SDE: Clinical Guidelines Ch7W

Clinical Procedure Guidelines for Connecticut School NursesPrintable version | Back to Contents
Specialized Health Care Procedures

W. Tracheostomy Care and Suctioning


Tracheostomy is a surgical opening creating a stoma through the neck into the trachea where a tracheostomy tube can be inserted.

Tracheostomy (“trach”) Tube is a plastic (most common) or metal tube inserted through the tracheostomy stoma that provides a fixed airway to accommodate breathing while bypassing the upper airway. This tube can be used with or without mechanical ventilation or supplemental oxygen, but generally requires at least some means of humidification. There are a variety of tracheostomy tube brands; the most common are Shiley and Bivona. Most pediatric trach tubes consist of a single cannula. If the tube has two cannulas, the inner cannula can be removed for cleaning while the outer cannula stays in place.

Obturator is a small plastic device used as a guide during the insertion of the tracheostomy tube.

Ambu-bag (manual ventilation bag) is a device used to manually instill air into the airway. A universal 15 mm adaptor allows it to fit directly onto the trach tube so that each “squeeze” of the bag correlates with a “breath.” A facemask can also be fitted onto the bag to instill air via the mouth in the event that the tracheostomy tube is occluded or not functioning.

Decannulization is the intentional or accidental removal of the trach tube out of the trachea

Passy-Muir Valve is a one-way valve that fits directly onto a trach tube, allowing air to be inspired through the trach tube, and forcing the exhaled air through the vocal cords and out of the mouth to facilitate vocalization and speech.



There are two broad medical indications for a tracheostomy:

  1. An acquired or congenital anatomic defect in the upper airway.
  2. An inability to maintain adequate respiratory function due to chronic intrapulmonary or extrapulmonary (neuromuscular or metabolic) disease.

Caregivers responsible for the student need to be CPR-certified and specifically trained in routine and emergency tracheostomy care and procedures for each individual student.

Nurses must understand the underlying etiology of the need for each student who has a tracheostomy. A student with a tracheostomy is at risk for life-threatening complications that can be avoided with accurate physical assessment and diligent care of the airway. Proper care of a tracheostomy includes adequate skin care around the stoma and ensures the maintenance of the student’s airway.



The essential equipment to be kept with the student at all times is as follows:

Never use an oil-based lubricant, such as Vaseline.

  • gloves;
  • portable oxygen with appropriate sized Ambu-bag;
  • Appropriate size Ambu-bag facemask (for emergencies when unable to reinsert a new tracheostomy tube;
  • portable suction machine that can operate with battery or electricity;
  • sterile suction catheters;
  • sterile saline vials;
  • water-based lubricant;
  • two spare tracheostomy tubes — one the size the student currently uses and one that is a size smaller in the event that the tube needs to be changed and there is difficulty passing it through the stoma;
  • spare tracheostomy ties;
  • blunt scissors;
  • personal protective equipment — to be used for all tracheostomy procedures;
  • emergency phone numbers; and
  • pulse oximeter — may be optional if student is not on oxygen or mechanical ventilation.

It is recommended that this equipment be stored together in an “emergency travel bag” that is easily transported with the student during transportation and the entire school day. Additional equipment may be indicated per the IHCP.


Stoma and skin care

  1. The frequency of stoma care and the care of the surrounding skin is based on the individual student’s current skin condition and associated factors, such as the amount of secretions and the degree of skin folds around the neck.
  2. Ensure all essential equipment or travel bag is within reach prior to initiating stoma and skin care.
  3. Use gauze sponges and cotton-tipped swabs with water or a diluted peroxide solution per IHCP:
    1. Cleanse outer portion of tracheostomy tube and surrounding skin going from using wet to dry sponges or swabs.
    2. Minimize direct moisture to the tracheostomy ties.
    3. Drying the skin is vital to maintaining skin integrity.

