Introduction

A tracheostomy is a operation opening into the trachea listed below the larynx v which an indwelling tube is inserted to conquer upper airway obstruction, facilitate mechanically ventilator support and/or the removed of tracheo-bronchial secretions.

You are watching: Which of the following patients has an open airway but is still at risk for airway compromise?

Aim

The target of the guideline is to synopsis the principles of administration for patients with a new or currently tracheostomy for clinicians in ~ the imperial Children’s Hospital (ugandan-news.com).

Definition of terms

*

Related Documents 

Tracheostomy Kit

A tracheostomykit is to accompany the patient at every times and also this need to be confirm eachshift through the nurse caring for the patient to certain all tools is available.

A crucial concept of tracheostomy monitoring is to ensure patency that the airway (tracheostomy tube). A clogged or partially blocked tracheostomy pipe may cause severe breathing difficulties and also this is a clinical emergency. Immediate accessibility to the tracheostomy kit (equipment) for the individual patient is essential.

Tracheostomy kit contains

 One tracheostomy tube of the same size insitu (with introducer if applicable) One tracheostomy tube one size smaller (with introducer if applicable) Spareinner pipe for twin lumen trache tube (if applicable) preventive ties (cotton and/or Velcro) Scissors Resuscitation bag and also mask (appropriate dimension for patient) One means valve (community use only) wall surface or portable suction equipment appropriate size suction catheters 0.9% sodium chloride ampoule and also 1ml syringe One warmth Moisture Exchanger filter (HME) or tracheostomy bib Fenestrated gauze dressing noodle wool applicator sticks Water based lubricant for tube transforms Mucous trap v suction catheter for emergency suction Occlusive ice (i.e. Sleek) 10 ml syringe if cuffed tube insitu

Special safety and security considerations

Ensure access to a working and also charged phone and/or mobile phone at all times the is recommended the all patients havecontinuous pulse oximetry (SpO2) throughout all periods of sleep (day and night)and when out of line of vision of competentcaregiver All children 6 years and also under are to have actually cotton ties only to for sure the tracheostomy tube. Youngsters 6 years and also over who are considered at threat of undoing Velcro ties should have actually cotton ties for patients through a newly developed tracheostomy that is recommended that tracheal dilators are easily accessible at the patient’s bedside until after the first successful tube readjust

Emergency Management

The bulk of kids with a tracheostomy space dependent ~ above the tube as their primary airway.

Cardiorespiratory arrest most frequently results native tracheostomy obstructions or inadvertently dislodgement that the tracheostomy tube from the airway.

Obstruction might be because of thick secretions, mucous plug, blood clot, foreign body, or kinking or dislodgement the the tube.

Early warning indications of obstruction include tachypnoea, boosted work of breathing, abnormal breath sounds, tachycardia and also a decrease in SpO2 levels.

Late indicators of obstruction incorporate cyanosis, bradycardia and also apnoea - perform not wait for these to develop prior to intervening.

*

 The Resuscitation Flowchart

(currently under review, new chart coming soon)

For a tracheostomy patient follows APLS principles.

It is recommended the a copy the this circulation chart is readily availablee.g. Put in a prominent position at the bedside or in the patients bed chartfolder.

Download the flowchart (PDF 21 KB)

*

Complications

Complications have the right to be divide by timing: intraoperative; early (usually characterized as the an initial postoperative week); late; and also post-decannulation.

 Complicationsin the very first post-tracheostomy main include:

Blocked tube (occluded cannula / mucous plugging) Bleeding indigenous the airway/tracheostomy pipe Stomal erosion epidemic or cellulitis at the stoma site waiting leak consisting of Pneumothorax, pneumo-mediastinum or subcutaneous emphysema respiratory and/or cardiovascular fallen Dislodged pipe or inadvertently decannulation Granulation organization in the trachea or in ~ the stoma website Tracheo-oesophageal fistula

Late complications include:

Acute airway obstruction Blocked tube (occluded cannula or mucous plugging) infection (localised come stoma or tracheo-bronchial) Aspiration Tracheal trauma Dislodged tube Stomal or tracheal granulation organization Tracheal stenosis

Post operative monitoring of a brand-new tracheostomy

After a tracheostomy is inserted, the patience is regulated in one of two people the Paediatric Intensive care (PICU - Rosella) or Neonatal Unit (NNU - Butterfly) in the early stage post-operative duration and till after the very first routine tracheostomy change.

patients return indigenous theatre with remain sutures (nylon sutures) put on either next of the tracheal opening. The remain sutures are videotaped to the chest and labelled left and right. Pulling the continue to be sutures up and also out will apply traction come the stoma opening to assist with insertion that the instead of tube. The remain sutures need to remain in situ and securely attached come the chest wall until the very first or second successful pipe change. Trache stoma maturation takes around 5 – 7 job after insertion that the tracheostomy pipe or 2 – 3 work if stoma maturation sutures are placed. The ENT team, in consultation v the parent medical team, will do the first tube change, consisting of the remove of the continue to be sutures. the is imperative the the first tracheostomy tie change is faced in the exact same manner together the first tracheostomy pipe change with both nursing and medical staff present who are skilled in tracheostomy management.  The tracheal stoma in the instant post-operative period requires regular assessment and also wound management consisting of once day-to-day dressing readjust following cleaning of the stoma area or more frequently if required. every child calls for a Tracheostomy tube Management kind to it is in completed and also placed in ~ the bedside. (see attached form)

Note: Most youngsters will experience their very first tracheostomy tube adjust while in the intensive treatment environment. However, on occasions, following consultation in between members that the PICU, ENT team and the parental unit, youngsters may be moved to a ward from PICU prior to their very first tracheostomy tube change if they satisfy the adhering to criteria:

have actually a non-critical airway i.e. These children are able to breathe and also maintain their airway in the occasion of inadvertently decannulation. Room not dependency on or require optimistic pressure ventilation/CPAP via the tracheostomy.

