These guidelines are intended to support practitioners caring for children/young people with a Tracheostomy.
Quick reference algorithms are included in these guidelines for practitioner use.
More children with chronic medical conditions are surviving, largely due to advances in tracheostomy care and technology support. The vast majority of these children are now being cared for in their own homes and at school.
Surgical tracheostomy in the paediatric population is indicated when a safe, protected airway is required in the long term. However, as with all surgical procedures, it is associated with risks and complications. Morbidity and mortality rates reported in Tracheostomy in Paediatrics carries a 2-3 times higher morbidity and mortality than is in adults (Alladi A, Rao S, et al, 2004). The overall mortality rate for a complication directly related to a paediatric tracheostomy is 0.7% (Carr M.M, Poje CP, et al, 1995-1998). The majority of reported adverse incidents do not occur in the immediate post-operative period, late complications occurring a week or more from the date of insertion are four times more common (Corbett HJ, Mann KS, et al. 2007). Therefore, consistent high quality tracheostomy care is essential and must be delivered by all those caring for these children in both the hospital and community environments. Establishing training in the management of paediatric tracheostomy which is based on formalised standards would improve the consistency and quality of care.
Currently, there are no formally accepted national standards in the United Kingdom (UK) for paediatric tracheostomy management. Tracheostomy management has been the focus of a number of reviews in the UK over the last decade; however, paediatric patients have thus far been excluded from the analysis (Thomas AN and McGrath BA. (2009) National Confidential Enquiry into Patient Outcome and Death (NCEPOD) (2014). As a tertiary paediatric centre, Great Ormond Street Hospital (GOSH) carries out approximately 70-90 tracheostomies per annum, with approximately 2000 being managed by the department as a whole. The author of this guideline has participated in the National Tracheostomy Safety Project and has collaborated widely with the key stakeholders in tracheostomy care and developed guidance by consensus. These resources are supported by local algorithms and podcasts which are linked to this document. For further info, please see the Paediatric section in Comprehensive Tracheostomy Care - The National Tracheostomy Safety Project manual (McGrath 2014)
A tracheostomy is an artificial opening in the trachea, usually between the 2nd and 4th tracheal rings, (depending on the size / anatomy of the child, see Figure 1), through which a tube is inserted to facilitate breathing. A tracheostomy can be a lifesaving operation but is also a life threatening one unless the airway is cared for appropriately and kept clear from secretions and blockages 24 hours a day.
Children with tracheostomies require constant supervision from those fully trained in its care.
Appropriate resuscitation and suction equipment and correct size face mask in full working order should be available as well as a 15mm Smiths Medical (Portex©) swivel connector (Rationale 1).
In addition flat-ended tubes such as Sheffield silver, GOS, Portex, require an appropriately sized tracheal tube adapter and a Smiths Medical (Portex©) swivel connector. This creates a 15mm termination that will be compatible with all resuscitation and ventilator equipment. Advice can be sought from the Tracheostomy Nurse Practitioner (TNP) or the Ear Nose and Throat (ENT) team.
A multi-disciplinary team discussion between Tertiary Paediatric hospitals led to the development of an updated (Hospital) Paediatric tracheostomy emergency algorithm (see page 1 and 2 of appendix 1).
A bed head notice (see page 1 of appendix 1) completed by the ENT Surgeons or TNP must be placed on the child young person’s cot/bed.
A Bed Head Hospital Resuscitation Algorithm was generated as part of the National Tracheostomy Safety Project. It highlights the basic first response to securing the child/young person’s airway, with the option of escalating this to advanced methods when specialist help arrives. It is imperative that practitioners know the reason for the tracheostomy and whether upper airway adjuncts would be an option if the tracheostomy cannot be re-placed (see page 2 of appendix 1).
The child must have a dedicated airway area (Rationale 2) by the bedside, containing the following equipment:
- suction catheters - correct size
- clean gauze
- Personal Protective Equipment (PPE) - Protective eye wear, gloves, face mask and apron
- clean receiver containing bottled water
- a 2ml syringe and ampoule 0.9 per cent sodium chloride for cleaning / irrigation
- orange waste bag for disposal of waste in line with the waste management policy
- an emergency tracheostomy box should be prepared with:
- A spare tracheostomy tube (same size/make)
- a Shiley tracheostomy tube (half size smaller than above)
- a water based lubricant such as Aqua lube® or K-Y jelly®
- round-ended scissors
- spare tracheostomy tapes
- a suction catheter (of the correct size- for the Seldinger technique)
Following an audit of use, competence and effectiveness, tracheal dilators are not used at GOSH (Rationale 3). Practitioners should refer to the emergency care section of this guideline.
