Tracheostomies are increasingly common, particularly in long-term skilled nursing facilities and intensive care units, which means all medical providers must master tracheostomy secretion management. Tracheostomy reduces cough strength, lowers subglottic pressure, and weakens sensations in the pharynx and larynx. This causes secretions to accumulate in the airway, although the volume and thickness of the secretions vary significantly from patient to patient. Medical professionals, first responders, and patients with tracheostomies must learn how to manage secretions to improve patient comfort and reduce the risk of infection, aspiration, and other complications. Show Tracheostomy Secretions 101: Understanding the ProblemSecretions are a natural reaction to tracheostomy, not a sign of a problem. A trach tube bypasses the upper airway, which normally cleans and moistens the air. This causes the body to produce more secretions. When tracheostomy cuffs are kept inflated for a prolonged period, these secretions can pool in the airway. This increases the risk of a number of health issues, including:
Many patients with tracheostomies already have other health issues, such as chronic obstructive pulmonary disease (COPD), a history of severe airway infections, prior airway trauma, or difficulty withdrawing from a mechanical ventilator. This makes them especially vulnerable to infections related to poorly managed secretions. When to Suction Tracheostomy PatientsSuctioning can greatly reduce the risk of tracheostomy-related complications. However, suctioning does present some risks, which makes it important to avoid over suctioning patients. Most healthcare providers recommend suctioning the tracheostomy twice a day, though recommendations are evolving. To reduce the risk of suctioning complications, a patient having trouble managing tracheostomy secretions should first try to clear their own airway by:
If the patient cannot breathe, shows signs of aspiration, or cannot follow instructions, do not waste time trying to get them to clear their own airway. When a patient cannot clear their own airway, proceed with suctioning. Strategies for Suctioning Tracheostomy SecretionsBefore suctioning a tracheostomy, thoroughly wash your hands and wear gloves to reduce the risk of transmitting pathogens to the patient. Change gloves and rewash hands after touching the patient or their secretions and before touching the suctioning machine or another patient. These tracheostomy suctioning guidelines can help reduce the risks to the patient:
After preparing the patient for suctioning, sterilizing the equipment, and applying gloves, these techniques ensure effective tracheostomy secretion management:
The right equipment is critical to ensuring that tracheostomy patients receive prompt, effective care. Transporting patients can be difficult, and may not be necessary. Portable emergency suction reduces treatment delays and allows your agency to treat patients wherever they are. However, it’s important not to forgo effective treatment for convenient treatment. The right emergency suction devices deliver both. For help selecting the appropriate machine for your agency, download our free guide, The Ultimate Guide to Purchasing a Portable Emergency Suction Device. *Editor's Note: This blog was originally published in July of 2020. It has since been updated with current content.
WHY: Aspiration (the misdirection of oropharyngeal secretions or gastric contents into the larynx and lower respiratory tract) is common in older adults with dysphagia and can lead to aspiration pneumonia. In fact, the risk of pneumonia is three times higher in patients with dysphagia (Hebert et al., 2016). Other harmful sequelae of dysphagia include malnutrition and dehydration (Wilmskoetter et al., 2017). Dysphagia is a significant predictor of worse clinical outcomes in hospitalized patients with dementia (Paranji et al., 2017). TARGET POPULATION: Dysphagia is common in persons with neurologic diseases such as stroke, Parkinson’s disease, and dementia. The older adult with one of these conditions is at even greater risk for aspiration because the dysphagia is superimposed on the slowed swallowing rate associated