Tracheostomy Nursing Care Guide 2026
Part of the ICU Emergencies Hub — browse every related guide in one place.
This article was created with AI assistance.
Always have at hand: Spare trach tube (same size + one size smaller), 10 mL syringe for cuff, suction equipment, obturator (taped to head of bed), bag-valve mask, and scissors to cut trach ties in emergency.
Tracheostomy Tube Types
| Type | Feature | Use |
|---|
| Cuffed | Balloon around tube that inflates to seal trachea | Ventilator-dependent; aspiration risk; acute/ICU |
| Cuffless | No balloon; allows air around tube | Patients who are deconditioned; speaking valve candidates |
| Fenestrated | Hole in tube allows airflow through vocal cords | Allows speech; used before decannulation |
| Double cannula | Inner cannula removable for cleaning | Most common type; reduces secretion buildup |
| Single cannula | No inner cannula | Low-profile; specific indications |
| Adjustable flange (XLT) | Extended or adjustable neck piece | Obese patients; unusual neck anatomy |
Daily Tracheostomy Care
Frequency
- Trach site care: every 8 hours and PRN (q shift minimum)
- Inner cannula cleaning (if reusable) or replacement (if disposable): every 8 hours or PRN
- Trach ties/holder: change when soiled; at least every 24 hours
Trach Care Procedure
- Explain procedure to patient; wash hands; don PPE (gloves, mask, eye protection)
- Suction trach and oral cavity PRN before care
- Set up sterile field with trach care kit
- Remove and clean (or discard) inner cannula: clean with H2O2 then rinse with NS; let dry; reinsert
- Clean stoma site with saline/cotton swabs; remove crusted secretions; assess skin integrity
- Apply split-drain gauze dressing under flange (if needed per policy — some facilities use no dressing)
- Change trach holder/ties — have second nurse hold trach in place during tie change
- Confirm tie tightness: one finger should fit under the tie
- Document: stoma appearance, secretion color/amount/consistency, patient tolerance
Two-nurse rule: Always have a second nurse stabilizing the trach tube when changing ties. Accidental decannulation during tie change is a real risk.
Suctioning Technique
Suction only when needed (PRN). Signs: audible secretions (gurgling), increased breathing effort, SpO2 drop, patient coughing or requesting suction. Routine scheduled suctioning can cause mucosal damage and is no longer recommended.
Open Suction Procedure (Standard)
- Pre-oxygenate: 100% O2 for 30–60 seconds (or several deep breaths)
- Set suction pressure: 80–120 mmHg for adults; 60–80 for pediatric
- Don sterile gloves; use dominant hand as sterile hand
- Insert catheter WITHOUT suction applied; advance until resistance (carina), then back off 1 cm
- Apply suction while withdrawing in a rotating motion; suction time ≤10–15 seconds maximum
- Repeat after re-oxygenating; limit to 3 passes per suction event
- Suction oropharynx last (non-sterile catheter)
- Re-oxygenate; assess SpO2, HR, breath sounds
NEVER: Suction without pre-oxygenating first. NEVER exceed 10–15 seconds of suctioning per pass. Prolonged suctioning causes hypoxia, bradycardia, and mucosal trauma.
Catheter Size Selection
Maximum catheter size (French) = trach tube inner diameter (mm) × 2. To keep open airway, use a catheter no larger than half the inner diameter of the trach.
Cuff Management
Cuff Inflation
- Inflate cuff to minimum occlusive volume (MOV): inflate until no air leak heard during positive-pressure breath
- Target cuff pressure: 20–30 cmH2O (15–22 mmHg)
- Check cuff pressure every 8 hours with manometer; document
Over-inflation (>30 cmH2O) causes tracheal mucosal ischemia leading to tracheomalacia and tracheal stenosis. ALWAYS verify with manometer, not just feel.
Cuff Deflation
- Suction above the cuff (via subglottic port if available) BEFORE deflating — pooled secretions will fall into airway
- Suction trach as cuff deflates
- Cuff deflation trials indicated for: speaking valve placement, decannulation, caps trials
- Never deflate cuff on ventilator-dependent patient without MD order and close monitoring
Complications & Emergency Response
| Emergency | Signs | Immediate Action |
|---|
| Accidental decannulation | Trach not in stoma; respiratory distress; no breath sounds from trach | Cover stoma with hand/dressing; call for help; attempt reinsertion if trained; BVM via stoma; call code if unresponsive |
| Obstructed trach | Increased resistance during suction; no air movement; patient in distress | Remove inner cannula; attempt suction; if still obstructed: deflate cuff + reinsertion or change tube |
| Hemorrhage from stoma | Bright red bleeding from stoma or trach | Apply pressure; suction blood; notify MD STAT; prepare for OR |
| Subcutaneous emphysema | Crepitus palpated around neck/chest; "crackling" under skin | Notify MD immediately; may indicate tracheal tear or pneumothorax |
| Tracheoesophageal fistula | Gastric contents in trach secretions; coughing with eating/drinking | Nothing by mouth; notify MD; imaging ordered |
Emergency: trach tube falls out within 72 hours of placement. The stoma may close rapidly. Do NOT attempt to reinsert without physician present — have patient breathe through mouth while calling for emergency help.
Speaking Valves (Passy-Muir Valve)
- One-way valve: air in through trach, air out through cords (allowing speech)
- Prerequisites: cuffed trach must be DEFLATED before placing; tube must allow air around it
- Contraindications: unconscious patient, full cuff inflation, severe aspiration risk, laryngeal obstruction
- Place during speech therapy eval; monitor SpO2 and work of breathing
- NEVER leave speaking valve on overnight without MD order
- Remove immediately if: SpO2 drops, increased WOB, stridor, or patient cannot tolerate
Decannulation Criteria
Decannulation (removing trach permanently) is considered when:
- Underlying reason for trach resolved
- Patient passes capping trial (trach capped 24–72 hours with no respiratory distress)
- Adequate cough/airway clearance
- Tolerates speaking valve or cuff deflation
- Swallowing assessed; aspiration risk acceptable
- Stoma is closed/cleaned daily after decannulation; heals within days to weeks
NCLEX High-Yield Points
- Keep replacement trach + one size smaller + obturator taped to HOB AT ALL TIMES
- Cuff pressure target: 20–30 cmH2O — over-inflation causes mucosal necrosis
- Pre-oxygenate before every suction; suction ≤10–15 seconds per pass
- Suction ABOVE cuff before deflating — prevents aspiration of pooled secretions
- Speaking valve = cuff MUST be deflated; never apply with inflated cuff
- New trach (<72 hrs): if tube falls out, cover stoma and call for help — stoma can close rapidly
- Two-nurse tie change: always stabilize trach to prevent accidental decannulation
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