An artificial airway is a tube inserted in the trachea either through the mouth or nose or by a surgical incision. Artificial airways have been known to medical science for 3000 years. George Washington ultimately died of upper airway obstruction because his physicians could not agree on the use of tracheostomy. It was not until 1909, when Chevalier Jackson published his classic paper on tracheotomy,¹ that this procedure gained some acceptance. The procedure did not become a highly specialized technique in patient care until the invention of modern tracheostomy tubes and the development of intermittent positive-pressure ventilators. In today’s clinical practice, artificial airways have the following four basic purposes: to bypass upper airway obstruction, to assist or control respirations over prolonged periods, to facilitate the care of chronic respiratory tract infections, and to prevent aspiration of oral and gastric secretions. Multiple disease processes and traumatic problems can require an artificial airway, but each situation, simple or complex, can fit into one or several of these categories (Box 44-1).

Box 44-1

Disease Processes That Could Require an Artificial Airway Because of Respiratory Insufficiency

Primary lung disease (e.g., emphysema, chronic bronchitis, pulmonary fibrosis, cystic fibrosis, severe pneumonia, burned lung, and toxic inhalation)

Systemic disease with secondary lung involvement (e.g., cardiac failure, renal failure [fluid overload], and multiorgan system failure)

Neuromuscular disease (e.g., polio, Guillain-Barré syndrome, myasthenia gravis, use of muscle relaxants, and tetanus)

Central nervous system depression (e.g., drugs, postanesthesia, metabolic coma, cerebrovascular accident, meningitis, and central nervous system tumors)

Trauma (e.g., head/neck/chest surgery or injuries)

Diseases complicated by extremes of age (e.g., premature infant or older adult)

Mechanical obstruction (e.g., upper airway infection, laryngeal paralysis, tumor, edema, bleeding, foreign body, and thyroid malignancy)

Recurrent aspiration (e.g., glottic incompetence, occlusive diseases of the esophagus, and swallowing disorders of various causes)

From Selecky PA: Tracheostomy—a review of present-day indications, complications, and care, Heart Lung 3:272-283, 1974.

Indications of Need

The respiratory care team can play a vital role in recognizing patient need for a tracheostomy by noting physiological changes that indicate respiratory distress.² Cardinal signs of dangerous airway obstruction are stridor and chest wall retractions. Early clinical signs may include restlessness, agitation, tachycardia, confusion, motor dysfunction, and decreased oxygen saturation on pulse oximetry. These signs may be accompanied by headache, flapping tremor, audible wheezing, congestion, and diaphoresis. Cyanosis from impaired oxygenation of the blood is a late, ominous sign.

In children, restlessness is due to the lack of oxygen unless another factor (e.g., thirst) is clearly evident. Extreme fatigue and an inability to sleep indicate impending danger. Apprehension, restlessness, and mental confusion at any age may be taken as early signs of hypoxemia.

Complications of Tracheostomy

Depending on the patient’s impairment, selection of the appropriate airway is made by considering the following factors: What is the best means of accomplishing the goal? Is it an emergency or a controlled, determined situation? Will the airway be needed for long-term care? In general, oral endotracheal tubes are inserted in emergencies. They are the quickest and easiest tubes to insert, even for relatively untrained personnel. A nasotracheal tube will generally replace the oral endotracheal tube for a long-term intubation. The nasal tube is more efficient in that it is better secured, allows the patient to eat, is easier to suction, and is generally more comfortable for the patient.

There are certain complications with nasotracheal tubes. Among these are sinus blockage and pain, vocal cord damage, and pressure necrosis to the cartilaginous structure of the nose. To reduce these complications, the airway should be evaluated daily. The tube should be removed as quickly as possible when the indication for intubation is reversed. If there appears to be a need for a more long-term airway, however, a tracheostomy should be considered. The procedure should not be taken lightly because many additional complications may occur.

