Chapter 22 Tracheostomy Care & Suctioning (2025)

Table of Contents

22.1. TRACHEOSTOMY CARE & SUCTIONING INTRODUCTION Learning Objectives References 22.2. BASIC CONCEPTS RELATED TO SUCTIONING Respiratory System Anatomy To read more details about the respiratory system, see the “Respiratory Assessment” chapter. Respiratory Failure and Respiratory Arrest Tracheostomy References 22.3. ASSESSMENTS RELATED TO AIRWAY SUCTIONING Subjective Assessment Objective Assessment References 22.4. OROPHARYNGEAL AND NASOPHARYNGEAL SUCTIONING CHECKLIST & SAMPLE DOCUMENTATION Checklist for Oropharyngeal or Nasopharyngeal Suctioning Sample Documentation References 22.5. CHECKLIST FOR TRACHEOSTOMY SUCTIONING AND SAMPLE DOCUMENTATION Checklist for Tracheostomy Suctioning[4] Video Review of Tracheostomy Suctioning:[5] Sample Documentation References 22.6. CHECKLIST FOR TRACHEOSTOMY CARE AND SAMPLE DOCUMENTATION Replacing and Cleaning an Inner Cannula Checklist for Tracheostomy Care With a Reusable Inner Cannula Sample Documentation References 22.7. SUPPLEMENTARY VIDEOS View these videos from Santa Fe College for more information on tracheostomy care and suctioning: References 22.8. LEARNING ACTIVITIES Learning Activities XXII. GLOSSARY References

22.1. TRACHEOSTOMY CARE & SUCTIONING INTRODUCTION

Learning Objectives

Safely perform nasal, oral, pharyngeal, and tracheostomy suctioning
Provide tracheostomy care
Explain procedure to patient
Adapt procedure to reflect variations across the life span
Document actions and observations
Recognize and report significant deviations from norms

This chapter will discuss tracheostomy care and various types of suctioning (e.g., oral, nasal, pharyngeal, and tracheostomy) performed by nurses. The purpose of respiratory suctioning is to maintain a patent airway and improve oxygenation by removing mucous secretions and foreign material (e.g., vomit or gastric secretions). During oral suctioning, a rigid plastic suction catheter is typically used in a patient’s mouth to remove oral secretions. Nasal and pharyngeal suctioning is performed with a sterile, soft, flexible catheter to remove accumulated saliva, pulmonary secretions, blood, vomitus, or other foreign material from nasopharyngeal areas that cannot be removed by the patient’s spontaneous cough or other less invasive procedures.^[1^]

Tracheostomy suctioning uses a sterile catheter that is inserted through a tracheostomy tube into a patient’s trachea. A tracheostomy tube is a tube that is inserted through a surgical opening in the neck to the trachea to create an artificial airway. Tracheostomies require routine care to prevent infection and obstruction, as well as frequent suctioning to maintain a patent airway.^[2^]Tracheostomy care and suctioning are performed collaboratively by nurses and respiratory therapists.

References

1.: American Association for Respiratory Care. AARC clinical practice guideline: Nasotracheal suctioning - 2004 revision & update. Respiratory Care. 2004;49(9):1080–1084. https://www.aarc.org/wp-content/uploads/2014/08/09.04.1080.pdf ↵
2.: This work is a derivative ofClinical Procedures for Safer Patient CarebyBritish Columbia Institute of Technologyand is licensed underCC BY 4.0.↵.

22.2. BASIC CONCEPTS RELATED TO SUCTIONING

Respiratory System Anatomy

It is important for the nurse to have an understanding of the underlying structures of the respiratory system before performing suctioning to ensure that care is given to protect sensitive tissues and that airways are appropriately assessed during the suctioning procedure. See Figure 22.1^[1^]for an illustration of the anatomy of the respiratory system.

Figure 22.1

Anatomy of the Respiratory System

Maintaining a patent airway is a top priority and one of the “ABCs” of patient care (i.e., Airway, Breathing, and Circulation). Suctioning is often required in acute-care settings for patients who cannot maintain their own airway due to a variety of medical conditions such as respiratory failure, stroke, unconsciousness, or postoperative care. The suctioning procedure is useful for removing mucus that may obstruct the airway and compromise the patient’s breathing ability.

To read more details about the respiratory system, see the “Respiratory Assessment” chapter.

Respiratory Failure and Respiratory Arrest

Respiratory failure and respiratory arrest often require emergency suctioning. Respiratory failure is a life-threatening condition that is caused when the respiratory system cannot get enough oxygen from the lungs into the blood to oxygenate the tissues, or there are high levels of carbon dioxide in the blood that the body cannot effectively eliminate via the lungs. Acute respiratory failure can happen quickly without much warning. It is often caused by a disease or injury that affects breathing, such as pneumonia, opioid overdose, stroke, or a lung or spinal cord injury. Acute respiratory failure requires emergency treatment. Untreated respiratory failure can lead to respiratory arrest.

Signs and symptoms of respiratory failure include shortness of breath (dyspnea), rapid breathing (tachypnea), rapid heart rate (tachycardia), unusual sweating (diaphoresis), decreasing pulse oximetry readings below 90%, and air hunger (a feeling as if you can’t breathe in enough air). In severe cases, signs and symptoms may include cyanosis (a bluish color of the skin, lips, and fingernails), confusion, and sleepiness.