*

Routine Tracheostomy Management

Routine tracheostomy management consists of:

Equipment and also environment

Each shift ensure

All tools for tracheostomy care is in ~ the bedside and within easy access/reach Suction devices is set up through correct pressure (add attach to suction procedure) Emergency oxygen equipment is collection up and in working order appropriate monitoring equipment available and exactly alarm parameters collection (as every Victor)

 Supervision and also monitoring

In determining the level of supervision and also monitoring i m sorry is required, the is recommended each patient with a tracheostomy is assessed on one individual basis by the dealing with medical and nursing team4 taking into factor to consider the adhering to factors:

Age specific alarm boundaries (as per VICTOR chart)
Clinical state Nature the the airway problem ability to breathe and maintain your airway in the event of accidental decannulation ability to clear very own secretions Frequency the suction/tracheostomy tube interventions required Ventilation or respiratory support demands e.g. CPAP, oxygen treatment Cognitive ability (neurological and also age related)

Decisions about required level of supervision, clinical observations and also monitoring room to be documented clearly in the patient"s medical record by the dealing with medical/nursing team.

Monitoring may include:

Heart price +/- constant cardiac surveillance Respiratory rate Pulse oximetry continuous/overnight Oxygen requirements Work of breathing Temperature Blood pressure Behaviour - alert, irritable, lethargic Additionalmonitoring and/or assessment:Blood gases, tcCO2 and etCO2 as per clinical orders.

It isrecommended that all patient have continuous pulse oximetry (SpO2) during allperiods of sleep (day and also night) and also when out of line of sight.

Children v a tracheostomy tube need to be carefully supervised once bathing or showering. They should additionally wear a HME filter or tracheostomy bib filter (unless top top CPAP or ventilation) come minimise the threat of aspiration.

Leaving the ward

The patient’s access to ward leave is assessed follow to:

Patient’s clinical stability, clinical vulnerability. Caregiver competency in tracheostomy care – consisting of knowledge and skill in airway (tracheostomy) emergency management.

Humidification

A tracheostomy tube bypasses the upper airway and also therefore prevents the normal humidification and filtration of inhaled wait via the upper airway. Uneven air inhaled via the tracheostomy pipe is humidified, the epithelium the the trachea and also bronchi will become dry, enhancing the potential for pipe blockage. Tracheal humidification deserve to be provided by a boil humidifier or Heat and Moisture Exchanger (HME) or a Tracheostomy bib filter.

Heatedhumidification 

Delivers gas at human body temperature saturated through water which avoids the thickening the secretions. The temperature is set at 37°C transferring a temperature varying from 36.5°C - 37.5°C at the tracheostomy site. Cook humidification for tracheostomy patients need to be yielded via a humidifier together per the Oxygen clinical pointer (nursing). Indications for the usage of cook humidification include:

Oxygen delivery via tracheostomy mask mechanical Ventilation Respiratory infection with increased secretions management of special secretions

warmth Moisture Exchanger (HME)

Contains a hygroscopic document surface the absorbs the humidity in expired air. Upon incentive the waiting passes end the hygroscopic file surface and also moistens and warms the air the passes right into the airway.

HME is recommended for all patients through a tracheostomy tube. HME fit straight onto the tracheostomy tube. Donot wet the HME filter before use HME are adjusted daily or as necessary if the filter shows up to it is in excessively moist or blocked. For tiny infants

*
*

Tracheostomy bibs 

Consist the aspecialized foam that traps the moisture in the expired air, upon inspirationthe foam moistens and warms the air the passes into the airway.

in ~ the ugandan-news.com BuchananTM tracheostomy bibs space used.Theseare readjusted daily or an ext frequently as required Tracheostomybibs space reusable - hand wash in heat water using a mild detergent/soap, thenrinse extensively and enable to wait dry.Tracheostomybibs have to be discarded monthly or an ext frequently if discoloured or thematerial is damaged.

*

Suctioning

Suctioning ofthe tracheostomy pipe is necessary to eliminate mucus, maintain a patent airway,and avoid tracheostomy pipe blockages. The frequency that suctioning different andis based on individual patient assessment.

Indications for suctioning include:

Audibleor visual indications of secretions in the tubeSignsof respiratory tract distressSuspicionof a blocked or partially blocked tubeInabilityby the child to clear the tube by coughing out the secretionsVomitingDesaturationon pulse oximetryChangesin ventilation pressures (in ventilated children)Requestby the kid for suction (older children)

security considerations:

Trachealdamage may be led to by suctioning. This deserve to be minimised by using theappropriate sized suction catheter, ideal suction pressures and also onlysuctioning in ~ the tracheostomy tube.Thedepth of insertion the the suction catheter demands to be established prior tosuctioning. Using a spare tracheostomy tube of the same type and size and a suctioncatheter insert the suction catheter to measure up the distance from the length ofthe tracheostomy tube 15mm connector come the finish of the tracheostomy tube.Ensure the tip of the suction catheter continues to be with-in the tracheostomy tube.Recordthe compelled suction depth on the ice cream measure placed at the bedside and also in thepatient records. Attach the tape measure to the cot/bedside/suction machine forfuture use.Use pre- measured suction catheters (where available) to ensure exact suction depthThepressure setup for tracheal suctioning is 80-120mmHg (10-16kpa). To avoidtracheal damage the suction pressure setting should no exceed120mmHg/16kpa.It isrecommended the the illustration of suctioning (including happen the catheter andsuctioning the tracheostomy tube) is completed in ~ 5-10 seconds.

