Abnormal breath sounds such as ‘whistling’, crepitus or diminished sounds.

Irregular breathing patterns.

Increase in coughing / inability to cough.

Cyanosis / deterioration in oxygen saturation.

AMBU bag connected to O ₂ supply.

Two extra tracheostomy tubes - one of the patient’s current size and a smaller one.

Tracheostomy mask.

An obturator of the correct size.

Extra set of trach ties.

Suctioning device.

Appropriately sized suction catheters.

Ensure that emergency tracheostomy equipments are present at bedside.

Note the size, brand, and type of the tracheostomy tube.

Check that the trach is patent, secured, and in midline position;1 finger should fit snugly under trach ties.

Check cuff pressure using manometer q 6 hours (14-30 cmH₂O).

Assess the stoma for bleeding, infection, swelling, and skin breakdown.

Suctioning should be performed using aseptic techniques, with the patient upright and in a neutral head alignment.

Suctioning should not be done routinely; it is done if there is persistent coughing /respiratory distress/ audible or visible secretions /worsening o ₂ saturations.

Explain procedure to patient and reassure.

Always suction with the inner tube in situ; change to a non-fenestrated inner tube.

The suction catheter should have a diameter no greater than half internal diameter of the tracheostomy tube.

Determine the correct size of Suction catheter

size (Fg) = 2 x (Size of tracheostomy tube – 2)

For example, 8.0 mm ID tube: 2 x (8 – 2) = 12 Fg

Patients with high oxygen requirements may require pre-oxygenation.

Use suction pressure of 80-120 mm Hg.

No suction applied on insertion of suction catheter.

Insert the suction catheter approximately 10-15cm (or less, depending on the length of the tracheostomy tube) into the tube before applying suction and slowly withdrawing the catheter.

Suction should be applied for a maximum of 10 seconds.

Note the color, tenacity and quantity of the secretions.

To prevent the occurrence of adverse events, bolus instillation of normal saline should not be used routinely during suctioning

Closed suctioning is preferred, especially in patients who are PEEP dependent.

The upper airway should be suctioned periodically to remove oral secretions and to minimize stasis of pooled secretions above the tracheostomy cuff with subsequent potential for aspiration to lower airway.

Any difficulty in passing the suction catheter should lead to consideration that the tube may be partially blocked, badly orientated or misplaced and requires immediate attention.

Observe for patient’s oxygen saturation, respiratory rate, pattern and heart rate closely.

Apply a new dressing at least once per shift and as required.

Keep stoma clean and dry.

Change a wet dressing immediately.

Clean the stoma with a gauze square moistened with 0.9% NS only.

Do not use cotton wool.

Gauze must be moist, not soaked, to prevent aspiration.

Wipe stoma from inner to outer direction.

Use a new gauze with each wipe.

Humidifier system – heated recommended for patients with

● New tracheostomy tubes.

● Dehydration.

● Immobility.

● Tenacious secretions.

● Prolonged mechanical ventilation (>7 days).

● Hypothermia.

Heat Moisture Exchanger (HME) Filter: recommended for patients with adequate hydration, mobility and with less copious secretions. Change HME whenever visibly soiled or according to manufacturer’s recommendation.

Two-person technique (is the standard).

One person holds the trach tube in place, other person changes the ties.

Secure new ties before removing the old ties.

Allow one finger to fit snugly between the skin and the ties.

Ensure emergency equipments are present at bedside before receiving patient.

Monitor site and vitals q 15mins for the first 2hrs, then q 1 hr.

Observe for acute complications of tracheostomy (i.e., <10 days) like hemorrhage, obstruction, pneumothorax, infection, and accidental decannulation and late complications like stenosis of the trachea and stoma, tracheomalacia, aspiration and pneumonia, tracheoesophageal fistula formation, obstruction, and accidental decannulation.

Notify the On-Duty Doctor immediately if any of the complications occurs or if patient is unstable.

Slight bleeding post-op is normal.

Check full blood count and coagulation profile.

Ensure cuff is inflated to prevent aspiration.

Notify ENT if bleeding is not controlled by usual measures for possible exploration.

In patients with accidental decannulation the approach depends upon tract maturity (after 7-10 days).

When decannulation occurs before the tract is mature (e.g., during the first week) oral intubation with cuff placement beyond the stoma is appropriate.

For those with a mature tract reinserting the tracheostomy is reasonable.

Ask the patient to cough.

The inner cannula, if present, should also be removed and inspected.

A suction catheter should be placed into the tracheostomy tube and passed into the trachea. These maneuvers should relieve most episodes of obstruction.

If the obstruction cannot be removed from the tracheostomy tube itself, the tracheostomy tube may need to be removed and replaced or an endotracheal tube placed.

Two people technique (Standard).

Check that emergency equipments are available.

Stop NG feeding at least 2 hours prior to procedure.

Pre-oxygenate prior to procedure.

Prepare equipments and check patency of new tracheostomy (no cuff leaks).

Lubricate new tracheostomy using sterile technique.

Deflate cuff of old tracheostomy.

Remove old trach in a “curve and downward” movement during expiration.

Insert new tracheostomy using an “up and over” movement.

Inflate cuff, if present, to 14-24 cm H₂0.

Ensure that new tracheostomy and airway is patent.

Provide supplemental O ₂ if required.

Monitor patient’s vitals.

Assess if patient meets objective criteria for decannulation.

Apply decannulation cap.

Apply facial oxygen supply and encourage patient to take deep breaths and cough.

Ensure patient is able to obtain adequate breath via upper airway.

Continue to monitor vital q 15mins for the first 2hrs, then q 1 hr.

If patient cannot tolerate decannulation cap: Remove cap and Return patient to tracheostomy breathing.

Tracheostomy tube can be removed after 24 consecutive hours of decannulation cap in an appropriate environment (ICU or Operating Room).

Deflate cuff if present.

Remove tracheostomy tube in a “curve and downward” movement during expiration.

Observe stoma and edges.

Apply occlusive gauze dressing.

Dressing should be changed every day and as required.

Advise patient to apply pressure over dressing to increase voice and during cough.