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Tracheostomy: care and management review

These guidelines are intended to support practitioners looking after children with tracheostomies to improve the care and safety of this group of children. While not intended 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 tracheostomy and should not rely solely on these guidelines for their practice.

Sections


1. Formation
  • Preparation of equipment and environment
  • Initial care
    • observations
      • initial observations and complications
      • post-procedural safety check
      • other initial complications
    • feeding
    • humidification
    • other care requirements
2. Management
  • suctioning
  • tape changes (cotton)
  • tube changes (planned)
  • Carer competency sheets
  • Resuscitation of a child with a tracheostomy
  • Subsequent care
    • stoma care
    • investigations
    • complications
  • Discharge
  • General information (link)

Background

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.

Tracheostomy is one of the oldest surgical procedures and was first successfully performed on children in the late 19th century. Today it is a common procedure and is life saving for many infants and children requiring airway and respiratory support. However, despite providing a safe and protective airway paediatric tracheostomy is often associated with significant morbidity and mortality (Midwinter et al,  2002).

A tracheostomy is an artificial opening in the trachea, usually between the 3rd and 4th tracheal rings (see Figure 1) into which a tube is inserted and through which tube the child breathes. A tracheostomy is initially a life saving operation but is also a life threatening one unless the airway is kept clear from secretions and blockages 24 hours a day.

Children with tracheostomies require constant supervision from those trained fully in its care. 

Figure 1: Tracheostomy positioning

Diagram of Tracheostomy positioning
Tracheostomy positioning for Tracheostomy guideline

Section 1 - Formation

Tracheostomy: preparation of equipment and environment

The child’s bed area must be made easily accessible from both sides without obstruction, e.g. patient luggage, chairs, etc (Rationale 1).

Appropriate resuscitation and suction equipment with correct tracheostomy fittings (15mm Smiths Medical (Portex©) swivel connector and a male Smiths Medical (Portex©) adaptor for GOS, Silver & Montgomery tubes) checked and in full working order (Rationale 2).

Note: All equipment must be checked whenever a practitioner takes over the care of a tracheostomised child, including breaks and transfers to another ward/department. The child MUST NEVER be left alone. The accompanying carer (including parents where applicable), as a minimum, must be able to:

  • Recognise signs of airway obstruction
  • Initiate suctioning of tracheostomy tube

The child should have a dedicated tracheostomy trolley by the bedside containing:

  • Oxygen saturation monitoring - if oxygen therapy is required (Rationale 3)
  • Suction catheters - correct size (Rationale 4)
  • Clean gloves (Rationale 5)
  • Clean gauze (Rationale 6)
  • Clean receiver with tap water (Rationale 7)
  • 2 ml syringe
  • Ampoule 0.9% sodium chloride for irrigation (Rationale 8)
  • Yellow waste bag “for incineration” (Rationale 9)
  • An ‘emergency trachi box’ with the following contents:
Goggles/protective eye wear should be available (Rationale 9).

A tube with a 15mm termination requires a Smiths Medical (Portex©) swivel connector which can be added to the resuscitator and must be available at the child's bedside.

A flat-ended tube requires an appropriately sized tracheal tube adapter and a Smiths Medical (Portex©) swivel connector that will ‘slip into’ the tube as required to create a 15mm termination that will be compatible with resuscitation equipment.

Following an audit of use and competence tracheal dilators are now to be kept in the Resuscitation Trolley (not at the child's bedside) and only used by competent practitioners (Rationale 16). Practitioners should use the seldinger technique when reinserting a tube.

Initial care

Nursing actions 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 17).

Communication between the hospital and community health carers must be commenced following surgery (Rationale 18).

The initial nursing care of a child with a tracheostomy is very different from that for an established stoma. At Great Ormond Street Hospital (GOSH), the first tube change occurs after one week (Rationale 19); other units advocate changing the tube after 3 days (Deutsch, 1998). The Tracheostomy Nurse Practitioner (TNP) or ENT Surgeons will perform the first tube change.

