Tracheostomy care guidelines

St. James’s Hospital / Royal Victoria Eye and Ear Hospital

Tracheostomy Care Working Group
October 2000

These guidelines have been produced as an educational support and guide for health
care professionals caring for tracheostomy patients in the clinical setting. Advice on
the care of a specific patient should always be sought from a suitably qualified
professional.

The guidelines have been ratified by the Head and Neck Nurses Association of
Ireland (HANNA) and are recommended for use by its members.

GUIDELINES WRITTEN BY: TRACHEOSTOMY CARE WORKING GROUP of

ST. JAMES’S / ROYAL VICTORIA EYE AND EAR HOSPITALS
Ms. Margaret Codd, RGN, BNS (St. James’s Hospital) - Chairperson
Ms. Yvonne Sheridan, RGN (St. James’s Hospital)
Ms. Hilary Collins, RGN (St. James’s Hospital)
Ms. Janine Ryan, RGN (St. James’s Hospital)
Ms. Maria Creggy, RGN (St. James’s Hospital)
Ms. Michelle Royale, RGN (St. James’s Hospital)
Ms. Kathleen Canavan, RN, BNS (St. James’s Hospital)
Ms. Mildred Grubb, RN, RM, Dip.Nsg.Ed.,
Dip.Med.Ed., M.Med. Ed (St. James’s Hospital)
Ms. Caroline Murphy RGN (Royal Victoria Eye and Ear Hospital)

GUIDELINES REVIEWED BY:

Prof. C. Timon, Consultant Otolaryngologist, (SJH / RVEEH)

Ms. D. Hyland, Acting Nurse Manager, St. John’s Ward,(St. James’s Hospital)
Mr. C. Huet, Nurse Tutor, (RVEEH)
Mr. C. Beirne Consultant Maxillofacial Surgeon, (St. James’s Hospital)
Dr. J. Moriarty, Consultant Anaesthetist, (St. James’s Hospital)
Dr. F. O’ Connell, Consultant Physician, (St. James’s Hospital)
Ms. A. O’Brien, Infection Control Sister, (St. James’s Hospital)
Ms. O.J. Power, Clinical Facilitator, ICU, (St. James’s Hospital)
Ms. S. James, Senior Speech and Language Therapist, (St. James’s Hospital)
Ms. S. Brady, Senior Clinical Nutritionist, (St. James’s Hospital)
Ms. A. M. O’Grady, Senior Physiotherapist, (St. James’s Hospital)
 GUIDELINES INCLUDED

• Overview of tracheostomies
• Bedside equipment.
• Care of the inner cannula, stoma site and tracheostomy ties.
• Suctioning via a tracheostomy tube.
• Humidification of inspired gases.
• Care of cuffed tracheostomy tube
• Care of fenestrated tracheostomy tube
• Care of Passy Muir speaking valves.
• Decannulation: removal of tracheostomy tube.
• Dealing with emergencies.
• Resuscitation via a tracheostomy tube.
 OVERVIEW OF TRACHEOSTOMY TUBES

DEFINITIONS INDICATIONS FOR TRACHEOSTOMY

TRACHEOTOMY: Incision made below the • Bypass acute upper airway obstruction.
cricoid cartilage through the 2nd-4th • Chronic upper airway obstruction.
tracheal rings • Facilitate weaning from mechanical
TRACHEOSTOMY: The opening or stoma made ventilation by decreasing anatomical
by this incision. deadspace.
TRACHEOSTOMY TUBE: Artificial airway • Prevention / treatment of retained
inserted into the trachea during tracheobronchial secretions.
tracheotomy • Prevention of pulmonary aspiration.

Figure 1. TRACHEOSTOMY TUBE IN SITU Figure 2. TRACHEOSTOMY TUBE COMPONANTS

COMPONANTS OF TRACHEOSTOMY TUBE (See Figure 2)

1. Outer tube
2. Inner tube: Fits snugly into outer tube, can be easily removed for cleaning.
3. Flange: Flat plastic plate attached to outer tube - lies flush against the patient’s
neck.
4. 15mm outer diameter termination: Fits all ventilator and respiratory equipment.

