Protocol for Changing Tracheostomy Tapes by WQ64Ogg

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									     GUIDELINES FOR THE CARE OF A
        CHILD WITH A TRACHEOSTOMY




Tracheostomy Group   Page 1   March 2009
                                    CLINICAL GUIDELINE


Lead Author:          Sarah Cozens – Children’s Home Ventilation Nurse Specialist (LTHT)

Co-Authors:           Nicola Rhodes - Children’s Home Ventilation Nurse (LTHT)
                      Karen Eaton - Children’s Community Nurses Manager (NHS Leeds)
                      Helen Hartley - Children’s Community Respite (NHS Leeds)
                      Anne Aspin - Neonatal Nurse Consultant (LTHT)
                      Sally Joy-Rose - Neonatal Surgical Outreach (LTHT)
                      Sue Shevill - Staff Nurse Ward 48a (LTHT)
                      Alyson Kemp - Paediatric Resuscitation Officer (LTHT)

Date Written:         March 2009

Review Date:          March 2011

Objective:            To review working practices.
                      To liaise with other professionals involved in caring for children
                      who require a tracheostomy.
                      To review existing evidence and obtain expert consensus.
                      To act upon the expert advice and evidence obtained, and implement
                      accordingly to update clinical practice.
                      To ensure continuity of care across the acute and community clinical
                      areas in Leeds and to inform regional practice

Clinical Condition:         Infants / Children who require a long term tracheostomy

Target Patient Group:       All children who have an established tracheostomy
                            either in the acute or community setting.

Target Professional Group:         All staff who will be required to care for children
                                   with a tracheostomy.

Adapted from:               The Leeds Children’s Tracheostomy Handbook (LTHT, 1997)

Recommendations:            To circulate guidelines amongst all members of the
                            Team, locally and regionally, and to ensure guidelines constitute
                            as foundation for all future training.

Benefits for the Patient: 1. To ensure continuity of care of patients across the
                          Acute and Community settings.

                            2. To ensure care delivered is research based and up
                             to date.

Contact:                    Sarah Cozens - Children’s Nurse Specialist
                            PICU, Leeds General Infirmary
                            0113 3923220 / 07899 988712


Tracheostomy Group                   Page 2                            March 2009
Contents                                          Page

Introduction and Criteria for Competence          4

Types of Tracheostomy Tubes                       5

Principles of Practice                            6

Changing Tracheostomy tapes / Care of the Stoma   7

Planned Tracheostomy Tubes Change                 9

Suction via a Tracheostomy Tube                   11

Appendix 1 - Troubleshooting Guide                15

Appendix 2 - Flow Charts                          19

References                                        24




Tracheostomy Group                 Page 3         March 2009
1.0       Introduction

Children with a compromised airway sometimes require a tracheostomy and this need arises from a
variety of conditions, from an upper airway abnormality to a need for long term ventilation. The
tracheostomy is inserted surgically in the regional centre, but as it is likely to be in place for many
months or years the child will go on to be managed in the local community. Children and infants with
tracheostomies have an increased vulnerability to a range of life threatening complications, and
therefore require someone trained in their care with them at all times. These guidelines have been
produced to support staff in the management and troubleshooting of an established tracheostomy and
apply to all healthcare staff caring for these children in hospital and the community. They are based on
evidence where it is available and on expert opinion where it is not. The aim is to reduce patient risk
in line with clinical governance requirements. If staff adhere to these guidelines it will significantly
reduce the risk to patients.


These guidelines should be read in conjunction with the Tracheostomy Teaching Pack (LTHT 2009)
and the Trust Infection Control Policy (LTHT 2007). These guidelines have been developed by a
multidisciplinary group from The Leeds Teaching Hospitals NHS Trust and The Leeds NHS Primary
Care Trust.


2.0       Criteria for competence

2.1       All staff undertaking care of a tracheostomy should be:

         Registered nurses

         Registered medical staff

         Trained Carers (e.g. Clinical Support Workers / School Teaching Assistants)

2.2       Professional staff must have undertaken a period of supervised practice in the management of
a tracheostomy tube and can provide evidence of competence as witnessed by a recognised
practitioner who is competent in the management of tracheostomy tubes. The number of supervised
practices required to achieve competence will be determined by the practitioner and supervisor, taking
into account the practitioner's own learning needs. Evidence of competence must be provided and a
copy kept in the practitioner's personal file. In hospital a copy is kept by the ward or department where
the skill is practised. In the Community it is recorded in training and development records.

2.3       Trained carers - i.e. relatives, Clinical Support Workers or other individuals involved in the
child's daily care can undertake the management of a tracheostomy provided they have been trained
by a recognised practitioner who is competent in management of a tracheostomy, and completed the
competency pack in the Tracheostomy Teaching Pack.

