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EN4.44 | Tracheostomy and Tracheostomy Care — SDL Guide (Part 2)

Interpretation: Normal and Abnormal Tracheostomy Care

Post-tracheostomy care is as important as the procedure itself — the majority of tracheostomy-related morbidity and mortality occurs in the post-operative period and is preventable with attentive nursing and medical care. Understanding what normal tracheostomy care looks like, and how to recognise and respond to complications, is the central clinical skill for any clinician who will encounter tracheostomy patients on the ward. A patient with a tracheostomy placed for bilateral vocal cord palsy in a district hospital may be discharged home with a tube in place, dependent on the family and the local healthcare system for basic tube care. An ICU patient on prolonged ventilation requires a full multi-professional nursing care protocol. In both settings, the principles are the same: keep the airway patent, maintain tube integrity, prevent infection, ensure adequate humidification, and have a response plan for every foreseeable complication. The clinician who understands these principles can manage a tracheostomy patient safely in any setting — from a tertiary ENT unit to a rural health centre.

Routine post-operative tracheostomy care:
- Wound care: the stoma wound is cleaned daily with normal saline and a non-adherent dressing is placed under the flange. The skin must be kept dry — moisture causes maceration and infection.
- Inner tube care: the inner tube is removed and cleaned (with a small brush under running water, or replaced with a spare clean tube) every 4-8 hours, or more frequently if secretions are copious. This prevents blockage of the airway with dried secretions.
- Suctioning: endotracheal suctioning via the tracheostomy is performed with a sterile technique, using an appropriate-sized catheter (the catheter should not exceed half the tracheostomy tube's internal diameter), inserted to approximately the level of the carina (when mild resistance is felt), with suction applied on withdrawal. Suctioning is not continuous — each pass is limited to 10-15 seconds to prevent desaturation.
- Humidification: the tracheostomy bypasses the normal humidifying and filtering function of the nose and upper airway. Inhaled air must be humidified (via a heated humidifier or heat-moisture exchanger/HME filter) to prevent the tracheal mucosa from drying out and secretions from becoming inspissated and blocking the tube.
- Tube change: the first tracheostomy tube change is not performed before 5-7 days, by which time the tracheostomy tract (the tissue channel between skin and trachea) has matured sufficiently to allow safe reinsertion if the tube is displaced during the change. The first change is a two-person procedure, performed with the patient prepared for emergency re-intubation and with a spare tube of the same size, a size smaller, and an introducer at the bedside.

Complications and their management:

Complication	Timing	Mechanism	Management
Haemorrhage (minor)	Immediate/early	Wound bleeding, thyroid isthmus vessel	Pressure, wound check, diathermy
Tube dislodgement	Any time	Unsecured tapes, patient agitation	Re-insert with obturator; if <5-7 days call ENT (tract not mature)
Tube blockage	Any time	Dried/inspissated secretions	Remove inner tube, clean/replace; suction outer tube
Surgical emphysema	Early	Air tracking into tissue planes	Usually self-resolving; ensure tube is in trachea
Wound infection	Early	Stoma contamination	Wound care, antibiotics
Tracheo-innominate fistula	Late (1-6 weeks)	Cuff erosion of innominate artery	SURGICAL EMERGENCY — massive haemorrhage; compress artery through stoma, emergency thoracotomy
Subglottic/tracheal stenosis	Late	Cuff over-inflation, tube at 1st ring	Endoscopic dilatation, laryngotracheal reconstruction
Tracheomalacia	Late	Chronic cuff pressure ≥25 mmHg	Airway stenting or surgery
Tracheo-oesophageal fistula	Late	Posterior tracheal wall erosion	Surgical repair

The most immediately life-threatening late complication is a tracheo-innominate fistula — erosion of a low-lying or over-inflated tracheostomy tube cuff through the posterior wall of the innominate artery. It presents with a sentinel bleed (small blood from the stoma as a warning) followed by catastrophic haemorrhage. Emergency management: insert a finger through the stoma and compress the innominate artery against the posterior surface of the sternum — then emergency operative repair.

Applied Practice: Weaning and Decannulation

Decannulation — the removal of the tracheostomy tube and closure of the stoma — is the goal for most tracheostomy patients once the original indication has resolved. A systematic weaning protocol ensures that decannulation is safe and that the patient's airway is adequate to sustain independent breathing, phonation, and swallowing without the tracheostomy.

