Tracheostomy Care Basics for Respiratory Therapists

A tracheostomy is a surgically or percutaneously created opening through the anterior neck into the trachea, providing a direct airway that bypasses the upper airway structures. It may be temporary — placed during prolonged mechanical ventilation weaning — or permanent, as in patients with permanent upper airway obstruction or neuromuscular disease.

Respiratory therapists are primary clinicians in tracheostomy management across ICU, stepdown, and long-term care settings. The RT role includes airway assessment, tube care, suctioning, humidification management, cuff management, speaking valve trials, and emergency preparedness — often spanning multiple daily interactions with the patient and coordinating closely with nursing and speech-language pathology.

Common indications for tracheostomy include: prolonged mechanical ventilation (typically >10–14 days), upper airway obstruction (tumor, bilateral vocal cord paralysis, trauma), inability to protect the airway due to neurological impairment, and facilitation of secretion management in patients with severe secretion burden.

Every encounter with a tracheostomy patient begins with a structured airway assessment. This is not a cursory check — the tracheostomy tube can dislodge, obstruct, or become a source of complication at any time, and early recognition is critical.

What to assess at each encounter:

• Tube position: Is the tube at the correct depth? Is the flange flush against the neck? Signs of anterior displacement include loss of tidal volume, reduced breath sounds, or patient distress.
• Secretion quality and quantity: Color, consistency, and volume. Thick secretions signal inadequate humidification. Bloody secretions warrant further investigation.
• Stoma site: Redness, swelling, granulation tissue, skin breakdown, or signs of infection. Document and escalate as appropriate.
• Breath sounds: Bilateral air entry. Unilateral breath sounds may indicate accidental right mainstem intubation if the tube is inserted too deeply.
• Cuff integrity: Pilot balloon should be palpable and soft. A deflated pilot balloon may indicate cuff failure.
• Patient work of breathing: Respiratory rate, use of accessory muscles, paradoxical breathing.

The tracheostomy bypasses the upper airway's natural humidification and filtration systems. Inspired air that would normally be warmed and humidified by the nose and oropharynx now enters the trachea at ambient conditions. Without adequate humidification, secretions thicken, mucociliary clearance is impaired, and the risk of mucus plugging — a life-threatening complication — increases substantially.

Humidification options:

• Active humidification (heated humidifier): Provides warmed, humidified gas to the circuit. Preferred for mechanically ventilated patients and those with thick secretions or high respiratory demand. Requires temperature monitoring to prevent condensate accumulation (rainout) in the circuit.
• Heat and moisture exchanger (HME): A passive device placed at the tracheostomy hub that captures heat and moisture from exhaled gas and returns it during inhalation. Suitable for ambulatory tracheostomy patients or those weaned from mechanical ventilation with thin secretions. Contraindicated in patients with thick, copious secretions, low tidal volumes, or who are mouth-breathing.
• Tracheostomy collar (T-piece or trach mask): Delivers humidified oxygen (from a large-bore circuit attached to a heated humidifier or heated aerosol generator) to the tracheostomy without full ventilator support. Commonly used during spontaneous breathing trials or for patients off the ventilator who still require supplemental oxygen.

Signs of inadequate humidification include increasing secretion thickness, more frequent need for suctioning, mucus plugging events, or patient-reported throat dryness. Adjust humidification strategy proactively rather than reactively.

Suctioning is one of the most frequently performed procedures in tracheostomy care. It is a skill that looks simple but carries real risk when performed improperly — including mucosal trauma, hypoxemia, dysrhythmia, bronchospasm, and introduction of pathogens.

Suctioning should be performed based on clinical need, not on a fixed time schedule. Indications include: audible or visible secretions, increased work of breathing, SpO₂ deterioration suggesting secretion retention, changes in ventilator waveforms indicating secretion accumulation, or patient request.

Key principles for safe suctioning through a tracheostomy:

• Pre-oxygenate: Increase FiO₂ before suctioning if the patient is oxygen-dependent or has marginal SpO₂ reserve.
• Use correct catheter size: Generally, catheter external diameter should not exceed half the internal diameter of the trach tube.
• Limit suction time: Each pass should be limited to approximately 10–15 seconds. Multiple passes with recovery time between are safer than prolonged single passes.
• Apply suction only on withdrawal: Insert without suction, apply suction intermittently or continuously as you withdraw.
• Assess outcome: Breath sounds, SpO₂, and patient comfort post-suction.

