6 Essential Tracheostomy Care Steps: A Comprehensive Guide

Caring for a tracheostomy can be pretty intimidating, especially for new nurses. Airways can be scary! In this post, we will explore tracheostomy care steps so that you’ll feel more comfortable and confident in no time.

Disclaimer: This is a sample of common tracheostomy care steps. Your organization will have a step-by-step procedure and corresponding policy to guide your steps.

This post is very long. Please click on the table of contents below👇 to jump to specific topics!

Definition of Tracheostomy

A tracheostomy is a surgical procedure that involves creating a stoma in the front of the neck, leading directly into the trachea. This procedure allows for inserting a tracheostomy tube, facilitating an alternate airway and aiding in breathing for patients who cannot breathe through their nose or mouth.

This is usually done by inserting a tracheostomy tube into the opening, which allows air to enter the lungs directly.

A tracheotomy is considered new for about seven days after surgery. The tract that the tube follows into the patient’s airway won’t remain open if the tube is removed during the first few days. Therefore new trachs (often called “fresh trachs”) are very important to care for with extreme caution.

Frequent Indications for Tracheostomy

This procedure is often indicated for various medical conditions, including long-term mechanical ventilation in conditions such as respiratory failure, neuromuscular disorders, high cervical spine features, or prolonged unconsciousness.

Other indications include the need for airway access in cases of upper airway obstruction, managing secretions, or when prolonged intubation is anticipated.

Cricothyrotomy versus Tracheostomy

Both procedures are used to establish emergency airways but differ in location and invasiveness. A cricothyrotomy (mini tracheostomy) involves an incision through the cricothyroid membrane, a small neck opening above the trachea. It is often used in emergencies to address upper airway obstruction and aspirate airway secretions.

In contrast, a tracheostomy creates a more permanent opening directly into the trachea below the cricoid cartilage, typically for long-term respiratory support. This planned procedure is performed in a controlled setting. If a patient is in an ICU, it can be performed at the bedside or in the operating room.

Types of Tracheostomy Tubes

There are different types of tracheostomy tubes designed to meet specific patient needs. The most popular are the following:

• Cuffed tubes ➡️ These tubes have a balloon around the lower part that can be inflated with air or saline to create a seal against the trachea wall. This helps prevent air leaks and allows for positive pressure ventilation (PPV). The Shiley tracheostomy tubes are made of plastic, have a cuff, and are commonly used. 
• Uncuffed tubes ➡️ These tubes do not have a cuff and are typically used for longer-term patients who do not require PPV. They are also used for patients with many secretions that often need suctioning. These tubes lack an inflatable cuff, reducing the risk of pressure-related complications and allowing for more comfortable long-term use.

There are plastic tubes, silicone tubes, and metal tubes. The trach can also have the following features:

• Fenestrated tubes: These tubes have a small opening on the side of the outer cannula that allows air to pass through the vocal cords. This can help patients speak with their tracheostomy tube in place.
  • Important note ➡️ You can only speak with a tracheostomy if it is an established trach. “Fresh trachs” need to heal more before a speaking valve can be used.
• Double-lumen tubes: These tubes have two channels, one for inhalation and one for exhalation. They are used in patients who require mechanical ventilation but also need to be able to cough and clear secretions.

The choice of tracheostomy tube depends on various factors, such as the patient’s medical condition, the need for ventilation, and individual anatomical considerations. The physician who inserts the tube will make the choice, not the nurse.

This medical device is similar to a central line in that we do not insert them, but we are responsible for care, surveillance, and maintenance.

Routine Trach Care vs. PRN Suctioning

You will be required to provide full trach care at a minimum of once per shift, but possibly more often (check your hospital’s policy). This includes cleaning, suctioning, changing the tube and trach ties, and a general inspection of the area.

Trach suctioning is much less involved and is done more frequently. If you notice your patient is coughing more or struggling to clear secretions from their airway, you can suction out their airway.

