Clinical Skills - Tracheostomy Care and Suctioning
by Ellis Parker February 27, 2022 Updated: April 13, 2022 10 min read
Hi, I'm Ellis with LevelUp RN. In this video, I'll be demonstrating how to perform tracheal suctioning, how to do tracheal site care, and how to work with a nondisposable inner cannula. I'll be following along on the steps and best practices included in our clinical nursing skills deck. So if you have the deck, grab these cards and you can follow along with me. If you don't have the deck, then pop on over to leveluprn.com to check it out. After the demonstration, I'll be coming back here to give you just a couple more tips.
Tracheostomy care is going to look different depending on the type of equipment that your patient has. So I'm going to demonstrate the steps that are a little bit more complicated. So we'll be working with a trach that has a reusable inner cannula. So I'm going to take the inner cannula out and clean it and put it back in. But you may come across patients that have a nonreusable inner cannula in which you would simply take the inner cannula out, throw it away, and get a new one. So you would get to skip those first couple of steps. But since that part is a little bit more complicated, we wanted to make sure that you see it the more complicated way. So to start off, I'm going to pull his oxygen down. Now, I would usually just kind of pull this down so that he was still getting oxygen during this procedure. But we're going to need to use our imagination a little bit because I want to make sure that you guys have a good visual. So I'm going to set his oxygen to the side there. But just know you can really kind of just pull it down and out of your way while you're working with trachs. So I'm going to pull his oxygen down a bit. I'm going to open my tray. I have clean hands and clean gloves on. I'm now going to open my sterile saline with my palm against the label. I'm going to pour some sterile saline into the container and then place this to the side.
I can now remove his inner cannula. So I'm going to start by just pinching the flanges on the side here. So I just pinch it and pull. And that's all I'm going to touch on this particular piece. And I'm just going to drop him in his little saline bath. And then I'm going to go ahead and take these gloves off and discard them and put some sterile gloves on. Your kits usually come with sterile gloves, but if you've seen my other videos, I just prefer to get my size. And as always, I grab my dominant hand's cuff, slipping that one on first. Then I tuck my fingers in, keeping my thumb out of my non-dominant hand, and slide that one on. All right. So now I can go ahead and clean his trach area. So I'm going to set my little sterile field up. In these trach kits, you have cotton swabs, a brush, and pipe cleaners actually. You'll also have a new trach tie. So this is to tie on the trach. You'll have trach dressing and you always only use the trach dressing. You never, ever cut a four X four to put around a trach and then just some additional sterile four X four.
So to start, I'm going to remove his old four X four. Noting that my left hand is now not sterile anymore, I'm going to just dispose of that. I can get some more saline into my container, again only using that left hand so I'm not getting my right hand dirty. I'm going to now get some cotton swabs and dip it into the container, and I'm going to clean starting at the stoma itself and pulling out. Just like when we do something like wound care, if I were to start farther away and drag in, I'm potentially dragging bacteria into the stoma and potentially into the respiratory tract, which we know is a sterile tract. And I don't want to do that. So I'm going to start at the stoma site itself and drag outward. And I would get a new swab each time so I could do this as many times as needed. I could also get a swab and clean the faceplate if there were something like sputum or dry mucosa on that faceplate. There was a little bit of dried mucosa on there so I clean that off. I can then use this dry sterile gauze to clean the site and discard that as well. I'm now going to pick the inner cannula up with my left hand because I don't need to be sterile to hold these flanges. Right? So I've got the flanges. I'm going to use this brush to really scrub in there. This has often got some mucosa in it.
So I just insert this just like I was cleaning a straw if you've got one of those reusable straws. Then I can discard my brush and the pipe cleaners are to dry the inner cannula. So I would insert my pipe cleaner. It's hard to get into that main part, and I would just twist it around to dry it. And then once I felt like that was dry, I could put it back in until I hear the click so that I know that it has clicked back into place and isn't at risk of falling out. To replace my ties-- oops, let's do this first actually. I'm just going to snuggle this up under that faceplate. And again, I only ever use these precut gauze sponges, because if I were to use a four X four and cut it myself, I could potentially fray the gauze and some of that could get sucked into his respiratory tract. I would not want that to happen. Right? And then to replace my tie, I actually first need to make sure that I add my new tie on. And most of the ties these days are that Velcro tie that he's already wearing. But this old-fashioned tie is what came in his kit, so I'm going to demonstrate that. But first, I tie his new tie on before I remove his older tie. Again, just to make sure that there is a securement device and he's not at risk for his trach to be expelled. Come on. There we go.
Now I can remove the Velcro from the old tie and discard that. And then I would, of course, replace his oxygen and make sure he's in a comfortable position. And that's how I change and clean my patient's tracheostomy site. Before I can suction a tracheostomy site, I set my patient up in a semi or high valors, and I need to hyper oxygenate them. And that can either be just turning up the oxygen on the wall so that it comes out faster on their oxygen tubing here or if they're on a ventilator, there's usually just a button that you push that says hyper oxygenate. So we'll say that I've already hyper-oxygenated my patient. And just like for cleaning, I can kind of just set this a little bit to the side while I'm working so they're still getting some oxygen flow. I am going to, for the purposes of this video, move it to the side though, so that you have a clearer view of the site that I'm working on today. Before I set up my kit, I'm going to make sure I've got my suction canister ready. So I need my canister. I need the tubing that goes from the canister to the vacuum. I need to make sure that the vacuum is functional so I can turn it on. And I see that it's functioning at 80, which is fine. And then I also need the tubing that goes from the canister to my suction catheter. So I'm going to go ahead and set that right here so that it's ready for me. And I'm actually going to go ahead and turn that on so that it's ready to suction when I need it. I can even test and make sure that suction is occurring. Then, before I get sterile, I'm going to go ahead and loosen my cap on my saline so I can work with that one-handed in a moment. All right, I'm going to open my suction kit.