Tracheostomy Group                        Page 4                           March 2009
2.4    Nurses, medical staff and clinical support workers in training can undertake the procedure
under the supervision of a recognised practitioner who is competent in the management of
tracheostomies.

2.5    Practitioners new to Leeds (LTHT or the community), who have regularly performed the skill
elsewhere, must familiarise themselves with this guideline. Evidence of appropriate education and
competence must be provided before undertaking this practice at LTHT, or in the community.

2.6    Evidence of continuing professional development and maintenance of skill level will be
required

2.7    The professional practitioner should accept accountability for their own practice.

3.0    Type of tracheostomy tubes
Single Lumen Disposable      - e.g. Shiley NEO / PED, Kapitex Tracoemini. Most frequently used in
                             infants and children under 8 years old. Once stoma is established tube
                             should be replaced and discarded after a maximum of 28 days, more
                             frequently if required (see manufacturer).
Double Lumen Disposable      - e.g. Shiley CFS, Kapitex Tracoetwist. Only used in older children /
                             adolescents. Consists of inner and outer tubes to aid clearance of
                             secretions without the need for a complete tube change should the inner
                             lumen become blocked. Once stoma is established tube should be
                             replaced and discarded after a maximum of 28 days, more frequently if
                             required (see manufacturer).
Fenestrated Tubes            - Double lumen tubes with additional holes built into the shaft of the tube
                             to allow air flow through the vocal cords to facilitate talking.
Cuffed Tubes                 - Uses a low pressure air / water / foam filled cuff circling the distal end
                             of the tube that inflates to fill any gap between the tube and the edges of
                             the trachea, sealing the airway. Used to facilitate ventilation and / or
                             prevent aspiration of secretions into the airways.
Reusable Tubes               - e.g. Bivona tubes / Kapitex Tracoecomfort. Softer, flexible and more
                             comfortable, often used as a long term option as tubes can be washed
                             and reused. Most types of tubes are available in a reusable option.
                             Changed and washed in a cleaning solution monthly (see manufacturer).
Silver Tubes                 - made of silver they are rarely used in children as they are hard and
                             uncomfortable. May be used if airway needs supporting internally as
                             they are rigid and unyielding.




Tracheostomy Group                     Page 5                                March 2009
4.0       Principles of practice

4.1       Nurses should adhere to The Code - Standards for conduct, performance and ethics for nurses
and midwives (NMC 2008)

4.2       Nurses should adhere to universal infection control precautions, and Trust Infection Control
policies and procedures to prevent the child developing a respiratory tract infection (LTHT 2007).

4.3       A child with a tracheostomy is at risk at any time of needing emergency intervention and if they
become cyanosed or have signs of respiratory distress follow the flow charts in appendix 2 and call for
appropriate help.

4.4       The emergency bag / box for a child with a tracheostomy must be kept with the child at all
times and consists of the following items and nothing more, if any other equipment is needed it should
be carried separately to ensure ease of access to the emergency equipment.:

         Tracheostomy tube the same size and make as the one insitu with Velcro tapes attached for
          single person emergency use

         Tracheostomy tube one size smaller (in sealed sterile packet with expiry date on)

         Spare tracheostomy tapes

         Lubricating gel

         Round ended scissors

         1 or 2 ml syringes

         Saline ampoules

The emergency equipment should be checked at least once per day and before every trip out. In the
hospital and the community the emergency equipment should be checked on each shift.

4.5       None of the procedures in these guidelines should be attempted unless a competent individual
is present (training maintained).




Tracheostomy Group                        Page 6                             March 2009
                         Changing Tracheostomy Tapes / Care of the Stoma

Indications:

The tracheostomy stoma and tapes holding the tracheostomy tube in place should be cleaned,
assessed and tapes changed at least daily. Tapes should also be changed if they become wet or
soiled. This allows you to observe the stoma site and skin under the tapes to ensure that they are
healthy and to ensure that neither is red or sore.

Frequency of cleaning can alter if the stoma / skin are not clean and dry. The stoma / skin can be
assessed as:
                 a) Healthy: clean and dry skin.
                 b) Infected: inflamed skin with pus and crusts
                 c) Damaged: broken skin and sometimes dry or fresh blood.

This procedure is described as a two person event, however it is understood that this is not always
possible in the child’s home. Two people should always be used in the hospital setting and when
available in the home setting.

Routine tape changes should be planned to fit in with the child’s daily routine, i.e. after a wash or bath,
and should not occur too soon after eating or being fed to reduce the risk of vomiting.

Types of tapes

The type of tapes used will be individually assessed depending on the needs of the child and family.
Generally whatever tapes are used they are only as good as the person applying them so please
ensure they are tied correctly and checked regularly.