The main goal of treating respiratory failure is to ensure that sufficient oxygen reaches the lungs and is transported to the other organs while carbon dioxide is cleared from the body.^[2^]Treatment measures may include suctioning to clear the airway while also providing supplemental oxygen using various oxygenation devices. Severe respiratory distress may require intubation and mechanical ventilation, or the emergency placement of a tracheostomy may be performed if the airway is obstructed. For additional details about oxygenation and various oxygenation devices, go to the “Oxygen Therapy” chapter.

Tracheostomy

Atracheostomyis a surgically-created opening called a stoma that goes from the front of the patient’s neck into the trachea. A tracheostomy tube is placed through the stoma and directly into the trachea to maintain an open (patent) airway. See Figure 22.2^[3^]for an illustration of a patient with a tracheostomy tube in place.

Figure 22.2

Patient with Tracheostomy Tube

Placement of a tracheostomy tube may be performed emergently or as a planned procedure due to the following:

A large object blocking the airway
Respiratory failure or arrest
Severe neck or mouth injuries
A swollen or blocked airway due to inhalation of harmful material such as smoke, steam, or other toxic gases
Cancer of the throat or neck, which can affect breathing by pressing on the airway
Paralysis of the muscles that affect swallowing
Surgery around the larynx that prevents normal breathing and swallowing
Long-term oxygen therapy via a mechanical ventilator^[4^]

See Figure 22.3^[5^]for an image of the parts of a tracheostomy tube. The outside end of the outer cannula has a flange that is placed against the patient’s neck. Theflangeis secured around the patient’s neck with tie straps, and a split 4″ x 4″ tracheostomy dressing is placed under the flange to absorb secretions. A cuff is typically present on the distal end of the outer cannula to make a tight seal in the airway. (See the top image in Figure 22.3.) The cuff is inflated and deflated with a syringe attached to the pilot balloon. Most tracheostomy tubes have a hollowinner cannulainside theouter cannulathat is either disposable or removed for cleaning as part of the tracheostomy care procedure. (See the middle image of Figure 22.3.) A solid obturator is used during the initial tracheostomy insertion procedure to help guide the outer cannula through the tracheostomy and into the airway. (See the bottom image of Figure 22.3.) It is removed after insertion and the inner cannula is slid into place.

Figure 22.3

Parts of a Tracheostomy Tube

When a tracheostomy is placed, the provider determines if a fenestrated or unfenestrated outer cannula is needed based on the patient’s condition. Afenestratedtube is used for patients who can speak with their tracheostomy tube in place. Under the guidance of a speech pathologist and respiratory therapist, the inner cannula is eventually removed from a fenestrated tube and the cuff deflated so the patient is able to speak. Otherwise, a patient with a tracheostomy tube is unable to speak because there is no airflow over the vocal cords, and alternative communication measures, such as a whiteboard, pen and paper, or computer device with note-taking ability, must be put into place by the nurse. Suctioning should never be performed through a fenestrated tube without first inserting a nonfenestrated inner cannula, or severe tracheal damage can occur. See Figure 22.4^[6^]for images of a fenestrated and nonfenestrated outer cannula.

Figure 22.4

Fenestrated and Nonfenestrated Outer Cannula

Caring for a patient with a tracheostomy tube includes providing routine tracheostomy care and suctioning. Tracheostomy care is a procedure performed routinely to keep the flange, tracheostomy dressing, ties or straps, and surrounding area clean to reduce the introduction of bacteria into the trachea and lungs. The inner cannula becomes occluded with secretions and must be cleaned or replaced frequently according to agency policy to maintain an open airway. Suctioning through the tracheostomy tube is also performed to remove mucus and to maintain a patent airway.

When caring for a patient with a tracheostomy tube in the acute care setting, it is important to ensure that proper safety equipment is present at the patient’s bedside. Patients with a tracheostomy should have the obturator used for initial tracheostomy placement present and readily available. Many health facilities recommend that obturators be taped to the wall at the head of the bed in case of the need for emergency tracheostomy tube reinsertion. Additionally, there should be spare tracheostomy tubes (same size and one size smaller), lubricant, syringe for cuff inflation, and tracheostomy ties (or means to resecure the tracheostomy tube) if reinsertion is required. A bag valve mask should always be kept at the bedside.

References

1.: “2301 Major Respiratory Organs.jpg” byOpenStaxis licensed underCC BY 3.0^↵.
2.: National Heart, Lung, and Blood Institute. (n.d.).Respiratory failure.https://www.nhlbi.nih.gov/health-topics/respiratory-failure↵.
3.: “Tracheostomy NIH.jpg” byNational Heart Lung and Blood Instituteis in thePublic Domain↵.
4.: A.D.A.M. Medical Encyclopedia [Internet]. Atlanta (GA): A.D.A.M., Inc.; c1997-2020. Nail abnormalities; [updated 2020, June 2]https://medlineplus.gov/ency/article/002955.htm↵.
5.: “Tracheostomy tube.jpg” byKaluse D Peter, Wiehl, Germanyis licensed underCC BY 2.0 DE↵.
6.: “Diagram showing a fenestrated and a non fenestrated tracheostomy tube CRUK 066.svg” byCancer Research UKis licensed underCC BY-SA 4.0.↵.

22.3. ASSESSMENTS RELATED TO AIRWAY SUCTIONING

Subjective Assessment

If appropriate, perform a focused interview collecting a brief history of respiratory conditions and assess for feelings of shortness of breath (dyspnea), sputum production, and coughing.

