{"id":1093,"date":"2015-06-18T15:24:37","date_gmt":"2015-06-18T19:24:37","guid":{"rendered":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/chapter\/10-6-tracheostomies\/"},"modified":"2019-09-19T18:00:37","modified_gmt":"2019-09-19T22:00:37","slug":"10-5-tracheostomies","status":"publish","type":"chapter","link":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/chapter\/10-5-tracheostomies\/","title":{"raw":"10.5 Tracheostomies","rendered":"10.5 Tracheostomies"},"content":{"raw":"<h2>Tracheostomy Tubes<\/h2>\r\nTracheostomy tubes (TTs) are artificial airways that can be permanent or temporary depending on the patient\u2019s condition. They are placed through a hole in the neck and into the trachea to overcome tracheal obstruction caused by head and neck trauma including surgery or tumour. Other reasons for tracheostomy tubes include the need for prolonged mechanical ventilation and\/or when the client is unable to maintain a patent airway because of conditions like neuromuscular disease or spinal cord injury (BTS, 2014; Perry et al., 2018; RCH, n.d.).\r\n\r\nNursing care of clients with tracheostomy tubes varies depending on how well established the tracheotomy is. The British Thoracic Society prioritizes humidification, ensuring the cleanliness and patency of the inner tube, secure fixation of the tube, and attention to cuff pressure as necessary for preventing TT related complications (BTS, 2014).\r\n\r\nIf the trach is temporary, decannulation (or removal) should be done as soon as possible to reduce the risk of complications. Decannulation should only be done by competent persons and is only done following thorough assessment of the upper airway.\r\n<table style=\"border-collapse: collapse;width: 100%;border: 0px solid #000000\">\r\n<tbody>\r\n<tr style=\"border: 0px solid #000000\">\r\n<td style=\"width: 50%;border: none\">\r\n\r\n[caption id=\"attachment_5052\" align=\"aligncenter\" width=\"300\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/08\/DSC_0683.jpg\"><img class=\"wp-image-5052 size-medium\" alt=\"DSC_0683\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_0683-300x199.jpg\" width=\"300\" height=\"199\" \/><\/a> Cross-section view of a tracheostomy (on a model) inserted in the trachea anterior to the esophagus[\/caption]<\/td>\r\n<td style=\"width: 50%;border: none\">\r\n\r\n[caption id=\"attachment_2666\" align=\"aligncenter\" width=\"318\"]<img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/man-with-trach-300x200.jpeg\" alt=\"\" class=\"wp-image-2666 \" width=\"318\" height=\"212\" \/> Figure 10.1 Person with TT in situ (capped)[\/caption]<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<p style=\"text-align: left\">Tracheostomy tubes can be soft plastic, hard plastic, or, at times, metal. All tracheostomy devices are made up of a number of pieces. Understanding the structure and function is key to providing safe trach care. (See Figure 10.2 and Table<span style=\"color: #000000\"> 10.2.<\/span>) TTs come in different sizes and may have a cuff and may be fenestrated. A cuffed tracheostomy produces a tight seal between the tube and the trachea. This seal prevents aspiration of oropharyngeal secretions and air leakages between the tube and the trachea.\u00a0Tracheostomies are firmly tied and secured around the patient\u2019s neck. The ties prevent accidental decannulation of the trachea (in other words, accidental trach removal). New tracheostomies require attention to principles of asepsis for stoma (wound) care. Tracheostomies that are well established require clean technique for stoma care.<\/p>\r\n\r\n\r\n[caption id=\"attachment_2664\" align=\"aligncenter\" width=\"400\"]<img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Tracheostomy_tube-1-1-300x225.jpg\" alt=\"\" class=\"wp-image-2664\" width=\"400\" height=\"299\" \/> Figure 10.2 Parts of a tracheostomy tube[\/caption]\r\n<table style=\"border-collapse: collapse;width: 100%\" border=\"1\">\r\n<tbody>\r\n<tr>\r\n<td style=\"width: 16.1349%\" colspan=\"2\">\r\n<h3 style=\"text-align: center\">Table 10.2 Parts of a Tracheostomy Tube<\/h3>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"width: 16.1349%\">Outer cannula<\/td>\r\n<td style=\"width: 83.8651%\">Sits in the trachea<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"width: 16.1349%\">Inner cannula<\/td>\r\n<td style=\"width: 83.8651%\">Fits inside the outer cannula. It is a safety feature and can be removed and replaced if obstructed. Whenever possible, TT that include an inner cannula should be used.<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"width: 16.1349%\">Flange \/ face plate<\/td>\r\n<td style=\"width: 83.8651%\">Rests against the patient\u2019s neck. Prevents the TT from migrating into the trachea.<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"width: 16.1349%\">Obturator<\/td>\r\n<td style=\"width: 83.8651%\">Sits inside the TT and is used when the TT is situated. It is replaced with an inner cannula.<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"width: 16.1349%\">Cuff<\/td>\r\n<td style=\"width: 83.8651%\">When inflated, provides protection from aspiration. Prevents the escape of air between the tube and tracheal wall. Cuff pressures that are too high can damage the tracheal mucosa. Follow your agency guidelines for monitoring cuff pressure. A note about uncuffed TTs: they allow patients some control with clearing their own airway, but they present increased risk of aspiration. Uncuffed TTs allow some patients to speak when the tube is in place.<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"width: 16.1349%\">Pilot balloon \/ cuff inflation line<\/td>\r\n<td style=\"width: 83.8651%\">Controls the inflation, deflation of the cuff.<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"width: 16.1349%\" colspan=\"2\">Data source: BTS, 2014<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\nFigure 10.3 shows a cuffed TT in situ (in place). Note the flow of air only occurs in and out of the TT. People with these kinds of TTs cannot talk because no air is allowed to pass the larynx.\u00a0Figure 10.4 shows an uncuffed TT in situ. The flow of air occurs in and out of the TT and through the natural airway. People with these kinds of TTs can talk by covering the trach tube opening to force all expired air through the larynx.\r\n<table style=\"border-collapse: collapse;width: 100%;border: 0px solid #000000\">\r\n<tbody>\r\n<tr style=\"border: 0px solid #000000\">\r\n<td style=\"width: 50%;border: none\">\r\n\r\n[caption id=\"attachment_2677\" align=\"aligncenter\" width=\"268\"]<img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/cuffed-TT-001.jpg\" alt=\"\" class=\"wp-image-2677\" width=\"268\" height=\"375\" \/> Figure 10.3 Cuffed TT[\/caption]<\/td>\r\n<td style=\"width: 50%;border: none\">\r\n\r\n[caption id=\"attachment_2678\" align=\"aligncenter\" width=\"314\"]<img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/uncuffed-TT-001.jpg\" alt=\"\" class=\"wp-image-2678\" width=\"314\" height=\"375\" \/> Figure 10.4 Uncuffed TT[\/caption]<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<div class=\"textbox shaded\">Watch the video <a href=\"https:\/\/barabus.tru.ca\/nursing\/tracheostomy_tubes.html\"><em>Tracheostomy Tubes - inflated versus deflated Cuff<\/em><\/a>\u00a0by Heather Noyes and Wendy McKenzie Thompson Rivers University (2019)<\/div>\r\n&nbsp;\r\n\r\nFenestrated TTs have a number of holes in the outer cannula to allow air to flow from the lungs over the vocal cords. They can be used in conjunction with an uncuffed TT often when weaning the patient from the TT. They are only to be used with patients who can swallow without risk of aspiration (St. George\u2019s University Hospital, n.d.).\r\n\r\n[caption id=\"attachment_2665\" align=\"aligncenter\" width=\"375\"]<img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/375px-Diagram_showing_a_fenestrated_and_a_non_fenestrated_tracheostomy_tube_CRUK_066.svg_.png\" alt=\"\" class=\"wp-image-2665 size-full\" width=\"375\" height=\"285\" \/> Figure 10.5 Fenestrated versus non-fenestrated tube[\/caption]\r\n\r\nOther considerations for persons with TTs:\r\n<ul>\r\n \t<li>Patients often need to lie at a 30-degree, or greater, angle to facilitate breathing and lung expansion.<\/li>\r\n \t<li>All persons with a tracheostomy must have suction equipment and emergency supplies at the bedside. Emergency equipment is usually in a clear bag on an IV pole attached to the patient's bed.<\/li>\r\n \t<li>People with tracheostomies cannot eat or drink (and often have difficulty swallowing) when the cuff is inflated. These people are NPO because of risk of aspiration.<\/li>\r\n \t<li>People with cuffed tracheostomies cannot talk because air cannot bypasses the larynx. As such, finding alternative forms of communication is paramount. For some, a permanent tracheostomy has led them to acquire a speaking valve (BTS, 2014). Others may use fenestrated TTs to help them communicate through speech\u00a0(The Ohio State\u00a0University\u00a0Wexner Medical Center, 2012). (See\u00a0Figure 10.5.)<\/li>\r\n \t<li>People with a tracheostomy must always have the tracheostomy tied securely around the neck using ties, according to agency policy. This prevents the tube from accidentally falling out.<\/li>\r\n \t<li>Patients with a tracheostomy produce more secretions than usual and may not be able to clear secretions from the tracheostomy with coughing. If secretions in the tracheostomy impair air entry and cause respiratory distress, the patient should be suctioned immediately.<\/li>\r\n \t<li>Persons who breathe through a tracheostomy bypass the upper airway where moisture is added to the breath. As such, dry air can dry out airways and cause possible tube blockage from tenacious sputum. Some patients with tracheostomies, particularly in the immediate post op period, require humidity (RCH, n.d.). Humidification may also help to prevent \u00a0ulceration of the tracheal mucosa, sputum retention, atelectasis, impaired gas exchange, and secondary infection (BTS, 2014).<\/li>\r\n \t<li>To optimize respiratory function and oxygenation, care should include physio, mobilization, hydration, suction, and medications as appropriate (BTS, 2014).<\/li>\r\n \t<li>New tracheostomies require attention to principles of asepsis for stoma (wound) care. Tracheostomies that are well established require clean technique for stoma care.<\/li>\r\n<\/ul>\r\n<h2>Potential Complications Associated with Tracheostomies<\/h2>\r\nEarly potential complications post tracheotomy may include hemorrhage, pneumothorax, subcutaneous emphysema, cuff leak, tube dislodgement, and respiratory\/cardiovascular arrest. Complications occurring later, after the tracheostomy is established, may include airway obstruction, fistulae, infection, aspiration, and tracheal damage\/erosion. Table 10.3 outlines potential complications, prevention strategies and interventions if the complication does occur.\r\n<table>\r\n<tbody>\r\n<tr>\r\n<td style=\"border: 1px solid #000000\" colspan=\"3\">\r\n<h3 style=\"text-align: center\">Table 10.3 Potential Complications Associated with Tracheostomies, Prevention and Interventions<\/h3>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;text-align: center;width: 20%\">\r\n<h4 style=\"text-align: center\">Complication<\/h4>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000;text-align: center;width: 40%\">\r\n<h4 style=\"text-align: center\">Prevention<\/h4>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000;text-align: center;width: 40%\">\r\n<h4 style=\"text-align: center\">Interventions<\/h4>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 140.906px\">Hemorrhage<\/td>\r\n<td style=\"border: 1px solid #000000;width: 385.906px\">\r\n<ul>\r\n \t<li>Assess stoma for\u00a0bleeding (excessive suctioning may also result in blood-streaked secretions).<\/li>\r\n \t<li>Report neck swelling.<\/li>\r\n \t<li>Report vigorous pulsation around the trachea.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000;width: 802.906px\">\r\n<ul>\r\n \t<li>Inflate cuff.<\/li>\r\n \t<li>Suction.<\/li>\r\n \t<li>Notify physician immediately if you suspect bleeding.<\/li>\r\n \t<li>CODE BLUE if pulsating frank blood.<\/li>\r\n \t<li>Monitor vital signs.<\/li>\r\n \t<li>Apply pressure to bleed if possible.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 140.906px\">Stomal \/ pulmonary infection<\/td>\r\n<td style=\"border: 1px solid #000000;width: 385.906px\">\r\n<ul>\r\n \t<li>Perform dressing changes and tracheostomy care every 8 hours, and as needed.<\/li>\r\n \t<li>Use sterile technique for tracheostomy suctioning (open method) prn.<\/li>\r\n \t<li>Use clean technique for tracheostomy care.<\/li>\r\n \t<li>Use humidified oxygen <span style=\"font-size: small\"><\/span>or air.<\/li>\r\n \t<li>Perform respiratory assessment.<\/li>\r\n \t<li>Have patient do deep breathing and coughing (DB&amp;C) exercises every\u00a02 to 4 hours, and\u00a0as needed.<\/li>\r\n \t<li>Maintain hydration.<\/li>\r\n \t<li>Take vital signs often (as per patient condition or agency guidelines).<\/li>\r\n<\/ul>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000;width: 802.906px\">Wounds are often kept moist by secretions and\/or humidity. Moisture impairs healing.\r\n\r\nClosed (in line) suction technique does not require sterile gloves.\r\n\r\nHumidity and hydration help to liquefy secretions for easier expectoration.\r\n\r\nReport potential signs of infection:\r\n<ul>\r\n \t<li>Redness<\/li>\r\n \t<li>Sweeping<\/li>\r\n \t<li>Purulent drainage<\/li>\r\n \t<li>Fever<\/li>\r\n \t<li>Abnormal breath sounds<\/li>\r\n \t<li>Increased secretions<\/li>\r\n \t<li>Decreased oxygen sats<\/li>\r\n<\/ul>\r\nRoutine instillation of NS to promote expectoration is not considered best practice.<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 140.906px\">Tube occlusion<\/td>\r\n<td style=\"border: 1px solid #000000;width: 385.906px\">\r\n<ul>\r\n \t<li>Keep inner cannula of dual tracheostomy tube in situ.<\/li>\r\n \t<li>Check patency of single-lumen tracheostomy tube regularly.<\/li>\r\n \t<li>Clean inner cannula\u00a0every 8 hours at a minimum, and as needed.<\/li>\r\n \t<li>Maintain humidification and hydration<\/li>\r\n \t<li>Do DB&amp;C\u00a0exercises every 2 to 4 hours, and as needed.<\/li>\r\n \t<li>Suction as needed.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000;width: 802.906px\">The inner cannula is a safety feature, and can be removed if occlusion occurs.\u00a0Whenever possible use double lumen tubes for this reason.\r\n\r\nIf tube occludes:\r\n<ul>\r\n \t<li>Place patient supine to expose neck and check for tube dislodgement.<\/li>\r\n \t<li>Try ventilation using ambu-bag, but do not force air entry.<\/li>\r\n \t<li>If unable to ventilate, try suction<\/li>\r\n \t<li>Remove inner cannula if suction catheter still does not pass; check patency and replace with new inner cannula.<\/li>\r\n \t<li>If still unable to ventilate, deflate cuff or cuffed tube and notify physician and\/or respiratory therapist.<\/li>\r\n \t<li>If patient is still unable to ventilate, call CODE BLUE and\u00a0cut tie tapes, remove tracheostomy tube, insert dilators, and hold stoma open with tracheal dilators until trained health care professional is able to reinsert a tracheostomy tube.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 140.906px\">Aspiration<\/td>\r\n<td style=\"border: 1px solid #000000;width: 385.906px\">\r\n<ul>\r\n \t<li>All persons with a tracheostomy require a swallow assessment (usually requires a physician order) prior to oral feeding.<\/li>\r\n \t<li>No swallow assessment or feeding occurs when cuff is inflated.<\/li>\r\n \t<li>Consult speech and language therapist.<\/li>\r\n \t<li>Patient should be placed in a semi- to high-upright sitting position.<\/li>\r\n \t<li>Ensure cuff is inflated\u00a0and check cuff pressure once per shift and as needed.<\/li>\r\n \t<li>Always suction above cuff prior to cuff deflation.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000;width: 802.906px\">High Fowler's positioning promotes lung expansion. During swallow assessment, helps to reduce risk of aspiration if the patient begins to choke.\r\n\r\nReport any signs of aspiration:\r\n<ul>\r\n \t<li>Excessive coughing and gagging (particularly with eating and drinking)<\/li>\r\n \t<li>Increased or changed secretions<\/li>\r\n \t<li>Presence of food in secretions<\/li>\r\n \t<li>Drop in O<sub>2 <\/sub>sats<\/li>\r\n<\/ul>\r\nIf patient vomits:\r\n<ul>\r\n \t<li>Inflate cuff, if present.<\/li>\r\n \t<li>Suction immediately.<\/li>\r\n \t<li>Raise head of bed; sit patient upright.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 140.906px\">Accidental decannulation<\/td>\r\n<td style=\"border: 1px solid #000000;width: 385.906px\">\r\n<ul>\r\n \t<li>Tracheostomy ties must be secure.<\/li>\r\n \t<li>Secure new ties <em>before <\/em>removing old ties.<\/li>\r\n \t<li>Assess patient for restlessness\/confusion.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000;width: 802.906px\">If partial decannulation occurs (air movement is felt from tube):\r\n<ul>\r\n \t<li style=\"padding-left: 30px\">Deflate cuff if inflated.<\/li>\r\n \t<li style=\"padding-left: 30px\">Remove inner cannula and insert obturator.