Ribbon:         Usual method of securing a tracheostomy tube. There are various methods of tying the
               ribbon. The simplest method is to use a single continuous loop, tied in a bow until the
               correct tension is achieved, then pull bow through and secure using a total of three
               knots.

Velcro:        May be preferred if skin broken or sore. Velcro tapes must only be used once as there
               is a risk of them stretching when wet. They should not be used if there is a risk of the
               tapes being undone by the child.


Equipment:

               Clean tapes (cut to length if ribbon tape)
               Neck roll / Sheet to swaddle (if under 1 year, older children may wish to sit up)
               Gauze (sterile if less than 1 year)
               To moisten gauze:
               Hospital       - Saline (0.9% Sodium Chloride)
               Home           - cooled boiled water (less than 1 year) / tap water (over 1 year)
               Dressing (if needed)
               Round ended scissors
               Suction equipment: see tracheostomy suction guideline
               Emergency equipment

               Professional Carers - gloves / apron / goggles




Tracheostomy Group                       Page 7                              March 2009
                Guideline for Changing Tracheostomy Tapes / Care of the Stoma

                        Action                                            Rationale
Wash hands thoroughly with soap and water.            To reduce the risk of cross infection.
Professional carers:
Put clean non-powdered gloves on.                     To reduce the risk of cross infection.
Prepare equipment                                     To minimise length of time procedure takes
Moisten some of the gauze swabs                       therefore reducing stress to patient and potential
Prepare tapes / dressing                              risk of decannulation.
If appropriate explain what you are about to do to    To help the child understand what is happening.
the child.                                            To get co-operation.
Position child so tracheostomy and neck are           For ease of access to the tracheostomy.
visible, loosening clothing if necessary. For         (Swaddling may be beneficial to keep arms out of
infants place a neck roll under their shoulders,      the way, but distraction therapy may cause less
older children may prefer to sit up.                  distress)
Assess the child’s need for suction before            To reduce the risk of decannulation if suction is
proceeding further.                                   needed when tapes not secure.
Decide who is going to do the care and who is         To ensure a smooth procedure where everyone
going to hold the tube.                               knows exactly what they have to do.
Hold the tube in position at all times, if using      To reduce the risk of accidental decannulation
connectors on the end of the tracheostomy the         and ensure a secure grip so the tube is not
tube must be held and not the connector               dislodged.
If a young child is sat up remember to place a        To ensure the child does not throw themselves
hand behind the child’s back as well                  backwards, dislodging the tube.
Cut / remove the old tracheostomy tape and            To visualise the skin and clean the site
dressing (if being used)
Assess the skin whilst gently cleaning around the     To remove debris /secretions which may irritate
stoma and back of the neck using cotton buds or       the skin or provide an area which bacteria could
gauze and saline / water.                             grow in.
If any areas of concern are noted (broken / red /     To action any intervention required
sore skin), report and record - see
troubleshooting guide.
Dry the skin with gauze and secure the new            To prevent skin from becoming sore.
tracheostomy tape, ensuring that once the child is    The neck tape must secure the tube without
sat up there is space for one small finger between    causing skin soreness.
their skin and the tape.
Releases their hold on the tube only when person      To reduce the risk of accidental decannulation.
A states that it is secure.
Replace dressing if required.                         To keep the stoma dry and stop irritation or
                                                      infection getting worse.
Assess the child for signs of respiratory distress    To prevent deterioration and reassure the child.
and ensure they are comfortable.
Dispose of all dirty equipment safely and correctly   To reduce the risk of cross infection and
as per local policy                                   contamination.
Wash and dry hands thoroughly with soap and           To reduce risk of cross infection
warm water.
Professional carer - document care given              To ensure contemporaneous records




Tracheostomy Group                      Page 8                              March 2009
                                 Planned Tracheostomy Tube Change

Indications

It is advisable to change a tracheostomy tube regularly to prevent the gradual build up secretions
which can block the tube, make suction difficult and cause respiratory distress. The frequency with
which a tube needs to be changed depends on the type and size of tube used but it is also affected by
how well the child is.

If a child’s secretions are sticky or there is a build up of debris on the flange of the tube it may well be
necessary to change the tube more frequently than the manufacturer’s guidelines state.

Although initially unnerving for the inexperienced, a tracheostomy change should not be an unpleasant
experience for the child. If a calm, relaxed approach using simple explanations is used the child will be
adequately prepared and able to co-operate.

Although it is preferable that two people should undertake this procedure, it is understood that this can
alter in the child’s home. If the circumstance arises that a single person is changing a tube then an
infant could be swaddled to prevent excess movement and Velcro tapes could be considered to
secure the tube until a second person is available. Two people should always be used in the hospital
environment and when available at home.



Equipment Required.