Changing tracheostomy ties

  1. The two most common forms of tracheostomy ties are a soft padded tie with Velcro tabs (most common) or a simple thin cloth or twill tie that requires tying to secure.
  2. Changing tracheostomy ties in the school setting is usually not done on a routine basis, rather it is an, as-needed (PRN) procedure based on the integrity of the ties, the skin, or as part of an emergency tracheostomy change;
  3. Two people should be present during the procedure in the event of accidental decannulization.
  4. A shoulder roll is recommended to assist with the visualization and access to the tracheostomy site.
  5. Remove the old ties while holding the tracheostomy tube in place:
    1. Use caution not to occlude the tracheostomy tube.
    2. Removal of cloth ties requires the use of a blunt scissor.
    3. Removal of Velcro tab ties is done by detaching each end of the tie.
  6. Skin care is performed as indicated.
  7. Maintaining the tracheostomy tube in place is always the priority:
    1. Insert one end of the tie through the slit opening on the side of the tracheostomy tube.
    2. Bring the other end of the tie around the back of the neck.
    3. Repeat with the other end of the tie through the slit opening on the other side of the tracheostomy tube.
    4. Velcro tabs are fastened back on themselves.
    5. Cloth ties are secured using a single square knot on the side or back of the neck.
    6. The ties should allow enough space for fingers between it and the neck.
  8. If a split gauze is used around the stoma, replace it now with a clean one.
  9. Re-assess the student’s respiratory status to ensure that the tracheostomy tube remained in place and patent during the procedure.

Cleaning an Inner Cannula

  1. Remove the inner cannula as indicated per manufacturer’s instructions.
  2. The inner cannula is generally cleansed with a half-strength hydrogen peroxide solution using pipe cleaners to remove any dried secretions from inside the cannula.
  3. Thoroughly rinse the cannula with sterile water and dry.
  4. Reinsert the inner cannula by turning it 90 degrees from its usual position, introduce the tip into the outer cannula, slowly rotating it back 90 degrees to its final position.
  5. Lock the cannula in place per manufacturer’s instructions.

Tracheostomy Tube Suctioning

Suctioning is performed based on clinical assessment with consideration of individual student factors and considerations. Many students can cough out their secretions through their tracheostomy tubes without the need for suctioning (this maneuver is synonymous with “blowing their nose”).

  1. As with all invasive procedures, carefully consider an appropriate and safe location based on degree of urgency and physical design of the school, student’s classroom, and the health office.
  2. Confirm that respiratory assessment requires the suctioning procedure.
  3. Emergency travel bag (essential equipment listed above) must be present before suctioning.
  4. Ensure the suction machine has the appropriate level of subatmospheric pressure:
    1. standard maximal pressure for children ranges from 80–100 mm Hg; and
    2. maximal pressure may be determined by turning on suction and occluding extension tubing by folding it in half. Pressure reading on the gauge when the tubing is completely occluded is the maximal suction pressure.
  5. The option of using a sterile catheter should be determined per treatment procedure authorization and IHCP.
  6. Positioning of the student is based on the clinical situation:
    1. students in wheelchairs or other supportive seating devices can remain sitting upright or reclined up to, but not exceeding, semi-fowlers or 45 degrees; and
    2. students who are lying either on the floor or health office couch should be turned on their side (this position may be commonly associated with a student experiencing a seizure who may require supplemental oxygen and/or suctioning).
  7. The respiratory assessment should be an ongoing process to determine:
    1. how well the student is tolerating the procedure; and
    2. the amount of time and suction attempts that are clinically indicated.
  8. Determine the length of catheter insertion:
    1. it should be limited to just beyond the distal end of the tracheostomy tube; and
    2. “deep suctioning” up to or beyond the tracheal carina (point of bronchial bifurcation and tissue resistance) should not be indicated in a school setting, as it may cause epithelial damage.
  9. Hold the suction catheter at the point of maximal insertion length.
  10. Lubricate the catheter with normal saline.
  11. The use of normal saline to lavage the tracheostomy tube needs is based on the IHCP and, if indicated, to assist with the removal of thick secretions, needs to be used judiciously.
  12. Remove tracheostomy mask or ventilator connection and promptly insert catheter while gently rotating within the cannula. Do not apply suction during catheter insertion.
  13. At point of maximal insertion, apply suction while gently rotating the catheter out of the cannula:
    1. tracheal suctioning should not exceed five seconds; and
    2. if secretions are visible at the onset of suctioning, an initial shallow pass may be appropriate before proceeding further down the cannula.
  14. Rinse the catheter and repeat as indicated based on the clinical assessment and treatment order.
  15. Provide hyperventilation with Ambu-bag, if indicated.
  16. Rinse suction catheter and extension tubing
  17. (Ireton, J., 2007; Cincinnati Children’s Hospital, 2009).