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 20).  In addition, two long looped “stay” sutures extend from inside the stoma and are taped to the child’s chest. These sutures are attached to the tracheal wall on either side of the stoma (Rationale 21). Tape on the child’s chest will be labelled “DO NOT REMOVE” (Rationale 22). These will be removed after the first tube change.

Figure 2: Position of Stay Sutures
Position of Stay Sutures for Tracheostomy guideline
Position of Stay Sutures for Tracheostomy guideline

Observations

The child’s vital signs should be recorded in accordance with local policy, with the frequency reducing as the child’s condition dictates (Rationale 23).

Initial observations and complications

Practitioners should also carry out routine non-invasive observations to rule out the following potential initial complications:

  • check that the tape tension is correct and able to support the tracheostomy tube
  • observe any neck swelling (surgical emphysema - see below)
  • check for air entry through tube - place finger above tube opening & feel for a passage of air
  • inspect the chest for bilateral chest movement
  • auscultate 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.

Post-procedural tube check

For the majority of children a chest  x-ray is performed in theatre, if this has not happened then a portable post-operative chest X-ray must be performed within one hour or soon after the child has returned to the ward to confirm tube position and to rule out a pnuemothorax and surgical emphysema (Tarnoff et al, 1998).

Other Initial Complications

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 (Rationale 24). Secretions may initially be blood stained but will settle within a few hours, if it continues then practitioners should contact the TNP, CSP or ENT team.
  • Tube Blockage (Rationale 26) At least:
  • The tube may visibly come out of the stoma or can be pulled out of the trachea and sit in the pre-tracheal tissues. 
  • Tube can be reinserted but must not be forced. On reinsertion, air entry must be checked and confirmed.
  • ENT team / TNP or clinical emergency team must be contacted immediately to review tube position. 
  • Common causes for this include: chubby infant neck, incorrectly chosen tube, loose trachy tapes or the child pulling at the tube.
  • Care must be taken to ensure that the tube is correctly secured and does not become displaced. If it does, early recognition is essential as this could be life-threatening. Practitioners must contact the ENT team/ TNP or clinical emergency team for immediate assistance.
  • Infection (chest/stoma site) (Rationale 25)
  • Surgical emphysema - Air may leak around the tube into the surrounding tissue - this is particularly problematic if the child has had neck sutures inserted (Rationale 28, 29 and 30). Checking tape tension not only confirms that the tube is secured correctly but also if they appear tighter may indicate swelling. Contact the ENT team, TNP or CSP's.

The child, where possible, should not leave the ward during the first week unless medically indicated (Rationale 31).

Feeding

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 anaesthetic chart (Rationale 32, 33, 34). For a child that has had feeding difficulties or has never orally fed, consultation with the Speech and Language Therapist (SALT) 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 SALT.

Humidification

  • DO NOT USE a Heat and Moisture Exchanger (HME) during the first week (Rationale 35).
  • Administer humidity via sterile 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.
  • Change humidity apparatus when the bottled water needs changing (usually 24hrs) 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).

Other care needs

  • Change the tapes at least daily or when soiled or wet (Rationale 36).
  • A suitable dressing, such as Trachi-dress®, should be inserted behind the flanges to protect the skin (shiny side to skin). Avoid using bulky substitutes as these may pull the tube away from the neck presipitating accidental decannulation.
  • Never use cotton wool or cut gauze dressings (keyhole)(Rationale 37).
  • The tracheostomy tube should be changed for the first time 7 days after surgery. The tracheostomy tube should normally be changed for the first time by the ENT surgeon or the TNP. The “stay” sutures will be removed at this time.

Once the stability of the tracheostomy stoma and tract has been verified the child may be allowed off the ward with a person appropriately trained in routine and emergency tracheostomy skills.

Section 2 - Management

Suctioning 

Airway suctioning is a common practice practice in the care of a child with a tracheostomy, and is undertaken to remove secretions from the child’s respiratory tract. A child with a tracheostomy 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 (Pritchard et al, 2001; Czarnik et al, 1991; Fiorentini, 1992; Raymond, 1995; Gemma et al, 2002; Dellinger, 2001; Spence et al, 2003; Ahn & Hwang, 2003; Prasad & Hussey, 1995).

