TRACHEOSTOMY CARE
TRACHEOSTOMY
is an opening into the trachea through the
neck just below the larynx through which an
indwelling tube is placed and thus an
artificial airway is created.
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.
PARTS OF TRACHEOSTOMY
TUBE
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)
EQUIPMENTS
 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
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. Eye blinking, 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.
 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.
 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. 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.
Tracheal Suctioning
It is clearing thick mucus and secretions
from the trachea and lower airway through
the application of negative pressure via a
suction catheter.
Tracheostomy Tube Cuff
PURPOSE
The purpose of the inflated tracheostomy
tube cuff is to direct airflow through the
tracheostomy tube. This is typically during
mechanical ventilation when the ventilator
circuit must be closed to control and
monitor ventilation for the ventilator
patient, who frequently has a more
seriously compromised system than
patients not on a ventilator.
The inflated cuff also may be important in
cases of gross emesis or reflux when gross
aspiration is present, to limit the
penetration of aspirated material into the
lower airway.
Inflated Cuff Considerations
The inflated cuff should be avoided
whenever possible because it has the
potential to cause multiple complications,
such as:
Increased risk of tracheal injury, including
mucosal injury, stenosis, granulomas, and
more;
Diminished ability to use the upper airway,
leading to disuse atrophy over time; and
Restriction of laryngeal movement
(laryngeal tethering) which may impact
swallowing negatively.
Cuff Deflation
Deflating the tracheostomy tube cuff, when
appropriate, has been shown to have
multiple patient benefits, including:
Reducing the risk of potential tracheal
mucosal damage;
Returning the patient to a more normal
physiology, including closing the system
through the use of a bias-closed position,
no-leak Valve;
Restoring speech and improving
communication;
Allowing for the possible improvement of
the swallow;
Potentially lowering the risk of aspiration;
Allowing rehabilitation to begin as early as
possible; and
Decreasing the time to decannulation. • Restlessness
Decannulation • Decreased oxygen saturation levels
It is the process whereby a tracheostomy • Diminished air entry
tube is removed once patient no longer • Change of colour
needs it. • Tachypnoea
Humidification CAUTION
The mechanical process of increasing the • Suspected epiglottitis
water vapour content of an inspired gas. • Occluded nasal passages
• Nasal Bleeding
Stoma
• Acute head, facial, or neck
An opening, either natural or surgically
injury(nasopharyngeal suctioning
created, which connects a portion of the
not advisable with basal skull
body cavity to the outside environment (in
fractures
this case, between the trachea and the
• Coagulopathy or bleeding disorder
anterior surface of the neck).
• Laryngospasm
OROPHARYGEAL and
• Irritable airway
NASOPHARYNGEAL • Tracheal surgery
SUCTIONING • Gastric surgery with high
OROPHARYGEAL SUCTIONING anastomosis
• Extends from the lips to the COMPLICATIONS
pharynx. Suctioning is not a benign procedure and
• Requires the insertion of a suction adverse physiological effects directly
catheter through the mouth to the attributed to oral or
pharynx. nasopharyngeal suctioning are well
NASOPHARYNGEAL documented e.g.:
SUCTIONING • Hypoxia
• Atelectasis
• Extends from the tip of the nose to
• Cardiovascular changes
the pharynx.
• Intra cranial pressure alterations
• The suction catheter is inserted
• Pneumothorax
through the nostrils in to the
• Bacterial infection
pharynx.
SAFETY CONSIDERATIONS
INDICATIONS
• Hand hygiene
Suction is indicated for visible or
• Review all safety considerations for
audible airway secretions, signs of
oral suctioning.
airway obstruction or signs of
• The mouth and pharynx contain
oxygen deficit that persist in spite of
bacteria that can potentially
the patient's best cough effort.
contaminate the trachea. If
INDICATIONS
necessary, suction the mouth with a
• Patient feels/ indicates the presence
different suction catheter / yankauer
of secretions in his / her airway
prior to beginning this procedure.
• Deteriorating arterial blood gas
Perform regular good mouth care.
values
• Altered chest movements
 • Monitor the client throughout the
procedure, and stop suctioning if the
client experiences rapid changes in
status.