Complications of tracheostomy can be surgical, postoperative, or physiological. Complications that occur at the time of the operation are more frequently direct results of the surgical procedure itself. Delayed complications may result directly or indirectly from surgery, postoperative care, or the abrupt physiological changes resulting from tracheostomy. Objectives of caring for the patient after a tracheostomy are to maintain patency of the tube, cleanliness of the wound site, and good aeration of the lungs, as well as to observe any changes in the patient’s vital signs and oxygenation by pulse oximetry.

In patients with artificial airways, the normal physiological mechanism for adding moisture to the air via the nasal mucosa is bypassed. Therefore supplemental humidification is extremely important to protect the mucosa from drying and crusting, which results in obstruction.

The dressing under the tracheostomy tube and tracheostomy ties should be changed when they become soiled because dried blood and other secretions near the incision can encourage bacterial growth. The incision should be checked frequently for bleeding. The skin may be cleaned with half-strength hydrogen peroxide and sterile saline when a new dressing is applied. The dressing should be folded into place, never cut. This eliminates the possibility of lint or frayed threads being aspirated. Commercially prepared dressings best meet these criteria.

When changing the tapes that hold the tube in place, it is best to have one nurse hold the tube in place while another replaces the old tapes. An angle is cut at the end of the tape to facilitate its placement through the flange of one side of the tube. The tape is then threaded through the back of the tracheostomy tube and through the other flanged opening and tied securely with a square knot placed on one side of the patient’s neck. One finger should be placed under the twill tape while tying it; this will prevent the tape from being tied too tight.

Pneumothorax can occur immediately after tracheostomy because of laceration of the mediastinal pleura at the time of or within 24 hours of surgery (this arises often in children and patients with chronic obstructive lung disease). Other problems include air embolism, aspiration, and subcutaneous and mediastinal emphysema. Recurrent laryngeal nerve damage or posterior tracheal penetration may occur but is uncommon.

Postoperative Physiological Complications

Attentive nursing care is the single most essential factor in postoperative tracheostomy management. Vigilant monitoring and observation by the entire respiratory care team is of vital importance.

Patients with an artificial airway are understandably apprehensive and have special communication needs. They should be reminded that their inability to speak is only temporary. These patients must be reassured that they will be monitored frequently and can trust and depend fully on the health care team to attend to their needs. If alert, patients must be equipped with a signal light or bell, paper and pencil, magic slate, or picture board for communication.

Airway obstruction is the foremost complication that exists postoperatively for the patient who has undergone tracheostomy. Tracheal secretions are the major source of obstruction, particularly if they are excessive or viscous. When using a cuffed tube, acute obstruction might occur from overinflating the cuff, which allows it to balloon over the end of the tube. Other causes of obstruction are dislodgement of the tube into a false tract anterior to the tube tracheal opening, and kinking of softened plastic cannula.

Tracheobronchitis, inflammation of the trachea and bronchus, is a complication resulting primarily from irritation due to incorrect suctioning technique and the presence of a foreign body in the trachea.

Crusting is a common and complex problem that may result from inadequate humidification of inspired air or patient dehydration. In many instances, ulceration of the tracheal mucosa results from irritation by the airway or incorrect suctioning. This ulcerated area becomes infected with various organisms and is virtually covered by crust. Further suctioning removes the crust, causing discharge of serum and bleeding. The discharge produces a wet eschar that is covered with mucus. Because of the drying effect of air passing over this mass, a hard crust can form. The development of this crust in the trachea might eventually produce a mass large enough to completely plug the tracheal cannula and almost completely obstruct the trachea. Cases have been cited in which an entire cast of the tracheobronchial tree has been removed.

Other physiological complications may be related to the following: hypoxemia developing before or during the procedure and resulting in an uncontrollable patient, cardiac arrest, and increased myocardial sensitivity to adrenalin; alkalosis developing from rapid carbon dioxide washout after establishment of the airway, resulting in myocardial fibrillation and apnea; and cardiac failure, resulting in profuse bronchorrhea caused by pulmonary edema and shock.