All remaining features are optional

5. 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...
6. Air inlet valve: One way valve that prevents spontaneous escape of the injected air.
7. Air inlet line: Route for air from air inlet valve to cuff.
8. Pilot cuff: Serves as an indicator of the amount of air in the cuff
9. 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.
10. 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.
 BEDSIDE EQUIPMENT

Every patient with a tracheostomy tube should have the following equipment available at the
bedside:

• Spare tracheostomy tubes Same size and type as patient is wearing.

Smaller size
• Tracheal dilator.

• Suctioning equipment Suction machine fitted with filter; suction tubing;

suction catheters (see suctioning page for sizes);
gloves (as below); bottle of sterile water to rinse
tubing - change daily.

Ensure equipment is assembled and working

properly.

• Humidification equipment Equipment depends on method used - see

humidification page.

Ensure equipment is assembled and working

properly.

• Gloves Non-sterile **
Sterile gloves (for suctioning)

• Infectious waste bag

• Dry clean container for holding the speaking valve, occlusive cap/button or spare inner
cannula when not in use. (Get from theatre)

**Natural rubber latex gloves to be used by all except those who have latex allergy.
Nitrile gloves to be used by those with latex allergy.
 CARE OF THE INNER CANNULA, STOMA SITE AND
TRACHEOSTOMY TIES

AIM: 1. To maintain a patent airway. 3. To prevent infection.

2. To maintain skin integrity. 4. To prevent tube displacement

FREQUENCY OF CLEANING EQUIPMENT FOR STOMA CARE

Inner Cannula: Dressing trolley Dressing pack

Check every shift Pair of sterile gloves Unsterile gloves
-see box below. Normal saline solution Scissors
Clean PRN Lyofoam dressing Suctioning equipment
Stoma: PRN to keep clean and dry New trach. ties Infectious waste bag
Ties: PRN to keep clean and dry (Sterile pipe cleaners - single use only)

To check inner cannula: Wash hands. Wearing a non-sterile glove, remove inner cannula.
Handle only the outer portion of the cannula. If clean, reinsert and lock into place. If soiled -
continue with step (d) below.

(a) Wash hands.

(b) Wearing unsterile gloves remove and dispose of the soiled dressing.
(c) Wash hands. Put on sterile gloves.
(d) First, remove and clean the inner cannula using sterile pipe cleaners and normal saline.
Dry. Reinsert.
(e) Secondly, clean the stoma site using gauze and normal saline. Pat dry. Apply lyofoam /
keyhole dressing if necessary.
(f) Lastly, if ties are soiled and need changing, have a second nurse hold the tracheostomy
tube securely in place, remove and replace tracheostomy ties. (Leave 1 finger space
between ties and the patient’s neck.)
(g) Ensure patient comfort.
(h) Discard of used equipment as per hospital policy.
(i) Wash Hands.
(j) Document procedure in the patient’s notes.

Note:
Leave first dressing intact for 24hrs if possible as the tracheostomy is a fresh wound.
 SUCTIONING VIA A TRACHEOSTOMY TUBE

AIM: To maintain a patent airway by removing endotracheal secretions.

FREQUENCY OF SUCTIONING WORKING OUT SUCTION

CATHETER SIZE

Suctioning is performed only as Size of trach. tube (mm) x 3

needed, NOT to a pre-set schedule 2
(Knipper ’84, Carroll ’89, Stone and
Turner ’89) E.g. 8x3 = size 12 suction
2 catheter

Be aware that suctioning will be

needed more frequently in the This ensures that suction catheter is </= ½
immediate post-operative period the internal diameter of tracheostomy tube.

(a) Explain the procedure to the patient - wash hands, put on gloves. Put on apron and
fluid shield mask if necessary for standard (universal) precautions). Turn on
suction apparatus and test that vacuum pressure is < -150mmHg.
(b) Open / expose only the vacuum control segment of the suction catheter and attach
to the suction tubing.
(c) Put on disposable sterile gloves over the non-sterile gloves and withdraw the
sterile catheter from the protective sleeve.
(d) Maintaining sterility, insert the suction catheter with NO suction applied until
resistance is met, then pull back about 1-2 cms before applying continuous suction
as the catheter is smoothly withdrawn from airway.
NOTE: Recommended suction time (i.e. from insertion to removal of suction
catheter) = <15secs
Use a new sterile catheter for each suction pass. (Stone et al ’91,
Young ’84, Carroll ’88, Link et al ’76).
No more than 3 passes recommended per treatment.
(e) On completing procedure, ensure patient comfort, discard of equipment as per
hospital policy, wash hands and document procedure in the patient’s notes.
 HUMIDIFICATIONOF INSPIRED GASES

Aims: 1. To prevent drying of pulmonary secretions.

