Secretion Management in Tracheostomy Patients

Suctioning Assessment and Indications

• Assess the need for suctioning based on clinical signs (visible/audible secretions, increased work of breathing, oxygen desaturation, or ventilator pressure changes) rather than performing routine scheduled suctioning. 1
• Routine suctioning should be avoided; suction only when the above indications are present. 2

Catheter Selection and Technique

• Use the largest catheter that fits inside the tracheostomy tube (instead of the traditional half‑diameter rule) to improve secretion removal efficiency and shorten suction time. 2
• Employ pre‑marked catheters to prevent insertion beyond the tube tip and reduce the risk of tracheal trauma. 1
• Rotate the catheter between the fingertips while suctioning to maximize secretion extraction. 1
• Apply suction pressure of approximately 80–100 mm Hg for pediatric patients; thicker secretions may require a stationary suction machine capable of higher vacuum. 2
• Perform suction continuously during both insertion and removal of the catheter. 2
• Limit each suction pass to less than 5 seconds using a rapid, pre‑measured technique. 2

Pre‑oxygenation and Hyperinflation

• Prior to delivering any hyperinflation breaths, make an initial suction pass to clear visible or audible secretions; delivering breaths with secretions present can force them into distal airways. 2
• Evaluate patients receiving supplemental oxygen for the need for hyper‑oxygenation during suctioning. 2

Saline Instillation

• Routine instillation of normal saline is not recommended because it does not effectively thin mucus, may lower oxygen saturation, and can contaminate the lower airway. 2
• Adequate humidification is a more effective strategy for maintaining thin secretions than saline instillation. 2

Humidification Requirements

• Provide humidification because a tracheostomy bypasses the upper airway’s natural warming and moisturizing functions. Target inspired gas temperature of 32–34 °C and humidity of 36–40 mg/L. 3
• Proper humidification improves secretion viscosity, lung function, and sputum production compared with no humidification. 3

Device Selection for Ventilated Patients

• Begin with heat‑and‑moisture‑exchange (HME) filters, changing them every 7 days in a dry circuit and inspecting the inner tube daily (changing every 24 hours). 4
• Monitor HME filters daily and whenever ventilation deteriorates; transition to active water‑based humidification if secretions thicken. 4

Device Selection for Non‑ventilated Patients

• Use passive humidifiers (HME, HMEF, HCH, or HCHF) for traveling children due to convenience. 3
• During sleep, active humidification via nebulizer may provide superior humidification despite reduced convenience. 3
• Hygroscopic condenser humidifier filters (HCHFs) add more airway moisture than other passive devices. 3

Special Considerations

• Patients receiving oxygen through a tracheostomy must receive humidified oxygen. 5
• Passive humidifiers are ineffective with speaking valves because no moisture is captured for the next inspiration. 3
• Adding mucolytic nebulizers (saline or hypertonic saline) can be useful, but concurrent humidification or saline use significantly reduces HME filter efficiency. 4

Equipment and Supplies

• Ensure a functional suction system with battery backup capability is always available at the bedside. 1
• Keep pre‑marked suction catheters readily accessible. 1

Infection Control (COVID‑19 Era)

• Use closed (in‑line) suction systems for ventilated patients to minimize aerosol generation. 4
• Maintain cuffed, non‑fenestrated tubes with cuff pressures of 20–30 cm H₂O. 4
• Reduce the frequency of routine care to the minimum required, reviewing the need daily. 4

Respiratory Physiotherapy

• Incorporate respiratory physiotherapy as a core component of the multidisciplinary team to maintain chest clearance. 4
• Perform physiotherapy regularly (e.g., every 8 hours) to optimize secretion mobilization. 4

Common Pitfalls to Avoid

• Do not deliver bag breaths before clearing the tube, as this can force secretions distally. 2
• Avoid petroleum‑based products around the tracheostomy site. 1
• Do not use routine saline instillation; it does not effectively thin secretions. 2
• Do not use undersized catheters; they prolong suction time and increase the risk of atelectasis. 2
• Verify home suction equipment before discharge to ensure adequate secretion clearance. 2

Management of Tracheostomy Secretions: Evidence‑Based Practices

Suction Catheter Selection and Technique

• Use pre‑marked suction catheters to prevent insertion beyond the tube tip, thereby reducing the risk of tracheal trauma in tracheostomy patients. 6
• Rotate the suction catheter between the thumb and index finger while withdrawing it to maximize secretion extraction efficiency. 6

Equipment and Bedside Setup

• Maintain a fully functional suction system with battery‑back‑up capability at the bedside for all tracheostomy patients, ensuring continuous availability of suction when needed. 6

Stoma and Skin Care

• Perform daily cleansing of the peristomal skin with mild soap and water to keep the area clean and dry. 6
• Apply a 1.5 % hydrogen peroxide solution to dissolve encrusted secretions, followed by rinsing with water and thorough drying of the skin. 6
• Avoid the use of petroleum‑based products around the tracheostomy site to prevent skin irritation and occlusion. 6
• Inspect the peristomal area and surrounding neck skin each day for signs of irritation, infection, or pressure injury. 6
• Change tracheostomy dressings with physiological saline three times per 24‑hour period to prevent moisture buildup and secretion accumulation at the stoma. 7

Special Populations

• Children who are mechanically ventilated or infants with short, thick necks are at heightened risk for infection and pressure necrosis; they require meticulous tracheostomy care and close monitoring. 6
• Patients with impaired airway clearance or severe underlying lung disease may need a lower threshold for intervention (e.g., earlier suctioning or humidification adjustments) to prevent respiratory compromise. 8