A less commonly known physiological complication is related to lack of good oral care. This means the patient with an artificial airway should have his or her teeth brushed at least twice a day (if this is not possible, the green disposable oral swabs can be used) to decrease potential pathogens as Staphylococcus aureus or gram-negative rods.

Chronic complications cited by Dailey and colleagues (1992)³ include the following: infection at the surgical site, aspiration, aerophagia, persistent stoma, and tracheal stenosis.

Postoperative Mechanical Complications

Dislocation of the tube may result from unsatisfactory nursing care, poor attention to the airway during positioning, or ventilator tubing pulling on the airway. If the tracheostomy tube tapes are not kept tight and tied with a square knot or if they become loose as a result of subcutaneous emphysema or edema, the tube may be coughed out of the trachea and become lodged in the tissues of the neck and obstruct the airway. In pediatric patients, stay sutures are frequently used to prevent dislodgement of the tracheostomy tube. These sutures are valuable during recannulization of the tube if it comes dislodged before a tract has been well established. Stay sutures will prevent entry into a false tract. Advantages of this technique include the following: rapid replacement of blocked or displaced tubes, improved exposure of the trachea at surgical intervention, firm anchoring of the trachea at the moment of incision, decreased trauma associated with extubation, and uniform tracheostomy technique for all ages.

Dislodgement of the outer cannula or required removal before a tract has been well established (usually 5 to 10 days) again requires diligence and quick action by the nurse. No attempt at reinsertion should be made without adequate light, satisfactory tissue retraction, tracheal hook, and a Trousseau’s dilator. A Trousseau’s dilator and tracheal hook should be readily available. A spare tracheostomy tube of the correct size should be kept at the patient’s bedside at all times. Should the tube be coughed out, the nurse uses the Trousseau’s dilator to hold the wound apart while summoning the physician. Tragedies have occurred from inserting the tube into the soft tissues of the neck or mediastinum because of a dislodged cannula and the frantic efforts to replace it. Once the tracheostomy tract has been firmly established, the tube can be replaced by the nurse on written order of the physician.

Tracheostomy Tubes

Metal Tubes

Tracheostomy tubes are of two basic types: metal and polyvinyl chloride (hard and soft). Metal tubes are no longer commonly used, but some patients with long-standing metal tracheostomies may prefer not to switch to a polyvinyl chloride tube. Metal tubes can be made of either stainless steel or sterling silver and are composed of the following three parts: an outer cannula that fits into the tracheal incision, an inner cannula that fits into the outer cannula, and an obturator that facilitates insertion of the tube. These three parts constitute a metal tracheostomy set and are not interchangeable with the parts of any other set. Before the outer cannula is inserted into the tracheal incision, the obturator is placed inside. The lower end of the obturator protrudes from the end of the outer cannula and facilitates its insertion into the trachea. This is the only purpose of the obturator. The protruding end of the obturator obstructs the lumen of the outer cannula. When the obturator is removed, it is immediately replaced with the inner cannula. If one part is lost or damaged, the entire set is useless. Therefore each part, including the obturator, must be accounted for carefully. Care should be exercised in handling sterling silver tubes because silver is easily dented.

The inner cannula should always be inspected to be sure it is clean and clear of secretions before it is reinserted. Mucus that has dried inside the inner cannula cannot be cleaned by merely rinsing it with water. The cannula should be soaked in hydrogen peroxide, scrubbed with a tracheostomy brush, and rinsed with saline to be sure all secretions have been removed. If a silver inner cannula becomes discolored, it may be cleaned with silver polish.

To prevent dislodgement, lock the inner cannula into position after reinsertion. The locking mechanism is different with each tube, and the therapist should become familiar with the types used. If the inner cannula is not locked, it may come out if the patient has a forceful exhalation or position change. It is vital that the inner cannula be reinserted quickly if the patient is on mechanical ventilation, especially if the patient is on full support.