<\/li>\r\n \t<li style=\"padding-left: 30px\">Gently reinsert tube while holding obturator in place.<\/li>\r\n \t<li style=\"padding-left: 30px\">Remove obturator and replace inner cannula.<\/li>\r\n \t<li style=\"padding-left: 30px\">Check correct placement.\r\n<ul>\r\n \t<li style=\"padding-left: 30px\">Feel for air movement from tube.<\/li>\r\n \t<li style=\"padding-left: 30px\">Check patient's O<sub>2 <\/sub>sats.<\/li>\r\n \t<li style=\"padding-left: 30px\">Ensure patient's breathing returns to baseline.<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t<li>Ensure tie tapes are secure and cuff is inflated, if ordered.<\/li>\r\n<\/ul>\r\nIf complete decanulation occurs, call for trained health care professional to reinsert tracheostomy tube. In the meantime:\r\n<ul>\r\n \t<li style=\"padding-left: 30px\">Maintain tracheal airway and ventilation with bag tracheostomy mask as best as possible.<\/li>\r\n \t<li style=\"padding-left: 30px\">Protect airway from foreign-body aspiration.<\/li>\r\n \t<li style=\"padding-left: 30px\">If stoma is less than 7 days old, use tracheal dilators to maintain stoma potency if necessary.<\/li>\r\n \t<li style=\"padding-left: 30px\">If patient is not ventilating adequately, close stoma and ventilate with bag and face mask with 100% O<sub>2<\/sub> until CODE team arrives. If patient has known upper-airway obstruction, or a laryngectomy, ventilate via stoma with a tracheostomy or pediatric mask.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 1361.91px\" colspan=\"3\"><strong>Note:<\/strong> Do not hyper-extend neck if patient has a known or suspected neck injury.<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;width: 1361.91px\" colspan=\"3\">Data sources: BCIT, 2015b; BTS 2014; Vancouver Coastal Health, 2012a<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\nEmergency equipment should be available at the bedside and should accompany the patient off the unit. Check the agency policy to confirm contents. A basic kit should include:\r\n<ol>\r\n \t<li>Suction equipment (portable unit if necessary).<\/li>\r\n \t<li>Oxygen equipment with humidification.<\/li>\r\n \t<li>An emergency bag containing (see Figure 10.6):\r\n<ul>\r\n \t<li>Two replacement tracheostomy tubes (one of the same size, and one a smaller size than the current tube)<\/li>\r\n \t<li>Obturator and spare inner cannula<\/li>\r\n \t<li>10 ml syringe<\/li>\r\n \t<li>Tracheal dilators<\/li>\r\n \t<li>Sterile gloves<\/li>\r\n \t<li>Water-soluble lubricant<\/li>\r\n \t<li>Scissors<\/li>\r\n \t<li>Cotton tip applicators<\/li>\r\n \t<li>Trach ties<\/li>\r\n \t<li>Sterile gauze<\/li>\r\n \t<li>Resuscitation bag and mask (appropriate size for patient)<\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ol>\r\n[caption id=\"attachment_6322\" align=\"aligncenter\" width=\"500\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18131.jpg\"><img src=\"https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18131.jpg\" alt=\"Equipment for emergency bag for tracheostomy patients. \" class=\"wp-image-6322 size-medium\" width=\"500\" \/><\/a> Figure 10.6 Emergency equipment for persons with a tracheostomy. Clockwise from top left: sterile gloves, spare tracheostomy tube, scissors, lubricant, cotton-tip applicators, ties, 10 ml syringe, tracheal dilators, inner cannula, obturator, sterile gauze[\/caption]\r\n<h2>Tracheostomy Care<\/h2>\r\nTracheostomy care is performed routinely and as required. Tracheostomy care is essential to avoid potential complications such as obstruction and infection. In addition to suctioning, tracheostomy care includes: changing, cleaning and replacing the inner cannula; changing the site dressing; and replacing the tracheostomy ties.\r\nIf possible, these three tasks of tracheostomy care should be performed at the same time to minimize handling of the tracheal device. Collect all supplies at once and complete the procedure in the order listed above. However, there may be times when each task may be performed separately. Ongoing assessment is essential when caring for a patient with a tracheostomy. Checklists 84-87 provide guidelines to do these things.\r\n\r\n&nbsp;\r\n\r\nAdditional care includes performing\u00a0more frequent respiratory assessments and checking patency of tracheostomy tube to assess if suction is required\u00a0(every two hours, and as needed) according to agency policy; keeping patient well hydrated (helps keep secretions thin); encouraging deep breathing and coughing (as required); reporting potential problems such as swelling, elevated temperature, change in sputum production, and decreasing or increasing O<sub>2<\/sub> requirements.\r\n<div class=\"textbox shaded\">Watch the video <a href=\"https:\/\/barabus.tru.ca\/nursing\/replacing_inner_tracheal_cannula.html\"><em>Replacing and Cleaning an Inner Tracheal Cannula<\/em><\/a> by Heather Noyes and Wendy McKenzie Thompson Rivers University (2019)<\/div>\r\n<h3><strong>Tracheal Suctioning<\/strong><\/h3>\r\nThe purpose of suctioning is to maintain a patent airway, to remove secretions from the trachea and bronchi, and to stimulate the cough reflex (Vancouver Coastal Health, 2006). Patients with tracheostomies often have more secretions than normal and will require suctioning to remove secretions from the airway to prevent airway obstruction. People with a tracheostomy should be assessed frequently to determine if suctioning is required. In hospital, sterile suction equipment is used each time tracheal suctioning is performed unless you are using an in line suction catheter which can be used for several suction procedures (Perry et al., 2018). In the home environment, it is common and accepted practice to use \"clean\" rather than sterile technique during suctioning. The basis of this being that home microorganisms are a part of the person\u2019s normal flora and less likely to make them sick (Lewarski, 2005).\r\n\r\n&nbsp;\r\n\r\nTracheal suctioning is indicated with noisy (moist) respirations, decreased O<sub>2<\/sub> sats, anxiousness, restlessness, increased respirations or work of breathing, change in skin colour, or wheezing or gurgling sounds. These are signs and symptoms of respiratory distress, and the patient should be suctioned immediately.\u00a0Checklist 84 outlines the steps for tracheal suctioning.\r\n<table style=\"border-color: #000000\">\r\n<tbody>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;text-align: center\" colspan=\"4\">\r\n<h3 style=\"text-align: center\"><a id=\"checklist84\"><\/a>Checklist 84: Tracheal Suctioning\u2014Open Method<\/h3>\r\n<h5 style=\"text-align: center\"><em><span style=\"color: #000000\">Disclaimer:\u00a0Always review and follow your agency policy regarding this specific skill.<\/span><\/em><\/h5>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;height: 242px\" colspan=\"4\">\r\n<h5><span style=\"color: #333333\">Safety considerations:\u00a0<\/span><\/h5>\r\n<ul>\r\n \t<li>Perform\u00a0hand hygiene.<\/li>\r\n \t<li>Complete <a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/chapter\/2-13-quick-priority-assessment-qpa\/\">QPA<\/a> including safety.<\/li>\r\n \t<li>Suctioning can cause increased intracranial pressure in patients with head injury. The nurse can reduce this risk by hyperoxygenating the patient before suctioning and\/or limiting the number of times a suction catheter is inserted into the trachea.\u00a0Pre-hyperoxygenate patient if required, and as per agency policy.<\/li>\r\n \t<li><span style=\"color: #333333\">Apply <a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/chapter\/1-5-principles-of-surgical-asepsis\/\">principles of\u00a0asepsis<\/a> for tracheal suctioning in acute care. Clean technique may be used in home settings.\u00a0<\/span><\/li>\r\n \t<li>Perform point of care risk assessment for PPE. Donne face shield, gown, gloves (sterile or clean depending on setting).<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 50%;text-align: center;height: 65px\" colspan=\"2\">\r\n<h4 style=\"text-align: center\">Steps<\/h4>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000;width: 50%;text-align: center;height: 65px\" colspan=\"2\">\r\n<h4 style=\"text-align: center\">\u00a0Additional Information<\/h4>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 393.906px;height: 107px\" colspan=\"2\">1. Assess need for suctioning including respiratory assessment, signs of hypoxia, excess secretions, or alterations in oxygen levels.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 403.906px;height: 107px\" colspan=\"2\">Perform baseline respiratory assessment including SpO<sub>2<\/sub>.\r\n\r\nDetermine if the patient is on any medications that increase risk of bleeding.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 393.906px;height: 169px\" colspan=\"2\">2. Explain the procedure in a calm, reassuring manner explaining the benefits are to remove secretions and to make breathing easier.\r\n\r\nPosition the patient in semi to high Fowler's unless contraindicated. Drape chest with towel or disposable pad.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 403.906px;height: 169px\" colspan=\"2\">Procedure can cause patient anxiety. This is part of the consent procedure.\r\n\r\nPositioning promotes lung expansion and promotes secretion clearance.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 393.906px;height: 10px\" colspan=\"2\">3. Perform hand hygiene. Gather equipment.\r\n\r\n&nbsp;<\/td>\r\n<td style=\"border: 1px solid #000000;width: 403.906px;height: 10px\" colspan=\"2\">Equipment should include suction canister, regulator, suction tubing, sterile suction catheter, water soluble lubricant, PPE (face shield, sterile gloves, gown), sterile saline or water, and pulse oximeter.\r\n\r\nPreparing equipment ahead of time promotes safety, organization, and timeliness.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 393.906px;height: 111px\" colspan=\"2\">4. Administer oxygen if needed. This includes hyper-oxygenating if necessary.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 403.906px;height: 111px\" colspan=\"2\">Hyper-oxygenating might be necessary if the patient is hypoxic or at risk of hypoxia during procedure.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 393.906px;height: 293px\" colspan=\"2\">5. Turn the suction device on, and set the vacuum regulator to the appropriate negative pressure. Set suction levels to medium \/ moderate.\r\n\r\nAttach the suction catheter to the tubing whilst remaining in the sterile package.\r\n\r\nOpen the sterile water \/ saline.\r\n\r\n&nbsp;<\/td>\r\n<td style=\"border: 1px solid #000000;width: 403.906px;height: 293px\" colspan=\"2\">\r\n\r\n[caption id=\"attachment_1071\" align=\"aligncenter\" width=\"150\"]<img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_18081-150x150.jpg\" alt=\"\" class=\"wp-image-1071 size-full\" width=\"150\" height=\"150\" \/> Portable suction unit[\/caption]\r\n\r\n[caption id=\"attachment_2679\" align=\"aligncenter\" width=\"300\"]<img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/suction-wall-unit-300x185.jpg\" alt=\"\" class=\"wp-image-2679 size-medium\" width=\"300\" height=\"185\" \/> Figure 10.7 Wall suction unit[\/caption]\r\n\r\nSuction setting:\r\n<ul>\r\n \t<li>Adult 80 to 100mmHg<\/li>\r\n \t<li>Children 60 to 80 mmHg<\/li>\r\n \t<li>Not to exceed 150 mmHg<\/li>\r\n<\/ul>\r\nExcessive negative pressure damages mucosa and induces greater possibility for hypoxia.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 393.906px;height: 155px\" colspan=\"2\">6. Perform hand hygiene and perform point of care risk assessment. Donne <a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/chapter\/1-4-additional-precautions-and-personal-protective-equipment-ppe\/\">PPE<\/a>.\r\n\r\n&nbsp;<\/td>\r\n<td style=\"border: 1px solid #000000;width: 403.906px;height: 155px\" colspan=\"2\">At minimum, PPE should include face shield and gloves (gown is highly recommended). This prevents transmission of microorganisms to healthcare provider.\r\n\r\nSterile gloves in acute care environments. Clean gloves in home environments.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 393.906px;height: 311px\" colspan=\"2\">7. Sterile procedure: <a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/chapter\/1-7-surgical-hand-scrub-applying-sterile-gloves-and-preparing-a-sterile-field\/\">Apply sterile gloves<\/a>\r\n\r\nWith the non-dominant hand, pick up the packaged connecting tubing. That hand is now contaminated.\r\n\r\nExpose the suction catheter enough to allow the dominant hand (sterile) to grab the sterile catheter.\r\n\r\nWrap the sterile catheter around the dominant hand.\r\n\r\nSuction a small amount of sterile NS \/ water.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 403.906px;height: 311px\" colspan=\"2\">\r\n\r\n[caption id=\"attachment_63342\" align=\"aligncenter\" width=\"150\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_1565-001.jpg\"><img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_1565-001-150x150.jpg\" alt=\" Apply sterile glove to each hand or apply non-sterile glove to non-dominant hand and sterile glove to dominant hand\" class=\"wp-image-6113 size-thumbnail aligncenter\" width=\"150\" height=\"150\" \/><\/a> Apply sterile glove to each hand or apply non-sterile glove to non-dominant hand and sterile glove to dominant hand[\/caption]\r\n\r\nYou can also apply a non-sterile glove to the non-dominant hand and a sterile glove to the dominant hand.\r\n\r\nThere is more than one way to remove the catheter from the packaging. The principle of sterile to sterile must apply to the tip of the suction catheter.\r\n\r\n[caption id=\"attachment_6334\" align=\"aligncenter\" width=\"150\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18261.jpg\"><img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_18261-150x150.jpg\" alt=\"Suction is initiated by covering the hole on the suctioning tube with your thumb\" class=\"wp-image-6334 size-thumbnail\" width=\"150\" height=\"150\" \/><\/a> Suction is initiated by covering the hole on the suctioning tube with your thumb[\/caption]\r\n\r\nSuctioning sterile NS \/ water ensures properly functioning equipment.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 393.906px;height: 213px\" colspan=\"2\">8. Insert suction catheter\u00a0into tracheostomy until resistance is felt, then pull back about 1 cm. Do <em>not<\/em> apply suction when inserting suction catheter.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 403.906px;height: 213px\" colspan=\"2\">\r\n\r\n[caption id=\"attachment_633422\" align=\"aligncenter\" width=\"150\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18211.jpg\"><img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_18211-150x150.jpg\" alt=\"Insert suction catheter into tracheostomy until resistance is felt, then pull back about 1\/2 inch\" class=\"wp-image-6329 size-thumbnail aligncenter\" width=\"150\" height=\"150\" \/><\/a> Insert suction catheter into tracheostomy until resistance is felt, then pull back about 1 cm[\/caption]\r\n\r\nResistance is felt at the level of the patient's carina.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 393.906px;height: 203px\" colspan=\"2\">9. Apply intermittent suction as the catheter is withdrawn. This means occluding and releasing the catheter vent with the non-dominant thumb. Some sources suggest twist the catheter back and forth as the catheter is withdrawn. Always encourage the patient to cough.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 403.906px;height: 203px\" colspan=\"2\">Do not apply suction for longer than 15 seconds. Suction removes oxygen and increases the risk of hypoxia as oxygen is sucked out.\r\n\r\nThe need to rotate the catheter is questioned in the literature because present day suction catheters have multiple eyes \/ holes.\r\n\r\nEncourage coughing to promote secretion clearance.\r\n\r\nRoutine installation of normal saline into the trachea to loosen and mobilize secretions is <span style=\"text-decoration: underline\">not best practice<\/span>.\r\n\r\nIf a sterile sputum sample is required, follow agency policy for specific directions related to type of equipment in the agency.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 393.906px;height: 82px\" colspan=\"2\">10. Replace oxygen delivery device and encourage deep breaths.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 403.906px;height: 82px\" colspan=\"2\">Promotes oxygenation.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 393.906px;height: 85px\" colspan=\"2\">11. Clear secretions from suction catheter by suctioning sterile normal saline or water from sterile container.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 403.906px;height: 85px\" colspan=\"2\">\r\n\r\n[caption id=\"attachment_63422\" align=\"aligncenter\" width=\"150\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18251.jpg\"><img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_18251-150x150.jpg\" alt=\"Clear secretions from suction catheter by suctioning sterile normal saline or water from sterile container\" class=\"wp-image-6333 size-thumbnail aligncenter\" width=\"150\" height=\"150\" \/><\/a> Clear secretions from suction catheter by suctioning sterile normal saline or water from sterile container[\/caption]\r\n\r\nClears tubing of secretions to maintain patency.