NOTE: We review our guidelines regularly and this guideline is now past its review date. The content of the guideline below may not reflect the most recent evidence-based practice. Please use with caution.
These guidelines are intended to support practitioners caring for a child with a Montgomery T-tube, to improve care and improve the safety of this group of children. While not intending to replace formal teaching, there are quick reference algorithms included in these guidelines for practitioner use.
All practitioners should have appropriate clinical experience in dealing with a child with a Montgomery T-tube and should rely solely on these guidelines to practice.
A Montgomery T-tube is a soft silicone tube that is shaped like a ‘T’. T-tubes are used for many reasons; to support the upper airway after reconstructive surgery and to support the upper airway that would have ordinarily collapsed, thus allowing the child to breathe in the normal way. The distinctive shape of the T-tube allows part of the tube to support (or stent) the upper airway, whilst the lower parts act like a tracheostomy tube, allowing the child to breathe easily.
It is an artificial airway and must be supervised at all times by someone competent in its care.
The T-tube sits in the same place as the tracheostomy would have been, between the third and fourth tracheal rings. A Montgomery T-tube, like a tracheostomy, is life-saving, but can become life-threatening unless the airway is kept clear from secretions 24 hours a day.
Paediatric Montgomery T-tubes
Paediatric Montgomery T-tubes are available in various sizes. The surgeon will determine this at the time of surgery.
The T-tube has five parts: external limb, upper limb, lower limb, a ring and a cap.
The external limb is what can be seen protruding from the child’s neck. This limb is connected to the upper and lower limbs.
The upper limb rests in the child’s upper airway. It supports or stents the airway after reconstructive surgery. The upper limb extends to an area just below, at, or just above the vocal cords. The length will vary so it is essential that practitioners know the exact length of the upper limb, for suctioning purposes.
This should be in the operation notes but contact surgeons if it is not.
The lower limb extends down the trachea and acts as a tracheostomy tube, allowing the child to breathe. As above, this length will vary, so it is essential that practitioners are aware of the length.
The ring sits on the external limb between grooves. They support and position the T-tube by minimising its movement back and forth. The ring should not be pushed flush to the skin, as this may create pressure-causing discomfort and probably skin irritation and/or breakdown.
The cap fits into the external limb and can be used when children are able to breathe through their (normal) upper airways. This will be individually assessed and determined and therefore should not always be used. Alternatively, the cap is left off and the child breathes through the external and lower limbs, just as they would through a tracheostomy.
Maintenance of the humidity and warmth of inspired air is an essential part of tracheostomy management, as the normal functions of the upper respiratory tract have been bypassed (Harking and Russell 2001).
The nose and naso-pharynx normally ensure that inspired air reaches a temperature of 37°C and 100 per cent relative humidity. Bypassing these with a tracheostomy dedicates such functions to the lower airways, which are poorly suited to the task.
Inspiration of cool and dry air may create many problems for the tracheostomised child. Impairment and destruction of cilia reduces the proximal transportation of mucus (Jackson 1996). Secretions become increasingly thick and tenacious, making their expulsion difficult. This may lead to blockage of the tube.
Additionally, cold inspired air increases heat loss from the respiratory tract and is a particular danger for the small infant. It is essential that there is a delivery of inspired air at 37°C and 100 per cent relative humidity to maintain the child's natural defence mechanisms (Ryan et al 2003).
The ill/hospitalised child may require extra humidity. This can be delivered via a nebuliser or by a continuous humidity system.
Nebulisers provide aerosol droplets in a saturated vapour. The advantage of using water droplets in the respiratory tract is not well documented or understood, and some argue that excessive saturation of the lower airways may cause atelectasis and impair the function of distal cilia (Conway and Holgate 1991; Harris and Riley 1967). For this reason, the primary method of humidification should be via a continuous hydration system; nebulisers should be used as an additional tool.
Water humidifiers are particularly useful when there is a higher requirement for humidification, eg when the child requires a high minute volume during an acute respiratory illness or post anaesthesia (Klein and Graves 1974). Care must be taken when assessing the effectiveness of water humidifiers. Water droplets must be visible along the whole of the elephant tubing. Warmed humidity must be used for small and vulnerable infants.
It is also important that the child with an artificial airway remains systemically hydrated. Practitioners should consider increasing the child’s intake during times of illness such as vomiting, diarrhoea, pyrexia, etc.