Equipment:

Suctionapparatus (wall attachment or portable unit)SuctioncanisterTubingSuctioncatheterSterilewater Table 1: recommended suction catheter sizes
Tracheostomy tube size (in mm)  3.0mm  3.5mm  4.0mm   4.5mm 5.0mm  6.0mm   7.0 mm and also >
Recommended suction catheter size (Fr)  7 8 8 10 10 10 -12 12

Preparation

Appropriatesize suction catheters (with graduations if available)Tapemeasure through depth compelled for tracheostomy pipe suctioningAppropriatesuction pressure: exactly suctionpressure for usage on a tracheostomy tube is 80-120mmHg best whenoccluded. The Medigas suction gauges used on the wards room measured inkPa. The indistinguishable of 80- 120mmHg is 10-16kPa.

Procedure

Explainto the patient and also their family that you space going to suction the tracheostomytube.Applyeye protectionPerformhand hygiene, apply non-sterile glovesRemoveHME, mask or circuitPeelopen suction catheter end and also attach to suction tubing, check and adjustsuction push gauge to in between 80 – 120 mmHg.Utilizinga non-touch technique gently present the suction catheter tip into the tracheostomytube come the pre-measured depth.Applyfinger come suction catheter hole & gently revolve the catheter whilewithdrawing. Each suction should not be any type of longer than 5-10 seconds.Assessthe patient"s respiratory rate, skin colour and/or oximetry reading to for sure the patient has actually not been jeopardized during the procedure. Repeat the suction as shown by the patient"s separation, personal, instance condition. Look in ~ the secretions in the suction pipe - lock should typically be clean or white and also move easily through the tubing. File changes from regular colour and also consistency and notify the dealing with team if the secretions space abnormal colour or consistency. wash the suction catheter with sterile water decanted into container (not directly from bottle). Replace suction catheter right into the packaging Dispose the waste, remove gloves and also perform hand hygiene

Note:

Suction catheters space to be on regular basis replaced every 24 hrs or at any type of time if contaminated or clogged by secretions.  Suction water/and the container to be replaced every 24 hours. Routine use of 0.9%sodium chloride is no recommended as over there is small clinical proof to support this. However, in instances where this might be of advantage e.g., thick secretions and/or to stimulate a cough 0.5ml the 0.9% sodium chloride have the right to be instilled into the tracheostomy tube immediately prior to the suction procedure.

Special safety and security considerations

Some patients may require helped ventilation before and after suctioning. If required, this will be requested by the parent medical team or respiratory tract CNC.

If the correct dimension suction catheter does not pass conveniently into the tracheostomy tube, suspect a clogged or partially blocked tube and prepare for instant tracheostomy tube change. 

Management of abnormal secretions

Changes in secretions e.g. Blood stained or yellow and also green secretions may show infection and also or trauma the the airway.

Notify the parental team for review who may request sending a sputum specimen for culture and sensitivity and consider commencement of antibiotics.

Persistent blood stained secretions native the tracheostomy tube should be investigated to recognize the cause.

Tracheostomy tie changes

If tie alters are required before the very first tube readjust – that is imperative that the procedure should be undertaken through both medical and nursing staff existing who are able to reinsert the tracheostomy tube in situation of inadvertently decannulation and also the ideal equipment is available at the bedside. Tracheostomy tie changes are perform daily in conjunction with stoma care, or as compelled if they become wet or soiled to maintain skin integrity. That is preferable to secure brand-new ties before removing the old ties together there is a potential risk for tracheostomy tube dislodgment once attending to tie alters a minimum of two people who are competent in tracheostomy treatment are required to wear tracheostomy tie changes. during the tracheostomy tie change, if the old tiesare removed before securing the new ties, one person is to preserve theairway by securing the tracheostomy tube in place and also not remove the handuntil the new tracheostomy ties room secured. The other human being inserts the brand-new ties right into the flange and also secures approximately the child’s neck. Ifthe ties become loosened it is a priority to re-secure immediately. AllChildren 6 years and also under are to have actually cotton ties only to certain the tracheostomy tube. Children6 years and over who are considered at hazard of undoing Velcro ties should have cotton ties.

Equipment

two equal lengths of cotton ties (approximately 40cm) or Velcro ties (for patient older 보다 6 years)

 Procedurefor changing cotton ties

define to the patient and also their family members that you are going to change the tracheostomy ties. Use eye protection perform hand hygiene, apply non-sterile gloves Prepare 2 equal lengths that ties long sufficient to go around the child’s neck. Place the patient; an child or child might lie down v the neck gently extended by a tiny rolled towel placed under the children shoulders. An larger child might like to sit up in a bed or chair Insert a clean tie into the holes on each side the the flange On each side tie a single loop approximately 0.5cm native the flange ~ above the tracheostomy tube. Climate tie both sides together in a bow come secure. Check the stress and anxiety of the ties. enable one finger come fit snugly in between the skin and the ties. Re-tie into in a dual (reef) knot to secure. Cut off excess length of ties leaving roughly 3cm. Utilizing scissors remove old ties and also recheck anxiety of new ties. Dispose of waste, eliminate gloves, and also perform hand hygiene. Observe about the patient’s neck to examine skin integrity.

NB: The old ties are to stay insitu till the clean ties room secured. In the occasion of removingexisting ties before securing the tube with clean ties the is recommended asecond person is current to hold the tracheostomy pipe ensuring it continues to be inplace till the ties are secured.

 Procedure for changing Velcro ties

transforming Velcro ties is a two person procedure. Check the Velcro top top the tracheostomy ties prior to each usage to certain adhesiveness. If not adherent discard and replace. Apply eye protection perform hand hygiene, apply non-sterile gloves One person holds the tracheostomy pipe securely in place. The 2nd person clears the currently Velcro ties and also then inserts the clean Velcro ties with one next of the flange, passing the tie around the earlier of the patient"s neck and inserting the Velcro tie with the various other side that the flange. Change the ties to permit one finger come fit snugly between the skin and the ties. Check to for sure the Velcro is securely fastened Dispose that waste, eliminate gloves, and perform hand hygiene. observe the patient"s neck to check skin integrity. Wash Velcro ties everyday in warm, soapy water, wash and allow to dry fully before re-using.

