- 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:
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).
- 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 who is 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 five 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.
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.
- 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.
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 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 skin's 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 three 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
Joanne Cooke, Clinical Nurse Specialist, Tracheostomy Care, Ear, Nose and Throat (ENT)
Joanne Cooke, Clinical Nurse Specialist, Tracheostomy Care, Ear, Nose and Throat (ENT)
Clinical Practice Committee
First introduced: 2 October 2000
Date approved: 25 January 2012
Review schedule: Two years
Next review: 25 January 2014 (currently being updated)
Document version: 2.0
Replaces version: 1.0