Nursing care during the first seven days following formation of the tracheostomy, centre on maintaining the correct positioning and patency of the new tube, stoma maintenance and parental teaching (if appropriate) (Rationale 4).
Communication between the hospital and community health care team must be commenced following surgery or earlier if a planned procedure (Rationale 5).
The initial nursing care of a child with a tracheostomy is very different from that of an established stoma.
At GOSH, the first tube change occurs after seven days (Rationale 6); the TNP or ENT Surgeons will perform the first tube change.
Initial complications are largely avoidable with careful and effective post-operative management. Early recognition of complications is essential and practitioners can contact the TNP or the ENT team for advice, but should never delay escalation of concerns in line with the Observation and CEWS Policy while this advice is sought.
The child has a portable chest x-ray immediately post operatively, (usually whilst in the anaesthetic room or if ventilated and transferred to ICU, on ICU) to confirm tube position and to rule out a pneumothorax and surgical emphysema (Tarnoff M, Moncure M, et al; 1998). The x-ray must be reviewed by the ENT team.
Accidental decannulation/tube displacement:
This is a clinical emergency, Phone x2222 to alert the clinical emergency team, as well as TNP and ENT.
- The tube may visibly come out of the stoma or can be pulled out of the trachea and sit in the pre-tracheal tissues. The tracheostomy Tube can be reinserted but must not be forced. On reinsertion contact ENT, TNP, Clinical Site Practitioner (CSP) team as the tube position must be checked and confirmed (Rationale 7). Common causes of accidental decannulation / displacement include: an infant with a chubby neck, use of an incorrect tube, loose tracheostomy tapes or the child / equipment pulling on the tube.
- Care must be taken to prevent decannulation by ensuring that the tube is correctly secured and does not become displaced. Practitioners should check and confirm the correct tension of the tapes and that the tube is in the stoma.
- To ensure the safety of the airway, the trachea is sometimes sutured onto the child’s skin with tiny interrupted disposable sutures - these are called maturation sutures (Rationale 8). In addition, two long looped “stay” sutures extend from inside the stoma and are taped to the child’s chest (see figure 2).These sutures are attached through the trachea on either side of the stoma (Rationale 9). Tape on the child’s chest will be labelled “DO NOT REMOVE” These will be removed after the first tube change.
The apexes of the lungs are placed high in children; there is a risk of causing a pneumothorax during the operation.
- check for air entry through tube - place finger ‘above’ tube opening & feel for a passage of air
- inspect/ feel the chest for bilateral chest movement
- close observation for respiratory distress - report immediately
- auscultate the chest for equal air entry
- a flexible endoscopy / chest x-ray may be performed post operatively if the child is distressed and or coughing.
This may be primary, reactionary or secondary.
- Observe and record the child’s vital signs and where there are concerns or visible haemorrhage, follow the Childrens Early Warning Score (CEWS) escalation procedure as detailed in the Observation and CEWS Policy (Rationale 10).
- Contact TNP or ENT if there are blood stained secretions present for longer than 24 hours.
Although suctioning should usually only occur on an ‘as required’ basis, the tube must be kept clear and suction should be performed at least ½ - hourly for the first 12 – 24 hours following insertion (Rationale 11).
Air may leak around the tube into the surrounding tissue.
- Palpate neck area and check for swelling.
- Checking tape tension not only confirms that the tube is secured correctly but also, if they appear tighter, this may indicate swelling (this is particularly important to check if you have never met the child before)
- If any swelling occurs, contact ENT medical team, TNP or CSP for advice. Again, do not delay escalation of concerns in line with the Observation and CEWS Policy while this advice is sought.
Infection (chest/stoma site):
- Observe the stoma site daily and change tapes, recording any changes to the condition of the skin
- Observe and record secretions for colour, consistency and quantity
- Record temperature.
DO NOT USE a Heat and Moisture Exchanger (HME) during the first week (Rationale 12).
- Administer humidity via bottled water and elephant tubing continuously for 1 week as far as is practicable. The child may come off for short periods, i.e. to feed, play, bathe, mobilise, etc.
- Small and vulnerable infants under one year must have continuous ‘warmed’ humidity (Rational 13).
