and contribute to higher rates of patient satisfaction.

(Click here to see our full list of the most common nursing duties and responsibilities).

Tracheostomy care is an essential step of the overall process. Nurses provide this service to lower the risk of infection, as air inhaled by the patient is no longer filtered by their upper airways. The important skill of tracheostomy care can be exciting yet daunting among new healthcare professionals. It’s especially important for Registered Nurses (RNs) to learn the proper techniques for this procedure in a medical environment.

Tracheostomy Definition

What is a Tracheostomy?

Though there are several types of tracheostomies, they all follow the same underlying principle: An opening is created in a patient’s neck in order to place a tube into their windpipe. This tube is inserted through a cut, below the vocal cords, so that air can fill the patient’s lungs.

To give you a better idea, here are some common terms and components of trach care.

Definition of Terms

• Decannulation: The removal a tracheostomy tube once it’s no longer needed.
• Humidification: The process of increasing the water vapor content of a gas.
• Stoma: An opening that connects part of the body to the outside environment.
• Tracheostomy: Surgical procedure that creates an opening between the tracheal rings and into the trachea (below the larynx).
• Tracheal Suctioning: Clearing mucus and secretions from the trachea and lower airway via a suction catheter.
• Tracheostomy tube: Curved, hollow tube made of rubber or plastic that’s inserted into the tracheostomy stoma.

Components of Tracheostomy Tube

• Outer tube: Used in a tracheotomy.
• Inner tube: Fits into outer tube and can be removed for cleaning.
• Flange: Flat, plastic plate that’s attached to outer tube and lies against the patient’s neck.
• 15mm outer diameter termination: Fits all ventilator and respiratory equipment.

Optional Features

• Cuff: Inflatable air reservoir that helps anchor the tracheostomy tube in place and provides maximum airway seal.
• Air inlet valve: One-way valve that prevents escape of injected air.
• Air inlet line: Route for air from inlet valve to cuff.
• Pilot cuff: Indicates the amount of air in the cuff.
• Fenestration: A hole on the curve of the outer tube that enhances airflow in and out of the trachea.
• Speaking valve/tracheostomy button or cap: Used to seal the tracheostomy tube opening to facilitate speech and swallowing or prior to decannulation.

What is the Purpose of a Tracheostomy?

A tracheostomy may be performed when an airway is restricted. This can be done during an emergency when your airway is blocked, or if a disease makes normal breathing impossible.

Common reasons for a tracheostomy:

• Anaphylaxis
• Birth defects of the airway
• Burns in the airway from inhalation of corrosive material
• Cancer in the neck
• Chronic lung disease
• Coma
• Diaphragm dysfunction
• Facial burns or surgery
• Infection
• Injury to the larynx or laryngectomy
• Injury to the chest wall
• Need for prolonged respiratory or ventilator support
• Obstruction of the airway by a foreign body
• Obstructive sleep apnea
• Paralysis of the muscles used in swallowing
• Severe neck or mouth injuries
• Tumors
• Vocal cord paralysis

How Long Does it Take to Perform a Tracheostomy?

A tracheostomy normally takes about 20 to 45 minutes to perform. When it comes to tracheostomy care, again, a tracheostomy may need to be suctioned and cleaned every one to two hours. Once the initial inflammatory response has subsided, care may only be required once or twice a day.

Who Performs a Tracheostomy?

A surgeon will typically perform tracheostomies in an operating room or other medical environment. However, a doctor or emergency medical technician (EMT) can also perform a tracheostomy at a patient’s bedside, which may occur in the intensive care unit (ICU), or elsewhere in life-threatening situations.

When Do Nurses Perform Tracheostomy Care?

Nurses provide tracheostomy care for patients to maintain the integrity of the tracheostomy tube and lower the risk of infection. This is partly because air inhaled by the patient is no longer filtered by their upper airways.

Overall, tracheostomy care necessitates the application of scientific knowledge, sterile technique, and problem solving. It needs to be performed by a nurse or respiratory therapist.

