A tracheostomy (trach) is a surgically created opening (stoma) through the neck and into the windpipe (trachea) to establish a direct airway. This stoma holds a specialized tube that allows a person to breathe without using their nose or mouth. Because the tube bypasses the body’s natural air-filtering and humidifying mechanisms, meticulous care is required to maintain a clear path for air and prevent infection. Daily care and routine suctioning are necessary procedures to avoid the buildup of mucus plugs and keep the stoma site healthy, ensuring the individual can breathe safely.
Preparation and Essential Supplies
Before beginning any tracheostomy care, gather all necessary materials to avoid leaving the patient unattended or breaking sterile technique. A typical care kit includes sterile gloves, a specialized brush for cleaning the inner cannula, cotton-tipped applicators, and gauze pads. You will also need a cleaning solution, usually normal saline or sterile water, and potentially a diluted hydrogen peroxide solution for stubborn secretions, as instructed by a healthcare provider.
Essential equipment includes a portable suction machine, appropriate-sized suction catheters, a connection tube, and sterile water or saline for flushing the tubing. For safety, always keep a spare tracheostomy tube of the same size, an obturator (the guide used for tube insertion), and a manual resuscitation bag (Ambu bag) readily available at the bedside. Begin by washing your hands thoroughly, setting up a clean work area, and positioning the individual comfortably, often in a semi-Fowler’s position (head of the bed raised) to optimize breathing.
Routine Stoma and Outer Cannula Cleaning
Cleaning the stoma site and the exterior of the tracheostomy tube prevents skin breakdown and infection from accumulated secretions. Start by gently removing any soiled dressing from beneath the tube’s faceplate and inspecting the skin around the stoma for signs of irritation, such as redness, swelling, or unusual discharge. The cleaning process involves using cotton-tipped applicators or gauze pads dampened with saline or the specified cleaning solution.
Wipe the skin around the stoma and the outer cannula’s faceplate, always cleaning outward to move bacteria away from the airway opening. For dried or crusted secretions, a half-strength hydrogen peroxide solution may be used, followed by a rinse with sterile saline or water to prevent irritation. After cleaning, use dry gauze to pat the skin and the flange of the outer tube completely dry, as moisture promotes bacterial growth.
Finally, secure the tube by applying a clean, specialized tracheostomy dressing (pre-cut gauze) under the faceplate and replacing soiled trach ties or holders. To change the ties, hold the outer cannula firmly in place while the old tie is cut and the new one is threaded through the faceplate. The new tie should be snug enough to prevent tube movement but loose enough to allow the insertion of one or two fingers comfortably beneath it, ensuring circulation is not compromised.
Managing the Inner Cannula and Suctioning
The inner cannula is a removable tube inside the outer cannula, serving as the primary barrier against secretion buildup that could block the airway. For reusable cannulas, the tube is unlocked and removed. It is then immersed in a cleaning solution, such as diluted hydrogen peroxide, to loosen secretions before being scrubbed thoroughly with the specialized brush. The cleaned cannula must be fully rinsed with sterile water or saline to remove all traces of cleaning solution and then dried before being reinserted and locked securely back into the outer tube.
Airway clearance is managed through suctioning, performed only as needed—when breathing sounds noisy, secretions are visible, or the individual feels congested. The suction catheter size should be no more than half the diameter of the tracheostomy tube to allow air to pass around it during insertion. After connecting the catheter to the suction tubing, insert it gently into the tracheostomy tube without applying suction, advancing it until resistance is felt or the individual coughs.
Suction is applied only as the catheter is being withdrawn, typically by covering the thumb port, while simultaneously rotating the catheter to clear secretions. The entire process, from insertion to complete withdrawal, should take no more than 10 to 15 seconds to prevent oxygen deprivation. After each suction pass, flush the catheter with saline to clear the secretions and allow the individual a rest period of at least 30 seconds to recover before attempting another pass.
Recognizing and Addressing Common Complications
Even with careful daily maintenance, it is important to recognize and respond quickly to potential complications, especially those affecting the airway. Signs of infection at the stoma site include increased redness, swelling, tenderness, fever, or thick, discolored, or foul-smelling drainage. These signs require a prompt call to a healthcare provider for evaluation and potential treatment.
A complication is tube obstruction, typically caused by a thick mucus plug, presenting as sudden difficulty breathing, noisy airflow, or an inability to pass a suction catheter. The immediate response is to suction the obstruction; if suctioning fails, the inner cannula must be removed and replaced immediately, as this often clears the blockage. Accidental decannulation, where the tube comes completely out of the stoma, is particularly dangerous if it occurs within the first week after placement.
If the tube is dislodged, the individual will likely experience immediate respiratory distress. The emergency response involves immediately calling emergency medical services and then attempting to reinsert the spare tracheostomy tube using the obturator. If reinsertion is unsuccessful, the stoma should be covered with a sterile dressing, and rescue breaths should be administered while awaiting professional help.