When a family member comes home from hospital with a tracheostomy, the question that causes most worry on the first night is: "What has to be done over a whole day?" How often the stoma needs cleaning, whether the inner tube needs washing, when to humidify and when to suction are the everyday details that carers have to sort out.
The main points first. A patient with a tracheostomy at home needs the stoma cleaned every day, the inner tube washed, the airway humidified, and suctioning to clear secretions. Nursing staff lead on the stoma wound, and physiotherapy covers only airway clearance. The limits also need to be stated clearly. The evidence for respiratory physiotherapy is generally of low certainty, and the core aim is safe care and secretion management. There is no firm conclusion that it cures disease or lowers infection. This page covers the daily routine at home and the division of professional roles. It is the tracheostomy care article in the series on home ventilator and tracheostomy care.
Four daily priorities in home tracheostomy care
After coming home with a tracheostomy, daily care centres on four basic tasks. The Canadian Thoracic Society guideline on home mechanical ventilation covers groups who need home ventilation, including motor neurone disease, spinal cord injury, muscular dystrophy, scoliosis and chronic obstructive pulmonary disease. It lists airway management in the transition from hospital to home as a shared core issue (McKim 2011). The focus of tracheostomy care is exactly the airway. The four tasks are listed below in the order of the day.
Home tracheostomy care revolves around these four things during the day.
- Stoma cleaning—Check the skin around the stoma every day and clean it as needed, and watch for discharge, redness or a bad smell. Nursing staff are responsible for this part. The physiotherapist does not handle wounds.
- Inner tube cleaning—If the tracheostomy tube has an inner tube, take it out at set times and wash it, remove the secretions stuck to it, and then put it back so that phlegm does not narrow the tube. The method and frequency should follow the discharge instructions and the teaching from nursing staff.
- Humidifying the airway—After a tracheostomy, the air breathed in no longer passes through the nose to be humidified naturally. The airway dries out easily and secretions become thick. The patient therefore needs extra humidification (for example with a humidifier bottle or a heat and moisture exchanger), so that secretions are easier to cough up or suction out.
- Suctioning when needed—Suction only when secretions can be heard, when the oxygen saturation drops, or when the patient feels phlegm that cannot be coughed up. Before suctioning, humidify well and position the patient so that the secretions loosen. This reduces the number of times suctioning is needed.
Of these four tasks, stoma and inner tube care are mainly nursing procedures, while humidification and the steps around suctioning belong to airway clearance. The moment of suctioning itself, including when to suction, how to do it, and the risks and contraindications, is a separate matter of technique. For details see the page on safe suctioning at home and carer training. This article covers only the steps before and after suctioning.
Roles of nursing staff and the physiotherapist in tracheostomy care
The easiest thing to confuse in tracheostomy care is who should handle which task. The British Thoracic Society (BTS) set out a formal guideline framework for the physiotherapy management of adult, medical, spontaneously breathing patients. It covers airway clearance and secretion management, and advises using standardised assessment to decide on the intervention rather than treating everyone the same way (Bott 2009). Applied to tracheostomy care, the most practical division has two areas: wounds and the stoma on one side, and airway clearance on the other.
- Cleaning and checking the skin around the stoma
- Changing dressings and the tube ties (neck tapes)
- Inner tube cleaning and stoma care teaching
- Managing bleeding, granulation tissue and signs of infection
- Positioning, and side-lying to help drain secretions
- Working with humidification and preparing before suctioning
- Encouraging an effective cough in awake patients
- Assessment and referral for cough assistance in selected patients
The two professions do not replace each other. They work together, each in its own area. In practice, when a Nova physiotherapist visits, they are responsible only for guidance on airway clearance and preparation before suctioning. If bleeding at the stoma, granulation tissue or signs of infection are found, they refer the patient to nursing staff or the treating team straight away, and never handle the wound themselves. To see how ventilator and tracheostomy care is shared among the four professions, return to the overview of home ventilator and tracheostomy care.
Carers must know when to ask for help immediately. The tracheostomy tube may be completely blocked by thick secretions or blood clots, the patient may remain severely breathless or look worse after suctioning, there may be continuing bleeding or redness and heat around the stoma, or the whole tube may have shifted or come out. These situations are beyond what can be handled at home with secretion clearance. In any of them, contact nursing staff or the treating medical team straight away, or seek help as set out in the discharge instructions, and do not try to cope alone.
Preparation before suctioning: positioning, humidification and cough assistance
Many family members suction as soon as they see secretions. If preparation is done well before suctioning, secretions come out more easily, fewer suction passes are needed and there is less irritation to the lining of the airway. To understand why secretions should be helped first, it helps to know the path secretions take in a patient with a tracheostomy. Secretions in the small deep airways first have to move to the large airways, and are then coughed out or suctioned near the larynx. A review of secretion-clearance techniques in neuromuscular disease divides the techniques along this path. One group helps to cough out forcefully secretions that have already reached the proximal airways, and the other group pushes secretions up from the peripheral small airways. The review also stresses checking the effect with objective measures such as PCF, and adding aids only for patients who need them after assessment, not routinely for everyone (Chatwin 2018). The steps before suctioning are broadly as follows.