Objective Assessment

Prior to suctioning, a baseline assessment for indications of respiratory distress and the need for suctioning should be obtained and documented, including, but not limited to, the following:

Secretions from the mouth and/or tracheal stoma
Auscultation of lung sounds
Heart rate
Respiratory rate
Cardiac rhythm
Oxygen saturation
Skin color and perfusion
Effectiveness of cough^[1^]

Prepare the patient by explaining the procedure and providing adequate sedation and pain relief as needed. Place the patient in semi-Fowler’s position if conscious or in a lateral position facing you if they are unconscious. While suctioning the patient, if signs of worsening respiratory distress occur, stop the procedure and request emergency assistance. The following should be monitored during and following the procedure:

Lung sounds
Skin color
Breathing pattern and rate
Oxygenation (pulse oximeter)
Pulse rate
Dysrhythmias if electrocardiogram is available
Color, consistency, and volume of secretions
Presence of bleeding or evidence of physical trauma
Subjective response including pain
Cough
Laryngospasm (spasm of the vocal cords that can result in airway obstruction)^[2^]

After completing suctioning, the outcomes from the procedure should be evaluated and documented, including the following:

Improvement of lung sounds
Removal of secretions
Improvement of pulse oximetry
Decreased work of breathing
Stabilized respiratory rate
Decreased dyspnea

Be aware that the patient’s lung sounds may not clear completely after suctioning, but the removal of secretions should improve the patency of the patient’s airway.

Potential complications resulting from this procedure include nasal irritation/bleeding, gagging/vomiting, discomfort and pain, and uncontrolled coughing. Potential adverse reactions include mucosal hemorrhage, laceration of nasal turbinate, perforation of the pharynx, hypoxia/hypoxemia, cardiac dysrhythmias/arrest, bradycardia, elevated blood pressure, hypotension, respiratory arrest, laryngospasm, bronchoconstriction, bronchospasm, hospital-acquired infection, atelectasis, increased intracranial pressure, and pneumothorax.

References

1.: American Association for Respiratory Care. AARC clinical practice guideline: Nasotracheal suctioning - 2004 revision & update. Respiratory Care. 2004;49(9):1080–1084. https://www.aarc.org/wp-content/uploads/2014/08/09.04.1080.pdf ↵
2.: American Association for Respiratory Care. AARC clinical practice guideline: Nasotracheal suctioning - 2004 revision & update. Respiratory Care. 2004;49(9):1080–1084. https://www.aarc.org/wp-content/uploads/2014/08/09.04.1080.pdf ↵
See Also
22.4 Oropharyngeal and Nasopharyngeal Suctioning Checklist & Sample Documentation – Nursing Skills (Nicolet College)22.4 Oropharyngeal and Nasopharyngeal Suctioning Checklist & Sample Documentation – Nursing Skills – 2e 22.4: Oropharyngeal and Nasopharyngeal Suctioning Checklist and Sample Documentation Performing Suctioning

22.4. OROPHARYNGEAL AND NASOPHARYNGEAL SUCTIONING CHECKLIST & SAMPLE DOCUMENTATION

Suctioning via theoropharyngeal(mouth) and nasopharyngeal (nasal) routes is performed to remove accumulated saliva, pulmonary secretions, blood, vomitus, and other foreign material from these areas that cannot be removed by the patient’s spontaneous cough or other less invasive procedures. Nasal and pharyngeal suctioning are performed in a wide variety of settings, including critical care units, emergency departments, inpatient acute care, skilled nursing facility care, home care, and outpatient/ambulatory care. Suctioning is indicated when the patient is unable to clear secretions and/or when there is audible or visible evidence of secretions in the large/central airways that persist in spite of the patient’s best cough effort. Need for suctioning is evidenced by one or more of the following:

Visible secretions in the airway
Chest auscultation of coarse, gurgling breath sounds, rhonchi, or diminished breath sounds
Reported feeling of secretions in the chest
Suspected aspiration of gastric or upper airway secretions
Clinically apparent increased work of breathing
Restlessness
Unrelieved coughing^[1^]

In emergent situations, a provider order is not necessary for suctioning to maintain a patient’s airway. However, routine suctioning does require a provider order.

For oropharyngeal suctioning, a device called aYankauer suction tipis typically used for suctioning mouth secretions. A Yankauer device is rigid and has several holes for suctioning secretions that are commonly thick and difficult for the patient to clear. See Figure 22.5^[2^]for an image of a Yankauer device. In many agencies, Yankauer suctioning can be delegated to trained assistive personnel if the patient is stable, but the nurse is responsible for assessing and documenting the patient’s respiratory status.

Figure 22.5

Yankauer Suction Tip

Yankauer suction devices are made of rigid firm plastic. The nurse or assistive personnel who performs suctioning with these devices should use care to protect the patient’s soft mucous membranes and prevent unnecessary trauma.

Nasopharyngeal suctioning removes secretions from the nasal cavity, pharynx, and throat by inserting a flexible, soft suction catheter through the nares. This type of suctioning is performed when oral suctioning with a Yankauer is ineffective. See Figure 22.6^[3^]for an image of a sterile suction catheter.

Figure 22.6

Sterile Suction Catheter

Extension tubing is used to attach the Yankauer or suction catheter device to a suction canister that is attached to wall suction or a portable suction source. The amount of suction is set to an appropriate pressure according to the patient’s age. See Figure 22.7^[4^]for an image of extension tubing attached to a suction canister that is connected to a wall suctioning source.