               Clean / New tracheostomy tube of the correct size and make
               Clean tapes (cut to length if ribbon tape)
               Neck roll / Sheet to swaddle (if under 1 year, older children may wish to sit up)
               Gauze (sterile if less than 1 year)
               To moisten gauze:
               Hospital       - Saline (0.9% Sodium Chloride)
               Home           - cooled boiled water (less than 1 year) / tap water (over 1 year)
               Dressing (if needed)
               Round ended scissors
               Suction equipment: see tracheostomy suction guideline
               Emergency equipment

               Professional Carers - gloves / apron / goggles




Tracheostomy Group                       Page 9                              March 2009
                                Planned Tracheostomy Tube Change

                       Action                                             Rationale
Wash hands thoroughly with soap and water.            To reduce the risk of cross infection.
Professional carers:
Put clean non-powdered gloves on.                     To reduce the risk of cross infection.
Prepare equipment                                     To minimise length of time procedure takes
Moisten some of the gauze swabs                       therefore reducing stress to patient and potential
Prepare tapes / dressing to hand                      risk of decannulation.
If appropriate explain what you are about to do to    To help the child understand what is happening.
the child.                                            To get co-operation.
Position child so tracheostomy and neck are           For ease of access to the tracheostomy.
visible, loosening clothing if necessary. For         (Swaddling may be beneficial to keep arms out of
infants place a neck roll under their shoulders,      the way, but distraction therapy may cause less
older children may prefer to sit up.                  distress)
Assess the child’s need for suction before            To reduce the risk of decannulation if suction is
proceeding further.                                   needed when tapes not secure.
Decide who will remove and insert the tube and        To ensure a smooth procedure where everyone
who will be assisting.                                knows exactly what they have to do.
Hold the existing tube securely                       To reduce the risk of accidental decannulation
Check introducer slides easily out of tube. Apply a   To decrease trauma when new tube inserted.
small amount of lubricating gel to the sides of the   Large amounts of gel can irritate and cause
tip of the new tracheostomy tube (some older          coughing and the need for suction.
children may prefer to have this action omitted).
Cut the tracheostomy tapes and if appropriate         To facilitate removal of the tube and to reassure
explain the next stage of the procedure to the        child.
child.
Disconnect any speaking values, artificial noses,     To facilitate removal of the tube and prevent
humidifiers, ventilators or oxygen connections        discomfort to the child
and carefully remove the old tube following the
curve of the tube
Gently but firmly insert the new tube, again          To prevent damage to the trachea
following the curve of the tube, and remove the       Child will be unable to breathe while introducer is
introducer                                            in situ.
Hold the new tube securely                            To avoid child coughing out new tube.
Reconnect any removed devices and allow any           To avoid any respiratory complications. The child
coughing to settle. Check the child is breathing      may gasp and cough but this is a natural
easily and has no signs of respiratory distress.      response and should settle
Administer suction if required as per guidelines (a   To clear airway.
single person would secure the tapes before
performing suction)
Assess and clean the stoma / neck and secure          To ensure the site is healthy and the tube is
the tapes as per guidelines                           secure.
Release the hold on the tube only when it is          To reduce the risk of accidental decannulation.
stated that it is secure.
Reassess the child for signs of respiratory           To prevent deterioration and reassure the child.
distress and ensure they are comfortable.
Dispose of all dirty equipment safely and correctly   To reduce the risk of cross infection and
as per local policy                                   contamination.
Wash and dry hands thoroughly with soap and           To reduce risk of cross infection
warm water.
Professional carer - document care given              To ensure contemporaneous records


Tracheostomy Group                     Page 10                              March 2009
                                  Suction via a tracheostomy tube

Indications:

Suction is required to ensure the tracheostomy tube does not become blocked with secretions and
allows maximum air passage for the child.

When is suction required?

          Only when necessary – to avoid damage. Suction should never be done routinely.
          If the child is restless
          Unexplained crying
          Anxious looking
          Pale colour
          Bubbling / rattling sounds from the tracheostomy
          Coughing
          When required should be carried out promptly to avoid distress.

More suction may be necessary if the child has a cold or a chest infection. The first sign of this may be
an increase in secretions.

Secretions may also become yellow/green and smell unpleasant – see troubleshooting guide for
further advice on problematic suctioning.

Suction Machine

It is important that when a portable unit is not in use it is kept on charge. Suction units should be
checked each shift /day to ensure cleanliness (liners & disposable tubing should be replaced each day
in Hospital or weekly at home, according to local infection control policy). Suction reservoirs (on
portable units) must be washed with household detergent and thoroughly dried everyday. The
equipment should be checked to ensure the pressure is set correctly (see table below). Pressure too
low will mean ineffective suctioning. Pressure too high could cause trauma to the trachea and air way
collapse. All children at home should have 2 working suction units that are regularly checked and
maintained.

