{"id":3650,"date":"2015-06-18T15:24:37","date_gmt":"2015-06-18T15:24:37","guid":{"rendered":"http:\/\/opentextbc.ca\/clinicalskills\/?post_type=chapter&#038;p=3650"},"modified":"2021-05-26T21:22:51","modified_gmt":"2021-05-26T21:22:51","slug":"10-6-tracheostomies","status":"publish","type":"chapter","link":"https:\/\/opentextbc.ca\/clinicalskills\/chapter\/10-6-tracheostomies\/","title":{"raw":"10.5 Tracheostomies","rendered":"10.5 Tracheostomies"},"content":{"raw":"A tracheostoma is an artificial opening made in the trachea just below the larynx. A tracheostomy tube is a tube that is inserted through the opening, or stoma, to create\u00a0an artificial airway. Patients who need long-term airway support (long-term patients who are intubated) or who have a need to bypass the upper airway may receive a tracheostomy. A tracheostomy (see Figure 10.1) can be very traumatic for a patient, and many find it difficult to adjust to\u00a0having one.\r\n\r\nThe tracheostomy may be permanent or temporary. It\u00a0is created surgically through the trachea (upper airway remains intact), larynx (upper airway is not patent), or cricothyroid (usually for temporary emergency access to airway). Tracheostomy tubes are inserted for airway maintenance, ventilation, removal of secretions, or as an alternate airway (e.g., following laryngectomy).\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\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/08\/DSC_0683-300x199.jpg\" alt=\"DSC_0683\" width=\"300\" height=\"199\" \/><\/a> Figure 10.1 Cross-section view of a tracheostomy (on a model) inserted in the trachea anterior to the esophagus[\/caption]\r\n<h2>Tracheostomy Tubes<\/h2>\r\nTracheostomy tubes can be soft plastic, hard plastic, or, at times, metal. All tracheostomy devices are made up of an outer cannula, inner cannula, and an <strong>obturator<\/strong> used to insert the tube (see Figure 10.2).\u00a0They come in different sizes and may have a cuff. A cuff 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 de-cannulation of the trachea. Sterile gauze and cleaning supplies are used daily to clean the trachea stoma and prevent infection to the site.\r\n\r\n[caption id=\"attachment_5024\" align=\"aligncenter\" width=\"286\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/08\/DSC_0664.jpg\"><img class=\"wp-image-5024\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/08\/DSC_0664-300x199.jpg\" alt=\"Figure 10.5.2 Left to right: Obturator, cuffed tracheostomy tube, non-cuffed tracheostomy tube, tracheal dilators\" width=\"286\" height=\"190\" \/><\/a> Figure 10.2 Left to right: obturator, cuffed tracheostomy tube, non-cuffed tracheostomy tube, tracheal dilators[\/caption]\r\n<h2>Humidification<\/h2>\r\nWhen a patient\u00a0has a tracheostomy, air is no longer filtered and humidified as it is when passing through the upper airways. Most patients will have humidification and oxygen support. The following is a list of the special considerations of patients with a tracheostomy tube (BCIT, 2015c).\r\n<ul>\r\n \t<li>Patients need to lie at a 30-degree, or greater, angle to facilitate breathing and lung expansion.<\/li>\r\n \t<li>All tracheostomy patients 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. A tracheostomy patient must be assessed every two hours to determine if suctioning is required.<\/li>\r\n \t<li>Tracheostomy patients are often not permitted anything to drink or eat. Consult with the RN in charge.<\/li>\r\n \t<li>A patient with a tracheostomy tube cannot speak; because the vocal cords are above the level of the tracheostomy tube, air cannot pass over the vocal cords. Speech is not possible without a speaking device.<\/li>\r\n \t<li>Tracheostomy patients always have the tracheostomy tied securely around the neck using ties, according to agency policy.<\/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 decrease air entry and cause respiratory distress, the patient should be suctioned immediately.<\/li>\r\n<\/ul>\r\n<h2>Potential Complications<\/h2>\r\nEarly potential complications may include hemorrhage, pneumothorax, subcutaneous emphysema, cuff leak, tube dislodgement, and respiratory\/cardiovascular arrest. Late potential complications may include airway obstruction, fistulae, infection, aspiration, and tracheal damage\/erosion.\r\n\r\nEmergency supplies at the bedside must include the following:\r\n\r\n1. Suction equipment\r\n\r\n2. Oxygen equipment with humidification\r\n\r\n3. An emergency bag containing (see Figure 10.3):\r\n<ul>\r\n \t<li>\u00a0Two\u00a0replacement tracheostomy tubes (one of the same size, and one a smaller size than the current tube)<\/li>\r\n \t<li>\u00a0Obturator and spare inner cannula<\/li>\r\n \t<li>\u00a010 ml syringe<\/li>\r\n \t<li>\u00a0Tracheal tube exchanger<\/li>\r\n \t<li>\u00a0Tracheal dilators<\/li>\r\n \t<li>\u00a0Sterile gloves<\/li>\r\n \t<li>\u00a0Water-soluble lubricant<\/li>\r\n \t<li>If the open stoma is below the sternal notch, an endotracheal tube as per the ENT physician<\/li>\r\n<\/ul>\r\n[caption id=\"attachment_6322\" align=\"aligncenter\" width=\"300\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18131.jpg\"><img class=\"wp-image-6322 size-medium\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18131-300x199.jpg\" alt=\"Equipment for emergency bag for tracheostomy patients. \" width=\"300\" height=\"199\" \/><\/a> Figure 10.3 Equipment for emergency bag for tracheostomy patients. Clockwise from top left: sterile gloves, spare tracheostomy tube, scissors, lubricant, cotton-tip applicators, ties, 10ml syringe, tracheal dilators, inner cannula, obturator, sterile gauze[\/caption]\r\n\r\nThe emergency bag must accompany patients when they are transported off the unit. Table 10.2 outlines methods to prevent possible complications that may arise from tracheostomies, and how to intervene if they do occur.\r\n<table style=\"height: 1668px;\" border=\"1px solid rgb(0, 0, 0)\" width=\"100%\"><caption>Table 10.2 Prevention and Interventions for Complications<\/caption>\r\n<tbody>\r\n<tr>\r\n<td style=\"border: 1px solid #000000; text-align: center;\">\u00a0<strong>Complication<\/strong><\/td>\r\n<td style=\"border: 1px solid #000000; text-align: center;\"><strong>Prevention<\/strong><\/td>\r\n<td style=\"border: 1px solid #000000; text-align: center;\"><strong>Interventions<\/strong><\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;\">Hemorrhage<\/td>\r\n<td style=\"border: 1px solid #000000;\">\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;\">\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;\">Stomal\/pulmonary infection<\/td>\r\n<td style=\"border: 1px solid #000000;\">\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.<\/li>\r\n \t<li>Use clean technique for tracheostomy care.<\/li>\r\n \t<li>Use humidified oxygen or air.<\/li>\r\n \t<li>Follow respiratory assessment as per agency policy.<\/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>Instill small amounts of normal saline when suctioning to help loosen secretions as needed.<\/li>\r\n \t<li>Suction as necessary.<\/li>\r\n \t<li>Maintain hydration.<\/li>\r\n \t<li>Take vital signs every four hours.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000;\">Report 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\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;\">Tube occlusion<\/td>\r\n<td style=\"border: 1px solid #000000;\">\r\n<ul>\r\n \t<li>Keep inner cannula of dual tracheostomy tube in situ at all times.<\/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.<\/li>\r\n \t<li>Maintain hydration (secretions should be loose and thin).<\/li>\r\n \t<li>Do DB&amp;C\u00a0exercises every 2 to 4 hours and as needed.<\/li>\r\n \t<li>Suction and instill normal saline to loosen secretions as needed.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000;\">If 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 and instillation of normal saline to clear cannula.<\/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;\">Aspiration<\/td>\r\n<td style=\"border: 1px solid #000000;\">\r\n<ul>\r\n \t<li>All tracheostomy patients 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;\">Report 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;\">Accidental decannulation<\/td>\r\n<td style=\"border: 1px solid #000000;\">\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;\">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<p style=\"text-align: center;\"><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"3\"><strong>Note:<\/strong> Do not hyperextend 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;\" colspan=\"3\">Data source: BCIT, 2015c; Vancouver Coastal Health, 2012a<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<h3><a id=\"video10.5\"><\/a>Video 10.5<\/h3>\r\n<div class=\"textbox shaded\" style=\"text-align: center;\">Watch the video <a href=\"https:\/\/barabus.tru.ca\/nursing\/tracheostomy_tubes.html\"><em>Trach Tubes \u2013 inflated versus deflated cuffs<\/em><\/a> by\u00a0<a href=\"\/clinicalskills\/back-matter\/appendix-3\/\">Ren\u00e9e Anderson &amp; Wendy McKenzie<\/a>, Thompson Rivers University.<\/div>\r\n<h2>Tracheal Suctioning<\/h2>\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. Tracheostomy patients should be assessed every two\u00a0hours and as required to see if suctioning is required. Sterile suction equipment is used each time tracheal suctioning is performed. Secretions can be aspirated using a suction catheter connected to a suction source.\r\n\r\nTracheal suctioning is indicated with noisy 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 82 outlines the steps for tracheal suctioning.\r\n<table style=\"border-color: #000000; height: 1547px; width: 100%;\" border=\"1px solid rgb(0, 0, 0)\" width=\"100%\"><caption><a id=\"checklist82\"><\/a>Checklist 82: Tracheal Suctioning<\/caption>\r\n<tbody>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 101.387%; text-align: center;\" colspan=\"4\">\r\n<h5 style=\"text-align: center;\"><span style=\"color: #000000;\">Disclaimer:\u00a0Always review and follow your hospital policy regarding this specific skill.<\/span><\/h5>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 101.387%;\" colspan=\"4\">\r\n<h5><span style=\"color: #333333;\">Safety considerations:\u00a0<\/span><\/h5>\r\n<ul>\r\n \t<li>Perform hand hygiene.<\/li>\r\n \t<li><span style=\"color: #333333;\">Check room for additional precautions.<\/span><\/li>\r\n \t<li><span style=\"color: #333333;\">Introduce yourself to patient.<\/span><\/li>\r\n \t<li><span style=\"color: #333333;\">Confirm patient ID using two patient identifiers (e.g., name and date of birth).<\/span><\/li>\r\n \t<li><span style=\"color: #333333;\">Explain process to patient;\u00a0offer analgesia, bathroom, etc.<\/span><\/li>\r\n \t<li><span style=\"color: #333333;\">Listen and attend to patient cues.<\/span><\/li>\r\n \t<li><span style=\"color: #333333;\">Ensure patient's privacy and dignity.<\/span><\/li>\r\n \t<li><span style=\"color: #333333;\">Assess ABCCS\/suction\/oxygen\/safety.<\/span><\/li>\r\n \t<li><span style=\"color: #333333;\">Apply principles of asepsis and safety.<\/span><\/li>\r\n \t<li><span style=\"color: #333333;\">Check vital signs.<\/span><\/li>\r\n \t<li><span style=\"color: #333333;\">Complete necessary focused assessments.<\/span><\/li>\r\n \t<li>Pre-hyperoxygenate patient if required and as per agency policy.