Figure 22.7

Tubing Attaching Suction Canister to Wall Suction Source

Follow agency policy regarding setting suction pressure. Pressure should not exceed 150 mm Hg because higher pressures have been shown to cause trauma, hypoxemia, and atelectasis. The following ranges are appropriate pressure according to the patient’s age:

Neonates: 60-80 mm Hg
Infants: 80-100 mm Hg
Children: 100-120 mm Hg
Adults: 100-150 mm Hg

Suction only when clinically indicated and for up to 15 seconds at a time to decrease the risk of respiratory complications. Hyperoxygenation and hyperventilation should be performed prior to the nasal and tracheal procedures to avoid the most common hazards of suctioning (hypoxemia, arrhythmias, and atelectasis). For nasal suctioning, increase the amount of O2 the patient is receiving for a few minutes prior to the procedure and instruct the patient to take several deep breaths. For tracheal suctioning, do the same. If the patient is on a ventilator, you can either hyperoxygenate and ventilate with the Ambu bag or provide a few extra machine assisted breaths prior to the procedure. Allow the patient to recover and hyperventilate and hyperoxygenate between each passing of the suction catheter. The patient should recover for 30-60 seconds between passes.^[5^]

When performing nasal suctioning, have the patient lean their head backwards to open the airway. This helps guide the catheter toward the trachea rather than the esophagus.

Checklist for Oropharyngeal or Nasopharyngeal Suctioning

Use the checklist below to review the steps for completion of “Oropharyngeal or Nasopharyngeal Suctioning.”

Steps

Disclaimer: Always review and follow agency policy regarding this specific skill.

1.

Gather supplies: Yankauer or suction catheter, suction machine or wall suction device, suction canister, connecting tubing, pulse oximeter, stethoscope, PPE (e.g., mask, goggles or face shield, nonsterile gloves), sterile gloves for suctioning with sterile suction catheter, towel or disposable paper drape, nonsterile basin or disposable cup, and normal saline or tap water.

2.

Perform safety steps:

Perform hand hygiene.
Check the room for transmission-based precautions.
Introduce yourself, your role, the purpose of your visit, and an estimate of the time it will take.
Confirm patient ID using two patient identifiers (e.g., name and date of birth).
Explain the process to the patient.
Be organized and systematic.
Use appropriate listening and questioning skills.
Listen and attend to patient cues.
Ensure the patient’s privacy and dignity.
Assess ABCs.

3.

Adjust the bed to a comfortable working height and lower the side rail closest to you.

4.

Position the patient:

If conscious, place the patient in a semi-Fowler’s position.
If unconscious, place the patient in the lateral position, facing you.

5.

Move the bedside table close to your work area and raise it to waist height.

6.

Place a towel or waterproof pad across the patient’s chest.

7.

Adjust the suction to the appropriate pressure:

Adults and adolescents: no more than 150 mm Hg
Children: no more than 120 mmHg
Infants: no more than 100 mm Hg
Neonates: no more than 80 mm Hg

For a portable unit:

Adults: 10 to 15 cm Hg
Adolescents: 8 to 15 cm Hg
Children: 8 to 10 cm Hg
Infants: 8 to 10 cm Hg
Neonates: 6 to 8 cm Hg
8.
Put on a clean glove and occlude the end of the connection tubing to check suction pressure.
9.
Place the connecting tubing in a convenient location (e.g., at the head of the bed).
10.
Open the sterile suction package using aseptic technique. (NOTE: The open wrapper or container becomes a sterile field to hold other supplies.) Carefully remove the sterile container, touching only the outside surface. Set it up on the work surface and fill with sterile saline using sterile technique.
11.
Place a small amount of water-soluble lubricant on the sterile field, taking care to avoid touching the sterile field with the lubricant package.
12.
Increase the patient’s supplemental oxygen level or apply supplemental oxygen per facility policy or primary care provider order.
13.
Don additional PPE. Put on a face shield or goggles and mask.
14.
Don sterile gloves. The dominant hand will manipulate the catheter and must remain sterile.
15.
The nondominant hand is considered clean rather than sterile and will control the suction valve on the catheter.
In the home setting and other community-based settings, maintenance of sterility is not necessary.
16.
With the dominant gloved hand, pick up the sterile suction catheter. Pick up the connecting tubing with the nondominant hand and connect the tubing and suction catheter.
17.
Moisten the catheter by dipping it into the container of sterile saline. Occlude the suction valve on the catheter to check for suction.
18.
Encourage the patient to take several deep breaths.
19.
Apply lubricant to the first 2 to 3 inches of the catheter, using the lubricant that was placed on the sterile field.
20.
Remove the oxygen delivery device, if appropriate. Do not apply suction as the catheter is inserted. Hold the catheter between your thumb and forefinger.
21.
Insert the catheter. For nasopharyngeal suctioning, gently insert the catheter through the naris and along the floor of the nostril toward the trachea. Roll the catheter between your fingers to help advance it. Advance the catheter approximately 5 to 6 inches to reach the pharynx. For oropharyngeal suctioning, insert the catheter through the mouth, along the side of the mouth toward the trachea. Advance the catheter 3 to 4 inches to reach the pharynx.
22.
Apply suction by intermittently occluding the suction valve on the catheter with the thumb of your nondominant hand and continuously rotate the catheter as it is being withdrawn.^[6^]
Suction only on withdrawal and do not suction for more than 10 to 15 seconds at a time to minimize tissue trauma.
23.
Replace the oxygen delivery device using your nondominant hand, if appropriate, and have the patient take several deep breaths.
24.
Flush the catheter with saline. Assess the effectiveness of suctioning by listening to lung sounds and repeat, as needed, and according to the patient’s tolerance. Wrap the suction catheter around your dominant hand between attempts:
Repeat the procedure up to three times until gurgling or bubbling sounds stop and respirations are quiet. Allow 30 seconds to 1 minute between passes to allow reoxygenation and reventilation.^[7^]
25.
When suctioning is completed, remove gloves from the dominant hand over the coiled catheter, pulling them off inside out.
26.
Remove the glove from the nondominant hand and dispose of gloves, catheter, and the container with solution in the appropriate receptacle.
27.
Assist the patient to a comfortable position. Raise the bed rail and place the bed in the lowest position.
28.
Turn off the suction. Remove the supplemental oxygen placed for suctioning, if appropriate.
29.
Remove face shield or goggles and mask; perform hand hygiene.
30.
Perform oral hygiene on the patient after suctioning.
31.
Reassess the patient’s respiratory status, including respiratory rate, effort, oxygen saturation, and lung sounds.
32.
Assist the patient to a comfortable position, ask if they have any questions, and thank them for their time.
33.
Ensure safety measures when leaving the room:
CALL LIGHT: Within reach
BED: Low and locked (in lowest position and brakes on)
SIDE RAILS: Secured
TABLE: Within reach
ROOM: Risk-free for falls (scan room and clear any obstacles)
34.
Perform hand hygiene.
35.
Document the procedure and related assessment findings. Report any concerns according to agency policy.