Polyvinyl Chloride (Plastic) Disposable Tubes

The development of plastic tracheostomy tubes brought about three major improvements that account for their widespread use: application of silicone to the inner surface of the plastic tube minimizes crusting and adherence of secretions; it is easier to attach a safe, dependable, permanent inflatable cuff to the plastic tube that cannot slip off and occlude the tracheal opening; and lower costs allow the tube to be disposable. Plastic tubes, unlike metal sets, generally have interchangeable parts. The tubes come with and without cuffs.

The cuffed tracheostomy tube is primarily used in conjunction with a positive-pressure ventilator to form a closed system (Figure 44-1). It is also used to reduce the possibility of aspiration because of absent reflexes, protective laryngeal reflexes, or pharyngeal reflexes. The inflatable cuff is located around the lower portion of the tube and, when inflated, seals the trachea from most airflow except through the tube itself (see Figure 44-1). The cuff, usually made of pliable plastic, is inflated by injecting air into the fine-bore tubing. A small pilot balloon is located proximally in the tubing and indicates that the cuff is inflated. The inflation end of the cuff and the balloon must be checked before insertion of the tube into the trachea to be certain that there are no leaks. The Luer valve inflation port to the pilot balloon is self-sealing. Some Luer valves have a relief valve when pressure exceeds 25 mm Hg.

Fig. 44-1 A, Cuffed adult tracheostomy tubes, uncuffed pediatric tracheostomy tube *(far left)*. B, Cuffed adult endotracheal tubes, uncuffed pediatric endotracheal tube *(far left)*.

Cuff Inflation

There are two commonly used methods of cuff inflation: minimal air leak, in which a small amount of air escapes on inspiration; and minimal occlusive volume, in which just enough air is placed in the cuff to stop air from escaping on inspiration. According to Crabtree Goodnough (1988)⁴, the minimal leak cuff technique may produce less injury than the minimal occlusive volume inflation technique. Regardless of which technique is used, the pressure of the cuff should be checked every 4 to 8 hours and the pressures documented. With continued research and monitoring of tracheal cuff pressures, potential tracheal injury can be prevented.

Once the cuff is inflated, the only route for air exchange is through the patient’s tracheostomy tube; therefore careful observation of the patient is essential. If the patient is on mechanical ventilation, observation is essential. Alarms are always to be in the “on” position when a patient is being mechanically ventilated. Some means of resuscitation, such as a manual resuscitation bag with mask, must be available at the bedside to ventilate the patient in case the tracheostomy tube comes out or is dislodged.

Considerable emphasis has been given to the incidence of tracheal ischemia and resulting stenosis from the use of a cuffed tube. Tracheal ischemia results from the pressure of the cuffed tube against the tracheal wall, which heals with scar formation and thereby leads to subsequent stenosis. This complication can be reduced or eliminated by minimal air leak or minimal occlusive volume. For the minimal occlusive volume, the cuff must be inflated to eliminate any air leak on inspiration. Cuff pressures should be monitored and documented every 4 to 8 hours to prevent tracheal injury. The recommended cuff pressure is 15 to 25 mm Hg. The cuff is inflated until there is no air leak between the wall of the trachea and the cuff, and then a small amount of air is released to allow only a slight air leak between the walls of the trachea and the cuff. This reduces the pressure of the cuff, still allows the ventilator to function properly, and reduces the likelihood of tracheal ischemia. Any difficulty in properly inflating the cuffed tracheostomy tube should be reported to the physician immediately.

If the tracheotomized patient is conscious, he or she may attempt to speak. If the cuff is properly inflated, the patient will be aphonic because no air can pass over the vocal cords. If the patient needs to speak, the cuff can be deflated, and the patient may be given a sterile dressing to hold over the tube. This will allow him or her to speak and also clear secretions by rapid exhalation (simulated cough).