<\/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: 49.9505%; 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: 51.4364%; 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: 49.9505%;\" colspan=\"2\">1. Connect one end of connecting tubing to suction machine and place other end in convenient location near patient.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">Preparing 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: 49.9505%;\" colspan=\"2\">2. Turn suction device on and set suction pressure to as low a level as possible that is still able to effectively clear secretions (between 80 and 120 mmHg in adults).<\/td>\r\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">\r\n\r\n[caption id=\"attachment_6320\" align=\"aligncenter\" width=\"150\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18081.jpg\"><img class=\"wp-image-6320 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18081-150x150.jpg\" alt=\"Set suction pressure between 80-120mmHg for adults\" width=\"150\" height=\"150\" \/><\/a> Set suction pressure between 80 and 120mmHg for adults[\/caption]\r\n\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: 49.9505%;\" colspan=\"2\">3. Occlude end of suction tubing to check suction pressure between 80 and 20 mmHg.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">This step ensures that equipment is functioning safely.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 49.9505%;\" colspan=\"2\">4. Using aseptic technique, open suction kit or catheter.\r\n\r\nDo not allow suction catheter to touch any non-sterile surfaces.\r\n\r\nKeep open suction package at bedside as a sterile surface on which to lay catheter between passes.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">This prepares catheter, maintains asepsis, and reduces transmission of microorganisms.\r\n\r\nThis provides sterile surface on which to lay catheter between passes.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 49.9505%;\" colspan=\"2\">5. Unwrap or open sterile container\u00a0and place on bedside table. Be careful not to touch inside of container. Fill with about 100 ml sterile normal saline solution or water.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">\r\n\r\n[caption id=\"attachment_6324\" align=\"aligncenter\" width=\"150\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18161.jpg\"><img class=\"wp-image-6324 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18161-150x150.jpg\" alt=\"Fill sterile container with about 100 mL sterile normal saline solution or water\" width=\"150\" height=\"150\" \/><\/a> Fill sterile container with about 100 ml sterile normal saline solution or water[\/caption]\r\n\r\nSaline or water is used to clean tubing after each suction pass.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 49.9505%;\" colspan=\"2\">6. Apply PPE as per agency policy (e.g., goggles and mask).<\/td>\r\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">This prevents transmission of microorganisms to health care provider.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 49.9505%;\" colspan=\"2\">7. Apply sterile glove to each hand or apply non-sterile glove to non-dominant hand and sterile glove to dominant hand.\r\n\r\n&nbsp;<\/td>\r\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">This reduces the transmission of microorganisms and maintains sterility of suction catheter.\r\n\r\n[caption id=\"attachment_6113\" align=\"aligncenter\" width=\"150\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_1565-001.jpg\"><img class=\"wp-image-6113 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/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\" 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]<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 49.9505%;\" colspan=\"2\">8. Pick up suction catheter with dominant hand without touching non-sterile surfaces. Pick up connecting tubing with non-dominant hand and secure catheter to tubing.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">This maintains catheter sterility and connects catheter to suction.\r\n\r\n[caption id=\"attachment_6323\" align=\"aligncenter\" width=\"150\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18151.jpg\"><img class=\"wp-image-6323 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18151-150x150.jpg\" alt=\"Use aseptic technique to attach suction catheter to suction tubing\" width=\"150\" height=\"150\" \/><\/a> Use aseptic technique to attach suction catheter to suction tubing[\/caption]<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 49.9505%;\" colspan=\"2\">9. Check that equipment is functioning properly by suctioning small amount of sterile normal saline or water\u00a0from\u00a0sterile container. Suction is initiated by covering the hole on the suctioning tube with your thumb.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">This ensures equipment is functioning and\u00a0lubricates internal catheter and tubing.\r\n\r\nToo high suction may increase tracheal damage.\r\n\r\n[caption id=\"attachment_6326\" align=\"aligncenter\" width=\"150\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18171.jpg\"><img class=\"wp-image-6326 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18171-150x150.jpg\" alt=\"Check that equipment is functioning properly by suctioning small amount of sterile normal saline or water from sterile container\" width=\"150\" height=\"150\" \/><\/a> Check that equipment is functioning properly by suctioning small amount of sterile normal saline or water from sterile container[\/caption]\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 class=\"wp-image-6334 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18261-150x150.jpg\" alt=\"Suction is initiated by covering the hole on the suctioning tube with your thumb\" width=\"150\" height=\"150\" \/><\/a> Suction is initiated by covering the hole on the suctioning tube with your thumb[\/caption]<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 49.9505%;\" colspan=\"2\">10. Insert suction catheter\u00a0into tracheostomy until resistance is felt, then pull back about 1\/2 inch. Do <em>not<\/em> apply suction when inserting suction catheter.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">Resistance is felt at the level of the patient's carina.\r\n\r\n[caption id=\"attachment_6329\" align=\"aligncenter\" width=\"150\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18211.jpg\"><img class=\"wp-image-6329 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18211-150x150.jpg\" alt=\"Insert suction catheter into tracheostomy until resistance is felt, then pull back about 1\/2 inch\" width=\"150\" height=\"150\" \/><\/a> Insert suction catheter into tracheostomy until resistance is felt, then pull back about 1\/2 inch[\/caption]<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 49.9505%;\" colspan=\"2\">11. Suction intermittently while simultaneously rotating and withdrawing catheter for a maximum of 10\u00a0seconds.\r\n\r\nImmediately reapply oxygen in between suctions to reoxygenate the patient.\r\n\r\n*Instill sterile normal saline into tracheostomy prior to suction <em>only<\/em> if prescribed to induce coughing.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">This reduces risk of tracheal damage and optimizes suction of secretions.\r\n\r\n[caption id=\"attachment_6331\" align=\"aligncenter\" width=\"150\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18231.jpg\"><img class=\"wp-image-6331 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18231-150x150.jpg\" alt=\"Suction intermittently while simultaneously rotating and withdrawing catheter for a maximum of 10 seconds\" width=\"150\" height=\"150\" \/><\/a> Suction intermittently while simultaneously rotating and withdrawing catheter for a maximum of 10 seconds[\/caption]\r\n\r\nSuctioning decreases patient's supply of oxygen. Oxgyen supports patient's return to adequate oxygenation.\r\n\r\n*Evidence-based practice indicates that normal saline is not effective in loosening or mobilizing secretions. Normal saline may occasionally be prescribed to induce coughing in patient.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 49.9505%;\" colspan=\"2\">12.\u00a0Clear secretions from suction catheter by suctioning sterile normal saline or water from sterile container.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">\r\n\r\n[caption id=\"attachment_6333\" align=\"aligncenter\" width=\"150\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18251.jpg\"><img class=\"wp-image-6333 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18251-150x150.jpg\" alt=\"Clear secretions from suction catheter by suctioning sterile normal saline or water from sterile container\" width=\"150\" height=\"150\" \/><\/a> Clear secretions from suction catheter by suctioning sterile normal saline or water from sterile container[\/caption]\r\n\r\nThis clears catheter of secretions and\u00a0avoids reintroducing pathogens into the airway.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 49.9505%;\" colspan=\"2\">13. 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.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">\r\n\r\n[caption id=\"attachment_6335\" align=\"aligncenter\" width=\"150\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18281.jpg\"><img class=\"wp-image-6335 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18281-150x150.jpg\" alt=\"Release suction to allow patient time to rest\" width=\"150\" height=\"150\" \/><\/a> Release suction to allow patient time to rest[\/caption]\r\n\r\nThis reduces the risk of tracheal damage.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 49.9505%;\" colspan=\"2\">14. Reassess respiratory status and O<sub>2<\/sub> saturation for improvements. Call for help if any abnormal signs and symptoms appear, or if respiratory status does not improve.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">This identifies positive response to suctioning procedure and provides objective measure of effectiveness.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 49.9505%;\" colspan=\"2\">15. When suctioning is complete, wrap catheter around gloved hand, pull glove over catheter, and disconnect from suction. Discard supplies in appropriate garbage bags. Turn off suction.\r\n\r\nEnsure all supplies are readily available at the bedside for next suction procedure.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">Wrapping catheter in glove prevents secretions from being spilled from the catheter.\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 class=\"wp-image-6342 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_17801-150x150.jpg\" alt=\"Wrap suction catheter in glove and dispose\" width=\"150\" height=\"150\" \/><\/a> Wrap suction catheter in glove and dispose[\/caption]\r\n\r\nSupplies 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: 49.9505%;\" colspan=\"2\">16. 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: 51.4364%;\" colspan=\"2\">This promotes patient safety.<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_2074.jpg\"><img class=\"alignnone size-medium wp-image-6378\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_2074-300x199.jpg\" alt=\"DSC_2074\" width=\"300\" height=\"199\" \/><\/a><\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 49.9505%;\" colspan=\"2\">17. Clean up and dispose of suction supplies according to\u00a0agency policy.