A tracheostomy or tracheotomy is a surgical incision of the front of the neck into the trachea to open the airway. A tracheostomy tube is placed into the opening and may be connected to a mechanical ventilator or another oxygen delivery device. The term “trach” is used as an abbreviation.
In this article:
- Overview
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Impaired Spontaneous Ventilation
- Impaired Verbal Communication
- Ineffective Airway Clearance
- Ineffective Breathing Pattern
Overview
If the normal breathing pathway is compromised or restricted or medical conditions necessitate prolonged use of a ventilator, a tracheostomy can assist patients in breathing. An emergency tracheotomy may be indicated due to acute airway obstruction from aspiration, a foreign body, trauma, anaphylaxis, and more.
A tracheostomy can be temporary or permanent. When a tracheostomy is no longer necessary, it is surgically sealed or left to heal independently. Some patients may require lifelong trachs.
Early tracheostomy should be done 5–7 days following the intubation of patients. It is indicated for patients with severe closed-head injuries or those requiring prolonged ventilatory support. It aims to reduce the risk of complications from long-term intubation, particularly subglottic stenosis (airway constriction between the vocal cords and trachea). Likewise, tracheostomy is also advised 5-7 days post-intubation in non-trauma patients with unsuccessful ventilator weaning.
The most common setting for performing tracheostomies is an operating room when patients are completely unconscious during the surgery. If general anesthesia will compromise the airway or if the procedure is performed outside the operating room, a local anesthetic to numb the neck and throat is employed.
Surgical vs. Percutaneous Tracheostomy
Types of tracheostomies include:
- Surgical (open) tracheostomy
- Performed in an operating room
- Surgical dissection to create an opening in the trachea to insert a tracheostomy tube for ventilation.
- Percutaneous tracheostomy
- Also known as a minimally invasive tracheotomy or beside tracheostomy
- Performed in a hospital room
- A small incision to insert a tracheostomy tube without a direct view of the trachea
Note: The type of tracheostomy depends on the indication and urgency to perform the procedure.
Both tracheostomies create an incision to insert a tracheostomy tube. Then, the faceplate of the tube is affixed to the neck with tape, ties, or temporary sutures to prevent it from slipping out of the opening.
Nursing Process
Tracheostomy is a safe and effective procedure that can maintain a patent airway. Post-operative and ongoing hygiene care is crucial to a complication-free tracheostomy.
A tracheostomy makes speaking and eating difficult or impossible for the patient. Over time, the patient can be taught how to speak and eat effectively with a tracheostomy. Nutrients and hydration are given enterally or peripherally to prevent aspiration and malnutrition if the patient is on a ventilator.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to a tracheostomy.
Review of Health History
1. Determine the indications for tracheostomy.
A tracheostomy may be necessary for the following reasons:
- Airway obstruction
- Trauma to the face or neck
- Prolonged ventilator dependence
- Prophylaxis prior to head or neck cancer treatment
- Obstructive sleep apnea with failed treatment
- Neuromuscular disease (ALS, stroke, MS, etc.)
- Management of secretions
2. Review the patient’s medical history.
Note for the following medical conditions that may indicate the need for tracheostomy:
- Facial and upper airway congenital anomalies
- Mechanical obstructions (foreign objects)
- Upper airway defects or conditions:
- Infection
- Edema
- Paralysis
- Dysphagia
- Sleep apnea
3. Determine the patient’s need for long-term mechanical ventilation.
Tracheostomy procedures can offer a long-term pathway for ventilatory support when respiratory failure occurs. It also aids the patient with ineffective coughing abilities and a risk for aspiration.
4. Assess the patient’s and family’s knowledge about tracheostomy.
Identify the patient’s and family’s knowledge and misconceptions about tracheostomy. Discuss how trachs may be permanent or temporary. Ensure the family understands the amount of care required for maintaining a trach.
Physical Assessment
1. Assess the ABCs.
Assess the airway, breathing, and circulation. Inspect the upper airway, including the nose, mouth, and throat, before and after tracheostomy.