A weak cough needs assessment first: PCF below 270 L/min is the line for cough assistance
The humidification, positioning and encouraged coughing described above are flexible measures adjusted to the situation. Only when the cough is weak to a certain degree is there a criterion set by a specific number. The AARC guideline sets a clear threshold.
When PCF is below 270 L/min, cough assistance is recommended.If a patient has neuromuscular disease and an impaired cough, and the peak cough flow (PCF) is below 270 L/min, the AARC guideline recommends using cough assistance (AARC 2013). The same guideline also notes that, because of insufficient evidence, techniques such as chest physiotherapy are not recommended routinely, including routine use in people with chronic obstructive pulmonary disease. Of all the care steps described on this page, this is the only one where a hard decision can be made from a single number. The patient's actual PCF value must be measured and judged by the medical team, and family members should not apply this number to the patient themselves.
Note that passing this line only means that use of cough assistance should be assessed. It does not mean it will work as soon as it is used, and whether to use MI-E still depends on individual clinical judgement (Chatwin 2018). When a patient clearly has a weak cough and repeated blockage by phlegm, Nova physiotherapists advise asking the medical team to assess PCF, and never promise the family that using it will prevent pneumonia.
Limits of the clinical evidence on airway clearance
To be responsible to families, the limits of the medical evidence need to be stated clearly. Suctioning and ventilator parameter adjustment are standard clinical procedures, not a treatment effect supported by randomised controlled trials. The secretion-clearance techniques themselves generally have only low-certainty evidence. They are safe and help clear phlegm in the short term, but they cannot be claimed to cure disease, reduce infection or lower mortality. The following three systematic reviews show the limits.
Safety and evidence quality of airway clearance techniques
- Airway clearance techniques in people with bronchiectasis "appear safe"
- They can clear more sputum and improve some lung function measures
- Whether they reduce the number of exacerbations is not yet clear. The claim of improved quality of life comes from only two small studies, and the evidence quality is low (Lee 2015)
Current evidence on mechanical insufflation-exsufflation (MI-E)
- Mechanical insufflation-exsufflation used in people with neuromuscular disease
- The current evidence is not sufficient to support or refute its use
- The studies could not assess important short-term and long-term outcomes, or the related adverse effects (Morrow 2013)
Evidence on chest physiotherapy for pneumonia
- The analysis covered 8 randomised controlled trials with 974 hospitalised patients
- The effect on mortality and cure rate is very uncertain
- Some techniques may slightly shorten hospital stay and fever duration, but the certainty of this evidence is very low (Chen 2022)
The real aim of home care
- The aim is to manage secretions well and keep care safe, not to cure the disease
- Secretion-clearance aids are only supplementary methods for particular patients (for example a weak cough or retained secretions)
- Families should not be promised that doing all of this will prevent pneumonia
Home tracheostomy care in Hong Kong and community support
In Hong Kong, patients who go home with a tracheostomy are mostly discharged from public hospitals and are in the transition to home care. A few common situations show what this looks like. After an older person is discharged with a tracheostomy, the family may need to check the stoma, wash the inner tube and suction as needed every 4 to 6 hours in the daytime, and get up at night to deal with secretions if there is a lot. Families living in subdivided flats or small units may have a suction machine and humidifier bottle beside the bed, with the carer working alone and trying to simplify the routine while also finding space for cleaning and disinfection. For older people with limited mobility, community nurses usually visit regularly to change dressings, while the physiotherapist separately guides airway clearance and positioning. The following are ways to get related support in Hong Kong.
Home nursing and referral services
- The Hospital Authority's Community Nursing Service is referred by the discharging hospital and provides home visits to change dressings, suction and teach stoma care
- The service needs a referral arranged by the treating doctor or the ward. Website: ha.org.hk
Multidisciplinary community support
- Hong Kong Society for Rehabilitation Community Rehabilitation Network
- Telephone (852) 2534 3300 / (852) 2855 1947
- Nurses, physiotherapists, occupational therapists and social workers together support people with long-term illness
The content above is mainly about managing secretions and stoma care, but many people with a tracheostomy also need to be connected to a ventilator, and the secretion-clearance steps must be timed together with the machine's breathing rhythm. To learn more about working with a ventilator, continue to the page in the same care series that explains ventilation support and the timing of secretion clearance: ventilation support and coordination for home NIV (BiPAP/CPAP).
When to arrange a therapist home visit
In the first few weeks after coming home with a tracheostomy, the questions families ask most are whether the phlegm has really been cleared and when cough assistance becomes useful. Judging this by eye often goes wrong, and it is safer to have a therapist who has assessed the stoma and cough ability at home decide. For people with a tracheostomy, the home physiotherapyservice provided by Nova Health has a registered physiotherapist measure the patient's cough ability on site, observe the amount of secretions, and demonstrate in person how to link humidification, positioning and coughing before suctioning in the right order. The therapist also sets the professional boundaries in advance and says clearly which situations go back to nursing staff or the treating team. Stoma wounds always belong to nursing, and only airway clearance falls under physiotherapy. If bleeding, granulation tissue or signs of infection are found, the therapist refers on straight away and never handles the wound.