Guide — Clinical Skills
Tracheostomy Care
A tracheostomy bypasses the upper airway that normally warms and humidifies each breath, and it creates a fragile, life-sustaining airway. This guide covers routine stoma and inner-cannula care, cuff and humidification management, and the decannulation emergency that depends on how old the trach is.
8 min read · Clinical Skills
Written by Apex Respiratory Editorial Team
Educational use only. This material supports respiratory therapy education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional protocols, or physician orders. Always follow facility policies and current provider orders, and verify calculations independently before clinical use.
Overview
Tracheostomy care keeps the artificial airway clean, patent, and secure. Its goals are to prevent infection at the stoma, avoid obstruction from dried or retained secretions, and eliminate the risk of accidental decannulation. Routine care bundles five tasks: stoma cleaning and dressing, inner-cannula maintenance, cuff pressure management, humidification, and securing the tube. Each task addresses a specific failure mode and is addressed in this guide.
Because the tracheostomy bypasses the nose and mouth entirely, the inspired gas reaches the trachea without any of the normal conditioning — warming, humidifying, or filtering — provided by the upper airway. Replacing that function is not optional; it is the first and most critical routine care step for every tracheostomy patient.
Key Concepts
- Tube types. Tracheostomy tubes are classified as cuffed or uncuffed, fenestrated or non-fenestrated, and single or dual cannula. A dual-cannula tube has a removable inner cannula that can be cleaned or replaced independently, preventing tube occlusion from dried secretions without requiring full tube change.
- Cuff management.The cuff should be inflated to the minimal leak volume or minimal occlusive volume. Target cuff pressure is 20–30 cmH₂O: above ~20 cmH₂O to seal the airway and limit aspiration; below ~30 cmH₂O to stay under tracheal capillary perfusion pressure and prevent mucosal ischemia.
- Humidification (mandatory). A heated humidifier is the standard for long-term tracheostomy. A heat-and-moisture exchanger (HME) is acceptable short-term in spontaneously breathing patients, but is contraindicated when secretions are copious or very thick. Without humidification, secretions desiccate and can occlude the tube.
- Securing the tube.Tracheostomy ties or a commercial holder should be snug enough that only one finger fits beneath the ties. Two clinicians are required to change ties — one holds the tube while the other replaces the ties — especially within the first week while the tract is immature and tube dislodgement is most dangerous.
- Suctioning. Suction only when clinically indicated (visible secretions, increased work of breathing, desaturation, coarse breath sounds), not on a routine schedule. Unnecessary suctioning causes mucosal trauma, hypoxemia, and bronchospasm.
Cuff Pressure Reference
| Cuff Pressure | Clinical Consequence |
|---|---|
| < 20 cmH₂O | Inadequate seal; risk of aspiration and ventilator leak |
| 20–30 cmH₂O | Target range: seals the airway while preserving mucosal perfusion |
| > 30 cmH₂O | Exceeds tracheal capillary pressure; ischemia, stenosis, fistula risk |
Assessment & Findings
- Stoma inspection. Examine the peri-stomal skin for erythema, swelling, purulent drainage, or breakdown. A small amount of clear or light serous drainage is normal in the first days after placement; purulence or unusual odor indicates infection.
- Secretion assessment. Note the color, consistency, and quantity of secretions. Thick, tenacious, or brown/tan secretions suggest inadequate humidification. Purulent secretions suggest tracheitis or pneumonia.
- Tube patency.Assess for increased work of breathing, decreased tidal volumes on the ventilator, difficulty passing a suction catheter, or oxygen desaturation — all signs of partial or complete tube obstruction.
- Cuff pressure. Check cuff pressure with a manometer at least every shift. Spontaneous drops may indicate a cuff leak; rising pressure requirements may indicate tracheal dilation or tube malposition.
- Breath sounds. Auscultate bilaterally. Unequal or absent breath sounds may indicate tube advancement into the right mainstem or obstruction of a segment.
- Tube position and ties. Confirm the tube sits at midline and the ties are secure but not constrictive. Note whether the flange markings have changed position, which can indicate accidental advancement or retraction.
RT Priorities & Interventions
- Stoma and dressing care. Clean the peri-stomal skin with normal saline or a designated cleanser using clean technique. Change the dressing when soiled or at least daily. Do not pack gauze into the stoma; use split-drain sponges specifically designed for tracheostomy.
- Inner-cannula care. For reusable inner cannulas, remove, clean with brushes and saline or hydrogen peroxide (per facility protocol), rinse, and replace. For disposable inner cannulas, replace on schedule. Never leave a dual-cannula tube without its inner cannula in place.
- Cuff pressure management.Measure cuff pressure with a calibrated manometer every shift and after any tube manipulation. Maintain 20–30 cmH₂O. Document the pressure and any adjustments made.
- Humidification. Ensure the heating element and water level are adequate in the humidifier circuit. Check for condensate in the circuit and drain away from the patient. If using an HME, assess it for saturation and replace per protocol.
- Suctioning. Suction when indicated: visible secretions, deteriorating SpO₂, increased peak airway pressure on ventilator, audible airway noise, or patient distress. Use the appropriate suction catheter size (no larger than half the tube inner diameter), apply suction only on withdrawal, and limit passes to what is needed to clear the airway.