Both trach care and trach suctioning are sterile procedures. We will discuss trach suctioning within the next section on tracheostomy care steps, but please know that you can suction without the full in-depth cleaning steps as needed.

Tracheostomy Supplies

One thing you will quickly pick up on as a nurse caring for trach patients is the amount of stuff in their room. These are all 100% necessary, it just really adds up quickly!

• Tracheostomy kits: A tracheostomy kit should be with the patient at all times, and the nurse responsible for the patient should verify its contents during each shift to ensure the availability of all necessary equipment. These kits typically contain sterile containers, nylon brushes, sterile applicators, and gauze squares. A suction catheter kit, saline solution, medical gloves, towels, a moisture-proof bag, tracheostomy dressing, cotton twill ties, and sterilized scissors are recommended.
• Tracheostomy masks: These are designed to deliver oxygen directly to a patient’s tracheostomy site, providing a secure fit over the tracheostomy tube. The tracheostomy mask is crucial for patients requiring supplemental oxygen or those undergoing respiratory therapy. 
• Tracheostomy collars: These adjustable straps secure around the neck and support the tracheostomy tube. They help maintain proper tube placement and prevent accidental displacement. The collars’ adjustable nature allows for a customized fit.
• Suction and suction catheters: The patient must have suction on and readily available. They will require frequent suction of their airway, which is sterile. This means there will be at least 4-5 suction catheter packages at the bedside
• Extra tracheostomy tubes (same size as current tube + one size smaller) and obturator: An obturator is a curved rod that fits inside the tracheal cannula. This, plus the extra tubes, must be at the bedside in case of dislodgement as stomas can quickly close.

Now that you know all of the different supplies, let’s start digging into routine tracheostomy care steps.

Daily Tracheostomy Care Steps

Tracheostomy care should be performed routinely, but frequency may vary based on the patient’s needs. If a patient is in the ICU with a brand new trach, that will require much more frequent care than someone who has had one for 15 years and was admitted for something unrelated to their respiratory status.

Let’s go through the step-by-step tracheostomy care steps.

Prepare the Equipment and Environment

Hand 🤚 hygiene: Duh. Go wash your hands. Gross, I can’t believe you’d even think about doing this without washing your hands … or at least use some hand sani.

Gather necessary supplies. Supplies often include sterile gloves, normal saline or prescribed cleaning solution (check orders and policy!), sterile gauze, a new disposable inner cannula (if applicable for the tracheostomy type), tracheostomy cleaning brush or cotton-tipped applicators, new trach ties or Velcro strap, and a container for dirty supplies. If you think you’ll need to suction the patient, make sure you get a suction catheter and extra sterile gloves.

Explain the procedure to the patient to reduce anxiety and ensure cooperation if awake. Remember, this isn’t cleaning the cut on their arm; this is cleaning their airway, which can be pretty scary.

Comfortably position the patient, ensuring proper support for their head and neck and positioning the bed 🛏️ so that you are not straining your back. Because this is a sterile procedure, you won’t be able to adjust the bed height once your sterile gloves are in place.

Assess their respiratory 🫁 status. We want something to compare to after we are done, so listen to their lungs, note their oxygen saturation, notice their work of breathing, and observe their skin color and mucous membranes.

Get yourself ready 💅. I like to use my patient’s bedside table as a workspace. Remove their belongings and clean off the table with a Cavi wipe. Then, prepare your workspace by opening your trach care kit and other necessary supplies nearby. Put on your surgical mask, gown, and clean gloves as required by your facility’s protocols.

Assess the area. Inspect the tracheostomy and stoma site for signs of infection, skin breakdown, or drainage, and check the tightness of the tracheostomy tube ties. Make a mental note 📝 of what you observe to document later.

Prepare your sterile 🥅 field. Before donning sterile gloves, open the sterile kit and use the packaging to create a sterile field. Often, this means carefully removing the drape with your clean-gloved hands and placing it on the patient’s chest by just touching the edges. Removing this drape exposes an area in the kit for you to carefully pour your solution in (which probably isn’t sterile since you grabbed it separately). Open the saline or prescribed cleaning solution and pour it into the designated container within the kit in a way that maintains the sterility of the solution and the container. This step is crucial for preserving sterility throughout the procedure.

