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Update On Tracheostomy Care: This Course Expires On December 21, 2015
Update On Tracheostomy Care: This Course Expires On December 21, 2015
Tracheostomy Care
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Acknowledgements
RN.com acknowledges the valuable contributions of
.Nadine Salmon, MSN, BSN, IBCLC, the Clinical Content Manager for RN.com. She is a South
African trained Registered Nurse, Midwife and International Board Certified Lactation Consultant.
Nadine obtained an MSN at Grand Canyon University, with an emphasis on Nursing Leadership. Her
clinical background is in Labor & Delivery and Postpartum nursing, and she has also worked in Medical
Surgical Nursing and Home Health. Nadine has work experience in three countries, including the
United States, the United Kingdom and South Africa. She worked for the international nurse division of
American Mobile Healthcare, prior to joining the Education Team at RN.com. Nadine is the Lead Nurse
Planner for RN.com and is responsible for all clinical aspects of course development. She updates
course content to current standards and develops new course materials for RN.com.
Susan Herzberger, RN, MSN, the original course author. Susan is a medical-surgical nurse who
has experience with burn and ED nursing before moving into nursing education.
Introduction
Providing care for a patient with a tracheostomy (trach) requires you to be familiar with natural and
artificial airway anatomy. As a caregiver, you should also recognize potential signs and symptoms of
hypoxia and have the ability to perform appropriate nursing actions if the patients trach tube
accidentally comes out. This course will focus on how to skillfully adapt your care to the patient with a
tracheostomy.
Tracheostomy Facts
Tracheotomy is the surgical procedure that creates an opening in the cervical trachea. It is rarely done
as an emergency because oral or nasal intubation or cricothyrotomy is much faster and less
complicated when managing respiratory arrest.
Tracheostomy is usually performed for the following reasons:
To bypass an obstruction
To maintain an open airway
To remove secretions more easily
To oxygenate and/or provide mechanical ventilation on a long-term basis
Tracheostomy care and tracheal suctioning are high-risk procedures, and nurses performing these
procedures must adhere to the latest evidence-based practice guidelines (Nance-Floyd, 2011). Always
check the policy and procedures for tracheostomy care in the facility and unit on which you are working.
A comatose patient
A patient with cancer of the larynx
A burn patient with inhalation damage
A COPD patient on mechanical ventilation
A pediatric patient with a congenital airway obstruction
Tracheostomy Procedures
Tracheostomy in the operating room (surgical tracheostomy) is usually performed under general
anesthesia, but can be done under regional anesthesia. The tracheostomy is usually formed between
the second and third or third and fourth tracheal cartilages (Freeman, 2011). Retention sutures are
often placed in the cartilage with the ends taped to the patients skin.
Percutaneous dilatational tracheostomy (PCT or PDT) is done at the patients bedside, usually in the
ICU. The patient is sedated with a narcotic and/or tranquilizer. Under local anesthesia, a large bore
needle is inserted into the trachea. A guide wire is placed in the opening and a series of dilators placed
over the guide wire to create a stoma into which a trach tube is inserted. This procedure takes
approximately 15 minutes. This procedure takes less time than surgery and causes less scarring
(Freeman, 2011).
Tracheostomy Procedures
A third procedural choice is surgical tracheostomy (mini-tracheostomy) done at the bedside
(Imperatore et al., 2004). This is a compromise solution that reduces the number of patients having to
go to the OR.
Percutaneous dilatational tracheostomy is contraindicated in a quarter of patients requiring
tracheostomy, mostly due to anatomical irregularities or coagulation problems.
Bedside tracheostomy can be preferable because it allows for continuity of monitoring, causes less
upheaval for the patient, and costs less than a tracheostomy in the operating room.
1: Vocal cords
2: Thyroid cartilage
3: Cricoid cartilage
4: Tracheal cartilage
5: Balloon cuff
Image provide courtesy of Wikipedia (2007.
adjusting to the trauma of surgery, the pain of a fresh incision, the presence of a foreign object in the
trachea, and the inability to communicate through speech.
Patients commonly report choking sensations (Robinson, 2000) and generally take one to three days to
adapt to breathing through a tracheostomy tube (Medline Plus, 2003).
If your patient had a PCT, it is standard procedure to check vital signs every fifteen minutes for one
hour, every half an hour for the next hour, then hourly for four hours (Caulfield & Astle, 2003).
Follow your organization's guidelines for the care of patients returning from the operating room.
Tracheostomy tubes may be made of metal, PVC material, or silicone and will differ accordingly in the
degree of flexibility they provide. They are disposable or reusable. You will encounter different kinds of
trach tubes selected for individual patient needs.
Image of tracheostomy tube showing outer cannula with inflatable cuff (top),
inner cannula (middle) and obturator (bottom).
