TRACHEOSTOMY CARE

A Nursing Lecturette Submitted to

The Faculty of the Nursing Department

Ma’am Charmaine Orocio, RN

In Partial Fulfillment of
the Requirement in NCM 218-RLE

ICU NURSING ROTATION

By:
Joshua Realista, St.N

Princess Alane Moreno, St.N

Chelsy Mina T. Solis St.N

BSN- 4H

November 18, 2020

Definition

Tracheostomy is an operative procedure that creates a surgical airway in the

cervical trachea. It is most often performed in patients who have had difficulty weaning
off a ventilator, followed by those who have suffered trauma or a catastrophic neurologic
insult. Infectious and neoplastic processes are less common in diseases that require a
surgical airway. Tracheostomy is a utilitarian surgical procedure of access; therefore, it
should be discussed in light of the problem it addresses: access to the tracheobronchial
tree. The trachea is a conduit between the upper airway and the lungs that delivers
moist warm air and expels carbon dioxide and sputum. Failure or blockage at any point
along that conduit can be most readily corrected with the provision of access for
mechanical ventilators and suction equipment. In the case of upper airway obstruction,
tracheostomy provides a path of low resistance for air exchange. The trachea is nearly
but not quite cylindrical but is flattened posteriorly. In cross-section, it is D-shaped, with
incomplete cartilaginous rings anteriorly and laterally, and a straight membranous wall
posteriorly. The trachea measures about 11 cm in length and is chondromembranous.
This structure starts from the inferior part of the larynx (cricoid cartilage) in the neck,
opposite the 6th cervical vertebra, to the intervertebral disc between T4-5 vertebrae in
the thorax, where it divides at the carina into the right and left main stem bronchi.

Indications
The advent of the antibiotic era and advances in anesthesia have made tracheostomy a
commonly performed elective procedure. Important to note, however, is that there are
situations when tracheostomy is quite urgent or emergent. This typically involves patient
who is immediate need of a surgical airway because of impending airway obstruction.

General indications include the following:

• Congenital anomaly (eg, laryngeal hypoplasia, vascular web)

• Upper airway foreign body that cannot be dislodged with Heimlich and basic
cardiac life support maneuvers
 • Supraglottic or glottic pathologic condition (eg, infection, neoplasm, bilateral
vocal cord paralysis)

• Neck trauma that results in severe injury to the thyroid or cricoid cartilages, hyoid
bone, or great vessels

• Subcutaneous emphysema

• Facial fractures that may lead to upper airway obstruction (eg, comminuted
fractures of the mid face and mandible)

• Upper airway edema from trauma, burns, infection, or anaphylaxis

• Prophylaxis (as in preparation for extensive head and neck procedures and the
convalescent period)

• Severe sleep apnea not amendable to continuous positive airway pressure

devices or other less invasive surgery

Tracheostomy may also be performed to provide a long-term route for mechanical

ventilation in cases of respiratory failure or to provide pulmonary toilet in the following
cases:
• Inadequate cough due to chronic pain or weakness

• Aspiration and the inability to handle secretions

The cuffed tube allows the trachea to be sealed off from the esophagus and its refluxing
contents. Thus, this intervention can prevent aspiration and provide for the removal of
any aspirated substances. However, some investigators argue that the risk of aspiration
is not actually lessened, as secretions can leak around the cuffed tube and reach the
lower airway. It is also important to outline what tracheostomy does not or will not do for
the patient. Specifically, tracheostomy does not prevent aspiration of airway or other
secretions. Additional diagnoses for which tracheostomy is often considered early in the
course include botulism, amyotrophic lateral sclerosis, and cervical spine injury, among
others.
Equipment
• Gallipots - 3
• Sterile towel
• Sterile nylon brush / tube brush
• Sterile gauze squares
• Cotton twill ties or tracheostomy tie tapes

Procedure with rationale (if applicable)

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.

Nursing Responsibilities

Special considerations (if applicable)

Should an aerosol generating procedure be undertaken on a patient under

droplet precautions then increase to airborne precautions by donning N95/P2 mask for
at least the duration of the procedure.

References
Boshoff, E. L. D., & Nakawunde, H. (2016, December 21).
Tracheostomy. Nurseslabs. https://nurseslabs.com/tracheostomy-nursing-
management/#providing_tracheostomy_care.