Tracheostomy Care and Suctioning Manual - Breath of Life

Tracheostomy Care and Suctioning Manual
© 2009 Breath of Life Home Medical Equipment and Respiratory Services

Parts of a Tracheostomy Tube:
• Outer Cannula - The outer cannula is
the main body of the tracheostomy
tube. It is held in place with a
trach tube holder that fits around the
patients neck.
Some trach tubes have a cuff on the
end of them. This cuff is an inflatable
balloon that seals against
the tracheal wall when inflated. It
helps to protect the airway from
aspiration of oral secretions and
prevents air from escaping through the mouth.
Some patients do not require a cuff such as a patient
who is not on a ventilator, patients who do not have
swallowing issues and pediatric patients.
Some outer cannulas have holes called fenestrations
that allow airflow to escape and allow the patient to
speak.
• Inner Cannula – Some trach tubes have
inner cannulas. The inner cannula fits
inside the outer cannula. It is important
to remove the inner canula and clean it
to prevent mucus plugging and build up.
The inner cannula locks into place to
avoid removal.

• Obturator - The obturator is used to help
make insertion of the trach tube easier. The
obturator has a round tip that sticks out of the
end of the outer
cannula. This
protects the
trachea from any
damage as the
trach tube is inserted into the airway. This
must be removed as soon as the trach tube
is inserted as it occludes the airway while in
place.
NOTE: Patients can NOT breathe while this is in place
How to Deflate and Inflate the Cuff
Minimal leak technique is used to limit the amount
of air that is put in the cuff that sits against the
tracheal wall. Once the cuff is inflated, withdraw
a small amount of air until you hear a slight leak at
the end of inspiration.
The inflated cuff seals the airway so that the patient
can get the prescribed tidal volume that the
physician has ordered. It is important to monitor
this pressure so that damage to the tracheal wall
does not occur.
Another technique used to check cuff pressure is to use
the minimal occluding volume. To do this procedure you
put enough air in the cuff so that no leak is heard during
inspiration. If you are using a pressure manometer it is preferred
to have a cuff pressure reading of 25 cm H2O.

Tracheosotmy Care
It is important to keep the stoma and the trach
tube clean. To do this trach care should be done
at least twice a day and as needed. This includes
cleaning the inner cannula, around the trach
tube and the stoma. Cleaning the trach tube is
done by using clean technique. The trach tube
should be changed once a month. This is always
done using a sterile technique.
Good hand washing technique is vital to prevent
infections. You must always use gloves when
dealing with trach tubes.
Tracheostomy Dressings:
Trach tubes have a dressing around them that is
used to protect the skin.
The dressing should be changed when doing trach
care or as needed.
Trach dressings should not be moist or soiled.
Tracheostomy Tube Ties:
Tracheostomy tube ties are used to keep
the trach tube in place to prevent accidental
removal and to minimize movement of the trach
tube. The ties should be changed daily with trach
care or as needed. They should not be moist or soiled.
Equipment Needed:
Suction equipment
Dale trach holder

Procedure:
Wash your hands
Take the old holder off while holding the tube
in place .
Insert the end of the new holder into the slit on
the side of the outer flange of the trach tube.
Place the other end in the other side.
Pull the sides so that they are tightly secure
making sure to get two fingers under the holder.
Wash your hands
Cleaning the Inner Cannula:
It is very important to keep the inner
cannula of the trach tube clean and free
from dried secretions. Dried secretions can
occlude the trach tube and make it difficult
for the patient to breathe.
To remove the inner cannula, turn the inner
cannula counter clockwise, then remove it.
If the inner cannula has flange clips, pinch
them and then remove the inner cannula.
The inner cannula should be changed at
least daily or as needed. It should be replaced with a clean new inner cannula or
should be washed using sterile technique if using a non-disposable inner cannula.

Tracheostomy Care:
It is important to use sterile technique to minimize infection.
Equipment Needed:
• Sterile tracheostomy cleaning kit which includes
� Sterile tray
� Sterile field
� Sterile brush
� Sterile 4x4 gauze pads
� Sterile pipe cleaners
� Sterile gloves
� Sterile dressing pads
� Sterile trach ties
• Clean inner cannula
• 3% Hydrogen peroxide
• Sterile water
• Sterile suction catheter
• Suction machine
• Ambu bag
Procedure:
1. Wash your hands
2. Open the cleaning kit and spread the sterile field out
on to the work area.
3. Pour the hydrogen peroxide in one tray and the sterile
water in the other side
4. Place the sterile glove on your dominant hand
5. Remove the items from the kit with the sterile gloved
hand and put them on the sterile field
6. Suction the patient
7. Disconnect the patient from the vent with your non-sterile
hand.