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">This reduces\u00a0the transmission of microorganisms.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 49.9505%;\" colspan=\"2\">18. Perform hand hygiene.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">Hand hygiene reduces the transmission of microorganisms.\r\n\r\n[caption id=\"attachment_5972\" align=\"aligncenter\" width=\"150\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-247.jpg\"><img class=\"wp-image-5972 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-247-150x150.jpg\" alt=\"Hand hygiene with ABHR\" width=\"150\" height=\"150\" \/><\/a> Hand hygiene with ABHR[\/caption]<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 49.9505%;\" colspan=\"2\">19. Document procedure according to\u00a0agency policy.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">Documentation may include the suction procedure; patient reaction; amount, thickness, and colour 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.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 101.387%;\" colspan=\"4\">Data source: BCIT, 2015c;\u00a0Halm &amp; Krisko-Hagel, 2008; Perry et al., 2014; Vancouver Coastal Health, 2006<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<h5>Special considerations:<\/h5>\r\n<ul>\r\n \t<li>Suctioning can cause nosocomial infections, hypoxia, injury to the airway, and cardiac dysrhythmias. Follow agency policy on suction to prevent these complications.<\/li>\r\n \t<li>Hyperoxygenate patient according to\u00a0agency policy.<\/li>\r\n \t<li>If a sterile sputum sample is required, follow agency policy for specific directions related to type of equipment in the agency.<\/li>\r\n<\/ul>\r\n<h3><a id=\"video10.6\"><\/a>Video 10.6<\/h3>\r\n<div class=\"textbox shaded\" style=\"text-align: center;\">Watch a video <em><a href=\"https:\/\/barabus.tru.ca\/nursing\/Closed_Tracheostomy.html\">Tracheostomy Suctioning \u2013 Closed in line Method<\/a><\/em> by\u00a0<a href=\"\/clinicalskills\/back-matter\/appendix-3\/\">Ren\u00e9e Anderson &amp; Wendy McKenzie<\/a>, Thompson Rivers University.<\/div>\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 the following tasks:\r\n<ul>\r\n \t<li>Changing and replacing the inner cannula<\/li>\r\n \t<li>Changing the outer dressing<\/li>\r\n \t<li>Replacing the tracheostomy ties<\/li>\r\n<\/ul>\r\nIf possible, these\u00a0three 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.\u00a0However, there may be times when each task may be performed separately.\u00a0Ongoing assessment is essential when caring for a patient with a tracheostomy.\r\n\r\nAdditional care includes:\r\n<ul>\r\n \t<li>Doing more 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<\/li>\r\n \t<li>Keeping patient well hydrated (helps keep secretions thin)<\/li>\r\n \t<li>Encouraging deep breathing and coughing (as required)<\/li>\r\n \t<li>Reporting potential problems such as swelling, elevated temperature, change in sputum production, decreasing or increasing O<sub>2<\/sub> requirements<\/li>\r\n<\/ul>\r\n<h3>Replacing and Cleaning an Inner Cannula<\/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 83 describes how to clean and replace an inner tracheal cannula.\r\n<table style=\"border-color: #000000; height: 1162px;\" border=\"1px solid rgb(0, 0, 0)\" width=\"100%\"><caption><a id=\"checklist83\"><\/a>Checklist 83: Cleaning an Inner Tracheal Cannula<\/caption>\r\n<tbody>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 75px; text-align: center;\" colspan=\"4\">\r\n<h5 style=\"text-align: center;\"><span style=\"color: #000000;\">Disclaimer:\u00a0Always review and follow your hospital policy regarding this specific skill.<\/span><\/h5>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 75px;\" 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: 250px; 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: 250px; 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. Perform 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, hydrogen peroxide, non-sterile gloves, waterproof pad, and PPE if required.<\/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\">Hand hygiene reduces the transmission of microorganisms.\r\n\r\n[caption id=\"attachment_5972\" align=\"aligncenter\" width=\"150\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-247.jpg\"><img class=\"wp-image-5972 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-247-150x150.jpg\" alt=\"Hand hygiene with ABHR\" width=\"150\" height=\"150\" \/><\/a> Hand hygiene with ABHR[\/caption]\r\n\r\nTracheal patients always 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: 250px;\" colspan=\"2\">3. Apply gloves and PPE (if required), 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.<\/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 class=\"wp-image-6336 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18331-150x150.jpg\" alt=\"Set up sterile tray and add cleaning solution and supplies\" 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 class=\"wp-image-6328 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18201-150x150.jpg\" alt=\"Remove oxygen mask to clean dressing\" 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 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.<\/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 class=\"wp-image-6349 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18391-150x150.jpg\" alt=\"Remove inner cannula by stabilizing neck plate and gently grasping the outer white area\" width=\"150\" height=\"150\" \/><\/a> Remove inner cannula by stabilizing neck plate 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 in appropriate solution and, if necessary, use a sterile pipe cleaner to remove exudate from the inner cannula.<\/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 class=\"wp-image-6351 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18411-150x150.jpg\" alt=\"Soak in appropriate solution and, if necessary, use a sterile pipe cleaner to remove exudate from the inner cannula\" width=\"150\" height=\"150\" \/><\/a> Soak in appropriate solution and, if necessary, 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. Once clean, rinse off inner cannula and ensure all solution is removed. The inner portion may be dried off with a sterile pipe cleaner prior to reinsertion.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">Ensure all cleaning solution is removed to prevent tracheal damage from the hydrogen peroxide (if used).<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">9. 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\">10. Ensure the inner cannula has \u201cclicked\u201d on by aligning the two dots,\u00a0or ensure the clamp is secure.<\/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 class=\"wp-image-6380 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_2076-150x150.jpg\" alt=\"Ensure that inner cannula is 'clicked' securely into place\" 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\">11. Perform hand hygiene.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">Hand hygiene reduces the transmission of microorganisms.\r\n\r\n[caption id=\"attachment_5972\" align=\"aligncenter\" width=\"150\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-247.jpg\"><img class=\"wp-image-5972 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-247-150x150.jpg\" alt=\"Hand hygiene with ABHR\" width=\"150\" height=\"150\" \/><\/a> Hand hygiene with ABHR[\/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 source: ATI, 2015b; BCIT, 2015c; Morris, Whitmer &amp; McIntosh, 2013; Perry et al., 2014; Vancouver Coastal Health, 2012b<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<h3><a id=\"video10.7\"><\/a>Video 10.7<\/h3>\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>\u00a0by\u00a0<a href=\"\/clinicalskills\/back-matter\/appendix-3\/\">Ren\u00e9e Anderson &amp; Wendy McKenzie<\/a>, Thompson Rivers University.<\/div>\r\n<h2>Cleaning Stoma and Changing the Sterile Dressing<\/h2>\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 84 provides a safe method to clean the tracheal stoma and replace the sterile dressing.\r\n<table style=\"border-color: #000000; height: 1547px; width: 100%;\" border=\"1px solid rgb(0, 0, 0)\" width=\"100%\"><caption><a id=\"checklist84\"><\/a>Checklist 84: Cleaning Stoma and Changing a Sterile Dressing<\/caption>\r\n<tbody>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 101.337%; text-align: center;\" colspan=\"4\">\r\n<h5 style=\"text-align: center;\"><span style=\"color: #000000;\">Disclaimer:\u00a0Always review and follow your hospital policy regarding this specific skill.<\/span><\/h5>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 101.337%;\" 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: 49.9257%; 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: 51.4116%; 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: 49.9257%;\" colspan=\"2\">1. Perform hand hygiene, verify physician orders for tracheostomy care, and collect supplies.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 51.4116%;\" colspan=\"2\">Supplies include sterile dressing change, pre-cut 4\u00a0x 4 gauze, normal saline, cotton-tip applicators, non-sterile gloves, and garbage bag.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 49.9257%;\" 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: 51.4116%;\" colspan=\"2\">This reduces the transmission of microorganisms.\r\n\r\n[caption id=\"attachment_5972\" align=\"aligncenter\" width=\"150\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-247.jpg\"><img class=\"wp-image-5972 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-247-150x150.jpg\" alt=\"Hand hygiene with ABHR\" width=\"150\" height=\"150\" \/><\/a> Hand hygiene with ABHR[\/caption]\r\n\r\nTracheal patients always 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: 49.9257%;\" colspan=\"2\">3. Apply non-sterile gloves and cover chest with waterproof pad.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 51.4116%;\" 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: 49.9257%;\" colspan=\"2\">4. 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: 51.4116%;\" colspan=\"2\">Organization ensures the process of cleaning is efficient and fast.\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 class=\"wp-image-6336 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18331-150x150.jpg\" alt=\"Set up sterile tray and add cleaning solution and supplies\" 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: 49.9257%;\" 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: 51.4116%;\" 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 class=\"wp-image-6328 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18201-150x150.jpg\" alt=\"Remove oxygen mask to clean dressing\" 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: 49.9257%;\" 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: 51.4116%;\" 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 class=\"wp-image-6337 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18341-150x150.jpg\" alt=\"Use forceps to remove the soiled dressing\" 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: 49.9257%;\" 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: 51.4116%;\" 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 class=\"wp-image-6338 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18351-150x150.jpg\" alt=\"Assess stoma site\" 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: 49.9257%;\" colspan=\"2\">8. Clean the stoma site with a gauze or cotton-tip applicator soaked in normal saline. Be careful not to disturb the tracheostomy tube. Dry surrounding area if required.