Tracheostomy care:

An evidence-based guide to
suctioning and dressing changes
Read up on the latest recommendations.
By Betty Nance-Floyd, MSN/Ed, RN, CNE

TRACHEOSTOMY CARE and tracheal • liquefying secretions • appropriate patient positioning

suctioning are high-risk procedures. • using the proper-size suction • evaluation.
To avoid poor outcomes, nurses catheter and insertion distance Also, be sure to keep emergency
who perform them—whether they’re
seasoned veterans or novices—must
adhere to evidence-based guidelines.
In fact, experienced nurses may
Trach tube positioning
overestimate their own trach care This illustration shows proper positioning of the tracheostomy tube. The upper
airway remains intact.
competence.
Tracheostomy patients aren’t
seen only in intensive care units. As
patients with more complex condi-
tions are admitted to hospitals, an
increasing number are being
housed on general nursing units.
Trach patients are at high risk for Epiglottis
airway obstruction, impaired venti-
lation, and infection as well as oth-
er lethal complications. Skilled bed-
Larynx
side nursing care can prevent these Thyroid (voicebox)
complications. This article describes cartilage
evidence-based guidelines for tra-
cheostomy care, focusing on open
and closed suctioning and site care. Cricothyroid
membrane Vocal
Suctioning a trach tube cords
A trach tube may have a single or Cricoid
double lumen; it may be cuffed or cartilage
uncuffed, fenestrated (allowing Trachea
speech) or unfenestrated. Each vari-
ation requires specific management.
For instance, before suctioning a
fenestrated tube, you must insert a
plain inner tube, because a suction Esophagus
Tracheostomy
catheter may puncture the small
tube
opening of the fenestrated tube.
(See Trach tube positioning.)
Regardless of the type of tube
used, suctioning always involves:
• assessment
• oxygenation management
• use of correct suction pressure

14 American Nurse Today Volume 6, Number 7 www.AmericanNurseToday.com

 to-nurse shift report and to the inter-
Be prepared for trach emergencies disciplinary team during daily rounds.
Emergency preparation starts during the shift-change safety huddle—the formal
communication between outgoing and oncoming shifts. Patients with trach tubes Trach site care and dressing
can’t call for assistance verbally, so all staff members (including the unit secretary) changes
need to know which patients on the unit have trach tubes. Tracheostomy dressing changes pro-
Keep the following emergency equipment at the bedside of trach patients:
mote skin integrity and help prevent
• manual ventilator bag
infection at the stoma site and in the
• two extra trach tubes—one of the patient’s current size and a smaller one
• an obturator of the correct size respiratory system. Typically, health-
• suctioning device and catheters. care facilities have both formal and
informal policies that address dress-
ing changes, although no evidence
equipment nearby. (See Be prepared catheter size shouldn’t exceed half suggests a particular schedule of
for trach emergencies.) the inner diameter of the internal dressing changes or specific supplies
trach tube. To determine the appro- for secretion absorption must be
When to suction priate-size French catheter, divide used. On the other hand, the evi-
Suctioning is done only for patients the internal trach tube size by two dence does show that:
who can’t clear their own airways. and multiply this number by three. • secretions can cause maceration
Its timing should be tailored to A #12 French catheter is routine- and excoriation at the site
each patient rather than performed ly used for closed suctioning. Pre- • the site should be cleaned with
on a set schedule. measure the distance needed for in- NSS
Start with a complete assessment. sertion. Experts suggest 0.5 to 1 cm • a skin barrier should be applied
Findings that suggest the need for past the distal end of the tube for to the site after cleaning
suctioning include increased work an open system, and 1 to 2 cm past • loose fibers increase the infec-
of breathing, changes in respiratory the distal end for a closed system. tion risk
rate, decreased oxygen saturation, • the trach tube should be secured
copious secretions, wheezing, and Liquefying secretions at all times to prevent accidental
the patient’s unsuccessful attempts The best ways to liquefy secretions dislodgment, using the two-person
to clear secretions. According to are to humidify secretions and hy- securing technique described be-
one researcher, fine crackles in the drate the patient. Do not use nor- low under “Securing the trach
lung bases indicate excessive fluid mal saline solution (NSS) or normal tube.”
in the lungs, and wheezing patients saline bullets routinely to loosen Start by assessing the stoma for
should be assessed for a history of tracheal secretions because this infection and skin breakdown
asthma and allergies. practice: caused by flange pressure. Then
• may reach only limited areas clean the stoma with a gauze
Suctioning technique • may flush particles into the low- square or other nonfraying material
Before suctioning, hyperoxygenate er respiratory tract moistened with NSS. Start at the
the patient. Ask a spontaneously • may lead to decreased post- 12 o’clock position of the stoma
breathing patient to take two to suctioning oxygen saturation and wipe toward the 3 o’clock po-
three deep breaths; then administer • increases bacterial colonization sition. Begin again with a new
four to six compressions with a • damages bronchial surfactant. gauze square at 12 o’clock and
manual ventilator bag. With a venti- Despite the potential harm caused clean toward 9 o’clock.
lator patient, activate the hyperoxy- by NSS use, one survey found that To clean the lower half of the
genation button. 33% of nurses and respiratory thera- site, start at the 3 o’clock position
Experts recommend using suc- pists still use NSS before suctioning. and clean toward 6 o’clock; then
tion pressure of up to 120 mm Hg Other researchers have found that wipe from 9 o’clock to 6 o’clock,
for open-system suctioning and up inhalation of nebulized fluid also is using a clean moistened gauze
to 160 mm Hg for closed-system ineffective in liquefying secretions. square for each wipe. Continue this
suctioning. For each session, limit pattern on the surrounding skin
suctioning to a maximum of three Evaluation and tube flange.
catheter passes. During catheter ex- When evaluating the patient after Avoid using a hydrogen peroxide
traction, suctioning can last up to suctioning, assess and document mixture unless the site is infected,
10 seconds; allow 20 to 30 seconds physiologic and psychological re- as it can impair healing. If using it
between passes. sponses to the procedure. Convey on an infected site, be sure to rinse
For open-system suctioning, your findings verbally during nurse- afterward with NSS.

