Tracheostomy Care

1. Routine Tube Maintenance

• Clean the skin around the stoma at least once daily (more often if secretions are heavy).
• Use sterile saline or mild antiseptic to clean around the stoma.
• Replace tracheostomy dressings (split gauze pads) when soiled or wet.
• Inspect the stoma for redness, swelling, breakdown, or signs of infection.
• Tracheostomy ties/securing devices should be used to prevent accidental decannulation. The tie should be snug enough to allow only one finger underneath. - Cummings Otolaryngology; Roberts and Hedges'

• For ventilated patients, cuff pressure must be monitored regularly.
• The cuff should be maintained at the lowest pressure that allows adequate ventilation (generally 20-25 cm H₂O).
• Over-inflation causes tracheal mucosal ischemia and can lead to tracheal stenosis or tracheomalacia; under-inflation leads to aspiration and inadequate ventilation. - Cummings Otolaryngology

2. Suctioning

• Use a sterile suction catheter sized appropriately (catheter outer diameter should not exceed half the inner diameter of the tracheostomy tube).
• Pre-oxygenate before suctioning if the patient is on supplemental oxygen.
• Insert the catheter gently without applying suction; apply suction only while withdrawing.
• Limit each suctioning pass to 10-15 seconds to avoid hypoxia.
• Monitor SpO₂ throughout; allow recovery between passes.
• Saline instillation is no longer routinely recommended as it does not effectively loosen secretions and may cause bronchospasm. - Roberts and Hedges'

3. Humidification

• The tracheostomy bypasses the upper airway, which normally warms and humidifies inspired air.
• Humidification is mandatory for all ventilated patients and in the immediate postoperative period for non-ventilated patients.
• Inadequate humidification leads to thick, crusted secretions, mucus plugging, and tube obstruction.
• Heat-moisture exchangers (HMEs/"Swedish nose") or active heated humidifiers are used. - Cummings Otolaryngology

4. Tube Changes

• The first tracheostomy tube change after an open (surgical) tracheostomy can be performed by an experienced physician between days 3 and 5 once the tract has matured.
• For percutaneous tracheostomy, the tube should not be changed until at least day 10 due to the higher risk of creating a false passage.
• After the first change, subsequent changes are generally performed every 4-8 weeks (frequency depends on tube type and secretion load).
• All equipment for replacement (same-size tube, one size smaller, obturator, suction, bag-valve device, light source) must be at the bedside before any tube change attempt. - Cummings Otolaryngology; Roberts and Hedges'

5. Complications to Monitor

• Tintinalli's Emergency Medicine; Roberts and Hedges'

6. Speaking Valve (Passy-Muir Valve)

• A speaking valve redirects expired air through the vocal cords to allow phonation.
• The cuff must be fully deflated before placing a speaking valve - failure to do so causes air trapping and respiratory distress.
• Speech-language pathology should be involved early to assess candidacy. - Cummings Otolaryngology

7. Patient and Caregiver Education (Pre-discharge)

• Suctioning technique
• Inner cannula removal and cleaning
• Emergency tube change
• Stoma care and dressing changes
• Recognizing signs of respiratory distress
• Use of all home equipment (suction machine, humidifier, ventilator if applicable)
• A written instruction manual should be provided, along with contact details for healthcare providers and equipment suppliers. - Cummings Otolaryngology (AAO-HNS Consensus Statement)

Key AAO-HNS Consensus Points (Tracheostomy Care Standards)

1. Patient and caregiver education should begin before elective tracheostomy.
2. All replacement supplies must be at the bedside at all times.
3. Initial tube change by experienced physician only.
4. Humidification for all ventilated patients.
5. Cuff pressure monitored and minimized in ventilated patients.
6. Speaking valve only with cuff deflated.
7. Competency assessment of caregivers before discharge.