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Care of the Patient with a Tracheostomy Tube (Adult) (7.19-A)

Care of the Patient with a Tracheostomy Tube (Adult) (7.19-A) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Pulmonary

7.19-A

NURSING PATIENT CARE POLICY & PROCEDURE





Effective Date:
November 30,
2016

Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 7.19A

Original
Revision

Page
1
of 8

Title: Care of the Patient with a
Tracheostomy Tube (Adult)

I. PURPOSE

A. To establish nursing practice for the care of ventilated and non-ventilated patients
with tracheostomy tubes.
B. To establish nursing practice for the maintenance and replacement of
tracheostomy tubes in adult patients.

II. POLICY

A. The following equipment should be at the bedside of every patient with a
tracheostomy:
1. Extra tracheostomy tube and obturator
2. Ties: Velcro
3. Sterile scissors
4. Resuscitation bag and mask of appropriate size with tracheostomy adaptor
attached to an oxygen flowmeter
5. Humidity - heated humidification system for the tracheostomy mask or
ventilator (as ordered)
6. Suction catheters of appropriate size and suction equipment
7. Sterile normal saline
8. Protective eyewear
9. Mask
10. Gloves
B. Document the following in the patient’s clinical record:
1. Brand
2. Size of tracheostomy tube
3. Dressing

NOTE: For pediatric information, please refer to UWHC Nursing Patient Care Policy
7.19P, Care of the Patient with a Tracheostomy Tube (Pediatric).

III. PROCEDURE FOR ROUTINE TRACHEOSTOMY CARE

A. Perform hand hygiene according to UWHC Hospital Administrative Policy 13.08,
Hand Hygiene, and don personal protective equipment.
B. Perform inner cannula care every eight (8) hours and PRN.
1. Disposable inner cannula (marked Disposable Cuffed Tracheostomy [DCT])
a. Equipment
i. Non-sterile gloves

Page 2 of 8

ii. Disposable inner cannula
iii. Normal saline
b. Steps
i. Remove inner cannula by squeezing the tabs on the connector until
both snaps clear the rigid lock on the outer cannula and withdraw
slowly.
ii. Dispose of the inner cannula only.
iii. May moisten the new disposable inner cannula with saline to
facilitate insertion and gently insert
iv. Lock into place by squeezing tabs and pushing gently until both
snaps lock firmly over the ridge on the outer cannula.
2. Non-disposable inner cannula
a. Equipment
i. Non-sterile gloves
ii. Tracheostomy care kit (CS Item Number 1220120)
iii. Normal saline
iv. Hydrogen peroxide (H2O2)
b. Steps
i. Open tracheostomy care kit on bedside table.
ii. While maintaining sterility, fill both sections of the container with
saline.
• Only sterile normal saline should be used for cleaning a
metal tracheostomy tube (H2O2 causes pitting of the metal
inner cannula).
• Equal parts saline and H2O2 may be used to loosen debris
from inner cannulas of reusable (not disposable) plastic inner
cannulas, followed by saline rinse.
iii. Remove oxygen source and inner cannula, placing the cannula in
sterile normal saline or 1:1 normal saline: H2O2 solution.
iv. Apply tracheostomy collar oxygen or ventilator to outer cannula, if
needed.
v. Remove and dispose of non-sterile gloves. Perform hand hygiene
according to UWHC Hospital Administrative Policy, 13.08, Hand
Hygiene.
vi. Don sterile gloves
vii. Clean inner cannula thoroughly with a small brush and pipe
cleaners.
viii. Rinse inner cannula in sterile normal saline container.
ix. Slide inner cannula into outer cannula and lock into place.
C. Perform stoma care every eight (8) hours and PRN
1. Equipment
a. Non-sterile gloves
b. Fenestrated sterile 4x4 or 2x2 gauze
c. Normal saline
d. Sterile cotton swabs
e. 4x4 gauze (non-sterile)
2. Steps
a. Perform hand hygiene according to UWHC Hospital Administrative
Policy, 13.08, Hand Hygiene, and don non-sterile gloves.

