Tracheostomy Care

Tracheostomy Car866.320.4573800.223.2273RE Q UE S T AN
AP P O I NTME NT CO NT ACT US

A tracheostomy is an opening (made by an incision) through the neck into the trachea
(windpipe). A tracheostomy opens the airway and aids breathing.

A tracheostomy may be done in an emergency, at the patient’s bedside or in an

operating room. Anesthesia (pain relief medication) may be used before the procedure.
Depending on the person’s condition, the tracheostomy may be temporary or
permanent.

When is a tracheostomy considered?

A tracheostomy may be performed for the following conditions:

 Obstruction of the mouth or throat

 Breathing difficulty caused by edema (swelling), injury or pulmonary (lung)
conditions
 Airway reconstruction following tracheal or laryngeal surgery
 Airway protection from secretions or food because of swallowing problems
 Airway protection after head and neck surgery
 Long-term need for ventilator (breathing machine) support

What is a tracheostomy tube?

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A tracheostomy (trach) tube is a small tube inserted into the tracheostomy to keep the
stoma (opening) clear.

Tracheostomy tubes are available in several sizes and materials including semi-flexible
plastic, rigid plastic or metal. The tubes are disposable or reusable. They may have an
inner cannula that is either disposable or reusable. The tracheostomy tube may or may
not have a cuff. Cuffed trach tubes are generally used for patients who have swallowing

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difficulties or who are receiving mechanical ventilation. Non-cuffed trach tubes are used
to maintain the patient’s airway when a ventilator is not needed. The choice of tube is
based on your condition, neck shape and size and purpose of the tracheostomy.

All trach tubes have an outer cannula (main shaft) and a neck-plate (flange). The flange
rests on your neck over the stoma (opening). Holes on each side of the neck-plate allow
you to insert trach tube ties to secure the trach tube in place.

What do I need to know after going home with a tracheostomy?

 Immediately after the tracheostomy, you will communicate with others by writing
until your healthcare provider gives you instruction for communication
techniques.
 Do not remove the outer cannula unless your healthcare provider has instructed
you to do so.
 Use tracheostomy covers to protect your airway from outside elements (such as
dust, cold air, etc.) Ask your healthcare provider for more information about
tracheostomy covers and where to purchase them.

When should I call my healthcare provider?

Contact your healthcare provider or physician immediately:

 If you have an irregular heart rate.

 If you feel increased pain or discomfort. Note: It is normal to feel some pain and
discomfort for about a week after the tracheostomy procedure.
 If you have difficulty breathing and it is not relieved by your usual method of
clearing secretions.
 When secretions become thick, if crusting occurs or mucus plugs are present.
Your physician may recommend increasing your fluids or using cool mist
humidification.
 If you have any other problems or concerns.

How do I take care of my tracheostomy tube?

Your nurse will teach you the proper way to care for your tracheostomy tube before you
go home. Routine tracheostomy care should be done at least once a day after you are
discharged from the hospital.

1. Gather the following supplies:

o Two non-sterile gloves
o A clean basin (or sink)
o Hydrogen peroxide
o Clean 4 x 4 fine mesh gauze pads
o Normal saline or tap water (Use distilled water if you have a septic tank or well
water)

