Clinical Guidelines (Nursing)

Tracheostomy Management Guidelines

    Introduction

    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.

    Definition of terms

    •  Decannulation: removal of a tracheostomy tube
    •  Heat moisture exchangers (HME): a hygroscopic material that retains the child's exhaled heat and moisture, which is then returned to subsequent inhaled air (gas).
    •  Humidification: the mechanical process of increasing the water vapour content of an inspired gas.
    •  Neopuff® : is a flow controlled, pressure limited mechanical device specifically designed for neonatal resuscitation. Breaths are delivered by occluding a T piece. Peek Inspiratory Pressure (PIP) is preset, and PEEP can be adjusted using the valve on the T piece.1
    •  Stoma: a permanent opening between the surface of the body, and an underlying organ (in this case, between the trachea and the anterior surface of the neck).
    •  Tracheostomy: a surgical opening between 2 - 3 ( 3- 4) tracheal rings into the trachea below the larynx 
    •  Tracheal Suctioning: is a means of clearing the airway of secretions or mucus through the application of negative pressure via a suction catheter.
    •  Tracheostomy tube: a curved hollow tube of rubber or plastic inserted into the trachea to relieve airway obstruction, facilitate mechanical ventilation or the removal of tracheal secretions. See image below.
    • Nursing guideline Trache tube image

    Aim

    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.

    Tracheostomy Kit

    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.

    Tracheostomy Kit
    •  x1tracheostomy tube of the same size insitu (with introducer if available)
    •  x1tracheostomy tube one size smaller (with introducer if applicable)
    •  Spare inner tubes for double lumen trache tubes
    •  Spare ties (cotton and velcro)
    •  Scissors (or chain cutters as applicable)
    •  Resuscitation bag and mask (appropriate size for patient)
    •  One way valve (community use only)
    •  Wall or portable suction
    •  Appropriate size suction catheters
    •  0.9% sodium chloride ampoule and 1 ml syringe
    •  x1 HME or tracheostomy bib
    •  Fenestrated gauze dressing
    •  Cotton wool sticks
    •  Water based lubricant for tube changes
    •  Mucous trap-for emergency suction
    •  Tape (ie sleek)

    NB: NeopuffTM is the resuscitation device used at the bedside in Neonatal Unit at RCH.

    Special Considerations

    •  All children 6 years and under are to have cotton ties only to secure tracheostomy tubes.
    •  Children 6 years and over who are considered at risk of undoing velcro ties should have cotton ties.
    •  For patients with a newly established tracheostomy it is recommended that tracheal dilators are available at the patient’s bedside until after the first successful tube change.

    Emergency Management

    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.

    It is recommended that a copy of this flow chart is readily available e.g. placed in a prominent position at the bedside or in the patients bed chart folder.

    Download the flowchart (PDF 21 KB)

    trachy chart

    Complications

    Immediate post-operative complications include:
    •  Blocked tube
    •  Bleeding from the airway/tracheostomy tube
    •  Pneumothorax
    •  Subcutaneous and/or mediastinal emphysema
    •  Respiratory and/or cardiovascular collapse
    •  Dislodged tube
    •  Granulation tissue
    •  Tracheo-oesophageal fistula
    Long term complications include:
    • Acute airway obstruction
    •  Blocked tube
    •  Infection (localised to stoma or tracheo-bronchial)
    •  Aspiration
    •  Tracheal trauma
    •  Dislodged tube
    •  Stomal or tracheal granulomation tissue
    •  Tracheal stenosis

     Post Operative Management of a New Tracheostomy

    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.

    • Patients return from theatre with stay sutures in situ, which should be taped to the chest and labeled left and right. The stay sutures should remain in situ and securely attached to the chest wall, , until the first successful tube change. The stay sutures facilitate the opening of the stoma during reinsertion of the tracheostomy tube.
    • The ENT team, in consultation with the parent medical team, will perform the first tube change, including the removal of the stay sutures. This is usually done 5-7 days after insertion of the tracheostomy tube.
    • Most children will undergo their first tracheostomy tube change while in the intensive care environment. However, on occasions, following consultation between members of the PICU, ENT team and the parent unit, children may be transferred to a ward from PICU prior to their first tracheostomy tube change if they meet the following criteria:
      • Have a non critical airway i.e. these children are able to breathe and maintain their airway in the event of accidental decannulation.
      • Are not dependent on positive pressure ventilation/CPAP via the tracheostomy.
    • It is imperative that the first tracheostomy tie change is dealt with in the same manner as the first tracheostomy tube change with both nursing and medical staff present who are competent in tracheostomy management. The tracheostomy kit should be present at the bedside.
    • The tracheal stoma in the immediate post operative period requires regular assessment and management including once daily dressing change following cleaning of the stoma area with 0.9% normal saline, or more frequently if required.
    • Each child requires a Tracheostomy Tube Management Form to be completed and placed at the bedside. (see attached form)

    Routine Management

    Routine tracheostomy management consists of:

     

     

    TrachThumbjpg

    Video of tracheostomy management


    Equipment and Environment

    • Each shift ensure emergency oxygen and suction equipment is set up and in working order
    • Ensure appropriate equipment is accessible at the bedside and accompanies the patient

    Activities of Daily Living

    • Maintain and review as required the child’s PUPPS and falls risk assessment
    • Children with tracheostomy tube should wear a HME filter (unless ventilated) and be closely supervised when bathing or showering.

