Tracheostomy

(with thanks to www.tracheostomy.com)

Definition

A tracheostomy is an opening surgically created through the neck into the trachea (windpipe). A tube is usually placed through this opening to provide an airway, and to remove secretions from the lungs. This tube is called a tracheostomy tube or trachy tube (the American’s call it a trach tube!).

Caring for a tracheostomy

1. Suctioning a tracheostomy
2. Changing the tracheostomy
3. Changing the tracheostomy ties
4. Precautions with a tracheostomy

1. Suctioning a Tracheostomy

The upper airway warms, cleans and moistens the air we breath. The trachy tube bypasses these mechanisms, so that the air via the tube is cooler, dryer and not as clean. In response to these changes, the body produces more mucus. The trachy tube is suctioned to remove mucus from the tube and trachea to allow for easier breathing. Generally, the child should be suctioned every 4 to 6 hours and as needed. There may be large amounts of mucus with a new tracheostomy. This is a normal reaction to an irritant (the tube) in the airway. The heavy secretions should decrease in a few weeks. While a child is in the hospital, suctioning is done using sterile technique, however a clean technique is usually sufficient for most children at home. If your child has frequent respiratory infections, trachy care and suctioning techniques may need to be addressed. Frequency of suctioning will vary from child to child and will increase with respiratory tract infections. Try to avoid suctioning too frequently. The more you suction, the more secretions can be produced. 

Care Techniques

1. Sterile Technique: sterile catheters and sterile gloves
2. Modified Sterile Technique: sterile catheters and clean gloves
3. Clean Technique: clean catheter and clean hands

The size of the suction catheter depends on the size of the tracheostomy tube.  Size 6, 8 or 10 French are typical sizes for neonatal and paediatric trachy tubes. The larger the number, the larger the diameter of the suction catheter.  Use a catheter with an outer diameter that is about half the inner diameter of the artificial airway — this will allow air to enter around it during suctioning.  You can also compute the catheter size with this formula:  Multiply the artificial airway’s diameter in millimetres by two. For example, 8 mm X 2 = 16, so a 16 French catheter. 

Older children may be taught to suction themselves.

Suction Depths

1. Shallow Suctioning: Suction secretions at the opening of the trachy tube that the child has coughed up.
2. Pre-measured Suctioning: Suction the length of the trachy tube. Suction depth varies depending on the size of the trachy tube.
3. Deep Suctioning: Insert the catheter until resistance is felt. (Deep suctioning is usually not necessary. Be careful to avoid vigourous suctioning, as this may injure the lining of the airway).

Signs That a Child Needs Suctioning

• Rattling mucus sounds from the trachy
• Fast breathing
• Bubbles of mucus in trachy opening
• Dry raspy breathing or a whistling noise from trachy
• Older children may vocalise or signal a need to be suctioned.
• Signs of respiratory distress

Equipment for Suctioning

Suction machine
Suction connecting tubing
Suction catheters
Normal saline
Sterile or clean cup
2 or 5 ml saline ampules
Ambu bag
Tissues
Gloves (optional for home care, use powder-free gloves)

Procedure

• Explain procedure in a way appropriate for child’s age and understanding.

• Wash hands.

• Set up equipment and connect suction catheter to machine tubing.

• Put on gloves (optional).

• Turn on suction machine (suction machine pressure for small children 50-100mm Hg, for older children/adults 100-120mm Hg)

• Instil sterile normal saline with plastic squeeze ampule into the trachy tube if needed for thick or dry secretions. Excessive use of saline is not recommended. Use saline only if the mucus is very thick, hard to cough up or difficult to suction. Saline may also be instilled via a syringe or eye dropper, which is less expensive than single dose units. Recommended amount per instillation is approximately 1 ml.

• Gently insert catheter into the trachy tube without applying suction. (Suction only length of trachy tube – pre-measured suctioning. Deeper insertion may be needed if the child has an ineffective cough.)

• Put thumb over opening in catheter to create suction and use a circular motion (twirl catheter between thumb and index finger) while withdrawing the catheter so that the mucus is removed well from all areas. Avoid suctioning longer than 10 seconds because of oxygen loss. Note: Some research has shown that by going in and then out, there is less hypoxia.

• Draw water from a cup through catheter to clear catheter.

• Let child rest and breathe, then repeat suction if needed until clear (allow at least 30 seconds between suctioning).

• Oxygenate as ordered (extra oxygen may be given before and after suction to prevent hypoxia).