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o Clean cotton-tipped swabs
o Clean pipe cleaners or small brush
o Clean washcloth
o Clean towel
o Trach tube ties
o Clean scissors
2. Wash your hands thoroughly with soap and water.
3. Stand or sit in a comfortable position in front of a mirror (in the bathroom over the
sink is a good place to care for your trach tube).
4. Put on the gloves.
5. Suction the trach tube. (Your healthcare provider will give you more information
about the suctioning procedure).
6. If your tube has an inner cannula, remove it. (If the trach tube does not have an
inner cannula, go to step 12.)
7. Hold the inner cannula over the basin and pour the hydrogen peroxide over and
into it. Use as much hydrogen peroxide as you need to clean the inner cannula
thoroughly.
8. Clean the inner cannula with pipe cleaners or a small brush.
9. Thoroughly rinse the inner cannula with normal saline, tap water or distilled water
(if you have a septic tank or well water).
10. Dry the inside and outside of the inner cannula completely with a clean 4 x 4 fine
mesh gauze pad.
11. Reinsert the inner cannula and lock it in place.
12. Remove the soiled gauze dressing around your neck and throw it away.
13. Inspect the skin around the stoma for redness, hardness, tenderness, drainage
or a foul smell. If you notice any of these conditions, call your nurse or physician
after you finish routine care.
14. Soak the cotton-tipped swabs in a solution of half hydrogen peroxide and half
water. Use the swabs to clean the exposed parts of the outer cannula and the
skin around the stoma.
15. Wet the wash cloth with normal saline, tap water or distilled water. Use the wash
cloth to wipe away the hydrogen peroxide and clean the skin.
16. Dry the exposed outer cannula and the skin around the stoma with a clean towel.
17. Change the trach tube ties.
o Measure and cut a piece of tie long enough to go around your neck twice. Cut
the tie at an angle (Illustration 17c.) so it is easier to insert the tie into the neck-
plate.
o Untie one side of the old tie and remove that side from the neck-plate. Do not
completely remove the old tie until the new one is in place and is securely
fastened.
o Holding the trach tube in place, lace the tie through one hole of the neck-plate,
around the back of your neck, through the other hole of neck-plate, and again
around the back of your neck.
o Pull the tie snugly and tie a square knot on the side of your neck. There should
be enough space for no more than two fingers between the tie and your neck.
(Illustration 17d.)

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o Cut, remove and discard the old tie. If you have a cuffed trach tube, be careful
not to cut the cuff balloon when removing the old trach tube tie.

18. Place a fine mesh gauze under the tracheostomy tie and neck-plate by folding it
or cutting a slit in it.Note: Some brands of mesh gauze are pre-cut. Important: Do
not use 4 x 4 gauze or toppers – they contain cotton fibers which could clog your
airway.
19. Remove your gloves and throw them away.
20. Wash your hands with soap and warm water.
21. Wash the basin and small brush with soap and warm water. Dry them and put
them away.
22. Put the used washcloth and towel in the laundry.
23. Wash your hands again with soap and warm water.

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A tracheostomy is an opening into the trachea through the neck just below
the larynxthrough which an indwelling tube is placed and thus an artificial
airway is created. It is used for clients needing long-term airway support.

Tracheostomy tubes have an outer cannula that is inserted into the trachea and
a flange that rests against the neck and allows the tube to be secured in place
with tape or ties. Tracheostomy tubes also have an obturator which is used to
insert the outer cannula which is then removed afterwards. The obturator is
kept at the client’s bedside in case the tube becomes dislodged and needs to be
reinserted.

Nurses provide tracheostomy care for clients with new or

recent tracheostomy to maintain patency of the tube and minimize the risk for
infection (since the inhaled air by the client is no longer filtered by the upper
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 airways). Initially a tracheostomy may need to be suctioned and cleaned as
often as every 1 to 2 hours. After the initial inflammatory response subsides,
tracheostomy care may only need to be done once or twice a day, depending on
the client.

Contents [hide]
 1 Definition of Terms
 2 Components of Tracheostomy Tube
 3 Providing Tracheostomy Care
 4 Suctioning a Tracheostomy Tube
 5 Dealing with Emergencies

Definition of Terms

 Decannulation: The process whereby a tracheostomy tube is removed

once patient no longer needs it.
 Humidification: The mechanical process of increasing the water vapour
content of an inspired gas.
 Stoma: An opening, either natural or surgically created, which connects a
portion of the body cavity to the outside environment (in this case,
between the trachea and the anterior surface of the neck).
 Tracheostomy: A surgical procedure to create an opening between 2-3
(3-4) tracheal rings into the trachea below the larynx.
 Tracheal Suctioning: A means of clearing thick mucus and secretions
from the tracheaand lower airway through the application of negative
pressure via a suction catheter.
 Tracheostomy tube: A curved hollow tube of rubber or plastic inserted
into the tracheostomy stoma (the hole made in the neck and windpipe
(Trachea) to relieve airway obstruction, facilitate mechanical ventilation or
the removal of tracheal secretions.