    Supervision and Monitoring

    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:

    • Age specific alarm limits
    • Clinical state
    • Nature of the airway problem
    • Ability to breathe and maintain their airway in the event of accidental decannulation
    • Ability to clear own secretions
    • Frequency of suction/tracheostomy tube interventions required
    • Ventilation requirements
    • Cognitive ability

    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:

    • Heart rate +/- continuous cardiac monitoring
    • Respiratory rate
    • Pulse oximetry continuous/overnight
    • Oxygen requirements
    • Work of breathing
    • Temperature
    • Blood pressure
    • Behaviour - alert, irritable, lethargic

    Additional tests/assessments

    • Measurement of blood gases, tcCO2 and etCO2 as per medical orders.

    Leaving the ward

    • The patient’s access to ward leave needs to be assessed according to the patient’s stability, vulnerability and the level of patient/caregiver knowledge and skill in airway (tracheostomy) and/or ventilation management

    Humidification

    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:

    • Oxygen delivery via tracheostomy mask
    • Mechanical Ventilation
    • Respiratory infection with increased secretions
    • Management of thick secretions

    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.

    • HME is recommended for all patients with a tracheostomy tube.
    • HME fit directly onto the tracheostomy tube.
    • HME are changed daily or as needed if the filter appears to be excessively moist or blocked.
    • For small infants <10kg HME filters may not be suitable. Consult Respiratory team to assess patient's suitability
    • HME with oxygen port are suitable for low flow oxygen administration (as per oxygen guideline)
    • Do not wet the HME filter prior to use.

     

    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.

    • At the RCH BuchananTM tracheostomy bibs are used.
    • Tracheostomy bibs are reusable. They are changed daily or more frequently as required.
    •  Hand wash in warm water using a mild detergent/soap, then rinse thoroughly and allowed to air dry.
    •  Tracheostomy bibs should be discarded monthly or more frequently if discoloured or the material is damaged..

    Suctioning

    Suctioning of the tracheostomy tube is necessary to remove mucus, maintain a patent airway, and avoid tracheostomy tube blockages. Indications for suctioning include:

    • Audible or visual signs of secretions in the tube
    • Signs of respiratory distress
    •  Suspicion of a blocked or partially blocked tube
    •  Inability by the child to clear the tube by coughing out the secretions
    •  Vomiting
    •  Changes in ventilation pressures (in ventilated children)
    •  Request by the child for suction (older children)
    •  Tracheal suctioning should be carried out regularly for patients with a tracheostomy tube. However the frequency varies between patients and is based on individual assessment.3
    •  Tracheal damage may be caused by suctioning. This can be minimised by using the appropriate sized suction catheter and only suctioning within the tracheostomy tube.
    Table 1: recommended suction catheter sizes

    Tracheostomy tube size (in mm) 

    3.0mm 

    3.5mm 

    4.0mm 

     4.5mm

    5.0mm 

    6.0mm 

     7.0mm

    Recommended suction catheter size (Fr) 

     7

     8

     8

     10

     10

     10-12

     12

    •   The suction depth is determined by the length of the individual tracheostomy tube.
    •  The depth of insertion of the suction catheter needs to be determined prior to suctioning to avoid airway trauma.3
    •  Using a spare tracheostomy tube of the same size and a measuring tape:
      •  measure the distance from the length of the tracheostomy tube connector to the end of the tracheostomy tube.
      •  record the suction depth on the tape measure and the patients observations chart.
      •  attach the tape measure to the cot/bedside/suction machine for future use.
      •  Use pre - measured suction catheters(where available) to ensure accurate suction depth
    •  The pressure setting for tracheal suctioning is 80-120mmHg (10-16kpa) to avoid tracheal damage. The suction pressure setting should not exceed 120mmHg/16kpa.
    •  It is recommended that the episode of suctioning (including passing the catheter and suctioning the tracheostomy tube) is completed within 5-10 seconds.3
    •  Suction catheters can be used for a 24hour period and then discarded unless indicated earlier.
    •  Routine use of 0.9% sodium chloride is not recommended however, In situations where this may be of benefit e.g., thick secretions and to stimulate a cough 0.2 - 0.5ml of 0.9% sodium chloride can be used.2,3

    Suctioning Equipment:

    • Suction apparatus (wall attachment or portable unit)
    • Suction canister
    • Tubing
    • Suction catheter
    • Sterile water

    Suctioning Checks:

    • Ensure tracheostomy kit is present
    • Appropriate size suction catheter
    • Depth required for tracheostomy tube suctioning3
    • Appropriate suction pressure.