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 51.4116%;\" 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[caption id=\"attachment_6346\" align=\"aligncenter\" width=\"150\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18371.jpg\"><img class=\"wp-image-6346 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18371-150x150.jpg\" alt=\"Clean the stoma site with a gauze or cotton-tip applicator soaked in normal saline\" width=\"150\" height=\"150\" \/><\/a> Clean the stoma site with a gauze or cotton-tip applicator soaked in normal saline[\/caption]<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 49.9257%;\" colspan=\"2\">9. Assess the site to determine if barrier film is required.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 51.4116%;\" colspan=\"2\">Follow\u00a0agency policy.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 49.9257%;\" 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: 51.4116%;\" colspan=\"2\">Avoid cutting gauze for tracheostomy care. Use non-fraying material. The small fibres from the cut gauze may become loose and accidentally travel into the inner cannula. Always use manufactured pre-cut gauze.\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 class=\"wp-image-6337 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18341-150x150.jpg\" alt=\"Apply new manufactured pre-cut tracheostomy dressing to tube using sterile forceps\" 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: 101.337%;\" colspan=\"4\">Data source: BCIT 2015c; Morris et al., 2013; Perry et al., 2014; Vancouver Coastal Health, 2012<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<h3><a id=\"video10.8\"><\/a>Video 10.8<\/h3>\r\n<div class=\"textbox shaded\" style=\"text-align: center;\">Watch this video <a href=\"https:\/\/barabus.tru.ca\/nursing\/changing_tracheostomy_site_dressing.html\"><em>Changing a Trachestomy Site Dressing<\/em><\/a> by\u00a0<a href=\"\/clinicalskills\/back-matter\/appendix-3\/\">Ren\u00e9e Anderson &amp; Wendy McKenzie<\/a>, Thompson Rivers University.<\/div>\r\n<h2>Replacing Tracheostomy Ties (Velcro or Twill Tape)<\/h2>\r\nTracheal 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. Ensure twill ties are knotted using a square knot.\r\n<div class=\"textbox shaded\" style=\"text-align: center;\"><a href=\"https:\/\/www.youtube.com\/watch?v=4FgO0s7i-ec\">Watch this <em>Securing an Endotracheal Tube with Twill Tape and a Rolling Hitch<\/em> video<\/a> to learn how to tie a square knot.<\/div>\r\nChecklist 85 lists the steps for replacing tracheostomy ties.\r\n<table style=\"border-color: #000000; height: 1547px; width: 100%;\" border=\"1px solid rgb(0, 0, 0)\" width=\"100%\"><caption><a id=\"checklist85\"><\/a>Checklist 85: Replacing Tracheostomy Ties (Velcro or Twill Tape)<\/caption>\r\n<tbody>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 101.436%; text-align: center;\" colspan=\"4\">\r\n<h5 style=\"text-align: center;\"><span style=\"color: #000000;\">Disclaimer:\u00a0Always review and follow your hospital policy regarding this specific skill.<\/span><\/h5>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 101.436%;\" 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: 49.9752%; 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: 51.4611%; 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: 49.9752%;\" colspan=\"2\">1. Perform hand hygiene, verify physician orders for tracheostomy care, and collect supplies.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 51.4611%;\" colspan=\"2\">Use twill ties or Velcro ties.\r\n\r\n[caption id=\"attachment_6220\" align=\"aligncenter\" width=\"150\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_1093.jpg\"><img class=\"wp-image-6220 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_1093-150x150.jpg\" alt=\"Wash hands\" width=\"150\" height=\"150\" \/><\/a> Wash hands[\/caption]<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 49.9752%;\" 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: 51.4611%;\" colspan=\"2\">If tracheostomy is less than\u00a024 hours old, or patient is confused, agitated, or unpredictable, always have an additional helper at the bedside to prevent accidental dislodgement.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 49.9752%;\" colspan=\"2\">3. 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: 51.4611%;\" colspan=\"2\">This reduces the transmission of microorganisms.\r\n\r\n[caption id=\"attachment_5972\" align=\"aligncenter\" width=\"150\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-247.jpg\"><img class=\"wp-image-5972 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-247-150x150.jpg\" alt=\"Hand hygiene with ABHR\" width=\"150\" height=\"150\" \/><\/a> Hand hygiene with ABHR[\/caption]\r\n\r\nTracheal patients always 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: 49.9752%;\" colspan=\"2\">4. Apply non-sterile gloves.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 51.4611%;\" colspan=\"2\">This reduces the transmission of microorganisms.\r\n\r\n[caption id=\"attachment_5559\" align=\"aligncenter\" width=\"150\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_1511.jpg\"><img class=\"wp-image-5559 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_1511-150x150.jpg\" alt=\"Apply non-sterile gloves\" width=\"150\" height=\"150\" \/><\/a> Apply non-sterile gloves[\/caption]<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 49.9752%;\" 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. This avoids potential dislodgement of the tube as this procedure can make the patient cough.<\/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 one little finger between the collar and the patient. 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.<\/li>\r\n<\/ul>\r\nTo secure the tracheostomy tube with ribbon\/twill tape:\r\n<ul>\r\n \t<li>Cut two pieces of cotton tape, each approximately 50 cm in length (depending on neck size).<\/li>\r\n \t<li>Divide the tape into thirds and fold the first third over the remaining two-thirds of the ribbon.<\/li>\r\n \t<li>Thread the folded edge through one flange hole, forming a loop.<\/li>\r\n \t<li>Thread the loose tape ends through this loop and pull until tight and secure.<\/li>\r\n \t<li>Repeat the process for the other side, securing the tapes with square knots on each side of the neck.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000; width: 51.4611%;\" colspan=\"2\">Tracheostomy ties are used to promote patient comfort and keep the tracheostomy secured and in situ.\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 class=\"wp-image-6353 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18471-150x150.jpg\" alt=\"Velcro ties\" width=\"150\" height=\"150\" \/><\/a> Velcro ties[\/caption]\r\n\r\n[caption id=\"attachment_6352\" align=\"aligncenter\" width=\"150\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18461.jpg\"><img class=\"wp-image-6352 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18461-150x150.jpg\" alt=\"Cotton twill ties\" width=\"150\" height=\"150\" \/><\/a> Cotton twill ties[\/caption]<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 49.9752%;\" colspan=\"2\">6. Perform hand hygiene.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 51.4611%;\" colspan=\"2\">Hand hygiene reduces the transmission of microorganisms.\r\n\r\n[caption id=\"attachment_5972\" align=\"aligncenter\" width=\"150\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-247.jpg\"><img class=\"wp-image-5972 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-247-150x150.jpg\" alt=\"Hand hygiene with ABHR\" width=\"150\" height=\"150\" \/><\/a> Hand hygiene with ABHR[\/caption]<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 101.436%;\" colspan=\"4\">Data source: BCIT, 2015c; Morris et al., 2013;\u00a0Perry et al., 2014<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<h3><a id=\"video10.9\"><\/a>Video 10.9<\/h3>\r\n<div class=\"textbox shaded\" style=\"text-align: center;\">Watch a video <a href=\"https:\/\/barabus.tru.ca\/nursing\/changing_traceostomy_ties.html\"><em>Changing Tracheostomy Ties<\/em><\/a>\u00a0by\u00a0<a href=\"\/clinicalskills\/back-matter\/appendix-3\/\">Ren\u00e9e Anderson &amp; Wendy McKenzie<\/a>, Thompson Rivers University.<\/div>\r\n<div class=\"textbox textbox--exercises\"><header class=\"textbox__header\">\r\n<p class=\"textbox__title\">Critical Thinking Exercises<\/p>\r\n\r\n<\/header>\r\n<div class=\"textbox__content\">\r\n<ol>\r\n \t<li>When suctioning your patient, 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<\/ol>\r\n<\/div>\r\n<\/div>","rendered":"<p>A tracheostoma is an artificial opening made in the trachea just below the larynx. A tracheostomy tube is a tube that is inserted through the opening, or stoma, to create\u00a0an artificial airway. Patients who need long-term airway support (long-term patients who are intubated) or who have a need to bypass the upper airway may receive a tracheostomy. A tracheostomy (see Figure 10.1) can be very traumatic for a patient, and many find it difficult to adjust to\u00a0having one.<\/p>\n<p>The tracheostomy may be permanent or temporary. It\u00a0is created surgically through the trachea (upper airway remains intact), larynx (upper airway is not patent), or cricothyroid (usually for temporary emergency access to airway). Tracheostomy tubes are inserted for airway maintenance, ventilation, removal of secretions, or as an alternate airway (e.g., following laryngectomy).<\/p>\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\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/08\/DSC_0683-300x199.jpg\" alt=\"DSC_0683\" width=\"300\" height=\"199\" srcset=\"https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/08\/DSC_0683-300x199.jpg 300w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/08\/DSC_0683-1024x678.jpg 1024w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/08\/DSC_0683-65x43.jpg 65w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/08\/DSC_0683-225x149.jpg 225w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/08\/DSC_0683-350x232.jpg 350w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a><figcaption id=\"caption-attachment-5052\" class=\"wp-caption-text\">Figure 10.1 Cross-section view of a tracheostomy (on a model) inserted in the trachea anterior to the esophagus<\/figcaption><\/figure>\n<h2>Tracheostomy Tubes<\/h2>\n<p>Tracheostomy tubes can be soft plastic, hard plastic, or, at times, metal. All tracheostomy devices are made up of an outer cannula, inner cannula, and an <strong>obturator<\/strong> used to insert the tube (see Figure 10.2).\u00a0They come in different sizes and may have a cuff. A cuff 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 de-cannulation of the trachea. Sterile gauze and cleaning supplies are used daily to clean the trachea stoma and prevent infection to the site.<\/p>\n<figure id=\"attachment_5024\" aria-describedby=\"caption-attachment-5024\" style=\"width: 286px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/08\/DSC_0664.