Components of Tracheostomy Tube

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  Outer tube
 Inner tube: Fits snugly into outer tube, can be easily removed for
cleaning.
 Flange: Flat plastic plate attached to outer tube – lies flush against the
patient’s neck.
 15mm outer diameter termination: Fits all ventilator and respiratory
equipment.

Parts of a tracheostomy
All remaining features are optional

 Cuff: Inflatable air reservoir (high volume, low pressure) – helps anchor
the tracheostomy tube in place and provides maximum airway sealing
with the least amount of local compression. To inflate, air is injected via
the…
 Air inlet valve: One way valve that prevents spontaneous escape of the
injected air.
 Air inlet line: Route for air from air inlet valve to cuff.
 Pilot cuff: Serves as an indicator of the amount of air in the cuff

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  Fenestration: Hole situated on the curve of the outer tube – used to
enhance airflow in and out of the trachea. Single or multiple fenestrations
are available.
 Speaking valve / tracheostomy button or cap: Used to occlude the
tracheostomy tube opening (a) former – during expiration to facilitate
speech and swallow, (b) latter – during both inspiration
and expiration prior to decannulation.

Providing Tracheostomy Care

Purposes

 To maintain airway patency by removing mucus and encrusted secretions.

 To maintain cleanliness and prevent infection at the tracheostomy site
 To facilitate healing and prevent skin excoriation around the tracheostomy
incision
 To promote comfort
 To prevent displacement

Assessment

 Respiratory status (ease of breathing, rate, rhythm, depth, lung sounds,

and oxygen saturation level)
 Pulse rate
 Secretions from the tracheostomy site (character and amount)
 Presence of drainage on tracheostomy dressing or ties
 Appearance of incision (redness, swelling, purulent discharge, or odor)

Planning

Tracheostomy care involves application of scientific knowledge, sterile

technique, and problem solving, and therefore needs to be performed by a
nurse or respiratory therapist.

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Equipment

 Sterile disposable tracheostomy cleaning kit or supplies (sterile

containers, sterile nylon brush or pipe cleaners, sterile applicators, gauze
squares)
 Sterile suction catheter kit (suction catheter and sterile container for
solution)
 Sterile normal saline (Check agency protocol for soaking solution)
 Sterile gloves (2 pairs)
 Clean gloves
 Towel or drape to protect bed linens
 Moisture-proof bag
 Commercially available tracheostomy dressing or sterile 4-in. x -in. gauze
dressing
 Cotton twill ties
 Clean scissors

Procedure

This well-organized, fixed, step-by-step sequence of the whole process of

tracheostomy care is taken from Kozier & Erb’s Fundamentals of Nursing.

1. Introduce self and verify the client’s identity using agency protocol. Explain to
the client everything that you need to do, why it is necessary, and how can he
cooperate. Eyeblinking, raising a finger can be a means of communication to
indicate pain or distress.

2. Observe appropriate infection control procedures such as hand hygiene.

3. Provide for client privacy.

4. Prepare the client and the equipment.

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  To promote lung expansion, assist the client to 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 including sterile applicators, suction
kit, and tracheostomy dressing.

5. Suction the tracheostomy tube, if necessary.

 Put a clean glove on your nondominant hand and a sterile glove on your
dominant hand (or put on a pair of sterile gloves).
 Suction the full length of the tracheostomy tube to remove secretions and
ensure a patent airway.
 Rinse the suction catheter and 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 it out toward you in line with its curvature. Place it in the soaking
solution. Rationale: This moistens and loosens secretions.
 Remove the soiled tracheostomy dressing. Place the soiled 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. Keep your dominant hand 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.

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  After rinsing, gently 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. Rationale: This removes excess
liquid from the cannula and prevents possible aspiration by the client,
while leaving a film of moisture on the outer surface to lubricate the
cannula for reinsertion.