    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.

    Suctioning: Procedure

    1. Explain to the patient and their family that you are going to suction the tracheostomy tube.
    2. Hand hygiene - ABHR
    3. Use personal protective equipment including non sterile gloves and safety glasses.
    4. Suction using a clean, non touch technique.
    5. Attach suction catheter to suction tubing
    6. Gently introduce the suction catheter into the tracheostomy tube to the pre-measured depth.3
    7. Apply suction & gently rotate the catheter while withdrawing. Each suction should not be any longer than 5-10 seconds.3
    8. Assess the patient's respiratory rate, skin colour and/or oximetry reading to ensure the patient has not been compromised during the procedure. Repeat the suction as indicated by the patient's individual condition.
    9. Rinse the suction catheter with sterile water decanted into bowl, not directly from bottle.
    10. Look at the secretions in the suction tubing - they should be clear or white and move easily through the tubing.
    11. Notify the parent team if the secretions are abnormal, and consider sending a specimen for culture and sensitivity.

    Suctioning: Special Considerations

    • Some patients may require assisted ventilation before and after suctioning. If required, this will be requested by the parent medical team or Respiratory Nurse.
    • If the correct size suction catheter does not pass easily into the tracheostomy tube, suspect a blocked or partially blocked tube and prepare for immediate tracheostomy tube change

    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.

    Management of abnormal secretions

    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.

    Tracheostomy tube tie changes

    • If tie changes are required before the 1st tube change – It is imperative that the procedure must be undertaken with both medical and nursing staff present who are able to reinsert the tracheostomy tube in case of accidental decannulation.
    • The first tracheostomy tube tie change and the appropriate equipment available at the bedside.
    • It is preferable to secure new ties before removing the old ties
    • There is a potential risk for tracheostomy tube dislodgment when attending to tie changes, therefore a minimum of two people who are competent in tracheostomy care are required to undertake tracheostomy tie changes. During the tracheostomy tie change, if the old ties are removed prior to securing the new ties, one person is to maintain the airway by securing the tracheostomy tube in place and not removing the hand until the new tracheostomy ties are secured The other person inserts the new ties into the flange and secures around the child’s neck. Tracheostomy tie changes are performed daily in conjunction with stoma care, or as required if they become wet or soiled to maintain skin integrity.
    • If the ties become loose it is a priority to re-secure immediately.
    • Tracheal chains – these can remain insitu and are changed with routine trache tube changes. The chains need to be checked every shift to ensure the correct tension and that the clasp is secure.
    • All Children 6 years and under are to have cotton ties only to secure tracheostomy tubes.
    • Children 6 years and over who are considered at risk of undoing velcro ties should have cotton ties.

    Tube tie change: Equipment


    • Tracheostomy kit
    • Two equal lengths of cotton ties or Velcro ties (for patients older than 6 years)

    Tube tie change: Procedure for changing cotton ties

    1. Explain to the patient and their family that you are going to change the tracheostomy ties.
    2. Hand hygiene – ABHR & use personal protective equipment including non sterile gloves and safety glasses.
    3. Prepare two equal lengths of ties long enough to go around the child's neck.
    4. Lie the child/infant down with the neck gently extended by a small rolled towel placed under the child's shoulders. An older child may like to sit up in a bed or chair
    5. Insert a clean tie on each side of the flange into the holes
    6. On each side tie a single loop approximately 0.5cm from the flange on the tracheostomy tube.
    7. Then tie both sides together in a bow to secure.
    8. Check the tension of the ties. Allow one finger to fit snugly between the skin and the ties.
    9. Re-tie into in a reef (double) knot to secure.
    10. Cut off excess length of ties leaving approximately 3cm.
    11. Remove old ties and recheck tension of new ties.
    12. NB: The old ties are to remain insitu until the clean ties are secured. In the event of removing existing ties prior to securing the tube with clean ties it is recommended a second person is present to hold the tracheostomy tube ensuring it remains in place until the ties are secured.
    13. Observe the patient's neck to ensure skin integrity.

    Tube tie change: Procedure for changing velcro ties


    1. Changing velcro ties is a two person procedure.
    2. Check the velcro on the tracheostomy ties prior to each use to ensure adhesiveness. If not adherent discard and replace.
    3. One person holds the tracheostomy tube securely in place.
    4. The second person removes the existing velcro ties and then inserts the clean velcro ties through one side of the flange, passing the tie around the back of the patient's neck and inserting the velcro tie through the other side of the flange.
    5. Adjust the ties to allow one finger to fit snugly between the skin and the ties.
    6. Observe the patient's neck to ensure skin integrity.
    7. Wash velcro ties daily in warm, soapy water, rinse and dry completely before re-using.

