Introduction Show
Aim Definition of Terms Related Documents Tracheostomy Kit Special Safety Considerations Emergency Management The Resuscitation Flowchart (under review) Complications Post-Operative Management of a New Tracheostomy Tracheostomy Tube Cuff Management Routine tracheostomy management
Documentation Special Considerations Companion Documents Evidence Table References Introduction
AimThe 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). Definition of terms
Related Documents
Tracheostomy KitA tracheostomy 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. Tracheostomy kit contains
Special safety considerations
Emergency ManagementThe 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: suction catheter not passing through tracheostomy tube, child with minimal leak suddenly able to vocalise/talk, General signs of
obstruction - any physiological changes due to airway obstruction including tachypnoea, increased work of breathing, noisy breathing – grunting/abnormal breath sounds, tachycardia and a decrease in SpO2 levels, change in level of consciousness - anxiety, restlessness or agitation. Late signs of obstruction include: cyanosis, bradycardia and apnoea - do not wait for these to develop before intervening. The Resuscitation FlowchartBelow is the resuscitation flowchart used at The RCH. 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. Click to download.
ComplicationsComplications can be classified by timing: intraoperative; early (usually defined as the first postoperative week); late; and post-decannulation. Complications in the first post-tracheostomy week include:
Late complications include:
Post-operative management of a new tracheostomyAfter 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 has been performed.
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:
Tracheostomy Tube Cuff Management
Indications for cuff tracheostomy tube:
The aim of tracheostomy cuff management is to use the minimum occlusive volume/minimum cuff pressure required. The cuff volume/pressure is to be checked at least every 8
hours and any time as required to prevent complications associated with tracheostomy tube placement. Equipment:
Preparation:Ensure tracheostomy kit present Procedure:
Safety considerations:
Routine Tracheostomy ManagementRoutine tracheostomy management consists of:
Equipment and environmentEach shift ensure
Supervision and monitoringIn 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 team 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:
It is 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. Leaving the wardThe patient’s access to ward leave is assessed according to:
HumidificationA 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. Heated humidificationDevices which deliver gas at body temperature saturated with water 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 Delivery Nursing Guideline. 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 bibsConsist 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.
SuctioningSuctioning of 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. Indications for suctioning include:
Safety considerations:
Equipment:
Table 1: recommended suction catheter sizes
Preparation
Procedure
Note:
Special safety considerationsSome 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. Management of abnormal secretions
Tracheostomy tie changes
Equipment
Procedure for changing cotton ties
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. Procedure for changing Velcro ties
Tracheostomy tube changesThe 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. Note: If the primary caregivers/family are performing the routine tracheostomy tube changes in the ward environment it is recommended that the bedside nursing team need to be aware of the procedure prior to commencing. Equipment
Preparation
Procedure
At the completion of the procedure:
Note: If unable to reinsert tracheostomy tube follow emergency procedure. Safety considerations
Stoma care
Equipment
Preparation
Procedure
Special considerations
Refer to Respiratory Clinical Nurse Consultant for advice on the frequency and type of dressing required. Feeding and nutritionThe 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. See: Enteral Feeding and Medication Administration Guideline. Oral carePatients 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. CommunicationChildren 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. Vocalisation depends on several factors such as
Communication aides include
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 valvesOne-way speaking valves are a small plastic device with a silicone one-way valve, they sit on the end of the tracheostomy tube. Various types of one-way speaking valves are available. The most commonly used at the Royal Children's are Passy-Muir™ one-way valves and the
Tracoe™ modular valve. Benefits of using a one-way speaking valve include:
Contraindications for one-way speaking valve assessment:
Before one-way speaking valve use: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. To determine if the child has adequate airway patency consider:
Bedside assessment of airway patency and use of one-way speaking valve:Preparation
Procedure
If the child fails to tolerate the one-way speaking valve:
Safety precautions when using one-way speaking valves:
Care and cleaning of the valve:
To avoid damage to the valve:Do not: wash in hot water, use a brush on the valve, use alcohol, peroxide or bleach to clean the valve Transition to the community and discharge planningReferral to Complex Care Hub (CCH)All children with a tracheostomy tube should be referred to Complex Care Hub after discussion with their family/primary caregiver. 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 discharge. 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 and Clinical Technology team or Equipment Distribution Centre. This should occur in consultation with the ward nursing staff, respiratory nurse consultants and the parent medical/nursing team 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. Tracheostomy DecannulationDecannulation is a planned intervention for the permanent removal of the tracheostomy tube once the underlying indication for the tracheostomy has been resolved or corrected Assessment and decannulation management
Decannulation trial - Day 1
Capping NOT successful: Capping Successful: The child is to be reviewed in the morning by the admitting team to determine whether the decannulation trial goes ahead or not. Decannulation – Day 2Decannulation is usually performed between the hours of 9am and 10am (following medical review). Decannulation should not be performed unless a member of the 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 tracheostomy equipment is at bedside and remains with the child until the child is discharged. Equipment
Preparation
Procedure
Following decannulation: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:
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. Stoma site care post decannulation
Decannulation - Day 3Following the first 24 hours post decannulation:
Stoma site care post decannulation:
Decannulation - Day 4Discharge homeThe child is usually discharged home when they're considered by the medical team to have a safe airway post decannulation. 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 Flowcharts - Australian Resuscitation Council Care of stoma site following discharge homeEnsure 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 and ensure an occlusive dressing is in place to prevent accidental aspiration. DocumentationEnsure 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. These include:
Special ConsiderationsShould 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. Evidence tablePlease remember to read the disclaimer. The development of this nursing guideline was coordinated by Sueellen Jones, Registered Nurse, Respiratory Medicine, and approved by the Nursing Clinical Effectiveness Committee. Updated July 2022. What must the nurse do when performing tracheostomy care quizlet?While performing tracheostomy care, the nurse should do the following:. carefully remove the inner cannula and place it into normal saline solution using sterile technique.. suction the outer cannula, if necessary.. rinse the inner cannula with noramle saline after it has been cleaned.. Which actions will the nurse include when doing tracheostomy care?1. Suction the client before starting tracheostomy care. 2. Use sterile technique when cleaning the inner cannula.. Verify that an inner cannula is in place.. Change the tracheostomy tube every week.. Clean the tracheostomy once a day.. Verify that a low-pressure cuff is in place.. Which measure should the nurse perform when suctioning a tracheostomy tube?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.
What infection control practices should be implemented when performing tracheostomy?Preventing infection with clean hands and supplies. Wash your hands. Always wash your hands before and after any tracheostomy tube care.. Clean tracheostomy equipment. ... . Keep your neck clean and dry. ... . Keep your mouth clean. ... . Clean your home equipment. ... . Keep hands clean. ... . Skin should not have. ... . Supplies you will need.. |