7. Replace the inner cannula, securing it in place.

 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 present) into position to
secure the flange of the inner cannula to the outer cannula.

8. Clean the incision site and tube flange.

 Using sterile applicators or gauze dressings moistened with normal saline,

clean the incision site. Handle the sterile supplies with your dominant
hand. Use each applicator or gauze dressing only once and then
discard. Rationale: This avoids contaminating a clean area with a soiled
gauze dressing or applicator.
 Hydrogen peroxide may be used (usually in a half-strength solution mixed
with sterile normal saline; use a separate sterile container if this is
necessary) to remove crusty secretions. Check agency policy. Thoroughly
rinse the cleaned area using gauze squares moistened with sterile normal
saline. Rationale: Hydrogen peroxide can be irritating to the skin and
inhibit healing if not thoroughly removed.
 Clean the flange of the tube in the same manner.
 Thoroughly dry the client’s skin and tube flanges with dry gauze squares.

9. Apply a sterile dressing.

 Use a commercially prepared tracheostomy dressing of non- raveling

material or open and refold a 4-in. x 4-in. gauze dressing into a V shape.

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 Avoid using cotton-filled gauze squares or cutting the 4-in. x 4-in.
gauze. Rationale: Cotton lint or gauze fibers can be aspirated by the
client, potentially creating a tracheal abscess.
 Place the dressing under the flange of the tracheostomy tube.
 While applying the dressing, ensure that the tracheostomy tube is
securely supported. Rationale: Excessive movement of the tracheostomy
tube irritates the trachea.

10. Change the tracheostomy ties.

 Change as needed to keep the skin clean and dry.

 Twill tape and specially manufactured Velcro ties are available. Twill tape
is inexpensive and readily available; however, it is easily soiled and can
trap moisture that leads to irritation of the skin of the neck. Velcro ties are
becoming more commonly used. They are wider, more comfortable, and
cause less skin abrasion.

Two-Strip Method (Twill Tape)

 Cut two unequal strips of twill tape, one approximately 25 cm (10 in.)
long and the other about 50 cm (20 in.) long. Rationale: Cutting one
tape longer than the other allows them to be fastened at the side of the
neck for easy access and to avoid the pressure of a knot on the skin at the
back of the neck.
 Cut a l-cm (0.5-in.) lengthwise slit approximately 2.5 cm (1 in.) from one
end of each strip. To do this, fold the end of the tape back onto itself
about 2.5 cm (1 in.), then cut a slit in the middle of the tape from its
folded edge.
 Leaving the old ties in place, thread the slit end of one clean tape through
the eye of the tracheostomy flange from the bottom side; then thread the
long end of the tape through the slit, pulling it tight until it is securely
fastened to the flange. Rationale: Leaving the old ties in place while
securing the clean ties prevents inadvertent dislodging of the

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 tracheostomy tube. Securing tapes in this manner avoids the use of knots,
which can come untied or cause pressure and irritation.
 If old ties are very soiled or it is difficult to thread new ties onto the
tracheostomy flange with old ties in place, have an assistant put on a
sterile glove and hold the tracheostomy in place while you replace the
ties. This is very important be- cause movement of the tube during this
procedure may cause irritation and stimulate coughing. Coughing can
dislodge the tube if the ties are undone.
 Repeat the process for the second tie.
 Ask the client to flex the neck. Slip the longer tape under the client’s neck,
place a finger between the tape and the client’s neck and tie the tapes
together at the side of the neck. Rationale: Flexing the neck increases its
circumference the way coughing does. Placing a finger under the tie
prevents making the tie too tight, which could interfere with coughing or
place pressure on the jugular veins.
 Tie the ends of the tapes using square knots. Cut off any long ends,
leaving approximately 1 to 2 cm (0.5 in.). Rationale: Square knots
prevent slippage and loosening. Adequate ends beyond the knot prevent
the knot from inadvertently untying.
 Once the clean ties are secured, remove the soiled ties and discard.