Klaus D. Peter (2008). Image provided under the Creative Commons Attribution License. Retrieved from:
http://en.wikipedia.org/wiki/File:Tracheostomy_tube.jpg
Cuffed Tubes
Also known as the Universal / Double Lumen Tube, the cuffed tracheostomy tube is the most common
type of tracheostomy tube. It consists of three parts:
An outer cannula with an inflatable cuff and pilot tube
An inner cannula
An obturator
The outer cannula has an inflated cuff that keeps the airway open. When inflated, this tube seals the
airway and prevents the aspiration of oral or gastric secretions. The cuff directs air through but not
around the tube. It is commonly used when mechanical ventilation is required, to provide a closed
airway system.
The inner cannula of the cuffed tube has a universal adaptor for use with a ventilator and other
respiratory equipment. The inner cannulas must be removed, cleaned, and reinserted, unless it is
disposable.
The obturator has a rounded tip for smoothly inserting the outer tube and avoiding trauma to the
tracheal wall. It is important to keep the obturator near the bedside in case of an emergency.
For the acute care patient, a pilot tube allows the cuff to be inflated with air, foam, or water, providing a
closed airway for mechanical ventilation and preventing aspiration of gastric or oral secretions.
Fenestrated Tubes
These tubes have an opening on the posterior wall of the outer cannula, which allows air to flow through
the upper airway and tracheostomy opening. This air movement allows the patient to speak and
produce a more effective cough.
The fenestrated tube is often used during weaning to ensure that patients can tolerate breathing
through the natural airway before tube removal.
More info:
Some clinicians believe fenestrated tubes aid in the clearance of secretions. Others feel these
tubes promote the development of granulation tissue. There is little scientific data to support
either of the latter two opinions (American Thoracic Society, 2009).
A fenestrated inner cannula inside a cuffed outer cannula allows speech when the cuff is deflated.
Some tubes have cuffs that expand on inspiration and deflate on expiration allowing speech as you
expire. Others have cuffs that have to be manually deflated.
A tracheostomy speaking valve is a device that attaches to the trach tube. The Passy-Muir Valve
is a commonly used speaking valve that contains a diaphragm that opens on inspiration and closes
on expiration so that air is exhaled through the vocal cords and upper airwary. The cuff of the
tracheostomy tube must be completely deflated during speaking valve use to allow for exhalation
through the upper airway.
A speaking trach tube forces air or oxygen from an outside source to flow across the vocal cords,
independent of the airflow within a closed system created by a cuffed trach tube. The patient has control
over this air line with a thumb port.
Image of the Passy-Muir Speaking Valve, placed on the hub of the tracheostomy tube, it redirects air flow through
the vocal folds, mouth and nose enabling voice and improved communication.
Image courtesy of Passy-Muir, Inc., Irvine, CA.
True or False:
In addition to listening to lung sounds, you should observe your patient for signs of hypoxia.
The correct answer is: True.
(Freeman, 2011). Therefore, it is essential to provide an alternate form of humidification. There are
various humidification methods available, including:
(Freeman, 2011)
Ensure that you are familiar with the method used in your organization.
Note! Humidifiers and nebulizers may be used with, or independent of, mechanical ventilation.
A moisture conservation device, called a heat moisture exchanger, can also be attached to the
outside of a trach tube for long-term trach patients (Bissell, 2004).
Position patient in semi-Fowlers. Time the suctioning procedure to occur prior to eating.
Select the appropriate size suction catheter, based on the size on the tracheostomy tube used.
Hyperoxygenate before each pass with the catheter, although some initial suctioning should be
done if using bag ventilation, so as not to drive secretions deeper toward the lungs. (Exceptions to
hyperoxygenation are children and those with long-term tracheostomies.)
Insert the catheter to a pre-measured depth matching the length of the tube and only to a point of
resistance, if deeper suctioning is necessary.
Supply suction intermittently while rotating unless the catheter has side holes.
(Controversy exists on whether to apply suction on withdrawal only or on both insertion and
withdrawal.)
Limit suctioning to 5 seconds for pre-measured depth and 10-15 seconds for deep suctioning
(Freeman, 2011).
Use suction pressure between 80 and 120 mmHg.
Limit suctioning to 3 passes and discontinue if heart rate drops by 20, increases by 40, produces
arrhythmias, or decreases oxygen saturation to less than 90%.
Suction mouth after trach suctioning to remove secretions above a cuffed tube. Do not contaminate
the trach by going from mouth back to trach.
Reassess the patient's condition after suctioning and recommence oxygen therapy as soon as
possible, ideally within 10 seconds of completing suctioning (Freeman, 2011).