Page 3 of 8

b. Remove soiled tracheostomy dressing.
c. Moisten swabs and 4x4s with normal saline. Clean stoma site and outer
cannula surface by wiping with cotton swabs and 4x4s.
d. Pat dry the skin area surrounding the stoma site with a dry 4x4.
e. Assess skin around stoma site for signs of pressure ulceration and apply
thin, nonadherent foam dressing prn to prevent pressure damage.
f. Apply clean, lint-free fenestrated (pre-cut) dressing under tracheostomy
site to absorb secretions. A thumb forceps or a cotton swab may be used
to help slide the dressing into place.
D. Tracheostomy ties are changed when soiled. Disposable Velcro tracheostomy ties
are preferable to twill tape and should be used whenever possible.
1. Equipment
a. Tracheostomy tie (Velcro)
b. Fenestrated sterile 4x4 or 2x2 gauze
i. Velcro ties
• Two staff members must be present when changing trach ties
to prevent trach dislodgement. Carefully remove the soiled
ties from patient's neck while holding the tracheostomy tube
steady. Thread fastener tabs through the flanges of the
tracheostomy tube plate and secure to the soft material.
• Place neck band around patient’s neck. Secure Velcro strap
so that it is secure to keep the tracheostomy tube in place, but
still able to place one finger between the patient's neck and
the tie.
• Apply clean, lint-free fenestrated dressing under
tracheostomy site to absorb secretions. A thumb forceps or a
cotton swab applicator may be used to help slide the dressing
into place.
E. For cuffed tracheostomy tubes, ensure that the cuff is at minimum occlusion
pressure. (Respiratory Therapy [RT] checks the cuff pressure with initial
placements and as needed. If the patient is mechanically ventilated cuff pressures
are checked twice daily by RT and can be requested PRN for change in patient
condition.)
1. Initially, while auscultating over the patient's trachea, add air to the cuff pilot
line during the inspiratory cycle of mechanical or manual ventilation to the
point where the audible leak around the artificial airway cuff is abolished,
using the smallest possible volume.
a. Lower cuff pressures are desirable and should be no greater than 20-25
cm H
2
O pressure. Cuff overinflation can cause tracheal ischemia,
necrosis, stenosis, or perforation.
b. Document in the clinical record the volume of air required to inflate
cuff, frequency of deflation, and usual cuff pressure.
c. If tracheostomy tube cuff is to be deflated, suction pharynx immediately
prior to cuff deflation.

IV. PROCEDURE FOR SUCTIONING

A. Equipment
1. Wall suction gauge and canister with liner or portable suction unit (from CS)

Page 4 of 8

2. Suction connection tubing
3. Closed in-line suction device
4. Sterile disposable suction kit(s) of appropriate size (comes with suction
catheter, sterile gloves, cup)
5. Normal saline for suction line irrigation (pink saline ‘jet’ for closed system or
100 mL bottle for open system)
6. Oxygen device
7. Manual resuscitation bag
8. Personal protective equipment: gloves, mask and goggles or face shield, gown
(if needed)
B. Procedure
1. Perform hand hygiene according to UWHC Hospital Administrative Policy
13.08, Hand Hygiene, and don personal protective equipment.
2. An individualized assessment, including respiratory status and auscultation of
bilateral breath sounds, should be performed to determine whether a patient
requires suctioning.
a. Signs and symptoms indicating a patient may require suctioning
i. Restlessness, agitation, apprehension, coughing
ii. Dyspnea, tachypnea
iii. Increased or decreased heart rate
iv. Increased or decreased blood pressure
v. Moist, noisy, rattling respirations
vi. Excessive secretions
vii. Crackles and gurgling over large airways
viii. Prolonged expiratory breath sounds
ix. Visible secretions in airway
x. High pressure alarm on mechanical ventilator activated
b. Routine, unnecessary suctioning is avoided to reduce irritation to the
mucosa and the potential for infection.
c. Non-mechanically ventilated patients who have tracheostomies may be
able to clear secretions by coughing deeply. Patients need to be educated
about coughing deeply and this method should be attempted prior to
suctioning the airway.
d. Saline instillation should not be a routine part of suctioning. Saline
instillation has been shown to have an adverse effect on oxygenation and
does not significantly improve secretion removal.
i. A major exception is for the patient who has had a trach
placed by the Adult Otolaryngology Service. In the hospital, the
RN should do this a minimum of every 4-8 hours and prn
according to provider order. See appendix A, Procedure for
Irrigation of Tracheostomies/Stomas in the Adult Otolaryngology
Patient Population for step-by-step irrigation instructions.
3. Position the patient in semi-Fowler’s unless contraindicated.
a. Closed in-line device for ventilated patients (preferred)
i. Connection tubing should remain attached to in-line device at all
times. Turn on suction device to 100-120 mm Hg.
ii. Using the mechanical ventilator, hyperoxygenate with 100%
oxygen for at least 30 seconds prior to suctioning. A manual
resuscitation bag (MRB) may be used for hyperoxygenation