The child should not leave the ward during the first week unless medically indicated, or being transferred between units. They must be escorted by the TNP or ENT team, in case of decannulation.
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 3 hours post-operation, but practitioners must confirm this with the instructions on the anaesthetic chart (Rationale 14).
If the child has never been orally fed, or if the child begins coughing on feeding / visible feed coming out of the tracheostomy, STOP feeding and consult with the Speech and Language Therapists (SALT).
Following a multi-disciplinary departmental review of morbidity associated with paediatric tracheostomy a TRACHE care bundle (Figure 3) was developed. It highlighted the 6 main areas of concern relating to tracheostomy care.
A tracheostomy tube is held in place with cotton tapes around the neck. Security of the tracheostomy tube is a key principle in maintaining airway safety. Paediatric patients provide a variety of challenges in achieving this, with accidental decannulation occurring in around 5% of paediatric tracheostomies (Alladi A, Rao S, et al, 2004).
It had been noted that Velcro® neck tapes were more easily undone by the patient or became attached to clothing and that, as a method of fixation, was associated with a higher rate of accidental decannulation. Accordingly, the departmental policy now is for the exclusive use of hand-tied cotton tapes to secure tracheostomy tubes.
To address issues related to these ties, a new product was developed with Marpac© from Platon Medical to offer increased comfort and safety. These were implemented across the hospital in 2013.
If a child / young person arrives in the trust with Velcro tapes, they should be changed to cotton for the duration of their stay. If Velcro ties are used then a risk assessment must be completed in accordance with Trust policy and documented in the local and Trust Risk Registers.
Tape changes (cotton) - Equipment
The following equipment should be prepared and be readily available:
- Appropriate emergency equipment (Rationale 15)
- Personal Protective Equipment (PPE) - Protective eye wear, gloves, face mask and apron
- 2 packs of sterile Gauze swabs and saline sachet/ampoules
- Tracheostomy dressing- GOSH uses Platon Trachi-dress’, and any other dressings the child might be using.
- Marpac tracheostomy tapes (come in neonatal 106, Infant 107 and adult 108 sizes). These tapes provide a comfortable soft backing but allow security of the tube by tying them to the flanges.
- Round ended scissors
- A rolled up towel/blanket (Rationale 16)
- A blanket to swaddle a baby or uncooperative toddler as required (Rationale 17). Some children may assist with the procedure by holding the tracheostomy tube in place and some may even prefer to sit during a change. These options must be discussed with the child and parents/carers as swaddling the child may cause increased distress.
- Suction equipment available
- Child’s own comforter, e.g. dummy, teddy
To change the tracheostomy tapes: This is a two person procedure
- Perform a hand wash; put on PPE (parents do not need to wear the protective clothing) this is a two person procedure.
- Prepare gauze and saline, cut tapes to desired length- threading through ends.
- Ensure emergency equipment is readily available
- Assistant to swaddle baby (if applicable), exposing shoulders, lay supine.
- Child positioned with a rolled up towel under shoulders; (some older children may wish to sit) this allows the head to be extended and gives good visibility of the stomal area.
- Assistant should hold tube in position using either their thumb and index finger, or index and middle finger; see figure 4 below (Rationale 18). Avoid undue pressure on the neck.
- Assistant to hold the tube until the stoma has been cleaned and the new tapes attached and secured.
- Tape changer should cut the tapes between the knot and the flange and remove old tapes and dressing.
- The stoma and neck are to be thoroughly washed and dried in 5 areas: above, below the stomal opening, under each flange, always wipe away from the stomal edges and finally sit the child forward, and clean around the back of the neck
- As you dry the back of the childs neck, with the child is sat forward, place the new tapes behind the child’s neck. Position the tapes with the foam padding with stitching placed next to the skin, and ensuring padding is central. Lay the child back down (older children can sit if they wish).
- Once the skin is dry, place the Trachi-Dress under the tracheostomy tube, shiny side to the skin (and any other dressings/ creams they child may be using).
- Thread the new tape through the flange on the side furthest away. Tie the tapes using a bow ensuring the tape is flat to the child’s skin to minimise excoriation. Ensure that the foam backing is as close to the tube flange as you can get it.
- Pick up the tension and pull the tapes tight. Thread the tape through near side flange, and make a bow (bows are easier to re-adjust if they are tight/loose). DO NOT knot at this stage.
Check tape tension by:
- Raising baby/child to a sitting position whilst assistant continues to hold tube in position. DO NOT check the tension from the side (Rationale 19).