    Tracheostomy tube changes


    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.

    • It is imperative that the first tracheostomy tube change is performed with both nursing and medical staff who are competent in tracheostomy management present and the tracheostomy kit is available at the bedside.
    • A minimum of two people who are competent in tracheostomy care are required for all tracheostomy tube changes (except in an emergency if a second person is not readily available – eg. Transporting the child).
    • The tube change should occur before a meal or at least one-hour after to minimise the risk of aspiration.
      • Utilise personal protective equipment including non sterile gloves and safety glasses.
      • The tube change is a clean, non touch technique.

    Tracheostomy tube changes: Equipment

    • Tracheostomy Kit
    • Suction device and appropriate sized suction catheters
    • Small towel (rolled to place under the patient's shoulders to extend their neck)
    • A cot sheet to wrap the patient (age dependant)
    • Appropriate light/ illumination

    Tracheostomy tube changes: Procedure


    1. Hand hygiene – ABHR & use personal protective equipment including non sterile gloves and safety glasses.
    2. Prepare the new tracheostomy tube by removing it from the packaging/container, check the expiry dates and inspect for any signs of damage to the tube and then thread the ties into the flange and tie.
    3. If using velcro ties- insert the ties on one side of the flange only
    4. Clearly explain the procedure to the patient and their family/carer.
    5. Consider distraction techniques and or procedural sedation.
    6. Swaddle the patient if age appropriate by wrapping the arms and containing them in the sheet.
    7. Place the rolled towel under the patient's shoulders to extend their neck (unless contraindicated). The older child may find it more comfortable to sit upright with their head tilted back.
    8. Position the child so that you have good visibility and access to the stoma. If necessary extend the neck further and open the stoma wider by using your thumb and forefinger.
    9. Suction the existing tracheostomy tube immediately before removing the existing tube and inserting the new one.
    10. Person 1 holds the existing tube with their hand, person 2 cuts and removes the cotton ties from around the child's neck. If using Velcro ties - undo and remove from the flange.
    11. Person 1 removes the existing tube. Person 2 immediately inserts the new tube into the stoma and removes the introducer (if applicable).
    12. Person 2 holds the tube in place while Person 1 ties and secures the tracheostomy ties.
    13. Check the tension of the ties to allow - one finger to fit snugly between the skin and the ties, adjust if necessary. If using cotton ties, finish by making a reef double knot and cut off any excess fabric leaving approximately3cm.
    14. Observe the child immediately after the tube change to:
    15. ensure they are breathing normally with no signs of respiratory distress.
    16. Check that air is moving in and out of the tube by:
    17. listening for sounds of air coming out of the tube
    18. looking at the rise and fall of the chest
    19. feeling with your hand for a flow of air
    20. Check the old tube for blockages and or wear and tear.
    21. Discard single use tubes or wash and dry reusable tubes tubes according to the manufacturers recommendations.
    Note: If unable to reinsert tracheostomy tube follow emergency procedure.

    Tracheostomy tube changes: Special Considerations


    • A rare complication is for the tube to slip into a false passage instead of the airway. If there are any signs of breathing difficulties/respiratory distress remove the tube and reinsert (a new tube) via the stoma into the airway.
    • Unless instructed otherwise, all single use tracheostomy tubes should be used once only and discarded after every tube change, do not clean or re-use single use tubes.
    • Difficulties in re-inserting the tracheostomy tube can occur at any time. These occur usually as a result of one of the following:
      • False tract
      • Patient agitation or distress
      • Closure of the stoma
      • Spasm of the trachea
      • Stoma is blocked by scar tissue (granuloma)
      • Skin flaps
      • Structural airway abnormalities eg: Tracheo/bronchomalaca.
      • At times the difficulty is for no obvious reason and cannot be explained

    Stoma care

    • Care of the stoma is commenced in the immediate post-operative period, and is ongoing.
    • Daily cleaning of the stoma is recommended using 0.9% sterile saline solution. After cleaning, ensure the skin is clean and dry to avoid breakdown.

