8.2 Tracheostomy Care, Suctioning & Mechanical Ventilation Nursing

8.2 Tracheostomy Care, Suctioning & Mechanical Ventilation Nursing

Indications and Bedside Safety Protocols for Tracheostomy Patients

A tracheostomy is a surgically created opening (stoma) into the trachea below the vocal cords to establish an artificial airway. Common indications in Singapore clinical practice include prolonged mechanical ventilation (>10–14 days), acute upper airway obstruction (tumors, angioedema, severe facial trauma), retention of severe tracheobronchial secretions, and protection of the lower respiratory tract in patients with severe bulbar paralysis.

Mandatory Bedside Emergency Equipment Checklist

According to Singapore Nursing Board standards and hospital Intensive Care Unit (ICU) / High Dependency (HD) clinical guidelines, every patient with a tracheostomy MUST have the following emergency equipment present at the bedside at all times:

1. Spare Tracheostomy Tubes: One tube of the same size and one tube one size smaller (including matching obturators).
2. Tracheal Dilator / Spreaders: Trosseau dilator or tracheal spreaders to maintain stoma opening during acute tube dislodgement.
3. Functional Suction Apparatus: Working wall suction with tubing, Yankauer tip, and sterile suction catheters (appropriate Fr size).
4. Manual Resuscitation Bag (Ambu Bag): Equipped with a face mask, dedicated tracheostomy adapter, and connected to a functional oxygen source set at 15 L/min.
5. Sterile Saline Flushes & Water-Soluble Lubricant: For emergency re-intubation or catheter lubrication.

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Stoma Care, Dressing Changes, and Cuff Pressure Management

Stoma & Inner Cannula Care

• Stoma Inspection: Perform stoma assessment at least every 8 to 12 hours. Clean surrounding skin with sterile 0.9% normal saline using single-stroke motions from the stoma outward. Inspect for signs of infection, erythema, purulent exudate, subcutaneous emphysema (crepitus), or tissue granulation.
• Dressing Changes: Use pre-cut split tracheostomy dressings (e.g., silicone or foam absorbent dressings). Never cut standard gauze sponges, as loose cotton fibers can be inhaled into the trachea, causing foreign body granulomas or airway obstruction.
• Securing Ties: Maintain two-finger tightness between the neck strap and skin to avoid pressure injury or accidental decannulation.
• Inner Cannula Maintenance: Dual-cannula tracheostomy tubes feature a removable inner cannula. Clean or replace the inner cannula every 8 hours (or PRN) using sterile technique to prevent mucus encrustation and sudden total lumen occlusion.

Cuff Pressure Monitoring

The tracheostomy/endotracheal tube cuff creates a seal between the tube and tracheal wall, directing airflow through the lumen and preventing pharyngeal secretion aspiration.

Target Cuff Pressure: 20 – 30 cmH2O (15 – 22 mmHg)
- Checked using a calibrated cuff pressure manometer every 8 hours and post-repositioning.

• Over-Inflation (> 30 cmH2O): Exceeds mucosal capillary perfusion pressure (~30 cmH2O), causing tracheal mucosal ischemia, necrosis, tracheal stenosis, tracheomalacia, or tracheoesophageal fistula.
• Under-Inflation (< 20 cmH2O): Allows micro-aspiration of pooled subglottic secretions into the lower respiratory tract, significantly increasing the risk of Ventilator-Associated Pneumonia (VAP) and ventilator air leaks.

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Airway Suctioning Protocols: Indications, Technique, and Complications

Airway suctioning removes accumulated secretions to maintain airway patency. Suctioning must NEVER be performed routinely on a fixed schedule; it must be performed based strictly on clinical indication.

Clinical Indications for Suctioning

• Audible or visible secretions in the artificial airway.
• Coarse rhonchi or crackles upon chest auscultation.
• Sudden drop in oxygen saturation ($SpO_2$).
• High peak inspiratory pressure (PIP) alarm sounding on the mechanical ventilator.
• Patient distress, coughing, or tachypnea.