- It should only be possible to slip one finger comfortably between the ties and the baby/child’s neck. (note: if hands are larger/ smaller than average use different fingers) See Figure 5 (Rationale 20).
- If the ties are too tight or loose lay the child back down, undo the bow and readjust, then sit up and check tension again, do this again until the tension is correct.
- If the tension is correct, lie child down and change the two bows into knots by pulling the loops of the bow through to create a second knot. If you pull the strands of the bow by accident, redo the bow and re-check the tension.
- Tie one further knot to secure the ties (do this to both sides).
- Cut off excess tape to leave ½ inch remaining.
- Assistant may release tube ONLY when told to do so.
- Ensure baby/child is made comfortable.
- Clear away equipment according to the Waste Management Policy.
- Wash hands.
- Record the tape change in the baby/child’s health care records.
- Check all equipment is replaced and restocked as necessary.
The hospital has a mandatory requirement for the completion of a Paediatric Intermediate Life Support course (PILS) by all clinical staff that includes teaching about resuscitation in a child with a tracheostomy. This information is further reinforced by attendance at dedicated tracheostomy simulation training and study days.
The resuscitation algorithm used at GOSH is shown on page 3 of appendix 1. This incorporates the Bed Head with the hospital algorithm for the emergency response to a tracheostomy concern.
Appendix 2 shows the BLS response to a tracheostomy emergency and will be taught to parents/ carers on going home
Cardio-pulmonary resuscitation (CPR) and Basic Life Support (BLS):
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
The airway element of BLS will require modification in children with tracheostomies, it is therefore essential that practitioners have received training in both routine and tracheostomy BLS.
BLS is similar in the sequence of skills to be performed for those with a tracheostomy:
Shout for help
For further information see:
- Basic Life Support for babies and children with a tracheostomy
- See the Emergency Paediatric Tracheostomy Managament information in appendix 1
Practitioners caring for a child with a tracheostomy must familiarise themselves with and practice the tracheostomy resuscitation algorithm.
Patients with a tracheostomy must always have their specific emergency equipment correctly assembled and easily accessible AT ALL TIMES.
Starting BLS quickly is extremely important (Rationale 21).
IF IN ANY DOUBT ABOUT CHILD’S CONDITION SUMMON THE CLINICAL EMERGENCY TEAM IMMEDIATELY (2222).
- Ensure safety of yourself and the child
- Stimulate the child and call their name, taking care to support their head and body
- Call for assistance from colleagues
- If you are by yourself DO NOT leave the patient at this stage.
- Open and check the child’s airway by placing supine on a flat firm surface
- It may be helpful to put a folded towel under the shoulders, only if this is immediately available. Do not waste time 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, i.e. signs of blockage: crusts, kinks or dislodgement.
- Suction the tracheostomy tube. In most circumstances suctioning will clear the obstruction.
- Change the tracheostomy tube immediately if the tube appears blocked or any resistance is felt and the child is in respiratory distress.
- Exercise caution if the stoma is less than one week old; if time, contact the TNP/ ENT team/ Emergency team first so help is on the way in case the tube cannot be replaced.
- The same size tube should be inserted.
- If unable to insert the same size tube try to insert the Shiley tube that is a half size smaller and stiffer.
- 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.
- Attempt to insert the end of the catheter through the stomal opening and guide the tracheostomy tube along the catheter and through the stoma (This is known as the Seldinger technique) (Lyons MJ, Cooke J, et al (2007)).
- If this is also unsuccessful, ventilation can be attempted via the stoma or by conventional rescue breaths (e.g. mouth-to-mouth or bag and mask over the mouth & nose). These options may not be appropriate for some children due to their underlying upper airway problem; practitioners must therefore always be aware of the underlying disease/ anatomy.
The Seldinger technique should be practised as a first line attempt at reinserting a tracheostomy tube. Tracheal dilators have been removed from routine paediatric tracheostomy care at GOSH (Rationale 22).
- Once a new tube is inserted, suction to tube to maintain patency.
- Support the new tube in position, 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 give regular suction and wait for the clinical emergency team. (Practitioners should decide if the /ENT/TNP should also be called).
- Secure tube with tapes.
- If the child is not breathing (or only making agonal gasps), commence artificial respiration with a bag-valve system directly connected to the tracheostomy tube and administer 5 breaths with high flow Oxygen. This is best achieved with a Smiths Medical (Portex©) 15mm swivel connector attached to the ambu bag.