Main complications requiring suction interventions:

  • Hypoxia
  • Formation of distal granulation tissue/ ulceration
  • Cardiovascular changes
  • Pnuemothorax
  • Atelectasis
  • Bacterial infection
  • Intracranial changes

The GOSH Guideline on Suctioning Techniques (Simpson, 2009) is a useful resource.

Practitioners trained in the skill should perform tracheostomy suctioning to minimise complications and maximise treatment (NMC, 2002). The child and family must be informed of the reasons for suctioning, positioning, risks and outcomes as appropriate.

A 'clean' technique must be used and the catheter should be discarded if the tip is contaminated with hands, cot sides, etc. Suction equipment must accompany the child at all times, regardless of the nature of the journey or the distance to be travelled.

Equipment

The following equipment should be prepared: 

  • Suction catheters of the correct size
  • Suction unit with variable vacuum control
  • Gloves
  • Apron (don if there is time - a child should never wait for suctioning)
  • Tap water (in clean container)
  • 2ml syringe with 0.9% sodium chloride for irrigation (not for routine suctioning)
  • Yellow waste bag “for incineration”

Practitioners must be aware that some pre-term, vulnerable infants and especially those who are requiring > 40% inspired oxygen, may require pre-oxygenation prior to suctioning to minimise a potential hypoxic event (Sigler & Willis, 1985; Odell et al, 1993; Pritchard et al, 2001).

Distal tracheal damage and hypoxia are very real and potential complications especially in the vulnerable paediatric airway. These complications may be reduced by having:

  • The correct size catheter, as a guide, practitioners should double the size of the tracheostomy tube to obtain the appropriate catheter size, e.g., 4.0 ID tracheostomy tube = size 8fg catheter. A suction catheter diameter should be less than half of the size of the tracheostomy tube to reduce potential for hypoxia and allow the child to breathe throughout the procedure (Odell et al, 1993; Glass & Grap, 1995; Wood, 1998; Ahn & Hwang, 2003).
  • 1 distal and 2 lateral ports with rounded ends allows secretions to be collected both distally and from the sides of the tube to minimise tube occlusion (Ahn & Twang, 2003). Any more than three lateral holes then the catheter wall would be 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 (Prasad & Hussey, 1995).
  • 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 (Brodsky et al 1987; Runton, 1992).
  • 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 but more specific guide (Dean 1997; McElery 1996; Mowery, 2002; Simpson, 2001;.Billau, 2004; Young, 1984). Excessive pressures can cause trauma, hypoxaemia and atelectasis (Czarnik et al, 1991).


 Age of child
 Approx tube size
 Suction pressures
 
Pre - term - 1 month
 
3.0
8 - 10 Kpa

60 - 75 mmHg

0 - 3 yrs

3.5 - 5.0
10 - 12 Kpa

75 - 90 mmHg

3 - 10 yrs

5.0 - 6.0
12 - 15 Kpa

90 - 112 mmHg

10 - 16 yrs

6.0 - 7.0
15 - 20 Kpa

112 - 150 mmHg
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.

Note: Suctioning a paediatric tracheostomy is very different from suctioning an adult tube, so adult practitioners will need to adapt their practice.

Constant observation of the child during suctioning is essential; practitioners should observe for an improvement or deterioration in respiratory rate and quality, child's colour, and oxygen saturations (if being monitored).