8. Unlock and remove the inner cannula with your non-sterile
hand and place it in the tray with the hydrogen peroxide to
soak. If using a non-disposable inner cannula.
9. Insert a clean inner cannula into the trach tube and
reconnect the patient to the vent.
10. Use the sterile brush to clean the inner
cannula with
11. Rinse the inner cannula with the sterile water
12. Use the sterile 4x4 to dry the inner cannula.
13. Store the clean inner cannula in a covered
container
14. Suction the patient as needed
15. Remove the soiled trach dressing using the
non-sterile hand
16. Clean the skin with a gauze pad moistened in the
sterile water. Dry the skin with a sterile 4x4.
17. Apply a clean trach dressing and change the tube
holder if needed.
18. Throw away all of the disposable supplies
19. Wash your hands

Tracheostomy Tube Change:
Tracheostomy tubes need to be changed monthly to decrease the chance of
infection. You should always have a back up trach tube. One of the same size and
one a size smaller.
Do Not change the trach tube unless you
have gone through proper training.
It is very important to use sterile technique during the trach change procedure.
Equipment Needed:
• Sterile tracheostomy tube
• Sterile gloves
• Sterile water soluble lubricant
• Sterile towel
• Suction equipment
• 10 cc syringe
• Ambu bag
• Sterile 4x4 gauze
• Trach tube holder
• Trach dressing
• Hydrogen Peroxide
Procedure:
1. Wash your hands
2. Open the sterile towel for the sterile field
3. Open the sterile supplies and place them on the
sterile field
4. Put the sterile glove on your dominant hand
5. Make sure the new trach tubes cuff is fully deflated.
Be sure to not contaminate the tube by touching anything
with it.
6. Remove the inner cannula and replace it with the obturator

7. Check the cuff by inserting 10 cc of air in the cuff and check
holes.
8. Lubricate the tip of the tube with a water soluble lubricant.
Do not use a petroleum based product.
9. Suction the patient if needed
10. If the patient has a cuff, deflate the cuff by
pulling out all of the air out of the cuff.
11. Remove the trach dressing and the trach tube
holder
12. Clean the skin as needed with a sterile 4x4 and
sterile water
13. Disconnect the patient from the ventilator. You
may need for someone to ventilate the patient
with the ambu bag while you change out the
trach
14. Remove the trach tube using a forward,
downward motion.
15. With your sterile hand, gently insert the new trach tube within
30 minutes with the obturator in place.
16. Immediately remove the obturator
17. Insert the inner cannula into the trach tube
18. Inflate the cuff using minimal leak technique or
using a Cuff manometer.
19. Check to see if adequate air exchange is taking
place by placing your hand over the opening of
the cannula. If no air exchange, the tube is not
in the trachea and should be removed
immediately and the patient manually
ventilated with a mask
20. Once the tube is in place, stabilize the tube
with one hand until secured in place with a
tube holder.

21. After the tube is secure, reconnect the patient to the ventilator
22. Apply trach dressing
23. Dispose of all supplies
24. Wash your hands
Early Warning Signs
It is very important for you to know the signs
and symptoms of infection or other problems.
Signs of Infection:
• Changes in sputum color, volume, odor and
consistency
Causes of infection include not washing hands properly,
using
• Dirty equipment
• Improper suctioning
• Improper trach changes
• Improper stoma care
Breathing Symptoms:
• Increased shortness of breath
• Wheezing
• Increased coughing
• Increased respiratory rate
• Increased accessory muscle use
Sputum Changes:
• Color change (yellow, green, tan or
brown)
• Increase in quantity
• Change in consistency
• Bloody

Stoma Symptoms:
• Pulsating tracheostomy tube
• Bleeding from the stoma
• Discharge or odor from the stoma
• Swelling or redness
Other Symptoms:
• Fever
• Loss of appetite
• Rapid weight gain
• Swelling of hands and feet
• Headaches
• Sleepiness
• Visual disturbances
• Dizziness
• Cyanosis
• Confusion or anxiety
Call Breath of Life with any equipment problems.
If you are having any physical problems contact your physician
If you are having severe physical problems call 911

Emergency Procedures
Emergency Reinsertion of the Tracheostomy Tube
Sometimes as a patient is being suctioned
or as trach care is being performed the trach
tube could accidentally become displaced.
If this happens, try to replace the trach
immediately. To keep the patients airway
open the following actions should be taken:
1. Replace the trach tube, using a new sterile trach tube
OR
2. Reinsert the original trach tube
OR
3. Occlude the stoma and use an ambu bag and mask to
ventilate the patient at a rate of 8-16 breaths per minute
until EMS arrives.
Reinsertion Procedure:
1. If at all possible, insert the obturator and put the
water soluable lubricant on the outer cannula.
2. Insert the trach tube, using an upward curved motion.
The tube will slide into place as you apply gentle pressure.
3. When the tube is in place, immediately pull the obturator out.
4. Apply the trach tube holder to stabilize the trach tube.
5. Insert the inner cannula .
6. Inflate the tracheostomy cuff.
7. Make sure you can feel air coming from the opening of the
cannula by placing your hand over the opening. If the
patient is on a ventilator, connect him/her to the ambu
bag and watch for the chest to rise and fall as you squeeze
the bag.