For a more detailed suctioning reference, see the dedicated guide.

Most adult tracheostomy tubes have a removable inner cannula — a smaller tube that fits within the outer cannula and can be removed for cleaning or replacement without disturbing the outer tube's position in the airway.

The inner cannula is the primary defense against mucus accumulation and tube occlusion. When secretions are thick or abundant, mucus can adhere to the inner cannula lumen and progressively narrow the airway. Regular inner cannula care prevents this complication.

Facilities typically use either disposable inner cannulas (replaced rather than cleaned) or reusable cannulas cleaned with sterile saline or brushed and dried before reinsertion. Follow your facility's protocol for specific cleaning intervals and methods.

Signs of inner cannula obstruction: increased work of breathing, difficulty passing a suction catheter, high-pressure alarms on the ventilator, or progressive SpO₂ decline without other explanation. Remove and replace or clean the inner cannula and reassess immediately.

Most adult tracheostomy tubes have a low-volume, high-pressure cuff or a high-volume, low-pressure cuff. The cuff, when inflated, creates a seal between the tube and the tracheal wall, enabling positive pressure ventilation and reducing aspiration of secretions from above the cuff.

Target cuff pressure is typically 20–30 cmH₂O (15–22 mmHg). This range maintains an adequate seal for ventilation while minimizing tracheal mucosal pressure. Pressures consistently above 30 cmH₂O can impair capillary perfusion of the tracheal mucosa, leading to ischemia, tracheomalacia, and tracheoesophageal fistula with prolonged exposure.

Measure cuff pressure with a manometer at routine intervals and whenever cuff-related concerns arise (audible leak around the cuff, loss of tidal volume on the ventilator, changes in ventilator graphics). Never rely solely on the feel of the pilot balloon.

Factors that may require cuff pressure adjustment:

• Audible air leak around the tracheostomy during positive pressure inspiration
• Large tidal volume discrepancy between set and delivered volumes on the ventilator
• High-pressure alarms suggesting a shift in tube position
• Change in patient position (supine to lateral can change cuff seal dynamics)

A Passy Muir Valve (PMV) or other one-way speaking valve allows air to enter through the tracheostomy tube on inspiration and redirects exhaled airflow through the upper airway on exhalation — allowing vocalization and improved swallowing function. Use of a speaking valve is a significant quality-of-life milestone for tracheostomy patients.

Key prerequisites for speaking valve trials:

• The cuff must be fully deflated before placing a one-way speaking valve. A speaking valve with an inflated cuff creates a closed system that prevents exhalation — this is a life-threatening error.
• Adequate upper airway patency: The patient must be able to exhale around and through the upper airway with the cuff deflated.
• Patient must be sufficiently awake and cooperative to tolerate the valve and signal distress.
• Secretion burden must be manageable — thick copious secretions can obstruct the valve.
• Verify oxygen requirements can be met with the valve in place.

Speaking valve trials are typically conducted collaboratively by respiratory therapy and speech-language pathology. The SLP guides communication and swallowing goals; the RT manages airway safety, oxygen delivery, and equipment.

Tracheostomy emergencies — tube dislodgement, obstruction, cuff failure, or accidental decannulation — can be immediately life-threatening. Preparation before an emergency occurs is the most important safety measure.

Required equipment at the bedside for all tracheostomy patients:

• Replacement tracheostomy tube of the same size and one size smaller
• Bag-valve mask (BVM) for manual ventilation via the tracheostomy or mouth if reintubation via the stoma is not immediately possible
• Suction equipment, immediately available and functional
• Tracheal dilators if the stoma is immature (tracheostomy less than 7–10 days old)
• Emergency call bell accessible to the patient

For patients with an immature stoma (<7–10 days post-procedure), replacement of a dislodged tube can be extremely difficult and risks creating a false passage. These patients may require emergency oral intubation while the stoma is held open. Know your facility's emergent tracheostomy replacement protocol and the timeline of the patient's stoma maturity.