Suction Pressures

Infants               60 - 80mmHg / 8-10kpa
Children              80 - 100 mmHg / 10-13kpa
Children maximum      120 mmHg / 16kpa

                                      (Royal Liverpool Children’s NHS Trust, 2006; Ireton, 2007)
Saline Instillation

Saline instillation should not be used routinely as it does not mix well with secretions and can cause
oxygen desaturation and excessive coughing. Effective humidification is essential and can be
delivered using Heat and Moisture Exchangers (HME’s - artificial noses), saline nebulisers and heated
water humidifiers.




Tracheostomy Group                     Page 11                             March 2009
                                  Suction via a tracheostomy tube

Equipment :

Suction unit in working order – see notes on machine maintenance.
Suction catheters – appropriate size (twice the size of the internal diameter of the tracheostomy tube,
e.g. size 4.0 ID tracheostomy tube requires size 8 suction catheter)
2 or 5ml syringe, depending on size and age of child.
Saline (0.9% Sodium Chloride)
Small bowl (filled with sterile / cooled boiled water)
Bag for waste
Emergency equipment

Professional carers - gloves / apron / goggles




www.tracheostomy.com




Tracheostomy Group                     Page 12                             March 2009
Suction via a tracheostomy tube

                      Action                                               Rationale
Observe Child:
       Are there secretions in the tube?
      What type of noise can you hear?
      Is the child restless?                          All indications to perform suction.
      Is the child’s crying unexplained?
      Is the child anxious looking?
      Is the child blue or pale looking?
      Is the child coughing?
Check suction unit is in working order                To ensure procedure can be performed
Wash & dry hands thoroughly with soap and             To reduce the risk of cross infection.
warm water (this may not always be possible in
an emergency)
Switch on suction unit
Check pressures                                       To avoid trauma or ineffective suctioning
Attach correct size suction catheter                  To ensure catheter goes down tube
Explain to child.                                     To gain co-operation.
Professional carers:                                  In all but emergency situation gloves must be
Put a clean non-powdered glove on your                used to reduce the risk of contamination and
dominant hand                                         cross infection
Withdraw the catheter from its packet preventing      To reduce the risk of contamination and cross
the tip from touching anything                        infection
Disconnect any speaking values, artificial noses,     To visualise the tube entrance and keep the
humidifiers, ventilators or oxygen connections        dominant hand clean to hold the suction catheter
with the non-dominant hand or ask for assistance.     to reduce risk of infection.
If a fenestrated tube is insitu remove fenestrated    To allow catheter to pass down tube
inner tube and insert a plain inner
Hold suction catheter in dominant hand & suction      This leaves one hand to perform suction & the
tubing in the other                                   other hand to regulate flow.
Pass suction catheter into tracheostomy to exact      The catheter tip should reach just below the end
measurement prescribed (length is pre-measured        of the tracheostomy tube.
by passing a catheter through a spare tube until      If the catheter goes too far it could hit the bottom /
the side holes close to the tip of the catheter are   sides of the windpipe causing bronchospasm,
seen just exiting the trachy tube) (ATS, 1999)        discomfort and some bleeding. If not inserted far
                                                      enough suctioning will be inadequate and will
                                                      need repeating. This pre-measured length also
                                                      ensures that the tube can be assessed
                                                      adequately for blockage.




Apply suction and gently remove catheter,             To remove secretions
rotating it round the tracheostomy as you
withdraw. (Suction should not be applied on           To avoid trauma by suction action.
insertion of catheter).




Tracheostomy Group                     Page 13                               March 2009
                                    Suction via a tracheostomy tube