Suction, If Necessary

Your patient may not require suctioning at this time, but you if think they need their airway cleared, this would be the best time to do so. The last thing we want is for our nicely cleaned trach to get dirty immediately.

Pre-oxygenate the patient if recommended. This prevents hypoxia during the procedure. (You would do that with clean gloves, rather than sterile.) Let the patient know you will suction out the secretions and explain what you’ll do so they’re not surprised, as you will elicit a cough.

Get your suction catheter and your suction tubing ready. Put on sterile gloves.

It’s helpful to hold the suction catheter with your dirty hand while securing the clean one into the suction with your clean hand. Connect the sterile suction catheter to the suction tubing.

Gently insert the catheter into the trach tube without applying suction. Advance it until resistance is met or the patient coughs, then withdraw it slightly before applying suction. While withdrawing the catheter, apply intermittent suction by covering and uncovering the suction port, and rotate the catheter between your fingers.

Limit suctioning to 10-15 seconds to minimize hypoxia and irritation. After suctioning, reassess the patient’s respiratory status, and provide supplemental oxygen if needed. You may need to swap out for a new set of clean sterile gloves if both got dirty during this process.

Let’s Get to Cleaning! 🧼

Before we can start cleaning the area, there is an important method to the madness of performing this sterile procedure by yourself. It would be ideal for two nurses to perform this task, with one sterile and one assistant. However, that’s not feasible in the healthcare environment. We need to be able to do this task by ourselves. To successfully complete our tracheostomy care steps, we need to establish a clean hand and a dirty hand.

When you are ready to remove the dirty inner cannula, it’s important to minimize the risk of contaminating your sterile field or the sterile gloves. Designate your dominant hand as the “clean” hand and the other as the “dirty” hand. The “dirty hand” can handle the potentially contaminated inner cannula. In contrast, the “clean” hand remains sterile for tasks requiring sterility, such as handling the new inner cannula or cleaning around the stoma.

Deflating the Cuff

When changing a disposable tracheostomy tube, it is necessary to deflate the cuff. The cuff is the inflatable part of the tracheostomy tube that seals the space between the tube and the tracheal wall to prevent air from leaking around the tube during mechanical ventilation and to prevent aspiration.

Deflating the cuff allows for the safe removal of the old tube and insertion of the new one. You will use a special syringe to withdraw air from the cuff prior to removal until resistance is met. The exact amount of air and process for this is completely dependent upon the manufacturer’s instructions.

Cannula Cleanin’

If the patient has a drain sponge in place, use your dirty hand to remove and discard it.

• Unlock the inner cannula and gently remove it. If it’s disposable, discard it according to your facility’s waste disposal policy. If it’s non-disposable, place it in a sterile solution for cleaning.
• For non-disposable ➡️ Clean the inner cannula with a cleaning brush or cotton-tipped applicators and sterile saline. Rinse thoroughly.
• For disposable ➡️ Insert a new one and lock it in place.

Clean the Stoma and Outer Cannula

Use sterile gauze soaked in normal saline to clean around the stoma and the outer cannula. Wipe away from the stoma to avoid dragging contaminants toward it.

Tip ➡️ Squeeze any excess solution from the gauze to prevent dripping into the stoma and accidental aspiration!

You can also use the long Q-Tips dipped in cleaning solution (cotton-tipped applicators) to clean behind the securement device and in small crevices. If the patient has sutures securing the trach in place, clean around those.

Closely inspect the area around the stoma for any signs of infection or irritation. If you’re concerned about infection, you will report that to the medical team once the tracheostomy care steps are complete.

Replace the drain sponge. There is often a square gauze dressing with a keyhole cutout to fit snugly around the trach. These get dirty easily and need to be changed often with fresh trachs. When doing a full cleaning, it’s best to put a fresh one.