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 393.906px;height: 170px\" colspan=\"2\">12. Assess need to repeat the procedure. Reassess respiratory status and O<sub>2<\/sub> saturation for improvements.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 403.906px;height: 170px\" colspan=\"2\">Allow periods of rest between suction. The length of time between suctioning depends on patient tolerance.\u00a0Patient may be suctioned up to three times with the same suction catheter. Do not pass (insert) suction catheter\u00a0more than three times.\r\n\r\nDeclining SpO<sub>2<\/sub> suggests the patient is not tolerating the procedure. Consult the prescriber and\/or respiratory therapist.\r\n\r\nCall for help if any abnormal signs and symptoms appear, or if respiratory status does not improve.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 393.906px;height: 239px\" colspan=\"2\">13. Discard suction catheter, sterile saline \/ water, and sterile gloves. Turn off suction. Remove gloves.\u00a0Perform hand hygiene.\r\n\r\nEnsure supplies are readily available at the bedside for next suction procedure.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 403.906px;height: 239px\" colspan=\"2\">Open suctioning method requires new suction catheter after each round of suctioning. Reuse may introduce microorganisms into the patient's respiratory tract increasing risk of infection.\r\n\r\n[caption id=\"attachment_6342\" align=\"aligncenter\" width=\"150\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_17801.jpg\"><img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_17801-150x150.jpg\" alt=\"Wrap suction catheter in glove and dispose\" class=\"wp-image-6342 size-thumbnail\" width=\"150\" height=\"150\" \/><\/a> One way to dispose of the suction catheter is to pull your glove over top of the catheter.[\/caption]\r\n\r\nAdditional suction supplies are essential in case of an emergency or respiratory distress.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 393.906px;height: 70px\" colspan=\"2\">14. Return patient to a safe and comfortable position and ensure that call bell is within patient's reach.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 403.906px;height: 70px\" colspan=\"2\">This promotes patient safety.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 393.906px;height: 326px\" colspan=\"2\">15. Document procedure according to\u00a0agency policy.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 403.906px;height: 326px\" colspan=\"2\">Documentation may include the suction procedure; patient reaction; amount, thickness, and color of secretions; if normal saline was instilled; and if sputum samples were sent to the lab. Documentation provides accurate details of response to suctioning and clear communication among the health care team.\r\n\r\nSample narrative documentation:\r\n\r\n<em>date \/ time: Audibly moist respirations. Thick yellow tinged secretions observed at trach site. T 37.5 HR 98 RR 24 BP 146\/79. SpO<sub>2<\/sub> 90% on 40% humidified oxygen @ 10L\/ min. Trach suctioned with #14 suction catheter for moderate think yellow secrrtions. Cough reflex apparent. Following procedure RR 20\/min.\u00a0 SpO<sub>2<\/sub> 98%. O<sub>2<\/sub> reestablished as noted above. ------ L,Owox\u00a0 RN<\/em><\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 813.906px;height: 16px\" colspan=\"4\">Data sources: BCIT, 2015c;\u00a0Halm &amp; Krisko-Hagel, 2008; Perry et al., 2018; Vancouver Coastal Health, 2006<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\nA closed method of tracheal suctioning involves a multi-use suction catheter enclosed in a plastic sleeve and attached to the patient's airway (tracheal tube). In comparison to the open suction method, the closed method presents less risk of hypoxia and cardiovascular complications. To initiate closed suctioning, consult a respiratory therapist.\r\n<div class=\"textbox shaded\" style=\"text-align: center\">Watch the video <em><a href=\"https:\/\/barabus.tru.ca\/nursing\/Closed_Tracheostomy.html\" target=\"_blank\" rel=\"noopener\">Tracheal Suctioning - Closed in line Method<\/a>\u00a0<\/em>developed by Heather Noyes and Wendy McKenzie of Thompson Rivers University, 2018.<\/div>\r\n<h3><strong>Replacing and Cleaning an Inner Tracheal Cannula<\/strong><\/h3>\r\nThe primary purpose of the inner cannula is to prevent tracheostomy tube obstruction. Many sources of obstruction can be prevented if the inner cannula is regularly cleaned\u00a0and replaced. The inner cannula can be cleansed with half-strength hydrogen peroxide or sterile normal saline. Always check the manufacturer's recommendations for tube cleaning. Some inner cannulas are designed to be disposable, while others are reusable for a number of days. Inner tube cleaning should be done as often as two or three\u00a0times per day, depending on the type of equipment, the amount and thickness of secretions, and the patient's ability to cough up the secretions.\r\n\r\nChanging the inner cannula may encourage the patient to cough, bringing mucous out of the\u00a0tracheostomy. For this reason, the inner cannula should be replaced prior to changing the tracheostomy dressing to prevent secretions from soiling the new dressing. If the inner cannula is disposable, no cleaning is required. Checklist 85 describes how to clean and replace an inner tracheal cannula.\r\n<table style=\"border-color: #000000\">\r\n<tbody>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;text-align: center\" colspan=\"4\">\r\n<h3 style=\"text-align: center\"><a id=\"checklist85\"><\/a>Checklist 85: Replacing and Cleaning an Inner Tracheal Cannula<\/h3>\r\n<h5 style=\"text-align: center\"><em><span style=\"color: #000000\">Disclaimer:\u00a0Always review and follow your agency policy regarding this specific skill.<\/span><\/em><\/h5>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000\" colspan=\"4\">\r\n<h5><span style=\"color: #333333\">Safety considerations:\u00a0<\/span><\/h5>\r\n<ul>\r\n \t<li>Reassess your patient's tolerance for tracheostomy care and watch for signs of respiratory distress.<\/li>\r\n \t<li>Pre-hyperoxygenate patient if required and according to\u00a0agency policy.<\/li>\r\n \t<li>If removing oxygen while performing\u00a0tracheostomy care, remember to replace it often to reoxygenate the patient.<\/li>\r\n \t<li>Disposable inner cannulae should be inspected \/ cleaned every 8 hours, or as needed.<\/li>\r\n \t<li>Disposable inner cannulae should be inspected every 8 hours (during tracheostomy care), and replaced every 24 hours and as needed.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 50%;text-align: center\" colspan=\"2\">\r\n<h4 style=\"text-align: center\">Steps<\/h4>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000;width: 50%;text-align: center\" colspan=\"2\">\r\n<h4 style=\"text-align: center\">\u00a0Additional Information<\/h4>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">1.\u00a0Perform hand hygiene, collect supplies, and verify whether inner cannula needs to be cleaned as per policy.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">Supplies include cotton-tip applicator, sterile pipe cleaner, sterile dressing tray, NS, non-sterile gloves, waterproof pad, and PPE.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">2. Perform hand hygiene, ID patient using two identifiers, explain procedure to patient, and create privacy if required.\r\n\r\nEnsure patient has a method to communicate with you during the procedure.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">Hand hygiene reduces the transmission of microorganisms.\r\n\r\nPeople with tracheostomies require a method to communicate with the healthcare provider.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">3. Apply gloves and <a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/chapter\/1-4-additional-precautions-and-personal-protective-equipment-ppe\/\">PPE<\/a>\u00a0, and cover chest with waterproof pad.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">This prevents contact with secretions and prevents gown from becoming soiled.\r\n\r\nUse sterile technique in acute care, clean technique in home environments.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">4. Set up sterile tray field; add cleaning solution and supplies.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">Organization ensures the process is efficient and fast for the patient.\r\n\r\n[caption id=\"attachment_6336\" align=\"aligncenter\" width=\"150\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18331.jpg\"><img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_18331-150x150.jpg\" alt=\"Set up sterile tray and add cleaning solution and supplies\" class=\"wp-image-6336 size-thumbnail\" width=\"150\" height=\"150\" \/><\/a> Set up sterile tray and add cleaning solution and supplies[\/caption]<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">5. Remove oxygen mask to clean dressing, but replace frequently as required by patient.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">\r\n\r\n[caption id=\"attachment_6328\" align=\"aligncenter\" width=\"150\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18201.jpg\"><img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_18201-150x150.jpg\" alt=\"Remove oxygen mask to clean dressing\" class=\"wp-image-6328 size-thumbnail\" width=\"150\" height=\"150\" \/><\/a> Remove oxygen mask to clean dressing[\/caption]\r\n\r\nReplace the tracheal oxygen mask frequently to prevent hypoxia.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">6. Remove inner cannula by stabilizing neck plate \/ flange and gently grasping the outer white area. Rotate inner cannula counter-clockwise to unlock it. Pull cannula out in a downward motion. Some inner cannulae will \u201cclick\" on, some twist on\/off. Do not touch the inner cannula; only handle the white outer area unless you are wearing sterile gloves.\r\n\r\nReplace the client's oxygen while cleaning the inner cannula to prevent the client from desaturating or drying out secretions<\/td>\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">Review policy for cleaning frequency and cleaning solution.\r\n\r\n[caption id=\"attachment_6349\" align=\"aligncenter\" width=\"150\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18391.jpg\"><img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_18391-150x150.jpg\" alt=\"Remove inner cannula by stabilizing neck plate and gently grasping the outer white area\" class=\"wp-image-6349 size-thumbnail\" width=\"150\" height=\"150\" \/><\/a> Remove inner cannula by stabilizing neck plate \/ flange and gently grasping the outer white area[\/caption]<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">7. Soak inner cannula in saline, if necessary, use a sterile pipe cleaner or cotton tipped applicators with gauze to remove exudate from the inner lumen. Rinse well.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">Soaking the cannula helps loosen the secretions.\r\n\r\n[caption id=\"attachment_6351\" align=\"aligncenter\" width=\"150\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18411.jpg\"><img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_18411-150x150.jpg\" alt=\"Soak in appropriate solution and, if necessary, use a sterile pipe cleaner to remove exudate from the inner cannula\" class=\"wp-image-6351 size-thumbnail\" width=\"150\" height=\"150\" \/><\/a> Use a sterile pipe cleaner to remove exudate from the inner cannula[\/caption]<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">8. Reinsert inner cannula by stabilizing neck plate, holding the white part with the end upright, and twisting into the shape of the\u00a0tracheostomy.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">This prevents trauma to the tracheal stoma.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">9. Ensure the inner cannula has \u201cclicked\u201d into place. Use sterile gauze to clean the outer cannula surfaces<\/td>\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">\r\n\r\n[caption id=\"attachment_6380\" align=\"aligncenter\" width=\"150\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_2076.jpg\"><img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_2076-150x150.jpg\" alt=\"Ensure that inner cannula is 'clicked' securely into place\" class=\"wp-image-6380 size-thumbnail\" width=\"150\" height=\"150\" \/><\/a> Ensure that inner cannula is \"clicked\" securely into place[\/caption]<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">10. Discard used equipment. Remove gloves.\u00a0Perform hand hygiene.\r\n\r\nEnsure the patient is in a safe and comfortable position.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">Hand hygiene reduces the transmission of microorganisms.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"4\">Data sources: BCIT, 2015c; Morris, Whitmer, &amp; McIntosh, 2013; Perry et al., 2018; Vancouver Coastal Health, 2012b<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<div>\r\n<div class=\"textbox shaded\" style=\"text-align: center\">Watch the video <a href=\"https:\/\/barabus.tru.ca\/nursing\/replacing_inner_tracheal_cannula.html\"><em>Replacing and Cleaning an Inner Tracheal Cannula<\/em><\/a>\u00a0 \u00a0 \u00a0by Heather Noyes and Wendy McKenzie Thompson Rivers University (2019)<\/div>\r\n<\/div>\r\n<h3><strong>Cleaning Stoma and Changing the Tracheosotomy Site Dressing<\/strong><\/h3>\r\nThe stoma should be cleaned and the dressing changed every 6 to\u00a012 hours or as needed, and the peristomal skin should be inspected for skin breakdown, redness, irritation, ulceration, pain, infection, or dried secretions. Patients with copious amounts of secretions often require frequent dressing changes to prevent maceration of the tissue and skin breakdown. Cotton-tip applicators can be used to get under the tracheostomy device, where cleaning can be done using a semi-circular motion, inward to outward. Always use aseptic technique. Checklist 86 provides a safe method to clean the tracheal stoma and replace the sterile dressing.\r\n<table style=\"border-color: #000000\">\r\n<tbody>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;text-align: center\" colspan=\"4\">\r\n<h3 style=\"text-align: center\"><a id=\"checklist86\"><\/a>Checklist 86: Cleaning Stoma and Changing a Sterile Dressing<\/h3>\r\n<h5 style=\"text-align: center\"><em><span style=\"color: #000000\">Disclaimer:\u00a0Always review and follow your agency policy regarding this specific skill.<\/span><\/em><\/h5>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000\" colspan=\"4\">\r\n<h5><span style=\"color: #333333\">Safety considerations:\u00a0<\/span><\/h5>\r\n<ul>\r\n \t<li>Reassess your patient's tolerance for tracheostomy care and watch for signs of respiratory distress.<\/li>\r\n \t<li>Pre-hyperoxygenate patient if required and according to\u00a0agency policy.<\/li>\r\n \t<li>If removing oxygen while preforming tracheostomy care, remember to replace it often to reoxygenate the patient.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 50%;text-align: center\" colspan=\"2\">\r\n<h4 style=\"text-align: center\">Steps<\/h4>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000;width: 50%;text-align: center\" colspan=\"2\">\r\n<h4 style=\"text-align: center\">\u00a0Additional Information<\/h4>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">1.\u00a0Perform hand hygiene, verify physician orders for tracheostomy care, and collect supplies.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">Supplies include sterile dressing kit, pre-cut 4 \u00d7 4 gauze, normal saline, cotton-tip applicators, non-sterile gloves, and garbage bag.\r\n\r\nPre-cut gauze is less likely to have loose fibers that could potentially enter wound and delay healing.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">2. Perform hand hygiene, ID patient using two identifiers, explain procedure to patient, and create privacy if required. Ensure patient has a method to communicate with you during the procedure.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">This reduces the transmission of microorganisms.\r\n\r\nPatients with trachs always require a method to communicate with the healthcare provider.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">3. Apply non-sterile gloves and cover chest with waterproof pad.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">This\u00a0prevents gown from becoming soiled.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">4. Sanitize your working surface. Organize all supplies and set up sterile tray field; add cleaning solution to sterile tray.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">Use agency approved cleaning solutions to wipe table tops.\r\n\r\nOrganization ensures the process of cleaning is efficient.\r\n\r\n[caption id=\"attachment_6336\" align=\"aligncenter\" width=\"150\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18331.jpg\"><img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_18331-150x150.jpg\" alt=\"Set up sterile tray and add cleaning solution and supplies\" class=\"wp-image-6336 size-thumbnail\" width=\"150\" height=\"150\" \/><\/a> Set up sterile tray and add cleaning solution and supplies[\/caption]<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">5. Remove oxygen mask to access the dressing but replace frequently as required by patient.