Do not leave the catheter in the tracheostomy for      While suction is being performed the child will be
any longer than it would take the child to hold its’   unable to breathe and oxygen and air pressure
breath.                                                are taken out of the lungs which can lead to
                                                       airway collapse.
Note colour, odour, type of secretions, presence       To be aware of potential problems, see part 3
of blood                                               action + rationale for problematic suctioning.
Allow the child to take a few breaths (return to       To allow lung expansion and oxygenation
oxygen or ventilator if using them) and assess the     To assess for deterioration or need for further
child again.                                           suctioning.
Should the child deteriorate during suction stop       To prevent deterioration and promote full
the procedure and initiate Basic Life Support as       recovery.
per local guidelines (see flow chart in appendix)
Repeat procedure if secretions persist.                To maintain airway.
The same catheter may be used if it is the same        To reduce the risk of contamination and cross
episode of suction as long as the catheter is not      infection
coated with secretions or contaminated (i.e.
touched something else).
Instil saline slowly into tracheostomy tube if         If the child has thick plugs, dry secretions or the
necessary:-                                            catheter is difficult to pass, saline may make
Less than 6mths - 0.25 to 0.5mls                       suction easier; however effective humidification is
6mths and older - 0.5 to 2mls                          needed long term.
Professional carers:                                   A new catheter & glove should be used for each
Wrap the catheter around your gloved hand & pull       suction episode to reduce the risk of
the glove off over it.                                 contamination and cross infection.
Dispose of all dirty equipment safely and correctly    To reduce risk of cross infection and ensure
as per local policy.                                   correct disposal.
If secretions pass through catheter into the           To clear the tubing and prevent build up of
suction tubing, flush through the tubing with          secretions that could prevent effective suctioning,
sterile water (hospital) or cooled boiled water        or increase the risk of contamination and cross
(home)                                                 infection.
Wash and dry hands thoroughly with soap and            To reduce risk of cross infection
warm water.
Turn off suction machine                               Equipment is ready for use.
DO NOT attach a new catheter to the suction            To prevent contamination of the new catheter.
tubing until ready to suction again
Reassure child and return to normal activities         To ensure further cooperation




Tracheostomy Group                       Page 14                             March 2009
                                  Appendix 1 – Troubleshooting Guide

Problem 1: - The child has yellow/ copious/ creamy/ sticky secretions.

Cause: - Infection (bacterial or viral).

Potential: - Respiratory distress/ blocked tube/ septicaemia.

Action: -                                                 Rationale: -

1. Inform relevant people of change in child’s            1. To ensure appropriate advice/support can
   respiratory status i.e. medical team/community            be given and any changes in care can be
   nurse/GP.                                                 instigated quickly.

2. Send sample of tracheostomy secretions to GP           2. To ensure an infection, if present, is
   and microbiology, and action the results.                 treated quickly and appropriately.

3. Consider increasing the frequency of tape              3. Altered secretions can lead to stoma and
   change/stoma care.                                        neck breakdown due to wet/soiled
                                                             dressings or tapes being left in place too
                                                             long.

4. Consider increasing the amount of humidification       4. To maintain tracheostomy tube potency
   the child is receiving i.e. initiating / increasing       and aid effective secretion removal. To
   number of saline nebulisers and ensuring HME              reduce the risk of child developing
   (artificial nose) or heated water humidifier used at      respiratory distress.
   all times.

5. Consider using saline when suctioning if               5. To help in effective secretion removal and
   secretions difficult to remove.                           to maintain tube patency.

6. Ensure adequate analgesia /temperature control.        6. To maintain comfort and minimise
                                                             distress.

7. Monitor tube patency                                   7. Children with chest infections can
                                                             deteriorate quickly and further intervention
                                                             may be necessary.

8. Monitor child’s condition and observe carefully for    8. If resistance is felt when inserting a
   signs of respiratory distress such as: - increased        suction catheter assume that the
   respiratory rate, use of accessory muscles, nasal         tracheostomy tube is partially blocked due
   flaring, head bobbing, recession, change in colour,       to secretions and try instillation of saline
   altered conscious level.                                  to allow smoother catheter insertion, but if
                                                             not effective change the tube as per
                                                             guidelines.

9. Seek medical / nursing advice as appropriate if at     9. To ensure appropriate advice and
   all worried about the child’s condition.                  intervention is given to prevent further
                                                             deterioration.


N.B. - If recurrent infection or child is failing to thrive, review by a paediatrician is
recommended.




Tracheostomy Group                         Page 15                          March 2009
                                Appendix 1 – Troubleshooting Guide

Problem 2: - Child has a red/ broken/ inflamed skin around neck, or oozing/ excessive crusting at
tracheostomy site

Cause: - Irritation from tracheostomy tapes or tube/ Possible skin infection.

Potential: - Further breakdown of skin/ Distress and discomfort.

Action: -                                                Rationale: -

1. Inform relevant medical / nursing professionals of    1. To ensure appropriate advice/support can
   change in child’s condition                              be given and any changes in care can be
                                                            instigated quickly.

2. Send swab of inflamed area to GP/microbiology/        2. To ensure an infection, if present, is
   virology, and action the results.                        treated appropriately and quickly.

3. Commence wound care assessment sheet                  3. To monitor affected area and
                                                            effectiveness of treatment.

4. Consider twice daily tape change and twice daily      4. To monitor area and prevent further
   clean.                                                   breakdown.

5. Consider use of scratch mitts (age dependant),        5. To prevent further breakdown and
   alternative wound dressing such as cavillon /            facilitate healing.
   duoderm / transorb may need to be prescribed.


N.B. Risk assessment for use of Velcro tapes may be appropriate whilst skin is healing


Problem 3: - Child has an overgrowth of inflammatory tissue (granuloma) around the tracheostomy
site.