Tracheostomy tube changes

The frequency that a tracheostomy tube changes is identified by the Respiratory and ENT teams other than in an emergency situation. This have the right to vary relying on the patient"s separation, personal, instance needs and also tracheostomy pipe type.

It is imperative that the first tracheostomy tube readjust is performed with both nursing and also medical staff who are skilled in tracheostomy administration are present and also the tracheostomy kit is available at the bedside.

A minimum of twopeople who are proficient in tracheostomy treatment are forced for every tracheostomy tube transforms (except in an emergency if a 2nd person is not readily accessible – e.g. Transferring the child).

The tube change should occur before a meal or at least one-hour after come minimise the danger of aspiration.

The tube readjust procedure is performed using typical aseptic ethics using a non-touch technique.

Equipment

Suction device and suitable sized suction catheters small towel (rolled to place under the patient"s shoulders to expand their neck) A cot paper to plunder the patient (age dependant) suitable light/ illumination

Preparation

apply eye protection do hand hygiene, use non-sterile gloves Prepare the equipment on a clean surface ar area Prepare brand-new tracheostomy pipe by removing that from the packaging/container, examine the expiry dates and also inspect for any type of signs of damage to the tube and also then subject the ties into the flange and also tie. for sure the spare smaller sized sized tracheostomy pipe is available within arm’s with If making use of Velcro ties insert the ties on one side of the flange only clearly explain the procedure come the patient and their family/carer. Swaddle the patience if age proper by pack the arms and also containing them in the sheet. Location the rolling towel under the patient"s shoulders to prolong their neck (unless contraindicated). The older boy may uncover it more comfortable come sit upright with their head tilted back. Place the son so the you have an excellent visibility and access to the stoma. If crucial extend the neck further and also open the stoma more comprehensive by using your thumb and also forefinger. Suction the existing tracheostomy tube instantly before removed the existing tube and inserting the brand-new one. Dispose that waste, remove gloves, and perform hand hygiene.

Procedure

Person 1 holds the existing tube v their hand and also keeps secured in location Person2 cuts and removes the cotton ties from approximately the child"s neck. If making use of Velcro ties - undo and remove indigenous the tracheostomy tube flange. Person2 holding the new tube asks person 1 to eliminate existing tracheostomy pipe Person2 immediately inserts the brand-new tube right into the stoma and removes the introducer (if applicable). Person2 holds the tube securely in location while Person 1 ties and secures the tracheostomy ties Person1 checks the anxiety of the ties to permit that one finger will certainly fit snugly/firmly in between the skin and also the ties, readjust if necessary. If making use of cotton ties, finish by do a double (reef) knot and cut off any excess towel leaving about 3cm.

observe the child immediately after the tube readjust to inspect they space breathing usually with no signs of respiratory tract distress and that air is relocating in and out of the pipe by:

listening because that sounds of waiting coming the end of the tube looking in ~ the rise and also fall of the chest feeling with your hand because that a circulation of air check the pipe for blockages, damage and/or wear and also tear  unless instructed otherwise, all tracheostomy tubes room a single use just item single use tracheostomy tubes must be provided once only and discarded after every pipe change. Do not clean or re-use solitary use tubes. Clean recycle tracheostomy tubes, wash and also dry reusable tubes follow to the manufacturer’s recommendations.  Dispose that waste, remove gloves, and also perform hand hygiene. 

Note: If can not to reinsert tracheostomy pipe follow emergency procedure.

Safety considerations

A rare complication is because that the tube to slip right into a false passage rather of the airway. If there are any type of signs of breathing difficulties/respiratory distress remove the tube and also reinsert (a new tube) via the stoma into the airway. Challenges in re-inserting the tracheostomy pipe can take place at any type of time. These take place 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 structure airway abnormalities e.g.: Tracheomalacia/Bronchomalacia or tracheal granulations At times the an obstacle is for no evident reason and also cannot it is in explained

Stoma care

treatment of the stoma is commenced in the immediate post-operative period, and also is ongoing. Check the stoma area at least daily to for sure the skin is clean and also dry to keep skin integrity and also avoid failure everyday cleaning of the stoma is recommended using 0.9% sterile saline solution. After everyday cleaning, certain dressing placed at stoma site

Equipment

Fenestrated gauze dressing 0.9% salt chloride cotton wool applicator sticks

Preparation

use eye protection do hand hygiene, use non-sterile gloves Collect and prepare all equipment for procedure ~ above a clean surface area

Procedure 

plainly explain the procedure to the patient and their family/carer carry out hand hygiene place the patient. Infants and young youngsters may place on their back with a little rolled bath towel under the shoulders. An enlarge child might prefer come sit increase in a bed or chair. Perform hand hygiene and also apply non-sterile gloves eliminate fenestrated dressing from around stoma check the stoma area roughly the tracheostomy tube carry out hand hygiene and apply non-sterile gloves Clean stoma with cotton structure applicator pole moistened v 0.9% sodium chloride. Use each cotton wool applicator stick once only taking the from one next of the stoma opened to the other and also then discard in waste. Continue cleaning stoma area as above with a brand-new cotton wool applicator stick every time till the skin area is totally free of secretions, crusting and also discharge. Allow skin come air dried or use a dry noodle wool applicator stick come dry. Insert the fenestrated gauze under the flanges (wings) of the tracheostomy pipe to avoid chafing of the skin. Dispose of waste, eliminate gloves, and also perform hand hygiene. Avoid using any powders or creams on the skin roughly the stoma uneven prescribed through a physician or respiratory tract nurse consultants as powders or creams could cause further irritation.

describe Respiratory Clinical Nurse Consultant for advice top top the frequency and type of dressing required.