To prevent the formation of crusts, inspired air must be continuously and adequately humidified by means of nebulizing equipment. The equipment used for this purpose can be a possible source of infection. Ideally, the nebulizer and tubing should be changed every 8 hours—at the very least, once every 24 hours.

The Communitrache I is a tracheostomy tube that permits the removal of secretions above the inflation cuff without nasotracheal suctioning. The other benefit to this tracheostomy tube is the patient’s ability to communicate, especially while on a ventilator. When the patient is weaned from the ventilator, a fenestrated tube may be used. The term fenestrated comes from the French word fenestre, meaning “window.” There is a window (fenestration) in the outer cannula. When the tube is used for speaking, the cuff is deflated, the inner cannula is removed, and an external plug is inserted to cap the tracheostomy tube to allow the patient to speak. The cuff must be deflated when the cap is in place. If the cuff is inflated, the patient is unable to breathe air into the lungs and will exhibit immediate distress. If a patient with a fenestrated tube needs to be suctioned, the inner cannula must be replaced so that the suction catheter does not enter the fenestration and cause injury to the tracheal wall mucosa.

Other Airway Devices

The Olympic tracheostomy button is used as an interim airway after tracheostomy tube removal (Figure 44-2). This method is another example of weaning a patient from the tracheostomy tube but still maintaining the stoma should a tracheostomy be again needed. Patients that may benefit most from this device are those with chronic obstructive pulmonary disease (COPD). This is one method used to facilitate secretion removal after hospitalization when it becomes necessary because of the disease process. The Olympic tracheostomy button allows the tracheostomy patient the opportunity to reestablish an unobstructed airway and at the same time allows the patient to speak.

Fig. 44-2 Dimensions and actual positioning of an Olympic tracheostomy button. *(From Pierson DJ, Kacmarek RM.* Foundations of respiratory care, *Churchill Livingstone, 1992, Edinburgh.)*

Many other speaking tracheostomy tubes are available.⁵ Airway clearance needs to be optimized before a speaking valve is used. If a patient has increased secretions, he or she may find it difficult to tolerate the procedure. A benefit of the valve, however, is that the patient may be able to simulate coughing and promote mobilization of upper airway secretions.

One common speaking valve is the Passy-Muir Swallowing and Speaking valve (Figure 44-3). The Passy-Muir is a one-way valve that allows inspiration only and redirects exhalation through the upper airway. It is important to note that the cuff must be deflated when using the valve, or a cuffless tracheostomy tube may be used. Breath stacking exercises (taking a few breaths in without exhaling) can be used to get more air into the lungs before exhalation. Using the valve, the upper airway muscles gradually recover, allowing for transition to a fenestrated tube or a smaller size tracheostomy tube and thereby preparing the patient for eventual decannulation.⁶ Another benefit may be an improved ability to swallow. Also, some patients claim that they can taste their food again, which may promote improved nutrition and hydration.^7,8

Fig. 44-3 The Passy-Muir Valve. This valve attaches to a standard 15-mm tracheostomy adapter. It allows inspiration via the valve, but exhalation must occur via the upper airway. (Courtesy Passy-Muir.)

The management of major airway obstruction by tracheal tumor, external compression, or tracheal disease below the thoracic inlet still presents difficult problems. The Montgomery T tube is a bifurcated silicone rubber stent designed to preserve patency of the airways in a patient with injury to the trachea or main stem bronchi (Figure 44-4). When the T tube is in place, the patient breathes normally through the nose and mouth and can speak. The T tube is helpful in long-term therapy to alleviate obstruction or during reconstructive surgery. This device does not cause any adverse tissue reaction on a long-term basis, according to Montgomery.^9,10

Fig. 44-4 The Montgomery T tube. *(From Montgomery WW: Manual care of the Montgomery silicone tracheal T tube,* Ann Otol, Rhinol & Laryngol *89 [Suppl 73]:3, 1980.)*