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">This prevents hypoxia.\r\n\r\n[caption id=\"attachment_6328\" align=\"aligncenter\" width=\"150\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18201.jpg\"><img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_18201-150x150.jpg\" alt=\"Remove oxygen mask to clean dressing\" class=\"wp-image-6328 size-thumbnail\" width=\"150\" height=\"150\" \/><\/a> Remove oxygen mask to clean dressing[\/caption]<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">6. Using forceps, remove the soiled dressing around the tube and discard in garbage bag.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">All soiled dressings should be removed, as they\u00a0may excoriate the surrounding peristomal skin.\r\n\r\n[caption id=\"attachment_6337\" align=\"aligncenter\" width=\"150\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18341.jpg\"><img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_18341-150x150.jpg\" alt=\"Use forceps to remove the soiled dressing\" class=\"wp-image-6337 size-thumbnail\" width=\"150\" height=\"150\" \/><\/a> Use forceps to remove the soiled dressing[\/caption]<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">7. Assess the stoma site for bleeding, appearance of stoma edges, and peristomal skin for evidence of infection or redness (assess for increase in pain, odour, or abscess formation).<\/td>\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">Assessment is important to identify and prevent further complications.\r\n\r\n[caption id=\"attachment_6338\" align=\"aligncenter\" width=\"150\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18351.jpg\"><img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_18351-150x150.jpg\" alt=\"Assess stoma site\" class=\"wp-image-6338 size-thumbnail\" width=\"150\" height=\"150\" \/><\/a> Assess stoma site[\/caption]<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">8. Clean the stoma site (including under faceplate) with a gauze or cotton-tip applicator soaked in normal saline. Clean in circular motion from the stoma outwards. Be careful not to disturb the tracheostomy tube. Dry area.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">Cleaning around the stoma removes any debris or exudate from the stoma. A tracheal stoma should be cleaned with normal saline.\r\n\r\n<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18371.jpg\"><img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_18371-150x150.jpg\" alt=\"Clean the stoma site with a gauze or cotton-tip applicator soaked in normal saline\" class=\"wp-image-6346 size-thumbnail aligncenter\" width=\"150\" height=\"150\" \/><\/a><\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">9. Assess the site to determine if skin protection (ie. barrier film)is required.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">Consult wound care specialist if needed.\r\n\r\nSkin protectant is sometimes necessary to prevent further skin breakdown.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">10. Apply new manufactured pre-cut tracheostomy dressing to tube using sterile forceps.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">Use non-fraying material as a dressing round the stoma. Avoid cutting gauze for tracheostomy care.\u00a0 The small fibres from the cut gauze may become loose and accidentally travel into the inner cannula.\r\n\r\n[caption id=\"attachment_63462\" align=\"aligncenter\" width=\"150\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18341.jpg\"><img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_18341-150x150.jpg\" alt=\"Apply new manufactured pre-cut tracheostomy dressing to tube using sterile forceps\" class=\"wp-image-6337 size-thumbnail aligncenter\" width=\"150\" height=\"150\" \/><\/a> Apply new manufactured pre-cut tracheostomy dressing to tube using sterile forceps[\/caption]<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"4\">Data sources: BCIT, 2015c; Morris et al., 2013; Perry et al., 2018; Vancouver Coastal Health, 2012<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<div>\r\n<div class=\"textbox shaded\" style=\"text-align: center\">Watch the video\u00a0<a href=\"https:\/\/barabus.tru.ca\/nursing\/changing_tracheostomy_site_dressing.html\"><em>Changing a Trachestomy Site Dressing<\/em><span style=\"text-decoration: underline\"><span style=\"color: #000000;text-decoration: underline\"> by<\/span><\/span><\/a>\u00a0Heather Noyes and Wendy McKenzie Thompson Rivers University (2019)<\/div>\r\n<\/div>\r\n<h2><span style=\"font-family: Tinos, Georgia, serif;font-size: 14pt;font-weight: normal\">Tracheal ties will become dirty and require replacing. Ties should be replaced as required, according to agency policy. Ideally, one person should hold the tracheostomy tube\u00a0in place while the tracheostomy ties are replaced by another person. Alternatively, secure the new tracheostomy ties prior to removing the old tracheostomy ties to avoid accidental dislodgement of the tracheostomy tube\u00a0if the patient coughs or the tracheostomy is accidentally bumped out. Once the new tracheostomy ties are on, only one finger should fit between the tracheostomy ties and the neck.<\/span><\/h2>\r\n<h3><strong>Replacing Tracheostomy Ties (Velcro)<\/strong><\/h3>\r\nChecklist 87 lists the steps for replacing tracheostomy ties.\r\n<table style=\"border-color: #000000;height: 1556px\">\r\n<tbody>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;text-align: center;height: 116px;width: 977.4px\" colspan=\"4\">\r\n<h3 style=\"text-align: center\"><a id=\"checklist87\"><\/a>Checklist 87: Replacing Tracheostomy Ties (Velcro)<\/h3>\r\n<h5 style=\"text-align: center\"><em><span style=\"color: #000000\">Disclaimer:\u00a0Always review and follow your agency policy regarding this specific skill.<\/span><\/em><\/h5>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;height: 249px;width: 977.4px\" colspan=\"4\">\r\n<h5><span style=\"color: #333333\">Safety considerations:\u00a0<\/span><\/h5>\r\n<ul>\r\n \t<li>Reassess your patient's tolerance for tracheostomy care and watch for signs of respiratory distress.<\/li>\r\n \t<li>Pre-hyperoxygenate patient if required and according to\u00a0agency policy<\/li>\r\n \t<li>If removing oxygen while preforming tracheostomy care, remember to replace it often to reoxygenate the patient.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 480.6px;text-align: center;height: 65px\" colspan=\"2\">\r\n<h4 style=\"text-align: center\">Steps<\/h4>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000;width: 479.8px;text-align: center;height: 65px\" colspan=\"2\">\r\n<h4 style=\"text-align: center\">\u00a0Additional Information<\/h4>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 480.6px;height: 115px\" colspan=\"2\">1.\u00a0Perform hand hygiene, collect supplies. Assess need for <a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/chapter\/1-4-additional-precautions-and-personal-protective-equipment-ppe\/\">PPE<\/a><\/td>\r\n<td style=\"border: 1px solid #000000;width: 479.8px;height: 115px\" colspan=\"2\">Hand hygiene reduces the transmission of microorganisms.\r\n\r\nSupplies include\u00a0twill or Velcro ties, a second person to secure the tracheostomy when old ties are removed, scissors if using twill tape ties.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 480.6px;height: 34px\" colspan=\"2\">2. Have an additional health care provider assist with the tracheal tie change as required.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 479.8px;height: 34px\" colspan=\"2\">An additional helper is there to secure the trachestomy tube and prevent accidental dislodgement.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 480.6px;height: 120px\" colspan=\"2\">3. ID patient using two identifiers, explain procedure to patient, and create privacy if required. Ensure patient has a method to communicate with you during the procedure.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 479.8px;height: 120px\" colspan=\"2\">Persons with a tracheostomy require a method to communicate with the health care provider.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 480.6px;height: 221px\" colspan=\"2\">4. Apply non-sterile gloves.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 479.8px;height: 221px\" colspan=\"2\">This reduces the transmission of microorganisms.\r\n\r\n<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_1511.jpg\"><img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/05\/DSC_1511-150x150.jpg\" alt=\"Apply non-sterile gloves\" class=\"wp-image-5559 size-thumbnail aligncenter\" width=\"150\" height=\"150\" \/><\/a><\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 480.6px;height: 567px\" colspan=\"2\">5. To secure the tracheostomy tube with velcro ties:\r\n<ul>\r\n \t<li>If patient is at risk of tracheostomy dislodgement due to confusion or agitation, replace velcro with ribbon tapes.<\/li>\r\n \t<li>If possible, one health care worker can keep the tracheostomy tube in place by holding the flange with gloved hands, while the other can replace the tapes.<\/li>\r\n \t<li>Thread the narrow velcro tab through the slit in the flange of the tracheostomy tube and fold it back to adhere to the main tube holder; repeat on other side. Overlap the shorter length of collar with the longer length of collar and secure with the wider velcro tab. Trim any excess length of collar to fit the size of the patient\u2019s neck.<\/li>\r\n \t<li>Check how secure the collar feels. Ensure you can fit two fingers between the collar and the patient.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000;width: 479.8px;height: 567px\" colspan=\"2\">Tracheostomy ties are used to promote patient comfort and keep the tracheostomy secured and in situ.\r\n\r\n&nbsp;\r\n\r\nAn assistant can hold the trach tube in place\u00a0to reduce risk of potential dislodgement of the tube if the patient coughs.\r\n\r\n[caption id=\"attachment_6353\" align=\"aligncenter\" width=\"150\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18471.jpg\"><img src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_18471-150x150.jpg\" alt=\"Velcro ties\" class=\"wp-image-6353 size-thumbnail\" width=\"150\" height=\"150\" \/><\/a> Velcro ties[\/caption]\r\n\r\nThe tape should be tight enough to keep the tracheostomy tube securely in place but loose enough to allow the little finger to fit between the tapes and the neck.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 480.6px;height: 53px\" colspan=\"2\">6. Clean the work area. Discard garbage appropriately. Perform hand hygiene. Leave the patient in a comfortable position.<\/td>\r\n<td style=\"border: 1px solid #000000;width: 479.8px;height: 53px\" colspan=\"2\">Hand hygiene reduces the transmission of microorganisms.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000\">\r\n<td style=\"border: 1px solid #000000;width: 977.4px;height: 16px\" colspan=\"4\">Data sources: BCIT, 2015c; Morris et al., 2013;\u00a0Perry et al., 2018<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<div>\r\n<div class=\"textbox shaded\" style=\"text-align: center\">Watch the video <a href=\"https:\/\/barabus.tru.ca\/nursing\/changing_traceostomy_ties.html\"><em>Replacing Tracheostomy Ties<\/em><\/a> by Heather Noyes and Wendy McKenzie Thompson Rivers University (2019)<\/div>\r\n<div class=\"bcc-box bcc-info\">\r\n<h3 style=\"text-align: center\">Critical Thinking Exercises<\/h3>\r\n<ol>\r\n \t<li>When suctioning your patient who has a tracheostomy, you notice thick, tenacious secretions. What interventions should be implemented?<\/li>\r\n \t<li>What methods of communication can you use for your patient with a tracheostomy tube who is unable to speak?<\/li>\r\n \t<li>Answer yes or no in relation to whether or not each of the following situations presents a concern:<\/li>\r\n<\/ol>\r\na)\u00a0If a person has a cuffed tracheostomy in place requires manual ventilation, such as with a bag and mask via the nose, will this deliver oxygen to the patient?\r\n\r\nb)\u00a0A suction catheter cannot pass through a tracheostomy.\r\n\r\nc)\u00a0A patient with an tracheostomy tube that has an inflated cuff is able to talk.\r\n\r\nd)\u00a0Decannulation occurred 4 days ago. The occlusive dressing has fallen off. The wound is now closed.\r\n\r\n<\/div>\r\n<h2>Attributions<\/h2>\r\n<p class=\"hanging-indent\">Figure 10.1.\u00a0<a href=\"https:\/\/www.pexels.com\/photo\/banner-cancer-disability-esophagus-415903\/\">Untitled<\/a> by <a href=\"https:\/\/www.pexels.com\/@pixabay\" target=\"_blank\" rel=\"noopener\">pixabay.com<\/a>\u00a0 is used under an open\u00a0<a href=\"https:\/\/www.pexels.com\/photo-license\/\">Pexels license.<\/a><\/p>\r\n<p class=\"hanging-indent\">Figure 10.2.\u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Tracheostomy_tube.jpg\">Tracheostomy Tube<\/a> by <a href=\"https:\/\/commons.wikimedia.org\/wiki\/User:Enigma51\">Klaus D. Peter<\/a> is used under a\u00a0<a href=\"https:\/\/creativecommons.org\/licenses\/by\/2.0\/de\/deed.en\"><span class=\"cc-license-identifier\"><span style=\"text-decoration: none\">CC BY 2.0 DE<\/span><\/span><\/a>\u00a0license.<\/p>\r\n<p class=\"hanging-indent\">Figure 10.3 &amp; 10.4. These are modified reproductions of\u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Endotracheal_tube_colored.png\" target=\"_blank\" rel=\"noopener\">\"Diagram of an inserted endotracheal tube\"<\/a>\u00a0by\u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/User:PhilippN\" target=\"_blank\" rel=\"noopener\">PhilippN<\/a>\u00a0in the\u00a0<a href=\"https:\/\/wiki.creativecommons.org\/Public_domain\" target=\"_blank\" rel=\"noopener\">Public Domain<\/a>\u00a0\/ A derivative from the\u00a0<a href=\"http:\/\/commons.wikimedia.org\/wiki\/Image:Endotracheal_tube_inserted.png\" target=\"_blank\" rel=\"noopener\">original work.<\/a><\/p>\r\n<p class=\"hanging-indent\">Figure 10.5.\u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Diagram_showing_a_fenestrated_and_a_non_fenestrated_tracheostomy_tube_CRUK_066.svg\">Diagram Showing a Fenestrated and a Non Fenestrated Tracheostomy Tube<\/a> by Cancer Research UK is used under a\u00a0<span class=\"cc-license-identifier\"><a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/deed.en\">CC BY-SA 4.0<\/a>\u00a0i<\/span>nternational license.<\/p>\r\nFigure 10.6 <a href=\"https:\/\/opentextbc.ca\/clinicalskills\/chapter\/10-6-tracheostomies\/\">Emergency equipment<\/a> is from BCIT\r\n\r\nFigure 10.7 WAll suction unit by author is\r\n\r\n<\/div>","rendered":"<h2>Tracheostomy Tubes<\/h2>\n<p>Tracheostomy tubes (TTs) are artificial airways that can be permanent or temporary depending on the patient\u2019s condition. They are placed through a hole in the neck and into the trachea to overcome tracheal obstruction caused by head and neck trauma including surgery or tumour. Other reasons for tracheostomy tubes include the need for prolonged mechanical ventilation and\/or when the client is unable to maintain a patent airway because of conditions like neuromuscular disease or spinal cord injury (BTS, 2014; Perry et al., 2018; RCH, n.d.).<\/p>\n<p>Nursing care of clients with tracheostomy tubes varies depending on how well established the tracheotomy is. The British Thoracic Society prioritizes humidification, ensuring the cleanliness and patency of the inner tube, secure fixation of the tube, and attention to cuff pressure as necessary for preventing TT related complications (BTS, 2014).<\/p>\n<p>If the trach is temporary, decannulation (or removal) should be done as soon as possible to reduce the risk of complications. Decannulation should only be done by competent persons and is only done following thorough assessment of the upper airway.<\/p>\n<table style=\"border-collapse: collapse;width: 100%;border: 0px solid #000000\">\n<tbody>\n<tr style=\"border: 0px solid #000000\">\n<td style=\"width: 50%;border: none\">\n<figure id=\"attachment_5052\" aria-describedby=\"caption-attachment-5052\" style=\"width: 300px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/08\/DSC_0683.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-5052 size-medium\" alt=\"DSC_0683\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_0683-300x199.jpg\" width=\"300\" height=\"199\" \/><\/a><figcaption id=\"caption-attachment-5052\" class=\"wp-caption-text\">Cross-section view of a tracheostomy (on a model) inserted in the trachea anterior to the esophagus<\/figcaption><\/figure>\n<\/td>\n<td style=\"width: 50%;border: none\">\n<figure id=\"attachment_2666\" aria-describedby=\"caption-attachment-2666\" style=\"width: 318px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/man-with-trach-300x200.jpeg\" alt=\"\" class=\"wp-image-2666\" width=\"318\" height=\"212\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/man-with-trach-300x200.jpeg 300w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/man-with-trach-768x512.jpeg 768w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/man-with-trach-1024x683.jpeg 1024w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/man-with-trach-65x43.jpeg 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/man-with-trach-225x150.jpeg 225w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/man-with-trach-350x233.jpeg 350w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/man-with-trach.jpeg 1125w\" sizes=\"auto, (max-width: 318px) 100vw, 318px\" \/><figcaption id=\"caption-attachment-2666\" class=\"wp-caption-text\">Figure 10.1 Person with TT in situ (capped)<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: left\">Tracheostomy tubes can be soft plastic, hard plastic, or, at times, metal. All tracheostomy devices are made up of a number of pieces. Understanding the structure and function is key to providing safe trach care. (See Figure 10.2 and Table<span style=\"color: #000000\"> 10.2.