All right. I'm going to grab my sterile gloves.
All right. Pick up that cuff of my dominant hand.
I don't know why these gloves always break on me. All right. Pick up by sliding into the cuff of my non-dominant hand, keeping my thumb out.
All right. That was a little more struggle than I hoped it was going to be, but that's okay. All right. I'm going to then move this into my garbage can that's right on the floor right there. I'm then going to open this container in which I'll be pouring some normal saline, and then I can slide my catheter out taking care to make sure it stays within that sterile packaging. All right. I can now pour some of the normal saline into my sterile cup, but since I'm wanting to stay sterile with my dominant hand, I need to make sure I'm only touching these things with my non-dominant hand. So with my left hand, which is nondominant for me, I'm going to go ahead and become nonsterile and pour some of this normal saline into my cup. I'm then going to pick up my catheter, slide that around here with my dominant hand which is still sterile. And then I'm going to make sure that this piece gets connected to my suction tubing. And then while I'm working with the catheter and suctioning, I'm going to use my left hand or my non-dominant hand to control the suction, because every time I occlude this hole, it suctions from the end of the catheter. I'm going to use my dominant hand to control the actual tip of the catheter as I insert it into the trach.
So we'll go ahead and make sure that this is functioning. I'm going to occlude it while it suctions. Then I can hear that it's suctioning some of that normal saline. Perfect. So I'm going to go ahead and get ready. I'm going to insert the catheter into the trachea until I meet resistance or he coughs a lot. I'm not going to apply suction while I do the inserting. So I'm going to insert it, insert it, insert it, insert it. Once I meet that resistance, I'm going to use this non-dominant thumb to intermittently apply suctions while I twist with my dominant hand. Each pass should take about 15 seconds. I'm then going to suck some saline up in there so that I can make sure that the tubing gets cleared. If I'm sucking thick mucosa out or anything like that, then sometimes the tubing gets occluded, and I don't want that to happen. I'm going to go ahead and allow him to re-oxygenate, giving him 30 seconds to a minute to just relax. This process denies them of oxygen temporarily. That can be really stressful. And I don't want to cause him any undue stress.
So you need to give them a break, let them catch their breath, give them some oxygen, and then once they're ready for another pass, the exact same thing happens. I insert it with my dominant hand, taking care that it only touches the inside of the trachea, and then apply intermittent pressure or suction, intermittent suction, as I withdraw, and I rotate it, collecting it in my hands so it's not trailing onto their gown. And then I clear my tubing. And I could do this a third time. I would again have them get some extra oxygen, take a break, and I could do one final pass. That would be the final pass for this time, though. I can only do three passes at a time. And then they really do need to recuperate and take a break. And then once I'm done, I just turn off my suction, discard this equipment. I no longer have to be sterile because I'm done with the procedure. And I make sure I replace their oxygen and make sure they're in a safe position. That's how you suction a trachea.
As you can see, that's a really difficult skill. There's just a lot of steps, a lot of things that need to be done in order, and sterility has to be maintained. And I'll be the first to admit in that particular demonstration, I probably didn't maintain perfect sterility so I want to encourage you to be really mindful when you're out practicing. You want to make sure you're not touching the catheter tip or catheter line itself, the trach site itself, the inner cannula itself, or anything that really needs to maintain its sterility. Part of that means setting things up in a certain way and being really mindful and proactive about what you're going to do in the future. So watch where your back is turned. Watch where your hands are reaching. Watch when you're moving with the suction catheter in your hands that it doesn't accidentally touch anything. Make sure that you check the suction and the suction level before you get started because you don't want to have to be messing with that after you're already set up with your sterility. So there's just a lot of different moving parts there. Even when I was showing you the gauze itself, that split gauze piece that goes up against the patient's site, should not be handled because I want it to maintain sterility. I'm just trying to clarify. There are things that I do when I'm teaching that I do for teaching purposes that I wouldn't do in practice and a lot of it is going to have to come down to I had to break sterility a little bit.
So just make sure that you're practicing these skills, maintaining sterility. I did combine all these skills together because they're often done in some type of combination. So make sure you just start practicing what your particular sites use, what your facilities use, what your school is requiring you to use, etc. One more thing I wanted to point out is that when I am changing the trach tie, which I did do in the video but I just didn't mention, I do want to make sure that the tie is secure and tight enough to maintain the trach in place but not so tight that I accidentally strangle my patience, of course, so similar to checking restraints, I'm going to check that trach tie by slipping one finger under the tie. I should be able to comfortably get one finger under the tie which means that there's enough slack on it for my patients to maintain breathing and be comfortable. But there's still enough tension that the trach will remain in place.
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