One-Strip Method (Twill Tape)

 Cut a length of twill tape 2.5 times the length needed to go around the
client’s neck from one tube flange to the other.
 Thread one end of the tape into the slot on one side of the flange.
 Bring both ends of the tape together. Take them around the client’s neck,
keeping them flat and untwisted.
 Thread the end of the tape next to the client’s neck through the slot from
the back to the front.
 Have the client flex the neck. Tie the loose ends with a square knot at the
side of the client’s neck, allowing for slack by placing two fingers under
the ties as with the two-strip method. Cut off long ends.

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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. Rationale: This reduces skin irritation from the knot and
prevents confusing the knot with the client’s gown ties.

12. Check the tightness of the ties.

Frequently check the tightness of the tracheostomy ties and position of the
tracheostomy tube. Rationale: Swelling of the neck may cause the ties to
become too tight, interfering with coughing and circulation. Ties can loosen in
restless clients, allowing the tracheostomy tube to extrude from the stoma.

13. Document all relevant information.

Record suctioning, tracheostomy care, and the dressing change, noting your
assessments.

Sample Documentation

12/23/2012 0900 Respirations 18-20/min. Lung sounds clear. Able to

expectorate secretions requiring little suctioning. Large amount of thick
secretions cleansed from inner cannula. Inner cannuLa changed. Trach dressing
changed. Skin around trach is intact but slightly red in color 0.2 cm around
entire opening. No broken skin noted in the reddened area. — G. Wayne, RN

Variation: Using a Disposable Inner Cannula

 Check policy for frequency of changing inner cannula because standards

vary among institutions.
 Open a new cannula package.
 Using a gloved hand, unlock the current inner cannula (if present) and
remove it by gently pulling it out toward you in line with its curvature.

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  Check the cannula for amount and type of secretions and discard properly.
 Pick up the new inner cannula touching only the outer locking portion.
 Insert the new inner cannula into the tracheostomy.
 Lock the cannula in place by turning the lock (if present).

Lifespan Considerations

Infant and Child

 An assistant may be necessary during tracheostomy care to prevent active

children from dislodging or expelling their tracheostomy tubes.
 Always make a sterile, packaged tracheostomy available at bedside for
emergency purposes.
 Encourage parents to participate with the procedure in an effort to
comfort the child and promote client teaching.
 Care for the skin at the tracheostomy site is important especially for the
elders whose skin is more fragile and prone to breakdown.

Home Care Modifications

 Emphasize the importance of handwashing before performing

tracheostomy care.
 Describe the function of each part of the tracheostomy tube.
 Explain the proper way on how to remove, change, and replace the inner
cannula.
 Clean the inner cannula two or three times a day.
 Check and clean the tracheostomy stoma.
 Suction tracheal secretions if necessary.
 Assess for symptoms of infection (i.e., increased temperature, increased
amount of secretions, change in color or odor of secretions).
 Advise and encourage parents to participate with the procedure in an
effort to comfort the child and promote client teaching.
 Provide contact information for emergencies.

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Suctioning a Tracheostomy Tube

Suctioning of tracheostomy tube is only done as necessary. Sterile technique

must be observed. Nurses should be aware that there is a frequency for the
need of suctioning during immediate postoperative period.

How to suction a tracheostomy tube

Purposes

 Removes thick mucus and secretions from the trachea and lower airway to
maintain patent airway and prevent airway obstructions
 To promote respiratory function (optimal exchange of oxygen and carbon
dioxide into and out of the lungs)
 To prevent pneumonia that may result from accumulated secretions

Assessment

 Assess the client for the presence of congestion on auscultation of the

thorax.
 Note the client’s ability or inability to remove the secretions through
coughing.

Planning

Suctioning a tracheostomy or endotracheal tube is a sterile, invasive technique

requiring application of scientific knowledge and problem solving. This skill is
performed by a nurse or respiratory therapist and is not delegated to UAP.