- Ensure that the breaths are effective by observing chest movement.
Look for signs of life and proceed with cardiac support and monitoring in line with resuscitation guidelines.
- Parents require both theoretical and practical teaching / practice of both emergency algorithms, namely action to take on a blocked tube and action to take if the tracheostomy tube cannot be replaced (Seldinger technique).
- Parents will be taught mouth to trachy resuscitation before going home, (except for ventilator dependent children or those deemed as high risk- who will have Oxygen and an ambu bag). In addition to the other equipment required they must be given a Laerdal one way valve © and two ‘emergency’ Velcro tapes (Rationale 21).
Practitioners teaching parents/ carers must have appropriate knowledge and experience in both areas. At GOSH, a modified 'Resus baby' and 'Little Junior' is used for BLS and a Smiths Medical (Portex©) percutaneous tracheostomy manikin for parents to practice the Seldinger technique.
The importance of precise suctioning cannot be underestimated in paediatric tracheostomy care. If the suction length is too short, the patient is at risk of tube blockage, yet if the suction length is too long it may lead to tracheal trauma and can result in distal soft tissue trauma and overgrowth.
Practitioners must be competent in respiratory assessment, indications for suctioning and suction technique this will minimise complications and maximise the effect of treatment.
Suctioning is associated with potential complications, and is only recommended when there are clear indications that the patency or ventilation of the children is compromised (Walsh B, Hood K Merritt G (2011); American Association for Respiratory Care (2010); Davies K, Monterosso, L. et al (2015); Argent AC (2009); Czarnik RE, Stone KS, et al (1991); Fiorentini A (1992); Raymond SJ (1995); Gemma M, Tommasino C, et al (2002); Dellinger K (2001); Spence K, Gillies D, et al (2003); Ahn Y, Hwang T (2003).
Potential complications include:
- formation of distal granulation tissue/ulceration
- cardiovascular changes
- bacterial infection
- intracranial changes
The GOSH clinical guideline on airway suction is a useful resource.
The procedure should be explained to the child/parent/carer (Rationale 23).
The following equipment should be prepared:
- suction catheters of the correct size
- suction unit with variable vacuum control
- PPE: in accordance with the local infection control policy.
- Bottled water (in clean container)
- orange waste bag for disposal of waste in line with waste management policy
Suction catheters must meet the following criteria:
- be double the internal diameter of the tracheostomy tube (American Association for Respiratory Care (2010), Ahn Y, Hwang T (2003), Glass C, Grap MJ, Wood CJ (1998), for example a tracheostomy tube size 4.0, use a suction catheter sized 8.0 (Rationale 24).
- have one distal and two lateral ports with rounded ends (Ahn Y, Hwang T (2003). This allows secretions to be collected distally and from the sides of the tube. Catheters with more than three lateral holes weaken the catheter.
- have a lateral port that is smaller than the distal ports, so that mucosal adhesion and biopsy do not occur.
- have an integrated valve for vacuum control.
- have numbered graduations for accurate insertion lengths
Technique for suctioning:
Suctioning is not a painful or distressing procedure to children when performed correctly. The following measures help to reduce complications but maximise effect.
- Suction should be applied only on withdrawal.
- Do not rotate the catheter on withdrawal, as both the distal and lateral holes on the new design of catheter allows for circumferential suctioning.
- Catheters should not be kinked prior to insertion, in an effort to control the vacuum. In infants and children while there is little evidence to support the optimal negative pressure to be applied, the lowest pressure that will effectively clear secretions should always be used (American Association for Respiratory Care (2010)).
- Suctioning should not be carried out on a routine basis but only when needed (except if the airway is new- i.e. less than 7 days and before the first tube change.
- Suctioning should be quick but effective enough to remove secretions and minimise complications especially atelectasis, hypoxia and cardiovascular changes (Walsh B, Hood K et al (2011), Davies K, Monterosso, L. et al (2015), Argent AC (2009).
- Practitioners must know the length of the tracheostomy tube. The tip of the Suction catheter should remain within the tracheostomy tube and not be passed further down. This allows the distal and lateral holes of the suction catheter to just go beyond the end of the tracheostomy tube but remain protected by the tube (Rational 25).
- Practitioners should only touch the proximal end of the catheter to minimise contamination being introduced into the tube. Catheters should be discarded prior to use if the distal end is contaminated.
