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AnttiMäkitie
TimoAtula

Tracheostomy Care

Essentials

  • A cuffed tube is used during the first days after the formation of a tracheostomy and if required by mechanical ventilation or problems with aspiration. Otherwise, an uncuffed tube is used.
  • In outpatient treatment, a cannula without a cuff is used, except for a respiratory paralysis patient who needs a respirator and has their own nurse.
  • As a rule, the tube has both an inner and an outer cannula. In long-term care, the outer cannula is changed about every month. The inner cannula is cleaned several times a day if necessary.
  • The first tube change may be challenging and is performed in specialized care. After a channel has been formed within 2 to 4 weeks the tube change is usually easily performed also in the primary care.

Care of the tracheostomy tube

  • A few days after the formation of a tracheostomy, an uncuffed tube should be inserted unless the patient's condition warrants a cuffed tube, e.g. mechanical ventilation, a large amount of secretions or risk of aspiration.
  • A fenestrated tube facilitates speech during expiration, provided that the opening of the tube is occluded with a finger.
  • The so-called automatic speaking valve is suitable for some patients with long-term tracheostomy and a fenestrated cannula without a cuff.
  • Tracheostomy tubes only need to be changed (video Replacement of Tracheostomy Cannule) approximately every 4 weeks, depending on the condition of the tube.
  • The inner cannula should be cleaned as necessary, usually several times a day, under running tap water using a suitable brush. If necessary, mild washing-up liquid may also be used.
  • It is important to humidify the inspired air; a heat-moisture exchanger should be attached either directly to the tube or to the tracheostomy tie. In problematic situations, additional humidification may be provided by a nebulizer.
  • If the patient is unable to cough sufficiently to remove mucus and secretions, the bronchi and trachea must be suctioned as necessary with the aid of a thin suction catheter, the frequency varying from a couple of times per day to several times per hour (suction must only be applied as the catheter is being withdrawn and the whole procedure should not take more than 15 seconds).
  • If, despite humidification and proper care of the tube, the mucus dries up in the lower respiratory tract, the condition of the patient may deteriorate. It may become necessary to attempt the removal of crusts and plugs with forceps from the stoma opening, and in a very severe situation a bronchoscopy may be required in specialized care.

Complications

  • Ample formation of crusts necessitates more frequent cleaning of the inner cannula and intensified humidification of the inspired air.
  • If the patient shows signs of respiratory distress, and the inner cannula is not blocked with dried up secretions, the patency of the airways and the correct positioning of the cannula may be checked with a fibreoptic endoscope via the tracheostomy tube (a specialist referral may be needed).
  • Scar tissue around the stoma might lead to stenosis and require surgical repair.
  • Granulation tissue might develop around the stoma and cause bleeding and scarring. Granulation can be removed with the aid of suction, forceps and silver nitrate, but a wider surgical excision might be indicated as well.
  • A badly positioned tube may rub the posterior tracheal wall and cause bleeding.

Decannulation

  • Carried out in specialized care.
  • Tracheostomy is discontinued as soon as it is no longer considered necessary.
  • The larynx is assessed with a nasolaryngoscope, and it should be ensured that there is no laryngeal stenosis.
  • After a temporary tracheostomy, e.g. during major surgery of the head and neck or following a neck infection, the cannula can be removed as soon as the larynx is found to be open.
  • After a long period of tracheostomy, it should be ensured that the patient is able to keep the cannula capped e.g. overnight.
  • Sometimes tubes of decreasing size may be used (downsizing) on consecutive days.
  • After decannulation, the stoma should be covered with a gauze dressing.
    • The stoma will usually close on its own over the next few days.
    • Stitches that bring the edges of the wound closer to each other can also help the stoma to close.

    References

    • Guia M, Ciobanu LD, Sreedharan JK, et al. The role of non-invasive ventilation in weaning and decannulating critically ill patients with tracheostomy: A narrative review of the literature. Pulmonology 2021;27(1):43-51. [PubMed]
    • Paul F. Tracheostomy care and management in general wards and community settings: literature review. Nurs Crit Care 2010;15(2):76-85. [PubMed]
    • O'Connor HH, White AC. Tracheostomy decannulation. Respir Care 2010;55(8):1076-81. [PubMed]