Equipment

 Resuscitation bag (Ambu bag) connected to 100% oxygen

 Sterile towel (optional)
 Equipment for suctioning

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  Goggles and mask if necessary
 Gown (if necessary) as Sterile gloves
 Moisture-resistant bag

Preparation

Determine if the client has been suctioned previously and, if so, review the
documentation of the procedure. This information can be very helpful in
preparing the nurse for both the physiologic and psychologic impact of
suctioning on the client

Procedure

This well-organized, fixed, step-by-step sequence of the whole process of

tracheostomy suctioning is taken from Kozier & Erb’s Fundamentals of Nursing.

1. Prior to performing the procedure, introduce self and verify the client’s
identity using agency protocol. Explain to the client what you are going to do,
why it is necessary, and how he or she can cooperate. Inform the client that
suctioning usually causes some intermittent coughing and-that this assists in
removing the secretions.

2. Perform hand hygiene and observe other appropriate infection

control procedures (e.g., gloves, goggles).

3. Provide for client privacy.

4. Prepare the client.

If not contraindicated because of health, place the client in the semi-Fowler’s

position to promote deep breathing, maximum lung expansion, and productive
coughing. Rationale:
Deep breathing oxygenates the lungs, counteracts the hypoxic effects of

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suctioning, and may induce coughing. Coughing helps to loosen and move
secretions.

If necessary, provide analgesia before suctioning. Endotracheal suctioning

stimulates the cough reflex, which can cause pain for clients who have had
thoracic or abdominal surgeryor who have experienced traumatic
injury. Rationale: Premedication can increase the client’s comfort during the
suctioning procedure.

5. Prepare the equipment.

 Attach the resuscitation apparatus to the oxygen source. O

 Adjust the oxygen flow to 100%.
 Open the sterile supplies in readiness for use.
 Place the sterile towel, if used, across the client’s chest below the
tracheostomy.
 Turn on the suction, and set the pressure in accordance with agency
policy. For a wall unit, a pressure setting of about 100 to 120 mm Hg is
normally used for adults, 50 to 95 mm Hg for infants and children.
 Put on goggles, mask, and gown if necessary.
 Put on sterile gloves. Some agencies recommend putting a sterile glove on
the dominant hand and an unsterile glove on the nondominant hand to
protect the nurse.
 Holding the catheter in the dominant hand and the connector in the
nondominant hand, attach the suction catheter to the suction tubing

6. Flush and lubricate the catheter.

 Using the dominant hand, place the catheter tip in the sterile saline
solution.
 Using the thumb of the nondominant hand, occlude the thumb control and
suction a small amount of the sterile solution through the
catheter. Rationale: This determines that the suction equipment is

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 working properly and lubricates the outside and the lumen of the catheter.
Lubrication eases insertion and reduces tissue trauma during insertion.
Lubricating the lumen also helps prevent secretions from sticking to the
inside of the catheter.

7. If the client does not have copious secretions, hyperventilate the lungs with a
resuscitation bag before suctioning.

 Summon an assistant, if one is available, for this step.

 Using your nondominant hand, turn on the oxygen to 12 to 15 L/min.
 If the client is receiving oxygen, disconnect the oxygen source from the
tracheostomy tube using your nondominant hand.
 Attach the resuscitator to the tracheostomy or endotracheal tube.
 Compress the Ambu bag three to five times, as the client inhales. This is
best done by a second person who can use both hands to compress the
bag, thus, providing a greater inflation volume.
 Observe the rise and fall of the client’s chest to assess the adequacy of
each ventilation.
 Remove the resuscitation device and place it on the bed or the client’s
chest with the connector facing up.

Variation: Using a Ventilator to Provide Hyperventilation

If the client is on a ventilator, use the ventilator for hyperventilation and

hyperoxygenation. Newer models have a mode that provides 1 0 0 % oxygen
for 2 minutes and then switches back to the previous oxygen setting as well as
a manual breath or sigh button. Rationale: The use of ventilator settings
provides more consistent delivery of oxygenation and hyperinflation than a
resuscitation device.