    Stoma Care: Equipment

    • Fenestrated dressing
    • 0.9% sodium chloride
    • Cotton buds/sticks

    Stoma Care: Procedure for stoma care

    1. Clearly explain the procedure to the patient and their family/carer
    2. Perform hand hygiene – ABHR or Wash hands.
    3. Use a clean non-touch technique and personal protective equipment e.g. safety glasses and gloves.
    4. Lay the child on their back with a small rolled towel under the shoulders. An older child may prefer to sit up in a bed or chair.
    5. Remove fenestrated dressing from around stoma.
    6. Inspect the stoma area around the tracheostomy tube.
    7. Clean stoma with cotton buds moistened with 0.9% sodium chloride. Use each cotton bud once only taking it from one side of the stoma opening to the other and then discard.
    8. Continue cleaning with new cotton buds until the skin area is free of secretions, crusting and discharge.
    9. Allow skin to air dry or use a dry cotton bud to dry.
    10. Insert the fenestrated gauze under the flanges (wings) of the tracheostomy tube to prevent chafing of the skin.

     

    • Avoid using any powders or creams on the skin around the stoma unless prescribed by a doctor or stomal therapist as powders or creams could cause further irritation.
    • If signs of redness or excessive exudate consider using a non adhesive hydrocellular foam dressing e.g. Allevyn®. Discuss with parent medical team and consider obtaining a specimen for culture and sensitivity.
    • If there are any signs of granulation tissue liaise with the respiratory nurse consultants and/or stomal therapists for appropriate management.

    The care of the stoma includes routine observation of the site and accurate documentation of the findings including:

    • Redness
    • Swelling
    • Evidence of granulation tissue
    • Exudate
    •  Increased discomfort during care
    •  Stomal odour.

    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.


    Feeding and Nutrition

    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.  

    Oral care

    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

    Communication

    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.

    • Vocalisation depends on several factors such as:
      •  Severity of airway obstruction
      •  Extent of vocal cord function
      •  The size and type of the tracheostomy tube insitu
      •  Respiratory muscle strength
      •  Cognitive ability and age related ability
    • For patients with a new tracheostomy, refer to a speech pathologist for assessment and provision of communication aids such as:
      • Pen and paper
      • Alphabet board
      • Picture communication device
      • Teaching manual for Auslan signing
      • Electronic devices
      • Assessment for suitablility of speaking valve attachement
    • For children with established tracheostomy tubes it is essential that the methods used for communication are identified via discussion with the patient (age appropriate), and the parent/carers. These methods should be documented in the medical record and verbally handed over to staff to ensure adequate communication and appropriate understanding of the patient and their needs.
    • Speaking valves are a small plastic device with a silicone one-way valve, they sit on the end of the tracheostomy tube. The one-way valve opens on inspiration allowing air to enter the tracheostomy tube and closes on exhalation directing air up through the trachea, larynx and nose and mouth as in normal breathing and normal speech. Not all children will be able to produce a voice when the speaking valve is first used.

    Speaking Valves:

    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:

    • Enhancing normal flow of air through the airway/nose and mouth
    • Restoration of physiological PEEP
    • Louder and clear voice
    • Improved ability to taste and smell foods
    • Improved secretions
    • Improved protection of the airways during swallowing and feeding
    • Improves development of speech and babbling in infants/toddlers

    Contraindications for PMV assessment:

    • Severe airway obstruction
    • Vocal cord paralysis - adducted position
    • Severe neurological deficit
    • tracheostomy tube with inflated cuff (any kind)
    • Foam-filled cuff (even if deflated)
    • Severe risk for aspiration
    • < 7 days post-operative tracheostomy tube insertion

    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:

    • Diagnosis of severe laryngeal or tracheal stenosis/subglottic stenosis
    • Size and type of the tracheostomy tube - appropriate to allow airflow through upper airway
    • Nasal obstruction - e.g. nasogastric tubes/choanal atresia etc
    Before trail of speaking valve ensure the child:
    • Post-operative tracheostomy 7 days or greater
      Medically stable
      Awake and responsive
      Doesn't have excessive tracheal secretions and is able to manage oral secretions
      Able to tolerate cuff deflation
      Has adequate patency of upper airway

    Perform bedside assessment of airway patency:

    • Explain procedure (age appropriate) to child and their family
    • Suction the tracheostomy tube before the valve is attached and then as required.
    • A cuffed tube must be deflated before attaching the speaking valve.
    • Gently occlude tracheostomy tube with a gloved finger and observe for exhaled air from nose and mouth or vocalization.
    • If finger occlusion is tolerated place the speaking valve on the end of the tracheostomy tube and observe for oral/nasal exhalation.
    • If the PMV is tolerated on the initial trial for a goal of 5 to 10 minutes, then a plan to improve consistency and length of tolerance is developed and provided to the child and their care-givers.
    • Once the child has adjusted to wearing the valve they should be able to wear it for long periods and the PMV can and should be worn at all awake times, particularly during rehabilitative therapy sessions and when eating.

    If the child fails to tolerate the PMV:

    • Remove the valve if any signs or symptoms of distress or changes in respiratory effort.
    • As it can be more difficult for the child to exhale with the valve in place, the child may initially fail a trial of PMV due to anxiety, discomfort.
    • Children may need to slowly build up longer periods of valve use and PMV placement will be repeated on subsequent days.
    • Many children however, have difficulty adjusting to changes to their airways. Children may initially experience increased coughing due to restoration of a closed respiratory system, which re-establishes subglottic pressure and normalizes exhaled airflow in the oral/nasal chambers.
    • In infants and young children consider using an device to secure the PMV to the child's ties - to prevent accidental loss of the PMV.
    • Some speaking valves are suitable for use in combination with oxygen therapy and during ventilation.

    Contraindication to PMV use:

    • If you determine there is no airway patency then the degree of stenosis is a contraindication to speaking valve use.
    • If the child has prolonged excessive coughing and obvious discomfit with increased respiratory effort and air trapping - remove the valve immediately and reassess for adequate airway patency before a repeat trial.
    • If airway patency adequate then aim to reassess the child at regular intervals to place the PMV gradually increasing the time and frequency of use.
    • PMV may be contraindicated depending on type of cuffed tube e.g. foam cuff

     
    Precautions when using speaking valves:

    • If the child has severe airway obstruction the speaking valve should not be used.
    • In cuffed tracheostomy tubes - ensure cuff is completely deflated.
    • The young child should always be supervised when wearing the speaking valve.
    • The speaking valve should not be worn when the child is sleeping.
    • Speaking valves do not humidify the air - therefore may be unsuitable for children with copious thick secretions.
    • If the speaking valve is not functioning properly (i.e. sticking, noisy or vibrates) or the child shows signs of respiratory distress/discomfort, then remove the valve immediately and replace.
    • Do not use in combination with HME (heat moisture exchanger)
    • Remove valve before aerosol/nebulizer medication is administered

    Care and cleaning of the Valve:

    • The speaking valve should be cleaned daily by washing the valve in warm mild soapy water, then rinsed thoroughly and allowed to air dry completely before reuse.
    • Once dry and when not in use, it should be stored in the appropriate storage container.
    • Ensure the valve is clean and not damaged in any way before each use.
    • Replace the valve immediately if any signs of wear/tear or damage are noted.

    To avoid damage to the valve:

    • do not wash in hot water
    • do not brush the valve
    • do not use alcohol, peroxide or bleach to clean the valve

     

    Transition to the Community and discharge planning

    • All children with a tracheostomy tube in situ require a referral to Family Choice Program to identify if support is required either for the patient or their family. The referral should be made as soon as possible following tracheostomy tube insertion to allow adequate time for planning home support services.
    • The referring team is responsible for ensuring appropriate equipment is organised in collaboration with the Equipment Distribution Centre. This should occur in consultation with the nursing staff, respiratory nurse consultants and the parent medical team.
    • Ensure all members of the medical, nursing and allied health teams are aware of the planned discharge.
    • Prior to discharge an intervention chart is required to be completed to provide detailed information about the interventions required for the patient over a past 24-48 hour period including:
      • Frequency of care the patient required including the amount of suctioning the child has required.
      • Level of dependency the patient has on their tracheostomy.
    • Assessment will be made in accordance to the above information as to the child's eligibility for assistance required at home and for discharge.
    • Education for primary care givers regarding tracheostomy care commences soon after insertion of the tube and is usually initiated by the respiratory CNC in collaboration with the parent unit nursing staff.
    • Principles of the care for children with a tracheostomy in the community who are managed by FCP are based on the recommendations of this clinical practice guideline. However individualised care plans are developed specifically to their care needs. These are located in the home care manuals in FCP department.

    Decannulation

    • Decannulation is a planned intervention for the permanent removal of the tracheostomy tube once the underlying indication for the tracheostomy has been resolved or corrected.
    • The patient is admitted to hospital for the procedure.
    • Bronchoscopy evaluation is usually performed prior to planned decannulation to evaluate airway stability, assess possible granulation or suprastomal collapse, to assess whether the child can maintain their airway and ventilation adequately without the tracheostomy tube.
    • Decannulation planning can also include a staged process with downsizing and capping of the tracheostomy tube in order to assess how the child would cope with a smaller tracheostomy in the airway and to encourage the use of the upper airway.
    • The tracheostomy is usually blocked off using a decannulation cap if tolerated the child is monitored overnight (downloadable oximetry) with the tube occluded.
    • To ensure the patient and the caregivers are prepared for the decannulation ensure the procedure has been explained.
    • Decannulation is usually performed between the hours of 9am and 6pm.
    • There should be a clearly documented plan for the decannulation process from the parent medical team
    • Decannulation should not be performed unless a member of the parent medical team is present in the ward at the time of decannulation. Inform the ENT team of the planned decannulation prior to removal of the tracheostomy tube.
    • It is recommended that the child's caregiver/s are present to alleviate the anxiety of the child.
    • The child should be fasted for 2 hours prior to the decannulation.
    • Post decannulation, the patient is ideally nursed 1:1 for 24 hours and should not leave the ward unless supervised by nursing staff. At the end of this 24 hour period the need for nursing supervision of the patient (away from the ward area) is assessed by the patient's parent medical team.3
    • Occasionally the trial of decannulation is unsuccessful requiring the need to re-insert the tracheostomy tube. This is an emergency procedure and it can occur at any time

