Tracheostomy Care and Management

Tracheostomy Care and Management

A tracheostomy is a surgically created opening (stoma) through the anterior neck into the trachea. Tracheostomy tubes maintain that airway opening and are used for patients who require prolonged mechanical ventilation, have upper-airway obstruction, or need long-term secretion management. As a respiratory therapist, you will perform routine tracheostomy care, change securing devices, and respond to emergencies such as accidental decannulation. Mastery of this skill is essential for patient safety and is within the core scope of practice tested by the NBRC.

Anatomy and Tube Components

Most tracheostomy tubes consist of an outer cannula, an inner cannula, and an obturator. The outer cannula sits in the stoma and maintains the airway passage. The inner cannula locks inside the outer cannula and can be removed for cleaning or replacement without disturbing the outer tube—this is the component you will clean routinely. The obturator is a smooth-tipped stylet inserted inside the outer cannula only during initial tube insertion or reinsertion; it is never left in place during normal use because it occludes the airway. Keep the obturator taped at the bedside at all times in case of emergency reinsertion.

Tubes may be cuffed or uncuffed, fenestrated or non-fenestrated, and are sized by inner diameter in millimeters. Cuff pressure should be monitored and maintained within facility protocol ranges to minimize tracheal wall injury while preventing aspiration around the cuff.

Principles of Aseptic Technique

Tracheostomy care is performed using clean to dirty technique and, in many facilities, sterile or surgical aseptic technique for fresh or healing stomas. Regardless of local policy, the core principle is the same: never introduce microorganisms into the stoma or lower airway. Perform hand hygiene before and after the procedure. Use sterile gloves when handling materials that will contact the stoma or inner cannula. Change gloves if contamination occurs. Never set sterile supplies on a non-sterile surface.

Stoma Care Procedure

1. Gather all supplies before beginning so the tube is never left unattended without a second clinician present.

2. Perform hand hygiene and don personal protective equipment (PPE) including gloves, mask, and eye protection.

3. Remove the inner cannula by unlocking it with a quarter-turn and pulling it straight outward. If the patient uses a disposable inner cannula, replace it with a new sterile one; skip the cleaning steps below.

4. For a reusable inner cannula, soak it in a solution per protocol (commonly normal saline or dilute hydrogen peroxide), then scrub the lumen with a small pipe-cleaner style brush, rinse thoroughly with sterile normal saline, and inspect it for damage before reinserting.

5. Clean the stoma site with sterile gauze moistened with the ordered solution, working in a circular motion from the stoma outward. Use each gauze piece only once.

6. Inspect the stoma skin for redness, granulation tissue, breakdown, or signs of infection, and document findings.

7. Place a fresh split-gauze dressing (trach dressing) under the flange—never cut regular gauze because loose fibers can be aspirated.

Tracheostomy Tie (Securing Device) Change

The tracheostomy tube can be expelled from the stoma if manipulated without proper stabilization—this is a life-threatening event. Tie changes always require two clinicians: one to hold the tube manually against the neck flange and one to remove and replace the ties.

Key steps:

• Clinician 1 places fingers on the flange and maintains firm, steady pressure throughout.
• Clinician 2 removes one old tie, threads and secures the new tie on that side, then removes and replaces the other old tie.
• New ties should be snug: allow one finger to pass easily between the tie and the neck—tight enough to prevent tube movement, loose enough to avoid skin breakdown or venous compression.
• Velcro trach holders follow the same two-person rule and allow easier tension adjustment.
• After the tie change, confirm tube position: look for symmetrical chest rise, auscultate bilateral breath sounds, and check that the tube tip has not migrated.

Accidental Decannulation: Recognition and Response

Accidental decannulation—unplanned removal of the tracheostomy tube—is a respiratory emergency. Your response sequence:

1. Call for help immediately.

2. Maintain the airway: cover the stoma with a gloved hand or sterile gauze to reduce air loss. If the patient is ventilator-dependent, place a bag-valve mask (BVM) over the nose and mouth to deliver ventilation while the stoma is covered, or attempt to ventilate through the stoma with the BVM depending on airway patency.

3. Attempt reinsertion of the backup tracheostomy tube (same size or one size smaller) using the obturator; if unsuccessful, insert a tube one size smaller.

4. If reinsertion fails, call a code and continue BVM ventilation. For a fresh surgical tracheostomy (typically fewer than 7 days old), treat reinsertion attempts with extreme caution and defer to the surgical team because the tract may not yet be mature.

5. Confirm tube placement after reinsertion: CO₂ detection (colorimetric or capnography), chest rise, bilateral breath sounds.

6. Document the event, time, interventions, and patient response on the patient care record.

Safety Summary

• Never remove the inner cannula without the outer cannula secured by a second clinician or confirmed stable ties.
• Keep the obturator and a backup tube (same and one size smaller) at the bedside at all times.
• Fresh stomas (less than approximately 7 days post-surgery) are fragile; reinsertion carries a risk of creating a false passage—escalate to a physician promptly.
• Suction only as needed and with appropriate catheter depth to avoid mucosal trauma.
• Document all findings and interventions accurately; errors of omission in documentation are a patient safety concern.