Tracheostomy Care: Best Practices for Ventilator Units and Post-Acute Care

Editor's note: This text-based course is a transcript of the course Tracheostomy Care: Best Practices for Ventilator Units and Post-Acute Care, presented by Zhanna Sorin, BSRT, RRT.

It is recommended that you download the course handout to supplement this text format.

Learning Outcomes

After this course, participants will be able to:

• Describe the indications for tracheostomy and differentiate between types of tracheostomy tubes.
• Explain the steps involved in routine tracheostomy care and infection prevention.
• Identify responses to emergency tracheostomy situations and complications in various patient populations.

Tracheostomy Definition

We are going to talk about tracheostomy care. So what is a tracheostomy? A tracheostomy is a surgical procedure that creates an opening in the trachea to provide an alternate airway for breathing. It is usually done in an operating room, but if an emergency arises, it might be performed even by paramedics if there is no other choice, the patient needs to be ventilated immediately, and there is no time to get to the hospital.

The purpose of a tracheostomy is to provide an artificial airway when the natural airway is compromised or blocked. Usually, when a patient needs to be intubated for ventilation, the first choice is an endotracheal tube. However, an endotracheal tube cannot remain in place for more than about 2 weeks. So if the patient still requires mechanical ventilation, a tracheostomy will be performed. In my experience working in a long-term ventilator unit, most of our patients are on ventilators, but the goal is always, if possible, to try to wean them off.

There is another purpose as well, one that applies even when the patient is no longer on a ventilator but still has a tracheostomy tube in. A lot of times, a patient can breathe on his own but still has a great deal of secretions and is unable to mobilize them. So a tracheostomy is also needed even when the patient is not being ventilated, to improve airway access and allow suctioning to help clear secretions.

Indications for tracheostomy include airway obstruction, respiratory failure, and airway protection. A tracheostomy can be temporary or permanent, depending on the patient's condition.

Once the tracheostomy tube is placed, if the patient requires ventilation, ventilator tubing is connected to the tracheostomy tube, with the other end connected to the ventilator. Trach holders, or straps, hold the tracheostomy tube in place, and putting them on correctly is very important, because otherwise the tracheostomy tube can come out or become displaced, which will obstruct the airway. That is very dangerous, and something we want to avoid.

Post Tracheostomy Airway Changes

The primary change we see, and want to see, after a tracheostomy is a significant decrease in airway resistance and a significant decrease in the work of breathing, because we are bypassing the upper airway. At this point, the patient is no longer inhaling through the mouth or nose; they are inhaling through the tube. The breathing pattern is the patient breathing through a tracheostomy tube, inhaling through the tube, which is most often connected to the ventilator, and exhaling through the mouth or nose.

Types of Trach Tubes: Cuffed and Uncuffed

Tracheostomy tubes come in different types for different purposes and patient needs, and they also come in different sizes depending on the patient's requirements.

Cuffed tubes are ideal for patients who require mechanical ventilation. These tubes have a cuff, or balloon: one balloon sits outside the tube, and another inflates inside the airway. Whatever we do to the outside balloon also happens to the inside one, since that is the only way we can control what is happening inside the airway. For a patient who requires mechanical ventilation, we need to keep this balloon inflated at all times, because it seals the airway and allows mechanical ventilation; otherwise, whatever we are giving the patient will not reach them if there is a leak. When checking on patients, it is important to ensure the balloon stays inflated, as it can partially deflate over time. For that reason, we always keep a syringe at the bedside so we can reinflate it as needed.

For cuff pressure, we want to ensure it is at the correct level. We use a manometer, attached to the balloon outside the tube, to measure the pressure. Different references give slightly different numbers, but ideally, we want cuff pressure between 20 and 22. There are some cases where we want to keep the pressure lower, for example, in tracheomalacia, which is a weakness of the tracheal wall. This can lead to tracheal stenosis, or narrowing of the airway. For those patients, we keep the cuff pressure lower, usually not exceeding 18.

Cuffed tubes allow sustained and effective positive pressure ventilation, because the cuff seals the airway, preventing gas from escaping above the tracheostomy tube. The cuff also helps prevent aspiration, which is important since many patients have a large amount of secretions.