2. Monitor the vital signs.
Closely monitor the vital signs before, during, and after the tracheostomy procedure. Oxygen desaturation and bleeding are common complications of tracheostomy insertion and care. Note any significant changes in the vital signs. Attach the patient to continuous pulse oximetry monitoring.
3. Assess the respiratory status.
Observe the patient’s airway and breathing. There is a high risk of respiratory complications during and post-tracheostomy. Pay close attention to any indications of respiratory distress, such as:
- Rapid breathing (tachypnea)
- Retractions
- Adventitious breath sounds
- Desaturation
- Cyanosis
4. Observe for complications related to tracheostomy.
Tracheostomy carries risks. Possible complications include:
- Bleeding
- Infection
- Edema
- Obstruction
- Fistula
- Pneumothorax
- Decannulation
- Necrosis
5. Assess the patient’s speaking and swallowing abilities.
The tracheostomy tube may affect the patient’s capacity for safe swallowing and speaking. A patient with a tracheostomy may not be able to talk due to the inability of air to pass through their vocal cords. In time, the patient can work with a speech-language pathologist to learn how to use a speaking valve to talk. The nurse should always assess the patient’s ability to swallow before offering food or liquids.
6. Assess for signs of infection.
Infection is a rare complication. Monitor for the presence of the following findings, which can be a sign of infection or trauma:
- Redness
- Swelling
- Edema
- Granulation
- Exudates
- Pain at the site
- Foul odor
- Secretions
Diagnostic Procedures
1. Obtain ABG.
Obtain an arterial blood gas after tracheostomy to assess the patient’s ventilation and acid-base balance. ABGs can be obtained as prescribed for the patient on a ventilator or if the patient develops signs of respiratory distress.
2. Confirm the tracheostomy placement.
In some instances, a chest X-ray may be performed to confirm tracheostomy placement or to evaluate complications.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with a tracheostomy.
Prepare for a Tracheostomy
1. Ensure completeness of informed consent.
Like with any invasive procedure, the patient, their family, and the healthcare provider should have an honest and open discussion about the advantages, disadvantages, and alternatives of tracheostomy. Encourage inquiries to clear any doubts. Ensure that they sign the informed consent after the discussion.
2. Prepare the equipment.
Percutaneous tracheostomy is done at the bedside, and the nurse may be tasked with obtaining a tracheostomy kit and suction equipment.
Prevent Tracheostomy Complications
1. Prevent infections.
Infections are rare following tracheostomy, and most can be treated through appropriate wound care.
2. Ensure the cuff is inflated.
Cuffed trachs are used in patients who require ventilation and act as a seal so no air passes around the tube. Cuffs should be monitored to maintain a pressure of 20 to 25 mmHg. Ensure the cuff is not overinflated to prevent pressure necrosis.
3. Pre-hyperoxygenate the patient.
Before insertion or suctioning, give 100% oxygen to the patient. Preoxygenation can prevent hypoxia. At the same time, hyperinflation can decrease the risk of suction-induced atelectasis.
4. Maintain sterility during insertion and care.
Sterile technique during insertion and care of the tracheostomy can prevent infection and stoma skin breakdown.
5. Encourage breathing and coughing exercises.
Encourage breathing and coughing exercises to clear secretions and maximize lung expansion.
6. Prevent aspiration.
Reduce the aspiration risk by:
- Elevating the head of the bed by more than 30 degrees
- Avoiding food or drinks until the healthcare provider/speech pathologist permits
- Ensuring the cuff is deflated before eating
Perform Post-Tracheostomy Care
1. Secure emergency equipment at the bedside.
Keep emergency supplies (such as a tracheostomy kit) and suction equipment at the bedside in the event of decannulation.
2. Provide humidification.
Humidified oxygen keeps the stoma moist and secretions thin. Mucolytics may also be used to prevent mucus plugs.
3. Provide trach care as ordered.
Routine trach care includes stoma site care, dressing changes, cleaning dried mucus with Q-tips or gauze, cleaning or disposing of the inner cannula, and changing the tracheostomy ties.
4. Suction as needed.
If the patient is unable to cough effectively or is coughing more than usual, the nurse should perform suctioning. Hyperoxygenate the patient before performing suctioning. Always insert the catheter without suction and slowly withdraw the catheter in a circular motion while applying suction. Do not apply suction for more than 10 seconds at a time.