Sample Documentation

Sample Documentation of Expected Findings

Patient complaining of not being able to cough up secretions. Order was obtained to suction via the nasopharyngeal route. Procedure explained to the patient. Vital signs obtained prior to procedure were heart rate 88 in regular rhythm, respiratory rate 28/minute, and O2 sat 88% on room air. Coarse rhonchi present over anterior upper airway. No cyanosis present. Patient tolerated procedure without difficulties. A small amount of clear, white, thick sputum was obtained. Post-procedure vital signs were heart rate 78 in regular rhythm, respiratory rate 18/minute, and O2 sat 94% on room air. Lung sounds clear and no cyanosis present.

Sample Documentation of Unexpected Findings

Patient complaining of not being able to cough up secretions. Order was obtained to suction via the nasopharyngeal route. Procedure explained to the patient. Vital signs obtained prior to procedure were heart rate 88 in regular rhythm, respiratory rate 28/minute, and O2 sat 88% on room air. Coarse rhonchi present over anterior upper airway. No cyanosis present. After first pass of suctioning, patient began coughing uncontrollably. Procedure was stopped and emergency assistance was requested from the respiratory therapist. Post-procedure vital signs were heart rate 78 in regular rhythm, respiratory rate 18/minute, and O2 sat 94% on room air. Coarse rhonchi continued to be present over anterior upper airway but no cyanosis present. Dr. Smith notified and a STAT order was received for a chest X-ray and to call with results.

References

1.: American Association for Respiratory Care. AARC clinical practice guideline: Nasotracheal suctioning - 2004 revision & update. Respiratory Care. 2004;49(9):1080–1084. https://www.aarc.org/wp-content/uploads/2014/08/09.04.1080.pdf ↵
2.: “Yankauer Suction Tip.jpg” byThomasriveis licensed underCC BY-SA 3.0↵.
3.: “DSC_0210-150x150.jpg” byBritish Columbia Institute of Technologyis licensed underCC BY 4.0.Access for free athttps://opentextbc.ca/clinicalskills/chapter/5-7-oral-suctioning/↵.
4.: “DSC_0206-e1437445438554.jpg” byBritish Columbia Institute of Technologyis licensed underCC BY 4.0.Access for free at https://opentextbc.ca/clinicalskills/chapter/5-7-oral-suctioning/↵.
5.: American Association for Respiratory Care. AARC clinical practice guideline: Endotracheal suctioning of mechanically ventilated patients with artificial airways 2010. Respiratory Care. 2010;55(6):758–764. http://www.rcjournal.com/cpgs/pdf/06.10.0758.pdf ↵ [PubMed: 20507660]
6.: Oronasopharyngeal suctioning. (2020). Lippincott procedures.http://procedures.lww.com↵.
7.: Oronasopharyngeal suctioning. (2020). Lippincott procedures.http://procedures.lww.com↵.

22.5. CHECKLIST FOR TRACHEOSTOMY SUCTIONING AND SAMPLE DOCUMENTATION

Tracheostomy suctioning may be performed with open or closed technique. Open suctioning requires disconnection of the patient from the oxygen source, whereas closed suctioning uses an inline suctioning catheter that does not require disconnection. This checklist will explain the open suctioning technique.

Indications for tracheostomy suctioning include the following:

The need to maintain the patency and integrity of the artificial airway
Deterioration of oxygen saturation and/or arterial blood gas values
Visible secretions in the airway
The patient’s inability to generate an effective spontaneous cough
Acute respiratory distress
Suspected aspiration of gastric or upper-airway secretions
The need to obtain a sputum specimen^[1^]

Similar assessments and monitoring apply when performing tracheostomy suctioning compared with other types of suctioning with the addition of assessing the stoma. The stoma should be free from redness and drainage. Hyperoxygenation using a bag mask valve attached to an oxygen source may be required before and during the open suctioning procedure based on the patient’s oxygenation status. See Figure 22.8^[2^]for an image of an example of sterile tracheostomy suctioning kit.

Figure 22.8

Example of a Sterile Tracheostomy Kit

To ensure patient safety, a replacement tracheostomy tube, an obturator, a bag valve mask (Ambu bag), and suction catheter kit must always be available in the room.
Communication should be facilitated with the patient using writing when possible.
Follow agency policy regarding hyperoxygenation and hyperventilation prior to and during suctioning.
Do not suction for more than 15 seconds per pass.^[3^]
During the procedure, it is important to continually monitor the patient’s pulse oximetry to determine if the oxygen saturation is maintaining at an adequate level.
Perform oral care after suctioning according to agency policy.

