This final article outlines the procedure for changing a tracheostomy dressing
- Figures and tables can be seen in the attached print-friendly PDF file of the complete article in the ‘Files’ section of this page
Dan Higgins, RGN, ENB100, ENB998, is senior charge nurse, critical care, University Hospitals Birmingham NHS Foundation Trust.
This final article in the series on care of patients with a tracheostomy outlines the procedure for changing a tracheostomy dressing. Most tracheostomies require some form of dressing to absorb secretions and protect the surrounding area.
A tracheostomy is a surgical wound and it is vital to prevent infection (Docherty and Bench, 2002). Tracheostomy patients have increased risk of infection (NHS Quality Improvement Scotland, 2007); the stoma is a potential route of infection and the proximity of secretions can increase infection risk.
Is dressing indicated?
In some patients, dressing may not be indicated as it creates an ideal environment for bacterial colonisation.
The decision to dress a tracheostomy should be based on clinical need, and should follow a comprehensive stomal assessment and consideration of patient comfort and respiratory secretions.
The frequency of dressing and cleaning of the site will vary, depending largely on the amount of secretions or soiling. There has been debate about the need for aseptic techniques when dressing tracheostomies; NHSQIS (2007) advocates a clean technique as the skin is colonised with organisms. Nurses should refer to local policy.
While some tracheostomies are sutured in place, dressing any tracheostomy carries a significant degree of risk, particularly as the fixation device is temporarily adjusted and may not be secure. This means that changing the dressing always requires two people, one to secure the position of the device while the other performs the dressing itself. This should only be undertaken in an area where emergency and safety equipment (see part 1) is present.
If the patient is receiving oxygen therapy, disruption should be kept to a minimum. The second practitioner may need to provide oxygen flow during the dressing procedure.
Cleaning the stoma
Once the old dressing is removed, the stoma must be inspected for colour and amount of secretions, and indicators of infection, which include: purulent discharge; pain around the site; odour; abcesses; and cellulitis or discolouration (Docherty and Bench, 2002).
If infection is suspected, a swab should be taken from the site or discharge for analysis. Any suspicion of infection should be reported immediately. If infected respiratory secretions are suspected, a sputum specimen should be taken the next time the patient is suctioned or expectorates sputum.
The area under the tracheostomy flanges should be cleaned by swabbing or irrigating with 0.9% saline solution. Cotton wool, which fragments easily, should not be used (Serra, 2000). Barrier films may be used around the stoma site to protect the skin (NHSQIS, 2007).
Gauze and similar materials should be avoided as they shed fibres that can stick to the wound and be inhaled (Serra, 2000).
Specific slimline tracheostomy dressings are recommended (NHSQIS, 2007). These usually have a ‘T’ shape cut into them - if not, one can be cut with sterile scissors. They have a foam and a mat side; the mat side should be placed against the skin.
Securing the tube
Devices for tube fixation usually have two holders. The shorter one is fixed through a hole in the tracheostomy flange on the side that the nurse is performing the dressing; the longer one is fixed, in the same way, on the same side as the assistant; this is then drawn underneath the patient’s neck and fixed to the shorter holder, using a Velcro-type fastener.
If the holder is too tight it will cause pressure damage, while if it is too loose the tracheostomy is left unsecured. Nurses are advised to seek local policy/guidelines if traditional-style tracheostomy tapes are used.
The following equipment is needed:
- Gloves and apron;
- Standard dressing pack;
- Sterile 0.9% saline;
- Tracheostomy dressing;
- Tracheostomy tube fixation device.
- Explain the procedure to the patient, reassure them and gain informed consent.
- Wash hands and don plastic apron.
- Prepare dressing field/equipment.
- Wash/clean hands with gel, apply gloves.
- Ask the second nurse to temporarily remove any oxygen delivery device.
- With the second nurse securing the tube (Fig 1), loosen the fixation device (Fig 2).
- Remove dressing and dispose of it.
- Observe the stoma as outlined above.
- Remove gloves, wash or clean hands with alcohol gel, apply fresh gloves.
- Using sterile 0.9% saline clean the stoma and the surrounding skin (Fig 3).
- Allow to dry.
- Apply skin barrier film if indicated, allow to dry (Fig 4).
- With the second nurse securing the tracheostomy, slide the dressing under each flange (Fig 5).
- Reapply tube fixation device.
- Assess the patency of the airway.
- Recommence oxygen therapy if required (Fig 6).
- Dispose of equipment, wash hands.
- Document the dressing change, fixation device change and all observations.
This procedure should be undertaken only after approved training, supervised practice and competency assessment, and carried out in accordance with local policies and protocols.
Docherty, B., Bench, S. (2002) Tracheostomy management for patients in general ward settings. Professional Nurse; 18: 2, 100-104.
NHS Quality Improvement Scotland (2007) Best Practice Statement - Caring for the Patient With a Tracheostomy.
Serra, A. (2000) Tracheostomy care. Nursing Standard; 14: 42, 45-52.
Woodrow, P. (2002) Managing patients with a tracheostomy in acute care. Nursing Standard; 16: 44, 39-46.