In this section
Note: this guideline is currently under review.
Definition of Terms
The Resuscitation Flowchart (under review)
Post-Operative management of a new tracheostomy
Routine tracheostomy management
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 ventilator 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 (RCH).
kit is to accompany the patient at all times and this must be checked each
shift by the nurse caring for the patient to ensure all equipment is available.
A key concept of tracheostomy management is to ensure patency of the airway (tracheostomy tube). A blocked or partially blocked tracheostomy tube may cause severe breathing difficulties and this is a medical emergency. Immediate access to the tracheostomy kit (equipment) for the individual patient is essential.
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.
Late signs of obstruction include cyanosis, bradycardia and apnoea - do not wait for these to develop before intervening.
(currently under review, new chart coming soon)
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
Download the flowchart (PDF 21 KB)
Complications can be classified by timing: intraoperative; early (usually defined as the first postoperative week); late; and post-decannulation.
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 and until after the first routine tracheostomy change.
Note: 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:
Routine tracheostomy management consists of:
Each shift ensure
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 and nursing team4 taking into consideration the following factors:
Decisions regarding required level of supervision, clinical observations and monitoring are to be documented clearly in the patient's medical record by the treating medical/nursing team.
Monitoring may include:
recommended that all patients have continuous pulse oximetry (SpO2) during all
periods of sleep (day and night) and when out of line of sight.
Children with a tracheostomy tube should be closely supervised when bathing or showering. They should also wear a HME filter or tracheostomy bib filter (unless on CPAP or ventilation) to minimise the risk of aspiration.
The patient’s access to ward leave is assessed according to:
A tracheostomy tube bypasses the upper airway and therefore prevents the normal humidification and filtration of inhaled air via the upper airway. Unless air inhaled via the tracheostomy tube is humidified, the epithelium of the trachea and bronchi will
become dry, increasing the potential for tube blockage. Tracheal humidification can be provided by a heated humidifier or Heat and Moisture Exchanger (HME) or a Tracheostomy bib filter.
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:
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.
Consist of 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.
the tracheostomy tube is necessary to remove mucus, maintain a patent airway,
and avoid tracheostomy tube blockages. The frequency of suctioning varies and
is based on individual patient assessment.
Some patients may require assisted ventilation before and after suctioning. If required, this will be requested by the parent medical team or Respiratory CNC.
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.
Changes in secretions e.g. blood stained or yellow and green secretions may indicate infection and or trauma of the airway.
Notify the parent team for review who may request sending a sputum specimen for culture and sensitivity and consider commencement of antibiotics.
Persistent blood stained secretions from the tracheostomy tube need to be investigated to determine the cause.
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.
The frequency of a tracheostomy tube changes is determined by the Respiratory and ENT teams except in an emergency situation. This can vary depending on the patient's individual needs and tracheostomy tube type.
It is imperative that the first tracheostomy tube change is performed with both nursing and medical staff who are competent in tracheostomy management are 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 – e.g. transporting the child).
The tube change should occur before a meal or at least one-hour after to minimise the risk of aspiration.
The tube change procedure is performed using standard
aseptic principles using a non-touch technique.
Observe the child immediately after the tube change to check they are breathing normally with no signs of respiratory distress and that air is moving in and out of the tube by:
Note: If unable to reinsert tracheostomy tube follow
Refer to Respiratory Clinical Nurse Consultant for advice on the frequency and type of dressing required.
The tracheostomy tube may have an impact on the child's ability to swallow safely, therefore a swallowing evaluation by a speech pathologist is recommended prior to the commencement of oral intake. The speech pathologist may recommend the optimum method of feeding as well as the types and consistency of foods and liquids.
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. For all patients with a new tracheostomy a referral to a speech pathologist for
assessment and provision of communication aids is recommended.
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/primary caregivers. 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.
One-way speaking valves are a small plastic device with a silicone one-way valve, they sit on the end of the tracheostomy tube. The most commonly used at the Royal Children's are Passy-Muir™ one-way valves and the Tracoe™ modular valve.
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 vocal sounds or voice when the speaking valve is first used.
Various types of one-way speaking valves are available.
One-way speaking valves are not suitable for all children with a tracheostomy. The child's tolerance to the one-way 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 one-way speaking valve in place the child may become distressed and air trapping/breath stacking or barotrauma to the lungs may occur. Therefore, a joint assessment involving the Respiratory nurse
consultant and a Speech pathologist is essential before the device is used to determine if the child has adequate airway patency.
All children with a tracheostomy tube should be referred to Complex Care Hub after discussion with the family. The referral should be made as soon as possible following tracheostomy tube insertion to allow adequate time for the planning of in-home health care support prior to the patients
Following the referral a needs assessment will be undertaken by CCH team to determine the support required for the patient and their family.
The referring team is responsible for ensuring appropriate equipment for discharge is organised in collaboration with the Complex Care Hub or Equipment Distribution Centre.
This should occur in consultation with the ward nursing staff, respiratory nurse consultants and the parent collaboration with the Complex Care Hub or Equipment Distribution Centre.
Ensure all members of the medical, nursing and allied health teams are aware of the planned discharge date.
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 supported by the Complex Care Hub are based on the recommendations of this clinical practice guideline and individualised care plans are developed specifically to the patient’s care
needs. These are located in the home care manuals provided by Complex care team.
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
If the child is unable to tolerate the downsizing and capping of the tracheostomy tube a medical review is required as the trial of decannulation may not proceed and the tube may be upsized.
If the child tolerates downsizing and capping of the tube ensure patient vital signs remain within appropriate parameters for age & as per VICTOR chart. Additional monitoring: Overnight oximetry monitoring (downloadable) and sleep diary are recorded throughout the night.
The child is reviewed in the morning by the admitting team to determine whether the decannulation trial goes ahead or not.
Decannulation is usually performed between the hours of 9am and 10am (following medical review).
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.
Note: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 – ensure equipment is at bedside and remains with the child until the child is discharged.
Monitor the patient's vital signs - respiratory rate, heart rate, oxygen saturation, colour and work of breathing continuously throughout the procedure then observe and document:
Immediately report any episodes of:
Note: The child is to remain on the ward for 24 hours post decannulation
and should not leave the ward without medical approval and supervised by nursing staff competent in tracheostomy care.
The child is usually discharged home when they're considered by the medical team to have a safe airway.
The average hospital length of stay post decannulation is 36 - 48 hours, however this maybe longer if clinically indicated.
Following a successful decannulation the family are able to return all tracheostomy and suctioning equipment on discharge from hospital but are encouraged to keep the pulse oximeter until seen at follow up outpatient appointment.
Advise the family/caregiver to observe for and contact the hospital and/or medical team if any episodes of:
Note: If child having severe breathing problems call 000 immediately and follow basic life support flowchart
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 there are any signs of infection at the stoma site including any:
If stoma site remains open the family are advised to carefully supervise their child around water to avoid aspiration.
Ensure 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 and flow sheets assessment.
Should an aerosol generating procedure be undertaken on a patient under droplet precautions then increase to airborne precautions by donning N95/P2 mask for at least the duration of the procedure.
Tracheostomy Management Evidence Table.
Please remember to read the
The development of this nursing guideline was coordinated by Sueellen Jones, Registered Nurse, Respiratory Medicine, and approved by the Nursing Clinical Effectiveness Committee. Updated April 2018.