Assessment After Reinsertion:
After you have reinserted the tracheost tracheostomy tube
observe the patient skin color and heart rate. If at
anytime during reinsertion you notice the patient
becoming blue or the heart rate changes significantly,
stop trying to reinsert the tube and occlude the stoma
and ventilate the patient with an ambu bag and mask.
Call 911 immediately and ventilate the patient.
Continue to ventilate the patient with the bag and
mask until EMS arrives.
Reinsertion of the trach tube should take no longer
than 30 seconds. You should have at least one trach
tube that is 1 size smaller than the tube that the
patient has. This will make insertion easier if you are
having difficulty due to a swollen airway.
NOTE: Reinsertion of trach tubes can be difficult.
It is important to make sure you perform this
procedure re in front of the respiratory therapist
at the hospital before the patient is discharged
to home.

Infection Control:
It is important to keep infections from spreading
to or from patients and caregivers. To prevent
this from occurring it is important to use good
handwashing techniques before and after having
contact with blood, body fluids and after removing
your gloves.
It is equally important to wear gloves when doing
any procedure where the hands may come into
contact with blood or body fluids.
A mask should be worn if the patient has any
communicable respiratory diseases.
Handwashing:
Good handwashing must be done with all
procedures to prevent infections. Not
doing proper handwashing technique is one
of the most common sources of infections.
The following is proper procedure for washing hands:
1. Wet your hands with warm water
2. Use antibacterial soap
3. Wash your hands for 1-2 minutes making sure
to wash with friction the back and palm of each
hand and between all fingers.
4. Rinse your hands thoroughly under the running
water
5. Dry hands well with a paper towel

Suctioning:
Coughing is important to clear out secretions
from the airway. Some patients with
respiratory illness have weak coughs and have
difficulty getting the secretions out of the
airway. Secretions can obstruct the airway
making it difficult for the lungs
to get the oxygen they need. Suctioning
removes the secretions from the airways which
will allow the patient to breathe better.
Suctioning can be done either by performing a
sterile procedure or a clean procedure.
When a patient needs suctioned they will begin to
breathe noisy, cough or if on a ventilator the high
pressure alarm may be alarming. More experienced
patients will request to be suctioned. Notify the
physician if you notice an increase in sputum
production or blood in the sputum.
Points to remember:
• Always wash your hands before and after
suctioning the patient.
• Always wear gloves when suctioning
• Make sure to follow either the sterile or
clean technique
• Discard used suction catheters
• Suctioning should only be done when necessary

The Suction Machine:
Suction machines have a negative
pressure when applied to the
airway, the secretions
can be removed. Each machine
comes with a vacuum gauge. The
recommended ranges are:
• Adults: -80 to -120mmHg
• Children: -80 to -100 mmHg
• Infants: -60 to -80 mmHg
There will also be a container for
the secretions to accumulate in; a
connection tube that attaches
to the suction catheter; a short
tube that connects
to the machine pump, and a bacterial filter.
How to Use the Suction Machine:
1. Connect the short, clear plastic tubing between
the canister and the suction machine.
2. Connect the long, clear plastic connecting tube
to the connector that goes to the canister.
3. Plug the machine into a standard wall outlet.
4. Turn the machine on and occlude the end of the
long connecting tube. Adjust the regulator setting
according to the recommended values.
• Clockwise – increases the suction
• Counterclockwise – decreases the suction
5. Empty and clean the canister at least once
a day, or whenever the fluid level reaches
the full line. Flush the fluid down the toilet.
6. Before the canister is replaced, it should be
washed with a mild, non-detergent soap such
as Palmolive and water. Rinse well with hot
water.

