Tracheostomy Care: Suctioning, Tube Care and What to Do in an Emergency

A tracheostomy is an opening in the front of the neck into the windpipe (trachea), with a tube inserted to help breathing. Patients with tracheostomies are cared for in intensive care, on general wards, in head and neck units, and increasingly at home. Tube blockage and accidental displacement can kill within minutes, so every nurse caring for these patients needs to know routine care and the emergency response. The UK National Tracheostomy Safety Project (NTSP) developed widely used guidance.

Bedside equipment (check every shift)

• Working suction with appropriately sized catheters.
• Oxygen and humidification.
• Spare tracheostomy tubes: one the same size and one a size smaller.
• Tracheal dilators, syringe (for cuff), tube ties, dressings, water-based lubricant.
• Bag-valve-mask and a catheter mount.
• A bedhead sign stating the tube type and size, whether the patient has a tracheostomy or laryngectomy, and whether the upper airway is patent.

Tracheostomy or laryngectomy?

Patients with a laryngectomy have had their larynx removed: their neck stoma is their only airway, and they cannot be oxygenated via the mouth or nose. Patients with a tracheostomy usually still have a connection to the upper airway. Know which your patient has.

Routine care

• Humidification: the tube bypasses the nose, which normally warms and moistens air. Without humidification, secretions become thick and can block the tube.
• Inner tube (cannula): check and clean or replace regularly (often at least every 4–8 hours, or as per policy) to prevent blockage.
• Cuff pressure (if cuffed): check with a manometer, commonly aiming for about 20–30 cmH₂O or per local policy, to prevent aspiration and tracheal damage.
• Stoma care: clean and inspect the skin at least daily; check for infection, bleeding or pressure damage; change the dressing.
• Tube ties: secure but allow one or two fingers underneath; change with two people, one holding the tube.
• Communication: provide a call bell, writing materials or picture boards; patients may not be able to speak.

Suctioning

• Suction when needed (audible or visible secretions, increased work of breathing, falling SpO₂), not on a fixed schedule.
• Use the correct catheter size (commonly no more than half the internal diameter of the tube) and suction pressure per policy.
• Pre-oxygenate if needed. Insert the catheter without suction, only to the length of the tube (or just beyond if policy allows), then apply suction while withdrawing.
• Each pass should last no more than 10–15 seconds.
• Monitor SpO₂ and heart rate; stop if the patient becomes distressed or bradycardic.
• Use aseptic technique and document the amount and nature of secretions.

Emergency: the patient can’t breathe

Based on the NTSP emergency algorithm for patients with a patent upper airway:

1. Call for help (airway expert and resuscitation team).
2. Look, listen and feel at the mouth and the tracheostomy. Apply high-flow oxygen to both the face and the tracheostomy.
3. Is the tube patent? Remove any speaking valve or cap; remove the inner tube; try passing a suction catheter.
4. If the suction catheter won’t pass, deflate the cuff (if present) and reassess.
5. If the patient is still not improving, remove the tracheostomy tube, then apply oxygen to the face and stoma.
6. If not breathing, call the resuscitation team and start CPR; oxygenate via the mouth/nose (bag-mask, with the stoma covered) or via the stoma with a small face mask.

For laryngectomy patients, oxygenation is via the stoma only. Follow your local algorithm and get hands-on training.

Other complications

• Bleeding: minor oozing is common early on; significant bleeding is an emergency.
• Surgical emphysema (crackling under the skin) may signal displacement.
• Infection of the stoma or chest.

Related: Oxygen therapy · BLS

Based on the National Tracheostomy Safety Project (NTSP) guidance and emergency algorithms. Educational content: follow your local policy and get hands-on training.