• The child’s mouth or nose may also be suctioned, if needed after suctioning the trachy, then dispose of that catheter (do not put same catheter back into trachy).

• Dispose of suction catheter, saline and gloves, turn off machine. In home care, catheters may sometimes be used more than once before disposal or cleaning if child need frequent suctioning. Keep tip of catheter sterile, and store into original package.

• Be aware of colour, odour, amount and consistency of the secretions and notify doctor (mother) of changes in secretions.

2. Changing the Tracheostomy

The tracheostomy tube is typically changed every 1-4 weeks to prevent mucus build-up and for cleanliness. This may very depending on the particular child. Check with the doctor for frequency of trachy change. Always change the trachy tube with two people present (unless this is not possible in an emergency). Change the trachy tube before a feeding or at least 2 hours after a feeding.

Supplies:

Same size trachy tube with introducer
Size smaller trachy tube with introducer
Trachy ties
Small blanket or towel roll
Blanket for restraint (if needed)
Sterile water soluble lubricant
Blunt ended scissors
Tweezers or forceps
Suction machine
Good light source
The kitchen or dining room table covered with a pad or blanket may be a good place for a trachy change.

Procedure

• Explain the procedure in a way appropriate for a child’s age and understanding. Use a calm gentle approach. If you are anxious, the child may sense this.

• Wash hands.

• Cut trachy ties to the appropriate length, cut the ends of the tape at an angle to make it easier to thread through the hole in the trachy wing (flange) and to prevent fraying.

• Inspect all tubes for cracks, tears, or decreased flexibility before use, especially if tubes are reused.

• Bring trachy tie through one end of new trachy tube. Avoid touching the part of the tube that is inserted into the trachea. Try to keep it sterile.

• Insert introducer into new tube; be sure it slides in and out easily. The introducer helps to guide the tube, and the rounded tip adds protection to the stoma during insertion.

• Place a small amount of sterile water soluble lubricant (eg KY Jelly) on the end of the new trachy tube and place the tube in sterile tray or clean surface until ready to insert. Note: Never use Vaseline or petroleum as a lubricant. 

• Have a suction machine and oxygen handy if needed.

• Place the child on his/her back with a small blanket or towel roll under his/her shoulders to help with hyperextension.

• Administer oxygen if needed.

• Cut the old trachy ties while holding onto trachy tube. Always hold the tube when ties are not secure; a cough can dislodge the tube.

• Gently remove the old trachy tube (follow angle of the tube, an upward and outward arc).

• Insert the new tube in a smooth curving motion directing the tip of the tube toward the back of the neck in a downward and inward arc (like inserting a suction catheter).

• Do not force the tube!

• Remove the introducer immediately while holding the tube securely with the other hand. Remember that the child cannot breath with the introducer in place.

• Changing the trachy tube will cause the child to cough; do not let go of the tube.

• Thread the trachy tie through other end of tube and tie, allowing one finger between the neck and the ties. Tweezers or forceps may be needed to thread ties through the hole of the wing of tracheostomy tube.

• Inspect old tube for colour, mucus plugs or odour, then discard. Most plastic paediatric trachy tubes are disposable and are not washed and reused.

• When changing trachy tube, observe for skin irritation, breakdown, and signs of infection.

• Remember to praise the child. A trachy change can be emotionally difficult for some children.

Risk Factors Associated with Difficult Tracheostomy Tube Changes

When the stoma is scarred, calcified, distorted or obscured by granulation tissue
When the trachea is deviated or rotated
When the trachea is narrowed or smaller than normal
When the patient is a child
When the patient is obese
If the tube must be placed quickly in an emergency
If it is a new or recent tracheostomy
If the person performing the change is not well-trained

Techniques for a Difficult Trachy Change

The introducer helps make insertion easy and trauma-free.

Reposition the child if needed

If the tube cannot be completely inserted, hold the tube in place, remove the introducer to let the child breathe, then continue to insert to tube.

If still unable to insert tube, remove the tube, re-lubricate and try again.

If this is unsuccessful, try to insert the one size smaller tube.

Try spreading the skin around stoma and try to insert tube as the child is breathing in.

If needed, insert a suction catheter through the smaller tube and guide the suction catheter into the trachy stoma. Then slide the trachy tube over the suction catheter and into the stoma. Remove the suction catheter. 