Page 5 of 8

(second staff member required to bag). If MRB is used, 5-6 breaths
of 100 percent oxygen should be delivered over 30 seconds.
iii. Quickly but gently advance catheter into artificial airway until a
cough is stimulated or length of the tube is reached to prevent
damage to trachea.
iv. Apply suction using button on device, and withdraw catheter back
into plastic sleeve over 10 seconds or less, rotating catheter as it is
withdrawn.
v. Procedure may be repeated 2-3 times to clear airway.
Hyperoxygenate patient and allow them to rest for 30-60 seconds
between suction passes.
vi. Upon completion, suction catheter must be rinsed with the pink
saline "jet".
• Withdraw catheter back until the black mark is seen inside
the sleeve.
• Open cap on irrigation port and instill saline jet while
depressing suction button.
• When catheter is clear of secretions, turn and lock suction
button.
• Remove pink saline jet and cap off port.
vii. The in-line suction will be maintained as a closed circuit and
changed by RT daily.
b. Open system
i. When using open system, two persons may be needed - one to
suction and one to manually ventilate and support the patient.
ii. Open suction kit and pour saline into disposable cup.
iii. Turn on suction device and pinch tube for 10 seconds to determine
amount of suction. The amount of suction needed is determined by
the type of secretions and size of tube. Use as little suction as
possible.
• Wall suction setting: 100-120 mm Hg
• Portable suction setting: 7-15 inches Hg
iv. Don sterile gloves. Glove on suctioning hand must remain sterile
throughout procedure, other glove can be clean.
v. Attach catheter to connection tubing and check suctioning
equipment by suctioning a small amount of normal saline or
sterile water from the cup. Saline also serves as a lubricant for the
catheter.
vi. Suction is created by placing thumb of non-sterile hand over thumb
port of catheter. Remove thumb to discontinue suction.
vii. Preoxygenate and hyperinflate patient as appropriate.
• For conscious, non-ventilated patients, ask the patient to
inhale deeply at least five (5) times; use oxygen as ordered.
• For unconscious or ventilated adult patients, hyperoxygenate
the patient at least 5-6 times over 30-60 seconds as ordered
by provider or to maintain vital signs and oximetry within
normal limits. 100 percent oxygen is most commonly used.

Page 6 of 8

viii. Quickly but gently advance the catheter with sterile glove into the
artificial airway until a cough is stimulated then pull back one (1)
centimeter.
ix. Apply intermittent suction and withdraw catheter over 10 seconds
or less, rotating catheter as it is withdrawn.
x. Oxygenate patient between suctioning passes. Procedure may be
repeated 2-3 times to clear airway. Allow patient to rest for 30-60
seconds between suction passes.
xi. Discard suction kit after use.
4. As patient tolerates, repeat suction procedure until patient's airway is clear.
a. Auscultate breath sounds to determine adequacy of suctioning.
b. Incomplete removal of secretions may cause airway obstruction.
c. If needed, change the inner cannula of the tracheostomy tube; secretions
can adhere to the inner cannula.
5. Suction oral cavity with Yankauer (tonsil tip) to remove oral secretions, as
needed. Clean Yankauer with saline after each use.
6. Turn off suction device. Wrap connection tubing around suction gauge to keep
it out of the way.
7. Assess and document amount, color, consistency and any additional
description of procedure in the patient’s clinical record.
8. Date and replace bottle of saline every 24 hours.
9. Suction canister liners used for airway suctioning are changed daily.

V. PROCEDURE FOR TRACHEOSTOMY TUBE CHANGES

A. Equipment
1. Sterile tracheostomy tube (current size and one size smaller)
2. Sterile water
3. Sterile container
4. Syringe 10 mL (for cuffed tube)
5. Tracheostomy Tube Ties
6. Suction catheter
7. Resuscitation bag and mask of appropriate size with tracheostomy adaptor
8. Blanket roll to extend neck
9. Sterile gloves
10. Water soluble lubricant
11. Suction Kit
B. Procedure
1. Routine tracheostomy changes are to be completed by RT staff or provider.
The first tracheostomy change must be performed by the placing service. In an
emergency, registered nurses (if trained) may change a trach tube.
2. It is recommended that a provider participate in any non-routine tracheostomy
change such as:
a. Fresh tracheostomy less than one (1) week post-op
b. Tube size or type change
c. History of difficult change
d. Unstable patient, or
e. Tube has never been changed.