Uncuffed tubes do not have a cuff on the inside or the outside. These are ideal for patients who can breathe independently. In other words, if the patient no longer requires ventilation and can breathe on his own but still needs the tracheostomy tube in place, we use an uncuffed tube. Uncuffed tubes help reduce the risk of tracheal damage from cuff inflation and are used in patients who require ongoing suctioning to clear secretions.

If a cuff becomes deflated, a low-pressure or low-minute-volume alarm will go off on the ventilator. I remember one incident where an alarm kept going off, low pressure, low minute volume, and everything appeared connected and intact. It turned out the patient had bitten off a cuff balloon and was chewing on it, so he was not receiving the air he should have been receiving from the ventilator. The tracheostomy tube needed to be changed immediately, since we could not properly ventilate the patient at that point.

Types of Trach Tubes, Continued

Tracheostomy tubes can come with either a disposable or a reusable inner cannula. They serve exactly the same purpose, but the disposable version is far more practical. Reusable inner cannulas must be kept scrupulously clean, since an unclean cannula can lead to infection or allow a mucous plug to form in the airway, requiring a full cleaning procedure. Disposable inner cannulas are simple: each facility has its own protocol, but in my facility, we change them every shift and as needed. We remove the old one, discard it, and insert a new sterile one, which reduces both the work involved and the risk of infection. We used to receive many patients from the hospital with reusable inner cannulas; today, we rarely see them, and if we do, they are typically switched to a disposable one within a day or so.

Extra-long tracheostomy tubes have a curved design that can help bypass granulation tissue or scarred areas in the trachea. Unusual anatomies, such as increased neck circumference, or patients with an elongated trachea or tracheal stenosis, may require extra-long tubes to ensure a proper fit.

These come in two types: tubes with proximally extended length and tubes with distally extended length. Extra proximal length is typically needed for patients with large necks due to obesity or neck masses. Extra distal length is often required for patients with tracheal abnormalities such as tracheomalacia or tracheal stenosis, even when the external neck anatomy appears normal. It is important, when changing these tubes, not to simply substitute any extra-long tube. The proximal or distal designation is marked on the tube itself, and a replacement should match what the patient already has, since it was chosen for a reason.

A patient may start with a standard-length tracheostomy tube and later require a change to an extra-long tube as complications develop, such as granulation tissue formation.

Fenestrated Trach Tube

A fenestrated tracheostomy tube has a small hole, called a fenestration, that is aligned over the vocal cords to permit airflow through the upper airway. This allows the patient to speak, by enabling airflow past the vocal cords. If a patient is able to speak, we want to give them the opportunity to do so, so we change the tube to a fenestrated one.

Capped Trach Tube

A capped tracheostomy tube is one that has been capped or occluded. The cap prevents airflow from passing through the tracheostomy tube, forcing the patient to breathe through the upper airway instead.

When a patient is on a ventilator, the ventilator does all the work, and the patient is not breathing through the mouth or nose but through the tracheostomy tube. Once we see the patient is doing better, our goal is always to first try to wean the patient off the ventilator, and then, if the patient is doing well and can mobilize secretions, to work toward decannulation (removal of the tracheostomy tube). We do not take this step lightly, because we want to be certain the patient will be able to manage on his own once the tube is out.

Protocols vary by facility, but at my facility, once the patient is off the ventilator and doing well, we refer the case to the ENT, who comes once a week and examines the airway with a scope to confirm there is no contraindication to decannulation. If everything looks good, we then refer the case to the pulmonologist, and if he agrees, he will write an order for capping. At that point, we begin capping the patient for a few hours per day, closely monitoring vital signs and watching for any distress. If the patient tolerates it well for those few hours, we gradually increase the duration. Once the patient can be capped for 24 hours, we continue and generally do not remove the cap again unless the patient requires it, keeping it in place for about 2 weeks. If the patient remains comfortable for those two weeks, around the clock, decannulation can proceed.