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-5024\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/08\/DSC_0664-300x199.jpg\" alt=\"Figure 10.5.2 Left to right: Obturator, cuffed tracheostomy tube, non-cuffed tracheostomy tube, tracheal dilators\" width=\"286\" height=\"190\" srcset=\"https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/08\/DSC_0664-300x199.jpg 300w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/08\/DSC_0664-1024x678.jpg 1024w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/08\/DSC_0664-65x43.jpg 65w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/08\/DSC_0664-225x149.jpg 225w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/08\/DSC_0664-350x232.jpg 350w\" sizes=\"auto, (max-width: 286px) 100vw, 286px\" \/><\/a><figcaption id=\"caption-attachment-5024\" class=\"wp-caption-text\">Figure 10.2 Left to right: obturator, cuffed tracheostomy tube, non-cuffed tracheostomy tube, tracheal dilators<\/figcaption><\/figure>\n<h2>Humidification<\/h2>\n<p>When a patient\u00a0has a tracheostomy, air is no longer filtered and humidified as it is when passing through the upper airways. Most patients will have humidification and oxygen support. The following is a list of the special considerations of patients with a tracheostomy tube (BCIT, 2015c).<\/p>\n<ul>\n<li>Patients need to lie at a 30-degree, or greater, angle to facilitate breathing and lung expansion.<\/li>\n<li>All tracheostomy patients 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. A tracheostomy patient must be assessed every two hours to determine if suctioning is required.<\/li>\n<li>Tracheostomy patients are often not permitted anything to drink or eat. Consult with the RN in charge.<\/li>\n<li>A patient with a tracheostomy tube cannot speak; because the vocal cords are above the level of the tracheostomy tube, air cannot pass over the vocal cords. Speech is not possible without a speaking device.<\/li>\n<li>Tracheostomy patients always have the tracheostomy tied securely around the neck using ties, according to agency policy.<\/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 decrease air entry and cause respiratory distress, the patient should be suctioned immediately.<\/li>\n<\/ul>\n<h2>Potential Complications<\/h2>\n<p>Early potential complications may include hemorrhage, pneumothorax, subcutaneous emphysema, cuff leak, tube dislodgement, and respiratory\/cardiovascular arrest. Late potential complications may include airway obstruction, fistulae, infection, aspiration, and tracheal damage\/erosion.<\/p>\n<p>Emergency supplies at the bedside must include the following:<\/p>\n<p>1. Suction equipment<\/p>\n<p>2. Oxygen equipment with humidification<\/p>\n<p>3. An emergency bag containing (see Figure 10.3):<\/p>\n<ul>\n<li>\u00a0Two\u00a0replacement tracheostomy tubes (one of the same size, and one a smaller size than the current tube)<\/li>\n<li>\u00a0Obturator and spare inner cannula<\/li>\n<li>\u00a010 ml syringe<\/li>\n<li>\u00a0Tracheal tube exchanger<\/li>\n<li>\u00a0Tracheal dilators<\/li>\n<li>\u00a0Sterile gloves<\/li>\n<li>\u00a0Water-soluble lubricant<\/li>\n<li>If the open stoma is below the sternal notch, an endotracheal tube as per the ENT physician<\/li>\n<\/ul>\n<figure id=\"attachment_6322\" aria-describedby=\"caption-attachment-6322\" style=\"width: 300px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18131.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-6322 size-medium\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18131-300x199.jpg\" alt=\"Equipment for emergency bag for tracheostomy patients.\" width=\"300\" height=\"199\" srcset=\"https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18131-300x199.jpg 300w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18131-1024x678.jpg 1024w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18131-65x43.jpg 65w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18131-225x149.jpg 225w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18131-350x232.jpg 350w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a><figcaption id=\"caption-attachment-6322\" class=\"wp-caption-text\">Figure 10.3 Equipment for emergency bag for tracheostomy patients. Clockwise from top left: sterile gloves, spare tracheostomy tube, scissors, lubricant, cotton-tip applicators, ties, 10ml syringe, tracheal dilators, inner cannula, obturator, sterile gauze<\/figcaption><\/figure>\n<p>The emergency bag must accompany patients when they are transported off the unit. Table 10.2 outlines methods to prevent possible complications that may arise from tracheostomies, and how to intervene if they do occur.<\/p>\n<table style=\"height: 1668px; width: 100%;\">\n<caption>Table 10.2 Prevention and Interventions for Complications<\/caption>\n<tbody>\n<tr>\n<td style=\"border: 1px solid #000000; text-align: center;\">\u00a0<strong>Complication<\/strong><\/td>\n<td style=\"border: 1px solid #000000; text-align: center;\"><strong>Prevention<\/strong><\/td>\n<td style=\"border: 1px solid #000000; text-align: center;\"><strong>Interventions<\/strong><\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;\">Hemorrhage<\/td>\n<td style=\"border: 1px solid #000000;\">\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;\">\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;\">Stomal\/pulmonary infection<\/td>\n<td style=\"border: 1px solid #000000;\">\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.<\/li>\n<li>Use clean technique for tracheostomy care.<\/li>\n<li>Use humidified oxygen or air.<\/li>\n<li>Follow respiratory assessment as per agency policy.<\/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>Instill small amounts of normal saline when suctioning to help loosen secretions as needed.<\/li>\n<li>Suction as necessary.<\/li>\n<li>Maintain hydration.<\/li>\n<li>Take vital signs every four hours.<\/li>\n<\/ul>\n<\/td>\n<td style=\"border: 1px solid #000000;\">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<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;\">Tube occlusion<\/td>\n<td style=\"border: 1px solid #000000;\">\n<ul>\n<li>Keep inner cannula of dual tracheostomy tube in situ at all times.<\/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.<\/li>\n<li>Maintain hydration (secretions should be loose and thin).<\/li>\n<li>Do DB&amp;C\u00a0exercises every 2 to 4 hours and as needed.<\/li>\n<li>Suction and instill normal saline to loosen secretions as needed.<\/li>\n<\/ul>\n<\/td>\n<td style=\"border: 1px solid #000000;\">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 and instillation of normal saline to clear cannula.<\/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;\">Aspiration<\/td>\n<td style=\"border: 1px solid #000000;\">\n<ul>\n<li>All tracheostomy patients 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;\">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;\">Accidental decannulation<\/td>\n<td style=\"border: 1px solid #000000;\">\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;\">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<p style=\"text-align: center;\">\n<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;\" colspan=\"3\"><strong>Note:<\/strong> Do not hyperextend neck if patient has a known or suspected neck injury.<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;\" colspan=\"3\">Data source: BCIT, 2015c; Vancouver Coastal Health, 2012a<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h3><a id=\"video10.5\"><\/a>Video 10.5<\/h3>\n<div class=\"textbox shaded\" style=\"text-align: center;\">Watch the video <a href=\"https:\/\/barabus.tru.ca\/nursing\/tracheostomy_tubes.html\"><em>Trach Tubes \u2013 inflated versus deflated cuffs<\/em><\/a> by\u00a0<a href=\"\/clinicalskills\/back-matter\/appendix-3\/\">Ren\u00e9e Anderson &amp; Wendy McKenzie<\/a>, Thompson Rivers University.<\/div>\n<h2>Tracheal Suctioning<\/h2>\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. Tracheostomy patients should be assessed every two\u00a0hours and as required to see if suctioning is required. Sterile suction equipment is used each time tracheal suctioning is performed. Secretions can be aspirated using a suction catheter connected to a suction source.<\/p>\n<p>Tracheal suctioning is indicated with noisy 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 82 outlines the steps for tracheal suctioning.<\/p>\n<table style=\"border-color: #000000; height: 1547px; width: 100%; width: 100%;\">\n<caption><a id=\"checklist82\"><\/a>Checklist 82: Tracheal Suctioning<\/caption>\n<tbody>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 101.387%; text-align: center;\" colspan=\"4\">\n<h5 style=\"text-align: center;\"><span style=\"color: #000000;\">Disclaimer:\u00a0Always review and follow your hospital policy regarding this specific skill.<\/span><\/h5>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 101.387%;\" colspan=\"4\">\n<h5><span style=\"color: #333333;\">Safety considerations:\u00a0<\/span><\/h5>\n<ul>\n<li>Perform hand hygiene.<\/li>\n<li><span style=\"color: #333333;\">Check room for additional precautions.<\/span><\/li>\n<li><span style=\"color: #333333;\">Introduce yourself to patient.<\/span><\/li>\n<li><span style=\"color: #333333;\">Confirm patient ID using two patient identifiers (e.g., name and date of birth).<\/span><\/li>\n<li><span style=\"color: #333333;\">Explain process to patient;\u00a0offer analgesia, bathroom, etc.<\/span><\/li>\n<li><span style=\"color: #333333;\">Listen and attend to patient cues.<\/span><\/li>\n<li><span style=\"color: #333333;\">Ensure patient&#8217;s privacy and dignity.<\/span><\/li>\n<li><span style=\"color: #333333;\">Assess ABCCS\/suction\/oxygen\/safety.<\/span><\/li>\n<li><span style=\"color: #333333;\">Apply principles of asepsis and safety.<\/span><\/li>\n<li><span style=\"color: #333333;\">Check vital signs.<\/span><\/li>\n<li><span style=\"color: #333333;\">Complete necessary focused assessments.<\/span><\/li>\n<li>Pre-hyperoxygenate patient if required and as per agency policy.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 49.9505%; text-align: center;\" colspan=\"2\">\n<h4 style=\"text-align: center;\">Steps<\/h4>\n<\/td>\n<td style=\"border: 1px solid #000000; width: 51.4364%; 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: 49.9505%;\" colspan=\"2\">1. Connect one end of connecting tubing to suction machine and place other end in convenient location near patient.<\/td>\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">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: 49.9505%;\" colspan=\"2\">2. Turn suction device on and set suction pressure to as low a level as possible that is still able to effectively clear secretions (between 80 and 120 mmHg in adults).<\/td>\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">\n<figure id=\"attachment_6320\" aria-describedby=\"caption-attachment-6320\" style=\"width: 150px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18081.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-6320 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18081-150x150.jpg\" alt=\"Set suction pressure between 80-120mmHg for adults\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-6320\" class=\"wp-caption-text\">Set suction pressure between 80 and 120mmHg for adults<\/figcaption><\/figure>\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: 49.9505%;\" colspan=\"2\">3. Occlude end of suction tubing to check suction pressure between 80 and 20 mmHg.<\/td>\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">This step ensures that equipment is functioning safely.