A tracheostomy is a life-saving surgical procedure that creates an opening in the trachea (windpipe) to establish an airway. It is commonly performed in critical care settings for patients who require long-term mechanical ventilation or have upper airway obstructions. For nursing students, understanding the tracheostomy procedure, indications, complications, and post-operative care is essential for providing optimal patient care.
This guide covers everything from definition and types to step-by-step procedure, nursing responsibilities, and FAQs to help you excel in your studies and clinical practice.
Table of Contents
What is a Tracheostomy?
A tracheostomy is a surgical opening made in the anterior wall of the trachea to insert a tracheostomy tube, allowing direct access to the airway. This bypasses the upper airway (nose, mouth, and larynx) and is used when prolonged ventilation or airway management is needed.
Types of Tracheostomy Tubes
Tracheostomy tubes vary based on material, design, and patient needs:
Cuffed Tube – Inflatable cuff to prevent aspiration and secure ventilation (used in ICU).
Uncuffed Tube – No cuff, allows speech and swallowing (used in stable patients).
Fenestrated Tube – Has openings to permit speech by allowing air to pass through vocal cords.
Metal vs. Plastic Tubes – Silver (reusable) or plastic (disposable).
Indications for Tracheostomy
A tracheostomy is performed when:
Prolonged mechanical ventilation (>7-10 days) is needed.
Upper airway obstruction (tumors, trauma, infections like epiglottitis).
Severe neck or mouth injuries.
Neuromuscular diseases (ALS, spinal cord injuries).
Chronic aspiration risk.
Difficulty weaning from a ventilator.
Contraindications
While rare, contraindications include:
Severe bleeding disorders (risk of hemorrhage).
Unstable cervical spine injuries.
Local infections at the incision site.
Pre-Procedure Preparation
Patient Preparation
Informed Consent: Explain risks, benefits, and alternatives.
NPO Status: Patient should fast for 6-8 hours before surgery.
Baseline Assessment: Check vitals, ABGs, and coagulation profile.
Positioning: Supine with neck extended (unless contraindicated).
Equipment Preparation
Sterile tracheostomy kit.
Tracheostomy tube (appropriate size).
Suction apparatus.
Oxygen supply and ambu bag.
Local or general anesthesia.
Tracheostomy Procedure Steps
Step-by-Step Tracheostomy Procedure with Rationale
| Procedure Step | Rationale (Detailed Explanation) |
|---|---|
| 1. Anesthesia Administration | Local anesthesia (lidocaine) for conscious patients or general anesthesia for high-risk cases. Ensures patient comfort, reduces pain, and prevents movement during the procedure. General anesthesia may be needed for uncooperative patients or pediatric cases. |
| 2. Positioning | Neck hyperextension (unless cervical spine injury is suspected). Places the trachea in an accessible position by stretching the skin and tissues over the trachea. A shoulder roll may be used for better exposure. |
| 3. Skin Incision | A 2-3 cm horizontal or vertical incision is made below the cricoid cartilage. A horizontal incision has better cosmetic results, while a vertical incision allows easier extension if needed. |
| 4. Dissection & Exposure | Blunt dissection through subcutaneous tissue and strap muscles. The thyroid isthmus is either retracted or divided. This provides a clear path to the trachea without damaging major blood vessels. |
| 5. Tracheal Incision | A small horizontal or vertical slit is made between the 2nd and 4th tracheal rings. Avoids the cricoid cartilage (to prevent subglottic stenosis) and ensures proper tube placement. |
| 6. Tube Insertion | The tracheostomy tube (with obturator) is inserted gently into the trachea. The obturator is removed, and the inner cannula is placed. Ensures a patent airway and minimizes trauma during insertion. |
| 7. Cuff Inflation (if cuffed) | The cuff is inflated with just enough air (20-25 cm H₂O pressure) to seal the airway. Prevents aspiration in ventilated patients but must not overinflate (risk of tracheal necrosis). |
| 8. Securing the Tube | The tube is secured with tracheostomy ties or sutures to prevent accidental decannulation. Double-check tightness (should allow one finger space under ties). |
| 9. Confirmation of Placement | Auscultate bilateral breath sounds, check for CO₂ detection (if ventilated), and observe chest rise. Ensures proper placement and rules out pneumothorax or false passage. |
| 10. Dressing Application | A sterile gauze dressing is placed around the stoma (not under the flange). Prevents infection and absorbs minor secretions. |
Tracheostomy Care: Nursing Responsibilities
Suctioning: As needed to maintain airway patency.
Stoma Care: Clean with sterile saline and change dressing daily.
Cuff Management: Ensure proper inflation pressure (20-25 mmHg).
Humidification: Prevents mucus thickening.
Emergency Preparedness: Keep a spare tube and obturator at bedside.
Key Notes for Nursing Students:
- Emergency Readiness: Always have a rescue tube, suction, and Ambu bag nearby in case of accidental decannulation.
- First 24 Hours: High risk for bleeding or tube dislodgement—frequent checks required.
- Cuff Pressure: Must be monitored every 8 hours to prevent tracheal damage.
Conclusion
Tracheostomy is a critical procedure for patients requiring long-term airway management. Nursing students must master the indications, procedure steps, complications, and post-operative care to ensure patient safety. Proper knowledge and skills in tracheostomy care can significantly improve patient outcomes in critical care settings.
FAQs About Tracheostomy
1. How long can a tracheostomy stay in place?
It can be temporary or permanent, depending on the patient’s condition. Some patients may decannulate (remove the tube) after recovery.
2. Can a patient speak with a tracheostomy?
With a fenestrated tube or speaking valve, some patients can speak by covering the tube.
3. How often should tracheostomy dressings be changed?
Daily or whenever soiled to prevent infection.
