Tracheostomy Care

Types of trachs: [cuffed, uncuffed and fenestrated]; [single-cannula & double-cannula]; and
[metal, plastic, or silicone].

Infants and small children typically have single cannula trachs.

Plastic or silicone are used more often compared to metal as they are more lightweight and cause
less secretions.

Cuffed- typically used for mechanical ventilation-dependent children.
Uncuffed- typically used for non-ventilator dependent children to allow speech and avoid
damage to the tracheal wall.
Fenestrated- typically used in older children who will have the trach for a longer period of time
or who have difficulty using a speaking valve, to allow for easier speech. Is also used to help
wean patients off of mechanical ventilation.



Figure 1: Single-cannula silicone tube

Figure 2: Double-cannula trach (plastic) with obturator

Figure 3: Double-cannula trach (metal) with obturator


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. Also, in an emergency, a solid inner cannula must be inserted in order to ventilate the
child through the trach.
Chart Summary of Indication for Use and Considerations
Tube Indication Recommendation

CuffedTube with Inner
Cannula
Used to obtain a closed circuit
for ventilation.
Cuff should be inflated when
using with ventilators.
Cuff should be inflated just
enough to allow minimal
airleak.
Cuff should be deflated if
patient uses a speaking valve.
Cuff pressure should be
checked twice a day. Desired
pressure setting will typically
be set by physician order or
documented in the chart, but is
typically below 25 cm H2O.
Inner cannula can be either
disposable or reusable. If
reusable, then needs to be
cleaned per institution/unit
policy.

Uncuffed Tube with Inner
Cannula
Used for patients with tracheal
problems.
Used for patients who are
ready for decannulation.

Save the decannulation plug if
the patient is close to getting
decannulated.
Patient may be able to eat and
may be able to speak without a
speaking valve.
Inner cannula can be either
disposable or reusable. If
reusable, then needs to be
cleaned per institution/unit
policy.


Fenestrated Cuffed
Tracheostomy Tube
Used for patients who are on
the ventilator but are not able
to tolerate a speaking valve to
speak.
There is a high risk for
granuloma formation at the
site of the fenestration.
There is a higher risk for
aspirating secretions.
It may be difficult to ventilate
the patient adequately. May
need to place solid inner
cannula for mechanical
ventilation.
Should not be used in patients
at high risk for aspiration
(secretions could leak through
the fenestration).

Fenestrated Uncuffed
Tracheostomy Tube
Used for patients who have
difficulty using a speaking
valve.
There is a high risk for
granuloma formation at the
site of the fenestration.



Metal Tracheostomy Tube
Not used as frequently
anymore. Many of the
patients who received a
tracheostomy years ago still
choose to continue using the
metal tracheostomy tubes.
Patients cannot get a MRI.
One needs to notify the
security personnel at the
airport prior to metal detection
screening.


Changing a Tracheostomy Tube
The majority of institutions have a policy that delineates how this procedure should be carried
out, by whom, and how often. Most of the policies require 2 trained personnel present to perform
a tracheostomy tube change, and the first tracheostomy tube change is typically performed by the
physician/surgeon.
Below is a video demonstration:
http://www.hopkinsmedicine.org/tracheostomy/video/changing.html

Resources used:
http://www.hopkinsmedicine.org/tracheostomy/

Tracheostomy Dressing Change/Tie Change
When to Perform:
Per policy/protocol or per patient schedule if more often
When you observe s/s of the need to perform trach care:
o Soiled or loose ties or dressing
o Non-stable tube
o Excessive secretions

Delegation
Tracheostomy care can only be delegated to AP in patients with well-established
tracheostomy tubes and if allowed by agency policy, and if the AP has be properly trained
May only be delegated if allowed per agency policy, included in the job description of the
AP, and the AP has had appropriate training and demonstrated competence in performing the
skill
RN must follow all the appropriate steps of the delegation process, including making sure it
is the right task, right circumstance, right person, right communication/direction, and right
supervision/evaluation

Required Equipment
Towel
Tracheostomy suction supplies
Sterile tracheostomy kit
o Sterile cotton tipped applicators
o Sterile tracheostomy dressing
o Sterile basin
o Tracheostomy ties
o Hydrogen peroxide
o Normal saline
o Scissors
o Sterile gloves (2)
o Face shield (eye & moth protection)