Unlike tracheostomy tubes, heat and moisture exchangers (HME) cannot be used. A home nebuliser with a tracheostomy mask should be considered for these children prior to discharge, to be used when secretions are difficult to retrieve.
If the eventual plan is to discharge the child with the external limb blocked, then the child (to some degree) will be able to humidify their airway in the normal way with supplementary facial nebulisers as required.
Oxygen can be delivered in two ways, either by nasal cannula (only if the external limb is occluded by the cap) or with a tracheostomy mask placed over the T-tube if the limb is to remain open.
It will be determined early on whether or not the child is to have the exterior limb occluded. If they do, then the child should be encouraged to cough and clear their own secretions in the normal way. If this is not the case, suctioning will have to be performed in both the upper and lower limbs. Both require the same level of accuracy and care. Both the upper and lower limbs must be kept clear, especially if the child is to have periodic exterior limb occlusion.
Preparation of equipment and environment
Prior to surgery, the child’s bed must be made easily accessible from both sides without obstruction, eg from patient luggage, chairs and foldaway beds.
Appropriate resuscitation and suction equipment (with correct T-tube fitting male to female portex adapter) and correct size face mask in full working order. There is also a requirement that a portex swivel connector is available.
The child must have a dedicated tracheostomy trolley by the bedside, containing the following equipment:
- oxygen saturation monitoring if oxygen therapy is required (Rationale 1)
- suction catheters - correct size (Rationale 2)
- clean gloves (Rationale 3)
- clean gauze (Rationale 4)
- clean receiver with tap water (Rationale 5)
- a 2ml syringe
- ampoule 0.9 per cent sodium chloride for irrigation (Rationale 6)
- yellow waste bag for incineration (Rationale 7)
- an emergency trachi box should be prepared with:
- a spare tracheostomy tube (same size and make) (Rationale 8)
- a tracheostomy tube (one size smaller) (Rationale 9)
- a water based lubricant such as Aqua lube® or K-Y jelly® (Rationale 10)
- round-ended scissors (Rationale 11)
- spare tracheostomy tapes (Rationale 12)
- a suction catheter (same ID as the suction catheter) (Rationale 13)
- goggles/protective eye wear
Initial care of Montgomery T-tube formation
Actions during the first few days following formation of the T-tube, concentrate on maintaining the patency of the new tube, stoma maintenance and parental training.
Most children having the T-tube would have already had a tracheostomy. The initial few weeks are a period of huge readjustment for the children and parents. Most parents will have already been familiar with tracheostomy care and so familiarisation, rather than re-teaching is required. If the child has not had a tracheostomy before, then contact the TNP for advice.
The child must be supervised at all times by someone who is competent in suctioning of at least the lower limb, has an understanding of how to remove the T-tube in an absolute emergency, and is able to insert and secure a tracheostomy tube.
Communication between the hospital and local health carers must be increased following surgery and when the equipment list is sent out to the community teams (Rationale 14).
The child’s vital signs should be recorded according to local policy, with the frequency reducing as the child’s condition dictates (Rationale 15).
Practitioners should also carry out routine non-invasive observations to rule out potential, initial complications, such as observing for neck swelling (emphysema), inspecting the chest for bilateral chest movement and auscultating the chest for equal air entry (pneumothorax/ tube position). A flexible endoscopy may be performed post operatively if the child is distressed and/or coughing.
Initial complications are largely avoidable if the procedure is carefully performed, together with careful and effective post-operative management.
Other initial complications include:
- Haemorrhage: may be primary, reactionary or secondary. A large haemorrhage may be fatal.
- Tube blockage: perform at least half hourly to one hourly suction for the first 12-24 hours (Yaremchuck 2003; Onakoya et al 2003; Friedman et al 2003; Seay et al 2002; Park et al 1999).
- Accidental decannulation/tube displacement: early recognition of complications is essential and practitioners must contact the ENT team/TNP and/or the clinical emergency team for immediate assistance.
- Infection (chest/stoma site).
- Surgical emphysema: air may leak around the tube into the surrounding tissue. This is particularly problematic if the child has had neck sutures inserted.
If there have been no previous feeding concerns, the child may recommence their normal feeds after a specified time of being ‘nil orally’. This is normally three hours post-operation, but practitioners must confirm this with the anaesthetic chart (Rationale 16, 17, 18).