The fundamental principle of decannulation is that the patient must demonstrate the ability to breathe adequately through the upper airway while the tracheostomy tube is occluded (capped), before the tube is actually removed. If a patient cannot tolerate capping for several hours at a time, the airway above the tracheostomy is insufficient for independent breathing and decannulation is premature.

Decannulation criteria — before attempting decannulation, the following must be satisfied:
1. The original indication for tracheostomy has resolved or significantly improved.
2. The patient can breathe spontaneously with adequate respiratory reserve.
3. Swallowing is adequate and aspiration risk is acceptable.
4. The patient can clear secretions by coughing (or can tolerate reduced suction frequency).
5. The patient can tolerate progressive capping trials — initially for 1 hour, then 4 hours, then overnight — without respiratory distress, desaturation, or stridor.

Weaning protocol (stepwise):
- Step 1: Deflate the cuff (if cuffed tube) — this allows air to flow past the tube and through the upper airway, testing the patency of the glottis and subglottis.
- Step 2: Downsize the tube progressively (replace with a smaller tube) — reduces airway resistance and allows more of the ventilation to pass through the natural upper airway.
- Step 3: Switch to a fenestrated tube — allows phonation and upper airway airflow, further testing glottic function.
- Step 4: Apply a speaking valve or cap (with the cuff fully deflated) — forces all ventilation through the upper airway; monitor SpO2 and work of breathing.
- Step 5: Progressive capping trials (as above).
- Step 6: Decannulation — once capping is tolerated overnight, the tube is removed; the stoma is covered with a small dressing and closes spontaneously within 1-2 weeks in most patients (a stoma open for more than 6 weeks may require surgical closure due to established epithelialisation of the tract).

Phonation and speaking valve: Patients with a cuffed tube cannot phonate because the inflated cuff prevents exhaled air from reaching the vocal cords. A speaking valve (e.g., Passy-Muir valve) placed on the outer tube allows phonation — but the cuff must be completely deflated first, to provide an escape route for exhaled air through the upper airway. Speech-language pathology involvement is essential for optimising voice and swallowing rehabilitation in long-term tracheostomy patients.

Self-Assessment: Tracheostomy

Work through these scenarios and key-point questions to test your mastery of the tracheostomy competency. The scenarios focus on the practical ward-level decisions that any doctor managing a post-tracheostomy patient must be able to make — not the technical details of the surgical procedure, but the clinical situations you will encounter as a junior doctor or intern. Apply the principles you have learned: the two-tube design, the cuff pressure importance, the decannulation criteria, and the critical distinction between tracheostomy and cricothyroidotomy.

Scenario A: A 35-year-old man with bilateral vocal cord palsy post-thyroidectomy had a tracheostomy placed 3 days ago. The nurse calls you at night because the tracheostomy tube has fallen out. The stoma opening is visible. You have a spare tracheostomy tube of the same size at the bedside. What do you do?

Scenario B: An ICU patient has been ventilated for 14 days after a head injury. The ICU team wants to place a tracheostomy to facilitate weaning. The family asks whether this will affect his ability to speak again. What would you tell them?

Scenario C: A 60-year-old woman with a tracheostomy for laryngeal carcinoma has been on a capping trial for the last 3 hours. She tolerates it well with SpO2 96% and no distress. The following day she tolerates a full overnight cap. What is the next step?

Key recall questions:
- State the correct level for a surgical tracheostomy (which tracheal rings, and why not the 1st ring, and why not too low).
- State the correct site for an emergency cricothyroidotomy and what anatomical landmark defines it.
- What is the immediate action if the obturator has been left inside a tracheostomy tube after insertion?
- What is the required cuff pressure range and what are the consequences of exceeding it?
- Name three criteria that must be met before a patient is decannulated.

Answers:
- 2nd and 3rd tracheal ring; not the 1st because it risks the cricoid cartilage causing subglottic stenosis; not too low because the innominate artery crosses the trachea at the 6th-7th ring level.
- The cricothyroid membrane (the soft palpable area between the lower border of the thyroid cartilage and the upper border of the cricoid cartilage).
- Remove the obturator immediately — it completely occludes the lumen and the patient cannot breathe through the tube while it is in place.
- 20-25 mmHg (15-20 cmH2O); exceeding this causes tracheal mucosal ischaemia → necrosis → tracheomalacia or tracheo-innominate fistula.
- Three from: resolution of the original indication; adequate spontaneous breathing; adequate swallow/aspiration control; ability to clear secretions; tolerance of progressive capping trials without desaturation.