Checklist for Tracheostomy Suctioning^[4^]

Use the checklist below to review the steps for “Tracheostomy Suctioning.”

Video Review of Tracheostomy Suctioning:^[5^]

Steps

Disclaimer: Always review and follow agency policy regarding this specific skill.

1.

Gather supplies: sterile gloves, trach suction kit, mask with face shield, gown, goggles, pulse oximetry, and bag valve device. It is helpful to request assistance from a second nurse if preoxygenating the patient before suction passes.

2.

Perform safety steps.

Perform hand hygiene.
Check the room for transmission-based precautions.
Introduce yourself, your role, the purpose of your visit, and an estimate of the time it will take.
Confirm patient ID using two patient identifiers (e.g., name and date of birth).
Explain the process to the patient and ask if they have any questions.
Be organized and systematic.
Use appropriate listening and questioning skills.
Listen and attend to patient cues.
Ensure the patient’s privacy and dignity.
Assess ABCs.

3.

Verify that there are a backup tracheostomy and bag valve device available at the bedside.

4.

Assess lung sounds, heart rate and rhythm, and pulse oximetry.

5.

Raise the head of the bed to waist level. Place the patient in a semi-Fowler’s position and apply the pulse oximeter for monitoring during the procedure.

6.

Turn on the suction. Set the suction gauge to appropriate setting based on age of the patient.

7.

Perform hand hygiene. Don appropriate PPE (gown and mask).

8.

Open the suction catheter package faced away from you to maintain sterility.

9.

Don the sterile gloves from the kit.

10.

Remove the sterile fluid and check the expiration date.

11.

Open the sterile container used for flushing the catheter and place it back into the kit. Pour the sterile fluid into the sterile container using sterile technique.

12.

Remove the suction catheter from the packaging. Ensure the catheter size is not greater than half of the inner diameter of the tracheostomy tube.

13.

Keep the catheter sterile by holding it with your dominant hand and attaching it to the suction tubing with your nondominant hand. Note that your nondominant hand is no longer sterile.

14.

Test the suction and lubricate the sterile catheter by using your sterile hand to dip the end into the sterile saline while occluding the thumb control.

15.

Ask an assistant to preoxygenate the patient with 100% oxygen for 30 to 60 seconds using a handheld bag valve mask (Ambu bag) per agency protocol. Alternatively, ask the patient to take two or three deep breaths if able.

16.

Insert the catheter into the patient’s tracheostomy tube using your sterile hand without applying suctioning:

For shallow suctioning, insert the catheter the length of the tracheostomy tube before beginning any suctioning.
For deep suctioning, insert the catheter until resistance is met (at the carina) and withdraw 1 centimeter before beginning suctioning.
Do not force the catheter.
Keep the dominant (sterile) hand at least one inch from the end of the trach tube.
To apply suction, place your nondominant thumb over the control valve

17.

Withdraw the catheter while continually rotating it between your fingers to suction all sides of the tracheostomy tube. Do not suction longer than 15 seconds to prevent hypoxia. Follow agency policy regarding the use of intermittent or continuous suctioning. Do not contaminate the catheter as you remove it from the trach tube.

18.

Suction sterile saline each time the suction catheter is removed to flush the catheter and suction tubing of secretions.

19.

Assess the patient response to suctioning; hyperoxygenation may be required. If dysrhythmia or bradycardia occur, stop the procedure.

20.

Allow the patient to rest. After the patient’s pulse oximetry returns to baseline, a second suctioning pass can be initiated if clinically indicated. Encourage the patient to cough and deep breath to remove secretions between suctioning passes.

21.

Do not insert the suction catheter more than two times. If the patient’s respiratory status does not improve or it worsens, call for emergency assistance.

22.

Reattach the preexisting oxygen delivery device to the patient with your noncontaminated hand.

23.

Evaluate the effectiveness of the procedure and the patient’s respiratory status. Assess patency of the airway and pulse oximetry.

24.

Remove the catheter from the tubing and then remove gloves while holding the catheter inside the glove. Perform hand hygiene.

25.

Turn off the suction.

26.

Perform proper hand hygiene and don clean gloves.

27.

Reassess lung sounds, heart rate and rhythm, and pulse oximetry for improvement .

28.

Perform patient oral care.

29.

Remove gloves and perform proper hand hygiene.

30.

Assist the patient to a comfortable position, ask if they have any questions, and thank them for their time.

31.

Ensure safety measures when leaving the room:

CALL LIGHT: Within reach
BED: Low and locked (in lowest position and brakes on)
SIDERAILS: Secured
TABLE: Within reach
ROOM: Risk-free for falls (scan room and clear any obstacles)

32.

Perform hand hygiene.

33.

Document the procedure and related assessment findings. Report any concerns according to agency policy.

Sample Documentation

Sample Documentation of Expected Findings

Mucus present at entrance to tracheostomy tube. Hyperoxygenation provided for 30 seconds before and after suctioning using a bag valve mask with FiO2 100%. Patient’s pulse oximetry remained 92-96% during suctioning. Moderate amount of thick, white mucus without odor was suctioned. Post procedure: HR 78, RR 18, O2 sat 96%, and lung sounds clear throughout all lobes. Patient tolerated the procedure without discomfort.

