An essential competency for every critical care and ward nurse in the Gulf. From tube types and daily care to suctioning, humidification, communication support and decannulation — with GCC-specific clinical and cultural context.
Understanding the procedure type and tube selection is the foundation of safe tracheostomy nursing care.
Nurses must know which procedure was performed and the exact tube in situ before providing any care.
Performed in the operating theatre under general anaesthesia by a surgical team. A formal incision is made in the neck, and the tube is sutured directly to the skin — making it the most stable and safest type in the early post-operative period.
A bedside ICU procedure performed under sedation. Most common tracheostomy technique in GCC ICUs. Two main techniques:
An emergency airway technique inserted through the cricothyroid membrane. Used when standard intubation is not possible (can't intubate, can't oxygenate — CICO scenario).
Systematic daily care prevents the leading causes of tracheostomy-related morbidity: tube obstruction, stoma infection, and skin breakdown.
Suction only when clinically indicated. Routine suction on a timed schedule without clinical indication increases risk of mucosal trauma, hypoxia, and infection.
Select a suction catheter that blocks no more than half the tube lumen. The formula:
Using a catheter that is too large causes significant hypoxia and mucosal trauma during suctioning.
Used for non-ventilated tracheostomy patients and some ventilated patients where closed-circuit suctioning is unavailable.
Preferred technique for mechanically ventilated patients in GCC ICUs. The catheter is permanently connected within the ventilator circuit in a sealed sleeve.
Higher pressures increase risk of mucosal trauma, atelectasis, and hypoxaemia without improving secretion clearance.
Tube changes require planning, preparation, and two clinicians. Never attempt a tube change alone in an unestablished tract.
The nose and upper airway normally warm and humidify inspired air. A tracheostomy bypasses this mechanism entirely — humidification is therefore not optional, it is mandatory.
Voice loss is one of the most distressing aspects of tracheostomy for patients. In the GCC, the combination of language barriers and communication disability requires creative, culturally sensitive solutions.
Patients with partially deflated cuffs who can tolerate it may achieve a soft voice by occluding the tracheostomy tube opening with a gloved finger (digital occlusion). This forces air upward through the larynx.
A one-way speaking valve placed on the tracheostomy tube hub. It opens on inhalation (air enters via tube) and closes on exhalation (air is redirected upward through the larynx, enabling voice).
An external handheld electronic device held against the neck or cheek. It produces vibration that the patient can articulate into speech. Available through speech and language therapy departments in most GCC tertiary hospitals.
Decannulation — removal of the tracheostomy tube — is the goal for most patients. It should be systematic and criteria-based, not rushed.
Rapid recognition and structured response to tracheostomy complications is life-saving. Every GCC nurse managing tracheostomy patients must know these scenarios.
| Complication | Recognition Signs | Immediate Action |
|---|---|---|
| Tube Obstruction | No air movement through tube, increasing respiratory distress, SpO₂ falling, no breath sounds over tube, high ventilator pressures, visible secretion plugging | EMERGENCY: Remove inner cannula and replace immediately. If no relief — attempt suction. If still obstructed — tube change. Call for urgent assistance. Prepare bag-valve mask. Do NOT leave the patient. |
| Tube Displacement / Accidental Decannulation | Tube visibly out of position or dislodged, air movement from stoma opening, respiratory distress, deteriorating SpO₂, patient panicking | Fresh trach (<7 days): Do NOT attempt blind reinsertion. Maintain tract with tracheal dilators. Give O₂ over stoma. Call senior urgently. Established trach (>7 days): Attempt gentle reinsertion with a smaller tube if same size fails. Confirm placement before securing. |
| Cuff Over-Inflation | Cuff pressure >25 cmH₂O on manometer check. Long-term: tracheal ulceration, tracheomalacia. Often silent until damage is done. | Check cuff pressure at least every 8–12h with a cuff manometer. Release air slowly until pressure reads 20–25 cmH₂O. Never estimate cuff inflation by feel. Document pressure readings each check. |
| Tracheomalacia | Long-term complication. Softening of tracheal cartilage from sustained cuff pressure. Signs: difficulty weaning, tracheal collapse on expiration, recurrent obstruction despite correct tube position. | Refer to ENT / cardiothoracic surgery. Specialist assessment and management required. May require airway stenting or surgical reconstruction. |
| Granulation Tissue | Raised, reddish, beefy tissue at stoma site or within the trachea. May bleed on contact. May impede tube reinsertion or cause airway narrowing. | Refer to ENT or surgeons. Treatment options include: silver nitrate cauterisation (minor), steroid cream, laser treatment (significant granuloma). Document appearance with wound chart. |
| Surgical Emphysema | Crepitus (crackling sensation) on palpation of neck and chest skin. Swelling of neck and face. Most common in PDT. | Inform medical team immediately. Minor: usually self-resolving. Significant: may indicate pneumothorax or tracheal tear — urgent review, chest X-ray, prepare for potential intervention. |
| Tracheo-Oesophageal Fistula (TOF) | Rare but serious. Recurrent aspiration despite care, food/secretions in tracheostomy, abdominal distension in ventilated patients, air in oesophagus on imaging. | Urgent surgical referral. Stop enteral feeding until assessed. Specialist investigation (endoscopy, imaging). Surgical repair required. |
| Innominate Artery Erosion | Rare but potentially catastrophic. Sentinel bleed (small bleed at stoma precedes massive bleed). Often preceded by excessive tube movement and pulsation of tube. | LIFE-THREATENING EMERGENCY: If sentinel bleed — call surgical team immediately. If massive bleed: digital pressure in stoma, inflate cuff to maximum, call code/emergency team. This is a surgical emergency. |
| Stoma Site Infection | Peri-stomal erythema >1–2cm, purulent discharge, swelling, warmth, pain at site, fever, elevated inflammatory markers. | Wound swab for culture and sensitivity. Increase dressing frequency. Saline wound cleansing. Inform medical team — systemic antibiotics may be required. Strict infection control precautions. |
Clinical practice in the Gulf region carries unique cultural, logistical, and environmental dimensions that every tracheostomy nurse must understand.
Saudi Arabia receives millions of pilgrims annually for Hajj and Umrah. A small but significant number of pilgrims have pre-existing tracheostomies or undergo emergency tracheostomy during their visit. Specific challenges include:
Long-term tracheostomy patients — particularly those with neurological conditions — are increasingly managed at home across the GCC. This creates a significant nurse-educator role.
In many GCC households, domestic workers (from the Philippines, India, Sri Lanka, Ethiopia) provide hands-on care. Training must be in a language they understand. Written instructions in Tagalog, Sinhala, or Amharic may be required — use certified medical interpreters for formal competency training, not family members for complex clinical skills.
Telehealth is rapidly expanding across the GCC (Seha in UAE, Mawid in Saudi Arabia, Health Plus). Tracheostomy follow-up via video consultation is an established and growing practice.
The neck is a visible and culturally significant body area for many patients in the GCC. A tracheostomy affects appearance and may cause body image distress, particularly for women who habitually cover their necks for modesty (hijab) or cultural preference.
GCC hospitals are among the most multilingual clinical environments in the world. A nurse may speak Filipino English, the patient speaks Arabic, and the patient's family speaks Urdu. Tracheostomy communication needs compound this challenge.
Key numbers and rules every GCC tracheostomy nurse must know by heart.