5. Collaborate with a respiratory therapist.
Respiratory therapists are involved in the care of the tracheostomy and ventilation. They help oxygenate the patient, assist with trach care, and troubleshoot abnormalities.
6. Aid the patient in communication.
The patient’s ability to speak normally may be affected by the tracheostomy. Provide the following communication aids, such as:
- Pen and paper
- Alphabet board
- Picture board
- Electronic devices (mobile phones or tablets)
- Sign language
- One-way speaking valve attachment
7. Support the patient and their family.
Having a tracheostomy or caring for a patient with a tracheostomy can be difficult. Support them by:
- Educating on how to care for long-term tracheostomy
- Demonstrating trach care
- Acknowledging the expression of emotions
Nursing Care Plans
Once the nurse identifies nursing diagnoses for a tracheostomy, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for a tracheostomy.
Deficient Knowledge
Deficient knowledge associated with tracheostomy can result in misunderstanding the tracheostomy procedure and care management.
Nursing Diagnosis: Deficient Knowledge
Related to:
- Lack of knowledge about tracheostomies
- Fear of tracheostomy procedure, outcomes, and complications
- Misconceptions about tracheostomy care
- Communication barriers
- Barriers with eating and speaking with a trach
As evidenced by:
- Expressed concerns about a tracheostomy
- Anxiety about the procedure or lifestyle changes
- Frustration with trach care
- Development of complications
- Uncooperative behavior
Expected outcomes:
- Patient will be able to express an understanding of the tracheostomy procedure and care management
- Patient will cooperate in the care of their tracheostomy
- Patient will not develop a complication from their tracheostomy
Assessment:
1. Assess the patient’s knowledge of tracheostomy surgery.
Assess the patient’s knowledge about the tracheostomy procedure, how the trach works, and what hygiene care is expected.
2. Identify factors affecting learning.
Since a tracheostomy can already interfere with communication with the patient, it can negatively impact the delivery of quality and safe care. Assess for other barriers, such as developmental or cognitive delays.
3. Determine misconceptions and beliefs about tracheostomy.
Determine the patient’s beliefs about tracheostomies to assess for knowledge gaps. Most patients believe that a tracheostomy is a long-term and permanent treatment.
Interventions:
1. Create a care plan with the patient.
Having a tracheostomy and being unable to communicate is frustrating. Patient engagement in decision-making before the tracheostomy will help the patient feel empowered and in control.
2. Involve the family.
Family members can be instructed on caring for the trach and recognizing complications. If the patient will have the trach long-term or permanently, the family must know how to care for it.
3. Welcome inquiries.
A welcoming and approachable manner invites questions to clarify misconceptions and misunderstandings. Patients with a tracheostomy experience anxiety, fear, and powerlessness; clarification can reduce these feelings.
4. Reinforce positive feedback.
When patients achieve their goals and prevent complications, reinforce positive feedback and show appreciation for their efforts and adherence to their care plan.
5. Clarify that tracheostomy can be temporary or permanent.
A tracheostomy is typically a temporary breathing alternative while addressing other medical problems. The tracheostomy is commonly the best long-term and permanent option if patients need a ventilator for life.
Impaired Spontaneous Ventilation
A tracheostomy may be necessary to sustain ventilation.
Nursing Diagnosis: Impaired Spontaneous Ventilation
Related to:
- Presence of artificial airway
- Airway obstruction
- Neuromuscular disease
- Trauma to the face or neck
As evidenced by:
- Low oxygen saturation
- Decreased cooperation
- Dyspnea
- Tachycardia
- Restlessness
Expected outcomes:
- Patient will demonstrate the ability to wean off the ventilator.
- Patient will maintain an effective airway.
Assessment:
1. Determine the need for tracheostomy.
A tracheostomy is utilized for the following reasons:
- Airway obstruction
- Trauma to the airway
- Prolonged ventilator dependence
- Preparing for head or neck cancer treatment
- Aspiration
- Neuromuscular disease
- Obstructive sleep apnea
2. Monitor breath sounds and oxygenation.
Assess breath sounds after the tracheostomy insertion and frequently thereafter for complications. Monitor CO2 levels to confirm tube placement into the trachea.