Technique

  • Perform a clinical hand wash (if there is time)(Rationale 9).
  • Put on a minimum of gloves (Rationale 9).
  • Turn suction unit on and check the vacuum pressure and set to the appropriate level, according to the child's age.
  • The carer MUST know the length of the tracheostomy tube. If the tube is fenestrated then an un-fenestrated inner tube should be inserted to prevent the catheter going through the fenestration and causing trauma.
  • Insert catheter gently into the tracheostomy tube, enough to ensure that the lateral and distal holes just pass through the tip of the tube, use 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 could only 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 previously though intermittent suctioning does not reduce trauma and is less effective, (Luce et al, 1993).
  • Slowly withdraw the catheter straight out of the tube maintaining the vacuum. Do not apply suction on insertion as this may cause mucosal irritation, damage and hypoxia.
  • There is absolutely no need to rotate the suction catheter on withdrawal, as both the distal and lateral holes on the new style of catheter allows for circumferential suctioning.
  • Suctioning should be quick but effective and should not exceed 5-10 seconds (Sumner, 1990; Young, 1984; Toiles and Stone, 1990), most of this literature is based on the adult population. In paediatrics, maximum durations should be based on the child's underlying medical condition and current clinical condition and practitioners should adjust timings accordingly, for example 10 seconds is a long time for a neonate with underlying lung disease (Rationale 38).
  • 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 39).
  • 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 40) and connect a new catheter to the tubing.
  • Wash hands (Rationale 9).

Record if the secretions are bloody, purulent, foul smelling or unusually thick in the child’s health care records. Take samples as required.

Note: Deep suctioning may be required in certain circumstances - for example during broncho-alveolar lavage - but this should not be routine practice (Bailey et al, 1988).

Instillation of saline - Saline should not be used routinely (Blackwood, 1999; Hudak & Bond-Domb, 1996; Pritchard et al, 2001; Ackerman & Mick, 1990; Scoble et al, 2001; Neill, 2001).

Tape changes (cotton) 

Note: Velcro ties are not routinely used at GOSH following a two severe untoward incidents in other centres. If children arrive in GOSH with Velcro ties then it must be explained to their parents that cotton tapes will be used 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. 

A tracheostomy tube is held in place with cotton tapes around the neck. It is essential that the ties are secure and the tension of the ties is correct. The tapes are secured with knots tied either side of the tracheostomy tube.

All staff/parents should be taught to tie the tapes in the same way (Rationale 41).

Parents may prefer to adopt another method of securing the tapes once they have established a routine at home. This method may be continued when the child is re-admitted to hospital but will need individual assessment.

Tracheostomy tape changes are normally performed daily.

Only Personnel trained and competent in the techniques involved must change tracheostomy tapes and two people are required (NMC, 2002).

Equipment

The following equipment should be prepared and be readily available:

  • Appropriate emergency equipment readily available (Rationale 42)
  • Gauze swabs and saline sachets
  • Two lengths of ¼ inch cotton tape with short plastic backing. The backing can be made from appropriately sized available tubing, e.g.24hr Urine or O2 tubing.  
  • Cut the ends of the tapes to a point (Rationale 43)
  • Round ended scissors
  • A rolled up towel (Rationale 44)
  • A blanket to swaddle a baby or uncooperative toddler (Rationale 45)
  • Suction equipment available (see suction guidelines)
  • Non-sterile gloves and an apron
  • Goggles/protective eye wear
  • Child’s own comforter, e.g. dummy, as appropriate
  • An older child may not require swaddling. 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.

To change the tracheostomy tapes:

  • Perform a clinical hand wash, put on gloves, apron and protective eye wear (parents do not need to wear the protective clothing)
  • The warmed water should be poured onto the gauze swabs
  • Assistant to swaddle baby, exposing shoulders and above
  • Place baby/child in supine position, with a rolled up towel under shoulders; (as mentioned above, some older children may wish to sit)
  • Place clean tapes behind the baby/child’s neck
  • Assistant should hold tube in position using either their thumb and index finger, or index and middle finger; see figure below (Rationale 46). Minimal pressure should be applied.

Figure 3: Positioning for a tape/tube change


Positioning for a tape/tube change
Positioning for a tape/tube change
  • Tape changer should cut the tapes between the knot and the flange and remove dirty ties.
  • The stoma site (above, below and under each flange) and back of the neck should be cleaned and thoroughly dried with the water and gauze using a clean technique.
  • Thread the new tape through the flange on the side furthest away from the tape changer.
  • Tie the tapes using three knots ensuring the tape is flat to the child’s skin.
  • Thread tape through near side flange, tie once and make a bow.
  • Check tape tension by:
  • Raising baby/child to a sitting position whilst assistant continues to hold tube in position.
  • With the baby/child’s head bent forward it should be possible to slip one finger comfortably between the ties and the baby/child’s neck. See Figure 4.