Change the Tracheostomy Ties 👔

If a second person is available, have them assist by holding the tracheostomy tube in place to prevent accidental dislodgement. It is ideal to have a second person do this and it is very simple. You’re doing all the hard tracheostomy care steps!

Remove the old trach ties, ensuring the tracheostomy tube is secured at all times.

Thread new, clean trach ties through the flanges of the tracheostomy tube and secure them. Ensure the fit is snug but not too tight; you should be able to fit one or two fingers comfortably between the tie and the patient’s neck.

Put a new drain sponge in place.

Reinflate the cuff per the manufacturer’s recommendations.

Reassess the Patient

Once the new inner cannula (if disposable) or clean cannula (if not disposable)is in place and everything is clean and secure, reassess the patient’s respiratory status. Check for signs of respiratory distress or discomfort. If they had a trach mask, put that back in place.

Final Touches ✨

Clean up your mess. If you used the patient’s bedside table, throw away your garbage, clean off the table, and put their items back. Ensure they have their call light within reach, and before leaving the room check to see if they need anything else.

Document the procedure in the patient’s medical record, including any observations made during the care, the condition of the stoma site, and the patient’s tolerance of the procedure. Write on your report sheet the time that you completed trach care so that you can inform the on-coming nurse at the end of the shift.

Congratulations! You have completed your tracheostomy care steps!

Tracheostomy Nursing Care Plan

Patients with trachs will have similar needs. Let’s discuss some appropriate nursing diagnoses.

Trach Nursing Diagnoses

The key 🔑 nursing diagnoses for tracheostomy care steps are:

• Ineffective airway clearance related to artificial airway and altered mucous production.
• Risk for infection related to a break in the skin barrier and potential for introduction of pathogens.
• Risk for impaired skin integrity related to friction and moisture around the stoma site.
• Impaired communication related to inability to speak due to tracheostomy tube
• Risk for aspiration related to impaired swallowing mechanism, cough reflex, and presence of tracheostomy tube.
• Risk for deficient knowledge related to tracheostomy care and self-management.

Nursing Assessment Findings For Trach Patients

• Assess respiratory status as ordered and more often if needed: note rate, depth, rhythm, and sounds.
• Assess the tracheostomy site for signs of infection or irritation.
• Monitor oxygen saturation continuously with pulse oximetry.
• Assess patient’s ability to communicate and their level of anxiety.
• Monitor for signs of bleeding or hematoma formation around the tracheostomy site.
• Assess for signs of tracheostomy dislodgment or obstruction.
• Evaluate the need for suctioning and the effectiveness post-procedure.
• Monitor nutritional status and ability to swallow, if applicable.

Planning and Goals

1. The patient will maintain a patent airway at all times.
2. The patient will show no signs of infection at the tracheostomy site.
3. The patient will communicate effectively with the healthcare team and family.
4. The patient will be free from aspiration during the hospital stay.
5. The patient will demonstrate reduced anxiety and increased coping skills.

Interventions

1. Airway Management
   • Perform tracheostomy care every 8 hours or per facility protocol to maintain patency.
   • Suction the tracheostomy as needed, ensuring to pre-oxygenate the patient as per protocol.
   • Monitor and manage humidity and hydration to help thin secretions.
2. Infection Control
   • Use sterile technique during tracheostomy care and suctioning.
   • Change tracheostomy dressings as needed, observing for signs of infection.
   • Administer antibiotics if prescribed, if ordered.
3. Communication
   • Provide the patient with a communication board or other aids if they are unable to speak.
   • Educate the patient and family on how to communicate with the tracheostomy.
4. Aspiration Precautions
   • Keep the head of the bed elevated at least 30 degrees.
   • Assess swallowing ability and collaborate with speech therapy if needed.
   • Provide oral care every 4 hours to reduce bacterial load.
5. Anxiety Reduction
   • Explain all procedures to the patient and family.
   • Show the patient all equipment and supplies first.
   • Ask the patient when would be an ideal time to perform routine cleaning.
   • Encourage family involvement in the patient’s care.
   • Utilize therapeutic communication to reduce anxiety.
   • Offer psychological support and, if needed, consult a mental health professional.