For a child that has had feeding difficulties or has never orally fed, consultation with the speech and language therapist should be sought before the commencement of oral feeding.
Begin with water. If the child shows signs of aspiration, for example, if there is coughing after/during drinking, or visible drink coming out of the tracheostomy, then maintain nil orally and contact ENT team and the speech and language therapist. It is common for a child to have some difficulties managing fluids, especially if the upper limb sits at or through the vocal cords.
Administer humidity via sterile water and elephant tubing continuously for 24 hours, then review. The length of time may differ and this will be discussed individually on the post operative ward round by the surgeons or TNP. The child may come off for short periods, ie to feed, play, mobilise, etc. It is rare to insert a Montgomery T-tube into small infants, but humidity must be warmed if they are under one year of age.
Change humidity apparatus when the bottled water needs changing (usually 24 hours) or earlier if contaminated with secretions, or if the mask comes into contact with the floor. When not in use the mask should be covered.
The insertion of the Montgomery T-tube must be confirmed by telephone with the child’s health visitor, GP, paediatric community nurse, school nurse and local hospital on the day the T-tube is inserted. As the majority of children would have already had a tracheostomy, they should still have all of their equipment.
T-tube sizes do not relate directly to the size of tracheostomy tubes. In most cases the T-tube will be much bigger than the original tracheostomy tube. Practitioners should confirm the size of the T-tube and ensure that the size of the spare emergency tracheostomy tube is appropriate. Practitioners can contact the TNP or surgeons for advice.
An equipment list and introductory letter must be sent to the community nurse, especially if there are any changes, so that equipment can be ordered immediately.
Discussion of respite and carer support should be broached. Most children will go straight home but, if they are being discharged back via their local hospital, negotiations to do this should begin as soon as the T-tube is formed.
Most children would have had a tracheostomy and so would be familiar in its care and techniques, so attention must be directed in providing training to the carers in the following:
- Competence in tracheostomy care.
- Suctioning of both the upper and lower limbs.
- Stoma care and removal of cap.
- Advice on occluding the outer limb (if applicable).
- Resuscitation skills/emergency care - including resuscitation via the T-tube using the portex adapter, checking for blockages and action to take if blockage is present, removal of T-tube. Parents are only to receive training from a resuscitation training officer and someone familar with the Montgomery T-tube and how to remove it. The TNP has a training video that is available for parents to watch.
- Carer must do an overnight stay with their child and carry out all care overnight.
- Carers must feel confident in taking the child out of the hospital.
They must be given the appropriate tracheostomy and T-tube resuscitation booklets to support their training. All training received must be recorded on the child’s discharge planner and kept in their health record for future reference. An eight-week ENT outpatient appointment must be arranged prior to discharge.
Confirm discharge of patient with health visitor and/or paediatric community nurse and GP as appropriate.
A T-tube is held in place only by the upper and lower limbs. Therefore undue pressure or pulling of the T-tube should be discouraged.
Stomal cleaning is normally performed daily. A clean with normal saline and gauze is all that is required. Observe for skin breakdown and granulation tissue and treat accordingly.
Crusting may also need to be removed from the T-tube and/or cap.
Only one person is usually needed to clean the stoma. Either the child’s family or the child’s nurse may carry it out. Older children may sit, smaller ones may have to lie down and be swaddled.
Suctioning a Montgomery T-tube
Airway suctioning is a common practice in the care of a child with a Montgomery T-tube, and is undertaken to remove secretions from the child's respiratory tract. A child with a Montgomery T-tube may find it difficult to clear their secretions effectively, therefore suction is an essential aspect of their care.
Suctioning is associated with many potential complications, and is now only recommended when there are clear indications that the patency or ventilation of the children could be compromised (Czarnik et al 1991; Fiorentini 1992; Raymond 1995; Gemma et al 2002; Dellinger 2001; Spence et al 2003; Ahn and Kwang 2003).
Potential complications include:
- formation of distal granulation tissue/ulceration
- cardiovascular changes
- bacterial infection
- intracranial changes
The GOSH clinical practice guideline on airway suction (Simpson 2009) is a useful resource.
Practitioners trained in the skill should perform tracheostomy suctioning to minimise complications and maximise treatment(Nursing & Midwifery Council 2008).