Figure 4: Tape tension

Tape Tension for Tracheostomy
Tape Tension for Tracheostomy
  • If the ties are too tight or loose lay the baby/child back down, undo the bow and readjust.
  • If the tension is correct, lie the baby/child down and change the bow into three knots by pulling the loops of the bow through to reate a second knot.
  • Tie one further knot to secure the ties.
  • Cut off excess tape to leave ½ inch remaining.
  • Assistant may release tube ONLY when instructed to do so.
  • Ensure baby/child is made comfortable.
  • Clear away equipment according to the Waste Policy.
  • Wash hands.
  • Record the tape change in the baby/child’s health care records.
  • Check all equipment is replaced and restocked as necessary.

Tube changes (planned)

Tracheostomy tubes can be changed weekly or monthly (refer to tube information sheets above).  Ask the TNP or child’s doctor if unsure.

Only personnel trained and competent in the techniques involved must perform a tracheostomy tube change and two people are required (NMC, 2002).

An older child should not require swaddling. Some children may assist with the procedure, such as cleaning the stoma site, holding the tracheostomy tube, etc. Some children may need to be swaddled to maintain their safety during the change; assess each child individually.

Equipment

The following equipment should be prepared:

  • Emergency equipment, oxygen and suction
  • A tracheostomy tube of the same size
  • A tracheostomy tube that is a size smaller
  • A water based lubricant such as Aqualube® or KY jelly®
  • Gauze swabs
  • Saline sachets
  • Two lengths of ¼ inch cotton tape
  • Round ended scissors
  • A rolled up towel
  • Gloves and an apron
  • Goggles/protective eye wear
  • Two syringes may be required if the child has a cuffed tube (Rationale 47

To change a tracheostomy tube:

  • Perform a clinical hand wash
  • Put on gloves, apron and protective eye wear
  • 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
  • Insert obturator into the tube
  • Position the rolled up towel under the child’s shoulders, as per tape changes.
  • Place clean tapes behind the baby/child’s neck
  • 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 dirty ties  
  • Remove the tube from the stoma with a curved action
  • Quickly insert new tube with a curved action
  • Remove obturator
  • The assistant should take over and hold the tube in position
  • The stomal area and back of the neck should be cleaned and dried with the water and gauze using a clean technique
  • The ties are then tied using the method previously described

Carer Competency Guide

Staff and carers should be trained and assessed in the following competencies:

1.Staff competency - home preparation (PDF, 434 KB)
2.Staff competency - ventilated child (PDF 476)
3.Carer competency - home preparation (PDF, 434 KB)
4.Carer competency - ventilated child (PDF, 468 KB)

Figure 5: 'Trache' Poster


'Trache' Poster
'Trache' Poster

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:

Safety

Stimulate

Shout

Suction*

Airway

Breathing

Circulation


TRACHEOSTOMY RESUSCITATION ALGORITHM (PDF, 153 KB)

When applied to a patient with a tracheostomy, CPR may be more difficult to teach and to learn because additional processes are required to determine and correct the cause of the collapse.  Practitioners caring for a child with a tracheostomy must familiarise themselves with the tracheostomy resuscitation algorithm.

Patients with a tracheostomy must always have their specific emergency equipment correctly assembled and easily accessible (as already discussed).

