Tracheostomy Care: Cleaning The Inner Cannula And Dressing Change

Tracheostomy Care: Cleaning the Inner Cannula and Dressing Change

Purpose:  Routine tracheostomy and stoma care is provided to aid in healing and prevent infection and skin breakdown. Frequent soiling and moisture from secretions leads to skin maceration and discomfort. The tracheostomy site should be kept clean and dry with dressing changes daily or whenever soiled or wet. Dressings should be sterile and non-woven to avoid fraying fibers from entering the trach tube. Accumulated secretions also contribute to occlusion and provide an environment for bacterial growth, so care also includes removal and cleaning of the inner cannula, if present.  

Nursing Considerations

Assessment:

  • Review provider orders and patient care plan.
  • Review trach care policies.  Evidence-based practice recommends two-person technique for trach care when possible to avoid dislodging tube.
  • Assess whether patient has an inner cannula.  Many patients have disposable inner cannulas, which eliminate the need for cleaning.
  • Assess secretions and pulmonary status and perform trach suction, if indicated.
  • Assess skin integrity and look for signs of infection near stoma and along the neck where trach ties lie.
  • Ensure that suction equipment, additional trach tubes, and an obturator is available at the bedside.
  • Check for an inner cannula.  It is important to remove the inner cannula and clean it to prevent mucus buildup. The inner cannula locks into place.
  • Assess the type of tracheostomy:  Many trachs are uncuffed.  Some trachs have inflated cuffs (balloons) to decrease the risk for aspiration and facilitate ventilator use.  These are generally used for patients with swallowing difficulties, pediatric patients, or ventilated patients.  Routine trach care is essential whether cuffed or uncuffed.  Cuff pressures are routinely checked and documented per facility policy to avoid damage to airway tissue over time and this can be done at the same time as cleaning if desired.  Cuffs are inflated or deflated per provider orders only, so it is important to assess each patient’s tracheostomy and orders.


Contraindications

  • none

Risks:

  • When performing tracheostomy care, emergency supplies should be available at all times in case the tube is inadvertently dislodged.

Patient Teaching:

  • Explain the procedure. Patients should verbalize understanding of proper care.

Procedure

Supplies:

  • trach cleaning tray (includes sterile gloves, sterile basins,  pipe cleaners, brush, cotton-tipped applicator, gauze)
  • presplit non-fraying 4x4 or split drain sponge
  • replacement inner cannula, if applicable
  • sterile normal saline
  • clean cotton trach ties or Velcro tube holder

Steps:

  • Confirm the patient’s ID using two identifiers.
  • Explain procedure to patient.
  • Open trach tray and put on one sterile glove in order to set up two basins.
  • With an un-gloved (non-sterile) hand, pour saline into each basin.
  • Don the second sterile glove - both hands are now sterile.
  • Remove inner cannula, if applicable:  Secure outer cannula neck plate with index finger and thumb.  Unlock inner cannula - usually by turning LEFT 90 degrees.  Gently pull cannula up and out - it should withdraw easily.
  • Soak and clean the inner cannula in sterile normal saline or discard if disposable.  Remove any secretions by cleansing and wiping the lumen with moistened brush.
  • Place cleaned inner cannula on sterile gauze and dry thoroughly.
  • Replace inner cannula with care, stabilizing outer flange with opposite hand.  Lock into place (turn RIGHT).
  • Cleanse skin around stoma with gauze or applicator soaked in sterile saline from the clean basin (the basin that was not used to clean inner cannula). Use a separate gauze/applicator to clean the outer cannula.
  • Apply new dressing:  Apply presplit non-fraying gauze/split drain sponge around stoma/trach tube with flaps pointing up. (See picture of how to make folded 4x4 dressing if a presplit is not available.)

  • Change trach ties/tube holder if needed.  (See: Changing tracheostomy tube ties)