- Catheters can be re-used during the same episode of suctioning if the distal end is clear from secretions.
- Repeat the procedure only as necessary.
- Installation of Saline drops is a contentious area and there is little evidence to support this practice so should not be used routinely (Scoble M, Copnell, B. Taylor, et al (2001), Pritchard M, Flenady V, et al (2001), Blackwood B (1999), Hudak M, Bond-Domb A (1996), Roberts FE (2009)). This should be done on an individualised basis and only by experienced practitioners.
- Record in the child’s health care records if the secretions are bloody, purulent, foul smelling or unusually thick. Take samples for analysis as required.
- Practitioners must be aware that some pre-term, vulnerable infants may require pre-oxygenation prior to suctioning (American Association for Respiratory Care (2010)).
- Observe for skin breakdown and granulation tissue and treat accordingly.
- Crusting may also need to be removed from the tracheostomy tube.
During a morbidity audit at GOSH cases of trauma and excoriation to the skin surrounding the child’s neck and stoma were carefully documented. The results showed that neck injuries and skin damage in this Institution were reduced from 20% in 2008 to 8% in 2014. Neonates and those with increased susceptibility to skin trauma e.g. vascular and lymphatic malformations or Epidermolysis Bullosa are most at risk.
The sternum and chin are areas of potential skin breakdown from abrasion by the tracheostomy tube and ventilation tubing over long periods of time. Children requiring ventilation or those with challenging anatomy were particularly at risk and Bivona Flextend© tube is preferential for patients with lymphatic malformations due to the increased length of the tube outside the airway.
The recommended practice is to review the stoma, assess the skin of the neck, and clean the local area around a tracheostomy thoroughly each day. This should be documented in the patient health care record. The Monolyke© range of thin and flexible hydrocolloid dressings are preferred due to their excellent skin protection and their limited impact on the positioning of the tracheostomy tube. Bulkier dressings have the potential to alter the angle of the tracheostomy affecting the stoma as well as abrading the tracheal wall.
GOSH now uses the silicone range of tracheostomy tubes from Bivona© in the vast majority of cases. Stomal granulation tissue has almost been completely eradicated, a dramatic reduction from the reported from our own data from 2007 (Refer to tape changing section within the guidelines).
The nose and naso-pharynx space provides an optimum environment within which inspired air is maintained at a temperature of 37°C in 100% relative humidity. The Tracheostomy tube bypasses this space and, instead, rests within the lower airway structures, which fail to provide the optimum environment. The natural warming, humidification and filtering of air, that usually takes place in the upper airway, is lost and, instead must be achieved artificially.
In the first week after a new tracheostomy is formed, warm humidification should be used as much as possible to counter thick secretions that can occlude the tracheostomy tube. This is a potential cause of an emergency first tracheostomy tube change before the stoma has matured.
After the first tube change it is recommended that an appropriately-sized Heat Moisture Exchange (HME) device is used. The size is calculated from the estimated tidal volume for the patient, with the Mini Vent© recommended for patients weighing less than 10Kg and the Thermovent T© for those weighing more than 10Kg. For provision of supplemental oxygen and a phonation device, Trachphone© is available.
Without appropriate humidification, secretions can become increasingly thick and tenacious, making their retrieval difficult. This may lead to blockage of the tube or retention of secretions in the lower airways (Rationale 26).
To reduce these risks, artificial humidification is recommended and can be given in many ways;
- A home nebuliser with a tracheostomy mask (over the Tracheostomy tube) should be considered for these children prior to discharge. Nebulisers provide aerosol droplets in a saturated vapour helping to keep the airway humidified and secretions loose so that are easily retrievable on suctioning. For more information about nebulisers, see the nebuliser guideline.
- After any anaesthetic the child should receive continuous humidity until such time the secretions are loose, they are coughing well and able to maintain their own hydration.
- It is also important that a child/young person with an artificial airway remains systemically hydrated, this again helps with keeping secretions loose enough to cough up or be retrieved with suctioning, thereby preventing tube blockages. Practitioners should consider increasing the child/young person’s fluid intake during times of illness such as respiratory disease, vomiting, diarrhoea, pyrexia, etc.
Once established the child can wear a Heat and Moisture Exchange (HME) or Swedish nose of the correct size. See additional information sheet (appendix 3) for further details.
The contents of the emergency tracheostomy box are designed to include the absolute essential equipment required in case of an accidental decannulation or for an emergency tube change. The emergency box accompanies the child at all times, reducing the time and potential consequences of unavailable equipment. The ‘Kapitex Trachi Box’© is easily recognizable and is used for all our patients.
