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M.A. de Mello Borba et al.
What Is theBest Way toTake Care
ofaPatient withaTracheostomy Tube?
LicaArakawa-Sugueno
Introduction
Tracheostomy is a scheduled or emergency procedure to facilitate temporary or
permanent breathing. Like any surgical procedure, fashioning of the tracheal stoma
is associated with risk and complications.
The professional team caring for tracheostomized patients should be able to
change the cannula, x it properly to the neck, manage the hygiene of the tracheal
stoma, perform an aspiration procedure, and handle the cuff. Resuscitation training
and knowledge of emergency actions are necessary.
The same team will be responsible for guiding and informing caregivers and
family members about breathing mechanisms in the presence of the tracheostomy,
the tracheal cannula function and type, basic care, and possible complications
related to tracheal breathing.
This chapter discusses the general and specic care needed to avoid possible
complications related to a tracheostomy.
Tracheostomy Care
The morbidity and mortality rates in the tracheostomized pediatric population are
two to three times higher than those in adults [1]. Incidents related to the cannula in
children occur much more frequently, being four times more frequent in the rst
L. Arakawa-Sugueno, Speech Therapist.
School of Medicine, University of São Paulo-USP, São Paulo, Brazil
e-mail: lica.sugueno@gmail.com
© Springer International Publishing AG 2018
T.P. de Farias (ed.), Tracheostomy, https://doi.org/10.1007/978-3-319-67867-2_22
377
378
L. Arakawa-Sugueno
postoperative week and also more frequent in the immediate or early postoperative
period [2].
Tracheostomy care includes learning to identify the color, consistency, odor, viscosity, and volume of secretions. Records of vital signs and patient temperature are
also constant measures.
The multidisciplinary team at Great Ormond Street Hospital for Children (GOSH)
in the UK makes use of an acrostic as a reminder of tracheostomy management—
“TRACHE”—which represents the following: T=tapes, regarding the use of tapes for
cannula xation; R=resus, regarding knowledge of resuscitation methods; A=airway,
allowing airow; C=care, regarding care of the stoma and cannula, and neck hygiene;
H=humidity, regarding the need for moisture to uidify secretions; E=emergency,
regarding the need to always have an emergency kit and training to use it [3].
T—tape
R—resus
A—airway
C—care
H—humidity
E—emergency
Cannula Fixation
Cotton tape is ideal to x the tracheal cannula to the neck. Velcro material is more
practical, but cotton is considered safer.
Both placement and replacement of fastening tapes require care.
The hands should be washed for the procedure. The professional should wear
gloves and a protective mask. Gauze and saline are required for local cleaning
around the stoma, with scissors to cut the tape to the required size. The patient
should be placed in a suitable position (adults and older children preferably seated,
and smaller children lying supine on a rolled-up towel to allow visibility of the
stoma). Strong neck pressure should be avoided.
Especially when caring for children, it is recommended to have one more person
present to help.
The tape should be placed only on clean and dry skin, but the procedure must be fast
and efcient. Avoid tying knots before the nal adjustment by making arcs in the xing
holes of the cannula itself. As a test for comfort, it should be possible to pass a nger
under the tape. If it is too tight and it is difcult to move your nger comfortably, it is
recommended to make an adjustment. After checking the comfort and tension adjustment of the tape, knots can be made on both sides. The procedure is detailed in Table1.
Resuscitation Procedure
All professionals working with tracheostomized patients should undergo cardiopulmonary resuscitation training.
What Is theBest Way toTake Care ofaPatient withaTracheostomy Tube?
Table 1 Cannula xation procedure
Action Observation
Cut the piece of tape long enough
to make two laps around the neck
Cut and remove the old tape In conscious adults, the patient themselves can hold the
Insert the ends of the tape into the
two cannula lateral holes to secure
the tape
Placing protective gauze between
the cannula and the skin aps is an
option for comfort and reduction
of injury
Fig. 1 Check space to a nger
(https://www.fairview.org/
patient-education/88997)
Leave an extra piece of tape to x it
cannula to prevent it from moving in the event of a cough
If this is not the case, it is safer to have a second person to
assist in the procedure by holding the cannula during
removal of the old tape and placement of the new one
Fix one side rst and, when adjusting the other side,
check that there is enough space for a nger between the
tape and the neck so it is not too tight, before making the
knot (Fig.1).
