How to Care for a Tracheostomy at Home After Surgery for Head and Neck Cancer

Heading home with a new tracheostomy after head and neck cancer surgery can feel intimidating, but if you follow instructions from your care team and establish a clear routine, you can build your confidence quickly.

“Before discharge, you (and your caregiver, if you have one) should be comfortable performing routine tracheostomy care and should demonstrate the process with your nurse, respiratory therapist, or physician,” says Sidharth V. Puram, MD, PhD, the chair of the department of otolaryngology–head and neck surgery and the director of the Robert Ebert and Greg Stubblefield Head and Neck Tumor Center at Washington University School of Medicine in St. Louis, adding that this is critical for patient safety.

Daily Tracheostomy Care: Step-by-Step Instructions

When it comes to daily trach care, it’s important to follow specific instructions from your care team regarding specific cleaning solutions, suction pressure, inner-cannula care, and the timing of the first trach change, because these details vary by tube, procedure, and institution, says Dr. Puram.

• Wash your hands thoroughly. Use soap and water and dry them well.

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• Gather your supplies before starting. Depending on your tracheostomy, these may include clean gloves, trach gauze or dressing, cotton-tipped applicators, sterile water or saline, suction equipment and catheters, replacement inner cannula if applicable, clean trach ties, and a trash bag. Always have a spare tracheostomy and obdurator (a curved tube used to guide the trach tube into the airway) available.

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• Position yourself comfortably. Stand in front of a mirror or have someone help you. Make sure you can clearly see the trach and surrounding skin.

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• Look at the stoma and surrounding skin. Check for any signs of infection such as redness, swelling, tenderness, skin breakdown, unusual drainage, odor, or bleeding.

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• Remove the old trach dressing. If you have dressing, remove it while carefully keeping the trach tube secure.
• Clean around the stoma. Your care team will likely give you cleaning instructions, and you should follow them accordingly. In most cases, Puram recommends gently cleansing the skin with water and mild soap or saline and reserving hydrogen peroxide for stubborn, dried secretions. Avoid allowing liquid to enter the tracheostomy opening. Remove dried mucus or crusting gently. Don’t aggressively scrape the skin or pull on the trach.

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• Clean or replace the inner cannula. If your trach has one, clean it according to your care team’s instructions.

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• Place a clean tracheostomy dressing on your skin. Change it whenever it becomes wet, soiled, or covered with secretions, even if this is out of cycle for your normal routine.

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• Check the trach ties or collar. They should hold the tube securely without being excessively tight. A common guide is to leave enough room for about two fingers underneath the ties. If you don't secure the tracheostomy tightly enough, it could fall out, or you could cough it out. It could also move back and forth and irritate the trachea.

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• Don’t remove or change a newly placed trach tube on your own. That is, unless your surgical team has specifically trained and instructed you to do so. The first tube change is often handled differently from later routine changes.
• Suction if needed. A tracheostomy generally needs to be suctioned so that mucus and secretions can be removed from the windpipe and tracheostomy tube.

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   But you should suction depending on symptoms, such as if you can’t cough up mucus, rather than repeatedly suctioning when the airway is already clear.
• Use a humidifier as prescribed. Because air entering through a tracheostomy bypasses the nose and mouth, it isn’t naturally warmed and humidified. Adequate humidification helps prevent thick secretions and mucus plugs.

Inner Cannula Care

• Hold the outer base of the cannula in place with one hand. Remove the inner cannula by gently squeezing the tabs with your other hand.
• Slide out the inner cannula and throw it away.
• Squeeze the tabs of a new inner cannula and slide it into the outer cannula. Release the tabs as it securely locks onto both sides of the connector rim.
• As you change the inner cannula, it’s important to also clean the area around your tracheostomy with moistened cloth or gauze.

Suctioning and Airway Clearance

“Suctioning removes mucus that you are unable to clear adequately by coughing,” says Puram. “This can be especially important during the early postoperative period, when secretions may be increased until the patient's body adjusts to the new tracheostomy.”

Suctioning should generally be done whenever needed, rather than simply as often as possible, he adds. “Unnecessary or overly frequent suctioning can irritate the airway and cause bleeding.”

“This can make it difficult to breathe normally,” she says. “Sometimes a mucus plug can even make it difficult for the suction catheter to pass into the tracheostomy appropriately.”

If the suction catheter can’t pass easily, contact your care team immediately, she says.

Other signs that you may need to suction your tracheostomy include hearing or feeling mucus rattling or gurgling in the trach, or your cough sounds wet or congested but does not clear the secretions, says Puram.

“You may also need suctioning if you’re breathing faster or working harder to breathe, or notice decreased airflow through the trach,” he says. “If you monitor oxygen at home and your oxygen level falls below the range your medical team told you is acceptable, you may need suctioning.”

It’s also important to follow the instructions your care team gives you — such as if you should suction at specific times, like right after waking up, or before certain treatments, Puram adds.

Protecting Your Stoma and Skin Health

• Keep the skin surrounding the stoma clean and dry, and clean the stoma at least daily or more often if secretions accumulate.
• Change the gauze or dressings around the trach whenever they become wet or soiled.
• Change the tracheostomy ties at least daily and more often if they become wet or soiled, or if you observe skin breakdown.

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• Avoid using any lotions, perfumes, ointments, powders, or creams around the stoma unless your care team specifically recommends them.

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• Remove any debris or dried mucus that may be present, says Rosamilia. “Once the area is cleaned, it’s important to dry the skin well by gently patting a dry cloth or gauze on the skin around the trach," she says. "The plastic back plate of a tracheostomy can aggravate moist skin, and if necessary, a skin protectant or dressing under this backplate may be needed to avoid skin breakdown.”
• Protect the stoma itself from environmental irritants.

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   Try to limit your contact with dust, smoke, aerosol sprays, perfumes, car exhaust fumes, powder, dry leaves, and any other type of airborne particles, which can get inside your tracheostomy. “When outdoors, use the trach cover or protection recommended by your team,” says Puram.
• Protect the tracheostomy from water. “Never allow shower water to spray directly into the opening,” says Puram. “Use the shower or trach protection recommended by your team.” Avoid swimming, as the tracheostomy cannot be submerged in water. “Water entering the opening can go directly into the lungs,” Puram says.

When to Call Your Care Team or Seek Emergency Help

Other situations that require immediate attention include increasing or unusual bleeding; a rash or worsening skin breakdown; much more mucus than usual; secretions that become difficult to cough or suction out; repeated mucus plugs; persistent cough or shortness of breath despite routine suctioning; or any new change in the trach that concerns you, he says.

“If you’re ever having trouble breathing, removing the inner cannula may help if there was something causing a blockage,” says Rosamilia. “Changing the inner cannula and suctioning can help in this case.”

If removing the inner cannula doesn't help, Rosamilia advises seeking emergency help immediately. “If the whole tracheostomy falls out, call 911," she says.

Puram also advises calling 911 or getting emergency medical help immediately if you are experiencing any of these other symptoms:

• The trach appears completely blocked and you cannot restore airflow with the emergency steps your team taught you.
• Suctioning doesn't improve severe breathing difficulty.
• There is significant, brisk, or persistent bleeding from the tracheostomy.
• Your lips, face, or skin become blue or gray.
• There is any other sudden airway emergency.

It’s important to understand that a newly created tracheostomy is not the same as a mature, established tracheostomy, Puram says. “Accidental tube displacement early after surgery can be especially dangerous because the trach may not yet be established,” he says. “Patients and caregivers should follow the surgeon's specific emergency plan rather than attempting maneuvers they have not been trained to perform.”