Tracheostomy Care: Humidifying and Suctioning

Why is humidifying and suctioning important?

When you breathe through your mouth and nose, air is naturally warmed, moistened, and cleaned. Air coming in from a tracheostomy (trach) tube does not get moistened and cleaned. When this cool, dry air comes into the tube, it causes the lungs to make more mucus. These thick mucus secretions can block the trach tube and make it hard for your child to breathe.

Making sure your child gets the right amount of humidity and suctioning to clear secretions will decrease the risk of an emergency because the tube is blocked. Blockages can be very dangerous and stressful. Work with your health care provider to learn how to manage your child's tracheostomy care and allow your child to have a normal, active life.

HUMIDIFICATION

Humidification is very important for thinning secretions so they do not block the trach tube. Humidification is needed even in very damp climates, at least at first. Humidity in the lungs helps to protect the lining of the lung and keep secretions thin.

How do I keep the air humidified?

Air is humidified using a humidifier or an HME (heat moisture exchanger) at different times during the day. The humidifier is used at night and periodically during the day. The HME is a device that your child can wear during the day to help keep the air moist without having to be hooked up to the humidifier.

Before your child is discharged from the hospital, your discharge planner or instructor should make arrangements with a medical supply company to get a humidifier, HME, and any other equipment you will need.

Humidifier: Several different types of humidifiers are available. They all have a water reservoir, a connecting hose, and a collar that fastens around your child's neck. The trach collar keeps a pocket of moist air at the opening of the trach tube. This type of humidifier should be used at night and periodically during the day.

Either your discharge instructor or the equipment supplier will teach you to use and clean the humidifier and how to order supplies. Usually, you will need to clean and disinfect the humidifier at least once a week, according to the supplier's instructions.

The thickness of the secretions as well as changes in your child's breathing rate and pattern will help you decide if your child needs to stay on the humidifier during the day. Faster breathing, a heavy cough and thicker secretions mean your child needs to use the humidifier. If these are not present, your child is probably ready for the HME (heat moisture exchanger) and normal activity.

HME (Heat Moisture Exchanger): An HME is also known by other names including an artificial nose, filter, or T-piece. They come in different shapes and styles, but it is usually a T-shaped device with gauze in it. The HME fits onto the end of the trach tube and collects exhaled moisture to humidify the next breath. This device should be worn whenever your child is out of the home or when the child is awake and active and needs freedom from humidifying equipment.

The goal is to use the HME when your child is awake and active. Then, use the humidifier during naps, meals, and at night to replenish the lost moisture in the lungs. Usually, a child with a new tracheostomy can start out wearing an HME for at least 1 hour at a time 2 or 3 times a day. As long as the secretions do not get too thick and your child seems to handle the HME well, he can start wearing the HME for a longer amount of time. Even after a short break using the humidifier, your child will be ready to use the HME again and lead an active life.

Disposable HMEs are meant for a single use and need to be thrown away when clogged with mucus. If too much mucus is a problem, a reusable HME (a plastic T-piece with replaceable gauze) is a less expensive option. The plastic T-piece can be washed and disinfected many times, whereas the disposable HMEs cannot. You may find it helpful to use both types. For example, use a T-piece with gauze in the morning (until the amount of secretions goes down) and then use a disposable HME in the afternoon.

If the child has been using the device for a long period of time, or if it is hot and dry or windy, a few drops of saline may be added to the gauze to replace the lost moisture. You can buy saline drops at your local drug store or pharmacy. If your child is drinking plenty of fluids and has been using the humidifier, no moistening of the gauze in the HME is needed.

The best way to judge how long your child can use an HME is to periodically suction the trach.

• If the secretions easily pass through the catheter, your child can wear the HME for a longer period of time.
• If secretions are sluggish through the catheter, your child may need a few drops of saline on the HME to replace the evaporated moisture.
• If secretions coat the outside of the catheter or clog it, your child may need to use the humidifier for at least 1/2 to 1 hour or need several drops of saline into put into the trach tube, followed by suctioning until the secretions thin out.

Remember to:

• Check the HME gauze to be sure it doesn't get covered over with secretions.
• Have your child drink plenty of fluid each day. Taking in plenty of fluid will help keep secretions thin.

Check with your specialist if you have questions about humidification or HMEs.

SUCTIONING

Suctioning is important to keep mucus from blocking the trach tube.

When do I suction the tube?

Suctioning should be done whenever it is needed. Signs that your child needs suctioning include:

• gurgling or bubbly sounds
• coughing.

Suctioning should also be done at the following set times:

• before eating (waiting until after eating may lead to vomiting)
• before and after sleeping (including naps).

How often your child needs to be suctioned depends on the child's age and the reason they needed a tracheostomy. A baby or toddler may need more frequent suctioning because of crying, a less efficient cough, and more frequent colds. An older child may need suctioning only occasionally when they are healthy and more often when he or she is sick. It also depends on how well you can tolerate the secretion noises. The best advice, especially for babies, is to first attend to what is making them upset, calm them, and then decide if they need to be suctioned. Frequently, you will find that after your child is quieted, the tube is actually quite clear.

Remember, babies and small children normally swallow their secretions and saliva. This is fluid that the body naturally recycles. If you suction too much, your child may not have a reserve of moisture for longer periods of time wearing the HME.

What equipment is needed?

You will need the following equipment:

• A suction machine with tubing
• A clean catheter (a catheter is a small tube that goes through the trach opening into the airway and removes the secretions). You will need to know how long your child's trach tube is so you know how much of the catheter you need to insert. Your discharge instructor should tell you the length of your child's trach tube before you leave the hospital.
• A rinsing solution of sterile water or saline.

You should also have access to a resuscitation bag in case of unexpected emergencies with the tracheostomy.

How do I suction the tube?

To suction the tube:

1. Wash your hands with soap and water and dry them well.
2. Pick up the catheter from the end that is attached to the suction machine. Do not pick up the end that will go into the trach tube.
3. Connect the catheter to the suction machine tubing and turn on the machine.
4. Insert the catheter into the trach tube. The catheter will follow the curve of the trach tube. Be sure you know how far the catheter should go in before you begin suctioning, usually the length of the trach tube plus 1/4 inch. Stop the catheter at this point.
5. Apply suction by putting your thumb over the hole in the catheter while you gently pull the catheter back out. Gently roll the catheter between your thumb and forefinger as you pull the catheter out.

Normal secretions are clear to white and are thin to slightly thick. If the secretions are very thick, you may need to suction a second time. Put several drops of saline (not plain sterile water) down the trach and suction again. Putting saline solution down the trach and suctioning will likely cause coughing and choking. This is normal and helps to loosen secretions.

NOTE: Expert opinions vary on the use of gloves, saline, and air.

• Gloves: Some experts recommend gloves when you suction, others do not.
• Saline drops: Some experts recommend a few drops of saline be put down the trach before you suction the first time. Others recommend suctioning without saline first so you can see what the secretions look like. Some advise making your own saline solution while others recommend buying the saline solution.
• Air: Some experts recommend giving a puff of air with a bag before and after suctioning to get oxygen into the child's lungs while others don't feel this is necessary.

Discuss these options with your specialist.

How do I clean the suctioning equipment?

Rinse the catheter with sterile water and store it in a commercially made solution or a solution of 1 part hydrogen pyroxide to 1 part sterile water. Rinse the catheter with sterile water just before using. The catheter suction machine, tubing, and any other parts that have touched the secretions must be cleaned regularly. The equipment supplier will tell you how and when to do this.