A tracheostomy is a surgically created opening, or stoma, established through the neck and into the trachea (windpipe). While this procedure provides an alternative airway for breathing, it bypasses the body’s natural humidification and filtration mechanisms. When these natural defenses are circumvented, the patient becomes highly susceptible to foreign pathogens entering the lower respiratory tract, significantly increasing the risk of serious lung infections like pneumonia. Therefore, the consistent application of meticulous infection control measures is paramount in the daily care of any patient with a tracheostomy tube.
Foundational Principles of Aseptic Technique
The first line of defense against infection involves rigorous adherence to hand hygiene protocols before and after every patient interaction. Healthcare providers must use an alcohol-based hand rub or soap and water to minimize the transfer of microorganisms. The proper donning of Personal Protective Equipment (PPE) is also required to protect both the patient’s open airway and the caregiver from exposure to respiratory secretions.
PPE typically includes wearing a gown and clean gloves for general care. A mask and eye protection, such as a face shield, should be added whenever there is a risk of splashing or aerosol generation, such as during coughing or suctioning. Establishing a sterile field is necessary for any procedure that involves entering the airway.
A distinction is made between the “sterile technique” required for inner airway procedures and the “clean technique” appropriate for routine external stoma site cleaning. While external cleaning can often be performed using clean gloves and equipment, any intrusion into the tracheostomy tube must be managed with sterile equipment and gloves. This prevents the introduction of pathogens directly into the lungs.
Minimizing Risk During Suctioning Procedures
Tracheal suctioning carries a high risk of introducing bacteria into the lower airway, requiring strict sterile technique. This involves using pre-measured, single-use, sterile suction catheters, which must be handled with a sterile hand throughout the procedure. The non-dominant hand is designated as the “clean” hand, managing suction controls and tubing while avoiding contact with the catheter that enters the airway.
Suction pressure must be carefully regulated, typically maintained between 80 to 120 millimeters of mercury (mmHg) for adults, and should never exceed 150 mmHg. This regulation prevents trauma to the tracheal lining, as mucosal damage creates micro-abrasions that increase infection risk. Catheter insertion should employ a “no-touch” technique, guiding the sterile catheter tip into the tracheostomy tube without touching the outer cannula or the stoma site.
The duration of suction application is strictly limited to 10 to 15 seconds per pass to minimize oxygen desaturation and tissue trauma. The catheter must be immediately disposed of after the procedure to eliminate contamination. Although sterile saline is used to clear the suction tubing, routine instillation of saline directly into the tracheostomy tube to loosen secretions is discouraged, as it can increase bacterial colonization.
Stoma Site and Dressing Management
The skin surrounding the tracheostomy stoma is vulnerable to moisture-related skin breakdown and infection due to constant secretions. The stoma site must be cleaned at least once every 24 hours, and immediately if the dressing becomes soiled or wet. Cleaning involves using a prescribed solution, such as normal saline, to gently clean the skin, working outward from the stoma opening to pull contaminants away from the airway.
For dried secretions or crusting, a cotton-tipped applicator soaked in sterile saline may be used to loosen the material. Following cleaning, the skin must be dried thoroughly to prevent tissue maceration, which accelerates skin breakdown and potential infection. A sterile, pre-cut tracheostomy dressing is then applied beneath the flange of the tube to absorb secretions and maintain a dry barrier.
Only pre-cut dressings should be used, as cutting gauze at the bedside can create loose fibers that might be inhaled into the airway. The site should be visually inspected for signs of infection during every dressing change. These signs include redness, swelling, tenderness, or any change in the color or odor of the discharge, which signals a need for medical evaluation.
Maintaining Equipment Sterility
The tracheostomy system components require frequent attention to maintain a sterile environment. The inner cannula, which is cleaned or replaced on a scheduled basis, prevents the outer tube from becoming blocked with thick secretions. Non-disposable inner cannulas must be cleaned using an aseptic technique, involving soaking and brushing with a cleaning solution, followed by a thorough rinse and air-drying before reinsertion.
The cleaning or replacement schedule for the inner cannula is determined by the patient’s secretions, but should occur at least every 12 to 24 hours. Tracheostomy ties or specialized holders must be kept clean and dry to prevent skin irritation and bacterial buildup. When changing soiled ties, a two-person technique is recommended to safeguard against accidental dislodgement.
For patients requiring humidification or mechanical ventilation, maintaining the respiratory tubing is important to prevent contamination. Water condensation collecting in the ventilator circuit tubing is a significant source of bacteria. This fluid must be managed by draining it away from the patient’s airway, never allowing it to flow back into the tracheostomy tube. All respiratory equipment must be changed or disinfected according to prescribed schedules to reduce biofilm formation that harbors pathogens.