4. What are signs of tracheostomy infection?
Redness, swelling, foul-smelling discharge, fever.
5. What should I do if the tracheostomy tube becomes dislodged?
Stay calm, provide oxygen, and attempt to reinsert the tube if trained. If unsuccessful, call for emergency help.
Final Tips for Nursing Students
Always ensure sterile technique during tracheostomy care.
Monitor for respiratory distress and tube obstruction.
Educate patients and families on home care if discharged with a tracheostomy.
By mastering tracheostomy procedures and care, nursing students can provide safe, effective, and compassionate care to critically ill patients.
Clinical Scenarios & Case Examples
Case 1: Post-Traumatic Airway Obstruction
Patient: 32-year-old male, motorcycle accident with facial fractures and severe neck swelling.
Scenario:
Patient presents with stridor and respiratory distress due to upper airway edema.
Emergency tracheostomy performed to bypass obstruction.
Key Learning Points:
✔️ Indication: Acute upper airway obstruction
✔️ Priority: Rapid intervention to prevent hypoxia
✔️ Nursing Role: Monitor for bleeding, tube dislodgement
Case 2: Long-Term Ventilation in ICU
Patient: 68-year-old female, COPD exacerbation, intubated for 14 days.
Scenario:
Decision made for surgical tracheostomy to facilitate weaning.
Transitioned from endotracheal tube to cuffed tracheostomy.
Key Learning Points:
✔️ Indication: Prolonged mechanical ventilation
✔️ Benefit: Improved comfort, easier oral care
✔️ Nursing Care: Cuff pressure checks, stoma care
Case 3: Pediatric Tracheostomy
Patient: 6-month-old with congenital subglottic stenosis.
Scenario:
Elective tracheostomy performed due to recurrent respiratory failure.
Parents trained in home care before discharge.
Key Learning Points:
✔️ Special considerations: Smaller tube size, higher dislodgement risk
✔️ Family education critical for home management
✔️ Humidification essential to prevent mucus plugs
Case 4: Emergency Decannulation
Patient: 45-year-old tracheostomy-dependent male found unresponsive at home.
Scenario:
EMS arrives to find dislodged tube and cyanosis.
Nurse reinserts obturator and secures new tube.
Key Learning Points:
✔️ Emergency protocol: Reinsert tube or ventilate via stoma
✔️ Always keep spare tube at the bedside
✔️ Rapid response prevents hypoxia
Case 5: Tracheostomy Infection
Patient: 72-year-old with purulent stoma discharge and fever.
Scenario:
Cellulitis diagnosed; cultures reveal MRSA.
Treated with IV vancomycin and sterile dressing changes.
Key Learning Points:
✔️ Signs of infection: Erythema, foul odor, fever
✔️ Aseptic technique mandatory for care
✔️ Antibiotics + wound care management
Why Include Cases?
Enhances critical thinking for real-world scenarios
Prepares students for clinical rotations
Improves patient safety through anticipatory learning
Key Point glossary
Why Key Point Glossary Matters:
Understanding tracheostomy-related terminology is essential for nursing students as it builds a strong clinical vocabulary needed for both exams and real-world practice. It enables you to accurately interpret healthcare provider orders, ensures clear and safe communication with patients and their families, and prepares you for NCLEX-style questions that test your knowledge of medical procedures and nursing responsibilities.
Here’s a comprehensive glossary of all key terms
| Terminology | Meanning |
|---|---|
| Tracheostomy (tray-kee-OSS-tuh-mee) | A surgical opening created through the neck into the trachea to establish an airway |
| Tracheotomy (tray-kee-OT-uh-mee) | The surgical procedure to create a tracheostomy |
| Stoma (STOH-muh) | The actual opening in the neck that leads to the trachea |
| Tracheostomy Tube (trach tube) | The curved tube inserted into the tracheostomy to maintain the airway |
| Outer Cannula | The main body of the tracheostomy tube that remains in place |
| Inner Cannula | Removable part of the tube that sits inside the outer cannula |
| Obturator (OB-tur-ay-tor) | Smooth guide used during tube insertion to prevent tissue damage |
| Cuff | Inflatable balloon around the tube that seals the airway |
| Fenestration (fen-uh-STRAY-shun) | Small holes in some trach tubes that allow air flow for speech |
| Decannulation (dee-can-you-LAY-shun) | Process of removing the tracheostomy tube permanently |
| Suctioning | Procedure to remove secretions from the airway |
| Humidification | Adding moisture to inspired air to prevent mucus thickening |
| Subglottic Space | Area below vocal cords and above trachea |
| Cricoid Cartilage (KRY-koyd) | The only complete ring of cartilage in the trachea |
| Tracheal Stenosis (stuh-NO-sis) | Abnormal narrowing of the trachea |
| Tracheomalacia (tray-kee-oh-muh-LAY-shuh) | Abnormal softening of tracheal cartilage |
| Granulation Tissue | Overgrowth of healing tissue around the stoma |
| Speaking Valve | Device that allows vocalization by redirecting air |
| Ventilator-Dependent | Patient requiring mechanical breathing support |
| Emergency Trach Kit | Supplies kept at bedside for tube emergencies |
| Percutaneous Tracheostomy | Minimally invasive procedure |
| Stridor | Harsh breathing sound indicating obstruction |
| Auscultation | Listening to breath sounds |
| Secretions | Mucus/phlegm in the airway |
Must read –
Comprehensive Guide to Tracheostomy: What Patients and Families Need to Know
Tracheostoma image
There are times when you may wonder whether a tracheostomy should be performed or how to manage tracheostomy care at home, including challenges like speaking valve training. We’re here to answer all your doubts and guide you through the process. So, feel free to leave a comment and stay connected with us!