Evaluation

• The patient’s airway remains patent as evidenced by clear breath sounds, normal respiratory rate, and satisfactory oxygen saturation.
• The tracheostomy site is without redness, swelling, or drainage, indicating no infection.
• The patient uses a communication board effectively to express needs.
• The patient has no episodes of aspiration and maintains adequate nutrition.
• The patient reports feeling less anxious and is able to participate in care.

This care plan should be individualized based on the patient’s specific conditions, needs, and responses to interventions. Regular reassessment is crucial to ensure the care plan remains effective and adjusts as the patient’s condition evolves.

Communication and Feeding

Tracheostomy patients may face challenges with communication and feeding, but there are options to help improve their quality of life that go beyond your routine tracheostomy care steps.

Can You Speak With a Tracheostomy?

A common question that patients frequently face is, ‘Can you talk with a tracheostomy?‘ as they consider the impact of the procedure on vocal communication. Speaking valves are one-way valves that attach to the tracheostomy tube and allow air to pass into the trachea, enabling individuals to vocalize and speak.

The speaking valve on tracheostomy redirects airflow, permitting exhaled air to pass through the vocal cords, and facilitating speech without compromising the ability to breathe. This is particularly effective for individuals with a cuffed tracheostomy tube. Speaking valves can be used for patients with tracheostomies once the tracheostomy site is sufficiently healed, and the patient is stable (7 days or more days after the placement). Besides helping the speech, the valves can aid with swallowing and coughing.

On the other hand, a tracheostomy cap serves a dual purpose in supporting speech and providing airway protection. Placing a tracheostomy cap on the tracheostomy tube redirects airflow through the upper airway, allowing individuals to speak more naturally. Moreover, caps help maintain moisture and warmth in the trachea, contributing to enhanced respiratory comfort.

Engaging in speech therapy is essential for individuals with a tracheostomy to enhance their vocalization and communication skills. Speech therapists can provide tailored exercises and techniques to improve speech clarity and strength.

Communication Ideas For Tracheostomy Patients

To communicate with the patient try these ideas:

• A communication board
• Alphabet chart
• A notebook where the patient can write or point
• Speech-generating devices
• Text-to-speech apps
• Communication apps on tablets
• Develop a system for yes/no responses and instead of open-ended questions, provide multiple choices so the patient can say yes/no to each choice

Collaborate with the patient’s family and caregivers to understand the patient’s preferences and unique communication methods.

Can You Eat With a Tracheostomy?

When it comes to eating with a tracheostomy, it is possible with the right precautions. A tracheostomy cap can be used to cover the tracheostomy tube, allowing the patient to eat and drink without the risk of food or liquid entering the airway. 

Most patients may need an enteral feeding tube at first, NG, PEG, jejunostomy tube feeding, or a combination of these approaches can be used. The choice depends on the patient’s overall health, swallowing ability, and the anticipated duration of tracheostomy use.     

Precautions include elevating the head during feeding to minimize the risk of aspiration, closely monitoring for signs of respiratory distress or discomfort, attention to tube placement, intolerance signs, and potential complications.

Before initiating oral intake, a thorough swallowing assessment is crucial to ensure that the individual can swallow safely without the risk of aspiration. This assessment is typically conducted by a speech-language pathologist (SLP). Introducing oral intake may start with small sips of liquids and soft, easy-to-swallow foods, purees, and thick liquids are advised.

A dietitian should also be working with this patient in addition to speech therapy. The progression is gradual and is closely monitored for any signs of aspiration or difficulty swallowing.

Additionally, the bedside swallow evaluation may include observing cough, gag reflexes, and oral motor skills. The instrumental assessments with fluoroscopic swallow studies or FEES (fiberoptic endoscopic evaluation of swallowing) might be used for detailed analysis.

