5.1 Tracheostomy and Tracheostomy Cares

A tracheostomy provides a secure, durable airway for prolonged mechanical ventilatory support in patients.  (See Figure 23^[1]) Quality of life issues, as well as end-of-life issues, should be addressed preoperatively with the patient or family members/guardians before proceeding, especially in the terminally ill and elderly. Tracheostomy is a safe, effective procedure that can be performed via an open or percutaneous technique. Indications include relief of airway obstruction, secretion management, and secure access for prolonged mechanical ventilation. The precise timing of placing a tracheostomy remains controversial, but most centers proceed within 5-14 days, depending on the prognosis of the patient and the cause of initial intubation. Complications can be categorized as intraoperative, early, and late. Postoperative management is best carried out by a multidisciplinary team that includes respiratory therapists^[2].

Tracheostomy care is provided on a routine basis to keep the tracheostomy tube’s flange, inner cannula, and surrounding area clean to reduce the number of bacteria entering the artificial airway and lungs.  Typically, healthcare facilities use tracheostomy care kits to clean a tracheostomy.  (See Figure 24^[3])

The primary purpose of the inner cannula is to prevent tracheostomy tube obstruction. Many sources of obstruction can be prevented if the inner cannula is regularly cleaned and replaced. Some inner cannulas are designed to be disposable, while others are reusable for a number of days. Follow policies for inner cannula replacement or cleaning, but as a rule of thumb, inner cannula cleaning should be performed every 12-24 hours at a minimum. Cleaning may be needed more frequently depending on the type of equipment, the amount and thickness of secretions, and the patient’s ability to cough up the secretions.

Changing the inner cannula may encourage the patient to cough and bring mucus out of the tracheostomy. For this reason, the inner cannula should be replaced prior to changing the tracheostomy dressing to prevent secretions from soiling the new dressing. If the inner cannula is disposable, no cleaning is required.

The stoma site should be assessed, and a clean dressing applied at least once per shift. Wet or soiled dressings should be changed immediately.