<\/span>) TTs come in different sizes and may have a cuff and may be fenestrated. A cuffed tracheostomy produces a tight seal between the tube and the trachea. This seal prevents aspiration of oropharyngeal secretions and air leakages between the tube and the trachea.\u00a0Tracheostomies are firmly tied and secured around the patient\u2019s neck. The ties prevent accidental decannulation of the trachea (in other words, accidental trach removal). New tracheostomies require attention to principles of asepsis for stoma (wound) care. Tracheostomies that are well established require clean technique for stoma care.<\/p>\n<figure id=\"attachment_2664\" aria-describedby=\"caption-attachment-2664\" style=\"width: 400px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Tracheostomy_tube-1-1-300x225.jpg\" alt=\"\" class=\"wp-image-2664\" width=\"400\" height=\"299\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Tracheostomy_tube-1-1-300x225.jpg 300w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Tracheostomy_tube-1-1-65x49.jpg 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Tracheostomy_tube-1-1-225x168.jpg 225w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Tracheostomy_tube-1-1-350x262.jpg 350w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Tracheostomy_tube-1-1.jpg 600w\" sizes=\"auto, (max-width: 400px) 100vw, 400px\" \/><figcaption id=\"caption-attachment-2664\" class=\"wp-caption-text\">Figure 10.2 Parts of a tracheostomy tube<\/figcaption><\/figure>\n<table style=\"border-collapse: collapse;width: 100%\">\n<tbody>\n<tr>\n<td style=\"width: 16.1349%\" colspan=\"2\">\n<h3 style=\"text-align: center\">Table 10.2 Parts of a Tracheostomy Tube<\/h3>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 16.1349%\">Outer cannula<\/td>\n<td style=\"width: 83.8651%\">Sits in the trachea<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 16.1349%\">Inner cannula<\/td>\n<td style=\"width: 83.8651%\">Fits inside the outer cannula. It is a safety feature and can be removed and replaced if obstructed. Whenever possible, TT that include an inner cannula should be used.<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 16.1349%\">Flange \/ face plate<\/td>\n<td style=\"width: 83.8651%\">Rests against the patient\u2019s neck. Prevents the TT from migrating into the trachea.<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 16.1349%\">Obturator<\/td>\n<td style=\"width: 83.8651%\">Sits inside the TT and is used when the TT is situated. It is replaced with an inner cannula.<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 16.1349%\">Cuff<\/td>\n<td style=\"width: 83.8651%\">When inflated, provides protection from aspiration. Prevents the escape of air between the tube and tracheal wall. Cuff pressures that are too high can damage the tracheal mucosa. Follow your agency guidelines for monitoring cuff pressure. A note about uncuffed TTs: they allow patients some control with clearing their own airway, but they present increased risk of aspiration. Uncuffed TTs allow some patients to speak when the tube is in place.<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 16.1349%\">Pilot balloon \/ cuff inflation line<\/td>\n<td style=\"width: 83.8651%\">Controls the inflation, deflation of the cuff.<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 16.1349%\" colspan=\"2\">Data source: BTS, 2014<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>Figure 10.3 shows a cuffed TT in situ (in place). Note the flow of air only occurs in and out of the TT. People with these kinds of TTs cannot talk because no air is allowed to pass the larynx.\u00a0Figure 10.4 shows an uncuffed TT in situ. The flow of air occurs in and out of the TT and through the natural airway. People with these kinds of TTs can talk by covering the trach tube opening to force all expired air through the larynx.<\/p>\n<table style=\"border-collapse: collapse;width: 100%;border: 0px solid #000000\">\n<tbody>\n<tr style=\"border: 0px solid #000000\">\n<td style=\"width: 50%;border: none\">\n<figure id=\"attachment_2677\" aria-describedby=\"caption-attachment-2677\" style=\"width: 268px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/cuffed-TT-001.jpg\" alt=\"\" class=\"wp-image-2677\" width=\"268\" height=\"375\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/cuffed-TT-001.jpg 322w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/cuffed-TT-001-215x300.jpg 215w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/cuffed-TT-001-65x91.jpg 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/cuffed-TT-001-225x314.jpg 225w\" sizes=\"auto, (max-width: 268px) 100vw, 268px\" \/><figcaption id=\"caption-attachment-2677\" class=\"wp-caption-text\">Figure 10.3 Cuffed TT<\/figcaption><\/figure>\n<\/td>\n<td style=\"width: 50%;border: none\">\n<figure id=\"attachment_2678\" aria-describedby=\"caption-attachment-2678\" style=\"width: 314px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/uncuffed-TT-001.jpg\" alt=\"\" class=\"wp-image-2678\" width=\"314\" height=\"375\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/uncuffed-TT-001.jpg 377w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/uncuffed-TT-001-251x300.jpg 251w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/uncuffed-TT-001-65x78.jpg 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/uncuffed-TT-001-225x269.jpg 225w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/uncuffed-TT-001-350x418.jpg 350w\" sizes=\"auto, (max-width: 314px) 100vw, 314px\" \/><figcaption id=\"caption-attachment-2678\" class=\"wp-caption-text\">Figure 10.4 Uncuffed TT<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<div class=\"textbox shaded\">Watch the video <a href=\"https:\/\/barabus.tru.ca\/nursing\/tracheostomy_tubes.html\"><em>Tracheostomy Tubes &#8211; inflated versus deflated Cuff<\/em><\/a>\u00a0by Heather Noyes and Wendy McKenzie Thompson Rivers University (2019)<\/div>\n<p>&nbsp;<\/p>\n<p>Fenestrated TTs have a number of holes in the outer cannula to allow air to flow from the lungs over the vocal cords. They can be used in conjunction with an uncuffed TT often when weaning the patient from the TT. They are only to be used with patients who can swallow without risk of aspiration (St. George\u2019s University Hospital, n.d.).<\/p>\n<figure id=\"attachment_2665\" aria-describedby=\"caption-attachment-2665\" style=\"width: 375px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/375px-Diagram_showing_a_fenestrated_and_a_non_fenestrated_tracheostomy_tube_CRUK_066.svg_.png\" alt=\"\" class=\"wp-image-2665 size-full\" width=\"375\" height=\"285\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/375px-Diagram_showing_a_fenestrated_and_a_non_fenestrated_tracheostomy_tube_CRUK_066.svg_.png 375w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/375px-Diagram_showing_a_fenestrated_and_a_non_fenestrated_tracheostomy_tube_CRUK_066.svg_-300x228.png 300w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/375px-Diagram_showing_a_fenestrated_and_a_non_fenestrated_tracheostomy_tube_CRUK_066.svg_-65x49.png 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/375px-Diagram_showing_a_fenestrated_and_a_non_fenestrated_tracheostomy_tube_CRUK_066.svg_-225x171.png 225w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/375px-Diagram_showing_a_fenestrated_and_a_non_fenestrated_tracheostomy_tube_CRUK_066.svg_-350x266.png 350w\" sizes=\"auto, (max-width: 375px) 100vw, 375px\" \/><figcaption id=\"caption-attachment-2665\" class=\"wp-caption-text\">Figure 10.5 Fenestrated versus non-fenestrated tube<\/figcaption><\/figure>\n<p>Other considerations for persons with TTs:<\/p>\n<ul>\n<li>Patients often need to lie at a 30-degree, or greater, angle to facilitate breathing and lung expansion.<\/li>\n<li>All persons with a tracheostomy must have suction equipment and emergency supplies at the bedside. Emergency equipment is usually in a clear bag on an IV pole attached to the patient&#8217;s bed.<\/li>\n<li>People with tracheostomies cannot eat or drink (and often have difficulty swallowing) when the cuff is inflated. These people are NPO because of risk of aspiration.<\/li>\n<li>People with cuffed tracheostomies cannot talk because air cannot bypasses the larynx. As such, finding alternative forms of communication is paramount. For some, a permanent tracheostomy has led them to acquire a speaking valve (BTS, 2014). Others may use fenestrated TTs to help them communicate through speech\u00a0(The Ohio State\u00a0University\u00a0Wexner Medical Center, 2012). (See\u00a0Figure 10.5.)<\/li>\n<li>People with a tracheostomy must always have the tracheostomy tied securely around the neck using ties, according to agency policy. This prevents the tube from accidentally falling out.<\/li>\n<li>Patients with a tracheostomy produce more secretions than usual and may not be able to clear secretions from the tracheostomy with coughing. If secretions in the tracheostomy impair air entry and cause respiratory distress, the patient should be suctioned immediately.<\/li>\n<li>Persons who breathe through a tracheostomy bypass the upper airway where moisture is added to the breath. As such, dry air can dry out airways and cause possible tube blockage from tenacious sputum. Some patients with tracheostomies, particularly in the immediate post op period, require humidity (RCH, n.d.). Humidification may also help to prevent \u00a0ulceration of the tracheal mucosa, sputum retention, atelectasis, impaired gas exchange, and secondary infection (BTS, 2014).<\/li>\n<li>To optimize respiratory function and oxygenation, care should include physio, mobilization, hydration, suction, and medications as appropriate (BTS, 2014).<\/li>\n<li>New tracheostomies require attention to principles of asepsis for stoma (wound) care. Tracheostomies that are well established require clean technique for stoma care.<\/li>\n<\/ul>\n<h2>Potential Complications Associated with Tracheostomies<\/h2>\n<p>Early potential complications post tracheotomy may include hemorrhage, pneumothorax, subcutaneous emphysema, cuff leak, tube dislodgement, and respiratory\/cardiovascular arrest. Complications occurring later, after the tracheostomy is established, may include airway obstruction, fistulae, infection, aspiration, and tracheal damage\/erosion. Table 10.3 outlines potential complications, prevention strategies and interventions if the complication does occur.<\/p>\n<table>\n<tbody>\n<tr>\n<td style=\"border: 1px solid #000000\" colspan=\"3\">\n<h3 style=\"text-align: center\">Table 10.3 Potential Complications Associated with Tracheostomies, Prevention and Interventions<\/h3>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;text-align: center;width: 20%\">\n<h4 style=\"text-align: center\">Complication<\/h4>\n<\/td>\n<td style=\"border: 1px solid #000000;text-align: center;width: 40%\">\n<h4 style=\"text-align: center\">Prevention<\/h4>\n<\/td>\n<td style=\"border: 1px solid #000000;text-align: center;width: 40%\">\n<h4 style=\"text-align: center\">Interventions<\/h4>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 140.906px\">Hemorrhage<\/td>\n<td style=\"border: 1px solid #000000;width: 385.906px\">\n<ul>\n<li>Assess stoma for\u00a0bleeding (excessive suctioning may also result in blood-streaked secretions).<\/li>\n<li>Report neck swelling.<\/li>\n<li>Report vigorous pulsation around the trachea.<\/li>\n<\/ul>\n<\/td>\n<td style=\"border: 1px solid #000000;width: 802.906px\">\n<ul>\n<li>Inflate cuff.<\/li>\n<li>Suction.<\/li>\n<li>Notify physician immediately if you suspect bleeding.<\/li>\n<li>CODE BLUE if pulsating frank blood.<\/li>\n<li>Monitor vital signs.<\/li>\n<li>Apply pressure to bleed if possible.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 140.906px\">Stomal \/ pulmonary infection<\/td>\n<td style=\"border: 1px solid #000000;width: 385.906px\">\n<ul>\n<li>Perform dressing changes and tracheostomy care every 8 hours, and as needed.<\/li>\n<li>Use sterile technique for tracheostomy suctioning (open method) prn.<\/li>\n<li>Use clean technique for tracheostomy care.<\/li>\n<li>Use humidified oxygen <span style=\"font-size: small\"><\/span>or air.<\/li>\n<li>Perform respiratory assessment.<\/li>\n<li>Have patient do deep breathing and coughing (DB&amp;C) exercises every\u00a02 to 4 hours, and\u00a0as needed.<\/li>\n<li>Maintain hydration.<\/li>\n<li>Take vital signs often (as per patient condition or agency guidelines).<\/li>\n<\/ul>\n<\/td>\n<td style=\"border: 1px solid #000000;width: 802.906px\">Wounds are often kept moist by secretions and\/or humidity. Moisture impairs healing.<\/p>\n<p>Closed (in line) suction technique does not require sterile gloves.<\/p>\n<p>Humidity and hydration help to liquefy secretions for easier expectoration.<\/p>\n<p>Report potential signs of infection:<\/p>\n<ul>\n<li>Redness<\/li>\n<li>Sweeping<\/li>\n<li>Purulent drainage<\/li>\n<li>Fever<\/li>\n<li>Abnormal breath sounds<\/li>\n<li>Increased secretions<\/li>\n<li>Decreased oxygen sats<\/li>\n<\/ul>\n<p>Routine instillation of NS to promote expectoration is not considered best practice.<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 140.906px\">Tube occlusion<\/td>\n<td style=\"border: 1px solid #000000;width: 385.906px\">\n<ul>\n<li>Keep inner cannula of dual tracheostomy tube in situ.<\/li>\n<li>Check patency of single-lumen tracheostomy tube regularly.<\/li>\n<li>Clean inner cannula\u00a0every 8 hours at a minimum, and as needed.<\/li>\n<li>Maintain humidification and hydration<\/li>\n<li>Do DB&amp;C\u00a0exercises every 2 to 4 hours, and as needed.<\/li>\n<li>Suction as needed.<\/li>\n<\/ul>\n<\/td>\n<td style=\"border: 1px solid #000000;width: 802.906px\">The inner cannula is a safety feature, and can be removed if occlusion occurs.\u00a0Whenever possible use double lumen tubes for this reason.<\/p>\n<p>If tube occludes:<\/p>\n<ul>\n<li>Place patient supine to expose neck and check for tube dislodgement.<\/li>\n<li>Try ventilation using ambu-bag, but do not force air entry.<\/li>\n<li>If unable to ventilate, try suction<\/li>\n<li>Remove inner cannula if suction catheter still does not pass; check patency and replace with new inner cannula.<\/li>\n<li>If still unable to ventilate, deflate cuff or cuffed tube and notify physician and\/or respiratory therapist.<\/li>\n<li>If patient is still unable to ventilate, call CODE BLUE and\u00a0cut tie tapes, remove tracheostomy tube, insert dilators, and hold stoma open with tracheal dilators until trained health care professional is able to reinsert a tracheostomy tube.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 140.906px\">Aspiration<\/td>\n<td style=\"border: 1px solid #000000;width: 385.906px\">\n<ul>\n<li>All persons with a tracheostomy require a swallow assessment (usually requires a physician order) prior to oral feeding.<\/li>\n<li>No swallow assessment or feeding occurs when cuff is inflated.<\/li>\n<li>Consult speech and language therapist.<\/li>\n<li>Patient should be placed in a semi- to high-upright sitting position.<\/li>\n<li>Ensure cuff is inflated\u00a0and check cuff pressure once per shift and as needed.<\/li>\n<li>Always suction above cuff prior to cuff deflation.<\/li>\n<\/ul>\n<\/td>\n<td style=\"border: 1px solid #000000;width: 802.906px\">High Fowler&#8217;s positioning promotes lung expansion. During swallow assessment, helps to reduce risk of aspiration if the patient begins to choke.<\/p>\n<p>Report any signs of aspiration:<\/p>\n<ul>\n<li>Excessive coughing and gagging (particularly with eating and drinking)<\/li>\n<li>Increased or changed secretions<\/li>\n<li>Presence of food in secretions<\/li>\n<li>Drop in O<sub>2 <\/sub>sats<\/li>\n<\/ul>\n<p>If patient vomits:<\/p>\n<ul>\n<li>Inflate cuff, if present.<\/li>\n<li>Suction immediately.<\/li>\n<li>Raise head of bed; sit patient upright.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 140.906px\">Accidental decannulation<\/td>\n<td style=\"border: 1px solid #000000;width: 385.906px\">\n<ul>\n<li>Tracheostomy ties must be secure.<\/li>\n<li>Secure new ties <em>before <\/em>removing old ties.<\/li>\n<li>Assess patient for restlessness\/confusion.<\/li>\n<\/ul>\n<\/td>\n<td style=\"border: 1px solid #000000;width: 802.906px\">If partial decannulation occurs (air movement is felt from tube):<\/p>\n<ul>\n<li style=\"padding-left: 30px\">Deflate cuff if inflated.<\/li>\n<li style=\"padding-left: 30px\">Remove inner cannula and insert obturator.<\/li>\n<li style=\"padding-left: 30px\">Gently reinsert tube while holding obturator in place.<\/li>\n<li style=\"padding-left: 30px\">Remove obturator and replace inner cannula.<\/li>\n<li style=\"padding-left: 30px\">Check correct placement.\n<ul>\n<li style=\"padding-left: 30px\">Feel for air movement from tube.<\/li>\n<li style=\"padding-left: 30px\">Check patient&#8217;s O<sub>2 <\/sub>sats.