During this period, we do not suction the patient, because doing so would defeat the purpose. We still want to know whether the patient will be able to mobilize secretions once the tube is out. The purpose of capping, in short, is to assess a patient's ability to breathe normally through the nose and mouth in preparation for decannulation.

If a patient does not require ventilation but still requires oxygen, that is not a problem. Not everyone who requires oxygen needs a tracheostomy tube. Once we occlude the tracheostomy tube with the cap, a nasal cannula can be used if the patient requires supplemental oxygen. A nasal cannula will not work for a patient with an uncapped tracheostomy tube, since that patient is not breathing through his mouth or nose. Once capped, the patient is breathing normally, the way he will once the trach is out, and a nasal cannula can be used at that point if oxygen is required.

Tracheostomy Care: Equipment and Supplies

For routine tracheostomy care, the necessary equipment and supplies include a waterproof trash bag, kept at the bedside so cleaning does not make a mess of the surrounding area; two sterile containers; sterile saline solution; hydrogen peroxide; sterile gloves; 4x4 gauze sponges; and a drain gauze sponge. Tracheostomy care kits vary somewhat by facility, but they generally include the same basic supplies. Some kits include a small container of hydrogen peroxide; others do not. If it is missing, a full bottle can always be brought in from the storage room.

Tracheostomy Care: Steps of the Procedure

As with any procedure, the first step is to come in, introduce yourself, confirm you have the right patient, typically verified against the name on the wristband, and explain the procedure to the patient. Even when working with patients who are heavily sedated, it is still important to introduce yourself and explain what you are about to do, because we never know how much a patient can hear.

Next, wash your hands, and make sure all equipment is ready before you begin, because stopping partway through to retrieve a missing supply means removing gloves and personal protective equipment, and washing your hands all over again. Before starting, assess the patient's condition to confirm there are no signs of respiratory distress. Check saturation, work of breathing, respiratory rate, and heart rate. At my facility, tracheostomy care is performed once per shift, and my shift is 12 hours long, so there is flexibility in timing. If the patient is not doing well at a given moment, it is not the right time to proceed.

During the procedure, always wear clean gloves after washing your hands. Sterile technique and sterile gloves are used for any procedure that involves the tracheostomy tract, such as inner cannula care. Before beginning, suction the patient to clear any mucus plugs and reduce the risk of secretions being coughed up during cleaning.

Remove and discard the old dressing into the bedside waterproof bag. To clean the trach site area, use the sterile containers from the tray kit filled with sterile solution, and wet a 4x4 gauze sponge in the solution. Squeeze excess liquid from the gauze before cleaning, as any liquid that gets into the trachea risks aspiration. If the patient has crusted secretions, a 50:50 mixture of hydrogen peroxide and sterile saline can be used instead of sterile saline alone. When cleaning around the tracheostomy site, always move the gauze away from the stoma, never toward it, to avoid pushing debris or liquid into the opening. Use a fresh gauze for each pass if the site is very soiled, and use as many as needed until the area is clean. Once clean, dry the area thoroughly with a dry gauze pad, as a wet stoma site should never be left as is.

Next, change the inner cannula. If it is disposable, which is most common, put a sterile glove on your dominant hand, remove the old inner cannula, discard it, and insert a new one. Always secure it properly in place; some click into place, and some require a twist. Once it is in, gently pull it slightly to confirm it is secure. An improperly secured inner cannula can come out during coughing or when the patient is repositioned.

If the inner cannula is reusable, the process is different: soak it in sterile solution in a separate container, then clean it thoroughly with a long brush, sometimes resembling an oversized cotton swab, designed to reach inside the cannula. After cleaning, hold it up to the light and inspect it closely to confirm that no secretions or plaques remain. This step matters because the inner cannula protects the outer cannula from becoming obstructed by mucous plugs; if the outer cannula becomes obstructed, the entire tracheostomy tube may need to be replaced.

Once the inner cannula is addressed, apply a new tracheostomy dressing, making sure the surrounding area is completely dry first, otherwise the new dressing will become wet immediately and serve no purpose.

