In this section
A tracheostomy is a surgical opening into the trachea below the larynx through which an indwelling tube is placed to overcome upper airway obstruction, facilitate mechanical ventilatory support and/or the removal of tracheo-bronchial secretions.
The aim of the guideline is to outline the principles of management for patients with a new or existing tracheostomy for clinicians at the Royal Children’s Hospital.
A blocked or partially blocked tracheostomy tube causes severe breathing difficulties. The key concept of tracheostomy management is to ensure patency of the airway. A tracheostomy kit is to accompany the patient at all times and be checked each shift by the nurse caring for the patient.
NB: NeopuffTM is the resuscitation device used at the bedside in Neonatal Unit at RCH.
The majority of children with a tracheostomy are dependent on the tube as their primary airway. Cardiorespiratory arrest most commonly results from tracheostomy obstructions or accidental dislodgement of the tracheostomy tube from the airway. Obstruction may be due to thick secretions, mucous plug, blood clot, foreign body, or kinking or dislodgement of the tube.
Early warning signs of obstruction include tachypnoea, increased work of breathing, abnormal breath sounds, tachycardia and a decrease in SpO2 levels . Cyanosis, bradycardia and apnoea are late signs - do not wait for these to develop before intervening.
The resuscitation flowchart for a tracheostomy patient follows APLS principles.
Download the flowchart (PDF 21 KB)
After a tracheostomy is inserted, the patient is managed in either the Paediatric Intensive Care (PICU - Rosella) or Neonatal Unit (NNU - Butterfly) in the initial post-operative period.
Routine tracheostomy management consists of:
Video of tracheostomy management
In determining the level of supervision and monitoring which is required, it is recommended each patient with a tracheostomy is assessed on an individual basis by the treating medical/surgical and nursing team4 taking into consideration the following factors:
It is recommended decisions regarding required level of supervision and required clinical observations/monitoring are documented clearly in the patient's medical record by the treating team.
Monitoring may include:
A tracheostomy bypasses the upper airway and therefore prevents normal humidification and filtration of inhaled air. Therefore, unless air inhaled via the tracheostomy tube is humidified, the epithelium of the trachea and bronchi will become dry which increases the potential for tube blockage. Tracheal humidification can be provided by a heated humidifier or Heat and Moisture Exchanger (HME) or a Tracheostomy bib.
Heated humidification: delivers gas at body temperature saturated with water which prevents the thickening of secretions. The temperature is set at 37°C delivering a temperature ranging from 36.5°C - 37.5°C at the tracheostomy site. Heated humidification for tracheostomy patients should be delivered via a humidifier as per the Oxygen clinical guideline (nursing). Indications for the use of heated humidification include:
Heat Moisture Exchanger (HME): contains a hygroscopic paper surface that absorbs the moisture in expired air. Upon inspiration the air passes over the hygroscopic paper surface and moistens and warms the air that passes into the airway.
Tracheostomy Bibs: are a specialized foam that traps the moisture in the expired air, upon inspiration the foam moistens and warms the air that passes into the airway.
Suctioning of the tracheostomy tube is necessary to remove mucus, maintain a patent airway, and avoid tracheostomy tube blockages. Indications for suctioning include:
Tracheostomy tube size (in mm)
Recommended suction catheter size (Fr)
The correct suction pressure for use on a tracheostomy tube is 80-120mmHg maximum when occluded. The Medigas suction gauges on the ward are measured on kPa. The equivalent of 80- 120mmHg is 10-16kPa.
Suction catheters are to be routinely replaced every 24hours or at any time if contaminated or blocked by secretions. Suction water/and the container to be replaced every 24 hours.
Changes in secretions e.g. blood stained or yellow/green secretions may indicate infection and/ or trauma of the airway. Notify the parent team, send a specimen for culture and sensitivity and consider commencement of antibiotics.
Persistant blood stained secretions from the tracheostomy tube need to be investigated to determine the cause.
At The Royal Children's Hospital the frequency of a tracheostomy tube change is determined by the Respiratory and ENT teams except in an emergency situation. This can vary from weekly to monthly depending on the patient's individual needs and tracheostomy tube type. Tracoeﾮ, Portexﾮ, Shileyﾮ and Bivonnaﾮ tracheostomy tubes are used at RCH.
The care of the stoma includes routine observation of the site and accurate documentation of the findings including:
If visible signs of infection are present obtain a specimen for culture/sensitivity.
Refer to stomal therapy/respiratory CNC for advice on the frequency and type of dressing required.
A tracheostomy may have an impact on the child's ability to swallow safely. It may also influence how the child feels about eating and drinking. Prior to commencing nasogatric or oral intake of food or drinks it is recommended that speech pathologist assesses the child's ability to swallow.
Consider a dietician referral to assess optimal nutritional intake – including oral versus tube feeding (PEG, PEJ or NG), continuous versus intermittent feeding.
Patients with a tracheostomy have altered upper airway function and may have increased oral care requirements. Mouth care should assessed by the nurse caring for the patient and documented in the patient care record
Children communicate in many different ways, such as using gestures, facial expressions and body postures, as well as vocalising. The tracheostomy may impact on the child's ability to produce a normal voice.
Various types of speaking valves are available. The most commonly used at the Royal Children's are Passy-Muir™ one-way valves.
Benefits of using a speaking valve include:
Contraindications for PMV assessment:
Before speaking valve use:A joint assessment involving the respiratory nurse consultant and a speech pathologist is essential before the device is used. While some children can use speaking valves without any difficulties Speaking valves are not suitable for all children with a tracheostomy.
The child's tolerance to the speaking valve will depend on their airway around and above the tracheostomy tube. To exhale sufficiently the child must have enough airway patency around the tracheostomy tube, up through the larynx and out of the nose and mouth. If exhalation is not adequate with the speaking valve in place the child may become distressed and air trapping/breath stacking or barotrauma to the lungs may occur.
To determine if the child has adequate airway patency consider:
Perform bedside assessment of airway patency:
If the child fails to tolerate the PMV:
Contraindication to PMV use:
Precautions when using speaking valves:
Care and cleaning of the Valve:
To avoid damage to the valve:
Tracheostomy Management Evidence Table.
Please remember to read the disclaimer.
The development of this clinical guideline was coordinated by Sueellen Jones, Registered Nurse, Respiratory Medicine. Approved by the Clinical Effectiveness Committee. Authorised by Bernadette Twomey, Executive Director Nursing Services. First published March 2008, reviewed February 2013 and most recently May 2014.