Downward traction of the tracheostomy tube can
occur with too much weight pulling down on it, as discussed
previously. Traction against the tube can be
directed out and downward by pulling against the tube
or inward, with the neck flange digging into the neck.
These traction forces must be prevented and the tube
kept in a neutral position. In addition to tracheomalacia,
tube dislodgement, and inadvertent decannulation,
traction can also be a factor in skin breakdown. Inward
traction can contribute to skin erosion under the neck
flange; outward traction can contribute to erosion, dislodgement,
decannulation, and enlargement of the
stoma from the inside.
Skin integrity can be compromised at any time in a
patient with a tracheostomy. Regular skin inspection is
important to prevent complications. Keeping the site as
dry as possible with drain sponges or skin barrier dressings
such as those made from carboxymethylcellulose
(Aquacel), polyurethane foam (Lyofoam), or silicone
foam (Mepilex) can prevent skin breakdown and prevent
infection. Skin care may be difficult while the sutures
remain in place until the stoma matures. The use of
cotton-tip applicators can help in reaching the tight
places. When a cotton-tip applicator is soaked with
hydrogen peroxide and sterile physiological saline, dried
blood and secretions can be more easily removed, especially
from tight spaces.
Maintaining the tracheostomy tube in a continuous
neutral position can ensure skin integrity while a patient
is receiving oxygen via mechanical ventilation or some
other delivery device. A continuous neutral position can
be achieved by making sure the oxygen delivery devices
are not putting any weight on or pulling on or twisting
the tracheos tomy tube or by placing a bolster (rolled
towel) under the ventilator circuit. Areas of skin breakdown
should be staged and treated as necessary. Protective
dressings can be used as needed to provide a cushion,
collect secretions, and encourage timely healing. Several
dressing products are available that guard against skin
breakdown from flange pressure and are extraabsorbent
to soak up excessive tracheal secretions. However, packaged
precut tracheostomy gauze is often sufficient to
protect the peristomal skin. The gauze should not cover
the opening of the tracheostomy tube.21 Table 6 lists
types of stomal dressings and indications for their use.