The final step is replacing the ties. If another therapist is available, it helps to have someone lightly hold the tracheostomy tube in place with a sterile glove while the tie is replaced, since nothing else is holding the tube during this step, and a cough could dislodge it. If no one is available to assist, it is still manageable to hold the tube steady with one hand while placing the tie with the other.

The tie should not be too tight or too loose. Too tight causes pain and can break the skin; too loose fails to hold the tube securely, which risks displacement and airway obstruction. A good way to check the fit is to make sure two fingers can fit between the tie and the neck on each side, not three or one. Proper fit helps prevent accidental decannulation due to a strong cough or during patient repositioning.

Emergency Situations

Airway obstruction may present as stridor, labored breathing, cyanosis, or an inability to pass a suction catheter. This requires quick action. The first step is to suction the patient to remove any mucus plug that may be causing the obstruction. If the suction catheter is difficult to pass, saline lavage can help break up mucus and facilitate removal. Sometimes the issue is not a mucus plug but tube positioning. Many patients have a positional tracheostomy, in which slight movement can shift the tube enough to obstruct the airway and cause respiratory distress.

To address this, reposition the tube. With a syringe kept at the bedside for cuff inflation and deflation, hold the tube in place with one hand and deflate the cuff with the other, so that repositioning does not damage the airway. Without fully removing the tube, slowly reposition it until the patient's breathing improves and labored breathing resolves. Then reinflate the cuff and suction again to confirm that the suction catheter passes freely, indicating the airway is clear. Always provide supplemental oxygen during this process if needed.

Accidental decannulation is another emergency, though it is not always truly accidental. Some patients repeatedly pull out their own tracheostomy tubes. In some cases, patients do not want the tracheostomy at all, but family members making decisions on their behalf, holding a health care proxy, do not authorize decannulation, and we have to continue reinserting the tube by the rules. Often, patients pull at the tube out of confusion or simply to occupy their hands; giving them another object to handle can sometimes redirect that behavior.

True accidental decannulation can also happen. A cuff balloon may rupture, or the ties may not be secure enough, allowing the tube to come out. This requires acting very quickly, since a stoma can close within seconds, or narrow significantly even if it does not close completely. An emergency tracheostomy kit with a spare tube should always be kept at the bedside, as the same tube cannot be reinserted due to infection control. Because a stoma can close quickly, it is wise to keep not only a same-size replacement tube on hand but also one size smaller, for example, keeping both a size 8 and a size 6 tracheostomy tube in the drawer. The same size should always be tried first, but if it will not pass and time is running out, particularly in a long-term care setting without immediate hospital transfer, a smaller tube may need to be used to manage the airway.

Bleeding is another emergency situation to watch for. Minor bleeding from the stoma is common and normal shortly after a tracheostomy is placed, or after a routine tube exchange (in my facility, the ENT doctor replaces the tube every three months). This should simply be monitored to confirm it does not worsen. Persistent or profuse bleeding, however, requires immediate medical attention and should be reported to the physician right away. If the physician is not on-site, it should be reported immediately to the nurse in charge, who will contact the doctor for instructions. In the meantime, confirm whether the patient is on any blood thinners, as anticoagulant therapy should be held immediately if the source of bleeding is unclear. Persistent, significant bleeding often requires hospital transfer for further testing to determine its source.

Tracheostomy Stoma Infections

The tracheostomy site should be inspected daily for signs of infection, as early detection makes treatment easier and less painful for the patient. Signs of infection include swelling, redness, and purulent discharge; the patient may also complain of pain at the site. For patients who can communicate, it is important to take pain complaints seriously and report them to the physician, as patients often report pain before any visible signs of infection appear. If a patient reports pain, monitor closely so that swelling, redness, or discharge can be caught and addressed as soon as they appear.

Preventing Infections

Infection rates in individuals with tracheostomies can be significantly reduced through standard infection control procedures. Proper hand hygiene before and after tracheostomy care is essential, since we are working with an essentially open wound and do not want to spread infection between patients. Personal protective equipment should be used whenever indicated. Most facilities post isolation signage on patient room doors specifying what is required, and this should never be skipped, even when time is limited.