Page 7 of 8

3. Patients may be NPO for one (1) hour prior to routine tube changes to
minimize risk of vomiting and aspiration.

VI. UWHC CROSS REFERENCES

A. Appendix A, Procedure for Irrigation of Tracheostomies/Stomas in the Adult
Otolaryngology Patient Population (see Related section on U-Connect)
B. Appendix B, Pictures of Tracheostomy Tube Types (see Related section on U-
Connect)
C. Health Facts For You 5340, Tracheostomy Care at Home
D. Hospital Administrative Policy 13.08, Hand Hygiene
E. Nursing Patient Care Policy 7.11A, Care of the Intubated Patient (Adult)
F. Nursing Patient Care Policy 7.19P, Care of the Patient with a Tracheostomy Tube
(Pediatric)
G. Respiratory Care Services Policy 3.20, Pulse Oximetry Check & Continuous
Monitoring (Includes Ambulating SPO2)
H. Respiratory Care Services Policy 3.45, Tracheostomy Change and Weaning
I. Respiratory Care Services Policy 3.46, Speaking Valves

VII. REFERENCES

A. American Thoracic Society (2000). Care of the child with a chronic tracheostomy.
American Journal Respiratory Critical Care Medicine, 161, 297-308.
B. Ireton, J. (2007). Tracheostomy suction: A protocol for practice. Pediatric
Nursing, 19(10), 14-19.
C. John, R. E. (2004). Airway management. Critical Care Nurse, 24(2), 93-96.
D. Lynn-McHale Wiegand, D. J., & Carlson, K. K. (Eds.) (2011). AACN Procedure
Manual for Critical Care (6
th
Ed.). Philadelphia, PA: WB Saunders Co.
E. Mathur, N. N. (2008). Pediatric tracheostomy: Treatment. Accessed at
www.emedicine.medscape.com McClean, E. B. (2012). Tracheal suctioning in
children with chronic tracheostomies: a pilot study applying suction both while
inserting and removing the catheter. Journal of Pediatric Nursing, 27(1), 50-54.
F. Verger, J. T., & Lebet, R. M. (Eds.) (2008). AACN Procedure Manual for
Pediatric Acute and Critical Care. St. Louis, MO: WB Saunders Co.
G. Zhu, H., Das, P., Woodhouse, R., Kubba, H. (2014). Improving the quality of
tracheostomy care. Breathe, 10(4), 287-294.
H. Kozin, E., Straton, J., and Kapo, J. (2012). Tracheostomy care #250. Journal of
Palliative Medicine, 15(3), 359-360.
I. Crosbie, R., Cairney, J., Calder, N., (2014). The tracheostomy clinical nurse
specialist: an essential member of the multidisciplinary team. Journal of
Laryngology and Otology, 128, 171-173.
J. Pearce, L, (2014). High risk that calls for better training. Nursing Standard,
29(1), 25-26.
K. Barnett, M., (2012). Back to basics: caring for people with a tracheostomy,
Nursing and Residential Care, 14(8), 390-394.
L. Schriber, M.L., Tracheostomy: Site care, suctioning and readiness. Medsurg
Nursing, 24(2), 121-122.
M. Dawson, D., (2014). Essential principles; tracheostomy care in the adult patient.
British Association of Critical Care Nurses, 19(2), 63-72.

Page 8 of 8

N. Morris, L.L., McIntosh, E., and Whitmer, A., (2014). The importance of
tracheostomy progression in the intensive care unit. Critical Care Nurse, 34(1),
40-49.
O. Mitchell, R.B., Hussey, H.M., Setzen., G., Jacobs, I.N., Nussenbaum, B., Dawson,
C., Brown, C.A., Brandt, C., Deakens, K., Hartnick, C., and Merati, A. (2016).
Clinical consensus statement: Tracheostomy care. Otolaryngology-Head and
Neck Surgery, 148(1), 6-20.
P. Sole, M.L., Aragon Penoyer, D., Sokol, S., Talbert, S., Bennett, M., and Wilson,
J., (2014). Characteristics, resource utilization and nursing care of patients who
undergo percutaneous tracheostomy. Clinical Nurse Specialist, 288-295.
Q. Rassekh, C.H., Zhao, J., Martin, N.D., Chalian, A.A., and Atkins, J.H., (2015).
Tracheostomy complications as a trigger for an airway rapid response: Analysis
and quality improvement considerations. Otolaryngology, 153(6), 921-
926.Weiland, A. (2016) Personal Communication.


VIII. REVIEWED BY

Respiratory Care Supervisor
Clinical Nurse Specialist, Cardiovascular ICU
Clinical Nurse Specialist, Trauma Life Support Center
Clinical Nurse Specialist, Gyn, Onc, ENT and Plastics
Clinical Nurse Specialist, Emergency Department
Nurse Manager, Gyn, Onc, ENT and Plastics
Nursing Patient Care Policy and Procedure Committee, November 2016

SIGNED BY

Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer