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.
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).
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. (hyper link- tracheostomy tube) picture.
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.
All children 6 years and under are to have cotton ties only to secure tracheostomy tubes.
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)
Immediate post-operative complications include:
Long term complications include:
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.
Routine tracheostomy management consists of:
Video of tracheostomy management
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:
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.
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 oxygen policy. 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:
Table 1: recommended suction catheter sizes
Tracheostomy tube size (in mm)
Recommended suction catheter size (Fr)
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
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.
Note: If unable to reinsert tracheostomy tube follow emergency procedure.
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 a speech pathologist assesses the child's ability to swallow.
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.
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.
Transition to the Community
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. Approveded by the Clinical Effectiveness Committee. Authorised by Bernadette Twomey, Executive Director Nursing Services. First published March 2008, reviewed February 2013.
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