3. Assess responsiveness to the ventilator.
Monitor for subjective complaints or signs that the patient is experiencing distress, such as accessory muscle use, agitation, and an alarming ventilator.
Interventions:
1. Hyperoxygenate the patient.
Prior to suctioning, hyperoxygenate the patient to prevent hypoxia.
2. Communicate effectively with the patient.
The patient with a tracheostomy will not be able to speak immediately. Find other ways to communicate, such as using nonverbal gestures, electronic devices, or writing. In time, the patient will be taught how to speak by occluding the trach or using a Passy-Muir valve.
3. Have family members demonstrate care.
Instruct on proper trach care, including hygiene care, suctioning, oxygenation, and when to seek emergency services.
4. Collaborate with the respiratory therapist.
Review ventilator settings, oxygen titration, and tracheostomy care with the RT.
Impaired Verbal Communication
Impaired verbal communication associated with tracheostomy can be caused by airflow diverting through the tracheostomy tube instead of passing through the vocal cords and the upper airway.
Nursing Diagnosis: Impaired Verbal Communication
Related to:
- No air flowing in the vocal cords (larynx)
- Damaged larynx
- Obstructed airway
- Mechanical ventilation
As evidenced by:
- Difficulty speaking
- Inability to communicate
- No voice sound
- Hoarseness
- Anxious appearance
- Fear of being misunderstood
- Frustration
Expected outcomes:
- Patient will be able to use a method and device to communicate.
- Patient will be able to express their needs clearly and effectively.
- Patient will be able to manifest satisfaction after communication.
Assessment:
1. Assess the patient’s ability to communicate.
Air must pass through the larynx to create voice sound—patients with a cuffed tracheostomy tube experience aphonia or speech loss.
2. Determine the best way for the patient to communicate.
Patients with a tracheostomy on a ventilator may need to write or type requests.
3. Note any signs of anxiety and frustration.
The inability to communicate can increase a patient’s sense of helplessness and isolation.
Interventions:
1. Offer communication methods and devices.
Communication alternatives available to patients with tracheostomy:
- Writing
- Gestures
- Mouthing words
- Speaking valves
- Use of AAC (Augmentative and Alternative Communication) devices such as communication boards, tablets, and picture boards
2. Provide emotional support.
Being unable to communicate and feeling misunderstood can cause anxiety, helplessness, and isolation and can be frustrating for the patient.
3. Closely monitor the patient.
Due to difficulty in communication, the patient may not be able to communicate symptoms or concerns. It is crucial to closely monitor and observe patients for nonverbal behaviors that signal changes in their health status.
4. Advise the patient to use the call bell when necessary.
Patients can notify any healthcare personnel of their need for assistance in a healthcare setting by using a nurse call bell system to ensure patient safety.
5. Use a communication board or gestures for simple questions.
A communication board is a device that shows images, symbols, or illustrations to assist people who struggle to communicate verbally. The patient, nurse, and family can use gestures or sign language as applicable for simple communication.
6. Ask questions answerable by yes or no reactions.
Try to construct questions that can be answered by “yes” or “no” responses. The patient can nod or blink their response.
7. Teach to use a Passy-Muir Valve.
This one-way valve attaches to the tracheostomy to allow air into the trach but not out. The patient is first suctioned to remove secretions, and then the cuff is deflated. The valve is twisted onto the trach tube and easily twisted off to remove.
8. Consult with the speech-language pathologist.
The SLP can assess the patient’s swallowing and language functions and their ability to produce voice and tolerate a speaking valve.
Ineffective Airway Clearance
Ineffective airway clearance associated with tracheostomy can be caused by an obstruction in the stoma or opening of the trachea.
Nursing Diagnosis: Ineffective Airway Clearance
Related to:
- Excessive secretions
- Thick secretions
- Misaligned tracheostomy
- Decannulation
As evidenced by:
- Abnormal breath sounds upon auscultation
- Dyspnea
- Irregular breathing pattern
- Coughing difficulty
- Use of accessory muscles
- Cyanosis
Expected outcomes:
- Patient will maintain an oxygen saturation of 95-100%.