NOTE: It is important to always clean the
suction canister after emptying the contents.
This helps to prevent bacteria from contaminating
the suction machine.
7. Clear the suction tubing by suctioning water up
through the tubing.
8. The longer suction tubing should be thrown away
monthly or whenever it can no longer be cleared
adequately.
Portable Suction Units
Portable suction units are used for those patients
who travel. It can also be used as a back-up
system in case of power failure.
Instructions:
1. Turn the unit on by turning the switch to
the ON position. The unit will be running
on power from one of three sources:
• Home electricity
• Vehicle, cigarette lighter adapter
• Units internal battery
2. The charging light will come on if the unit is
plugged into a wall outlet.
3. The suction pressure can be adjusted by
Turning the knob on the top of the side
unit clockwise.
4. Empty and clean the canister at least once
per day. The fluids should be flushed down
the toilet.
5. The canister should be washed with a mild
non-detergent soap and water and rinsed with
warm water.

Sterile Suction Procedure:
When sterile technique is used, a sterile suction
catheter kit is used each time.
Equipment:
Instructions:
• Suction machine and tubing
• Sterile suction catheter kit
• Sterile distilled water
• Sterile normal saline, for thick secretions
• Ambu bag
• Oxygen if ordered
1. Wash your hands
2. Plug in the suction machine, connect
the
tubing to the jar and turn on the
machine
3. Set the vacuum gauge to the proper
suction
pressure.
4. Open the sterile catheter kit being
careful not
to touch the glove or the catheter.
5. Fill the suction kit water cup with
sterile water.
6. Ambu the patient for 4-6 breaths. If
oxygen is
ordered, make sure the ambu bag is
attached
to the oxygen source.
7. Put the sterile glove on your dominant hand.
8. With the non-sterile hand, grasp the suction tubing

9. With the sterile hand, pick up the package with the suction catheter and
attach the suction catheter to the suction tubing.
10. Remove the protective covering from the suction
catheter with your non-sterile hand. DO NOT
touch anything but the catheter with your sterile hand.
11. Coil the catheter around the gloved hand making
sure to protect the tip of the catheter with your
gloved hand.
12. Disconnect the patient from the ambu bag
13. Gently insert the catheter into the trach tube
until resistance is met. Do not jam the catheter
into the trach. Do not apply suction as you
are inserting the catheter.
14. Apply suction as you withdraw the suction
catheter from the airway. DO not suction
longer than 10-15 seconds.
15. Reconnect the patient to the ambu bag and
ventilate the patient for 30 seconds. Do not
touch the ambu bag with the sterile hand.
16. Repeat the suctioning and ventilating procedure,
give several deep breaths with the ambu bag.
17. If the patient has trouble swallowing, you may
use the same catheter and glove to suction the
mouth and around the trach.
Note: Remember once you have suctioned
the mouth or around the trach tube, you
cannot re-suction the trach until you have
replaced the suction catheter with a new one.
18. If the patient is on a ventilator, reconnect them
to the ventilator.
19. Rinse the suction tubing until it is clear by using
the tip of the catheter in the sterile water with
the suction turned on.
20. Discard the disposable suction kit supplies.

Clean Suction Procedure:
A clean suction technique utilizes clean gloves,
but not sterile gloves each time the patient
is suctioned.
Instructions:
1. Wash your hands before starting
the procedure
2. Plug in the suction machine, connect
the tubing to the suction canister.
3. Set the vacuum gauge to the proper
suction pressure.
• Adult: -80 to -120mmHg 120mmHg
• Children: -80 80 to -100mmHg
• Infants: -60 to --80mmHg
4. Put on clean gloves.
5. Attach a clean suction catheter to the
suction tubing.
6. Connect the patient to an ambu bag
and ventilate for 30 seconds
7. Gently insert the catheter into the
trach tube until resistance is met. Do
not apply suction as you with withdraw the
catheter from the airway. Never
suction
longer than 10-15 15 seconds.
8. Reconnect the patient to the ambu bag
and ventilate for 30 seconds.
9. Repeat suctioning until the airway is
clear.
10. You may clear the mouth and around the
trach with the same cat catheter and glove
if needed. It is important to remember
you can not re-suction suction the trach until you
replace the catheter with a new one.

11. Place the patient back on the ventilator
and ensure that he or she is comfortable.
12. Rinse the catheter and suction connecting tube
with distilled water until it is clear of mucus.
13. Wash your hands