A clean technique must be used and the catheter should be discarded if the tip is contaminated with hands, cot sides etc. Suctioning equipment must accompany the child at all times, regardless of the nature of the journey or the distance to be travelled.
The following equipment should be prepared:
- suction catheters of the correct size
- suction unit with variable vacuum control
- gloves and apron (if there is time - a child should never have to wait for suctioning)
- tap water (in clean container)
- a 2ml syringe with 0.9 per cent sodium chloride for irrigation
- yellow waste bag for incineration
Distal tracheal damage and hypoxia are potential complications, especially with the paediatric airway. These complications can be reduced by having:
- A suction catheter with diameter less than half the diameter of the T-tube (Ahn and Hwang 2003; Odell et al 1993; Glass and Grap 1995; Wood 1998). As a guide, practitioners should double the size of the tube to obtain the appropriate catheter size, for example an equivalent T-tube to a 4.0 ID tracheostomy tube is a size 8fg catheter. A suction catheter should be less than half the size of the tracheostomy to reduce the potential for hypoxia and allow the child to breathe throughout the procedure.
- One distal and two lateral ports with rounded ends (Ahn and Kwang 2003; Simpson 2009). This allows secretions to be collected both distally and from the sides of the tube, to minimise tube occlusion. Any more than three lateral holes, then the catheter wall will become too weak.
- A lateral port that is smaller than the distal port, so that mucosal adhesion and biopsy does not occur (Fiorentini 1992; Luce et al 1998).
- An integrated valve for vacuum control, as suction should only be applied on removal. Catheters should not be kinked prior to insertion, in an effort to control the vacuum.
- It is preferable to use suction catheters with graduations, so that practitioners can measure the exact depth to be suctioned. Suctioning should not occur distal to the tube tip. Catheters should only be inserted so that the distal hole sits at the end of the tube. This allows collection of secretions, but not trauma to the distal tracheal mucosa.
- Suction pressures should be kept to a minimum. As a general guide, pressures should not exceed 60-80mmHg (8-10kPa) for neonates/small infants and up to 120mmHg (16kPa) for older children. Below is an approximate guide (Simpson 2009; Billau 2004). Excessive pressures can cause trauma, hypoxaemia and atelectasis (Czarnik et al 1991).
Tube sizes and suction pressures for children with Montgomery T-tubes
|Age of child||Approx size of tube||Suction pressure|
|Pre-term - one month||3.0||8-10 Kpa
|0-3 years||3.5-5.0||10-12 Kpa
|3-10 years||5.0-6.0||12-15 Kpa
|10-16 years||6.0-7.0||15-20 Kpa
Suctioning is not a painful or distressing procedure. In fact, most infants will remain asleep throughout. If the child becomes distressed during suctioning, then practitioners should revise their technique. Suctioning a paediatric tracheostomy is very different from suctioning an adult tube, so adult practitioners will need to adapt their practice.
Steps to perform suctioning:
- Perform a clinical hand wash (Rationale 3).
- Put on a minimum of gloves (Rationale 3).
- Turn the suction unit on and check the vacuum pressure. Set to the appropriate level according to age.
- The carer must know the length of the T-tube, both the upper and lower limb.
- Insert catheter gently into the tracheostomy tube, enough to ensure that the lateral and distal holes just pass through the tip of the tube, using the graduations on the catheter as a guide.
- Adult literature suggests longer distances (Luce et al 1998). However, the distance between the tube tip and a child’s carina can be a matter of millimetres.
- Handle only the proximal end of the catheter.
- Catheters should be discarded if the end has been touched before insertion.
- Apply suction by placing thumb over the valve, found either on catheter or suction tubing.
- Do not kink the catheter (Czarnik et al 1991).
- Do not employ an intermittent suction technique as intermittent suctioning does not reduce trauma and is less effective.
- Slowly withdraw the catheter straight out of the tube maintaining the vacuum.
- Do not apply suction insertion as this may cause mucosal irritation, damage and hypoxia (NPSA 2009).
- There is no need to rotate catheter on withdrawal, as both the distal and lateral holes on the new catheters allow for circumferential suctioning.
- Suctioning should be quick but effective.
- Repeat the procedure as necessary (Rationale 19).
- The catheter may be re-used if immediate suction is required, as long as secretions have not occluded the suction ports (Scoble et al 2001)(Rationale 20).