<\/li>\n<li style=\"padding-left: 30px\">Ensure patient&#8217;s breathing returns to baseline.<\/li>\n<\/ul>\n<\/li>\n<li>Ensure tie tapes are secure and cuff is inflated, if ordered.<\/li>\n<\/ul>\n<p>If complete decanulation occurs, call for trained health care professional to reinsert tracheostomy tube. In the meantime:<\/p>\n<ul>\n<li style=\"padding-left: 30px\">Maintain tracheal airway and ventilation with bag tracheostomy mask as best as possible.<\/li>\n<li style=\"padding-left: 30px\">Protect airway from foreign-body aspiration.<\/li>\n<li style=\"padding-left: 30px\">If stoma is less than 7 days old, use tracheal dilators to maintain stoma potency if necessary.<\/li>\n<li style=\"padding-left: 30px\">If patient is not ventilating adequately, close stoma and ventilate with bag and face mask with 100% O<sub>2<\/sub> until CODE team arrives. If patient has known upper-airway obstruction, or a laryngectomy, ventilate via stoma with a tracheostomy or pediatric mask.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 1361.91px\" colspan=\"3\"><strong>Note:<\/strong> Do not hyper-extend neck if patient has a known or suspected neck injury.<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;width: 1361.91px\" colspan=\"3\">Data sources: BCIT, 2015b; BTS 2014; Vancouver Coastal Health, 2012a<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>Emergency equipment should be available at the bedside and should accompany the patient off the unit. Check the agency policy to confirm contents. A basic kit should include:<\/p>\n<ol>\n<li>Suction equipment (portable unit if necessary).<\/li>\n<li>Oxygen equipment with humidification.<\/li>\n<li>An emergency bag containing (see Figure 10.6):\n<ul>\n<li>Two replacement tracheostomy tubes (one of the same size, and one a smaller size than the current tube)<\/li>\n<li>Obturator and spare inner cannula<\/li>\n<li>10 ml syringe<\/li>\n<li>Tracheal dilators<\/li>\n<li>Sterile gloves<\/li>\n<li>Water-soluble lubricant<\/li>\n<li>Scissors<\/li>\n<li>Cotton tip applicators<\/li>\n<li>Trach ties<\/li>\n<li>Sterile gauze<\/li>\n<li>Resuscitation bag and mask (appropriate size for patient)<\/li>\n<\/ul>\n<\/li>\n<\/ol>\n<figure id=\"attachment_6322\" aria-describedby=\"caption-attachment-6322\" style=\"width: 500px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18131.jpg\"><img decoding=\"async\" src=\"https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18131.jpg\" alt=\"Equipment for emergency bag for tracheostomy patients.\" class=\"wp-image-6322 size-medium\" width=\"500\" \/><\/a><figcaption id=\"caption-attachment-6322\" class=\"wp-caption-text\">Figure 10.6 Emergency equipment for persons with a tracheostomy. Clockwise from top left: sterile gloves, spare tracheostomy tube, scissors, lubricant, cotton-tip applicators, ties, 10 ml syringe, tracheal dilators, inner cannula, obturator, sterile gauze<\/figcaption><\/figure>\n<h2>Tracheostomy Care<\/h2>\n<p>Tracheostomy care is performed routinely and as required. Tracheostomy care is essential to avoid potential complications such as obstruction and infection. In addition to suctioning, tracheostomy care includes: changing, cleaning and replacing the inner cannula; changing the site dressing; and replacing the tracheostomy ties.<br \/>\nIf possible, these three tasks of tracheostomy care should be performed at the same time to minimize handling of the tracheal device. Collect all supplies at once and complete the procedure in the order listed above. However, there may be times when each task may be performed separately. Ongoing assessment is essential when caring for a patient with a tracheostomy. Checklists 84-87 provide guidelines to do these things.<\/p>\n<p>&nbsp;<\/p>\n<p>Additional care includes performing\u00a0more frequent respiratory assessments and checking patency of tracheostomy tube to assess if suction is required\u00a0(every two hours, and as needed) according to agency policy; keeping patient well hydrated (helps keep secretions thin); encouraging deep breathing and coughing (as required); reporting potential problems such as swelling, elevated temperature, change in sputum production, and decreasing or increasing O<sub>2<\/sub> requirements.<\/p>\n<div class=\"textbox shaded\">Watch the video <a href=\"https:\/\/barabus.tru.ca\/nursing\/replacing_inner_tracheal_cannula.html\"><em>Replacing and Cleaning an Inner Tracheal Cannula<\/em><\/a> by Heather Noyes and Wendy McKenzie Thompson Rivers University (2019)<\/div>\n<h3><strong>Tracheal Suctioning<\/strong><\/h3>\n<p>The purpose of suctioning is to maintain a patent airway, to remove secretions from the trachea and bronchi, and to stimulate the cough reflex (Vancouver Coastal Health, 2006). Patients with tracheostomies often have more secretions than normal and will require suctioning to remove secretions from the airway to prevent airway obstruction. People with a tracheostomy should be assessed frequently to determine if suctioning is required. In hospital, sterile suction equipment is used each time tracheal suctioning is performed unless you are using an in line suction catheter which can be used for several suction procedures (Perry et al., 2018). In the home environment, it is common and accepted practice to use &#8220;clean&#8221; rather than sterile technique during suctioning. The basis of this being that home microorganisms are a part of the person\u2019s normal flora and less likely to make them sick (Lewarski, 2005).<\/p>\n<p>&nbsp;<\/p>\n<p>Tracheal suctioning is indicated with noisy (moist) respirations, decreased O<sub>2<\/sub> sats, anxiousness, restlessness, increased respirations or work of breathing, change in skin colour, or wheezing or gurgling sounds. These are signs and symptoms of respiratory distress, and the patient should be suctioned immediately.\u00a0Checklist 84 outlines the steps for tracheal suctioning.<\/p>\n<table style=\"border-color: #000000\">\n<tbody>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;text-align: center\" colspan=\"4\">\n<h3 style=\"text-align: center\"><a id=\"checklist84\"><\/a>Checklist 84: Tracheal Suctioning\u2014Open Method<\/h3>\n<h5 style=\"text-align: center\"><em><span style=\"color: #000000\">Disclaimer:\u00a0Always review and follow your agency policy regarding this specific skill.<\/span><\/em><\/h5>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;height: 242px\" colspan=\"4\">\n<h5><span style=\"color: #333333\">Safety considerations:\u00a0<\/span><\/h5>\n<ul>\n<li>Perform\u00a0hand hygiene.<\/li>\n<li>Complete <a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/chapter\/2-13-quick-priority-assessment-qpa\/\">QPA<\/a> including safety.<\/li>\n<li>Suctioning can cause increased intracranial pressure in patients with head injury. The nurse can reduce this risk by hyperoxygenating the patient before suctioning and\/or limiting the number of times a suction catheter is inserted into the trachea.\u00a0Pre-hyperoxygenate patient if required, and as per agency policy.<\/li>\n<li><span style=\"color: #333333\">Apply <a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/chapter\/1-5-principles-of-surgical-asepsis\/\">principles of\u00a0asepsis<\/a> for tracheal suctioning in acute care. Clean technique may be used in home settings.\u00a0<\/span><\/li>\n<li>Perform point of care risk assessment for PPE. Donne face shield, gown, gloves (sterile or clean depending on setting).<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 50%;text-align: center;height: 65px\" colspan=\"2\">\n<h4 style=\"text-align: center\">Steps<\/h4>\n<\/td>\n<td style=\"border: 1px solid #000000;width: 50%;text-align: center;height: 65px\" colspan=\"2\">\n<h4 style=\"text-align: center\">\u00a0Additional Information<\/h4>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 393.906px;height: 107px\" colspan=\"2\">1. Assess need for suctioning including respiratory assessment, signs of hypoxia, excess secretions, or alterations in oxygen levels.<\/td>\n<td style=\"border: 1px solid #000000;width: 403.906px;height: 107px\" colspan=\"2\">Perform baseline respiratory assessment including SpO<sub>2<\/sub>.<\/p>\n<p>Determine if the patient is on any medications that increase risk of bleeding.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 393.906px;height: 169px\" colspan=\"2\">2. Explain the procedure in a calm, reassuring manner explaining the benefits are to remove secretions and to make breathing easier.<\/p>\n<p>Position the patient in semi to high Fowler&#8217;s unless contraindicated. Drape chest with towel or disposable pad.<\/td>\n<td style=\"border: 1px solid #000000;width: 403.906px;height: 169px\" colspan=\"2\">Procedure can cause patient anxiety. This is part of the consent procedure.<\/p>\n<p>Positioning promotes lung expansion and promotes secretion clearance.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 393.906px;height: 10px\" colspan=\"2\">3. Perform hand hygiene. Gather equipment.<\/p>\n<p>&nbsp;<\/td>\n<td style=\"border: 1px solid #000000;width: 403.906px;height: 10px\" colspan=\"2\">Equipment should include suction canister, regulator, suction tubing, sterile suction catheter, water soluble lubricant, PPE (face shield, sterile gloves, gown), sterile saline or water, and pulse oximeter.<\/p>\n<p>Preparing equipment ahead of time promotes safety, organization, and timeliness.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 393.906px;height: 111px\" colspan=\"2\">4. Administer oxygen if needed. This includes hyper-oxygenating if necessary.<\/td>\n<td style=\"border: 1px solid #000000;width: 403.906px;height: 111px\" colspan=\"2\">Hyper-oxygenating might be necessary if the patient is hypoxic or at risk of hypoxia during procedure.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 393.906px;height: 293px\" colspan=\"2\">5. Turn the suction device on, and set the vacuum regulator to the appropriate negative pressure. Set suction levels to medium \/ moderate.<\/p>\n<p>Attach the suction catheter to the tubing whilst remaining in the sterile package.<\/p>\n<p>Open the sterile water \/ saline.<\/p>\n<p>&nbsp;<\/td>\n<td style=\"border: 1px solid #000000;width: 403.906px;height: 293px\" colspan=\"2\">\n<figure id=\"attachment_1071\" aria-describedby=\"caption-attachment-1071\" style=\"width: 150px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_18081-150x150.jpg\" alt=\"\" class=\"wp-image-1071 size-full\" width=\"150\" height=\"150\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_18081-150x150.jpg 150w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_18081-150x150-65x65.jpg 65w\" sizes=\"auto, (max-width: 150px) 100vw, 150px\" \/><figcaption id=\"caption-attachment-1071\" class=\"wp-caption-text\">Portable suction unit<\/figcaption><\/figure>\n<figure id=\"attachment_2679\" aria-describedby=\"caption-attachment-2679\" style=\"width: 300px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/suction-wall-unit-300x185.jpg\" alt=\"\" class=\"wp-image-2679 size-medium\" width=\"300\" height=\"185\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/suction-wall-unit-300x185.jpg 300w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/suction-wall-unit-65x40.jpg 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/suction-wall-unit-225x139.jpg 225w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/suction-wall-unit-350x216.jpg 350w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/suction-wall-unit.jpg 600w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><figcaption id=\"caption-attachment-2679\" class=\"wp-caption-text\">Figure 10.7 Wall suction unit<\/figcaption><\/figure>\n<p>Suction setting:<\/p>\n<ul>\n<li>Adult 80 to 100mmHg<\/li>\n<li>Children 60 to 80 mmHg<\/li>\n<li>Not to exceed 150 mmHg<\/li>\n<\/ul>\n<p>Excessive negative pressure damages mucosa and induces greater possibility for hypoxia.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 393.906px;height: 155px\" colspan=\"2\">6. Perform hand hygiene and perform point of care risk assessment. Donne <a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/chapter\/1-4-additional-precautions-and-personal-protective-equipment-ppe\/\">PPE<\/a>.<\/p>\n<p>&nbsp;<\/td>\n<td style=\"border: 1px solid #000000;width: 403.906px;height: 155px\" colspan=\"2\">At minimum, PPE should include face shield and gloves (gown is highly recommended). This prevents transmission of microorganisms to healthcare provider.<\/p>\n<p>Sterile gloves in acute care environments. Clean gloves in home environments.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 393.906px;height: 311px\" colspan=\"2\">7. Sterile procedure: <a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/chapter\/1-7-surgical-hand-scrub-applying-sterile-gloves-and-preparing-a-sterile-field\/\">Apply sterile gloves<\/a><\/p>\n<p>With the non-dominant hand, pick up the packaged connecting tubing. That hand is now contaminated.<\/p>\n<p>Expose the suction catheter enough to allow the dominant hand (sterile) to grab the sterile catheter.<\/p>\n<p>Wrap the sterile catheter around the dominant hand.<\/p>\n<p>Suction a small amount of sterile NS \/ water.<\/td>\n<td style=\"border: 1px solid #000000;width: 403.906px;height: 311px\" colspan=\"2\">\n<figure id=\"attachment_63342\" aria-describedby=\"caption-attachment-63342\" style=\"width: 150px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_1565-001.jpg\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_1565-001-150x150.jpg\" alt=\"Apply sterile glove to each hand or apply non-sterile glove to non-dominant hand and sterile glove to dominant hand\" class=\"wp-image-6113 size-thumbnail aligncenter\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-63342\" class=\"wp-caption-text\">Apply sterile glove to each hand or apply non-sterile glove to non-dominant hand and sterile glove to dominant hand<\/figcaption><\/figure>\n<p>You can also apply a non-sterile glove to the non-dominant hand and a sterile glove to the dominant hand.<\/p>\n<p>There is more than one way to remove the catheter from the packaging. The principle of sterile to sterile must apply to the tip of the suction catheter.<\/p>\n<figure id=\"attachment_6334\" aria-describedby=\"caption-attachment-6334\" style=\"width: 150px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18261.jpg\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_18261-150x150.jpg\" alt=\"Suction is initiated by covering the hole on the suctioning tube with your thumb\" class=\"wp-image-6334 size-thumbnail\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-6334\" class=\"wp-caption-text\">Suction is initiated by covering the hole on the suctioning tube with your thumb<\/figcaption><\/figure>\n<p>Suctioning sterile NS \/ water ensures properly functioning equipment.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 393.906px;height: 213px\" colspan=\"2\">8. Insert suction catheter\u00a0into tracheostomy until resistance is felt, then pull back about 1 cm. Do <em>not<\/em> apply suction when inserting suction catheter.<\/td>\n<td style=\"border: 1px solid #000000;width: 403.906px;height: 213px\" colspan=\"2\">\n<figure id=\"attachment_633422\" aria-describedby=\"caption-attachment-633422\" style=\"width: 150px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18211.jpg\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_18211-150x150.jpg\" alt=\"Insert suction catheter into tracheostomy until resistance is felt, then pull back about 1\/2 inch\" class=\"wp-image-6329 size-thumbnail aligncenter\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-633422\" class=\"wp-caption-text\">Insert suction catheter into tracheostomy until resistance is felt, then pull back about 1 cm<\/figcaption><\/figure>\n<p>Resistance is felt at the level of the patient&#8217;s carina.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 393.906px;height: 203px\" colspan=\"2\">9. Apply intermittent suction as the catheter is withdrawn. This means occluding and releasing the catheter vent with the non-dominant thumb. Some sources suggest twist the catheter back and forth as the catheter is withdrawn. Always encourage the patient to cough.<\/td>\n<td style=\"border: 1px solid #000000;width: 403.906px;height: 203px\" colspan=\"2\">Do not apply suction for longer than 15 seconds. Suction removes oxygen and increases the risk of hypoxia as oxygen is sucked out.<\/p>\n<p>The need to rotate the catheter is questioned in the literature because present day suction catheters have multiple eyes \/ holes.<\/p>\n<p>Encourage coughing to promote secretion clearance.<\/p>\n<p>Routine installation of normal saline into the trachea to loosen and mobilize secretions is <span style=\"text-decoration: underline\">not best practice<\/span>.<\/p>\n<p>If a sterile sputum sample is required, follow agency policy for specific directions related to type of equipment in the agency.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 393.906px;height: 82px\" colspan=\"2\">10. Replace oxygen delivery device and encourage deep breaths.<\/td>\n<td style=\"border: 1px solid #000000;width: 403.906px;height: 82px\" colspan=\"2\">Promotes oxygenation.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 393.906px;height: 85px\" colspan=\"2\">11. Clear secretions from suction catheter by suctioning sterile normal saline or water from sterile container.