Procedure
1) Observe for signs and symptoms of need to perform tracheostomy care:
a. Soiled/loose ties or dressing.
b. Nonstable tube.
c. Excessive secretions.
(2) Suction tracheostomy. Before removing gloves, remove soiled tracheostomy dressing and
discard in glove with coiled catheter.
(3) Prepare equipment.
a. Open two packages of cotton-tipped swabs, and pour normal saline (NS) on one
package and hydrogen peroxide on the other. Do not recap hydrogen peroxide and NS.
b. Open sterile tracheostomy package.
c. Unwrap sterile basin, and pour about 2 cm (3/4 inch) of hydrogen peroxide into it.
d. Open small sterile brush package, and place aseptically into sterile basin.
e. If using large roll of twill tape, cut appropriate length of tape and lay aside in dry area.
f. Apply gloves. Keep dominant hand sterile throughout procedure.
g. Remove oxygen source. Apply oxygen source loosely over tracheostomy if client
desaturates during procedure.
h. Tracheostomy with inner cannula care:
i. While touching only the outer aspect of the tube, remove the inner cannula with
nondominant hand. Drop inner cannula into hydrogen peroxide basin.
ii. Place tracheostomy collar or T tube and ventilator oxygen source over or near
outer cannula. (NOTE: T tube and ventilator oxygen devices cannot be attached to
all outer cannulas when inner cannula is removed.)
iii. To prevent oxygen desaturation in affected clients, quickly pick up inner
cannula and use small brush to remove secretions inside and outside cannula.
iv. Hold inner cannula over basin, and rinse with NS, using nondominant hand to
pour.
v. Replace inner cannula, and secure locking mechanism. Reapply ventilator or
oxygen sources.
i. Tracheostomy with disposable inner cannula care:
i. Remove cannula from manufacturers packaging.
ii. While touching only the outer aspect of the tube, withdraw inner cannula and
replace with
new cannula. Lock into position.
iii. Dispose of contaminated cannula in appropriate receptacle, and apply oxygen
source.
(4) Using hydrogen peroxideprepared cotton-tipped swabs and 4 4 gauze, clean exposed outer
cannula surfaces and stoma under faceplate, extending 5 to 10 cm (2 to4 inches) in all directions
from stoma. Clean in circular motion from stoma site outward, using dominant hand to handle
sterile supplies.
(5) Using NS-prepared cotton-tipped swabs and 4 4 gauze, rinse hydrogen peroxide
from tracheostomy tube and skin surfaces.
(6) Using dry 4 4 gauze, pat lightly at skin and exposed outer cannula surfaces.
(7) Secure tracheostomy.
a. Tracheostomy tie method:
i. Instruct assistant, if available, to hold tracheostomy tube securely in
place while ties are cut.
ii. Cut length of twill tape long enough to go around clients neck two times,
about 60 to 75 cm (24 to 30 inches) for an adult.
iii. Cut ends on a diagonal.
iv. Take prepared tie, and insert one end of tie through faceplate eyelet
and pull ends even.
v. Slide both ends of tie behind head and around neck to other eyelet, and insert
one tie through second eyelet.
vi. Pull snugly.
vii. Tie ends securely in double square knot, allowing space for only one finger in
tie.
b. Tracheostomy tube holder method:
i. While wearing gloves, maintain a secure hold on the tracheostomy tube.
You can do this with an assistant or, when an assistant is not available, by
leaving the old trach tube holder in place until the new device is secure.
ii. Align strap under clients neck. Be sure that the Velcro attachments are
positioned on either side of the tracheostomy tube.
iii. Place narrow end of the ties under and through the faceplate eyelets.
Pull ends even, and secure with the Velcro closures.
iv. Verify that there is space for only one loose or two snug finger width(s)
under neck strap.
(8) Insert fresh tracheostomy dressing under clean ties and faceplate.
(9) Position client comfortably, and assess respiratory status.
7. Replace any oxygen delivery devices
8. Remove and discard gloves. Perform hand hygiene.
9. Compare respiratory assessments before and after procedure.
10. Observe depth and position of tubes.
11. Assess security of tape or commercial ET or tracheostomy tube holder by tugging at tube.
12. Assess tracheostomy stoma for drainage, pressure, and signs of irritation.
13. Record respiratory assessments before and after care.
A. Record tracheostomy care: type and size of tracheostomy tube, frequency and extent
of care, client tolerance, and any complications related to presence of the tube.

Unexpected Outcomes and Related Interventions

Accidental Extubation
Call for assistance
Maintain patent airway; replace old tracheostomy tube with new one
Observe VS and signs of respiratory distress

Hard, reddened areas with or without excessive foul-smelling secretion observed
Indicates infection: notify MD
Increase frequency of tracheostomy care
Clean inner cannula if applicable

Tube not secure
Assess respiratory status; check for mucus plugs
Adjust or apply new ties

Breakdown, Pressure Areas or Stomatitis
Increase frequency of tracheostomy care
Keep skin areas clean and dry

Documentation
Respiratory assessment before and after
Record tracheostomy care; type & size of tube, frequency & extent of care, client tolerance,
and any complications r/t tube.