The goal of caring for a patient with a tracheostomy is to ensure that the airway is maintained at all times.

Clinical management issues to consider

• establish indication for tracheostomy and patency of upper airway
• note date of tracheostomy insertion
• note size of tracheostomy tube
• inspect tracheostomy site
• ensure that equipment required (including tracheostomy safety box) is at the bedside and accompanies the patient if transferred off the ward

Daily care interventions to ensure the patency of the tracheostomy tube

Humidification

Breathing through a tracheostomy bypasses the normal warming, filtering and humidification of inspired air.

All tracheostomy patients will require a form of artificial humidification.

• Deliver heated circuit humidification to immediately post-operative neck breathers.
• Assess humidification effectiveness by observing tenacity of secretions and ease at coughing and clearing secretions.
• Effective humidification will allow loose secretions to be easily cleared on coughing or suction.

Nebuliser

• ensure that humidified oxygen and nebulisers are prescribed
• dispense one 5ml saline ampoule into nebuliser chamber
• ensure tracheostomy mask is clean, place mask over tracheostomy tube and secure
• turn on, ampoule will take approx 5–10 mins to disperse
• when finished turn off, remove and dry mask with paper towel
• saline nebuliser should be used 4–6 hourly. However, if secretions are dry nebulisers can be increased in frequency to 2 hourly to loosen and moisten secretions. If dry secretions persist contact tracheostomy nurse specialist
• ensure patient is well hydrated if secretions remain thick
• change nebuliser kits as per manufacturers’ guidelines

Inner tube cleaning

• remove tracheostomy aids, eg. speaking valve or Swedish nose / trachphone if being used
• with one hand supporting the outer tube, remove the inner tube using a curved downward motion
• insert spare, clean inner tube with one hand supporting outer tube reinsert the inner tube using an upward curved motion
• using the tracheostomy cleaning brush or swab, clean the inner tube with sterile water until no secretions remain
• tap any excess water off tube and store in a clean pot
• ensure tube has clicked into place
• reapply tracheostomy aid if being used
• inner tube should be cleaned 2–4 hourly. However, frequency of cleaning should increase if required, eg. when secretions increase due to a cold or chest infection or if secretions are dry (if secretions become dry, humidification should be increased, ie. saline nebuliser (up to 2 hourly/5ml ampoule)
• all tracheostomy care given should be recorded on the tracheostomy care chart
• ensure patient has call bell, pen and paper or another aid to communicate with staff / relatives

Suctioning

• ensures suction apparatus is working and suction chamber is not full
• suction pressure should be between 13.5 and 20kPa (100–150mmHg)
• wear non-sterile gloves
• connect suction catheter to suction tubing – see below

Inner diameter of tracheostomy tube (mm)		Suction catheter
(NB: see manufacturers details to confirm)		FG	(mm)
10mm		14	(4.5)
9mm		14	(4.5)
8mm		12	(4)
7mm		12*	(4)
6mm		10	(3.3)

* It is more appropriate to use a size 12 catheter as although it is slightly larger than ½ the diameter it is more effective for secretion removal.

• insert suction catheter using a non-touch technique, to the length of the inner tube plus 1cm if patient able to cough, or to carina and draw back 1cm (1/3 of catheter length) if patient cannot cough. (See chart below.)

For patients unable to cough (approx 16cm on uni-medical marked suction catheter) (approx 22cm for adjustable flange tube (Uni-Perc)		For patients able to cough (approx 11cm on uni-medical marked suction catheters)
Action	Rationale	Action	Rationale
Insert catheter to the depth of the carina or until resistance felt. Withdraw catheter 1cm and then apply suction	Withdrawal of 1cm limits suction causing damage to the carina	Insert suction catheter to the length of the tracheostomy tube plus 1cm	Patients will cough on suctioning so therefore do not need deeper suctioning

• occlude suction port with thumb to apply suction
• remove suction catheter steadily, this should take no longer than 15 seconds
• throw away used suction catheter and reattach new suction catheter if required for further suctioning
• if there are any signs of infection, eg. thick, green smelly secretions that are difficult to clear, inform doctors or tracheostomy specialist nurse to assess further

Tracheostomy dressing

• Remove dressing and clean around stoma site with normal saline and gauze, ensure that the flange of the tube is clean and any crusting removed.
• Observe stoma site for signs of redness, sores or ulceration. (If any of these are visible inform the doctors or tracheostomy nurse specialist to assess further.)
• Apply barrier cream around stoma site.
• Reapply clean tracheostomy dressing. Dressing should be changed daily, however, if required change more frequently.

Neck collar

When removing the tracheostomy ties, two people will be required, one to hold the tube whilst tapes are removed to prevent accidental decannulation.

• With one hand supporting the tube, carefully untie and remove the neck collar. Replace with a clean collar.
• Ensure that only two fingers fit down the side of the collar. If the collar is too loose the tube can become displaced.
• Collars should be changed daily. Where ventilatory support is required use ribbon tracheostomy ties.

Monitoring

• Baseline observations including oxygen saturation and respiratory rate are done at the required frequency
• Monitor daily for signs of DOPE: displacement, obstruction, pneumothorax / neumonia, faulty equipment.

Accidental decannulation

DON'T PANIC

Once the tracheostomy tube has been in place for about five 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 / anaesthetist. 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

Check tube position by (a) asking the patient to inhale deeply – they should be able to do so easily and comfortably, and (b) place hand in front of the opening – you should feel the patient exhaling if in correct position.

Weaning

Tracheostomy weaning should be agreed by the Multi Disciplinary Team (MDT) and specific, individual care plans put in place by the Tracheostomy Nurse Specialist and Speech and Language Therapy (SLT).