www.AmericanNurseToday.com July 2011 American Nurse Today 15

Dressing the site
At least once per shift, apply a new dressing to the YOU LIVE FOR YOUR JOB.
stoma site to absorb secretions and insulate the skin.
After applying a skin barrier, apply either a split-drain or OTHERS LIVE BECAUSE OF IT.
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 eas-
ier to apply.
The literature overwhelmingly recommends a two-
person technique when changing the securing device
to prevent tube dislodgment. In the two-person tech-
nique, 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 per-
forms 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 evidence-
based practice, consider urging colleagues and man-
agers to conduct a patient-care study comparing differ-
ent approaches to suctioning. Then follow the
evidence by advocating for changes if necessary. ✯

Selected references
Chulay M. Suctioning: endotracheal or tracheostomy tube. In: Wie-
gand DJ, Carlson KK, eds. AACN Procedure Manual for Critical
Care. 6th ed. Philadelphia, PA: Elsevier Saunders; 2010:62-70.
Dennis-Rouse MD, Davidson JE. An evidence-based evaluation of tra-
cheostomy care practices. Crit Care Nurs Q. 2008;31(2):150-160.
Edgtton-Winn M, Wright K. Tracheostomy: a guide to nursing care. Aust
Nurs J. 2005;13(5):1-4.
Harkreader H, Hogan MA, Thobaben M. Fundamentals of Nursing:
Caring and Clinical Judgment. 3rd ed. Philadelphia, PA: Saunders;
2007.
Klockare M, Dufva A, Danielsson AM, et al. Comparison between
direct humidification and nebulization of the respiratory tract at me-
chanical ventilation: distribution of saline solution studied by gamma
camera. J Clin Nurs. 2006;15(3):301-307.
Nursing is a passion first and a
Kuriakose A. Using the Synergy Model as best practice in endotra- job second. That’s why we offer
cheal tube suctioning of critically ill patients. Dimens Crit Care Nurs. healthcare professionals far more
2008;27(1):10-15. than just jobs. You’ll connect with
Lewis SL, Dirksen SR, Heitkemper MM, Bucher L, Camera I. Med- others who share your passion in the
ical-Surgical Nursing: Assessment and Management of Clinical healthcare community, for career or
Problems. 8th ed. St. Louis, MO: Mosby; 2010. just social networking. Plus, check
out Monster career resources and
Smith-Miller C. Graduate nurses’ comfort and knowledge level re-
find expert advice that can help
garding tracheostomy care. J Nurses Staff Dev. 2006;22(5):222-229.
you do what you do, better.
Wiegand DJ, Carlson KK, eds. AACN Procedure Manual for Critical
Care. 6th ed. Philadelphia, PA: Elsevier Saunders; 2010. FIND OUT WHERE
YOU’RE NEEDED MOST AT
Betty Nance-Floyd is a clinical assistant professor at the University of North HTTP://HEALTHCARE.MONSTER.COM
Carolina at Chapel Hill School of Nursing.

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