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 49.9505%;\" colspan=\"2\">4. Using aseptic technique, open suction kit or catheter.<\/p>\n<p>Do not allow suction catheter to touch any non-sterile surfaces.<\/p>\n<p>Keep open suction package at bedside as a sterile surface on which to lay catheter between passes.<\/td>\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">This prepares catheter, maintains asepsis, and reduces transmission of microorganisms.<\/p>\n<p>This provides sterile surface on which to lay catheter between passes.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 49.9505%;\" colspan=\"2\">5. Unwrap or open sterile container\u00a0and place on bedside table. Be careful not to touch inside of container. Fill with about 100 ml sterile normal saline solution or water.<\/td>\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">\n<figure id=\"attachment_6324\" aria-describedby=\"caption-attachment-6324\" style=\"width: 150px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18161.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-6324 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18161-150x150.jpg\" alt=\"Fill sterile container with about 100 mL sterile normal saline solution or water\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-6324\" class=\"wp-caption-text\">Fill sterile container with about 100 ml sterile normal saline solution or water<\/figcaption><\/figure>\n<p>Saline or water is used to clean tubing after each suction pass.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 49.9505%;\" colspan=\"2\">6. Apply PPE as per agency policy (e.g., goggles and mask).<\/td>\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">This prevents transmission of microorganisms to health care provider.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 49.9505%;\" colspan=\"2\">7. Apply sterile glove to each hand or apply non-sterile glove to non-dominant hand and sterile glove to dominant hand.<\/p>\n<p>&nbsp;<\/td>\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">This reduces the transmission of microorganisms and maintains sterility of suction catheter.<\/p>\n<figure id=\"attachment_6113\" aria-describedby=\"caption-attachment-6113\" 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\" class=\"wp-image-6113 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/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\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-6113\" 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<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 49.9505%;\" colspan=\"2\">8. Pick up suction catheter with dominant hand without touching non-sterile surfaces. Pick up connecting tubing with non-dominant hand and secure catheter to tubing.<\/td>\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">This maintains catheter sterility and connects catheter to suction.<\/p>\n<figure id=\"attachment_6323\" aria-describedby=\"caption-attachment-6323\" style=\"width: 150px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18151.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-6323 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18151-150x150.jpg\" alt=\"Use aseptic technique to attach suction catheter to suction tubing\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-6323\" class=\"wp-caption-text\">Use aseptic technique to attach suction catheter to suction tubing<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 49.9505%;\" colspan=\"2\">9. Check that equipment is functioning properly by suctioning small amount of sterile normal saline or water\u00a0from\u00a0sterile container. Suction is initiated by covering the hole on the suctioning tube with your thumb.<\/td>\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">This ensures equipment is functioning and\u00a0lubricates internal catheter and tubing.<\/p>\n<p>Too high suction may increase tracheal damage.<\/p>\n<figure id=\"attachment_6326\" aria-describedby=\"caption-attachment-6326\" style=\"width: 150px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18171.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-6326 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18171-150x150.jpg\" alt=\"Check that equipment is functioning properly by suctioning small amount of sterile normal saline or water from sterile container\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-6326\" class=\"wp-caption-text\">Check that equipment is functioning properly by suctioning small amount of sterile normal saline or water from sterile container<\/figcaption><\/figure>\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\" class=\"wp-image-6334 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18261-150x150.jpg\" alt=\"Suction is initiated by covering the hole on the suctioning tube with your thumb\" 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<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 49.9505%;\" colspan=\"2\">10. Insert suction catheter\u00a0into tracheostomy until resistance is felt, then pull back about 1\/2 inch. Do <em>not<\/em> apply suction when inserting suction catheter.<\/td>\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">Resistance is felt at the level of the patient&#8217;s carina.<\/p>\n<figure id=\"attachment_6329\" aria-describedby=\"caption-attachment-6329\" 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\" class=\"wp-image-6329 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18211-150x150.jpg\" alt=\"Insert suction catheter into tracheostomy until resistance is felt, then pull back about 1\/2 inch\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-6329\" class=\"wp-caption-text\">Insert suction catheter into tracheostomy until resistance is felt, then pull back about 1\/2 inch<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 49.9505%;\" colspan=\"2\">11. Suction intermittently while simultaneously rotating and withdrawing catheter for a maximum of 10\u00a0seconds.<\/p>\n<p>Immediately reapply oxygen in between suctions to reoxygenate the patient.<\/p>\n<p>*Instill sterile normal saline into tracheostomy prior to suction <em>only<\/em> if prescribed to induce coughing.<\/td>\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">This reduces risk of tracheal damage and optimizes suction of secretions.<\/p>\n<figure id=\"attachment_6331\" aria-describedby=\"caption-attachment-6331\" style=\"width: 150px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18231.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-6331 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18231-150x150.jpg\" alt=\"Suction intermittently while simultaneously rotating and withdrawing catheter for a maximum of 10 seconds\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-6331\" class=\"wp-caption-text\">Suction intermittently while simultaneously rotating and withdrawing catheter for a maximum of 10 seconds<\/figcaption><\/figure>\n<p>Suctioning decreases patient&#8217;s supply of oxygen. Oxgyen supports patient&#8217;s return to adequate oxygenation.<\/p>\n<p>*Evidence-based practice indicates that normal saline is not effective in loosening or mobilizing secretions. Normal saline may occasionally be prescribed to induce coughing in patient.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 49.9505%;\" colspan=\"2\">12.\u00a0Clear secretions from suction catheter by suctioning sterile normal saline or water from sterile container.<\/td>\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">\n<figure id=\"attachment_6333\" aria-describedby=\"caption-attachment-6333\" 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\" class=\"wp-image-6333 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18251-150x150.jpg\" alt=\"Clear secretions from suction catheter by suctioning sterile normal saline or water from sterile container\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-6333\" class=\"wp-caption-text\">Clear secretions from suction catheter by suctioning sterile normal saline or water from sterile container<\/figcaption><\/figure>\n<p>This clears catheter of secretions and\u00a0avoids reintroducing pathogens into the airway.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 49.9505%;\" colspan=\"2\">13. 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.<\/td>\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">\n<figure id=\"attachment_6335\" aria-describedby=\"caption-attachment-6335\" style=\"width: 150px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18281.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-6335 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18281-150x150.jpg\" alt=\"Release suction to allow patient time to rest\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-6335\" class=\"wp-caption-text\">Release suction to allow patient time to rest<\/figcaption><\/figure>\n<p>This reduces the risk of tracheal damage.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 49.9505%;\" colspan=\"2\">14. Reassess respiratory status and O<sub>2<\/sub> saturation for improvements. Call for help if any abnormal signs and symptoms appear, or if respiratory status does not improve.<\/td>\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">This identifies positive response to suctioning procedure and provides objective measure of effectiveness.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 49.9505%;\" colspan=\"2\">15. When suctioning is complete, wrap catheter around gloved hand, pull glove over catheter, and disconnect from suction. Discard supplies in appropriate garbage bags. Turn off suction.<\/p>\n<p>Ensure all supplies are readily available at the bedside for next suction procedure.<\/td>\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">Wrapping catheter in glove prevents secretions from being spilled from the catheter.<\/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\" class=\"wp-image-6342 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_17801-150x150.jpg\" alt=\"Wrap suction catheter in glove and dispose\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-6342\" class=\"wp-caption-text\">Wrap suction catheter in glove and dispose<\/figcaption><\/figure>\n<p>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: 49.9505%;\" colspan=\"2\">16. 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: 51.4364%;\" colspan=\"2\">This promotes patient safety.<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_2074.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-medium wp-image-6378\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_2074-300x199.jpg\" alt=\"DSC_2074\" width=\"300\" height=\"199\" srcset=\"https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_2074-300x199.jpg 300w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_2074-1024x678.jpg 1024w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_2074-65x43.jpg 65w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_2074-225x149.jpg 225w, https:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_2074-350x232.jpg 350w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a><\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 49.9505%;\" colspan=\"2\">17. Clean up and dispose of suction supplies according to\u00a0agency policy.<\/td>\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">This reduces\u00a0the transmission of microorganisms.