    Decannulation: Equipment

    Equipment - to stay at bedside until the child is discharged:
    • Tracheostomy Kit
    • Set of tracheostomy tubes (same size and smaller sizes than tube child has insitu down to a size 3mm - keep a size 3mm in freezer).
    • Surgical scissors
    • Tracheostomy ties or velcro ties
    • Gauze dressing and an occlusive dressing - Comfeel™ with hypafix borders or tegaderm™/opsite™ to cover the tracheostomy stoma
    • Oxygen and suction
    • Cotton tipped applicators
    • Small towel (if applicable)
    • Oxygen and suction equipment
    • Laerdal Resuscitator kit

    Decannulation: Procedure

    • Obtain baseline observations including heart rate, respiratory rate, haemoglobin-oxygen saturation, and work of breathing. Ensure patient vital signs are within appropriate parameters forage
    • Monitor patient continuously throughout the procedure.
    • Clean the stoma and suction the tracheostomy tube immediately prior to decannulation.
    • Cut/undo tracheostomy tube ties.
    • Remove tracheostomy tube.
    • Observe for any signs of respiratory distress including:
      • Tachypnoea
      • Stridor
      • Retraction
      • Tachycardia
      • Colour
      • Decreased perfusion
      • Haemoglobin-oxygen desaturation or low oximetry reading.
      • Restlessness
      • cough effectiveness swallow and voice quality
      • activity levels
    • Apply occlusive dressing to stoma site post decannulation if no evidence of respiratory distress.
    • Patient should again be assessed for signs of respiratory distress after applying occlusive dressing to stoma site.
    • Patient should be nursed 1:1 for the first 24 hours post decannulation if complications with the decannulation are anticipated.

    Following decannulation:

    • Monitor the patient's respiratory rate, heart rate, oxygen saturation, colour and work of breathing continuously throughout the procedure then:
      • 15 minutely for the first hour
      • Half hourly for the next 4 hours
      • Hourly for 24 hours
      • Continuous pulse oximetry (SpO2) for patients during all periods of sleep (day and night) post decannulation for 24 hours.
      • Call a MET for assistance as per RCH guidelines

    Report any episodes of:

    • Tachypnoea/bradypnoea
    • Tachycardia/bradycardia
    • SpO2 desaturation
    • Increased WOB - as evidenced by: sternal/intercostal retraction, tracheal tug, nasal flaring, stridor
    • Restlessness/anxiety
    • Colour change/ Cyanosis
    • Failure to clear secretions - gagging
    • Offer light diet 2 hours after decannulation unless contraindicated by increased respiratory effort
    • Encourage the child to undertake normal activities while on the ward.
    • Continuous pulse oximetry (SpO2) during sleep
    • Observe carefully for signs of any airway obstruction during sleep.
    • The child should not leave the ward for 24 hours following decannulation.
    • Following the first 24 hours post decannulation the patient may leave the ward if the admitting team has assessed the patient to have a "safe airway" unless supervised by nursing/medical staff competent in emergency tracheostomy care.
    • Encourage coughing to clear secretions from upper airway if required. If the child is not coughing and clearing secretions well, gentle oropharyngeal suction (only) may be performed. Contact the physiotherapist for support.
    • Avoid suctioning the stoma unless otherwise indicated in an emergency situation as this may cause trauma.
    • Referral to speech pathology should be considered if the child does not resume normal voice production following decannulation.

    Stoma site care post decannulation:

    Dressings:
    • The stoma site is covered by a small gauze square and then by an occlusive dressing (sleek™/tegaderm™) until it has closed or no secretions are seeping out.
    • Assess occlusive tracheal stoma dressing for air leaks every shift and document absence or presence of these in medical record.
    • Stoma site to be assessed daily and cleaned (as per tracheostomy CPG) or more frequently if indicated.