Cause: - Pressure caused by tracheostomy tube or position of ventilation tubing.

Potential: - Difficulty in inserting tracheostomy tube. Pain/ trauma when changing tracheostomy tube.
Changes to airway patency.

Action: -                                                Rationale: -

1. Inform relevant medical / nursing professionals of    1. To ensure appropriate advice/support can
   change in child’s condition                              be given and any changes in care can be
                                                            instigated quickly.

2. Ensure wound care plan commenced.                     2. To monitor size and position of
                                                            granuloma.

3. Consider using a tracheostomy dressing                3. To minimise pressure and friction

4. Monitor site. Short term topical treatment such as    4. Observe for change to stoma site and
   Maxitrol / Adacortyl / Betnovate may need to be          effectiveness of treatment.
   prescribed.




Tracheostomy Group                     Page 16                              March 2009
                                Appendix 1 – Troubleshooting Guide

Problem 4: - Child’s tracheostomy site is red/ broken/ bleeding.

Cause: - Localised infection/ irritation/ pressure damage.

Potential: - Further breakdown to site – risk to airway.

Action: -                                                  Rationale: -

1. Inform relevant medical / nursing professionals of      1. To ensure appropriate advice/support can
   change in child’s condition                                be given and any changes in care can be
                                                              instigated quickly

2. Send swab of area to GP, microbiology and               2. To ensure an infection, if present, is
   virology and action the results.                           treated quickly and appropriately.

3. Consider using a tracheostomy dressing, or              3. To minimise further breakdown.
   increase the frequency of cleaning and changing            Alternative wound dressing such as
   the dressing                                               lyofoam may be appropriate.

4. Commence wound care assessment sheet.                   4. To monitor affected area and
                                                              effectiveness of treatment.

5. Monitor temperature and secretions for any              5. For systemic signs of infection and signs
   changes.                                                   that infection may have spread to lungs.
                                                              Pyrexia can be treated with prescribed
                                                              antipyretic agents. For problematic
                                                              secretions see Problem 1 of
                                                              troubleshooting guide.

6. Ensure child is pain free – administer prescribed       6. Tracheostomy site breakdown can cause
   analgesia as required.                                     pain and discomfort.

7. Consider position/ type of tracheostomy tube            7.    Pressure areas can develop around
   being used, refer to specialist for advice.                  tracheostomy site and a different position
                                                                / tube may alleviate the pressure.




Tracheostomy Group                      Page 17                              March 2009
                                 Appendix 1 – Troubleshooting Guide

Problem 5: - Child has stained secretions on suctioning.

Causes: - Irritation to stoma site, insufficient humidity, too frequent/ deep/ vigorous suctioning, suction
pressure too high, infection, trauma/ manipulation of tracheostomy, foreign body, excessive coughing.

Potential:- Risk to airway / Respiratory distress

 Action: -                                                   Rationale: -

 1. If small amounts of blood only (pink or red              1. To determine if transient staining only
    streaked mucous) observe closely and modify                 and if it self resolves.
    care that might have caused problem.

 2. Consider sending a sample of tracheostomy                2. To rule out infection as cause of blood
    secretions to GP and microbiology, and action the           staining
    results.

 3. IF significant amount of fresh bleeding                  3. To ensure appropriate advice/support
     Inform relevant medical / nursing professionals           can be given and any changes in care
        of change in child’s condition                          can be instigated quickly. Child’s
     Consider initiating Basic Life Support (as per            condition could change depending on
        flow charts in appendix) and activating                 what is causing the bleeding.
        Emergency Services if child’s condition
        deteriorates.




Tracheostomy Group                      Page 18                              March 2009
                                 Appendix 2 - FLOW CHARTS

              Flowchart for Difficult Tube Change - Normal Upper Airway


                                    CANNOT INSERT NEW
                                   TRACHEOSTOMY TUBE




                        MAKE SURE THAT
                              o Obturator is in place                               DO
                              o Child is positioned correctly.                      NOT
                                 (rolled blanket/sheet under                      FORCE
                                 shoulders to extend the neck)
                                                                                   TUBE
                              o Lubrication is used




              Tracheostomy                                   SAME SIZE TRACHEOSTOMY
              safely replaced                                TUBE WILL NOT GO IN
              Monitor respiratory
              status and ensure
                                                                             ALERT EMS/
              comfort.
                                                                             CALL 999

                                                              INSERT TRACHEOSTOMY
                                                              TUBE ½ SIZE SMALLER
                                                              USING SAME TECHNIQUE
           If replaced with a
           smaller size the
           appropriate size tube
           can be reinserted
           once medical                                      SMALLER SIZE
           support is available                              TRACHEOSTOMY TUBE
           and respiratory
                                                             WILL NOT GO IN
           status is stable




