Tracheostomy and Tracheostomy Care
Key Points
- Tracheostomy provides a secure durable airway for prolonged ventilatory support and secretion management.
- Typical placement timing in many centers is within 5-14 days, guided by prognosis and intubation context.
- Inner cannula maintenance is central to preventing tube obstruction and should occur at least every 12-24 hours.
- Stoma care and dressing management reduce bacterial burden and lower lower-airway contamination risk.
Pathophysiology
Tracheostomy creates a direct airway through the neck into the trachea, bypassing upper airway structures when prolonged ventilatory support or airway protection is needed. This route reduces airway resistance from upper tract pathology and allows ongoing access for secretion clearance.
Because the tracheostomy is an artificial airway, colonization and obstruction risks increase without structured care. Secretions can accumulate in the inner cannula, and stoma breakdown or contamination can progress to local and pulmonary complications if routine cleaning and monitoring are delayed.
Classification
- Open tracheostomy: Surgical approach in controlled operative setting.
- Percutaneous tracheostomy: Bedside-focused approach in selected patients.
- Complication timing: Intraoperative, early postoperative, and late complications require staged surveillance.
Nursing Assessment
NCLEX Focus
Priority questions often test obstruction prevention and timing of dressing and cannula care during routine shift management.
- Assess tracheostomy tube patency and secretion burden at each care interval.
- Inspect inner cannula status and evaluate need for cleaning or replacement per policy and secretion thickness.
- Assess stoma condition and dressing integrity at least once per shift.
- Monitor for wet or soiled dressings and replace immediately when contamination is present.
Nursing Interventions
- Perform routine tracheostomy care to clean flange, inner cannula, and surrounding skin using facility kit/policy.
- Clean or replace inner cannula at least every 12-24 hours, or more frequently when heavy thick secretions are present.
- Replace the inner cannula before dressing change to reduce soiling from cough-stimulated secretions.
- Apply clean dressing each shift and change immediately if wet or soiled.
- Coordinate multidisciplinary management with respiratory therapy for long-term airway and ventilatory planning.
Tube Obstruction Risk
Delayed inner cannula maintenance can lead to tracheostomy obstruction and rapid respiratory deterioration.
Pharmacology
| Drug Class | Examples | Key Nursing Considerations |
|---|---|---|
| mucolytics | Secretion-thinning therapy context | Thick secretions may increase cannula obstruction risk; coordinate secretion management with airway care schedule. |
| oxygen-therapy | Supplemental oxygen via trach setup | Reassess oxygenation during and after tracheostomy care interventions. |
Clinical Judgment Application
Clinical Scenario
A patient with prolonged ventilation has increased thick secretions and rising work of breathing through a cuffed tracheostomy.
Recognize Cues: Secretions are heavy, airflow is reduced, and dressing is damp. Analyze Cues: Inner cannula obstruction and local contamination are likely contributing to deterioration. Prioritize Hypotheses: Immediate priority is airway patency restoration and infection-risk reduction. Generate Solutions: Perform inner cannula care first, then complete stoma cleansing and dressing replacement. Take Action: Replace/clean inner cannula, reassess airflow and oxygenation, then document findings and care timing. Evaluate Outcomes: Airflow improves, secretion burden decreases, and dressing remains clean and dry.
Related Concepts
- endotracheal-intubation-procedure - Tracheostomy is often considered after prolonged translaryngeal intubation.
- advanced-airways-and-intubation - Shared escalation framework for definitive airway control.
- airway-adjuncts - Basic adjuncts may precede definitive airway pathways.
- bag-valve-mask-manual-ventilation - Rescue ventilation remains essential during airway emergencies.
- respiratory-failure - Common underlying condition requiring long-term airway support.
Self-Check
- Why should inner cannula replacement often precede tracheostomy dressing change?
- Which findings indicate tracheostomy care frequency should increase beyond routine intervals?
- How does delayed tracheostomy maintenance increase risk for acute respiratory decline?