with normal aging. Conditions that suppress the cough reflex (such as sedation) further increase the risk for aspiration. BEST PRACTICES: ASSESSMENT AND PREVENTION ASSESSMENT: A multidisciplinary approach to identify dysphagic patients is important (Aoki et al., 2016). While dysphagia screening by nurses does not replace assessment by other health professionals, it enhances the provision of care to at-risk patients by allowing for early recognition and intervention (Hines et al., 2016; Palli et al., 2017). Assessment may begin at the bedside, using a variety of tools. Most swallow screens use varying volumes of water to assess the ability to swallow (Smithard, 2016). For more specific swallowing assessments, fiberoptic endoscopy of swallowing (FEES) or videofluoroscopy (VFS) may be used (Gallegos et al., 2017). BEST PRACTICES: PREVENTION Clinical Symptoms of Aspiration:
Aspiration Pneumonia:
PREVENTION OF ASPIRATION DURING HAND FEEDING:
PREVENTION OF ASPIRATION DURING TUBE FEEDING: For patients with tube feedings, the following considerations are important:
PREVENTION OF ASPIRATION PNEUMONIA BY ORAL CARE:
MORE ON THE TOPIC: Aoki, S., Hosomi, N., Hirayama, J., et al. (2016). The multidisciplinary swallowing team approach decreases pneumonia onset in acute stroke patients. PLoS ONE (Electronic Resource), 11(5)e0154608. Aslan, M., & Vaezi, M.F. (2013). Dysphagia in the elderly. Gastroenterology & Hepatology, 9(12), 784-795. Boullata, J.I., Harvey, A.L, Hudson, L., et al. (2017). ASPEN Safe Practices for Enteral Nutrition Therapy. Journal of Parenteral and Enteral Nutrition, 41(1), 15-103. Gallegos, C., Brito-de la Fuente, E., Clave, P., Costa, A., & Assegehegn, G. (2017). Nutritional aspects of dysphagia management. Advances in Food and Nutrition Research, 81, 271-318. Hebert, D., Lindsay, M.P., McIntyre, A., et al. (2016). Canadian stroke best practice recommendations: Stroke rehabilitation practice guidelines, update, 2015. International Journal of Stroke, 11(4), 459-484. Hines, S., Kynoch, K., & Munday, J. (2016). Nursing interventions for identifying and managing acute dysphagia are effective for improving patient outcomes: A systematic review update. Journal of Neuroscience Nursing, 48(4), 215-223. Joyce, A., Robbins, J., & Hind, J. (2015). Nutrient intake from thickened beverages and patient-specific implications for care. Nutrition in Clinical Practice, 30(3), 440-445. Maeda K., & Akagi, J. (2014). Oral care may reduce pneumonia in the tube-fed elderly: A preliminary study. Dysphagia, 29(5), 616-621. Moran, C., & O’Mahony, S. (2015). When is feeding via a percutaneous endoscopic gastrostomy indicated? Current Opinion in Gastroenterology, 31(2), 137-142. Murray, J., Miller, M., Doeltgen, S., & Scholten, I. (2013). Intake of thickened liquids by hospitalized adults with dysphagia after stroke. International Journal of Speech-Language Pathology, 16(5), 486-494. Onur, O.E., Onur, E., Guneysel, O., Akoglu, H., Denizbasi, A., & Demir, H. (2013). Endoscopic gastrostomy, nasojejunal and oral feeding comparison in aspiration pneumonia patients. Journal of Research in Medical Sciences, 18(12), 1097-1102. Palli, C., Fandler, S., Doppelhofer, K., et al. (2017). Early dysphagia screening by trained nurses reduces pneumonia rate in stroke patients: A clinical intervention study. Stroke, 48(9), 2583-2585. Paranji, S., Paranji, N., Wright, S., & Chandra, S. (2017). A nationwide study of the impact of dysphagia on hospital outcomes among patients with dementia. American Journal of Alzheimer’s Disease & Other Dementias, 32(1), 5-11. Sarin, J., Balasubramaniam, R., Corcoran, A.M., Laudenbach, J.M., & Stoopler, E.T. (2008). Reducing the risk of aspiration pneumonia among elderly patients in long-term care facilities through oral health interventions. Journal of the American Medical Directors Association, 9(2), 128-135. Smithard, D.G. (2016). Dysphagia management and stroke units. Current Physical Medicine and Rehabilitation Reports, 4(4), 287-294. Wilmuskoetter, J., Herbert, T.L., Bonilha, H.S. (2017). Factors associated with gastrostomy tube removal in patients with dysphagia after stroke: A review of the literature. Nutrition in Clinical Practice, 12(2), 166-174. |