- Wrap the catheter around the gloved hand, remove the glove by inserting it over the used catheter and discard in yellow waste bag according to waste policy.
- Flush suction tubing with tap water (Rationale 23) and connect a new catheter to the tubing.
- Wash hands (Rationale 3).
Record if the secretions are bloody, purulent, foul smelling or unusually thick in the child’s health care records.
A GOSH audit/review of tracheostomy care in 100 children was carried out in 2007. Endoscopic images of the trachea were obtained intra-operatively, reviewed retrospectively and assessed for injury to the distal trachea and carina. The review revealed that out of 100 images of children taught suctioning technique, 91 had no distal damage, six had damage associated with the underlying disease, and four had distal granulation tissue probably associated with distal trauma (Forbes and Cooke 2007).
It will be determined early on whether or not the child is to have the exterior limb occluded. If they do then the child should be encouraged to cough and clear their own secretions in the normal way. If this is not the case, suctioning will have to be performed in both the upper and lower limbs. Both require the same level of accuracy and care. Both the upper and lower limbs must be kept clear, especially if the child is to have periodic exterior limb occlusion.
Angulation of the external limb, either upwards or downwards, is required to facilitate suctioning in the upper or lower limb.
Resuscitation of the child with a Montgomery T-tube
The basics of cardio-pulmonary resuscitation (CPR) and basic life support (BLS) are universal to all protocols for emergency care:
- airway management
- rescue breathing
- circulatory support
Airway management aspects of BLS will require modification. Therefore, practitioners caring for children with T-tubes must have had both routine and tracheostomy BLS training, formally and practically.
When applied to a patient with a T-tube/tracheostomy, CPR may be more difficult to teach and to learn, because a more complex process is required to determine and correct the cause of the collapse. Practitioners caring for a child with a T-tube must familiarise themselves with the T-tube/tracheostomy resuscitation algorithm.
Patients with a Montgomery T-tube must always have their own emergency equipment correctly assembled and easily accessible.
Starting BLS quickly is extremely important (Rationale 21).
- Ensure safety of yourself and the child.
- Stimulate the child and call their name, taking care to support their head and body (Rationale 22).
- Call for assistance from colleagues (Rationale 23). If the cap is on the external limb then remove it immediately.
- If you are by yourself DO NOT leave the patient at this stage.
- Open and check the child’s airway by placing the child supine on a flat firm surface.
- It may be helpful to put a folded towel under the shoulders, but only if this is immediately available. Do not waste time by collecting this equipment.
- Gently tilt the tip of the chin upward, taking care not to press on soft tissue underneath.
- Inspect tube for obvious problems, ie signs of blockage, such as crusts, kinks or dislodgement.
- Suction the T-tube both inferiorly and superiorly to clear any secretions. This will identify whether the tube is blocked or if the airway is clear. If the tube is partially blocked and the child is still breathing, take time to clear the tube rather than change it, which is both difficult, dangerous and distressing for the child. A member of the ENT team or the TNP should be called prior to its removal if there is time. Removal of the T-tube is a decision that should not be taken lightly or undertaken by inexperienced practitioners, and it must be only removed if all attempts to clear it have failed and it is a clinical emergency. If the tube is clear but the child is not breathing, then ventilation can be administered via the T-tube using the bag and a male connector (appropriate size).
- The T-tube can be removed by grasping the external limb, either with fingers or blue plastic clamps, and pulling gently and slowly until either of the upper or lower limb is pulled from the stoma, then gently assist the other limb from the stoma. On removal a tracheostomy tube can be inserted into the stoma and resuscitation can commence via this.
- If in any doubt about child's condition, call for clinical emergency team immediately (2222).
- Suction the T-tube. In most circumstances suctioning will clear the obstruction and ventilation can be delivered.
- If obstruction cannot be cleared or the child is lifeless and not breathing, remove the T-tube immediately and insert a tracheostomy. Refer to cautionary and removal notes above.
- The equivalent size tracheostomy tube should be inserted. If unable to insert the same size tube, try to insert the one that is a size smaller.
- If the stoma closes and the smaller tube cannot be replaced, remove the obturator from the smaller tube and pass a suction catheter through the tube. Then attempt to insert the end of the catheter through the stomal opening. Then attempt to guide the tracheostomy tube along the catheter and through the stoma (Seldinger technique).