2..To preserve muco-ciliary function.

NOTE: All patients with tracheostomy tubes require humidification of inspired gases.

CHOOSING METHOD EQUIPMENT NEEDED

A) HEATED HUMIDIFIERS - Recommended for: A) * Heating unit,

• patients with new tracheostomy tubes * Sterile water ,
• dehydrated patients * Oxygen tubing,
• immobile patients * Tracheostomy mask.
• patients with tenacious secretions

B) HEAT MOISTURE EXCHANGE FILTERS - B) * Heat moisture exchange

Recommended for: filter
• patients that are adequately hydrated * Oxygen tubing to fit filter
• mobile patients if O2 therapy requested
• Not suitable for patients with copious secretions
C) * Nebulizer
C) NEBULIZERS - nebulized normal saline is effective
in helping to loosen secretions and soothing irritable * Oxygen tubing
airways. * Sterile saline

• The method used for humidification can be altered as the patient’s condition changes
• Do not combine methods - use one at a time.
.

NURSING MANAGEMENT

HEATED HUMIDIFERS
• Set up as per operators manual.
• Monitor temperature of inspired gases. This is easily achieved if the system used
has a digital temperature display. If it does not, then test the temperature by
holding the oxygen tubing against a clean bared inner arm. Gas flow should feel
at body temperature.
• Monitor water level and change bottles PRN.
• If condensation collects in tubing, - drain tubing into a sterile jug and dispose of
into sluice.
• Using clean technique, change all tubing weekly. (Date tubing when changed)

HEAT MOISTURE EXCHANGERS

• Change daily and PRN to keep clean and dry. (Swedish noses/thermovents can be
easily “coughed off” - apply new Swedish nose each time this happens).
• Discard of soiled Swedish noses in infectious waste.

NEBULIZERS
• Administer as prescribed.
• Wash in warm soapy water, rinse and dry thoroughly after each treatment.
 CARE OF CUFFED TRACHEOSTOMY TUBE

INDICATIONS FOR CUFFED TUBE

• Immediately post-operatively - to
prevent aspiration of blood or serous
fluid from the wound
• To seal the trachea during mechanical
ventilation
• To seal the trachea during swimming!
• To prevent aspiration of leakage from
tracheo-oesophageal fistula
• To prevent aspiration due to laryngeal
incompetence

NURSING MANAGEMENT

• It is unusual for ward patients to need their cuff inflated.

• Tracheostomy cuff is inflated only - (a) if the patient is being mechanically ventilated,
(b) if inflation is specifically ordered by doctor.

• Check with doctor that it is OK to do so , and then proceed with cuff deflation......

• Patients can be extremely sensitive to changes in cuff pressure. A little coughing is not
unusual during manipulation. Take care to explain the procedure to the patient and to
inflate / deflate the cuff slowly.

• To deflate cuff: First, suction the oropharynx to remove any secretions that may have
pooled on top of the inflated cuff. Then, using a syringe, slowly aspirate air from the air
inlet port. Once deflated, expiratory noises may be heard as air passes up around the
tracheostomy tube. Reassure the patient that these are normal and will settle.

• To inflate cuff: Inject approximately 5-7mls of air via the air inlet port to achieve airway
seal. A one-way valve system prevents injected air from escaping.

NOTE:
• If used correctly, there is no need for low pressure cuffs to be deflated ever hour. (Powaser et
al 1976, Bryant et al 1971)
• Cuff pressures can be measured by using a spirometer attached to the air inlet port of the
tracheostomy tube. Recommended cuff pressure is <25mmHg. This is presently no policy
regarding this practice in this hospital.
 CARE OF FENESTRATED TRACHEOSTOMY TUBE

USES OF FENESTRATED TUBES

1. To facilitate / improve speech - The
fenestration (hole) allows increased
volumes of air to be forced up through
the larynx during exhalation.

