TRACHEOSTOMY CARE and tracheal suctioning are high-risk procedures.
To avoid poor outcomes, nurses who perform them—whether they’re
seasoned veterans or novices—must adhere to evidence-based guidelines.
In fact, experienced nurses may overestimate their own trach care
Tracheostomy patients aren’t seen only in intensive care units. As
patients with more complex conditions are admitted to hospitals, an
increasing number are being housed on general nursing units.
Trach patients are at high risk for airway obstruction, impaired ventilation,
and infection as well as other lethal complications. Skilled bedside
nursing care can prevent these complications. This article describes
evidence-based guidelines for tracheostomy care, focusing on open
and closed suctioning and site care.
Suctioning a trach tube
A trach tube may have a single or double lumen; it may be cuffed or uncuffed, fenestrated (allowing
speech) or unfenestrated. Each variation requires specific management.
For instance, before suctioning a fenestrated tube, you must insert a
plain inner tube, because a suction catheter may puncture the small
opening of the fenestrated tube. (See Trach tube positioning by clicking the PDF icon above.)
Regardless of the type of tube used, suctioning always involves:
- oxygenation management
- use of correct suction pressure
- liquefying secretions
- using the proper-size suction
catheter and insertion distance
- appropriate patient positioning
Also, be sure to keep emergency equipment nearby. (See Be prepared
for trach emergencies by clicking the PDF icon above.)
When to suction
Suctioning is done only for patients
who can’t clear their own airways.
Its timing should be tailored to
each patient rather than performed
on a set schedule.
Start with a complete assessment.
Findings that suggest the need for
suctioning include increased work
of breathing, changes in respiratory
rate, decreased oxygen saturation,
copious secretions, wheezing, and
the patient’s unsuccessful attempts
to clear secretions. According to
one researcher, fine crackles in the
lung bases indicate excessive fluid
in the lungs, and wheezing patients
should be assessed for a history of
asthma and allergies.
Before suctioning, hyperoxygenate
the patient. Ask a spontaneously
breathing patient to take two to
three deep breaths; then administer
four to six compressions with a
manual ventilator bag. With a ventilator
patient, activate the hyperoxygenation
Experts recommend using suction
pressure of up to 120 mm Hg
for open-system suctioning and up
to 160 mm Hg for closed-system
suctioning. For each session, limit
suctioning to a maximum of three
catheter passes. During catheter extraction,
suctioning can last up to
10 seconds; allow 20 to 30 seconds
For open-system suctioning,
catheter size shouldn’t exceed half
the inner diameter of the internal
trach tube. To determine the appropriate-
size French catheter, divide
the internal trach tube size by two
and multiply this number by three.
A #12 French catheter is routinely
used for closed suctioning. Premeasure
the distance needed for insertion.
Experts suggest 0.5 to 1 cm
past the distal end of the tube for
an open system, and 1 to 2 cm past
the distal end for a closed system.
The best ways to liquefy secretions
are to humidify secretions and hydrate
the patient. Do not use normal
saline solution (NSS) or normal
saline bullets routinely to loosen
tracheal secretions because this
- may reach only limited areas
- may flush particles into the lower
- may lead to decreased postsuctioning
- increases bacterial colonization
- damages bronchial surfactant.
Despite the potential harm caused
by NSS use, one survey found that
33% of nurses and respiratory therapists
still use NSS before suctioning.
Other researchers have found that
inhalation of nebulized fluid also is
ineffective in liquefying secretions.
When evaluating the patient after
suctioning, assess and document
physiologic and psychological responses
to the procedure. Convey
your findings verbally during nurseto-
nurse shift report and to the interdisciplinary
team during daily rounds.
Trach site care and dressing changes
Tracheostomy dressing changes promote
skin integrity and help prevent
infection at the stoma site and in the
respiratory system. Typically, healthcare
facilities have both formal and
informal policies that address dressing
changes, although no evidence
suggests a particular schedule of
dressing changes or specific supplies
for secretion absorption must be
used. On the other hand, the evidence
does show that:
- secretions can cause maceration
and excoriation at the site
- the site should be cleaned with
- a skin barrier should be applied
to the site after cleaning
- loose fibers increase the infection
- the trach tube should be secured
at all times to prevent accidental
dislodgment, using the two-person
securing technique described below
under "Securing the trach
Start by assessing the stoma for
infection and skin breakdown
caused by flange pressure. Then
clean the stoma with a gauze
square or other nonfraying material
moistened with NSS. Start at the
12 o’clock position of the stoma
and wipe toward the 3 o’clock position.
Begin again with a new
gauze square at 12 o’clock and
clean toward 9 o’clock.
To clean the lower half of the
site, start at the 3 o’clock position
and clean toward 6 o’clock; then
wipe from 9 o’clock to 6 o’clock,
using a clean moistened gauze
square for each wipe. Continue this
pattern on the surrounding skin
and tube flange.
Avoid using a hydrogen peroxide
mixture unless the site is infected,
as it can impair healing. If using it
on an infected site, be sure to rinse
afterward with NSS.
Dressing the site
At least once per shift, apply a new dressing to the
stoma site to absorb secretions and insulate the skin.
After applying a skin barrier, apply either a split-drain or
a foam dressing. Change a wet dressing immediately.
Securing the trach tube
Use cotton string ties or a Velcro holder to secure the
trach tube. Velcro tends to be more comfortable than
ties, which may cut into the patient’s neck; also, it’s easier
The literature overwhelmingly recommends a twoperson
technique when changing the securing device
to prevent tube dislodgment. In the two-person technique,
one person holds the trach tube in place while
the other changes the securing device.
Review trach tube policy and procedures
To achieve positive outcomes in patients with trach
tubes, keep abreast of best practices and develop and
maintain the necessary skills. Every nurse who performs
trach care needs to be familiar with facility policy
and procedure on trach tube care. If your facility’s
current policy and procedures don’t support evidencebased
practice, consider urging colleagues and managers
to conduct a patient-care study comparing different
approaches to suctioning. Then follow the
evidence by advocating for changes if necessary.
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Betty Nance-Floyd is a clinical assistant professor at the University of North
Carolina at Chapel Hill School of Nursing.