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Training Requirements for Tracheostomy Care

When it comes to tracheostomy care requirements, most licensed professionals such as Registered Nurses and Licensed Vocational Nurses will typically learn how to perform this vital task through educational programs and medical training.

For example, tracheostomy training is a component of some Vocational Nursing (VN) or Practical Nursing (PN) programs. Tracheostomy suctioning and management are often considered a key skill in courses that cover nursing fundamentals. You can expect to demonstrate this skill on the NCLEX exam as well.

Tracheostomy Care Procedure

A Detailed Guide to Tracheostomy Care

By reviewing the following steps, you can begin to learn more about the process of tracheostomy care. Like any other skill, tracheostomy care requires a lot of time and practice to master. Try not to feel disheartened if you don’t get it right the first time, and don’t hesitate to ask your instructor for help.

Tracheostomy Prep

Before you do anything, assess the following for your patient:

• Respiratory status (ease of breathing, rate, rhythm, depth, lung sounds, and oxygen saturation level)
• Pulse rate
• Secretions from the tracheostomy site (i.e. character and amount)
• Presence of drainage on tracheostomy dressing or ties
• Appearance of incision (i.e. redness, swelling, weeping discharge, or odor)

Necessary Equipment for Tracheostomy Care

The suggested supplies for tracheostomy care may include the following:

• Sterile/disposable tracheostomy cleaning kit or supplies (i.e. sterile containers, sterile nylon brush or pipe cleaners, sterile applicators, gauze squares, etc.)
• Suction catheter kit
• Saline
• Medical gloves
• Towels
• Moisture-proof bag
• Tracheostomy dressing or sterile gauze dressing
• Cotton twill ties
• Sterilized scissors

Tracheostomy Steps

Here are some of the general guidelines from Kozier & Erb’s Fundamentals of Nursing that you should follow when administering trach care in a controlled setting.

1. Introduce yourself and verify the patient’s identity. Explain everything that you need to do, why it is necessary, and how they can cooperate. For instance, they could blink their eyes or raise a finger to indicate pain or distress.
2. Ensure that infection-control procedures are in place (i.e. hand hygiene).
3. Ensure the patient’s privacy.
4. Prepare the patient and your equipment.
   • Help the patient to a Semi-Fowler’s or Fowler’s position.
   • Open the tracheostomy kit or sterile basins.
   • Pour the soaking solution and sterile normal saline into separate containers.
   • Establish the sterile field.
   • Open other sterile supplies as needed, such as sterile applicators, suction kit, and tracheostomy dressing.
5. If needed, suction the tracheostomy tube.
   • Put on a pair of sterile gloves.
   • Suction the full length of the tracheostomy tube to remove secretions and reinforce the airway.
   • Rinse the suction catheter, wrap the catheter around your hand, and peel the glove off so that it turns inside out over the catheter.
   • Unlock the inner cannula with the gloved hand.
     • Remove it by gently pulling toward you in line with its curvature.
     • Place it in the soaking solution.
   • Remove the soiled tracheostomy dressing.
     • Place the dressing in your gloved hand and peel the glove off so that it turns inside out over the dressing.
     • Discard the glove and the dressing.
   • Put on sterile gloves. Make sure your dominant hand is sterile during the procedure.
6. Clean the inner cannula.
   • Remove the inner cannula from the soaking solution.
   • Clean the lumen and entire inner cannula thoroughly using the brush or pipe cleaners moistened with sterile normal saline.
     • Inspect the cannula for cleanliness by holding it at eye level and looking through it into the light.
   • Rinse the inner cannula thoroughly in the sterile normal saline.
   • Tap the cannula against the inside edge of the sterile saline container.
   • Use a pipe cleaner folded in half to dry only the inside of the cannula; do not dry the outside.
7. Replace the inner cannula and secure it.
   • Insert the inner cannula by grasping the outer flange and inserting the cannula in the direction of its curvature.
   • Lock the cannula in place by turning the lock (if applicable) into position. This will secure the flange of the inner cannula to the outer cannula.
8. Clean the incision site as well as the tube flange.
   • Clean the incision site using sterile applicators or gauze dressings that have been moistened with normal saline.
     • Remember to handle the sterile supplies with your dominant hand.
     • Use each applicator or gauze dressing only once and then discard.
   • Hydrogen peroxide can typically be used in a half-strength solution—mix it with sterile normal saline—in order to remove crusty secretions (check hospital policy).
     • Thoroughly rinse the cleaned area using gauze squares moistened with sterile normal saline.
   • Clean the flange of the tube in the same manner.
   • Thoroughly dry the patient’s skin and tube flanges with dry gauze squares.
9. Apply a sterile dressing.
   • Use a commercially prepared tracheostomy dressing of non-raveling material. Alternatively, you can open and refold a 4-in. x 4-in. gauze dressing into a V shape.
     • Tip: Avoid using cotton-filled gauze squares or cutting the 4-in. x 4-in. gauze.
   • Place the dressing under the flange of the tracheostomy tube.
   • While applying the dressing, make sure that the tracheostomy tube is firmly supported.
10. Change the tracheostomy ties.
    • Change as needed to keep the skin dry and clean.
    • Twill tape and specially manufactured Velcro ties are available.
      • Twill tape is inexpensive and available; however, it’s easily soiled and can trap moisture that often leads to skin irritation.
      • Velcro ties are wider, more comfortable, and cause fewer abrasions.
11. Tape and pad the tie knot. Place a folded 4-in. x. 4-in. gauze square under the tie knot and apply tape over the knot.
12. Check the tightness of the ties. Regularly check the tightness of the tracheostomy ties as well as the position of the tube.
13. Document relevant information. Record suctioning, tracheostomy care, and the dressing change.