2. To improve swallow function -

Restoring more normal airflow restores
some of the protective mechanisms of
normal swallow.

Figure 4. Fenestrated tracheostomy tube

NURSING CONSIDERATIONS WHEN USING FENESTRATED TUBES.

• A fenestrated tracheostomy tube can only function as such if both the outer and inner
cannulas contain a fenestration (hole)!

• The fenestration allows secretions as well as air to pass up and down the patient’s airway.
If needed, give the patient a sputum container or tissues and bag for secretions.

• Speaking: Speech is facilitated by inserting the fenestrated inner cannula, and occluding
the tracheostomy tube opening by using one of the following: (CUFF SHOULD BE
DEFLATED) a) the patients finger
b) a speaking valve
c) a decannulation plug / cap / button.

• Suctioning: If suctioning is required, change to a non-fenestrated inner cannula. This is

to prevent the suction catheter passing through the fenestration and traumatising the
delicate lining of the posterior tracheal wall.

• Eating: While using a fenestrated tube restores some of the normal swallow protection
mechanisms, nurses should be aware of and observe for signs of aspiration. Swallowing is
further improved by having the cuff deflated and the tracheostomy opening occluded at
the moment of swallow - methods outlined above.

• Cleaning of a fenestrated inner cannula is the same as for non-fenestrated tube.

• Store cleaned speaking valve, cap and spare inner cannula in a sealed, clean, dry
container at the patient’s bedside (specimen containers available from theatre).
 CARE OF PASSY MUIR SPEAKING VALVE

HOW IT WORKS CLEANING INSTRUCTIONS.

The speaking valve contains a movable Clean daily - as per inner cannula
plastic disc that opens on inspiration but or
closes on expiration. This means that Wash in soapy water.
during expiration no air can escape Rinse thoroughly in cool-tepid water (not hot).
through the tracheostomy tube opening. It Air dry.
is redirected up through the larynx instead.

WHILE WEARING THE VALVE, THE PATIENT WILL NOTICE........

• Air exhaling via the nose and mouth. • Expectoration returns to the normal
• Speech is improved, full sentences are route, i.e. the oral cavity.
possible. • Patients are able to blow their nose/sneeze
• Oral + nasal secretions lessen because of • Occassional dryness of mucosa may occur.
evaporation of secretions as air is exhaled. • Lung backpressure - normal feeling of
• Energy levels may increase. restored volume - may take getting used to.
• Strong coughing may blow off valve.

NURSING CONSDERATIONS WITH THE PASSY MUIR VALVE.