Open vs. Closed (Inline) Suctioning Systems

• Closed Inline Suctioning: Highly preferred in ICUs, mechanically ventilated patients, and mandatory in Airborne Infection Isolation Rooms (AIIR) for suspected airborne pathogens (e.g., Mycobacterium tuberculosis, COVID-19 per NCID guidelines). It maintains PEEP, prevents alveolar derecruitment, and minimizes environmental aerosol contamination.
• Open Suctioning: Used for non-ventilated tracheostomy patients using strict sterile technique (sterile gloves, sterile catheter, sterile flush).

Step-by-Step Sterile Suctioning Technique

1. Pre-Oxygenation: Administer 100% oxygen for 30 to 60 seconds prior to catheter insertion.
2. Catheter Sizing: The outer diameter of the suction catheter should not exceed 50% of the internal diameter of the artificial airway.
   Formula: $ ext{Catheter Size (Fr)} = ( ext{Internal Diameter in mm} imes 2)$. (e.g., an 8.0 mm ETT uses a Fr 14 or Fr 12 catheter).
3. Insertion: Advance the catheter gently without applying negative pressure until resistance is met or the patient coughs, then withdraw 1 to 2 cm.
4. Suction Application: Apply continuous or intermittent suction while gently rotating and withdrawing the catheter. Limit suction application to < 10 to 15 seconds per pass.
5. Suction Pressure: Set negative pressure to 80 – 120 mmHg for adults (never exceed 150 mmHg).
6. Post-Oxygenation: Re-oxygenate with 100% $O_2$ for 30–60 seconds; reassess breath sounds, $SpO_2$, and heart rate.

Potential Complications

• Severe hypoxemia, cardiac dysrhythmias (bradycardia from vagal stimulation; tachycardia or PVCs from hypoxia), mucosal erosion/bleeding, and transient spikes in Intracranial Pressure (ICP).

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Nursing Management of Mechanical Ventilation

Mechanical ventilation supports or replaces spontaneous breathing in acute respiratory failure.

Overview of Common Ventilation Modes

Ventilator Alarm Troubleshooting

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Emergency Management of Tracheostomy Dislodgement

Handling accidental decannulation depends on the age of the tracheostomy stoma:

1. Fresh Stoma (< 7 Days Post-Op): The tissue tract is unformed and fragile. Do NOT attempt blind reinsertion, as this creates a false subcutaneous tract, leading to fatal airway obstruction and tension pneumomediastinum.
   Nursing Action: Call emergency response / ENT / ICU code team immediately. Position patient supine, open upper airway, and perform Bag-Valve-Mask (BVM) ventilation over the mouth and nose while an assistant covers the stoma with a gloved hand or occlusive dressing.
2. Established Stoma (> 7–14 Days Post-Op): The tract is mature.
   Nursing Action: Extend patient's neck, insert a spare tracheostomy tube of the same or smaller size using the obturator, immediately remove the obturator, verify air flow, and secure the tube.

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Singapore MOH Ventilator-Associated Pneumonia (VAP) Prevention Bundle

Ventilator-Associated Pneumonia is a major hospital-acquired infection. All Singapore ICUs strictly enforce the evidence-based MOH VAP Prevention Bundle:

1. Head-of-Bed Elevation: Maintain elevation between 30° and 45° at all times (unless contraindicated) to reduce gastroesophageal reflux and aspiration.
2. Daily Sedation Interruption: Perform daily "sedation vacations" and evaluate readiness for spontaneous breathing trials (SBT).
3. Oral Decontamination: Perform oral care every 6 to 12 hours using 0.12% to 0.2% Chlorhexidine Gluconate oral rinse.
4. Subglottic Secretion Drainage: Use endotracheal tubes with continuous or intermittent subglottic suctioning ports (CASS) to clear pooled secretions above the cuff.
5. Peptic Ulcer & DVT Prophylaxis: Administer prescribed H2-receptor antagonists/PPIs and pharmacological/mechanical thromboprophylaxis.