- Patient will be able to manifest clear breath sounds upon auscultation.
- Patient will remain absent of signs of respiratory distress such as cyanosis and dyspnea.
Assessment:
1. Assess the respiratory status.
Continuously monitor the patient’s oxygen saturation and observe any changes in the breathing pattern. Intervention should occur when oxygen saturation levels go below 95%.
2. Determine the placement of the tracheostomy.
A displaced tracheostomy tube needs urgent manual ventilation attempts and suction with a sodium chloride solution to remove the mucus plug. A displaced tracheostomy can be fatal for the patient if management is delayed.
3. Review the confirmatory tracheostomy placement results.
Tracheostomy position is essential to airway patency. Direct visualization (bronchoscopy), end-tidal carbon dioxide, ventilation efficiency, and adequate oxygen saturation confirm proper placement.
4. Check for tracheal secretions.
With a tracheostomy tube, the upper airway that purifies and moisturizes the inhaled air is bypassed. Secretions are a normal response to the presence of a tracheostomy. However, these secretions may accumulate in the airway if tracheostomy cuffs are left inflated for an extended period.
5. Inspect for any signs of bleeding or edema in the tracheostomy site.
The most frequent tracheostomy complication is bleeding. Bleeding can be fatal if it obstructs the airway. Bleeding and edema can happen during or after surgery due to the development of a fistula. The tracheostomy tube typically erodes through the trachea’s wall or a major vessel to cause late hemorrhage.
7. Auscultate for breath sounds.
Wheezing suggests partial airway obstruction. Crackles and rhonchi may indicate the presence of secretions. Diminished or absent breath sounds indicate a mucus plug or other airway obstruction.
8. Obtain arterial blood gas (ABG).
Perform an ABG test to determine whether the oxygen delivered via tracheostomy and ventilator (if a mechanical ventilator is attached) is adequate.
Interventions:
1. Maintain an upright position.
For conscious patients, maintain a semi-Fowler’s position to prevent aspiration of secretions. On the other hand, a side-lying position is best for unconscious patients to facilitate the drainage of secretions by gravity and decrease the risk of aspiration.
2. Suction the secretions.
Suction excess and thick secretions to maintain a patent airway. Suction can also be used to obtain sputum samples for diagnostic testing if an infection is suspected.
3. Remember to hyperoxygenate before suctioning.
Preoxygenate the patient with 100% oxygen prior to suctioning. Preoxygenation aids in preventing hypoxia, while hyperinflation lessens suction-induced atelectasis.
4. Maintain sterility in tracheostomy care.
Tracheostomy care removes mucus and cleans encrusted secretions to facilitate airway patency. It also prevents infection and skin breakdown at the stoma site. Sterility of equipment will maintain a pathogen and microorganism-free environment in the trachea.
5. Perform tracheostomy care as prescribed.
Follow the healthcare provider’s orders or the institution’s policy regarding the frequency of care and prescribed solutions. It is usually recommended to use saline or half-strength hydrogen peroxide to clean the stoma area and cannula.
6. Provide humidified oxygen as ordered.
In a client with a tracheostomy, the typical humidification process, warming and filtering of air by the nose and mouth, is bypassed. Humification can keep secretions thin.
7. Change tracheostomy ties regularly or as needed.
Get help changing the ties holding the tracheostomy in place, then cut and remove the old ties after placing the new ones. A trach tube may also be held in place by velcro, which can also be changed.
8. Keep an emergency tracheotomy kit at the bedside.
An emergency tracheotomy kit should include:
- Spare tracheostomy tubes (one identical size and one size smaller than the patient’s current tracheostomy tube)
- Obturator
- Clamps
- Manual resuscitation (Ambu) bag
9. Encourage deep breathing and coughing exercises.
Deep breathing and coughing exercises can help move secretions, preventing atelectasis and pneumonia.
10. Collaborate with a respiratory therapist.
Managing mechanical ventilation and tracheostomies is a function of respiratory therapists. They set up the equipment, provide input regarding the right size and kind of tracheostomy tube, and assist in ventilating the patient throughout the process.
