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Tracheostomy Management Guidelines

    1. Introduction
    2. Definition of terms
    3. Aim
    4. Tracheostomy Kit
    5. Emergency Management
    6. Complications
    7. Post operative management of a new tracheostomy
    8. Routine Management
    9. Decannulation
    10. Documentation
    11. Evidence Table
    12. References

    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).

    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. 

    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, labeled left and right, 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 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.
    • The comfort of patients is imperative throughout the post-operative period.  Pain should be managed effectively as per RCH procedural pain management policy.
    • 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

    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
    • 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.

    Monitoringmay include:

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

    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 oxygen policy.  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 CPG)
    • 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

    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

    • It is preferably to secure new ties before removing the old ties
    • If tie changes are required before the 1st tube change - the procedure must be undertaken with appropriate staff who are able to reinsert the tracheostomy tube in case of accidental decannulation.
    • There is a potential risk for tracheostomy tube dislodgment when attending totie changes, thereforea 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.

    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.  Tracoe, Portex, Shiley and Bivonna tracheostomy tubes are used at RCH. 

    • It is imperative that thefirst 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).
    • 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 

    Note: If unable to reinsert tracheostomy tube follow emergency procedure.

    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.
    • 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 a speech pathologist assesses the child's ability to swallow.  

    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.

    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
      • 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.

    Transition to the Community

    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 it is advisable to complete an intervention chart that provides 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.  The patient is admitted to hospital for the procedure.
    • Sometimes the tracheostomy tube is "downsized" 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. Procedure for 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.3Avoid suctioning the stoma. Encourage the patient to cough or to swallow.
    • The stoma site is covered by an occlusive dressing.
    • Commencement of eating and drinking following decannulation is in consultation with speech therapy, ENT and parent medical team.

    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.
      respir. Care. 1990;35:785-790.
    4. Choate, K and Snadford, M (2003) "Tracheostomy: Clinical Practoce and the formation of policy and guidelines" Australian Nursing Journal, 10, 8 p:CU1.
    5. 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.
    6. 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.
    7. 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.
    8. Griggs, A. (1998) "Tracheostomy suctioning and humidification". Nursing Standard vol 13 (2) pp: 49-53, 55-56.
    9. Woodrow, P. (2002) "Managing patients with a tracheostomy in acute care". Nursing Standard vol 16 (44) pp: 39-48.
    10. Carr, M. Poje, C.P.  Kingston, L.  Kielma, D.  Heard, C. (2001) "Complications in Pediatric Tracheostomies" Laryngoscope 111: November 2001.
    11. Edwards, E.A. Byrnes, C.A (1999) " Humidification Difficulties in Two Tracheostomized Children" Anaesthesia and Intensive Care, 27, 6, pp: 656-58.
    12. 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.
    13. 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.
    14. Dixon, L.and Wasson, D. (1998) "Comparing Use and Cost Effectiveness of Tracheostomy Tube Securing Devices.  Medsurg Nursing, 7, 5 pp: 270-274
    15. Tamburri, L.M. (2000) "Care of the Patient with a Tracheostomy".  Orthopedic Nursing, 19, 2 pp:49-60.
    16. Oberwaldner, B. Eber, E. (2006) "Tracheostomy care in the home".  Paediatric Respiratory Reviews, 7, 185-190.
    17. 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. 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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