    Discharge:

    • The child is usually discharged home when they're considered to have a safe airway. The average length of stay post decannulation is 24 -48 hours but this maybe longer if required.
    • Ensure the caregivers are provided with adequate supplies and are aware of how to care for stoma site - this includes daily cleaning of the site and dressing changes as required.
    •  Advise the family/caregiver to contact the hospital and/or medical team if any episodes of:
      •  Tachypnoea/bradypnoea
      •  SpO2 desaturation
      •  Increased WOB - as evidenced by: sternal/intercostal retraction, tracheal tug, nasal flaring, stridor
      •  Restlessness/anxiety
      •  Colour change/ Cyanosis
      •  Unable to clear secretions - gagging
    •  Advise the family/caregiver to contact the hospital and/or medical team if there are any signs of infection at the stoma site including any
      •  Redness
      •  Odour
      •  Swelling
      •  Discharge
    •  Following a successful decannulation the family are able to return all tracheostomy and suctioning equipment but are encouraged to keep the pulse oximeter until seen at follow up outpatient appointment

    Documentation

    • All written documentation related to the management of a patient with a tracheostomy is in accordance with the RCH documentation policy.
    • Record the reason and type of the interventions performed relating to tracheostomy care and appropriate outcomes in the progress notes. These include:
      • Suctioning (amount, colour and consistency of aspirates)
      • Tracheostomy cares including tie changes and stoma dressings
      • Stoma condition (ongoing documentation and any changes eg: signs of infection)
      • Significant changes in patient's condition
    • In the event of a tube change (routine or emergency), the following should be documented in the progress notes:
      • The size and type of tube inserted
      • Lot number
      • Expiry date of the tracheostomy tube
      • Name of person who inserted the tube
      • Patient condition throughout the tube change
      • Any difficulties experienced during changing the tracheostomy tube.

    Evidence Table

    Tracheostomy Management Evidence Table

    References

    1. Hussey, S.G, Ryan, C.A and Murphy, B.P. (2007) "Comparison of three manual ventilation devices using an intubated mannequin". Arch Dis. Child. Fetal Neonatal Ed. (2004); 89; 490-93.
    2. Raymond SJ. Normal Saline Instillation Before suctioning: Helpful or Harmful? A review of the Literature". American Journal of Critical Care July 1995 Volume 4, No. 4 267-271.
    3. Gray JE, MacIntyre NR, Kronenberger WG. The effects of bolus normal saline instillation in conjunction with endotracheal suctioning.
    4. respir. Care. 1990;35:785-790.
    5. Choate, K and Snadford, M (2003) "Tracheostomy: Clinical Practoce and the formation of policy and guidelines" Australian Nursing Journal, 10, 8 p:CU1.
    6. Scoble M, Copnell, B. Taylor, A. Kinney, S and Shann, F. (2001) "Effect of reusing suction catheters on the occurence of pneumonia in children" Heart and Lung vol 30, 3 p: 225-233.
    7. Celik, S and Kanan, N (2006) " A current conflict use of Isotonic Sodium Chloride Solution on the Endotracheal Suctioning in Critically Ill Patients" Dimensions of Critical Care Nursing vol 25/No1 pp:11-14.
    8. Ridling, D. Martin, LD and Bratton, S. (2003) "Endotracheal Suctioing With or Without Instillation of Isotonic Sodium Chloride Solution in Critically Ill Children". American Journal of Critical Care vol 12, no 3 pp:212-219.
    9. Griggs, A. (1998) "Tracheostomy suctioning and humidification". Nursing Standard vol 13 (2) pp: 49-53, 55-56.
    10. Woodrow, P. (2002) "Managing patients with a tracheostomy in acute care". Nursing Standard vol 16 (44) pp: 39-48.
    11. Carr, M. Poje, C.P. Kingston, L. Kielma, D. Heard, C. (2001) "Complications in Pediatric Tracheostomies" Laryngoscope 111: November 2001.
    12. Edwards, E.A. Byrnes, C.A (1999) " Humidification Difficulties in Two Tracheostomized Children" Anaesthesia and Intensive Care, 27, 6, pp: 656-58.
    13. Wyatt, M.E. Bailey, C.M. Whiteside, R.N (1999) "Update on paediatric tracheostomy tubes" The Journal of Laryngology and Otology , 113, 1, Health and Medical Complete pp:35-40.
    14. Wetmore, R.F. Marsh, R.R. Thompson, M.E. Tom, L.W. (1999) "Pediatric Tracheostomy: A Changing Procedure". The Annals pf Otology, Rhinology and Laryngology, 108, 7, pp:695-699.
    15. Dixon, L.and Wasson, D. (1998) "Comparing Use and Cost Effectiveness of Tracheostomy Tube Securing Devices. Medsurg Nursing, 7, 5 pp: 270-274
    16. Tamburri, L.M. (2000) "Care of the Patient with a Tracheostomy". Orthopedic Nursing, 19, 2 pp:49-60.
    17. Oberwaldner, B. Eber, E. (2006) "Tracheostomy care in the home". Paediatric Respiratory Reviews, 7, 185-190.
    18. O'Toole, EA. Wallis, C. (2004) "Sending children home on tracheostomy dependent ventilation:pitfalls and outcomes". BMJ vol 89 (3) pp: 251-255.

     

    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.