Starting BLS quickly is extremely important (Rationale 48):

  • Ensure safety of yourself and the child
  • Stimulate the child and call their name, taking care to support their head and body (Rationale 49)
  • Call for assistance from colleagues (Rationale 50)
  • 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 (Rationale 51)
  • It may be helpful to put a folded towel under the shoulders, 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: crusts, kinks or dislodgement.
  • IF IN ANY DOUBT ABOUT CHILD’S CONDITION SUMMON THE CLINICAL EMERGENCY TEAM IMMEDIATELY (2222)
  • 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 distress. Exercise caution if the stoma is less than one week old; if time, contact the TNP/ ENT team/ Emergency team first. However, if the child’s condition is unstable, summon the Clinical Emergency Team (2222) immediately.
  • The same size 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 (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 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 should only be used by practitioner’s familiar and practised in their use. Tracheal dilators are currently kept in the resuscitation trolley for use on request from experienced practitioners (Lyons and Cooke et al, 2007).

Assess breathing:

  • 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 CSP’s to arrive (practitioners should decide on whom best to call).  
  • 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. 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.
  • 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 Medical (Portex©) catheter mount 15mm female, and two ‘emergency ‘Velcro tapes. 


Further BLS instructions (PDF, 18 KB)

Although community teams will supply the equipment for the child's discharge home, after emergency care from a suitably qualified BLS instructor with trachesostomy experience, they should give the parents two pairs of velcro tapes, two disconnection wedges, and two tracheostomy extensions from Smiths Medical (Portex©) +/- male to female adapters depending on tube chosen. Practitioners should seek advice from the TNP; these items should be added to their emergency boxes when they get home.

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). 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.

Discharge

TRACHEOSTOMY DISHARGE ALGORITHM

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. An equipment list and introductory letter must be sent so that equipment can be ordered immediately - New Equipment Form (PDF, 227 KB)(Rationale 38). The community team must be contacted after one week 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. Most children will be discharged back via their local hospital, which will allow local services and support to be activated. Negotiations to do 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. Some equipment may have to be provided to facilitate this; this should be discussed individually with the communities involved. All appropriate documentation and medicines should be ordered/ completed.

Ensure that the portable suction unit has been collected from the community team before the day of discharge and bought to the hospital for the transfer home and parents are aware of how it works.

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)
  • Tracheostomy tape changes
  • Stoma care
  • Suctioning
  • 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 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 (unless indicated otherwise by the medical team).

Confirm discharge of patient with HV and/or PCN and GP as appropriate.

Although community teams will supply the equipment for the child's discharge home, after emergency care training from a suitably qualified BLS instructor with trachesostomy experience, they should give the parents two pairs of velcro tapes, two disconnection wedges and two tracheostomy extensions from Smith Medical (Portex©)+/- male to female adapters, depending on tube chosen (Rationale 52). Practitioners should seek further advice from the TNP as required.

Parents require both theoretical and practical teaching/ practice of both both emergency algorithms, namely: action to take on a blocked tube and action to take if the tracheostomy tube cannot be replaced (Seldinger technique), therefore practtioners teaching parents/ carers must have appropriate knowledge and experience in both areas. At GOSH we use a modified 'Resus baby' and 'Little Junior' for the BLS aspect and the percutaneous tracheostomy manikin from Smiths Medical for parents to practice the Seldinger technique.

General Information
IMPORTANT:  GENERAL INFORMATION ON TRACHEOSTOMY FORMATION, TYPES OF TRACHEOSTOMY TUBE WITH TUBE INFORMATION SHEETS, HUMIDIFICATION METHODS AND HME'S PLEASE REFER TO THIS SEPERATE PDF DOCUMENT.(PDF, 44 KB)