• Suctioning can cause increased
intracranial pressure in patients with
head injury. The nurse can reduce
this risk by hyper-oxygenating the
patient before suctioning and/or
limit the number of times a suction
catheter is inserted into the trachea.
• Use sterile technique for
oropharyngeal suctioning.
PROCEDURE
Steps and Additional Information
1. Assess the need for suctioning
including respiratory assessment,
signs of hypoxia, inability to clear
own secretions adequately,
alterations in oxygenation levels
Additional Information:
 Perform baseline respiratory
assessment including SpO2.
 Assess for additional factors that might
influence procedure, i.e., recent
surgery; head, chest, or neck tumors;
facial or nasal trauma; and
neuromuscular diseases.
 Determine if the patient is on any
medications that increase risk of
bleeding
2. Determine if the patient is on any
medications that increase risk of
bleeding
Additional Information:
 Procedure can cause patient anxiety.
This is part of the consent procedure.
Allow the patient an opportunity to ask
questions.
3. Position the patient in semi to high
Fowler’s – unless contraindicated.
Drape chest with towel or disposable
pad
Additional Information:
 Promotes lung expansion and promotes
secretion clearance.
4. Perform hand hygiene. Gather
equipment. Ensure suction set up is
working
Additional Information:
 Suction machine (portable or wall);
canister & liner; connective tubing (2),
suction catheter, lubricant, sterile saline
or water (acts as lubricant), PPE (sterile
gloves, face shield and / or gown), pulse
oximeter.
5. Administer oxygen if needed
 Hyper-oxygenating might be necessary
if the patient is hypoxic or at risk of
hypoxia during procedure
6. Estimate the appropriate suctioning
depth by measuring the catheter from
the tip of the patient’s nose to the angle
of the mandible or to the earlobe
 This is done with the suction catheter
still in the sterile package. Ensures that
the catheter remains sterile and at
minimum reaches the pharynx.
7. Turn the suction device on, and set the
vacuum regulator to the appropriate
negative pressure. Set suction levels to
medium / moderate.
Attach the suction catheter to the
tubing whilst remaining in the sterile
package.
Open the sterile water / saline.
If using lubricant, squeeze water soluble
lubricant onto sterile surface.

Additional Information:
 It is the tip of the catheter that you try
to keep sterile.
Suction setting:
Adult 80 to 100 mmHg
Children 60 to 80 mmHg
*Not to exceed 150 mmgHg (AARC
2004)
Oropharyngeal Suctioning Video
Nasotracheal Suctioning Video
OXYGEN SATURATION
measures the percentage of oxyhemoglobin
(oxygen bound hemoglobin) in the blood,
and it is represented as arterial oxygen
saturation (SaO2) and venous oxygen
saturation (SvO2).
is a vital parameter to define blood oxygen
content and oxygen delivery.
Normal arterial oxygen is approximately
75 to 100 millimeters of mercury (mm Hg).
Values under 60 mm Hg usually indicate the
need for supplemental oxygen.
Normal pulse oximeter readings usually
range from 95 to 100 percent.
Values under 90 percent are considered low
METHODS FOR MEASURING
OXYGEN SATURATION LEVEL
PULSE OXIMETER
is a small clip that is often put on a finger,
although it can also be used on the ear or
toe. It measures blood oxygen indirectly by
light absorption through a person’s pulse.
is a device intended for the non-invasive
measurement of arterial blood oxygen
saturation and pulse rate. Typically it uses
two LEDs (light-emitting diodes) generating
red and infrared lights through a
translucent part of the body. Bone, tissue,
pigmentation, and venous vessels normally
absorb a constant amount of light over
time. Oxy-hemoglobin and its deoxygenated
form have significantly different absorption
pattern. The arteriolar bed normally
pulsates and absorbs variable amounts of
light during systole and diastole, as blood
volume increases and decreases. The ratio
of light absorbed at systole and diastole is
translated into an oxygen saturation
measurement.