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 49.9505%;\" colspan=\"2\">18. Perform hand hygiene.<\/td>\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">Hand hygiene reduces the transmission of microorganisms.<\/p>\n<figure id=\"attachment_5972\" aria-describedby=\"caption-attachment-5972\" style=\"width: 150px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-247.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-5972 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-247-150x150.jpg\" alt=\"Hand hygiene with ABHR\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-5972\" class=\"wp-caption-text\">Hand hygiene with ABHR<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 49.9505%;\" colspan=\"2\">19. Document procedure according to\u00a0agency policy.<\/td>\n<td style=\"border: 1px solid #000000; width: 51.4364%;\" colspan=\"2\">Documentation may include the suction procedure; patient reaction; amount, thickness, and colour 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.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 101.387%;\" colspan=\"4\">Data source: BCIT, 2015c;\u00a0Halm &amp; Krisko-Hagel, 2008; Perry et al., 2014; Vancouver Coastal Health, 2006<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h5>Special considerations:<\/h5>\n<ul>\n<li>Suctioning can cause nosocomial infections, hypoxia, injury to the airway, and cardiac dysrhythmias. Follow agency policy on suction to prevent these complications.<\/li>\n<li>Hyperoxygenate patient according to\u00a0agency policy.<\/li>\n<li>If a sterile sputum sample is required, follow agency policy for specific directions related to type of equipment in the agency.<\/li>\n<\/ul>\n<h3><a id=\"video10.6\"><\/a>Video 10.6<\/h3>\n<div class=\"textbox shaded\" style=\"text-align: center;\">Watch a video <em><a href=\"https:\/\/barabus.tru.ca\/nursing\/Closed_Tracheostomy.html\">Tracheostomy Suctioning \u2013 Closed in line Method<\/a><\/em> by\u00a0<a href=\"\/clinicalskills\/back-matter\/appendix-3\/\">Ren\u00e9e Anderson &amp; Wendy McKenzie<\/a>, Thompson Rivers University.<\/div>\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 the following tasks:<\/p>\n<ul>\n<li>Changing and replacing the inner cannula<\/li>\n<li>Changing the outer dressing<\/li>\n<li>Replacing the tracheostomy ties<\/li>\n<\/ul>\n<p>If possible, these\u00a0three 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.\u00a0However, there may be times when each task may be performed separately.\u00a0Ongoing assessment is essential when caring for a patient with a tracheostomy.<\/p>\n<p>Additional care includes:<\/p>\n<ul>\n<li>Doing more 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<\/li>\n<li>Keeping patient well hydrated (helps keep secretions thin)<\/li>\n<li>Encouraging deep breathing and coughing (as required)<\/li>\n<li>Reporting potential problems such as swelling, elevated temperature, change in sputum production, decreasing or increasing O<sub>2<\/sub> requirements<\/li>\n<\/ul>\n<h3>Replacing and Cleaning an Inner Cannula<\/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 83 describes how to clean and replace an inner tracheal cannula.<\/p>\n<table style=\"border-color: #000000; height: 1162px; width: 100%;\">\n<caption><a id=\"checklist83\"><\/a>Checklist 83: Cleaning an Inner Tracheal Cannula<\/caption>\n<tbody>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 75px; text-align: center;\" colspan=\"4\">\n<h5 style=\"text-align: center;\"><span style=\"color: #000000;\">Disclaimer:\u00a0Always review and follow your hospital policy regarding this specific skill.<\/span><\/h5>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 75px;\" 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: 250px; text-align: center;\" colspan=\"2\">\n<h4 style=\"text-align: center;\">Steps<\/h4>\n<\/td>\n<td style=\"border: 1px solid #000000; width: 250px; 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. Perform 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, hydrogen peroxide, non-sterile gloves, waterproof pad, and PPE if required.<\/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\">Hand hygiene reduces the transmission of microorganisms.<\/p>\n<figure id=\"attachment_5972\" aria-describedby=\"caption-attachment-5972\" style=\"width: 150px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-247.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-5972 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-247-150x150.jpg\" alt=\"Hand hygiene with ABHR\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-5972\" class=\"wp-caption-text\">Hand hygiene with ABHR<\/figcaption><\/figure>\n<p>Tracheal patients always 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: 250px;\" colspan=\"2\">3. Apply gloves and PPE (if required), 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.<\/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\" class=\"wp-image-6336 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18331-150x150.jpg\" alt=\"Set up sterile tray and add cleaning solution and supplies\" 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\" class=\"wp-image-6328 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18201-150x150.jpg\" alt=\"Remove oxygen mask to clean dressing\" 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 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.<\/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\" class=\"wp-image-6349 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18391-150x150.jpg\" alt=\"Remove inner cannula by stabilizing neck plate and gently grasping the outer white area\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-6349\" class=\"wp-caption-text\">Remove inner cannula by stabilizing neck plate 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 in appropriate solution and, if necessary, use a sterile pipe cleaner to remove exudate from the inner cannula.<\/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\" class=\"wp-image-6351 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18411-150x150.jpg\" alt=\"Soak in appropriate solution and, if necessary, use a sterile pipe cleaner to remove exudate from the inner cannula\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-6351\" class=\"wp-caption-text\">Soak in appropriate solution and, if necessary, 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. Once clean, rinse off inner cannula and ensure all solution is removed. The inner portion may be dried off with a sterile pipe cleaner prior to reinsertion.<\/td>\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">Ensure all cleaning solution is removed to prevent tracheal damage from the hydrogen peroxide (if used).<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">9. 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\">10. Ensure the inner cannula has \u201cclicked\u201d on by aligning the two dots,\u00a0or ensure the clamp is secure.<\/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\" class=\"wp-image-6380 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_2076-150x150.jpg\" alt=\"Ensure that inner cannula is 'clicked' securely into place\" 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\">11. Perform hand hygiene.<\/td>\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"2\">Hand hygiene reduces the transmission of microorganisms.<\/p>\n<figure id=\"attachment_5972\" aria-describedby=\"caption-attachment-5972\" style=\"width: 150px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-247.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-5972 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-247-150x150.jpg\" alt=\"Hand hygiene with ABHR\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-5972\" class=\"wp-caption-text\">Hand hygiene with ABHR<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 250px;\" colspan=\"4\">Data source: ATI, 2015b; BCIT, 2015c; Morris, Whitmer &amp; McIntosh, 2013; Perry et al., 2014; Vancouver Coastal Health, 2012b<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h3><a id=\"video10.7\"><\/a>Video 10.7<\/h3>\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>\u00a0by\u00a0<a href=\"\/clinicalskills\/back-matter\/appendix-3\/\">Ren\u00e9e Anderson &amp; Wendy McKenzie<\/a>, Thompson Rivers University.<\/div>\n<h2>Cleaning Stoma and Changing the Sterile Dressing<\/h2>\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 84 provides a safe method to clean the tracheal stoma and replace the sterile dressing.<\/p>\n<table style=\"border-color: #000000; height: 1547px; width: 100%; width: 100%;\">\n<caption><a id=\"checklist84\"><\/a>Checklist 84: Cleaning Stoma and Changing a Sterile Dressing<\/caption>\n<tbody>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 101.337%; text-align: center;\" colspan=\"4\">\n<h5 style=\"text-align: center;\"><span style=\"color: #000000;\">Disclaimer:\u00a0Always review and follow your hospital policy regarding this specific skill.<\/span><\/h5>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 101.337%;\" 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: 49.9257%; text-align: center;\" colspan=\"2\">\n<h4 style=\"text-align: center;\">Steps<\/h4>\n<\/td>\n<td style=\"border: 1px solid #000000; width: 51.4116%; 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: 49.9257%;\" colspan=\"2\">1. Perform hand hygiene, verify physician orders for tracheostomy care, and collect supplies.<\/td>\n<td style=\"border: 1px solid #000000; width: 51.4116%;\" colspan=\"2\">Supplies include sterile dressing change, pre-cut 4\u00a0x 4 gauze, normal saline, cotton-tip applicators, non-sterile gloves, and garbage bag.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 49.9257%;\" 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: 51.4116%;\" colspan=\"2\">This reduces the transmission of microorganisms.<\/p>\n<figure id=\"attachment_5972\" aria-describedby=\"caption-attachment-5972\" style=\"width: 150px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-247.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-5972 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-247-150x150.jpg\" alt=\"Hand hygiene with ABHR\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-5972\" class=\"wp-caption-text\">Hand hygiene with ABHR<\/figcaption><\/figure>\n<p>Tracheal patients always 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: 49.9257%;\" colspan=\"2\">3. Apply non-sterile gloves and cover chest with waterproof pad.<\/td>\n<td style=\"border: 1px solid #000000; width: 51.4116%;\" 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: 49.9257%;\" colspan=\"2\">4. Organize all supplies and set up sterile tray field; add cleaning solution to sterile tray.<\/td>\n<td style=\"border: 1px solid #000000; width: 51.4116%;\" colspan=\"2\">Organization ensures the process of cleaning is efficient and fast.