Tracheostomy Recovery

It usually takes one to three days for a patient to adapt to breathing through the tracheostomy tube. It’ll also take some practice for them to talk and make sounds. Some people find it easier to talk if they cover the tube.

Alternately, certain valves that permit speech by allowing air to exit the mouth and nose may be attached to the tracheostomy tube.

If a tracheostomy is no longer needed, the site can either heal shut or be surgically closed.

Potential Risks or Complications of a Tracheostomy

There is always a small risk for infection or excessive involved with any medical procedure in which skin is broken. Although rare, some people can also have an allergic reaction to anesthesia.

Serious tracheostomy risks or complications can include the following conditions:

• Damage to the thyroid gland in the neck
• Erosion of the trachea, although this is rare
• Lung collapse
• Scar tissue in the trachea

You can avoid some of these adverse reactions by following the appropriate steps. What they say is true: practice makes perfect.

Pro Tips for Mastering the Art of Tracheostomy Care

The following are some pro tips for advanced students of tracheostomy procedures:

Safety Considerations:

• An assistant may be necessary during tracheostomy care to prevent children from dislodging or expelling their tracheostomy tubes.
• Always make sure a sterile, packaged tracheostomy kit is available at their bedside for emergency purposes.
• Encourage parents to participate with the procedure to help comfort the child and promote a teaching opportunity.
• Care for the skin at the tracheostomy site is critical, especially for the elderly, as their skin is more fragile and prone to breakdown.

Home Care Instructions & Recommendations:

• Emphasize the importance of handwashing before performing any tracheostomy care.
• Describe the function of each part of the tracheostomy tube.
• Explain how to remove, change, or replace the inner cannula.
• Clean the inner cannula two to three times per day.
• Check and clean the tracheostomy stoma.
• If necessary, suction the tracheal secretions.
• Assess for symptoms of infection, which may include a higher temperature, more secretions, and change in color or odor of secretions.
• Provide contact information for emergencies.

Why Should Nurses Learn How to Perform Tracheostomy Care?

Like other tasks they perform, proper tracheostomy care is vital for the health and safety of the patient. As a nurse, you will be responsible for maintaining airway patency, preventing infection at the tracheostomy site, facilitating the healing process, and promoting patient comfort. These crucial steps can help prevent trach risks or complications.

In the nursing field, you never know when you may encounter life-or-death situations. Reflecting on your professional goals can help determine which specialization is best for you. Ensure that you work in a facility that suits your needs.

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