- If this is also unsuccessful, ventilation can be attempted via the catheter threaded in to the stoma (as described previously) or by conventional rescue breaths (eg mouth-to-mouth or bag and mask over the mouth and nose if the child’s overall clinical diagnosis allows this).
The Seldinger technique should be practised as a first line attempt at reinserting a tracheostomy tube. Tracheal dilators should only be used by practitioner’s competent in their use. All sizes of dilator are currently kept in the resuscitation trolley for use on request from experienced practitioners (Lyons et al 2007).
- Supporting the new tube, place the side of your face over the tracheostomy tube to listen and feel for any breathing. At the same time look at the child’s chest to observe any breathing movement. Take up to a maximum of ten seconds to do this.
- If the child is breathing adequately, give oxygen and keep their airway open by regular suction and await for the clinical emergency team/ENT/TNP and/or CSPs to arrive (practitioners should decide on whom best to call).
- If the child is not breathing (or only making agonalgasps), commence artificial respiration with a bag-valve system directly connected to the tracheostomy tube, and administer five breaths. This is best achieved with a Portex 15mm swivel connector attached to the ambu bag.
- Ensure that the breaths are effective by observing chest movement.
- Oxygen should be set at a minimum of 10 litres/minute for a paediatric system and 15 litres/minute for the adult system.
- Parents will be taught mouth to trachy resuscitation for going home. In addition to the other equipment required, they must be given a Smiths catheter mount 15mm female, and two emergency Velcro® tapes.
Rationale 1: To enable continual assessment of oxygen requirements.
Rationale 2: To safely suction tracheostomy tube.
Rationale 3: To minimise the risk of cross-contamination.
Rationale 4: To clean stoma/secretions.
Rationale 5: To flush through suction tubing after use.
Rationale 6: To draw up saline for instillation
Rationale 7: To meet hospital waste disposal guidelines.
Rationale 8: To replace a blocked tube.
Rationale 9: If the stomal opening shrinks and the normal size tube cannot be inserted.
Rationale 10: Smoother insertion of the tracheostomy tube.
Rationale 11: To prevent trauma to the neck when cutting the ties.
Rationale 12: To secure the tube.
Rationale 13: To railroad the tube into the stoma (Seldinger technique).
Rationale 14: To ensure effective discharge planning.
Rationale 15: To ensure safe recovery from effects of anaesthesia.
Rationale 16: The vocal cords are sprayed with a paralysing agent during the operation, making them ineffective at protecting the airway.
Rationale 17: The effect of the paralysing agent continues for up to three hours.
Rationale 18: Other physical complications accompanied with post surgical oedema and restricted laryngeal elevation, preventing complete and safe closure of the lower respiratory tract, may cause aspiration and/or regurgitation of food.
Rationale 19: Although where possible secretions should be cleared on the first attempt. Adult literature suggests that episodes should be limited to three, to limit potential side effects and maximise the recovery period (Luce et al 1993).
Rationale 20: If the distal end of the catheter has not been contaminated prior to the suctioning episode, then there is no evidence to suggest that by using the same catheter up to three times at the same suctioning episode, increases the risk of infection (Scoble 2001). In fact with effective re-training on technique, some institutions have repeatedly used the same catheter on the same patient for a 24-hour period and have reported no increase in infection.
Rationale 21: This may be sufficient to rouse the child.
Rationale 22: Always summon more help to assist in tube changes, bring other equipment etc.
Rationale 23: To clear the tubing from secretions.
Harking H, Russell C (2001) Preparing the patient for tracheostomy tube removal. Nursing Times 97 (26): 34-36.
Jackson C. (1996) Humidification in the upper respiratory tract: physiology review. Intensive and Critical Care Review 12: 22-32.
Ryan S, Chaplin J, Baker K, Dorman B (2003) Benefits of an optimal humidification strategy for patients at home with a chronic tracheostomy: a case series . European Respiratory Society (e-pub) https://www.ersnetsecure.org/public/prg_congres.abstract?ww_i_presentati....
Conway JH, Holgate ST (1991) Humidification for patients with chronic chest disease. Prob of Resp Care 4: 463-467.
Harris RL, Riley HD Jr (1967) Reactions to aerosol medication in infants and children. JAMA 201 (12): 953-5.