<\/td>\n<td style=\"border: 1px solid #000000;width: 403.906px;height: 85px\" colspan=\"2\">\n<figure id=\"attachment_63422\" aria-describedby=\"caption-attachment-63422\" style=\"width: 150px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18251.jpg\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_18251-150x150.jpg\" alt=\"Clear secretions from suction catheter by suctioning sterile normal saline or water from sterile container\" class=\"wp-image-6333 size-thumbnail aligncenter\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-63422\" class=\"wp-caption-text\">Clear secretions from suction catheter by suctioning sterile normal saline or water from sterile container<\/figcaption><\/figure>\n<p>Clears tubing of secretions to maintain patency.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 393.906px;height: 170px\" colspan=\"2\">12. Assess need to repeat the procedure. Reassess respiratory status and O<sub>2<\/sub> saturation for improvements.<\/td>\n<td style=\"border: 1px solid #000000;width: 403.906px;height: 170px\" colspan=\"2\">Allow periods of rest between suction. The length of time between suctioning depends on patient tolerance.\u00a0Patient may be suctioned up to three times with the same suction catheter. Do not pass (insert) suction catheter\u00a0more than three times.<\/p>\n<p>Declining SpO<sub>2<\/sub> suggests the patient is not tolerating the procedure. Consult the prescriber and\/or respiratory therapist.<\/p>\n<p>Call for help if any abnormal signs and symptoms appear, or if respiratory status does not improve.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 393.906px;height: 239px\" colspan=\"2\">13. Discard suction catheter, sterile saline \/ water, and sterile gloves. Turn off suction. Remove gloves.\u00a0Perform hand hygiene.<\/p>\n<p>Ensure supplies are readily available at the bedside for next suction procedure.<\/td>\n<td style=\"border: 1px solid #000000;width: 403.906px;height: 239px\" colspan=\"2\">Open suctioning method requires new suction catheter after each round of suctioning. Reuse may introduce microorganisms into the patient&#8217;s respiratory tract increasing risk of infection.<\/p>\n<figure id=\"attachment_6342\" aria-describedby=\"caption-attachment-6342\" style=\"width: 150px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_17801.jpg\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_17801-150x150.jpg\" alt=\"Wrap suction catheter in glove and dispose\" class=\"wp-image-6342 size-thumbnail\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-6342\" class=\"wp-caption-text\">One way to dispose of the suction catheter is to pull your glove over top of the catheter.<\/figcaption><\/figure>\n<p>Additional suction supplies are essential in case of an emergency or respiratory distress.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 393.906px;height: 70px\" colspan=\"2\">14. Return patient to a safe and comfortable position and ensure that call bell is within patient&#8217;s reach.<\/td>\n<td style=\"border: 1px solid #000000;width: 403.906px;height: 70px\" colspan=\"2\">This promotes patient safety.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 393.906px;height: 326px\" colspan=\"2\">15. Document procedure according to\u00a0agency policy.<\/td>\n<td style=\"border: 1px solid #000000;width: 403.906px;height: 326px\" colspan=\"2\">Documentation may include the suction procedure; patient reaction; amount, thickness, and color of secretions; if normal saline was instilled; and if sputum samples were sent to the lab. Documentation provides accurate details of response to suctioning and clear communication among the health care team.<\/p>\n<p>Sample narrative documentation:<\/p>\n<p><em>date \/ time: Audibly moist respirations. Thick yellow tinged secretions observed at trach site. T 37.5 HR 98 RR 24 BP 146\/79. SpO<sub>2<\/sub> 90% on 40% humidified oxygen @ 10L\/ min. Trach suctioned with #14 suction catheter for moderate think yellow secrrtions. Cough reflex apparent. Following procedure RR 20\/min.\u00a0 SpO<sub>2<\/sub> 98%. O<sub>2<\/sub> reestablished as noted above. &#8212;&#8212; L,Owox\u00a0 RN<\/em><\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 813.906px;height: 16px\" colspan=\"4\">Data sources: BCIT, 2015c;\u00a0Halm &amp; Krisko-Hagel, 2008; Perry et al., 2018; Vancouver Coastal Health, 2006<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>A closed method of tracheal suctioning involves a multi-use suction catheter enclosed in a plastic sleeve and attached to the patient&#8217;s airway (tracheal tube). In comparison to the open suction method, the closed method presents less risk of hypoxia and cardiovascular complications. To initiate closed suctioning, consult a respiratory therapist.<\/p>\n<div class=\"textbox shaded\" style=\"text-align: center\">Watch the video <em><a href=\"https:\/\/barabus.tru.ca\/nursing\/Closed_Tracheostomy.html\" target=\"_blank\" rel=\"noopener\">Tracheal Suctioning &#8211; Closed in line Method<\/a>\u00a0<\/em>developed by Heather Noyes and Wendy McKenzie of Thompson Rivers University, 2018.<\/div>\n<h3><strong>Replacing and Cleaning an Inner Tracheal Cannula<\/strong><\/h3>\n<p>The primary purpose of the inner cannula is to prevent tracheostomy tube obstruction. Many sources of obstruction can be prevented if the inner cannula is regularly cleaned\u00a0and replaced. The inner cannula can be cleansed with half-strength hydrogen peroxide or sterile normal saline. Always check the manufacturer&#8217;s recommendations for tube cleaning. Some inner cannulas are designed to be disposable, while others are reusable for a number of days. Inner tube cleaning should be done as often as two or three\u00a0times per day, depending on the type of equipment, the amount and thickness of secretions, and the patient&#8217;s ability to cough up the secretions.<\/p>\n<p>Changing the inner cannula may encourage the patient to cough, bringing mucous out of the\u00a0tracheostomy. For this reason, the inner cannula should be replaced prior to changing the tracheostomy dressing to prevent secretions from soiling the new dressing. If the inner cannula is disposable, no cleaning is required. Checklist 85 describes how to clean and replace an inner tracheal cannula.<\/p>\n<table style=\"border-color: #000000\">\n<tbody>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;text-align: center\" colspan=\"4\">\n<h3 style=\"text-align: center\"><a id=\"checklist85\"><\/a>Checklist 85: Replacing and Cleaning an Inner Tracheal Cannula<\/h3>\n<h5 style=\"text-align: center\"><em><span style=\"color: #000000\">Disclaimer:\u00a0Always review and follow your agency policy regarding this specific skill.<\/span><\/em><\/h5>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000\" colspan=\"4\">\n<h5><span style=\"color: #333333\">Safety considerations:\u00a0<\/span><\/h5>\n<ul>\n<li>Reassess your patient&#8217;s tolerance for tracheostomy care and watch for signs of respiratory distress.<\/li>\n<li>Pre-hyperoxygenate patient if required and according to\u00a0agency policy.<\/li>\n<li>If removing oxygen while performing\u00a0tracheostomy care, remember to replace it often to reoxygenate the patient.<\/li>\n<li>Disposable inner cannulae should be inspected \/ cleaned every 8 hours, or as needed.<\/li>\n<li>Disposable inner cannulae should be inspected every 8 hours (during tracheostomy care), and replaced every 24 hours and as needed.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 50%;text-align: center\" colspan=\"2\">\n<h4 style=\"text-align: center\">Steps<\/h4>\n<\/td>\n<td style=\"border: 1px solid #000000;width: 50%;text-align: center\" colspan=\"2\">\n<h4 style=\"text-align: center\">\u00a0Additional Information<\/h4>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">1.\u00a0Perform hand hygiene, collect supplies, and verify whether inner cannula needs to be cleaned as per policy.<\/td>\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">Supplies include cotton-tip applicator, sterile pipe cleaner, sterile dressing tray, NS, non-sterile gloves, waterproof pad, and PPE.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">2. Perform hand hygiene, ID patient using two identifiers, explain procedure to patient, and create privacy if required.<\/p>\n<p>Ensure patient has a method to communicate with you during the procedure.<\/td>\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">Hand hygiene reduces the transmission of microorganisms.<\/p>\n<p>People with tracheostomies require a method to communicate with the healthcare provider.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">3. Apply gloves and <a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/chapter\/1-4-additional-precautions-and-personal-protective-equipment-ppe\/\">PPE<\/a>\u00a0, and cover chest with waterproof pad.<\/td>\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">This prevents contact with secretions and prevents gown from becoming soiled.<\/p>\n<p>Use sterile technique in acute care, clean technique in home environments.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">4. Set up sterile tray field; add cleaning solution and supplies.<\/td>\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">Organization ensures the process is efficient and fast for the patient.<\/p>\n<figure id=\"attachment_6336\" aria-describedby=\"caption-attachment-6336\" style=\"width: 150px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18331.jpg\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_18331-150x150.jpg\" alt=\"Set up sterile tray and add cleaning solution and supplies\" class=\"wp-image-6336 size-thumbnail\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-6336\" class=\"wp-caption-text\">Set up sterile tray and add cleaning solution and supplies<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">5. Remove oxygen mask to clean dressing, but replace frequently as required by patient.<\/td>\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">\n<figure id=\"attachment_6328\" aria-describedby=\"caption-attachment-6328\" style=\"width: 150px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18201.jpg\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_18201-150x150.jpg\" alt=\"Remove oxygen mask to clean dressing\" class=\"wp-image-6328 size-thumbnail\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-6328\" class=\"wp-caption-text\">Remove oxygen mask to clean dressing<\/figcaption><\/figure>\n<p>Replace the tracheal oxygen mask frequently to prevent hypoxia.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">6. Remove inner cannula by stabilizing neck plate \/ flange and gently grasping the outer white area. Rotate inner cannula counter-clockwise to unlock it. Pull cannula out in a downward motion. Some inner cannulae will \u201cclick&#8221; on, some twist on\/off. Do not touch the inner cannula; only handle the white outer area unless you are wearing sterile gloves.<\/p>\n<p>Replace the client&#8217;s oxygen while cleaning the inner cannula to prevent the client from desaturating or drying out secretions<\/td>\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">Review policy for cleaning frequency and cleaning solution.<\/p>\n<figure id=\"attachment_6349\" aria-describedby=\"caption-attachment-6349\" style=\"width: 150px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18391.jpg\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_18391-150x150.jpg\" alt=\"Remove inner cannula by stabilizing neck plate and gently grasping the outer white area\" class=\"wp-image-6349 size-thumbnail\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-6349\" class=\"wp-caption-text\">Remove inner cannula by stabilizing neck plate \/ flange and gently grasping the outer white area<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">7. Soak inner cannula in saline, if necessary, use a sterile pipe cleaner or cotton tipped applicators with gauze to remove exudate from the inner lumen. Rinse well.<\/td>\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">Soaking the cannula helps loosen the secretions.<\/p>\n<figure id=\"attachment_6351\" aria-describedby=\"caption-attachment-6351\" style=\"width: 150px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18411.jpg\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_18411-150x150.jpg\" alt=\"Soak in appropriate solution and, if necessary, use a sterile pipe cleaner to remove exudate from the inner cannula\" class=\"wp-image-6351 size-thumbnail\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-6351\" class=\"wp-caption-text\">Use a sterile pipe cleaner to remove exudate from the inner cannula<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">8. Reinsert inner cannula by stabilizing neck plate, holding the white part with the end upright, and twisting into the shape of the\u00a0tracheostomy.<\/td>\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">This prevents trauma to the tracheal stoma.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">9. Ensure the inner cannula has \u201cclicked\u201d into place. Use sterile gauze to clean the outer cannula surfaces<\/td>\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">\n<figure id=\"attachment_6380\" aria-describedby=\"caption-attachment-6380\" style=\"width: 150px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_2076.jpg\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_2076-150x150.jpg\" alt=\"Ensure that inner cannula is 'clicked' securely into place\" class=\"wp-image-6380 size-thumbnail\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-6380\" class=\"wp-caption-text\">Ensure that inner cannula is &#8220;clicked&#8221; securely into place<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">10. Discard used equipment. Remove gloves.\u00a0Perform hand hygiene.<\/p>\n<p>Ensure the patient is in a safe and comfortable position.<\/td>\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">Hand hygiene reduces the transmission of microorganisms.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"4\">Data sources: BCIT, 2015c; Morris, Whitmer, &amp; McIntosh, 2013; Perry et al., 2018; Vancouver Coastal Health, 2012b<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<div>\n<div class=\"textbox shaded\" style=\"text-align: center\">Watch the video <a href=\"https:\/\/barabus.tru.ca\/nursing\/replacing_inner_tracheal_cannula.html\"><em>Replacing and Cleaning an Inner Tracheal Cannula<\/em><\/a>\u00a0 \u00a0 \u00a0by Heather Noyes and Wendy McKenzie Thompson Rivers University (2019)<\/div>\n<\/div>\n<h3><strong>Cleaning Stoma and Changing the Tracheosotomy Site Dressing<\/strong><\/h3>\n<p>The stoma should be cleaned and the dressing changed every 6 to\u00a012 hours or as needed, and the peristomal skin should be inspected for skin breakdown, redness, irritation, ulceration, pain, infection, or dried secretions. Patients with copious amounts of secretions often require frequent dressing changes to prevent maceration of the tissue and skin breakdown. Cotton-tip applicators can be used to get under the tracheostomy device, where cleaning can be done using a semi-circular motion, inward to outward. Always use aseptic technique. Checklist 86 provides a safe method to clean the tracheal stoma and replace the sterile dressing.<\/p>\n<table style=\"border-color: #000000\">\n<tbody>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;text-align: center\" colspan=\"4\">\n<h3 style=\"text-align: center\"><a id=\"checklist86\"><\/a>Checklist 86: Cleaning Stoma and Changing a Sterile Dressing<\/h3>\n<h5 style=\"text-align: center\"><em><span style=\"color: #000000\">Disclaimer:\u00a0Always review and follow your agency policy regarding this specific skill.<\/span><\/em><\/h5>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000\" colspan=\"4\">\n<h5><span style=\"color: #333333\">Safety considerations:\u00a0<\/span><\/h5>\n<ul>\n<li>Reassess your patient&#8217;s tolerance for tracheostomy care and watch for signs of respiratory distress.<\/li>\n<li>Pre-hyperoxygenate patient if required and according to\u00a0agency policy.<\/li>\n<li>If removing oxygen while preforming tracheostomy care, remember to replace it often to reoxygenate the patient.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 50%;text-align: center\" colspan=\"2\">\n<h4 style=\"text-align: center\">Steps<\/h4>\n<\/td>\n<td style=\"border: 1px solid #000000;width: 50%;text-align: center\" colspan=\"2\">\n<h4 style=\"text-align: center\">\u00a0Additional Information<\/h4>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">1.\u00a0Perform hand hygiene, verify physician orders for tracheostomy care, and collect supplies.<\/td>\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">Supplies include sterile dressing kit, pre-cut 4 \u00d7 4 gauze, normal saline, cotton-tip applicators, non-sterile gloves, and garbage bag.<\/p>\n<p>Pre-cut gauze is less likely to have loose fibers that could potentially enter wound and delay healing.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">2. Perform hand hygiene, ID patient using two identifiers, explain procedure to patient, and create privacy if required. Ensure patient has a method to communicate with you during the procedure.