Airway Care

Normally, the mucociliary escalator and the cough reflex provide airway clearance. When these mechanisms fail, suctioning of the airways, manual cough assistance, or the cough machine is indicated. Suctioning does have potential hazards, but it should be a safe procedure with proper guidance and care.¹¹ Health care professionals also need to protect themselves during open system suctioning. This procedure can cause dissemination of particle droplets in the immediate area. Ng and colleagues (1999)¹² studied 50 consecutive suctioning procedures with intubated patients using an open system (i.e., the mechanical ventilator tubing is removed from the tracheostomy or endotracheal tube to suction the patient). Visible droplets were scattered from 25 to 168 cm from the artificial airway. When they were cultured, the same bacteria aspirated grew on the agar plates. This highlights how important it is for the person performing the suction procedure to use protective eyewear and to take necessary precautions.¹²

Suctioning

When preparing to suction, three phases should be considered (Table 44-1)^13,14:

Table 44-1

The Three Phases of Suctioning

Before suctioning

Patient assessment and preparation, as well as hyperoxygenation, are essential. Proper catheter size will be discussed later in the chapter.

During suctioning

Awareness of the appropriate depth of insertion is essential, and time limits for the procedure must be observed.

A decision must be made as to how many passes of the catheter will be needed.

Monitoring of the patient by ECG and pulse oximetry will demonstrate the patient’s tolerance of the procedure.

After suctioning

The patient needs to be reassured and positioned comfortably.

Reconnection to the ventilator or previous level of equipment must be completed in cases of open-system suctioning.

1. Preparation before suctioning

2. The actual suctioning procedure

3. Postsuctioning

Open Versus Closed Suctioning Systems

Patients on mechanical ventilators may be suctioned by disconnecting the ventilator tubing and suctioning (open system), or suctioning may be done directly in-line with the ventilator tubing (closed system). Studies have shown that a closed system maintains better physiological stability, less oxygen desaturation, and fewer dsyrhythmias.15–18

Suction Procedure

Proper explanation of the suctioning technique to the patient helps allay apprehension and enhance cooperation. Medicate the postoperative patient before suctioning to decrease the pain of coughing. Always maintain a calm and reassuring manner.

Maintain aseptic technique throughout the entire procedure. Use sterile gloves and a sterile, disposable catheter for each suctioning.

Position the patient properly unless contraindicated. Nasotracheal and/or pharyngeal suctioning should be done with the patient in Fowler position, 60 to 70 degrees (Figure 44-5, A), or semi-Fowler position, approximately 45 degrees, with the neck hyperextended (Figure 44-5, B). The supine position is best for the patient with tracheostomy or endotracheal tubes (Figure 44-5, C).

Fig. 44-5 Positioning for suction. A, Fowler’s position. B, Semi-Fowler’s position. C, Supine position.

Pharyngeal suctioning may be necessary before deflating the cuffed tracheostomy tube. The nurse should not suction the pharynx and then the trachea with the same catheter; however, the trachea may be suctioned first and then the pharynx with the same catheter.

Duration of suctioning is very important. Each suctioning procedure should last no longer than 5 to 10 seconds to avoid hypoxia.

Prolonged suctioning may result in precipitating a dysrhythmia or cardiac arrest. A good way to judge the elapsed time is to hold one’s own breath and be guided by the development of discomfort. This is most important for the patient who depends on ventilatory assistance.

Use the lowest possible vacuum settings (below 120 mm Hg) that will still support suctioning the tracheostomy tube. The higher the setting is raised, the greater the risk for trauma to the tracheal mucosa. Caution should be exercised to avoid kinking the suction tubing or catheter. When negative pressure is excessive and released suddenly, inadvertent removal of portions of tracheal mucosa may occur.