Klein EF Jr, Graves SA (1974) "Hot pot" tracheitis. Chest 65 (2): 225-6.
Yaremchuck K (2003) Regular tube changes to prevent formation of granulation tissue. Laryngoscope 113(1): 1-10.
Onakoya PA, Nwaorgu OG, Adebusoye LA (2003) Complications of classical tracheostomy and management. Trop Doct 33 (3): 148-50.
Friedman E, Kennedy A, Neitzschman H (2003) Inominate artery compression of trachea: an unusual cause of apnoea in a 12 year old boy. Southern Medical Journal 96(11): 1161-1164.
Seay SJ, Gay S, Strauss M (2002) Tracheostomy emergencies: correcting accidental decannulation or displaced tracheostomy tube. American Journal of Nursing 102(3): 59-63.
Park JY, Suskind DL, Prater D, Muntz HR, Lusk RP (1999) Maturation of the pediatric tracheostomy stoma: effect on complications. Ann Otol Rhinol Laryngol 108 (12): 1115-9.
Czarnik RE, Stone KS, Everhart CC Jr, Preusser BA (1991) Differential effects of continuous versus intermittent suction on tracheal tissue. Heart Lung 20 (2): 144-51.
Fiorentini A (1992) Potential hazards of tracheobronchial suctioning. Intensive Critical Care Nursing 8(4): 217-226.
Raymond SJ (1995) Normal saline instillation before suctioning: helpful or harmful? A review of the literature. Am J Crit Care 4 (4): 267-71.
Gemma M, Tommasino C, Cerri M, Giannotti A, Piazzi B, Borghi T (2002) Intracranial effects of endotracheal suctioning in the acute phase of head injury. J Neurosurg Anesthesiol 14 (1): 50-4.
Dellinger K (2001) Suction injuries: education is the key to prevention. J Pediatr Nurs 16 (3): 147-8.
Spence K, Gillies D, Waterworth L (2003) Deep versus shallow suction of endotracheal tubes in ventilated neonates and young infants. Cochrane Database Syst Rev (3): CD003309.
Ahn Y, Hwang T (2003) The effects of shallow versus deep endotracheal suctioning on the cytological components of respiratory aspirates in high-risk infants. Respiration 70 (2): 172-8.
Simpson S (2009)Airway suction.www.ich.ucl.ac.uk/clinical_information/clinical_guidelines/cpg_guideline.... Viewed on: 31/03/2010
Nursing & Midwifery Council (NMC) (2008) The Code: Standards of conduct, performance and ethics for nurses and midwives. London, NMC
Glass C, Grap MJ (1995) Ten tips for safe suctioning. American Journal of Nursing 5(5): 51-53.
Wood CJ (1998) Endotracheal suctioning: a literature review. Intensive Crit Care Nurs 14 (3): 124-36.
Luce JM, Pierson DJ, Tyler ML (1998) Internsice Respiratory Therapy (2nd Edition). Philadelphia, WB Saunders & Co
Billau C (2004) Suctioning Russell C, Matta B In: Tracheostomy a multiprofessional handbook. Cambridge, Cambridge University Press
Pritchard M, Flenady V, Woodgate P (2001) Preoxygenation for tracheal suctioning in intubated, ventilated newborn infants. Cochrane Database Syst Rev (3): CD000427.
Blackwood B (1999) Normal saline instillation with endotracheal suctioning: primum non nocere (first do no harm). J Adv Nurs 29 (4): 928-34.
Hudak M, Bond-Domb A (1996) Postoperative head and neck cancer patients with artificial airways: the effect of saline lavage on tracheal mucus evacuation and oxygen saturation. ORL Head Neck Nurs 14 (1): 17-21.
Ackerman MH, Gugerty BP (1990) The effects of normal saline bolus instillation on artificial airways. The Journal of the Society if Otolaryngology Nursing Spring: 14-17.
Neill K (2001) Normal saline instillation prior to endotracheal suction. Nursing in Critical Care 6(1): 34-39.
Lyons MJ, Cooke J,Cochrane LA, Albert DM (2007) Safe reliable atraumatic replacement of misplaced paediatric tracheostomy tubes. Int J Pediatr Otorhinolaryngol 71(11): 1743-6.
Appendix 1: Further BLS instructions(PDF, 18 KB).