• To use the valve the tracheostomy cuff should be deflated (see page on cuff care)
• To use the valve patients should also be medically stable, and have enough pulmonary
compliance to exhale around the tracheostomy tube, and out through the nose and mouth.
• Stay with the patient during first wearing. (i.e.5-10mins or until patient is confident
wearing valve).
• Increase wear-time as tolerated.
• Ensure patient has a sputum container or tissues and bag for orally expectorated
secretions.
• Increased mouthcare is necessary if the patient experiences dry mouth.
• Assess the patient’s work of breathing. Observe for adequate exhalation - so that stacking
of breaths is avoided.
• Observe secretions. Thick unmanageable secretions require a medical review by the
patient’s team so that they are carefully evaluated and treated.
• If the patient complains of difficulty exhaling, downsizing of the tracheostomy tube
usually allows enough airflow to enable valve use.
• DO NOT WEAR SPEAKING VALVE WHILE SLEEPING - this is to avoid the risk
of the disc becoming clogged with sputum and preventing the patient breathing while
he/she is sleeping.
• DO NOT THROW AWAY -speaking valves are not disposable, (they are single patient
use).
 DECANNULATION : REMOVAL OF TRACHEOSTOMY TUBE
Once the need for tracheostomy tube has resolved the doctor will decide to proceed with steps
towards decannulation.
Encouragement and support are particularly important throughout this phase of patient care.
STEPS OF DECANNULATION
STEP 1
Downsizing of the tracheostomy tube
• (at least 5-7 days after original tube insertion)
• means changing to smaller size, cuffless, tube.
(Check with doctor if fenestrated tube to be
inserted at this time.)
• This first tube change is ALWAYS carried
out by a doctor.
• Sometimes a second downsizing is necessary,
before proceeding to....
STEP 2
Capping of the tracheostomy tube
• This is achieved by applying an occlusive cap
to the front of the tracheostomy tube.
• Once capping is tolerated for at least 24
consecutive hours the doctor will decide if
decannulation can occur.
STEP 3
Decannulation
• The tracheostomy tube is removed, stoma
edges are approximated, and an occlusive
gauze + sleek dressing is applied
• It takes approximately 10 days for the
tracheotomy to heal.
NURSING CONSIDERATIONS
Equipment required: Trolley, set with - Dressing pack,
sterile gloves, new tube (+ smaller tube), tracheal dilators.
stylet or suction catheter (to function as “guide-wire”
during tube change), normal saline, KY gel, pencil torch,
scissors, clinical waste bag. suctioning equipment, ambu-
bag, ventilatory equipment if patient is ventilated. New
dressing and ties.
Leakage of air +/- secretions around the new tracheostomy
tube may be noticed after smaller tube has been inserted.
This is expected and will settle once the stoma reduces in
size around the tube.
• Once capped, the patient must breathe through their
nose and mouth again. (Give 02 and nebulizers by
face-mask now)
• CLOSE OBSERVATION is essential in case of
respiratory difficulty.
• While many patients can tolerate continuous wearing
of the cap, some find that it may takes getting used to.
Therefore wear -time needs to be increased as
tolerated.
• PATIENTS MUST BE TAUGHT TO REMOVE
THE CAP THEMSELVES IF THEY
EXPERIENCE ANY BREATHING
DIFFICULTY.
• If breathing does not settle with removal of cap -
inform doctor.
• Encourage patient to press on the stoma dressing
when coughing to prevent it being “coughed off”, and
to prevent secretions escaping via the stoma.
• Change dressing if loose or soiled.
 DEALING WITH EMERGENCIES

NOTE: Tracheostomies are usually sutured in place for the first week after insertion and so
are unlikely to be displaced.

IF THE TRACHEOSTOMY TUBE FALLS OUT !!...

• DON’T PANIC!
• Once the tracheostomy tube has been in place for about 5 days the tract is well formed
and will not suddenly close.
• Reassure the patient
• Call for medical help.
• Ask the patient to breathe normally via their stoma while waiting for the doctor.
• The stay suture (if present) or tracheal dilator may be used to help keep the stoma open if
necessary.
• Stay with patient.
• Prepare for insertion of the new tracheostomy tube
• Once replaced, tie the tube securely, leaving one finger-space between ties and the
patient’s neck.
• 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.

ACUTE DYSPNOEA

..is most commonly caused by partial or complete blockage of the tracheostomy tube by
retained secretions. To unblock the tracheostomy tube.....

1. ASK THE PATIENT TO COUGH: A strong cough may be all that is needed to expel
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 the
secretions are lower down the patients airway. Use the suction machine to remove the
secretions.
4. If these measures fail - commence low concentration oxygen therapy via a tracheostomy
mask, and call for medical assistance.

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

IN THE EVENT OF A CARDIOPULMONARY ARREST, TREAT TRACHEOSTOMY

PATIENTS AS ANY OTHER PATIENTS

...... PLUS.....

STEP 1

EXPOSE THE PATIENT’S NECK

Remove any clothing covering the tracheostomy tube

DO NOT remove tracheostomy

STEP 2

CHECK THAT INNER CANNULA IS PATENT

To check inner cannula: Wearing a non-sterile glove, remove

inner cannula. If clean, reinsert and lock into place. If soiled -
replace. Continue resuscitation.

STEP 3

VENTILATE -

by using ambu-bag attached directly to tracheostomy tube

IF UNABLE TO VENTILATE:

..TRY SUCTIONING: This will clear any secretions blocking

the airway below the end of the tracheostomy tube.

..IF STILL UNABLE TO VENTILATE: The tracheostomy

tube may have become displaced. Doctor should:
1) Change tracheostomy tube - if unsuccessful......
2) Orally intubate
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