A tracheostomy is a surgically created opening in the trachea. A tracheostomy tube is placed in the incision to secure an airway and to prevent it from closing. Tracheostomy care is generally done every eight hours and involves cleaning around the incision, as well as replacing the inner cannula of the tracheostomy tube. After the site heals, the entire tracheostomy tube is replaced once or twice per week, depending on the physician's order.
The goals of tracheostomy care are to maintain the patency of the airway, prevent breakdown of the skin surrounding the site, and prevent infection . Sterile technique should be used during the procedure.
Inner cannula —Smaller tube that fits inside the tracheostomy tube, which can be removed quickly if it becomes obstructed. This is often used for patients who have copious secretions.
Tracheostomy tube —An indwelling tube used to maintain patency of the tracheostomy. It can be made of metal (for long term use) or disposable plastic. The tube can be cuffed (a balloon is inflated to keep the tube in place) or uncuffed (air is allowed to flow freely around the tube). It can also be fenestrated, which allows the patient to speak.
Extra precautions should be taken when performing site care during the first few days after the tracheostomy is surgically created. The site is prone to bleeding and is sensitive to movement of the tracheostomy tube. It is recommended that another health care professional securely hold the tube while site care is performed. Tracheostomy care should not be done while the patient is restless or agitated, since this increases the chance that the tube may be pulled out and the airway lost.
Tracheostomy care starts with suctioning the patient's airway, both via the tracheostomy and orally. Sterile technique must be used when suctioning the tracheostomy. The gauze dressing is removed from the tracheostomy site, and the amount and color of drainage should be noted. Using sterile technique, the skin and external portion of the tube are cleaned with hydrogen peroxide. Cotton-tipped applicators should be used to clean closely around the stoma. The condition of the skin and stoma should be noted. The area is then wiped with gauze dampened in 0.9% sodium chloride and a new tracheostomy dressing is applied.
If the patient has a disposable inner cannula, the old cannula can simply be removed and discarded. A new cannula is inserted using sterile technique. If the inner cannula is not disposable, it must be cleaned with hydrogen peroxide, rinsed with 0.9% sodium chloride, and reinserted. Sterile technique must be used, and the cannula should be tapped against the side of the sterile container to remove excess fluid. It should not be completely dried, as the film of saline facilitates reinsertion.
All supplies needed for tracheostomy care should be at the bedside prior to beginning the procedure. There are prepackaged tracheostomy care kits available that contain gauze pads, cotton-tipped applicators, a tracheostomy dressing, and hydrogen peroxide. In addition, a container of 0.9% sodium chloride solution, a suction kit, and sterile gloves are needed. The velcro strap that holds the tracheostomy tube in place may be soiled and need to be replaced as well.
The patient should be preoxygenated with 100% oxygen prior to suctioning. If the patient is agitated, a sedative should be given or the procedure should be rescheduled for a later time when the patient is calm. Pain medication may be offered, especially during the first few days after surgery when manipulating the incision can cause discomfort.
After tracheostomy care is finished, the soiled dressing and supplies should be discarded, either in the garbage or in a biohazard container if there is a large amount of blood . The patient may need to be suctioned again, and his or her respiratory status should be reassessed. Again, pain medication should be offered as appropriate.
Tracheostomy care is a relatively benign procedure. The greatest risk is that the tube may be inadvertently removed and the airway lost.
The anticipated outcomes of tracheostomy care include continual patency of the airway, prevention of skin breakdown around the stoma, and prevention of infection.
Health care team roles
The nurse has the primary role in tracheostomy care, as he or she is responsible for doing it in the acute care setting. The respiratory therapist may assist the nurse during the procedure and during respiratory assessment. Some patients may be sent home with a tracheostomy. In this case, the nurse and respiratory therapist are both responsible for teaching the patient and the family how to perform site care at home.
McGovern, Kate & Marguerite Ambrose. "Providing Tracheostomy Tube Care." In Critical Care Skills: A Nurse's PhotoGuide, edited by June Norris. Springhouse: Springhouse Corporation, 1996, pp. 298-311.
Thelan, Lynne, et al. Critical Care Nursing: Diagnosis and Management. St. Louis, MO: Mosby, 1998.
Abby Wojahn, RN, BSN, CCRN