Reference — Airway Management
Tracheostomy Care Reference
The parts of a tracheostomy tube, the routine care that keeps it patent, and the emergencies — decannulation, obstruction, and bleeding — that demand a fast, correct response at the bedside.
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
A tracheostomy bypasses the upper airway, which means inspired gas is no longer warmed and humidified by the nose and mouth — humidification is not optional. Routine care keeps the inner cannula and stoma clean and the tube secure, while a small set of emergencies requires a rehearsed response. The single most important distinction is the age of the stoma: a fresh tract is not yet safe to reinsert into blindly.
Tube Anatomy & Types
| Component | What It Is |
|---|---|
| Outer cannula | The main body of the tube that holds the stoma open; stays in place during inner-cannula care |
| Inner cannula | Removable liner cleaned or exchanged to clear secretions; either disposable or reusable |
| Obturator | Smooth-tipped guide used only during insertion, then removed immediately; kept at the bedside for reinsertion |
| Cuffed vs uncuffed | A cuff seals the airway for positive-pressure ventilation and reduces aspiration; uncuffed tubes allow airflow around the tube |
| Fenestrated | An opening in the outer cannula directs airflow to the vocal cords to permit speech |
| Pediatric | Often uncuffed and frequently has no inner cannula because of the small lumen |
Routine Care
- Inner-cannula care. Clean a reusable inner cannula or swap a disposable one on a schedule and whenever secretions accumulate.
- Stoma care. Clean and inspect the stoma site, keeping the skin dry and free of secretions and breakdown.
- Ties.Secure tube ties to allow one finger underneath — snug enough to hold the tube, loose enough to avoid skin injury.
- Humidification — always. The bypassed upper airway no longer conditions inspired gas, so continuous humidification is required to keep secretions thin and mobile.
- Suction as needed, not on a schedule. Suction in response to assessed need — audible secretions, a rising work of breathing — rather than at fixed intervals.
Emergencies
| Problem | Action |
|---|---|
| Decannulation, early (< 7 days, immature stoma) | Do NOT blindly reinsert into a fresh tract. Call for help, ventilate with a bag-mask over the mouth (or over the stoma) and prepare for oral intubation if needed |
| Decannulation, mature stoma | Reinsert the same-size tube (or one size smaller) using the obturator, then confirm placement and ventilation |
| Obstruction / mucus plug | Remove or replace the inner cannula, suction the airway, and instill saline per protocol; escalate if the obstruction does not clear |
| Bleeding | Distinguish minor stomal bleeding from a sentinel bleed; a tracheo-innominate fistula is a surgical emergency requiring immediate help |
Keep at the bedside
- Spare tracheostomy tube of the same size
- Tracheostomy tube one size smaller
- Obturator for the in-place tube
- Suction setup and catheters
- Bag-valve-mask (BVM)
Clinical Notes
- Always humidify. Because the upper airway is bypassed, inspired gas must be humidified continuously to prevent thick, retained secretions and plugging.
- The first tube change belongs to the surgical or ENT team. The initial change is performed by the team that placed the tube, once the tract is mature enough to reinsert safely.
- Speaking valve only with the cuff deflated. A speaking valve is a one-way valve: air enters through the tube and must exit around it and through the upper airway. With the cuff inflated there is no path for exhalation, which is lethal — deflate the cuff before placing the valve.
- In a fresh stoma, the first move is rarely blind reinsertion. For early decannulation through an immature tract, call for help and ventilate over the mouth or stoma rather than forcing a tube into a false passage.
Related Resources
Sources
- Kacmarek RM, Stoller JK, Heuer AJ. Egan's Fundamentals of Respiratory Care. 12th ed. Elsevier; 2021. Airway management chapter.
- Mitchell RB, Hussey HM, Setzen G, et al. Clinical consensus statement: tracheostomy care. Otolaryngol Head Neck Surg. 2013;148(1):6-20.