Tracheostomy tubes can be changed weekly or monthly. Ask the TNP or ENT team if unsure for advice. See additional information sheet (appendix 3) for further details.
Only personnel trained and competent in the techniques involved must perform a tracheostomy tube change (Roberts FE (2009)).
An older child should not require swaddling. Some children may assist with the procedure, such as, holding the tracheostomy tube, etc. Some children may need to be swaddled to maintain their safety during the change; assess each child individually.
The following equipment should be prepared:
- Emergency equipment, oxygen and suction
- A tracheostomy tube of the same size the child is currently using
- A tracheostomy tube that is half a size smaller, this should be a Shiley tube
- A water based lubricant such as Aqualube® or KY jelly®
- Gauze swabs/ Tracheostomy dressing /other dressings and creams that are being used
- Saline sachets
- Marpac cotton tape
- Round ended scissors
- A rolled up towel
- Personal Protective Equipment (PPE)
- Two syringes may be required if the child has a cuffed tube (Rationale 27).
To change a tracheostomy tube:
- Wash hands
- Put on appropriate PPE
- Assistant to swaddle baby, exposing shoulders and above (baby in supine position) if appropriate
- Lubricate new tube with a “dot” of water-based lubricant on the outside bend of the tube only.
- Measure the length of the tube for suction distance. Insert obturator. If the tube has a cuff inflate and check it works- deflate before insertion.
- Have the spare smaller tube available, in case the tube fails to go in
- Position the rolled up towel under the child’s shoulders, as with tape changes.
- Assistant should hold the tube in position using either their thumb and index finger, or index and middle finger.
- Tube changer should cut the ties between knot and flange
- Remove the old ties and dressing.
- Once the child is settled gently remove the tube from the stoma with a curved action
- Quickly insert new tube with a curved action into the stoma
- Remove obturator quickly as the child cannot breathe with this in place
- The assistant should take over and hold the tube in position
- The stomal area and back of the neck should be cleaned and dried and tube secured as described in the tape changing procedure above.
Staff and carers should be trained and assessed in the following competencies:
Appendix 4: Staff Competencies for Tracheostomy Care at Home
Appendix 5: Staff Competencies for Ventilation via an artificial airway
Appendix 6: Carer Competencies for Tracheostomy Care at Home
Appendix 7: Carer Competencies for Ventilation via an airway
- The formation of a tracheostomy must be confirmed by telephone with the child’s Health Visitor (HV), GP, Paediatric Community Nurse (PCN), School Nurse & local Hospital on the day the tracheostomy is inserted (before if its planned).
- An equipment list and introductory letter must be sent so that equipment can be ordered immediately. The community team must be contacted again after the first tube change to confirm tube style/ size, which may have had to be changed during the first week.
- The progress of supply orders should also be checked. Discussion of respite and carer support should be broached with community team.
- The majority of children will always be discharged back via their local hospital, which will allow local services and support to be activated. Planning for this should begin as soon as the tracheostomy is formed.
- However some children, such as those who have had a planned tracheostomy or who have been in hospital for a long time may be discharged home straight from hospital. All appropriate documentation and medicines should be ordered/ completed.
- The child’s parents, or two main carers, must be taught and be deemed as competent in the following: (sometimes it is not possible to complete all the training at GOSH and local teams may have to complete this
- Tracheostomy tube changes (minimum of two each)
- Tracheostomy tape changes
- Stoma care
- Resuscitation skills/ emergency care
- Carer must stay and do an overnight stay with their child and carry out all care overnight
- Feel confident in themselves taking the child out of the hospital
- They must be given the appropriate GOSH tracheostomy and resuscitation booklets.
- All training received must be recorded on the child’s discharge planner and kept in their health record for future reference; parents are given a copy for their records.
- An eight-week TNP/ ENT outpatient appointment must be arranged prior to discharge (unless indicated otherwise by the medical team).
- Confirm transfer/discharge of patient with HV and/or PCN and GP as appropriate.
Reasons for paediatric tracheostomy
Types of tube available for use in Paediatrics
Accessory products to support tracheostomies
Rationale 1: Correct Emergency equipment must be readily available to facilitate an immediate response and possible resuscitation. The swivel connector allows the attachment of the ambu bag to the tracheostomy tube.