In this case, it is suggested that the open portion of the
gauze faces upward (Fig.2)
379
Fig. 2 Protective gauze (rehabmart.
com)
Trach tie
380
L. Arakawa-Sugueno
Enabling air passage is the greatest emergency. After an emergency service call,
the patient should be positioned with the chin up without pressure on the soft tissue
of the submandibular region to allow more chance of ventilation. The presence of
corneal secretions, blood crusts, or tube displacement are frequent complications
and should be investigated.
If obstruction occurs, the intermediate cannula (if any) should be removed
(Fig.3). A single-tube cannula needs to be aspirated with a catheter. Solid obstructions (dry secretions) may persist. In this case, it will be necessary to remove the
cannula, replacing it immediately with a new one of the same size. For this reason,
the emergency exchange kit should always be available.
In some cases, the stoma may close very fast, especially in the early postoperative period. The use of the Seldinger technique is characterized by the use of the
catheter tip as a guide in the tracheal orice for placement of the tracheal cannula.
It may be an indication in some cases of fast closing. There is a tracheal dilator, but
there are contraindications related to this procedure [4].
15mm Connector
Inner Cannula
Fig. 3 Parts of cannula
(http://trachs.com/
parts-of-a-trach-tube/)
Cuff
Outer Cannula
Pilot Balloon
Obturator
Neck Flange
Inflation
Line
Valve
What Is theBest Way toTake Care ofaPatient withaTracheostomy Tube?
381
If ventilation has not yet been achieved, rescue breathing methods such as mouthto- mouth or a ventilation mask should be used.
After the tube is replaced, it is necessary to monitor the patient for respiratory comfort. The patient should not be left alone. If the cannula xation is adequate, If the cannula xation is adequate, it is important to initiate the ventilation support conduct.
Suction
Care in the suction procedure should take into account the following aspects:
• Length of suction tube (catheter): a shorter tube may not allow adequate aspira-
tion while a volume of secretions persists in the unreached area, whereas a longer
tube may cause trauma to the tracheal wall.
• Diameter of the catheter: there is There is suggested size for safe suction pressure
and to avoid discomfort [5]. A catheter size of 12French is recommended for
cannula sizes 6–9, or 10Fr for a smaller cannula.
• Side holes smaller than the distal orice in the catheter: this allows less adher-
ence to the mucosa with less risk of injury.
• Valve: this allows vacuum control with digital occlusion.
• Catheter markings: these allow the insertion of the catheter to be done more
accurately.
• Equipment with a variable vacuum control unit.
• Personal protective equipment: procedure gloves before sterile gloves, protective
mask, goggles.
• Bottled water in a clean container.
• Equipment for waste disposal.
• Training/practice.
Fig. 4 Cannula with
supracuff probe (Cuffed Blue
Line Ultra
®
Suctionaid)
382
L. Arakawa-Sugueno
If the tracheal cannula is of the type containing a supracuff probe (Fig.4), it
should be aspirated directly with the suction tube before attachment of the sterile
catheter.
Suction should be started only at the return of the catheter and not at the insertion. It is not necessary to rotate the catheter if there are lateral orices. Avoid twisting the catheter to obtain a vacuum. Greater pressure is not always what is needed
for suction. The aspiration should not be slow, but rather quick, and its indication
and frequency will be related to the need and the degree of severity. It is recommended that each suction never exceed 15s. This minimizes the risk of complications such as hypoxia and cardiovascular changes [6]. The catheter should be
discarded if the tip is contaminated (by contact with any surface) prior to insertion.
Saline should not be used routinely before suction, but only when there is difculty in suction of secretions because of thickened consistency or presence of
obstructive dry secretion stopper.
The procedure should be documented, with a description of the quality of secretions
regarding the color, consistency, odor, viscosity, volume, and presence of blood.
