Tracheostomy care and suctioning are high-risk procedures that require adherence to evidence-based guidelines to avoid complications, even for experienced nurses. Tracheostomy patients are at risk for airway issues and infection both in intensive care and general units. Skilled nursing care through proper suctioning technique, emergency preparation, trach site care, and securing the trach tube can prevent complications.

1. Tracheostomy care and suction
By: Quiel K. Damandaman BSU-SN

2. 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.

3. 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.

4. 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.

5. Suctioning a trach tube
• 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.

6. Emergency preparation starts during the shift-
change safety huddle—the formal communication
between outgoing and oncoming shifts. Patients
with trach tubes can’t call for assistance verbally, so
all staff members (including the unit secretary)
need to know which patients on the unit have trach
tubes.
Keep the following emergency equipment at the
bedside of trach patients:
• manual ventilator bag
• two extra trach tubes—one of the patient’s
current size and a smaller one
• an obturator of the correct size
• suctioning device and catheters

7. 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

8. • the patient’s unsuccessful attempts to clear
secretions. (According to one researcher, fine crackles in
the lung bases indicate excessive fluid in the lungs, and
wheezing patients should be assessed for a history of asthma
and allergies.)

9. Suctioning technique
1. 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.

10. 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:
- may reach only limited areas
-may flush particles into the lower
-respiratory tract
-may lead to decreased postsuctioning oxygen
saturation
-increases bacterial colonization
-damages bronchial surfactan

11. 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 fluid also is
ineffective in liquefying secretions.

12. Evaluation
• When evaluating the patient after suctioning,
assess and document physiologic and
psychological responses to the procedure.
• Convey your findings verbally during nurse
nurse-to-nurse shift report and to the
interdisciplinary team during daily rounds.

13. 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
specific supplies for secretion absorption must
be used.

14. 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 fibers increase the infection risk
• the trach tube should be secured at all times to
prevent accidental dislodgment, using the two-
personsecuring technique

15. 1. Start by assessing the stoma for infection and
skin breakdown caused by flange pressure.
2. 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.
3. 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
flange.

16. Caution!
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

17. 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

18. 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.