<\/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\" class=\"wp-image-6336 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18331-150x150.jpg\" alt=\"Set up sterile tray and add cleaning solution and supplies\" 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: 49.9257%;\" 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: 51.4116%;\" 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\" class=\"wp-image-6328 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18201-150x150.jpg\" alt=\"Remove oxygen mask to clean dressing\" 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: 49.9257%;\" 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: 51.4116%;\" 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\" class=\"wp-image-6337 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18341-150x150.jpg\" alt=\"Use forceps to remove the soiled dressing\" 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: 49.9257%;\" 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: 51.4116%;\" 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\" class=\"wp-image-6338 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18351-150x150.jpg\" alt=\"Assess stoma site\" 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: 49.9257%;\" colspan=\"2\">8. Clean the stoma site with a gauze or cotton-tip applicator soaked in normal saline. Be careful not to disturb the tracheostomy tube. Dry surrounding area if required.<\/td>\n<td style=\"border: 1px solid #000000; width: 51.4116%;\" 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<figure id=\"attachment_6346\" aria-describedby=\"caption-attachment-6346\" style=\"width: 150px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18371.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-6346 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18371-150x150.jpg\" alt=\"Clean the stoma site with a gauze or cotton-tip applicator soaked in normal saline\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-6346\" class=\"wp-caption-text\">Clean the stoma site with a gauze or cotton-tip applicator soaked in normal saline<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 49.9257%;\" colspan=\"2\">9. Assess the site to determine if barrier film is required.<\/td>\n<td style=\"border: 1px solid #000000; width: 51.4116%;\" colspan=\"2\">Follow\u00a0agency policy.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 49.9257%;\" colspan=\"2\">10. Apply new manufactured pre-cut tracheostomy dressing to tube using sterile forceps.<\/td>\n<td style=\"border: 1px solid #000000; width: 51.4116%;\" colspan=\"2\">Avoid cutting gauze for tracheostomy care. Use non-fraying material. The small fibres from the cut gauze may become loose and accidentally travel into the inner cannula. Always use manufactured pre-cut gauze.<\/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\" class=\"wp-image-6337 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18341-150x150.jpg\" alt=\"Apply new manufactured pre-cut tracheostomy dressing to tube using sterile forceps\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-6337\" 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: 101.337%;\" colspan=\"4\">Data source: BCIT 2015c; Morris et al., 2013; Perry et al., 2014; Vancouver Coastal Health, 2012<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h3><a id=\"video10.8\"><\/a>Video 10.8<\/h3>\n<div class=\"textbox shaded\" style=\"text-align: center;\">Watch this video <a href=\"https:\/\/barabus.tru.ca\/nursing\/changing_tracheostomy_site_dressing.html\"><em>Changing a Trachestomy Site Dressing<\/em><\/a> by\u00a0<a href=\"\/clinicalskills\/back-matter\/appendix-3\/\">Ren\u00e9e Anderson &amp; Wendy McKenzie<\/a>, Thompson Rivers University.<\/div>\n<h2>Replacing Tracheostomy Ties (Velcro or Twill Tape)<\/h2>\n<p>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. Ensure twill ties are knotted using a square knot.<\/p>\n<div class=\"textbox shaded\" style=\"text-align: center;\"><a href=\"https:\/\/www.youtube.com\/watch?v=4FgO0s7i-ec\">Watch this <em>Securing an Endotracheal Tube with Twill Tape and a Rolling Hitch<\/em> video<\/a> to learn how to tie a square knot.<\/div>\n<p>Checklist 85 lists the steps for replacing tracheostomy ties.<\/p>\n<table style=\"border-color: #000000; height: 1547px; width: 100%; width: 100%;\">\n<caption><a id=\"checklist85\"><\/a>Checklist 85: Replacing Tracheostomy Ties (Velcro or Twill Tape)<\/caption>\n<tbody>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 101.436%; text-align: center;\" colspan=\"4\">\n<h5 style=\"text-align: center;\"><span style=\"color: #000000;\">Disclaimer:\u00a0Always review and follow your hospital policy regarding this specific skill.<\/span><\/h5>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 101.436%;\" 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: 49.9752%; text-align: center;\" colspan=\"2\">\n<h4 style=\"text-align: center;\">Steps<\/h4>\n<\/td>\n<td style=\"border: 1px solid #000000; width: 51.4611%; 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: 49.9752%;\" colspan=\"2\">1. Perform hand hygiene, verify physician orders for tracheostomy care, and collect supplies.<\/td>\n<td style=\"border: 1px solid #000000; width: 51.4611%;\" colspan=\"2\">Use twill ties or Velcro ties.<\/p>\n<figure id=\"attachment_6220\" aria-describedby=\"caption-attachment-6220\" style=\"width: 150px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_1093.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-6220 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_1093-150x150.jpg\" alt=\"Wash hands\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-6220\" class=\"wp-caption-text\">Wash hands<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 49.9752%;\" 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: 51.4611%;\" colspan=\"2\">If tracheostomy is less than\u00a024 hours old, or patient is confused, agitated, or unpredictable, always have an additional helper at the bedside to prevent accidental dislodgement.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 49.9752%;\" colspan=\"2\">3. 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: 51.4611%;\" colspan=\"2\">This reduces the transmission of microorganisms.<\/p>\n<figure id=\"attachment_5972\" aria-describedby=\"caption-attachment-5972\" style=\"width: 150px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-247.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-5972 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-247-150x150.jpg\" alt=\"Hand hygiene with ABHR\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-5972\" class=\"wp-caption-text\">Hand hygiene with ABHR<\/figcaption><\/figure>\n<p>Tracheal patients always 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: 49.9752%;\" colspan=\"2\">4. Apply non-sterile gloves.<\/td>\n<td style=\"border: 1px solid #000000; width: 51.4611%;\" colspan=\"2\">This reduces the transmission of microorganisms.<\/p>\n<figure id=\"attachment_5559\" aria-describedby=\"caption-attachment-5559\" style=\"width: 150px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_1511.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-5559 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_1511-150x150.jpg\" alt=\"Apply non-sterile gloves\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-5559\" class=\"wp-caption-text\">Apply non-sterile gloves<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 49.9752%;\" 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. This avoids potential dislodgement of the tube as this procedure can make the patient cough.<\/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 one little finger between the collar and the patient. 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.<\/li>\n<\/ul>\n<p>To secure the tracheostomy tube with ribbon\/twill tape:<\/p>\n<ul>\n<li>Cut two pieces of cotton tape, each approximately 50 cm in length (depending on neck size).<\/li>\n<li>Divide the tape into thirds and fold the first third over the remaining two-thirds of the ribbon.<\/li>\n<li>Thread the folded edge through one flange hole, forming a loop.<\/li>\n<li>Thread the loose tape ends through this loop and pull until tight and secure.<\/li>\n<li>Repeat the process for the other side, securing the tapes with square knots on each side of the neck.<\/li>\n<\/ul>\n<\/td>\n<td style=\"border: 1px solid #000000; width: 51.4611%;\" colspan=\"2\">Tracheostomy ties are used to promote patient comfort and keep the tracheostomy secured and in situ.<\/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\" class=\"wp-image-6353 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18471-150x150.jpg\" alt=\"Velcro ties\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-6353\" class=\"wp-caption-text\">Velcro ties<\/figcaption><\/figure>\n<figure id=\"attachment_6352\" aria-describedby=\"caption-attachment-6352\" style=\"width: 150px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18461.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-6352 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_18461-150x150.jpg\" alt=\"Cotton twill ties\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-6352\" class=\"wp-caption-text\">Cotton twill ties<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 49.9752%;\" colspan=\"2\">6. Perform hand hygiene.<\/td>\n<td style=\"border: 1px solid #000000; width: 51.4611%;\" colspan=\"2\">Hand hygiene reduces the transmission of microorganisms.<\/p>\n<figure id=\"attachment_5972\" aria-describedby=\"caption-attachment-5972\" style=\"width: 150px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-247.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-5972 size-thumbnail\" src=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Book-pictures-2015-247-150x150.jpg\" alt=\"Hand hygiene with ABHR\" width=\"150\" height=\"150\" \/><\/a><figcaption id=\"caption-attachment-5972\" class=\"wp-caption-text\">Hand hygiene with ABHR<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 101.436%;\" colspan=\"4\">Data source: BCIT, 2015c; Morris et al., 2013;\u00a0Perry et al., 2014<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h3><a id=\"video10.9\"><\/a>Video 10.9<\/h3>\n<div class=\"textbox shaded\" style=\"text-align: center;\">Watch a video <a href=\"https:\/\/barabus.tru.ca\/nursing\/changing_traceostomy_ties.html\"><em>Changing Tracheostomy Ties<\/em><\/a>\u00a0by\u00a0<a href=\"\/clinicalskills\/back-matter\/appendix-3\/\">Ren\u00e9e Anderson &amp; Wendy McKenzie<\/a>, Thompson Rivers University.<\/div>\n<div class=\"textbox textbox--exercises\">\n<header class=\"textbox__header\">\n<p class=\"textbox__title\">Critical Thinking Exercises<\/p>\n<\/header>\n<div class=\"textbox__content\">\n<ol>\n<li>When suctioning your patient, 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<\/ol>\n<\/div>\n<\/div>\n","protected":false},"author":5,"menu_order":5,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":""},"chapter-type":[],"contributor":[],"license":[],"class_list":["post-3650","chapter","type-chapter","status-publish","hentry"],"part":3632,"_links":{"self":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapters\/3650","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/wp\/v2\/users\/5"}],"version-history":[{"count":30,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapters\/3650\/revisions"}],"predecessor-version":[{"id":10180,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapters\/3650\/revisions\/10180"}],"part":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/parts\/3632"}],"metadata":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapters\/3650\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/wp\/v2\/media?parent=3650"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapter-type?post=3650"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/wp\/v2\/contributor?post=3650"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/wp\/v2\/license?post=3650"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}