Routine tracheostomy care and dressing changes should be performed as per protocol, including an as-needed component. Even if a dressing was already changed once during a shift, if it becomes soiled with secretions, blood, or leaked medication, it should be changed again rather than left as is. This small extra effort helps prevent infection and keeps the patient more comfortable.

The stoma site should be kept clean and dry at all times and monitored regularly for swelling, redness, or discharge.

Topical Treatment for Tracheostomy Site Infection

For mild redness or irritation, bacitracin ointment can be applied one to two times daily after cleaning, since applying ointment to unclean skin serves no purpose. For moderate to severe skin breakdown, silver sulfadiazine (Silvadene) cream may be used as ordered, particularly for raw or open skin, though it should be avoided in patients with a sulfa drug allergy.

In my facility, as respiratory therapists, we do not apply topical treatments like these ourselves; that is typically handled by nursing staff. We coordinate closely with the nurse caring for the patient, notifying her after tracheostomy care so that any needed topical treatment can be applied.

When to Escalate Care

Escalate care if redness or swelling persists or worsens despite topical treatment, if there is purulent or foul-smelling drainage from the site, if the patient develops a fever, or if there are signs of increased work of breathing, such as retractions or nasal flaring. Granulation tissue that bleeds easily, causes pain, or makes tracheostomy care difficult, for example, if the tube becomes increasingly difficult to suction or increasingly positional, signals a growing amount of granulation tissue that may eventually obstruct the airway. This should be addressed to the ENT physician immediately so it can be examined with a scope; occasionally, the patient requires hospital transfer for surgical removal.

Long-Term Complications

Tracheal stenosis is a narrowing of the trachea caused by prolonged friction from the tracheostomy tube and, unfortunately, is a complication we see fairly often. A tracheoesophageal fistula is an abnormal connection between the trachea and the esophagus that can lead to aspiration and feeding difficulties. Granulation tissue, or granuloma, is excess tissue growth at the tracheostomy site or within the airway that may cause bleeding, obstruction, or difficulty with tube changes; this is the same complication that sometimes requires ENT referral and surgical removal.

Populations at Higher Risk for Tracheostomy Complications

Certain populations face a higher risk for tracheostomy complications: infants and young children, due to smaller airways and greater vulnerability to blockage or infection; older adults, who often experience delayed wound healing; individuals who smoke, due to impaired mucociliary clearance and delayed healing; individuals with alcohol use disorder, due to increased aspiration risk and poor healing; people with diabetes, due to delayed wound healing and higher infection risk; immunocompromised individuals, including those on immunosuppressive therapy or with HIV/AIDS; and people with chronic respiratory conditions such as COPD, cystic fibrosis, or severe asthma.

Role of the RT in Tracheostomy Care

Respiratory therapists care for a wide range of patients, from premature infants to elderly individuals with lung disease. Our responsibilities include administering oxygen, managing mechanical ventilators, and performing routine tracheostomy care. We also play a key role in weaning patients off ventilators and in the capping process that leads toward decannulation.

Beyond inpatient responsibilities, respiratory therapists coordinate outpatient services, helping ensure patients have access to appropriate medical equipment, and provide ongoing education to patients and families at the time of discharge, covering tracheostomy care and infection prevention at home.

We work closely with other disciplines. With nursing staff, we communicate constantly about any changes in patient condition and coordinate on tasks such as applying topical treatments for infection. With physicians, who are not on-site around the clock, we provide updates, suggest treatment changes, and participate in weaning discussions during rounds. In speech-language pathology, we assist during swallow evaluations, such as blue-dye testing, and during the introduction of a speaking valve. With physical and occupational therapy, we advise on whether a patient is ready for therapy on a given day, and provide oxygen support and monitoring during sessions, such as ambulation, watching for any signs of respiratory distress.

Altogether, our role as respiratory therapists extends to clinical protocols, evidence-based practices, and supporting patients through transitions of care from the hospital to home or long-term care settings.

References

References are provided in the course handout.

Citation

Sorin, Z. (2025). Tracheostomy care: best practices for ventilator units and post-acute care. Continued.com - Respiratory Therapy. Available at www.continued.com/respiratory-therapy.