If all else fails, cut a section of suction catheter to place it into the stoma in order to keep the stoma open and maintain an airway. Be sure to cut the catheter long enough so that it cannot be aspirated! Hold on to the catheter and call emergency services.

Give supplemental oxygen if needed and available

Do not force tube! If you absolutely cannot get any tube or catheter into the stoma, and the child is breathing fairly comfortably (through the stoma or through the mouth and nose), go immediately to A&E. Sometimes, the airway can be made worse by a trachy tube inserted in the wrong place.

3. Changing the Tracheostomy Ties

Tracheostomy ties will need to be changed more often than the tube if they become soiled, wet, loose or cause pressure on the child’s skin. Some specialists recommend changing ties daily, although this is usually not necessary in home care. However, infants with short fat necks, overweight children, and children on high humidification will probably need daily tie changes. Trachy tie changes should also be done with two people. The important thing to remember is to be sure the ties are snug, but not too tight. You should be able to slip one finger under the ties.

4. Precautions with a Tracheostomy

A child with a tracheostomy can do most things that other children do. Try to treat the child as normally as possible. It is important not to be overly protective. However, children with trachys must be watched very closely, since they may not be able to verbally indicate discomfort. Water represents a particularly serious threat, as drowning can easily occur if the tube is submerged in water. Here are some precautions for children with tracheostomies. Remember that each child is different and that common sense goes a long way when caring for a child with a trachy.

Use extreme caution with baths. Use shallow water and prevent water from splashing into the trachy. A trachy mask, mist collar or thermovent can be worn during baths for added protection. Never leave a child alone in the bathtub!
No Swimming
No Showering
When holding a child with a trachy, be sure the chin is up and that the tube opening is unobstructed.
Check with the doctor before applying any salves or ointments near the trachy.
Avoid powder, talc, chlorine bleach, ammonia, aerosol sprays or perfumes near a child with a trachy.
Prevent foreign objects from entering the trachy tube, such as water, sand, dust, small toy pieces, etc.
Avoid sandboxes and beaches
Avoid chalk dust.
Watch play with other children so that toys, fingers and food are not put into trachy tube and that other children don‘t pull on the trachy.
No contact sports
Avoid clothing that blocks the trachy tube, such as crew necks, turtlenecks, and shirts that button in the back.
No plastic bibs
No necklaces
No fuzzy or fur clothing or stuffed toys
Avoid animals with fine hair or that shed excessively.
Do not allow anyone to smoke near child.
Keep the home as free from lint, dust and mould as possible.
Limit the use of wood stoves and fireplaces, which dry the air.
During cold weather, avoid allowing child to breathe freezing cold air directly into trachy.
Use a heat moisture exchanger (thermovent), gauze bandage, loose cotton scarf or surgical mask to protect the tracheostomy on dusty, smoggy or windy days.
No Latex balloons, these are dangerous for all children. Latex over any airway will block breathing.
There must be a trained person with your child at all times. At minimum, this person must be trained in CPR and be able to suction and change a tracheostomy tube. For school-age children, there should be a trained person (preferably an RN or LPN) with the child at school and on the bus to and from school.
Avoid exposure to people with colds or other contagious illnesses.
Be sure your child is up-to-date on all immunisations.
Administer yearly flu shots if recommended by your doctor.

Infection Control

Hand washing, hand washing, hand washing! Hand washing is the single most important way to stop the spread of infection. Have antibacterial soap at every sink in your home.
Screen all visitors for colds, limit visit time and avoid crowds. Do not let strangers touch your child: be defensive, not paranoid.
Use masks for family members with colds.
Flu vaccines maybe recommended by your paediatrician.
Open windows for 10 minutes each day, to ventilate house.
Coal, wood stoves, or fireplaces may aggravate respiratory problems (they dry the air).
Humidify air with cool mist, but remember to clean the humidifier each day with soap and water, disinfectant or bleach solution (1 part bleach to 10 parts water).
Daycare is a leading risk factor for upper respiratory infections. It is not always possible for parents to be at home with their children, but this is helpful when possible. Also, a smaller daycare poses less risk of infection than a larger one.
Parental smoking (second hand smoke) is a major risk factor for respiratory infections. Smoke must be avoided.
Remember, cold viruses can survive several hours on objects such as toys, doorknobs, remote controls, and telephones. Disinfect these objects properly. (The dishwasher is useful for disinfecting many washable items.)
A cold is contagious 2-4 days after symptoms appear.
Keep tissues in every room of the house and dispose of them promptly and properly after use. No hankies, please.