Tracheostomy Ties
To lower the risk of a new trach tube accidentally dislodging, ties are usually not changed within the first
24 hours following insertion of a new tracheostomy tube. Thereafter, ties are generally changed daily
after the first 24 hours.
To lower the risk of accidental decannulation (the trach tube coming out) the tie changes should be
performed by two people or with new ties secured before old ties are removed (McConnell, 2002;
Bissell, 2004).
Twill tapes, Velcro tapes, metal chains, and plastic IV tubing are some of the options available. You
should be able to easily slip one or two fingers between the ties and the neck for a proper fit. Do not use
Velcro if there is a possibility the patient will try to pull them apart.
The majority of trach tubes have inner cannulas that require cleaning one to three times daily unless
they are disposable.
Use sterile technique to clean the reusable cannula with half-strength hydrogen peroxide and normal
saline solution, or normal saline.
Reinsert and lock in place within a fifteen minute time frame.
Let secretions above the cuff to drain down so you can suction them.
The frequency of this procedure should be coordinated with suctioning and the routine care schedule.
There are two ways to determine the best cuff pressure:
The occlusive technique is used when the cuff has a pressure relief valve for self-adjustment.
The minimal leak technique is used to provide some pressure slack by releasing a small amount of
pressure after inflating the cuff to a point indicating a tight seal. With a stethoscope placed on the
neck, inflate the cuff until you no longer hear hissing. Deflate the cuff in tiny increments until a slight
hiss returns.
Test Yourself:
If your patient has a cuffed trach, check cuff pressure every:
A. One to two hours
B. Two to four hours
C. Four to eight hours
D. Twenty four hours
The correct answer is C: Four to eight hours.
Complications
Complications from a tracheostomy can arise in the first few days or within several weeks. Initially, the
most common complications are:
If humidity is insufficient, mucous membranes dry out and the irritation of an inserted catheter will cause
small amounts of bleeding during routine suctioning.
Long-term complications from the presence of a tracheostomy tube are due to tracheal scarring and
erosion.
Stenosis, the narrowing of the trachea from scar tissue, occurs in 5 to 15% of patients (Fenstermacher
& Hong, 2004). This development escalates with a history of endotracheal intubation and/or excessive
tracheostomy tube cuff pressure.
Scarring can occur at the stoma, the tube cuff site, or at the point where the distal end of the tube
presses on the tracheal wall. It may cover a large area extending beyond the trachea, in weblike
fashion, or appear as a localized granuloma.
True or False:
Long-term complications from the presence of a trach tube are due to coughing.
The correct answer is: False. Long-term complications from the presence of a trach tube are
due to tracheal scarring and erosion.
Complications
Common
Long-term
Tracheal irritation
Stenosis
Fistulas
Stenosis: Is a fairly common complication of tracheostomies, but are usually not significant enough for
surgical intervention unless it narrows the airway more than 50% (Fenstermacher & Hong, 2004). Thus,
a patient will usually not be scoped to assess tracheal stenosis until after the trach tube is taken out.
Ulceration and scarring: May occur with prolonged exposure to a tracheostomy tube. Treatment
options for scarring may include:
Serial dilation
Endoscopic excision
Anterior cricoid split or laryngotracheoplasty (Bissell, 2004)
Fistula Formation: Fistulas may take months to develop. The constant pressure from a poorly fitted
tracheostomy tube, excessive cuff volume, and/or a nasogastric feeding tube all contribute to tissue
necrosis. A fistula can develop between the trachea and the esophagus or can grow into the wall
containing a major artery.
Aspiration of gastric contents: Is the consequence for one path of erosion; hemorrhage results from
the other. If your patient is coughing and choking during meals, and trach cuff inflation requires
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increasing amounts of air, your patient may have a tracheal-esophageal fistula. A patient with a fistula
should be NPO and evaluated for surgery.
Decannulation
Tracheostomy tubes are discontinued surgically or through a transition process of intermittent trials.
The trach tube is capped or plugged for lengthening periods of time until the patient can tolerate it for 24
hours. During these times, the patient should be closely observed for respiratory distress (Freeman,
2011). Systematic downsizing of the tube may also be used for the weaning process.
Assess your patients risk of aspiration before removing the tube. It is advisable to keep the patient nil
by mouth for at least four hours beforehand and / or have their nasogastric tube aspirated (Feeman,
2011). Once the tube is removed, an occlusive dressing should be placed over the remaining stoma to
form a seal so that the patient can breathe normally through the nose and mouth (Woodrow, 2002 in
Freeman, 2011). Once the tube is taken out, the stoma usually gradually closes by itself. If not, minor
surgery will be required.
The patient should be instructed to apply gentle pressure over the stoma dressing when coughing or
speaking to aid the closure of the stoma (Intensive Care Society, 2008 in Freeman, 2011). Dressings
need to be kept dry and may require frequent changes.
