20/1/2018 Tracheostomy care: An evidence-based guide - American Nurse Today

Tracheostomy care: An evidence-based guide

July 2011 Vol. 6 No. 7
Author: Betty Nance-Floyd, MSN/Ed, RN, CNE

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 competence. 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 cu ed or uncu ed, fenestrated
(allowing speech) or unfenestrated. Each variation requires speci c 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:
assessment
oxygenation management
use of correct suction pressure
liquefying secretions
using the proper-size suction catheter and insertion distance
appropriate patient positioning
evaluation.
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, ne crackles in the lung bases indicate excessive uid in the lungs, and wheezing patients should
be assessed for a history of asthma and allergies.

Suctioning technique
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 button. 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 between passes. 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.

Liquefying secretions
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 practice:

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may reach only limited areas

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20/1/2018 Tracheostomy care: An evidence-based guide - American Nurse Today
may ush particles into the lower respiratory tract
may lead to decreased postsuctioning oxygen saturation
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 uid also is ine ective in liquefying secretions.

Evaluation
When evaluating the patient after suctioning, assess and document physiologic and psychological responses to the procedure. Convey your
ndings verbally during nurse-to-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 speci c 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 NSS
a skin barrier should be applied to the site after cleaning
loose bers increase the infection risk
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 tube.”
Start by assessing the stoma for infection and skin breakdown caused by ange 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 ange. 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 to apply. The literature overwhelmingly recommends a two person 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
di erent approaches to suctioning. Then follow the evidence by advocating for changes if necessary.
Selected references
Chulay M. Suctioning: endotracheal or tracheostomy tube. In: Wiegand 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 tracheostomy 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 humidi cation and nebulization of the respiratory tract at
mechanical ventilation: distribution of saline solution studied by gamma camera. J Clin Nurs. 2006;15(3):301-307.
Kuriakose A. Using the Synergy Model as best practice in endotracheal tube suctioning of critically ill patients. Dimens Crit Care
Nurs. 2008;27(1):10-15.
Lewis SL, Dirksen SR, Heitkemper MM, Bucher L, Camera I. Medical-Surgical Nursing: Assessment and Management of Clinical Problems. 8th
ed. St. Louis, MO: Mosby; 2010.
Smith-Miller C. Graduate nurses’ comfort and knowledge level regarding tracheostomy care. J Nurses Sta Dev. 2006;22(5):222-229.
Wiegand DJ, Carlson KK, eds. AACN Procedure Manual for Critical Care. 6th ed. Philadelphia, PA: Elsevier Sauders; 2010.
Betty Nance-Floyd is a clinical assistant professor at the University
(https://www.americannursetoday.com/goto/http://application.aspen.edu/aspenu/rn_bsn_mr3/ANT1029) of North Carolina at
Chapel Hill School (https://www.americannursetoday.com/goto/http://application.aspen.edu/aspenu/rn_bsn_mr3/ANT1029) of
Nursing.

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