In young children, it is recommended that the tip of the catheter does not extend
beyond the end of the tracheostomy cannula. Some children require oxygen therapy
before the suction procedure, so check for this.
Mistakes in the suction procedure can lead directly or indirectly to hypoxia, distal granulation, ulcerations, cardiovascular changes, pneumothorax, atelectasis,
bacterial infections and, in extreme cases, intracranial complications.
Fig. 5 Self-suction
(https://www.allinahealth.
org/mdex/ND0413G.
HTM)
Tracheostomy Self-suction
Catheter
Suction
valve
What Is theBest Way toTake Care ofaPatient withaTracheostomy Tube?
Fig. 6 Suction with catheter
(https://www.mountnittany.
org/articles/
healthsheets/7411)
Valve
383
The suction procedure is as follows:
1. Immerse the catheter in a clean container with sterile water.
2. The patient should sit comfortably in front of the mirror (Fig.5).
3. Insert the catheter 10–15cm without occlusion of the suction valve.
4. Occlude the suction valve with a thumb to promote aspiration while withdrawing
the catheter in a rotating movement (in a catheter without lateral orices) (Fig.6).
5. If there are more secretions, immerse the catheter in sterile water and repeat the
procedure until the secretions are minimized.
6. It is not a comfortable procedure; however, it is important that the patient has
time to calm down and not get too agitated.
7. Discard the catheter after use.
Care oftheCannula, Stoma, andNeck
Skin evaluation and careful daily cleaning can avoid complications such as skin
trauma, epidermolysis bullosa, vascular problems, and lymphatic malformations,
especially with a long-term cannula.
Cleaning of the inner cannula is done once a day or, if necessary, more often.
Running water and a cleaning brush are sufcient.
384
Fig. 7 Inner cannula removal
( http://purecath.com/en/
cpshow1.html)
Fig. 8 Cleaning with brush
under running water (https://
www.mskcc.org/cancer-care/
patient-education/
caring-your-tracheostomy)
L. Arakawa-Sugueno
The procedure to clean the inner cannula is as follows:
1. With clean hands (gloves for the health professional), remove the inner cannula
and wash it under running water (Fig.7).
2. Ask the patient to cough to avoid obstructions in the external cannula, and per-
form a suction procedure if necessary.
What Is theBest Way toTake Care ofaPatient withaTracheostomy Tube?
385
3. Clean the internal cannula with a brush to release all adherence of secretions
(Fig.8).
4. Remove excess liquid from the cannula, drying it only by shaking it in the air,
without using any material.
5. Replace the inner cannula.
6. Wash the hands.
The region around the cannula (peristoma) is also cleaned daily. If the frequency
of accumulation of secretions is high, this procedure should be repeated as frequently as needed.
The procedure to clean the tracheal stoma (around the cannula) is as follows:
1. For the patient, it is recommended to use a mirror and a seated position.
2. Remove the old bandage.
3. Wash the hands.
4. Clean the skin and the outer cannula with clean gauze wet with sterile water.
5. Use saline if there are more viscous or dry secretions.
6. Dry with a clean towel after cleaning.
7. If necessary, use a bandage on the ends of the cannula to avoid contact lesions.
8. Document and inform medical staff if you observe edema, bleeding, irritation, or
secretions with an altered color (greenish, bloody, etc.).
Humidity
Air ow directly through the trachea does not allow the humid environment (100%
relative humidity) and 37°C body temperature that the nose offers in normal breathing. For this reason, especially in the rst few weeks, it is important to articially
offer warm moisture to avoid thick, sticky secretions.
Medications or combined use of oxygen therapy are individually targeted interventions to be used as needed.
A nebulizer provides humidication via a direct aerosol in the lower airway, with
a mask on the tracheostomy cannula.
Intake of water orally or via a feeding tube should be indicated for systemic
hydration. On average, intake of two liters of water per day is recommended.
Other humidication systems will be discussed by the multidisciplinary team on
a case-by-case basis.
Emergency Kit
It is imperative that the following materials are always available in a clean and dry
place to avoid contamination and to be easily accessible.
• Suction equipment
• Suction catheters or tubes—length and gauge suitable for the patient’s age and
physical structure