Home Care
A patient discharged home with a tracheostomy usually requires home nursing services, however,
patient and family education should start in the hospital. Two adult caregivers should be trained so that
at least one individual is available to the patient at all times (American Thoracic Society, 2012).
Care of a tracheostomy tube at home depends on whether the tube is temporary or permanent. A
temporary tube will be removed and the area allowed to heal when the tube is no longer needed. With a
permanent tube, the tracheostomy will need to remain open.
Some tubes may have an inner cannula that will require cleaning several times a day or whenever it
becomes clogged with secretions.
Initial care of a tracheostomy at home might include:
Test Yourself:
Home care teaching for a tracheostomy patient includes instructing them that a _____
compress to the incision site to help relieve discomfort.
A. hot
B. cold
C. warm
D. roxanol
The correct answer is C: warm.
Individualize your care plan to accommodate the patient and their environment.
Instruct the tracheostomy patient to avoid:
Portable suction equipment is available for travel and should be tested before depending on it.
You may direct patients and families to go online to a nurse-created website designed for pediatric
trach patients but applicable to adults as well. This award-winning site contains both educational and
support resources (copy and paste the following link into your Internet browser):
http://www.tracheostomy.com
Conclusion
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Tracheostomy care requires specific equipment and planning to provide individualized patient care.
Early and ongoing preventive strategies for tracheostomy care will be essential to meet the needs of
your patients.
Many of the tracheostomy patients you care for will only require a tracheostomy temporarily during an
acute phase of critical care. Other patients may be trached for life. You must be prepared to care
effectively for all patients with tracheostomies.
To achieve positive outcomes in patients with tracheostomies, nurses must keep abreast of best
practices and develop and maintain skills necessary to manage tracheostomies.
References
American Thoracic Society. (2012). Care of the child with a chronic tracheostomy. Retrieved
September 10, 2004 from http://www.thoracic.org
Bissell, Cyntia. (2004). Aarons tracheostomy page. Retrieved September 11, 2004 and November
19, 2009 from http://www.tracheostomy.com
Caulfield, E. & Astle, S. (2003). Bedside tracheostomy: A step-by-step guide. RN Magazine, 66:41.
Retrieved September 11, 2004 from http://www.rnweb.com
Dixon, L. (2003). Tracheostomy: Postoperative recovery. Retrieved September 10, 2004 from
http://www.perspectivesinnursing.org .
Fenstermacher, D. & Hong, D. (2004). Mechanical ventilation: What have we learned? Critical Care
Nursing Quarterly, 27(3): 258-294.
Freeman, S. (2011). Care of adult patients with a temporary tracheostomy. Nursing Standard, 26 (2), p.
49-56.
Imperatore, F.; Diurno, F.; Passannanti, T.; Liguori, G.; dIgnazio, N.; Marsilia, P.; Munciello, F. &
Occhiochiuso, L. (2004). Early and late complications after elective bedside surgical tracheostomy: Our
experience. Medscape General Medicine, 6(2). Retrieved September 11, 2004 from
http://www.medscape.com
Lewis, S.; Heitkemper, M. & Dirksen, S. (2000). Medical-Surgical Nursing: Assessment and
management of clinical problems. Fifth edition. St. Louis, Missouri: Mosby, Inc.
McConnell, E. (2002). Providing tracheostomy care. Nursing 2002, 32(1): 17.
Medline Plus. (2003). Medical Encyclopedia: Tracheostomy. Retrieved September 10, 2004 from
http://www.nlm.nih.gov/medlineplus/ency/article/002955.htm
Nance-Floyd, B. (2011). Tracheostomy Care: An evidence-based guide to suctioning & dressing
changes. American Nurse Today, 6 (7), p. 14-16.
National Cancer Institute. (2007). NCI Visuals Online. Larynx and Nearby Structures. Image retrieved
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National Heart, Lung & Blood Institute (2012). Tracheostomy Care Image. Retrieved Nov 14, 2012
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Peter, K. (2008). Tracheostomy Tube Image. Retrieved
from:http://en.wikipedia.org/wiki/File:Tracheostomy_tube.jpg
Robinson, E. (2000). Critical pointers: Tracheostomies. Retrieved September 10, 2004 from
http://tracheostomy.com
Schreiber, D. (2001). Trach care at home: A how-to guide. RN Magazine, 7:43. Retrieved September
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Smith-Medical, INC. (2009).Tracheostomy Images. Reproduced with permission from Smiths-Medical.
At the time this course was constructed all URL's in the reference list were current and accessible. rn.com. is
committed to providing healthcare professionals with the most up to date information available.
Copyright 2004, AMN Healthcare, Inc.
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