Rationale 2: A dedicated area with the correct equipment must be readily available to facilitate an immediate response, and possible resuscitation.
Rationale 3: Tracheal Dilators are wider than the smallest tracheostomy tube, it can be quite difficult to use, to gage competency and to insert a tracheostomy tube. Reported tracheal and stomal damage has been associated with their use. The trust audit demonstrated that we couldn’t maintain competence of staff using them, and their effectiveness of facilitating the insertion of a tracheostomy tube was in question. GOSH moved to the more non-invasive method of Seldinger to re-insert a tracheostomy tube (Lyons et al 2007).
Rationale 4: Although every effort is made to make the stomal opening as safe as possible, with the use of stay and maturation sutures, decannulation of the tube within the first few days will compromise the airway and can make reinsertion of a tube difficult. Care must be concentrated on maintaining patency with good humidity, securing and regular suctioning.
Rationale 5: Early engagement with local hospital and community team is essential, so that discharge planning/ obtaining the necessary equipment/ training staff can be started as soon as possible. For the majority of children the aim is to always transfer back to the local hospital prior to discharge home.
Rationale 6: This allows the stoma to heal and establish itself ensuring the tube change is uneventful.
Rationale 7: If the stoma has not established itself there is risk that early decannulation. With the re-insertion of the tube, this may not go back into the stoma, but instead go into the pre tracheal tissue/space. Position can be confirmed with flexible endoscopy if concerned.
Rationale 8: These support stoma maturation, so that the pathway from skin to trachea is established sooner.
Rationale 9: The sutures allow the trachea to be lifted to the surface and pulled apart for the tube to be re-inserted.
Rationale 10: Haemorrhage may be life threatening and the child will have to be returned to theatre.
Rationale 11: Regular and frequent suctioning in the first 24 hours reduces the risk of needing to change the tube early whilst the stoma is healing. It’s essential that secretions don’t build up and block the tube.
Rationale 12: The HME will not offer enough humidity in the first instance, increasing the risk of thick secretions and blockage.
Rationale 13: Cold humidity increases the heat loss from the respiratory tract, impacting overall on the small infant.
Rationale 14: The child may have a paralysing spray to the back of the throat which will prevent them from protecting their airway from aspiration. The effect of this paralysing spray wears off after a number of hours.
Rationale 15: Correct Emergency equipment must be readily available to facilitate an immediate response and possible resuscitation.
Rationale 16: This is placed under the child’s shoulders which in turn hyper-extends the neck, exposing the stomal area, making it easier to assess, clean or change the tube.
Rationale 17: Once the tapes are cut the tube is vulnerable to accidental decannulation, the child must be settled/ not able to pull at the tube. Individual assessments must be made as the majority of children will learn to sit still during tape changes.
Rationale 18: Do not push down hard the child will find this uncomfortable and will not sit still, use just enough pressure to support the tube.
Rationale 19: Sitting the child up allows any neck ‘chubbiness’ to fall down, giving a better indication of the tension.
Rationale 20: The tapes must be tight enough to support the tube, not too loose that the tube decannulates and not too tight that there is excoriation of the surrounding skin. Adjust accordingly.
Rationale 21: Correct emergency equipment must be readily available to facilitate an immediate response and possible resuscitation.
Rationale 22: Tracheal Dilators are wider than the smallest tracheostomy tube, it can be quite difficult to use, to gage competency and to insert a tracheostomy tube. Reported tracheal and stomal damage has been associated with their use. The trust audit demonstrated that we couldn’t maintain competence of staff using them, and their effectiveness of facilitating the insertion of a tracheostomy tube was in question. GOSH moved to the more non-invasive method of Seldinger to re-insert a tracheostomy tube (Lyons et al 2007).
Rationale 23: To gage cooperation and understanding
Rationale 24: Use of suctions catheters that occupy half the diameter of the tracheostomy tube, allows the child to continue breathing during the procedure.
Rationale 25: Passing the distal and lateral holes of the suction catheter just out of the end of the tracheostomy tube, allows retrieval of secretions coughed up, keeping the tracheostomy tube tip clear. By just going beyond the tip of the tracheostomy tube, the tube provides protection for the suction catheter, preventing the tip of the suction catheter from adhering to the vulnerable tracheal mucosa or hitting the carina.
Rationale 26: Thick gloopy secretions are more difficult to for the child to cough out of the tube, and more difficult to retrieve on suctioning, running the risk of occluding the tracheostomy tube.
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