Stoma care is an important part of the standard of care for individuals with a tracheostomy. Secretions from above the cuff leak out of the stoma site producing a moist environment and can lead to infection and irritation. The physician’s order should have information on how often stoma care should be provided and what materials to use for stoma care.
For infection prevention, the stoma site should be assessed and cleaned at least once in a 24 hour period using a clean technique (ICS, 2015). More frequent cleaning may be required if there is skin irritation, odor, or with any noticeable secretions or blood. Dried secretions or blood can be more easily removed with a cotton tip applicator soaked in hydrogen peroxide and sterile saline (Morris, L et al, 2005). Keep the skin dry with drain barriers or skin dressings. Routinely prepackaged and pre-cut gauze are placed under the flange of the tracheostomy tube which absorb secretions. The application of moist dressing may be superior to gauze, giving a lower incidence of site infection and pressure ulcers as well as shorter wound closing times and lower dressing change frequency (Yue, M et al, 2019).
Subglottic suctioning can be helpful in reducing secretions and the amount of dressing changes in patients with a large amount of secretions. There are endotracheal and tracheostomy subglottic suctioning tubes that collect secretions above the cuff. An automatic intermittent suctioning machine can then be used to remove the secretions from above the cuff.
Always maintain infection control procedures prior to stoma care, which should always include hand washing. Make sure that your work station is cleaned with soap and water or a disinfectant wipe. If doing stoma care in a hospital, skilled nursing home or other facility, gloves are recommended. Personal protective equipment (PPE) is also recommended including a face mask and gown.
If visible signs of infection are present consider obtaining a swab specimen for culture and sensitivity. Document any findings including redness, swelling, evidence of granulation tissue, exudite, increased discomfort or pain at the site or offensive odor. Notify the physician for any signs of infection.
Skin breakdown may have occurred due to the initial tracheotomy surgery or from pressure injury due to the flange. Movement of the tracheostomy tube can cause irritation. This occurs more often due to the weight of ventilator tubing, and can result in the flange putting pressure onto the neck. Any wounds should be staged and treated accordingly. Keeping the tracheostomy tube in a neutral position is important in preventing skin breakdown, as well as for preventing tracheostomy tube dislodgement and accidental decannulation.
Patients may have sutures to secure the flange of the tracheostomy to the skin. Sutures should be removed 5-10 days post surgery depending on local policy.
O’Toole et al (2017) used a bundle that included placement of a hydrocolloid dressing under the tracheostomy flange in the postoperative period, removal of plate sutures within 7 days of the tracheostomy procedure, placement of a polyurethane foam dressing after suture removal, and neutral head positioning. The researchers found a significant reduction in the rate of hospital acquired tracheostomy-related pressure ulcers using the bundle when compared to the pre-bundle group.
At this time, research is still needed as to the optimal frequency and cleaning method for tracheostomy stoma care. In the long term patient, care standards often evolve from the availability of reimbursed resources, such as tracheostomy-care cleaning supplies. Third-party insurance policies often dictate practice by limiting the type and quantity of tracheostomy supplies that will be paid for under the home medical equipment and supply insurance benefit. In many instances, one tracheostomy-care cleaning kit per day is the “allowed amount,” and therefore common practice is once-daily tracheostomy and stoma-site cleaning and care (Lewarski, J, 2005).
Standards of care for the adult patient with temporary tracheostomy. Intensive Care Society, 2018.
The application of moist dressings in wound care for tracheostomy patients: A meta‐analysis. J Clin Nurs. 2019; 00: 1– 8. https://doi.org/10.1111/jocn.14885, , , .