8. If the client has copious secretions, do not hyperventilate with a

resuscitator. Instead:

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  Keep the regular oxygen delivery device on and increase the liter flow or
adjust the Fi02 to 100% for several breaths before suctioning. Rationale:
Hyperventilating a client who has copious secretions can force the
secretions deeper into the respiratory tract.

9. Quickly but gently insert the catheter without applying any suction.

 With your nondominant thumb off the suction port, quickly but gently
insert the catheter into the trachea through the tracheostomy
tube. Rationale: To prevent tissue trauma and oxygen loss, suction is not
applied during insertion of the catheter.
 Insert the catheter about 12.5 cm (5 in.) for adults, less for children, or
until the client coughs or you feel resistance. Rationale: Resistance usually
means that the catheter tip has reached the bifurcation of the trachea. To
prevent damaging the mucous membranes at the bifurcation,
withdraw the catheter about 1 to 2 cm (0.4 to 0.8 in.) before applying
suction.

10, Perform suctioning.

 Apply suction for 5 to 10 seconds by placing the nondominant thumb over

the thumb port. Rationale: Suction time is restricted to 10 seconds or
less to minimize oxygen loss.
 Rotate the catheter by rolling it between your thumb and forefinger while
slowly withdrawing it. Rationale: This prevents tissue trauma by
minimizing the suction time against any part of the trachea.
 Withdraw the catheter completely, and release the suction.
 Hyperventilate the client.
 Suction again, if needed.

11. Reassess the client’s oxygenation status and repeat suctioning.

 Observe the client’s respirations and skin color. Check the client’s pulse if
necessary, using your nondominant hand.

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  Encourage the client to breathe deeply and to cough between suctions.
 Allow 2 to 3 minutes with oxygen, as appropriate between suctions when
possible. Rationale: This provides an opportunity for reoxygenation of
the lungs.
 Flush the catheter and repeat suctioning until the air passage is clear and
the breathing is relatively effortless and quiet.
 After each suction, pick up the resuscitation bag with your nondominant
hand and ventilate the client with no more than three breaths.

12. Dispose of equipment and ensure availability for the next suction.

 Flush the catheter and suction tubing.

 Turn off the suction and disconnect the catheter from the suction tubing.
 Wrap the catheter around your sterile hand and peel the glove off so that
it turns inside out over the catheter.
 Discard the glove and the catheter in the moisture-resistant bag.
 Replenish the sterile fluid and supplies so that the suction is ready for use
again. Rationale: Clients who require suctioning often require it quickly,
so it is essential to leave the equipment at the bedside ready for use.
 Be sure that the ventilator and oxygen settings are returned to pre
suctioning settings. Rationale: On some ventilators this is automatic, but
always check. It is very dangerous for clients to be left on 100% oxygen.

13. Provide for client comfort and safety.

 Assist the client to a comfortable, safe position that aids breathing. If the
person is conscious, a semi-Fowler’s position is frequently indicated. If the
person is unconscious, Sims’ position aids in the drainage of secretions
from the mouth.

14. Document relevant data.

Record the suctioning, including the amount and description of suction returns
and any other relevant assessments.

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Sample Documentation

12/23/2012 1000 Coarse rales in RLL and LLL. Requires suctioning every 1-2
hrs. Obtain large amount of pinkish tinged white thin mucous via ETT. Breath
sounds clearer after suctioning. Pt. signals when he wants to be suctioned. — J.
Roberts, RN

Variation: Closed Airway/Tracheal Suction System (In-Line Catheter)