Sample Documentation of Unexpected Findings

Mucus present at entrance to tracheostomy tube. Hyperoxygenation provided for 30 seconds before and after suctioning using a bag valve mask with FiO2 100%. During the first suctioning pass, the ECG demonstrated bradycardia with HR dropping into the 50s. Suctioning was stopped. Trach tube was reattached to the mechanical ventilator and emergency assistance was requested from the respiratory therapist. Moderate amount of thick, white mucus without odor was suctioned. Post procedure, HR 78, RR 18, O2 sat 96% and lung sounds clear throughout all lobes.

References

1.: American Association for Respiratory Care. AARC clinical practice guideline: Endotracheal suctioning of mechanically ventilated patients with artificial airways 2010. Respiratory Care. 2010;55(6):758–764. http://www.rcjournal.com/cpgs/pdf/06.10.0758.pdf ↵ [PubMed: 20507660]
2.: “Example of a Sterile Tracheostomy Kit” by Julie Teeter atGateway Technical Collegeis licensed underCC BY 4.0↵.
3.: American Association for Respiratory Care. AARC clinical practice guideline: Endotracheal suctioning of mechanically ventilated patients with artificial airways 2010. Respiratory Care. 2010;55(6):758–764. http://www.rcjournal.com/cpgs/pdf/06.10.0758.pdf ↵ [PubMed: 20507660]
4.: Tracheostomy suctioning. (2020). Lippincott procedures.http://procedures.lww.com↵.
5.: Open RN Project. (2021, November 11). Tracheostomy Suctioning. [Video]. YouTube. Video licensed under CC-BY-4.0.https://youtu.be/VJ6kSydvaog↵.

22.6. CHECKLIST FOR TRACHEOSTOMY CARE AND SAMPLE DOCUMENTATION

Tracheostomy care is provided on a routine basis to keep the tracheostomy tube’s flange, inner cannula, and surrounding area clean to reduce the amount of bacteria entering the artificial airway and lungs. See Figure 22.9^[1^]for an image of a sterile tracheostomy care kit.

Figure 22.9

Sterile Tracheostomy Care Kit

Replacing and Cleaning an Inner Cannula

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 and replaced. Some inner cannulas are designed to be disposable, while others are reusable for a number of days. Follow agency policy for inner cannula replacement or cleaning, but as a rule of thumb, inner cannula cleaning should be performed every 12-24 hours at a minimum. Cleaning may be needed more frequently depending on the type of equipment, the amount and thickness of secretions, and the patient’s ability to cough up the secretions.

Changing the inner cannula may encourage the patient to cough and bring mucus out of the tracheostomy. 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.^[2^]

Checklist for Tracheostomy Care With a Reusable Inner Cannula

Use the checklist below to review the steps for completion of “Tracheostomy Care.”

Stoma site should be assessed and a clean dressing applied at least once per shift. Wet or soiled dressings should be changed immediately.^[3^]Follow agency policy regarding clearing the inner cannula; it should be inspected at least twice daily and cleaned as needed.

Steps

Disclaimer: Always review and follow agency policy regarding this specific skill.

1.

Gather supplies: bedside table, towel, sterile gloves, pulse oximeter, PPE (i.e., mask, goggles, or face shield), tracheostomy suctioning equipment, bag valve mask (should be located in the room), and a sterile tracheostomy care kit (or sterile cotton-tipped applicators, sterile manufacturedtracheostomy split sponge dressing,sterile basin, normal saline, and a disposable inner cannula or a small, sterile brush to clean the reusable inner cannula).

2.

Perform safety steps:

Perform hand hygiene.
Check the room for transmission-based precautions.
Introduce yourself, your role, the purpose of your visit, and an estimate of the time it will take.
Confirm patient ID using two patient identifiers (e.g., name and date of birth).
Explain the process to the patient and ask if they have any questions.
Be organized and systematic.
Use appropriate listening and questioning skills.
Listen and attend to patient cues.
Ensure the patient’s privacy and dignity.
Assess ABCs.

3.

Raise the bed to waist level and place the patient in a semi-Fowler’s position.

4.

Verify that there is a backup tracheostomy kit available.

5.

Don appropriate PPE.

6.

Perform tracheal suctioning if indicated.

7.

Remove and discard the trach dressing. Inspect drainage on the dressing for color and amount and note any odor.

8.

Inspect stoma site for redness, drainage, and signs and symptoms of infection.

9.

Remove the gloves and perform proper hand hygiene.

10.

Open the sterile package and loosen the bottle cap of sterile saline.

11.

Don one sterile glove on the dominant hand.

12.

Open the sterile drape and place it on the patient’s chest.

13.

Set up the equipment on the sterile field.

14.

Remove the cap and pour saline in both basins with ungloved hand (4″-6” above basin).

15.

Don the second sterile glove.

16.

Prepare and arrange supplies. Place pipe cleaners, trach ties, trach dressing, and forceps on the field. Moisten cotton applicators and place them in the third (empty) basin. Moisten two 4″ x 4″ pads in saline, wring out, open, and separately place each one in the third basin. Leave one 4″ x 4″ dry.

17.

With nondominant “contaminated” hand, remove the trach collar (if applicable) and remove (unlock and twist) the inner cannula. If the patient requires continuous supplemental oxygen, place the oxygenation device near the outer cannula or ask a staff member to assist in maintaining the oxygen supply to the patient.

18.

Place the inner cannula in the saline basin.

19.

Pick up the inner cannula with your nondominant hand, holding it only by the end usually exposed to air.

20.

With your dominant hand, use a brush to clean the inner cannula. Place the brush back into the saline basin.

21.

After cleaning, place the inner cannula in the second saline basin with your nondominant hand and agitate for approximately 10 seconds to rinse off debris. Repeat cleansing with brush as needed.