Tracheostomy Tube Change

The changing of a tracheostomy tube in the school setting should be considered an emergency situation based on clinical assessment and the student’s history. Any concern that the situation is potentially life-threatening requires the activation of the EMS/911 system while the procedure is being performed. If there are complications during the procedure, the nurse must have an understanding of the student’s underlying need for the tracheostomy and ability to breathe without one. The nurse must be prepared to take control of the situation by acting swiftly, calmly, and clearly. The two most common emergency scenarios are:

  • accidental decannulization; and
  • tracheostomy tube obstruction unrelieved by reasonable suction attempts. Obstruction can be caused by thick secretions/mucous plugging, foreign body, or airway granuloma tissue. Airway granuloma tissue can persist to obstruct a new tracheostomy tube, resulting in the highest degree of medical emergency.
  1. Ensure the emergency travel bag is present.
  2. Ensure the presence of another responsible adult, preferably another nurse if available.
  3. If not already done, attach Ambu-bag to oxygen with gauge set at > 10 L/min.
  4. If able, position the student supine on the floor with a shoulder roll to gently hyperextend the neck.
  5. Open the new tracheostomy tube that is the same size as is currently in the student. Have the size smaller new tracheostomy tube readily available if needed.
  6. Taking care to not touch the curved part of the tracheostomy tube:
    1. be sure the obturator is in the tube;
    2. attach one end of the tracheostomy tie to a slot on the side of the tracheostomy tube;
    3. lubricate the distal end of the new tracheostomy tube with water-based lubricant; and
    4. return it to the clean package that it was sealed in.
  7. Remove or cut old tracheostomy ties.
  8. If possible, have assistant hold old tracheostomy tube in place:
    1. most students will not have cuffed tracheostomy tubes (with a balloon); and
    2. if this student does, deflate the cuff at this time per manufacturer’s instructions.
  9. With one hand remove the old tracheostomy tube and set it out of the way.
  10. Gently and quickly insert the new tracheostomy tube, pushing back and then down, in an arching motion:
    1. if unable to insert the new tracheostomy tube, attempt the same procedure using the new tracheostomy that is one size smaller; and
    2. if still unable to insert a new tracheostomy tube, use the Ambu-bag with facemask as indicated to maintain a stable airway while awaiting the emergency medical system (EMS).
  11. Once inserted, immediately remove the obturator (if used).
  12. Have assistant continue to hold new tracheostomy in place.
  13. Since this procedure done in school would most likely be an emergency situation, provide the student with manual breaths using the Ambu Bag and oxygen while auscultating the lungs to confirm adequate and symmetrical air movement.
  14. Continue the respiratory assessment, using pulse oximetry if available to confirm a return to the student’s baseline status.
  15. Secure the new tracheostomy tube in place by fastening the tracheostomy ties:
  16. If this is a cuffed tracheostomy tube, inflate at this time per manufacturer’s instructions.
  17. Position the student comfortably and observe to ensure he or she remains stable on their baseline level of supplemental or ventilator support (if any).
  18. If EMS was activated, the RN in charge can determine, in collaboration with the family and health care provider if necessary, if transportation to the local emergency room is still indicated.
  19. Regardless of outcome, notify family and medical provider that student required a tracheostomy change procedure.
  20. (Cincinnati Children’s Hospital, 2011)

Delegation Considerations

All students with a tracheostomy require a level of skilled nursing assessment by a RN. Care and management of the student’s tracheostomy may be assigned to an LPN during transportation and throughout the school day.

Select Nursing Considerations

See Oral Feeding for guidelines and references associated with orally feeding a student with a tracheostomy.

  • Maintaining adequate hydration is essential to minimize thick and crusting secretions.
  • Do not permit the use of powders, aerosols, or any small airborne particles around the student, especially if the tracheostomy tube is not covered with a ventilator, filter, or Passy-Muir valve.
  • If foreign material is aspirated into the tracheostomy tube, attempt to suction prior to giving breaths with an Ambu-bag.
  • Potential complications related to suctioning are bronchospasm and bleeding, which generally occur as a result of excessive suctioning or insertion of catheter past the distal end of the tracheostomy tube.
  • Comprehensive oral hygiene is required for a student with a tracheostomy
  • Water activities must be carefully considered and supervised.
  • The emergency travel bag should be inspected daily to ensure all used essential supplies have been replaced and are present.
  • Gauze used around the tracheostomy tube should be pre-split, not cut, to prevent threads from entering the airway.


Bowden, V.R., and Greenberg, C.S. (2008). Pediatric Nursing Procedures, 2nd edition. Philadelphia, PA: Lippincott Williams and Wilkins.

Ireton, J. (2007). Tracheostomy suction: A protocol for practice. Paediatric nursing, 19(10), 14-8.

Cincinnati Children’s Hospital. (2009). Suctioning. Retrieved January 19, 2012.

Cincinnati Children’s Hospital. (2011). Basic Pediatric Tracheostomy Care. Retrieved January 19, 2012.


Content Last Modified on 6/10/2014 9:51:46 AM