Insertion of the suction catheter should be done gently, using aseptic technique and sterile gloves. Goggles are used as part of universal precautions if there is any danger of coughed-out secretions. The catheter should first be moistened in sterile saline or with a water-soluble gel. Suction is not applied while the catheter is passed down into the trachea. Proper insertion of the catheter will stimulate coughing when it contacts the carina (Figure 44-6, A). It is then immediately withdrawn one cm before suction is applied (Figure 44-6, B). Do not force the catheter up and down while suctioning. Suction is applied only while the catheter is being withdrawn. Rotating the catheter during withdrawal results in suctioning a larger area and increases the surface contact of the trachea and tracheostomy tube (Figure 44-7).

Fig. 44-6 Suctioning procedures. A, The catheter will stimulate coughing when it contacts the carina (in a patient with cough reflex). B, The catheter is withdrawn 1 cm after it reaches the carina, before applying suction.

Fig. 44-7 The catheter is rotated during withdrawal in order to suction a larger surface area.

Left main-stem bronchus aspiration is more difficult because of the anatomical arrangement of the bronchus. It was formerly thought that left bronchial aspiration was facilitated by turning the patient’s head to the right. Studies by Kirimli and colleagues (1970)¹⁹ and Panacek and colleagues (1989)²⁰ indicate that left bronchial aspiration is best accomplished by using a Coudé tip catheter. After its insertion into the trachea, the curved tip should be positioned to point toward the left main-stem bronchus. Even so, insertion is difficult, and auscultation by stethoscope is necessary to thoroughly access the suctioning.

Right main-stem bronchus aspiration is the usual method because of the more direct alignment of this bronchus with the trachea. This can almost always be carried out with a straight tracheal catheter. The deeper suction would rarely be indicated; generally when the catheter hits the carina, it is withdrawn before suctioning.

Excessive suctioning can be harmful. Use judgment to determine just how often a patient requires suctioning. It should not be routine; rather, it should be based on the need of the patient.21,22 Assessment by auscultation and patient clinical observations should be used to determine the need for suctioning. Suction only when it is needed.²³ Allow the patient to rest and breathe between each insertion of the suction catheter and, if necessary, ventilate the patient for a few minutes before further suctioning. Remember that each suctioning attempt removes air as well as secretions. Hyperoxygenation with 100% oxygen has been suggested to provide better results and fewer complications. Hyperventilation was previously encouraged, but studies have shown that it is not necessary; hyperoxygenation is the important factor.^24,25

Table 44-2

The Pediatric Tracheostomy Card

Tracheostomy Size	Recommended Catheter Size
Pediatric tubes
00 PT	6.5 F
0 PT	6.5 F
1 PT	8 F
2 PT	8 F
3 PT	10 F
4 PT	10 F
Neonatal tubes
00 NT	6.5 F
0 NT	6.5 F
1 NT	6.5 F
Single cannula tracheostomy (SCT) tubes
5 SCT	10 F
6 SCT	12 F
7 SCT	14 F
8 SCT	14 F

From Warnoch C, Porpora K: A pediatric trache card: transforming research into practice, Pediatric Nursing 20:186-188, 1994.

The catheter used for pharyngeal suctioning should never be used for subsequent suctioning of the artificial airway, but using an artificial airway suction catheter for pharyngeal suction is acceptable. Aseptic technique is absolutely necessary to minimize the risk for infection, and ideally, only disposable catheters should be used.

Suctioning may be necessary every few minutes when the patient initially returns from surgery because there is an increase in secretions, which is usually the result of irritation of the endotracheal tube plus a reflex mechanism initiated by the surgical trauma. Usually, by paying attention to the patient’s color, respiratory rate, lung sounds, and oxygen saturation on pulse oximetry, the nurse or therapist can determine the amount of secretions present. Excessive mucus in the trachea or large bronchi is usually indicated by coarse, rattling sounds. Fine bubbling sounds usually suggest fluid located more peripherally (i.e., in the alveolar spaces). If accumulated secretions are not cleared, they can cause respiratory and cardiac rates to increase; effective oxygen and carbon dioxide transfer is impaired, causing cyanosis to appear and low-grade fever to develop.