<\/td>\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">This reduces the transmission of microorganisms.<\/p>\n<p>Patients with trachs always require a method to communicate with the healthcare provider.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">3. Apply non-sterile gloves and cover chest with waterproof pad.<\/td>\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">This\u00a0prevents gown from becoming soiled.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">4. Sanitize your working surface. Organize all supplies and set up sterile tray field; add cleaning solution to sterile tray.<\/td>\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">Use agency approved cleaning solutions to wipe table tops.<\/p>\n<p>Organization ensures the process of cleaning is efficient.<\/p>\n<figure id=\"attachment_6336\" aria-describedby=\"caption-attachment-6336\" style=\"width: 150px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18331.jpg\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_18331-150x150.jpg\" alt=\"Set up sterile tray and add cleaning solution and supplies\" class=\"wp-image-6336 size-thumbnail\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-6336\" class=\"wp-caption-text\">Set up sterile tray and add cleaning solution and supplies<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">5. Remove oxygen mask to access the dressing but replace frequently as required by patient.<\/td>\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">This prevents hypoxia.<\/p>\n<figure id=\"attachment_6328\" aria-describedby=\"caption-attachment-6328\" style=\"width: 150px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18201.jpg\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_18201-150x150.jpg\" alt=\"Remove oxygen mask to clean dressing\" class=\"wp-image-6328 size-thumbnail\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-6328\" class=\"wp-caption-text\">Remove oxygen mask to clean dressing<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">6. Using forceps, remove the soiled dressing around the tube and discard in garbage bag.<\/td>\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">All soiled dressings should be removed, as they\u00a0may excoriate the surrounding peristomal skin.<\/p>\n<figure id=\"attachment_6337\" aria-describedby=\"caption-attachment-6337\" style=\"width: 150px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18341.jpg\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_18341-150x150.jpg\" alt=\"Use forceps to remove the soiled dressing\" class=\"wp-image-6337 size-thumbnail\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-6337\" class=\"wp-caption-text\">Use forceps to remove the soiled dressing<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">7. Assess the stoma site for bleeding, appearance of stoma edges, and peristomal skin for evidence of infection or redness (assess for increase in pain, odour, or abscess formation).<\/td>\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">Assessment is important to identify and prevent further complications.<\/p>\n<figure id=\"attachment_6338\" aria-describedby=\"caption-attachment-6338\" style=\"width: 150px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18351.jpg\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_18351-150x150.jpg\" alt=\"Assess stoma site\" class=\"wp-image-6338 size-thumbnail\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-6338\" class=\"wp-caption-text\">Assess stoma site<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">8. Clean the stoma site (including under faceplate) with a gauze or cotton-tip applicator soaked in normal saline. Clean in circular motion from the stoma outwards. Be careful not to disturb the tracheostomy tube. Dry area.<\/td>\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">Cleaning around the stoma removes any debris or exudate from the stoma. A tracheal stoma should be cleaned with normal saline.<\/p>\n<p><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18371.jpg\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_18371-150x150.jpg\" alt=\"Clean the stoma site with a gauze or cotton-tip applicator soaked in normal saline\" class=\"wp-image-6346 size-thumbnail aligncenter\" width=\"150\" height=\"150\" \/><\/a><\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">9. Assess the site to determine if skin protection (ie. barrier film)is required.<\/td>\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">Consult wound care specialist if needed.<\/p>\n<p>Skin protectant is sometimes necessary to prevent further skin breakdown.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">10. Apply new manufactured pre-cut tracheostomy dressing to tube using sterile forceps.<\/td>\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"2\">Use non-fraying material as a dressing round the stoma. Avoid cutting gauze for tracheostomy care.\u00a0 The small fibres from the cut gauze may become loose and accidentally travel into the inner cannula.<\/p>\n<figure id=\"attachment_63462\" aria-describedby=\"caption-attachment-63462\" style=\"width: 150px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18341.jpg\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_18341-150x150.jpg\" alt=\"Apply new manufactured pre-cut tracheostomy dressing to tube using sterile forceps\" class=\"wp-image-6337 size-thumbnail aligncenter\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-63462\" class=\"wp-caption-text\">Apply new manufactured pre-cut tracheostomy dressing to tube using sterile forceps<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 250px\" colspan=\"4\">Data sources: BCIT, 2015c; Morris et al., 2013; Perry et al., 2018; Vancouver Coastal Health, 2012<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<div>\n<div class=\"textbox shaded\" style=\"text-align: center\">Watch the video\u00a0<a href=\"https:\/\/barabus.tru.ca\/nursing\/changing_tracheostomy_site_dressing.html\"><em>Changing a Trachestomy Site Dressing<\/em><span style=\"text-decoration: underline\"><span style=\"color: #000000;text-decoration: underline\"> by<\/span><\/span><\/a>\u00a0Heather Noyes and Wendy McKenzie Thompson Rivers University (2019)<\/div>\n<\/div>\n<h2><span style=\"font-family: Tinos, Georgia, serif;font-size: 14pt;font-weight: normal\">Tracheal ties will become dirty and require replacing. Ties should be replaced as required, according to agency policy. Ideally, one person should hold the tracheostomy tube\u00a0in place while the tracheostomy ties are replaced by another person. Alternatively, secure the new tracheostomy ties prior to removing the old tracheostomy ties to avoid accidental dislodgement of the tracheostomy tube\u00a0if the patient coughs or the tracheostomy is accidentally bumped out. Once the new tracheostomy ties are on, only one finger should fit between the tracheostomy ties and the neck.<\/span><\/h2>\n<h3><strong>Replacing Tracheostomy Ties (Velcro)<\/strong><\/h3>\n<p>Checklist 87 lists the steps for replacing tracheostomy ties.<\/p>\n<table style=\"border-color: #000000;height: 1556px\">\n<tbody>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;text-align: center;height: 116px;width: 977.4px\" colspan=\"4\">\n<h3 style=\"text-align: center\"><a id=\"checklist87\"><\/a>Checklist 87: Replacing Tracheostomy Ties (Velcro)<\/h3>\n<h5 style=\"text-align: center\"><em><span style=\"color: #000000\">Disclaimer:\u00a0Always review and follow your agency policy regarding this specific skill.<\/span><\/em><\/h5>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;height: 249px;width: 977.4px\" colspan=\"4\">\n<h5><span style=\"color: #333333\">Safety considerations:\u00a0<\/span><\/h5>\n<ul>\n<li>Reassess your patient&#8217;s tolerance for tracheostomy care and watch for signs of respiratory distress.<\/li>\n<li>Pre-hyperoxygenate patient if required and according to\u00a0agency policy<\/li>\n<li>If removing oxygen while preforming tracheostomy care, remember to replace it often to reoxygenate the patient.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 480.6px;text-align: center;height: 65px\" colspan=\"2\">\n<h4 style=\"text-align: center\">Steps<\/h4>\n<\/td>\n<td style=\"border: 1px solid #000000;width: 479.8px;text-align: center;height: 65px\" colspan=\"2\">\n<h4 style=\"text-align: center\">\u00a0Additional Information<\/h4>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 480.6px;height: 115px\" colspan=\"2\">1.\u00a0Perform hand hygiene, collect supplies. Assess need for <a href=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/chapter\/1-4-additional-precautions-and-personal-protective-equipment-ppe\/\">PPE<\/a><\/td>\n<td style=\"border: 1px solid #000000;width: 479.8px;height: 115px\" colspan=\"2\">Hand hygiene reduces the transmission of microorganisms.<\/p>\n<p>Supplies include\u00a0twill or Velcro ties, a second person to secure the tracheostomy when old ties are removed, scissors if using twill tape ties.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 480.6px;height: 34px\" colspan=\"2\">2. Have an additional health care provider assist with the tracheal tie change as required.<\/td>\n<td style=\"border: 1px solid #000000;width: 479.8px;height: 34px\" colspan=\"2\">An additional helper is there to secure the trachestomy tube and prevent accidental dislodgement.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 480.6px;height: 120px\" colspan=\"2\">3. ID patient using two identifiers, explain procedure to patient, and create privacy if required. Ensure patient has a method to communicate with you during the procedure.<\/td>\n<td style=\"border: 1px solid #000000;width: 479.8px;height: 120px\" colspan=\"2\">Persons with a tracheostomy require a method to communicate with the health care provider.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 480.6px;height: 221px\" colspan=\"2\">4. Apply non-sterile gloves.<\/td>\n<td style=\"border: 1px solid #000000;width: 479.8px;height: 221px\" colspan=\"2\">This reduces the transmission of microorganisms.<\/p>\n<p><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_1511.jpg\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/05\/DSC_1511-150x150.jpg\" alt=\"Apply non-sterile gloves\" class=\"wp-image-5559 size-thumbnail aligncenter\" width=\"150\" height=\"150\" \/><\/a><\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 480.6px;height: 567px\" colspan=\"2\">5. To secure the tracheostomy tube with velcro ties:<\/p>\n<ul>\n<li>If patient is at risk of tracheostomy dislodgement due to confusion or agitation, replace velcro with ribbon tapes.<\/li>\n<li>If possible, one health care worker can keep the tracheostomy tube in place by holding the flange with gloved hands, while the other can replace the tapes.<\/li>\n<li>Thread the narrow velcro tab through the slit in the flange of the tracheostomy tube and fold it back to adhere to the main tube holder; repeat on other side. Overlap the shorter length of collar with the longer length of collar and secure with the wider velcro tab. Trim any excess length of collar to fit the size of the patient\u2019s neck.<\/li>\n<li>Check how secure the collar feels. Ensure you can fit two fingers between the collar and the patient.<\/li>\n<\/ul>\n<\/td>\n<td style=\"border: 1px solid #000000;width: 479.8px;height: 567px\" colspan=\"2\">Tracheostomy ties are used to promote patient comfort and keep the tracheostomy secured and in situ.<\/p>\n<p>&nbsp;<\/p>\n<p>An assistant can hold the trach tube in place\u00a0to reduce risk of potential dislodgement of the tube if the patient coughs.<\/p>\n<figure id=\"attachment_6353\" aria-describedby=\"caption-attachment-6353\" style=\"width: 150px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18471.jpg\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_18471-150x150.jpg\" alt=\"Velcro ties\" class=\"wp-image-6353 size-thumbnail\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-6353\" class=\"wp-caption-text\">Velcro ties<\/figcaption><\/figure>\n<p>The tape should be tight enough to keep the tracheostomy tube securely in place but loose enough to allow the little finger to fit between the tapes and the neck.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 480.6px;height: 53px\" colspan=\"2\">6. Clean the work area. Discard garbage appropriately. Perform hand hygiene. Leave the patient in a comfortable position.<\/td>\n<td style=\"border: 1px solid #000000;width: 479.8px;height: 53px\" colspan=\"2\">Hand hygiene reduces the transmission of microorganisms.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000\">\n<td style=\"border: 1px solid #000000;width: 977.4px;height: 16px\" colspan=\"4\">Data sources: BCIT, 2015c; Morris et al., 2013;\u00a0Perry et al., 2018<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<div>\n<div class=\"textbox shaded\" style=\"text-align: center\">Watch the video <a href=\"https:\/\/barabus.tru.ca\/nursing\/changing_traceostomy_ties.html\"><em>Replacing Tracheostomy Ties<\/em><\/a> by Heather Noyes and Wendy McKenzie Thompson Rivers University (2019)<\/div>\n<div class=\"bcc-box bcc-info\">\n<h3 style=\"text-align: center\">Critical Thinking Exercises<\/h3>\n<ol>\n<li>When suctioning your patient who has a tracheostomy, you notice thick, tenacious secretions. What interventions should be implemented?<\/li>\n<li>What methods of communication can you use for your patient with a tracheostomy tube who is unable to speak?<\/li>\n<li>Answer yes or no in relation to whether or not each of the following situations presents a concern:<\/li>\n<\/ol>\n<p>a)\u00a0If a person has a cuffed tracheostomy in place requires manual ventilation, such as with a bag and mask via the nose, will this deliver oxygen to the patient?<\/p>\n<p>b)\u00a0A suction catheter cannot pass through a tracheostomy.<\/p>\n<p>c)\u00a0A patient with an tracheostomy tube that has an inflated cuff is able to talk.<\/p>\n<p>d)\u00a0Decannulation occurred 4 days ago. The occlusive dressing has fallen off. The wound is now closed.<\/p>\n<\/div>\n<h2>Attributions<\/h2>\n<p class=\"hanging-indent\">Figure 10.1.\u00a0<a href=\"https:\/\/www.pexels.com\/photo\/banner-cancer-disability-esophagus-415903\/\">Untitled<\/a> by <a href=\"https:\/\/www.pexels.com\/@pixabay\" target=\"_blank\" rel=\"noopener\">pixabay.com<\/a>\u00a0 is used under an open\u00a0<a href=\"https:\/\/www.pexels.com\/photo-license\/\">Pexels license.<\/a><\/p>\n<p class=\"hanging-indent\">Figure 10.2.\u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Tracheostomy_tube.jpg\">Tracheostomy Tube<\/a> by <a href=\"https:\/\/commons.wikimedia.org\/wiki\/User:Enigma51\">Klaus D. Peter<\/a> is used under a\u00a0<a href=\"https:\/\/creativecommons.org\/licenses\/by\/2.0\/de\/deed.en\"><span class=\"cc-license-identifier\"><span style=\"text-decoration: none\">CC BY 2.0 DE<\/span><\/span><\/a>\u00a0license.<\/p>\n<p class=\"hanging-indent\">Figure 10.3 &amp; 10.4. These are modified reproductions of\u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Endotracheal_tube_colored.png\" target=\"_blank\" rel=\"noopener\">&#8220;Diagram of an inserted endotracheal tube&#8221;<\/a>\u00a0by\u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/User:PhilippN\" target=\"_blank\" rel=\"noopener\">PhilippN<\/a>\u00a0in the\u00a0<a href=\"https:\/\/wiki.creativecommons.org\/Public_domain\" target=\"_blank\" rel=\"noopener\">Public Domain<\/a>\u00a0\/ A derivative from the\u00a0<a href=\"http:\/\/commons.wikimedia.org\/wiki\/Image:Endotracheal_tube_inserted.png\" target=\"_blank\" rel=\"noopener\">original work.<\/a><\/p>\n<p class=\"hanging-indent\">Figure 10.5.\u00a0<a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Diagram_showing_a_fenestrated_and_a_non_fenestrated_tracheostomy_tube_CRUK_066.svg\">Diagram Showing a Fenestrated and a Non Fenestrated Tracheostomy Tube<\/a> by Cancer Research UK is used under a\u00a0<span class=\"cc-license-identifier\"><a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/deed.en\">CC BY-SA 4.0<\/a>\u00a0i<\/span>nternational license.<\/p>\n<p>Figure 10.6 <a href=\"https:\/\/opentextbc.ca\/clinicalskills\/chapter\/10-6-tracheostomies\/\">Emergency equipment<\/a> is from BCIT<\/p>\n<p>Figure 10.7 WAll suction unit by author is<\/p>\n<\/div>\n","protected":false},"author":397,"menu_order":5,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":"cc-by"},"chapter-type":[],"contributor":[],"license":[50],"class_list":["post-1093","chapter","type-chapter","status-publish","hentry","license-cc-by"],"part":1017,"_links":{"self":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/1093","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/users\/397"}],"version-history":[{"count":25,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/1093\/revisions"}],"predecessor-version":[{"id":5092,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/1093\/revisions\/5092"}],"part":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/parts\/1017"}],"metadata":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/1093\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/media?parent=1093"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapter-type?post=1093"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/contributor?post=1093"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/license?post=1093"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}