22.

Dry the inner cannula with the pipe cleaners and place the inner cannula back into the outer cannula. Lock it into place and pull gently to ensure it is locked appropriately. Reattach the preexisting oxygenation device.

23.

Clean the stoma with cotton applicators using one on the superior aspect and one on the inferior aspect.

24.

With your dominant, noncontaminated hand, moisten sterile gauze with sterile saline and wring out excess. Assess the stoma for infection and skin breakdown caused by flange pressure. Clean the stoma with the moistened gauze starting at the 12 o’clock position of the stoma and wipe toward the 3 o’clock position. Begin again with a new gauze square at 12 o’clock and clean toward 9 o’clock. To clean the lower half of the site, start at the 3 o’clock position and clean toward 6 o’clock; then wipe from 9 o’clock to 6 o’clock, using a clean moistened gauze square for each wipe. Continue this pattern on the surrounding skin and tube flange. Avoid using a hydrogen peroxide mixture because it can impair healing.^[4^]

25.

Use sterile gauze to dry the area.

26.

Apply the sterile tracheostomy split sponge dressing by only touching the outer edges.

27.

Replace trach ties as needed. (The literature overwhelmingly recommends a two-person technique when changing the securing device to prevent tube dislodgement. In the two-person technique, one person holds the trach tube in place while the other changes the securing device). Thread the clean tie through the opening on one side of the trach tube. Bring the tie around the back of the neck, keeping one end longer than the other. Secure the tie on the opposite side of the trach. Make sure that only one finger can be inserted under the tie.

28.

Remove the old tracheostomy ties.

29.

Remove gloves and perform proper hand hygiene.

30.

Provide oral care. Oral care keeps the mouth and teeth not only clean, but also has been shown to prevent hospital-acquired pneumonia.

31.

Lower the bed to lowest the position. If the patient is on a mechanical ventilator, the head of the bed should be maintained at 30-45 degrees to prevent ventilator-associated pneumonia.

32.

Assist the patient to a comfortable position, ask if they have any questions, and thank them for their time.

33.

Ensure safety measures when leaving the room:

CALL LIGHT: Within reach
BED: Low and locked (in lowest position and brakes on)
SIDE RAILS: Secured
TABLE: Within reach
ROOM: Risk-free for falls (scan room and clear any obstacles)

34.

Perform hand hygiene.

35.

Document the procedure and related assessment findings. Report any concerns according to agency policy.

Sample Documentation

Sample Documentation of Expected Findings

Tracheostomy care provided with sterile technique. Stoma site free of redness or drainage. Inner cannula cleaned and stoma dressing changed. Patient tolerated the procedure without difficulties.

Sample Documentation of Unexpected Findings

Tracheostomy care provided with sterile technique. Stoma site is erythematous, warm, and tender to palpation. Inner cannula cleaned and stoma dressing changed. Patient tolerated the procedure without difficulties. Dr. Smith notified of change in condition of stoma at 1315 and stated would assess the patient this afternoon.

References

1.: “Sterile Tracheostomy Care Kit” by Julie Teeter atGateway Technical Collegeis licensed underCC BY 4.0↵.
2.: This work is a derivative ofClinical Procedures for Safer Patient CarebyBritish Columbia Institute of Technologyand is licensed underCC BY 4.0.↵.
3.: Nance-Floyd, B. (2011). Tracheostomy care: An evidence-based guide.American Nurse.https://www.myamericannurse.com/tracheostomy-care-an-evidence-based-guide-to-suctioning-and-dressing-changes/↵.
4.: Nance-Floyd, B. (2011). Tracheostomy care: An evidence-based guide.American Nurse.https://www.myamericannurse.com/tracheostomy-care-an-evidence-based-guide-to-suctioning-and-dressing-changes/↵.

22.7. SUPPLEMENTARY VIDEOS

View these videos from Santa Fe College for more information on tracheostomy care and suctioning:

Trach Care Suction Video^[1^]

Trach Care – Washing the Inner Canula^[2^]

References

22.8. LEARNING ACTIVITIES

Learning Activities

(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)

1.

You are caring for a patient with a tracheostomy.What supplies should you ensure are in the patient’s room when you first assess the patient?

2.

Your patient with a tracheostomy puts on their call light. As you enter the room, the patient is coughing violently and turning red.Prioritize the action steps that you will take.

a.: Assess lung sounds
b.: Suction patient
c.: Provide oxygen via the trach collar if warranted
d.: Check pulse oximetry

XXII. GLOSSARY

Fenestrated cannula: Type of tracheostomy tube that contains holes so the patient can speak if the cuff is deflated and the inner cannula is removed.
Flange: The end of the tracheostomy tube that is placed securely against the patient’s neck.
Inner cannula: The cannula inside the outer cannula that is removed during tracheostomy care by the nurse. Inner cannulas can be disposable or reusable with appropriate cleaning.
Oropharyngeal suctioning: Suction of secretions through the mouth, often using a Yankauer device.
Outer cannula: The outer cannula placed by the provider through the tracheostomy hole and continuously remains in place.
Suction canister: A container for collecting suctioned secretions that is attached to a suction source.
Suction catheter: A soft, flexible, sterile catheter used for nasopharyngeal and tracheostomy suctioning.
Tracheostomy: A surgically created opening that goes from the front of the neck into the trachea.
Tracheostomy dressing: A manufactured dressing used with tracheostomies that does not shed fibers, which could potentially be inhaled by the patient.
Yankauer suction tip: Rigid device used to suction secretions from the mouth.