PULSE OXIMETER
ARTERIAL BLOOD GAS ANALYSIS (ABG)
This is a blood test using samples extracted
from an artery. The test determines the pH
of the blood, the partial pressure of carbon
dioxide and oxygen, and the bicarbonate
level. Many blood gas analyzers will also
report concentrations of lactate,
hemoglobin, several electrolytes, oxy-
hemoglobin, carboxyhemoglobin and
methemoglobin. The arterial blood gas
analysis determines gas exchange levels in
the blood related to lung function.
SYMPTOMS OF LOW BLOOD OXYGEN LEVEL
Low blood oxygen levels can result in
abnormal circulation and cause the
following symptoms:
 high blood pressure
 lack of coordination
 visual disorders
 sense of euphoria
 rapid heartbeat
 confusion
CAUSES
Hypoxemia, or oxygen levels below the
normal values, may be caused by:
not enough oxygen in the air inability of the
lungs to inhale and send oxygen to all cells
and tissues inability of the bloodstream to
circulate to the lungs, collect oxygen, and
transport it around the body
Several medical conditions and situations
can contribute to the above factors,
including:
 asthma
 heart diseases, including congenital
heart disease
 high altitude
 anemia
 chronic obstructive pulmonary
disease or COPD
 interstitial lung disease
 emphysema
 acute respiratory distress syndrome
or ARDS
 pneumonia
 obstruction of an artery in the lung,
for instance, due to a blood clot
 pulmonary fibrosis or scarring and
damage to the lungs
 presence of air or gas in the chest
that makes the lungs collapse
 excess fluid in the lungs
 sleep apnea where breathing is
interrupted during sleep
 certain medications, including some
narcotics and painkillers
NEBULIZATION THERAPY
NEBULIZATION
is the process of medication
administration via inhalation. It utilizes a
nebulizer which transports medications to
the lungs by means of mist inhalation.
INDICATION
Nebulization therapy is used to deliver
medications along the respiratory tract and
is indicated to various respiratory problems
and diseases such as:
 Bronchospasms
 Chest tightness
 Excessive and thick mucus
secretions
 Respiratory congestions
 Pneumonia
 Atelectasis
 Asthma
CONTRAINDICATION
In some cases, nebulization is restricted or
avoided due to possible untoward results or
rather decreased effectiveness such as:
 Patients with unstable and increased
blood pressure
 Individuals with cardiac irritability
(may result to dysrhythmias)
 Persons with increased pulses
  Unconscious patients (inhalation 10. Offer the nebulizer to the patient, offer
may be done via mask but the assistance until he is able to perform proper
therapeutic effect may be inhalation (if unable to hold the nebulizer
significantly low) [pediatric/geriatric/special cases], replace
EQUIPMENTS: the mouthpiece with mask
1. Nebulizer and nebulizer connecting 11. Continue until medication is consumed
tubes 12. Reassess patient status from breath
2. Compressor oxygen tank sounds, respiratory status, pulse rate and
3. Mouthpiece/mask other significant respiratory functions
4. Respiratory medication to be needed. Compare and record significant
administered changes and improvement. Refer if
5. Normal saline solution necessary
6. NEBULIZER 13.Attend to possible side effects and
7. MASK inhalation reactions
PROCEDURE NURSING RESPONSIBILITY
1. Position the patient appropriately, As nurses, it is important that we teach the
allowing optimal ventilation. patients the proper way of doing the
2. Assess and record breath sounds, therapy to facilitate effective results and
respiratory status, pulse rate and prevent complications (demonstration is
other significant respiratory very useful). Emphasize compliance to
functions. therapy and to report untoward symptoms
3. Teach patient the proper way of immediately for apposite intervention.
inhalation:
 Slow inhalation through the mouth
via the mouthpiece
 Short pause after the inspiration
 Slow and complete exhalation.
 Some resting breaths before
another deep inhalation
4. Prepare equipments at hand
5. Check doctor’s orders for the medication,
prepare thereafter
6. Place the medication in the nebulizer
while adding the amount of saline solution
ordered.
7. Attach the nebulizer to the compressed
gas source
8. Attach the connecting tubes and
mouthpiece to the nebulizer
9. Turn the machine on (notice the mist
produced by the nebulizer)