Ineffective Breathing Pattern
An ineffective breathing pattern may lead to the need for a tracheostomy or may occur as a complication following a tracheostomy.
Nursing Diagnosis: Ineffective Breathing Pattern
Related to:
- Hypoxia
- Airway obstruction
- Infection
- Neuromuscular impairment
- Trauma to the face or neck
- Secretions
As evidenced by:
- Bradypnea
- Tachypnea
- Altered rate, rhythm, and depth of breathing
- Dyspnea
- Accessory muscle use
Expected outcomes:
- Patient will maintain a respiratory rate and pattern within acceptable limits.
- Patient will maintain SpO2 levels within normal range.
Assessment:
1. Assess for signs of complications.
An ineffective breathing pattern, stridor, or cyanosis are signs of respiratory distress from possible tracheostomy complications, like tube malposition, inappropriate tube size, or stenosis.
2. Review underlying conditions.
Review the medical record for conditions that may cause an ineffective breathing pattern or complicate a tracheostomy like neuromuscular conditions, COPD, or ARDS.
Interventions:
1. Don’t overinflate or underinflate the cuff.
Overinflation may cause necrosis, mucosal injury to the trachea, or impaired airflow, while an underinflated cuff may allow air to leak around the cuff.
2. Provide humidification.
Humidification prevents secretions from being thick and dried out, which can lead to obstruction.
3. Suction as needed.
If the client is unable to cough or has an ineffective cough, provide suctioning to prevent a mucus plug or the build-up of secretions.
4. Provide routine trach care.
Routine trach care should be performed daily, and it should include cleaning or replacing the inner cannula that may become plugged with mucus, causing alterations in breathing.
References
- Anderson, R., Doyle, G. R., & McCutcheon, J. A. (2018). Clinical procedures for safer patient care. BCcampus Open Publishing – Open Textbooks Adapted and Created by BC Faculty. https://opentextbc.ca/clinicalskills/chapter/10-6-tracheostomies/
- Blakeley, S. (2020). A guide to tracheostomies (1st ed.). Portsmouth Hospitals NHS Trust. https://www.portsmouthicu.com/resources/2017-06-30-TracheHandbook(2017).pdf
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
- Lindman, J. P. (2021, October 12). Tracheostomy Periprocedural care: Patient education and consent, equipment, patient preparation. Diseases & Conditions – Medscape Reference. Retrieved October 2023, from https://emedicine.medscape.com/article/865068-periprocedure#b7
- Mayo Clinic. (2019, October 22). Tracheostomy. Retrieved January 2023, from https://www.mayoclinic.org/tests-procedures/tracheostomy/about/pac-20384673
- National Center for Biotechnology Information. (2022, July 1). Tracheostomy – StatPearls – NCBI bookshelf. Retrieved January 2023, from https://www.ncbi.nlm.nih.gov/books/NBK559124/
- Nursing guidelines : Tracheostomy management. (n.d.). The Royal Children’s Hospital. Retrieved October 2023, from https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/tracheostomy_management/#Communication
- Raimonde, A. J., Westhoven, N., & Winters, R. (2023, July 24). Tracheostomy – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. Retrieved October 2023, from https://www.ncbi.nlm.nih.gov/books/NBK559124/
- Silvestri, L. A., & Silvestri, A. E. (2022). Saunders comprehensive review for the NCLEX-RN examination (9th ed.). Elsevier Inc.
- Tracheostomy Education. (2022, July 17). Complications of tracheostomy | Tracheostomy education. Retrieved January 2023, from https://tracheostomyeducation.com/blog/complications-of-tracheostomy/
- Tracheostomy – Mayo Clinic. (2019, October 22). Mayo Clinic. Retrieved October 2023, from https://www.mayoclinic.org/tests-procedures/tracheostomy/about/pac-20384673
- Tracheostomy: What it is, procedure & purpose. (2022, June 9). Cleveland Clinic. Retrieved October 2023, from https://my.clevelandclinic.org/health/treatments/23231-tracheostomy
- UK National Health Service. (2017, October 20). Tracheostomy. NHS UK. Retrieved January from https://www.nhs.uk/conditions/tracheostomy/