Guidelines For Caregiver Training
Caregiver training will be into sections that will require successful completion of a section of
training; the caregiver will continue to be involved, on a weekly basis, with the care of the
patient.
The caregiver will complete each individual section of the training record with instruction from
Breath of Life staff and then will return demonstrate each task without assistance and then will
return demonstrate each task without assistance and/or verbal cues from the staff. The staff
will be present at the bedside to observe.
Section One:
� Caregiver will begin learning care
� Staff will be teaching trach care, trach changes, suctioning and manual resuscitation
� Caregiver will demonstrate 2 independent trach changes
� Caregiver will demonstrate 5 independent suctioning
� Caregiver will be required to do trach changes and suctioning on a weekly basis
� Patient will have a pulse oximeter on at all times
� Caregiver will be independent in use of manual resuscitator
Section Two:
� Completion of section one
� CPR module
� Education will be started on the ventilator and the circuit
� Caregiver will be able to recognize signs and symptoms of respiratory distress after a
discussion with the attending physician and/or staff member
� Caregiver will complete ventilator and/or CPAP training. Patient will have a pulse
oximeter on at all times
Section Three:
� Completion of section two
� Caregiver will review CPR
� Caregiver will independently change 2 circuits on ventilator. (No Cues)
� Caregiver will demonstrate getting the child and the equipment in and out of the care
independently a minimum of one (1) time
� Caregiver will have completed all training records and have records signed

Section Four:
� Caregiver will complete total independent care of their patient as ordered by the
attending physician
Section Five:
� Completion of section four
� Caregiver will have a pulse oximeter at all times
I have read the above guidelines for the caregiver and understand that I will required to
participate with the Breath of Life staff to have training completed.
Caregiver Signature: __________________________________________________________
BOL Staff Signature: __________________________________________________________
Date: __________________________

HOME NEBULIZER TREATMENTS
Many medications are most effective when inhaled directly into lungs. To be
inhaled into the airways of the lungs, medication must be changed from a liquid
to a fine mist. To create this fine mist at home, you need a nebulizer and an air
compressor. A nebulizer is a plastic container that changes liquids into a fine
mist using a jet of air. The compressor, runs by electricity or battery, provides
the jet of air to the nebulizer.
How is the home nebulizer used?
1. Place the compressor on a hard surface. Make sure the filter is free of dust
and dirt. If it is dirty, rinse it with water and then dry it. Plug in the
compressor.
2. Place the prescribed amount of medication(s) into the nebulizer with a
dropper or a syringe. Two medications can usually be mixed together. If you
have any questions please contact your physician or Breath of Life.
3. Some asthma medicines come premixed with saline. Other medications
need saline added. You can buy sterile normal saline in two ways: in unit
dose plastic vials or a pressurized canister (Bronchosaline). Two squirts from
the canister should be enough. Never put a homemade saline solution into a
nebulizer.
4. Attach the nebulizer to the compressor tubing. Turn the power on. (The
medication will immediately begin to nebulizer) Place the mouthpiece in the
mouth and breathe in and out slowly through the mouth until the medication
is gone. If the patient is able, tell them to take an extra deep breath every 10
breaths or so, hold that breath for 10 seconds, and then breathe out slowly.
This technique permits the medication to stay in the lungs longer for better
effect.
If the patient can’t use a mouthpiece, use a mask. The mask can be secured loosely over the
nose and mouth if needed.
Most nebulizers must be held in an upright position to work well. If the mixture has coated the
sided and isn’t being nebulized, gently shake the nebulizer occasionally during the treatment.
An average treatment takes 10-15 minutes. The treatment is over when all medication is gone
and the nebulizer makes a constant sputtering noise.
Some patients cough up mucus after breathing treatments. Observe the mucus color and
thickness. Normal secretions are usually thin and white or clear. Thick and sticky mucus that is
yellow or green may indicate an infection. Call your physician to report a change.
If the patient needs more treatments than prescribed by your doctor, or if the treatments do
not improve the symptoms, call your physician.

HUMIDIVENT OR “ARTIFICIAL NOSE”
Purpose: To provide humidification for the respiratory system, to assist
in keeping secretions manageable, and to prevent airway damage due to
dryness.
When to use a humidivent: When the patient is disconnected from
bedside, water humidity source.
How to use: The humidivent is placed between the trach tube under the patient’s chin and the
ventilator tubing attachment. If the patient has a trach, but not a ventilator, the humidivent
sits directly on the trach opening.
How it works: There is moisture in our exhaled air. The tiny, rolled fiber inside the humidivent
collects the moisture from the patients exhaled air, holds it in the paper, and uses that moisture
to humidify the next breath taken in.
NOTE: The humidivent helps add moisture to each inhaled breath, but doesn’t do as thorough
of a job as the heated humidifier used at the patients bedside. IF the patient will be away from
the bedside humidification system for several hours, or the air is particularly dry, it may be
helpful to place three or four drops of normal saline on the rolled fiber areas of the humidivent.
REMEMBER: The humidivent is disposable and is not to be cleaned. For infection control
purposes, it would be wise to discard the used humidivent daily. If the inside of the humidivent
is saturated with secretions, discard it and use a new humidivent.