 If a catheter is not attached, put on clean gloves, aseptically open a new

closed catheter set, and attach the ventilator connection on the T piece to
the ventilator tubing. Attach the client connection to the endotracheal
tube or tracheostomy.
 Attach one end of the suction connecting tubing to the suction connection
port of the closed system and the other end of the connecting tubing to
the suction device.
 Turn suction on, occlude or kink tubing, and depress the suction control
valve (on the closed catheter system) to set suc- tion to the appropriate
level. Release the suction control valve.
 Use the ventilator to hyperoxygenate and hyperinflate the client’s lungs.
 Unlock the suction control mechanism if required by the manufacturer.
 Advance the suction catheter enclosed in its plastic sheath with the
dominant hand. Steady the T piece with the non- dominant hand.
 Depress the suction control valve and apply suction for no more than 10
seconds and gently withdraw the catheter.
 Repeat as needed remembering to provide hyperoxygenation and
hyperinflation as needed.
 When completed suctioning, withdraw the catheter into its sleeve and
close the access valve, if appropriate. Rationale:
 If the system does not have an access valve on the client connector, the
nurse needs to obsen/e for the potential of the catheter migrating into the
airway and partially obstructing the artificial airway.

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  Flush the catheter by instilling normal saline into the irrigation port and
applying suction. Repeat until the catheter is clear.
 Close the irrigation port and close the suction valve.

Lifespan Considerations

Infant and Child

 Restrain the child gently with the help of an assistant and maintain the
child’s head in the midline position.
 To be aware of any special problems, do a thorough lung assessment
before and after the whole procedure.

Home Care Considerations

 Encourage the client to clear airway by coughing, if possible.

 If cannot cough properly, encourage the client to suction their secretions.
 Advise the client or caregiver to use clean gloves in performing the
procedure.
 The nurse should teach the caregiver on how to determine the need for
suctioning.
 Discuss to the caregiver the correct process and rationale underlying the
practice of suctioning.
 Emphasize the importance of adequate hydration as it thins secretions,
which can aid in the removal of secretions by coughing or suctioning.

Dealing with Emergencies

If the tracheostomy tube falls out

1. DON’T PANIC!
2. Once the tracheostomy tube has been in place for about 5 days the tract
is well formed and will not suddenly close.

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 3. Reassure the patient
4. Call for medical help.
5. Ask the patient to breathe normally via their stoma while waiting for the
doctor.
6. The stay suture (if present) or tracheal dilator may be used to help keep
the stoma open if necessary.
7. Stay with patient.
8. Prepare for insertion of the new tracheostomy tube
9. Once replaced, tie the tube securely, leaving one finger-space between
ties and the patient’s neck.
10. Check tube position by (a) asking the patient to inhale deeply – they
should be able to do so easily and comfortably, and (b) hold a piece of
tissue in front of the opening – it should be “blown” during
patient’s exhalation.

Patient is having Acute Dyspnea

Acute dyspnea for patient with tracheostomy is most commonly caused by

partial or complete blockage of the tracheostomy tube retained secretions. To
unblock the tracheostomy tube:

1. ASK THE PATIENT TO COUGH: A strong cough may be all that is

needed to expectorate secretions.
2. REMOVE THE INNER CANNULA: If there are secretions stuck in the
tube, they will automatically be removed when you take out the inner
cannula. The outer tube – which does not have secretions in it – will allow
the patient to breath freely. Clean and replace the inner cannula.
3. SUCTION: If coughing or removing the inner cannula do not work, it may
be that secretions are lower down the patients airway. Use the suction
machine to remove secretions.
4. If these measures fail – commence low concentration oxygen therapy via
a tracheostomy mask, and call for medical assistance.

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It is possible that the tracheostomy may have become displaced. Stay with the
patient until assistance arrives. Prepare for change of tracheostomy tube.

Patient needing Cardiopulmonary Resuscitation

In the event of cardiopulmonary arrest, treat tracheostomy patients as other

patients:

1. Step 1: Expose the patient’s neck. Remove any clothing covering the
tracheostomy tube and the neck area. Do not remove tracheostomy.
2. Step 2: Check the patency of the inner cannula. To check inner
cannula: Wearing a non-sterile glove, remove inner cannula. If clean,
reinsert and lock into place. If soiled – replace. Continue resuscitation.
3. Step 3: Ventilate. Use the ambu-bag directly to the t-tube.
4. If unable to ventilate:

o Try to suction. To remove or clear the secretions blocking the

tube.
o If still unable to ventilate. The tube may be displaced and the doctor
may:
 Change the tube
 Intubate orally

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