Rationale

Rationale 1: Child's airway is at risk and they may need immediate attention
Rationale 2: To enable effective emergency attention if required
Rationale 3: To enable continual assessment of oxygen requirements
Rationale 4: To safely suction tracheostomy tube
Rationale 5: To minimise the risk of cross-contamination
Rationale 6: To clean stoma/secretions
Rationale 7: To flush through suction tubing after use
Rationale 8: To draw up saline for instillation
Rationale 9: To meet hospital Waste Disposal guidelines
Rationale 10: To replace a blocked tube
Rationale 11: If the stoma opening shrinks and the normal size tube cannot be inserted
Rationale 12: Smoother insertion of the tracheostomy tube
Rationale 13: To prevent trauma to the neck, when cutting the ties
Rationale 14: To secure the tube
Rationale 15: To 'railroad' the tube into the stoma (Seldinger technique)
Rationale 16: To be used only on request by practitioners able and competent to use
Rationale 17: To maximise safety. Replacing tubes in the first week may be problematic where the stoma has not yet been established.
Rationale 18: To ensure effective discharge planning
Rationale 19: It is essential that the tube stay in situ long enough for the tract to form avoiding a difficult and possibly dangerous first tube change
Rationale 20: To form a more permanent and safer stoma, if the tube requires changing in the first week.
Rationale 21: To assist with the opening of the stoma during the first week, by raising the trachea to the skins surface and pulling the stoma apart so that a tube can be inserted
Rationale 22: Stay sutures will be removed AFTER the first tube change
Rationale 23: To ensure safe recovery from effects of anaesthesia
Rationale 24: Expect small amounts of bloodstained secretions in the first few hours. Any concerns call the ENT or emergency teams as required.
Rationale 25: The stoma site must be cleaned daily or when soiled. Using a clean technique and sterile gauze/saline. The wound must be inspected for signs of inflammation/ and or infection. Observe colour and nature of secretions
Rationale 26: Although children should only be suctioned when required, it is imperative that this trachy tube is kept clear at all times. Children must be nursed in continuous humidity for the first week (may come off for short periods only)
Rationale 27: Check correct tension of the tapes, ensuring that only one finger between the neck and tapes. Close observation of respiratory rate, effort, chest movements and air entry on return to the ward
Rationale 28: Contact ENT team as stomal sutures may need to be removed
Rationale 29: Observe for neck/face swelling or if the child complains of discomfort, pain or difficulty with breathing
Rationale 30: Regularly check tape tension for increased tightness
Rationale 31: Their airway is at risk and they must remain in an environment that can cope with any complications
Rationale 32: The vocal cords are sprayed during procedure, making them less responsive/effective in protecting the airway from aspiration
Rationale 33: The effect of the paralysing agent continues for up to 3 hours
Rationale 34: Other physical complications accompanied with post surgical oedema, restricted laryngeal elevation preventing complete and safe closure of the lower respiratory tract may cause aspiration and/or regurgitation of food
Rationale 35: The HME does not provide enough humidity in the initial phase, children require extra humidity to prevent tube occlusion in the first week
Rationale 36: To monitor stoma/ healing
Rationale 37: Flecks of displaced cotton may enter the respiratory tract
Rationale 38: 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 39: 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 et al, 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 40: To clear the tubing from secretions
Rationale 41: To ensure continuity of training
Rationale 42: In case of accidental decannulation
Rationale 43: To allow insertion into the tube flanges
Rationale 44: To place under the child’s shoulders, which will hyper extend the neck, making observation and cleaning of the stoma easier
Rationale 45: If a child is moving during the procedure there is potential of accidental decannulation. Involve the play specialist where possible. Most children will settle once they get used to the procedure and especially when parents begin to carry it out
Rationale 46: To support the tracheostomy tube and preventing an accidental decannulation
Rationale 47: To facilitate deflation and inflation of the cuff
Rationale 48: To prevent/minimise hypoxia and subsequent tissue death. Early intervention may prevent progression into full cardio-respiratory arrest
Rationale 49: This may be sufficient to rouse the child
Rationale 50: Always summon more help, to assist in tube changes, bring other equipment etc
Rationale 51: To tilt head and expose airway
Rationale 52: Parents/carers can add these items to the emergency box when they get home.

 

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Document control information

Lead author(s)
Joanne Cooke, Clinical Nurse Specialist, Tracheostomy Care, Ear, Nose and Throat (ENT
Document owner
Joanne Cooke, Clinical Nurse Specialist, Tracheostomy Care, Ear, Nose and Throat (ENT)
Approved by
Clinical Practice Committee
First introduced:  2 October 2000
Date approved: 25 January 2012
Review schedule: Two years
Next review:
25 January 2014
Document version: 2.0
Replaces version: 1.0