- Bedside emergency equipment. Keep at the bedside at all times: the obturator, a spare tracheostomy tube of the same size, a tube one size smaller, and bag-valve-mask capable of oral ventilation. This is a regulatory and safety requirement, not a suggestion.
Accidental decannulation emergency. The response depends on tract age. A fresh tracheostomy (less than ~7 days) has an immature tract — the stoma can close within minutes, and blind reinsertion risks creating a false passage into the mediastinum. Call for help immediately, cover the stoma with a gloved hand or dressing to maintain some airway resistance, and be prepared for oral intubation. A mature tracheostomy (tract well established, typically after 7 days) can usually be recannulated by inserting the obturator into the spare same-size tube and guiding it through the stoma. If resistance is met, use the one-size-smaller spare. For sudden tube obstruction: remove or replace the inner cannula first, then suction; if obstruction persists, replace the entire tube.
Common Pitfalls
- Cuff overinflation.Inflating above 30 cmH₂O is common when clinicians “top off” the cuff by feel. Over days to weeks, excess pressure causes mucosal ischemia, which leads to tracheal stenosis, tracheomalacia, or — in severe cases — a tracheo-innominate artery fistula. Always use a manometer; never inflate by feel alone.
- No humidification. Skipping humidification or allowing the humidifier circuit to run dry is the most common cause of mucus plugging and sudden tube occlusion. In a ventilated patient, this presents as a rapid rise in peak airway pressure and inability to pass a suction catheter.
- Routine (scheduled) suctioning.Suctioning on a fixed schedule — regardless of need — causes unnecessary mucosal trauma and hypoxemia. Suction only when secretions are present and clinically significant.
- Missing bedside emergency equipment.Removing the obturator or spare tubes “temporarily” is a common systems failure. When a tube dislodges, there is no time to locate supplies. Emergency equipment must be at the bedside during every care interaction and at all times between.
- Single-person tie change on a fresh trach.Without a second clinician stabilizing the tube, changing ties on a patient with an immature tract risks accidental decannulation — the emergency described above. Always use two people for tie changes and for any full tube change in the first week.
Board Exam Pearls
- Target cuff pressure: 20–30 cmH₂O. Below 20 risks aspiration and ventilator leak; above 30 risks tracheal mucosal ischemia and stenosis.
- Humidify the bypassed airway. Tracheostomy eliminates upper airway humidification. Heated humidity is the standard; HME is a short-term alternative. Failure to humidify causes mucus-plug obstruction.
- Keep the obturator and spare tubes at the bedside. Same-size and one-size-smaller spare tubes plus the obturator must be immediately available at all times.
- Fresh trach decannulation is an emergency. A tracheostomy less than ~7 days old has an immature tract. Blind reinsertion risks a false passage. Oral intubation is the priority while help is summoned.
- Suction as needed, not on a schedule. Routine suctioning without clinical indication causes mucosal trauma and hypoxemia.
FAQ
Why does a tracheostomy require humidification?
The nose and upper airway normally warm and humidify inspired gas before it reaches the trachea. A tracheostomy bypasses that system entirely, so every breath arrives cold and dry directly at the trachea. Without active humidification — a heated humidifier or, short-term, an HME — secretions thicken and dry, leading to mucus plugging and tube occlusion, which is life-threatening.
What is the correct cuff pressure for a tracheostomy tube?
Maintain cuff pressure at 20–30 cmH₂O. The lower limit (~20 cmH₂O) provides an adequate seal and limits aspiration of subglottic secretions. The upper limit (~30 cmH₂O) stays below tracheal capillary perfusion pressure; exceeding it causes mucosal ischemia and, over time, tracheal stenosis, tracheomalacia, or a tracheo-innominate fistula.
What should I do if the tracheostomy tube falls out?
The response depends on tract maturity. A fresh trach (less than about 7 days old) has an immature tract — the stoma can close rapidly and blind reinsertion risks creating a false passage. Call for help immediately and prepare for oral intubation. A mature trach (tract well established) can usually be recannulated using the obturator to guide reinsertion of the same-size tube or, if resistance is met, the one-size-smaller spare tube kept at the bedside.
Why must the obturator and spare tubes stay at the bedside?
The obturator is a curved, blunt-tipped stylet that fits inside the tracheostomy tube to guide it through the stoma without traumatizing the posterior tracheal wall. Without it, reinsertion after accidental decannulation is difficult and risky. The spare same-size tube covers the primary scenario; the one-size-smaller tube is insurance if the stoma narrows slightly before replacement. Removing these from the bedside creates a preventable airway emergency.
Go deeper
Cuffed or uncuffed, fenestrated or not, single or dual cannula — the tube-type reference lays out what to choose and why.
See tracheostomy tube types →Related Resources
Sources
- Kacmarek RM, Stoller JK, Heuer AJ. Egan's Fundamentals of Respiratory Care. 12th ed. Elsevier; 2021. Airway management: tracheostomy care.
- Cairo JM. Mosby's Respiratory Care Equipment. 11th ed. Elsevier; 2022. Artificial airways.