Managing Tracheostomy Emergencies

Having an emergency plan allows nurses to respond faster, reduces confusion and stress, and also ensures that standardized care is provided regardless of the specific nurse involved. Emergencies may include sudden respiratory distress, decreased chest rise, loss of consciousness or unresponsiveness, a dislodged or blocked tube, mucus plugging, bleeding around the tube site, cuff leak, or signs of infection. 

Remember to always follow your facility’s specific emergency protocols for tracheostomy emergencies, and to maintain calm and professionalism while reassuring the patient. These are examples of possible management techniques.

Here are some common tracheostomy complications and their management:

1. Tube blockage ➡️ Difficulty breathing, noisy breathing, bluish skin (cyanosis), agitation.
   • Management: Suction the inner cannula (if present) and outer cannula. If the blockage persists, attempt to replace the inner cannula or the entire tube (if trained). Administer oxygen therapy as needed.
2. Tube dislodgement ➡️ Sudden difficulty breathing, gasping, distress.
   • Management: Ventilate gently with a bag valve mask and carefully occlude the stoma with a gloved hand. If the patient is not in respiratory distress, you can put him/her in a semi-Fowler´s position and provide the oxygen using a face mask. If the tube is partially out, try to gently reinsert it while stabilizing the stoma site with one hand. If the tube is entirely out, ensure the stoma opening remains open (use a tracheotomy button if available). Supplies for tube reinsertion should be placed at the bedside, as well as oxygen and equipment for endotracheal intubation, just in case it is needed.
3. Bleeding 🩸 ➡️ Bright red blood around the stoma, coughing up blood.
   • Management: Apply gentle pressure with sterile gauze to the bleeding site. Do not pack the stoma. Elevate the head of the bed. Maintain airway patency and administer oxygen therapy as needed.
4. Infection 🌡️ ➡️ Fever, redness around the stoma, purulent drainage, foul odor.
   • Management: Keep the stoma clean, and use a sterile technique for suctioning and changing supplies. Monitor vital signs and oxygen saturation levels. Antibiotics may be prescribed depending on the severity of the infection.
5. Granulation tissue ➡️ Excessive tissue growth around the stoma may obstruct airflow.
   • Management: A physician may need to remove excess tissue using a laser or other methods.

In general, always monitor vital signs and oxygen saturation, keep emergency equipment nearby, such as spare tubes and an Ambu bag, and be prepared to assist with additional medical interventions as needed, such as administering oxygen, or initiating CPR if necessary.

To mitigate the risks of complications, meticulous hygiene practices around the tracheostomy site are vital. Careful monitoring for signs of infection or distress is key, as well as proper communication within the interdisciplinary team.

Long-Term Care and Living with a Tracheostomy

Tracheostomy care should be adapted as the patient’s needs and abilities evolve in long-term recovery. 

In the long-term management of a tracheostomy, the use of a tracheostomy collar can offer several benefits. It helps prevent accidental dislodgment of the tracheostomy tube, reducing the risk of complications. The collar also provides a barrier between the tracheostomy site and external contaminants, minimizing the risk of infections. Additionally, it can contribute to improved speech and voice quality for individuals who have undergone a laryngectomy.

Regular cleaning and maintenance are necessary. Proper fitting and adjustment of the collar are crucial to avoid discomfort or pressure-related issues.

Final Thoughts on Tracheostomy Care Steps

Mastering tracheostomy care steps is crucial for new nursing graduates. The ability to effectively care for patients with tracheostomies is a vital skill that can greatly impact patient outcomes and overall quality of care. By familiarizing yourself with tracheostomy nursing care plans, understanding the use of tracheostomy kits, and being prepared for emergencies, you can ensure the safety and well-being of your patients.

With practice and dedication, you can become proficient in tracheostomy care steps quickly! Of all of the patient care skills for new nurses to learn, taking care of trachs is one of the most challenging. We discuss it in-depth in our Nursing Skills Refresh course if you’d like to see a few experienced nurses perform trach care in a sim lab and give you tips and encouragement!

Tracheostomy Care Steps FAQs