General Suctioning Procedure for an Artificial Airway

The procedure for suctioning an artificial airway begins after the clinician has taken all of the same appropriate procedure preparatory measures, including sterile technique procedures, as are required when suctioning without an artificial airway.

Hyperoxygenate with 100% oxygen for three to five breaths with manual resuscitation bag.

Place the patient’s neck in extension.

Lubricate the catheter with sterile saline or water-soluble gel.

Place the catheter (without suction) upward and backward in short increments. Continue until an obstruction (the carina) is reached.

When the carina is stimulated, the patient will generally cough unless his or her reflexes are obtunded.

Pull the catheter back slightly from the carina; then apply suction with no more than 120 mm Hg pressure as the catheter is withdrawn in a rotating motion.

Aspiration time should be within 10 to 15 seconds total. A good guideline is for the therapist to hold his or her own breath during suctioning (because the patient is also not breathing). This gives the therapist a better sensitivity for what the patient is experiencing.

Allow the patient to rest for several seconds and preoxygenate the patient again.

Check the patient’s breath sounds and repeat the procedure, if necessary, to remove more secretions.

Suction pharynx.

Observe the patient and monitor for any dysrhythmias.

Use pulse oximetry to monitor desaturation.

Instillation of Saline

Saline instillation is not recommended. Studies have shown that it is ineffective and can cause reflex and uncomfortable airway responses (i.e. cough, bronchospasm). Also, the saline instillation potentiates infection. It is not a recommended practice.26,27

Extubation/Decannulation

Extubation or decannulation is the removal of the artificial airway. In general, this is done when the reason for establishing the artificial airway no longer exists. In certain cases the artificial airway may be removed to facilitate airway clearance and aspiration. This can be prevented with thorough attention and care of the tracheostomy tube.28,29 The patient is aided in gradually relearning normal breathing through his or her upper respiratory tract before the tube is removed. This can be a time of considerable fear and anxiety for patients because they have learned they can breathe safely through their tracheostomy, and they may become apprehensive when asked to breathe in a normal manner. The relearning process can be accomplished under the physician’s direction by reducing the lumen of the tube for a day or two or by partially obstructing the tube’s outer opening for increasing lengths of time. Eventually the patient is able to tolerate the complete occlusion of the tracheostomy opening. This is sometimes difficult and similar to breathing through a straw.

When occluding the tracheostomy opening with a cuffed tube, the cuff must be deflated first. Failure to do this will result in total obstruction of the patient’s airway as the tube opening is occluded.

Fenestrated tubes are excellent for weaning the patient from the tracheostomy tube. They are probably more effective than using cuff tubes; furthermore, they do not actually increase the airway resistance, as do cuffed tubes. Fenestrated tubes also allow the patient to talk and attempt to cough to mobilize secretions. Other methods used in decannulation include the Olympic tracheostomy button and the Passy-Muir valve. The Olympic tracheostomy button allows the airway to remain patent for suctioning and reinsertion of a tracheostomy tube should it become necessary. The Passy-Muir valve allows for normal recovery of the upper airway muscle, making it possible to reduce the size of the tracheostomy tube, leading to eventual plugging and decannulation. Careful observation and documentation of the patient’s ability to ventilate must be done when any of these devices are used in the decannulation process.

Close supervision should continue after extubation. After a tracheostomy tube is removed, the skin edges are usually taped together with butterfly strips for a few days until the wound heals. During healing, air will escape through the wound and reduce the effectiveness of the patient’s cough. The patient should be instructed that the noise from the partially closed trachea is normal, and small secretions should be removed from this area. The patient should be taught and instructed to hold a sterile dressing firmly over the incision when coughing until the opening heals.