Feeding and nutrition

The tracheostomy tube may have actually an affect on the child"s capability to sloop down safely, thus a swallowing testimonial by a speech pathologist is recommended prior to the start of dental intake. The decided pathologist might recommend the optimum technique of feeding and the types and consistency the foods and liquids.

Consider a dietician referral to assess optimal nutritional intake – consisting of oral versus pipe feeding (PEG, PEJ or NG), constant versus intermittent feeding.

Oral care

Patients v a tracheostomy have altered upper airway role and may have increased oral treatment requirements. Mouth treatment should assessed by the nurse caring for the patient and also documented in the patient care record.

Communication

Children connect in many different ways, together as making use of gestures, face expressions and body postures, and vocalising. The tracheostomy may impact on the child"s ability to produce a common voice. For all patients with a brand-new tracheostomy a referral come a speech pathologist for assessment and also provision of communication aids is recommended.

Vocalisation relies on several factors such as

Severity of airway obstruction degree of vocal cord duty The dimension and type of the tracheostomy tube insitu respiratory tract muscle strength Cognitive capacity and age related ability

Communication aides include

Pen and file Alphabet board picture communication machine Electronic devices - phone/tablets Teaching hand-operated for Auslan signing One-way speak valve attachment

For children with established tracheostomy tubes the is vital that the techniques used for interaction are determined via conversation with the patience (age appropriate), and the parent/primary caregivers. These techniques should be documented in the clinical record and verbally handed over to staff to ensure enough communication and appropriate expertise of the patient and also their needs.

One- means speaking valves

One-way speaking valves room a tiny plastic machine with a silicone one-way valve, lock sit on the end of the tracheostomy tube. The most commonly used at the royal Children"s space Passy-Muir™ one-way valves and the Tracoe™ modular valve.

The one-way valve opens on inspiration permitting air to get in the tracheostomy tube and closes on exhalation directing wait up through the trachea, larynx and also nose and also mouth together in common breathing and also normal speech.

Not all kids will be able to produce a vocal sounds or voice once the speaking valve is an initial used.

Various types of one-way speaking valves space available.

 Benefits of utilizing aone-way speaking valve include:

enhancing normal flow of air v the airway/nose and also mouth restoration of physiological PEEP Louder and clearer voice Improved capability to taste and also smell food boosted secretion management improved protection of the airways throughout swallowing and also feeding Improves development of speech and also babbling in infants/toddlers

Contraindications because that one-way speak valve assessment:

severe airway obstruction Vocal cord paralysis - adducted place Severe neurological deficit Tracheostomy tube with inflated cuff (any kind) Foam-filled cuff (even if deflated) major risk for aspiration less than 7 job post-operative tracheostomy tube insertion

Before one-way speak valve use:

One-way speaking valves space not an ideal for every children with a tracheostomy. The child"s yongin to the one-way speaking valve will depend on your airway about and above the tracheostomy tube. To exhale sufficiently the child must have sufficient airway patency approximately the tracheostomy tube, up v the larynx and out the the nose and also mouth. If exhalation is not sufficient with the one-way speaking valve in location the boy may end up being distressed and also air trapping/breath stacking or barotrauma come the lungs might occur. Therefore, a joint assessment including the respiratory nurse consultant and a decided pathologist is essential before the machine is offered to recognize if the child has adequate airway patency.

To recognize if the child has adequate airway patency consider: Diagnosis of severe laryngeal or tracheal stenosis/subglottic stenosis dimension and kind of the tracheostomy tube - proper to allow airflow through upper airway sleep obstruction - e.g. Nasogastric tubes/choanal atresia

Before utilizing the one-way speaking valve for sure the child is: median stable higher than 7 days article tracheostomy insertion Awake, alert and also responsive Able to tolerate cuff deflation Doesn’t have actually a foam cuffed tracheostomy tube insitu has adequate patency of upper airway Does not have too much tracheal secretions able to manage their oral secretions

Contraindication come one-way speak valve use: If you recognize there is no or inadequateairway patency this is a contraindication to speaking valve use. If the son has an extensive excessive coughing and obvious discomfit with increased respiratory effort and also air trapping - eliminate the valve immediately and reassess for sufficient airway patency before a repeat trial. If airway patency sufficient then target to reassess the kid at continuous intervals to place the one-way speak valve progressively increasing the time and frequency that use. One-way speak valve  may be contraindicated depending on kind of cuffed tube e.g. Foam cuff

Bedside assessment of airway patency and also use the one-way speak valve:

Preparation apply eye protection do hand hygiene, apply non-sterile gloves Collect and also prepare all tools for procedure ~ above a clean surface area Procedure

describe procedure (age appropriate) to child and also their family Suction the tracheostomy tube before the valve is attached and then together required. A cuffed tube have to be totally deflated prior to attaching the speak valve. Gently occlude tracheostomy tube through a gloved finger and also observe because that exhaled wait from nose and mouth or vocalization. If finger occlusion is tolerated ar the speaking valve ~ above the end of the tracheostomy tube and observe because that oral/nasal exhalation. If the one-way speaking valve is tolerated top top the early stage trial for a goal of 5 come 10 minutes. A management plan to progressively increase the size of time i beg your pardon the valve is provided will be listed for the patience when the boy has readjusted to put on the one-way speaking valve lock should have the ability to wear the for long periods and be may be to be wear at every awake periods, specifically during rehabilitative therapy sessions and when eating.

