Nursing care
Tracheostomy Care: the nurse's role, start to finish
Written and reviewed by Dana Whitfield, RN, MSN · 5 min read · Updated September 2026
Short answer
Tracheostomy care nursing management keeps the airway patent through suctioning, stoma care, and cuff management, but the defining safety habit is bedside equipment: an obturator and a spare tube of the same size, always within reach. The greater emergency is the tube coming out, not the tube blocking, because a dislodged tube can close the airway within minutes.
What the procedure achieves
A tracheostomy creates a surgical airway through the neck into the trachea, bypassing the upper airway to provide long-term mechanical ventilation access, relieve upper airway obstruction, or protect the airway when a patient can't manage their own secretions. It reduces the work of breathing compared with prolonged endotracheal intubation and allows the patient to eat, speak with a valve, and be weaned more comfortably from a ventilator.
Indications include prolonged ventilator dependence, usually beyond one to two weeks, upper airway tumours or trauma, severe obstructive sleep apnoea, and neuromuscular conditions that impair airway protection. Compared with an endotracheal tube, a tracheostomy lowers the risk of vocal cord damage and allows for better oral hygiene and patient comfort over time.
Pre-procedure nursing responsibilities
Confirm consent and correct patient identification, and review coagulation studies since bleeding at the insertion site is a recognised early complication. Position the patient supine with the neck extended, using a shoulder roll if tolerated, to expose the trachea for the surgeon or intensivist performing the procedure.
Have suction, oxygen, and a bag-valve-mask ready at the bedside before the procedure starts, and confirm sedation or local anaesthesia is administered as ordered. Explain to the patient, if they're able to understand, that they'll be unable to speak immediately afterward and that this is expected, not a sign something has gone wrong.
Equipment and positioning
Keep an obturator and a spare tracheostomy tube of the same size, plus one size smaller, at the bedside at all times, along with a suction catheter, saline, and a bag-valve-mask with a tracheostomy adaptor. This is the single most important safety habit in tracheostomy care, because a dislodged or accidentally decannulated tube is an airway emergency that can close within minutes, while a blocked tube usually still allows some time to suction and troubleshoot.
Position the patient with the head of bed elevated 30-45 degrees to reduce aspiration risk and ease secretion clearance. Secure the tube with ties snug enough to prevent dislodgement but loose enough to fit two fingers underneath, and check tie tension and skin condition at least once per shift, since swelling in the first 24-48 hours after insertion can make ties suddenly too tight.
Complications and early signs
Watch for bleeding at the stoma in the first 24-48 hours, subcutaneous emphysema, and signs of tube displacement such as new difficulty ventilating, absent chest rise, or the patient suddenly able to vocalise despite a cuffed tube, which suggests the cuff or tube has shifted out of position. Accidental decannulation is the emergency to prepare for constantly, which is why the spare tube and obturator sit at the bedside rather than in a supply room.
Longer-term risks include tracheal stenosis, tracheo-oesophageal fistula, and stoma infection. Monitor for increasing secretions, fever, or foul-smelling drainage, and assess the stoma site at each dressing change for redness, breakdown, or granulation tissue that could narrow the airway over time.
Post-procedure care
Suction only when indicated by clinical signs, audible or visible secretions, rising respiratory rate, desaturation, or a request from the patient, rather than on a fixed schedule, since unnecessary suctioning irritates the mucosa and can cause trauma or hypoxia. Use the smallest suction catheter that clears secretions effectively and limit each pass to under 15 seconds.
Provide stoma care with saline and sterile gauze at least once per shift, cleaning around the tube and changing ties as needed. Monitor cuff pressure if the tube is cuffed, keeping it within 20-25 cmH2O to prevent tracheal mucosal ischaemia while still sealing the airway, and deflate per protocol before speaking valve use once the patient can tolerate it.
What to teach before discharge
Teach the patient and caregiver to suction safely, recognise signs of a blocked or displaced tube, and perform stoma care and tie changes at home. They need to demonstrate, not just describe, these skills before discharge, since a return demonstration catches gaps that verbal teach-back misses.
Reinforce that a spare tube, obturator, and suction equipment should travel with the patient everywhere, including a card or list of the tube's exact size and type for emergency responders. Cover humidification needs, since a tracheostomy bypasses the nose's natural warming and moistening function, and review when to call for help versus when to manage a problem at home.
The next step on this is the same as on everything else here: answer questions and read the rationales. Our respiratory practice questions are the closest set to what this page covers.
Common questions
Why keep an obturator and spare tube at the bedside?
Because accidental decannulation, the tube coming out, is the true airway emergency with a tracheostomy, and it can close the airway within minutes if a matching spare tube and obturator aren't immediately available to reinsert. A blocked tube usually still allows time to suction, but a missing tube does not.
How often should a tracheostomy be suctioned?
Suction based on clinical need, not a fixed schedule: audible or visible secretions, rising respiratory rate, desaturation, or the patient signalling discomfort. Routine unnecessary suctioning irritates the tracheal mucosa and increases the risk of trauma and hypoxia without clinical benefit.
What cuff pressure is safe for a tracheostomy tube?
Cuff pressure is generally maintained at 20-25 cmH2O, high enough to seal the airway for ventilation but low enough to avoid ischaemic damage to the tracheal mucosa. Pressure should be checked regularly with a manometer rather than estimated by feel.
What are early signs of tracheostomy tube displacement?
New difficulty ventilating, absent or reduced chest rise, subcutaneous emphysema, or a cuffed patient suddenly able to vocalise are all warning signs the tube has shifted out of the trachea. Any of these should prompt immediate assessment and readiness to remove and replace the tube using the bedside spare.
Can a patient with a tracheostomy talk?
Speech is possible once the cuff is deflated, or with a fenestrated tube or speaking valve, because air can then pass over the vocal cords. Not every patient qualifies immediately; readiness depends on their ability to tolerate cuff deflation and manage secretions safely.