If the child falls short to tolerate the one-way speaking valve: eliminate the valve if any type of signs or symptom of distress or changes in respiratory tract effort. Together it can be more difficult for the child to exhale v the valve in place, the child may at first fail a trial of one-way speak valve as result of anxiety or discomfort. The child may need to slowly develop up much longer periods of one-way speaking valve use and placement will be repetitive on succeeding days. Some kids have difficulty adjusting to transforms to your airways. Youngsters may originally experience boosted coughing because of restoration that a closed respiratory tract system, i m sorry re-establishes subglottic pressure and also normalizes exhaled airflow in the oral/nasal chambers. In infants and also young children consider using a machine to certain the one-way speak valve to the child"s ties - to avoid accidental loss of the one-way speak valve. Part speaking valves are suitable for use in mix with oxygen therapy and also during ventilation.

 Safety precautions once using one-way speaking valves: If the child has severe airway obstruction the speaking valve need to not it is in used. In cuffed tracheostomy tubes - for sure cuff is completely deflated. The young child should always be supervised when wearing the speak valve. The one-way speak valve should not be worn once the boy is sleeping. One-way speak valves perform not humidify the wait - thus may be unsuitable for youngsters with copious thick secretions. If the one-way speak valve is not functioning correctly (i.e. Sticking, loud or vibrates) or the son shows signs of respiratory tract distress/discomfort, then eliminate the valve immediately and also replace. Carry out not use in combination with HME (heat moisture exchanger) ensure the one-way speaking valve is clean and not damaged in any means before each use. Discard and also replace automatically if any signs the wear/tear or damage are noted. Eliminate valve prior to aerosol/nebulizer medication is administered

Care and cleaning of the valve: The one-way speak valve have to be cleaned at least everyday after usage by washing in warmth mild soapy water, then rinsed extensively and permitted to air dry fully before reuse. When dry and also when not in use, it need to be save on computer in an ideal storage container Dispose the waste, eliminate gloves, and also perform hand hygiene. come avoid damages to the valve: donot wash in hot water donot use a brush top top the valve donot use alcohol, peroxide or bleach to clean the valve

Transition come the community and discharge planning

Referral to complex Care Hub (CCH)

All youngsters with a tracheostomy tube need to be referred to complicated Care Hub after discussion with the family. The referral need to be made as shortly as feasible following tracheostomy pipe insertion to permit adequate time for the to plan of in-home health treatment support prior to the patient discharge.

Following the referral a requirements assessment will be undertaken by CCH team to identify the support required for the patient and their family.

The introduce team is responsible because that ensuring appropriate equipment for discharge is ugandan-news.comanised in participation with the complex Care Hub or Equipment distribution Centre.

This should occur in consultation through the ward education staff, respiratory tract nurse consultants and the parent participation with the facility Care Hub or Equipment distribution Centre.

Ensure all members of the medical, nursing and also allied health and wellness teams are mindful of the plan discharge date.

Education because that primary treatment givers regarding tracheostomy treatment commences shortly after insertion that the tube and is usually initiated through the respiratory tract CNC in cooperation with the parental unit nursing staff.

ethics of the treatment for kids with a tracheostomy in the ar who are supported through the complex Care Hub are based on the referrals of this clinical practice guideline and individualised treatment plans are developed specifically to the patient’s treatment needs. This are located in the home care manuals provided by complicated care team.

Tracheostomy Decannulation

Decannulation is a planned intervention for the irreversible removal the the tracheostomy tube once the underlying indication for the tracheostomy has been resolved or corrected

Assessment and decannulation management

come formally assess whether the child can maintain their airway and also ventilation adequately without the tracheostomy tube, an endoscopic/bronchoscopy is perform to evaluate if the basic indication for the tracheostomy has been resolved, corrected, and to assess for other determinants which might impede a successful decannulation for example: granulation tissue or supra-stomal collapse. This procedure is performed in ~ 6 weeks prior to admission because that decannulation. Following the endoscopic testimonial the ENT and Respiratory groups will recognize and paper in the patient record the child’s certain decannulation plan.

Preparation

Decannulation monitoring is usually a staged procedure commenced as an outpatient clinic with assessment following capping the the tracheostomy tube. If this is tolerated the is ongoing at home with intermittent daytime/awakecapping
(using a decannulation cap) v caregiver supervision. Downsizing the the tracheostomy tube might be done in conjunction with the capping in order to assess how well the child manages with a smaller tracheostomy in their airway and also to encourage the use of their upper airway. The decannulation process is perform in the hospital as an in-patient. This is typically a 3 – 4 work admission. The patience is nursed 1:1 for at least 8 hours article decannulation. At the end of this duration the require for 1:1 parenting supervision that the patience is assessed through the patient"s parent medical team. If complications v the decannulation space anticipated the patient should be nursed 1:1 because that the an initial 24 hours post decannulation

Decannulation - day 1

The tracheostomy pipe is downsized to a 3.5 mm tracheostomy pipe or together according the patient particular decannulation monitoring plan. Ensure documented plan for the decannulation process from the parent clinical team Baseline observations including heart rate, respiratory rate, SpO2 (haemoglobin-oxygen saturation), and work the breathing are recorded. The pipe is capped (occluded making use of a decannulation cap and the son is observed for any type of signs of raised respiratory effort or respiratory tract distress including: Tachypnoea Stridor Retraction Tachycardia Colour lessened perfusion Oxygen desaturation or short oximetry reading Restlessness or anxiety lessened cough effectiveness, swallow and voice quality

If the son is can not to pardon the downsizing and capping the the tracheostomy pipe a medical review is compelled as the trial of decannulation may not proceed and also the tube might be upsized.

If the child tolerates downsizing and also capping that the tube ensure patient vital signs continue to be within appropriate parameters for age & as per VICTOR chart. Added monitoring: Overnight oximetry monitoring (downloadable) and sleep diary are videotaped throughout the night.

The child is the review in the morning by the admitting team to recognize whether the decannulation attempt goes ahead or not.

Decannulation – job 2

Decannulation is normally performed in between the hrs of 9am and also 10am (following clinical review).

Decannulation shouldnot be performed unless a member that the parent clinical team is present in the ward at the time of decannulation. Inform the ENT team of the planned decannulation before removal of the tracheostomy tube.

Note:Occasionally the attempt of decannulation is not successful requiring the must re-insert the tracheostomy tube. This is anemergency procedure and it can happen at any time – ensure equipment is at bedside and remains v the child until the kid is discharged.

Equipment set of tracheostomy tubes (same size and smaller sizes than tube child has actually insitu down to a dimension 3mm – including extr size 3mm in freezer. Operation scissors Tracheostomy ties or Velcro ties Suction tools Gauze and an occlusive dressing – e.g. Comfeel™ v hypafix boundaries or tegaderm™/opsite™ to cover the tracheostomy stoma noodle wool applicators small towel (if applicable) Oxygen equipment Manual Resuscitator bag security equipment

Preparation

use eye protection perform hand hygiene, apply non-sterile gloves Collect and also prepare all devices for procedure on a clean surface area for sure the child has actually been fasted for 2 hrs prior to the decannulation (i.e. Decannulation planned at 9am-10am fast from 7am) acquire baseline observations including: heart rate, respiratory tract rate, SpO2 (haemoglobin-oxygen saturation), and also work that breathing. For sure patient an essential signs are within proper parameters for age & as per VICTOR chart. Proceed to visually observe and monitor patient continuously throughout the procedure Procedure  clearly explain the procedure come the patient and also their family/carer the is recommended that the child"s caregiver/s are present during the decannulation procedure to reduce the anxiety of the child. Execute hand hygiene use a standard aseptic an approach using non-touch method place the patient. Infants and also young children may lay on their back with a tiny rolled towel under the shoulders. An older child may prefer to sit increase in a bed or chair. Carry out hand hygiene and also apply non-sterile gloves eliminate fenestrated dressing from roughly stoma Clean the stoma site and also suction the tracheostomy tube instantly prior to decannulation Cut/undo tracheostomy pipe ties eliminate tracheostomy tube Observe very closely for any signs of respiratory tract distress including: Tachypnoea Stridor Retraction Tachycardia Colour reduced perfusion Oxygen desaturation or low oximetry analysis Restlessness or anxiety reduced cough effectiveness, swallow and also voice quality activity levels If no evidence of respiratory tract distress one occlusive dressing is applied to stoma site to ensure an airtight seal and reassess patience for any kind of sign of respiratory tract distress. Following decannulation:

Monitor the patient"s an essential signs - respiratory tract rate, heart rate, oxygen saturation, colour and also work of breathing continuously throughout the procedure then observe and document:

15 minutely for the very first hour half hourly because that the following 4 hrs Hourly for 24 hours continuous pulse oximetry (SpO2) during all periods of sleep (day and night) post decannulation because that 24 hours. Observe closely for any signs of airway obstruction or enhanced respiratory effort throughout sleep periods

Immediately report any type of episodes of:

Tachypnoea or bradypnoea Tachycardia or bradycardia SpO2desaturation increased WOB – mild, middle or serious - as evidenced by: sternal or intercostal retraction, tracheal tug, nasal flaring, or stridor Restlessness and or anxiety Colour readjust and or cyanosis failure to clean secretions – gagging sell light diet 2 hours after decannulation (unless contraindicated) Encourage the son to undertake their normal tasks while top top the ward. Protect against suctioning the stoma uneven otherwise indicated in one emergency situation as this may cause trauma.

Note: The kid is to remain on the ward because that 24 hours short article decannulationand need to not leave the ward without medical approval and supervised by education staff competent in tracheostomy care.

Stoma site care article decannulation The stoma website is covered by a small gauze square and also then by one occlusive dressing (sleek™/tegaderm™) until it has closed or no secretions room seeping out. Evaluate occlusive tracheal stoma dressing because that air leaks every transition and document absence or presence of these air leaks in clinical record. Stoma site to it is in assessed and cleaned and dressing used daily or an ext frequently if indicated. Watch for skin reaction to dressing used – if redness or irritation trial different dressing

Decannulation - job 3

Following the very first 24 hours article decannulation: Patient might leave the ward if the parental team has assessed the patience to have actually a "safe airway" Encourage usual activities to assess exercise tolerance – if age appropriate consider practice testing/respiratory role tests Encourage coughing to clear secretions from upper airway if required. If the boy is no coughing and also clearing secretions well, tenderness oropharyngeal suction (only) might be performed. Contact the physiotherapist because that support. Referral to speech pathology need to be thought about if the boy does not resume regular voice production adhering to decannulation or poor swallow.

See more: How To Get Rid Of Fluid In Uterus : Causes, Symptoms, And Treatment

Stoma website care post decannulation: The stoma website is extended by a small gauze square and also then by one occlusive dressing (sleek™/tegaderm™) till it has actually closed or no secretions are seeping out. Assess occlusive tracheal stoma dressing because that air leaks every change and file absence or existence of these air leaks in medical record. Stoma site to be assessed and cleaned day-to-day or an ext frequently if indicated. Observe for skin reactions to dressing supplied – if redness or irritation trial alternative dressing

Decannulation - job 4

Discharge home

The child is commonly discharged residence when they"re taken into consideration by the medical team to have a for sure airway.

The mean hospital size of stay post decannulation is 36 - 48 hours, but this maybe longer if clinically indicated.

Following a successful decannulation the family members are able to return all tracheostomy and suctioning devices on discharge from hospital but are urged to keep the pulse oximeter till 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:

enhanced Work of breathing as shown by: sternal/intercostal retraction, tracheal tug, nasal flaring, stridor Tachypnoea/bradypnoea SpO2 desaturation Restlessness/anxiety colour change/ Cyanosis unable to clear secretions – gagging Exercise constraints Unable to eat or drink as usual

Note: If child having actually severe breathing problems speak to 000 immediately and also follow an easy life support flowchart

Care that stoma site adhering to discharge home

Ensure the caregivers are noted with enough supplies and are mindful of how to care for stoma website - this contains daily cleaning of the site and dressing transforms as required. Advise the family/caregiver to contact the hospital and/or medical team if over there are any kind of signs of epidemic at the stoma site consisting of any:

Redness Odour swelling Discharge

If stoma site remains open up the family are advised to carefully supervise their child around water to avoid aspiration.

Documentation

Ensure all written documentation related to the monitoring of a patient through a tracheostomy is in accordance with the ugandan-news.com documentation policy.

Record the factor and type of the interventions perform relating come tracheostomy care and also appropriate outcomes in the progression notes and flow sheets assessment.

These include:

Suctioning (amount, colour and consistency of secretions) Tracheostomy cares performed consisting of tie changes and stoma dressings Stoma problem (at least day-to-day review and ongoing documentation and also any changes e.g. Indicators of infection) once a tracheostomy tube change (routine or emergency) is performed record the date and time the the tracheostomy insertion, surname of person who put the tube, dimension and type of tube placed (including inner and also outer diameter, tube length and also suction depth), lot of number, expiry date of the tracheostomy tube, patient problem throughout and following the tube change and any difficulties experienced during or after the tracheostomy pipe change.

Special Considerations

Should one aerosol generating procedure be undertaken top top a patient under droplet precautions then boost to airborne precautions by donning N95/P2 mask for at least the expression of the procedure.

Companion Documents

Evidence table

Tracheostomy Management proof Table.

References

Blackwood, and also Bronagh. (1999). “Normal saline instillation through endotracheal suctioning: primum no nocere (first perform no harm)” newspaper of progressed Nursing, 29 (4), 928-934. Carr, M. Poje, C.P. Kingston, L. Kielma, D. And Heard, C. (2001) "Complications in Pediatric Tracheostomies" Laryngoscope 111: November 2001. Celik, S. And also Kanan, N (2006) " A current conflict use that Isotonic salt Chloride systems on the Endotracheal Suctioning in Critically ill Patients" size of crucial Care education vol 25/No1 pp:11-14. Choate, K and Snadford, M (2003) "Tracheostomy: Clinical Practice and also the development of policy and also guidelines" Australian nursing Journal, 10, 8 p: CU1. Dixon, L. And also Wasson, D. (1998) "Comparing Use and Cost effectiveness of Tracheostomy pipe Securing Devices. Medsurg Nursing, 7, 5 pp: 270-274 Edwards, E.A. And Byrnes, C.A (1999) “Humidification obstacles in two Tracheostomized Children". Anaesthesia and Intensive Care, 27, 6, pp: 656-58. Evans, j., Syddall,S., Butt,W., and Kinney, S. (2014) “Comparison of open and closed suction top top safety, efficacy and also nursing time in a paediatric intensive treatment unit”. Australian critical Care 27 (2014) 70 -74. Gray JE, MacIntyre NR, Kronenberger WG. The results of bolus common saline instillation in conjunction v endotracheal suctioning. Griggs, A. (1998) "Tracheostomy suctioning and also humidification". Nursing standard vol 13 (2) pp: 49-53, 55-56. Halm, M and also Krisko-Hagel, K (2008) “Instilling common Saline v Suctioning: Beneficial an approach or potentially Harmful sacred Cow?” American newspaper of vital Care, 17: 469-472. Hussey, S.G, Ryan, C.A and also Murphy, B.P. (2007) "Comparison that three manual ventilation gadgets using an intubated mannequin". Augandan-news.com Dis. Child. Fetal Neonatal Ed. (2004); 89; 490-93. Oberwaldner, B. And Eber, E. (2006) "Tracheostomy treatment in the home". Paediatric respiratory Reviews, 7, 185-190. O"Toole, EA. Wallis, C. (2004) "Sending kids home top top tracheostomy dependency ventilation:pitfalls and outcomes". BMJ vol 89 (3) pp: 251-255. Raymond SJ. Common Saline Instillation before suctioning: advantageous or Harmful? A testimonial of the Literature". American journal of vital Care July 1995 Volume 4, No. 4 267-271. Respir. Care. 1990;35:785-790. Scoble M, Copnell, B. Taylor, A. Kinney, S and also Shann, F. (2001) "Effect the reusing suction catheters on the occurrence of pneumonia in children" Heart and Lung vol 30, 3 p: 225-233. Schultz, J., Mitchell, M., Cooke, M., and Schibler, A. (2018) “Efficacy and also safety of common saline instillation and paediatric endotracheal suction: an integrative review”. Australian vital Care 31 (2018) 3-9. Ridling, D. Martin, LD and Bratton, S. (2003) "Endotracheal Suctioning v or without Instillation the Isotonic salt Chloride solution in Critically okay Children". American journal of crucial Care vol 12, no 3 pp:212-219. Tamburri, L.M. (2000) "Care the the Patient through a Tracheostomy". Orthopedic Nursing, 19, 2 pp:49-60. Wang, CH et al (2017) “Normal saline instillation prior to suctioning: A meta-analysis that randomized regulated trials”. Australian vital Care, Sep: 30(5): 260-265. Woodrow, P. (2002) "Managing patients with a tracheostomy in acute care". Nursing typical vol 16 (44) pp: 39-48. Wyatt, M.E. Bailey, C.M. Whiteside, R.N (1999) "Update ~ above paediatric tracheostomy tubes" The journal of Laryngology and Otology , 113, 1, Health and also Medical complete pp:35-40.