                     Keep stoma and upper airway patent
                     using BLS airway opening technique
                     until help arrives; provide flow by oxygen
                     near stoma if available


                                                 Stops Breathing / Not
                                                 Breathing Normally

                                    Follow BLS protocol
                                     until help arrives


Tracheostomy Group                    Page 19                            March 2009
                 Flowchart for Difficult Tube Changes - Upper Airway Abnormality


                                CANNOT INSERT NEW TRACHEOSTOMY
                                              TUBE




                                     MAKE SURE THAT
                                           o Obturator is in place                                                 DO
                                           o Child is positioned correctly.                                        NOT
                                              (rolled blanket/sheet under                                        FORCE
                                              shoulders to extend the neck)                                       TUBE
                                           o Lubrication is used




                    Tracheostomy                                                SAME SIZE TRACHEOSTOMY
                    safely replaced                                             TUBE WILL NOT GO IN
                    Monitor respiratory
                    status and ensure
                    comfort.                                                                             ALERT EMS/
                                                                                                         CALL 999

                                                                                  INSERT TRACHEOSTOMY
                                                                                  TUBE ½ SIZE SMALLER
                     If replaced with a                                           USING SAME TECHNIQUE
                     smaller size the
                     appropriate size tube
                     can be reinserted
                     once medical
                     support is available
                     and respiratory
                                                                                SMALLER SIZE
                     status is stable
                                                                                TRACHEOSTOMY TUBE
                                                                                WILL NOT GO IN



                      Use suction catheter as
                      bougee (seldinger                                                Use catheter to deliver
                                                                   Unsuccessful
                      technique #1) to advance                                         oxygen if avalible (#2),
                      trachy tube into stoma                                           until help arrives.

                                                                                                           Stops Breathing / not
                                                                                                           breathing normally


                                                                                     Remove catheter and
                                                                                     follow BLS protocol until
                                                                                     help arrives
#1 Thread the tracheostomy tube over a clean suction catheter. Insert the catheter into the stoma to around the same depth you would
normally suction to. Gently feed the tracheostomy tube over the catheter and into the stoma. Remove the catheter.
#2 A suction catheter can be used to deliver oxygen in an emergency through the stoma. Remember to occlude the suction port. This
procedure can only be carried out if the child is breathing. If respiratory function deteriorates the BLS protocol should be followed.


Tracheostomy Group                                  Page 20                                        March 2009
                       Tracheostomy Resuscitation for INFANTS
                                  Aged 0 - 1 year

        CHANGE IN COLOUR/
       DIFFICULTY BREATHING


      CHECK RESPONSIVENESS                IF NOT
                                        RESPONSIVE


                    SHOUT FOR HELP
        ND
  IF 2       PERSON:ACTIVATE EMERGENCY SERVICES



        SUCTION / CHANGE
       TRACHEOSTOMY TUBE

                                    IF BREATHING

         CHECK BREATHING
                                                         GET HELP,
       LOOK, LISTEN AND FEEL
                                                     RECHECK BREATHING
IF NOT BREATHING/NOT
BREATHING NORMALLY


                       BREATHE                            IF NO CHEST RISE:
      5 EFFECTIVE RESCUE BREATHS                        SUCTION & RE-ATTEMPT
          (Via Tracheostomy Tube)                       BREATHS UP TO 5 TIMES

                                                            IF NO SUCCESS:
    ASSESS FOR SIGNS OF CIRCULATION*                    REMOVE TRACHEOSTOMY
           LOOK FOR SIGNS OF LIFE:                     PUT FINGERS OVER STOMA
     (Moving / Breathing - MAX. 10 SECONDS)                  OPEN AIRWAY
                                                          NEUTRAL POSITION
NO SIGNS OF LIFE
                                                                BREATHE
                  COMPRESS CHEST
                                                        COVER NOSE AND MOUTH
           15 COMPRESSIONS TO 2 BREATH
                                                            IF NO SUCCESS:
            100 COMPRESSIONS / MINUTE
                                                       BREATHE THROUGH STOMA


         CONTINUE - UNTIL HELP ARRIVES                  WHEN GET CHEST RISE…
          OR … IF ALONE … AFTER 1 MIN …                      ASSESS FOR
          ACTIVATE EMERGENCY SERVICES                  *SIGNS OF CIRCULATION*
        Tracheostomy Group         Page 21                   March 2009
                       Tracheostomy Resuscitation for CHILDREN
                              Aged 1 – SMALL Teenager

        CHANGE IN COLOUR/
       DIFFICULTY BREATHING


      CHECK RESPONSIVENESS                IF NOT
                                        RESPONSIVE


                    SHOUT FOR HELP
        ND
  IF 2       PERSON:ACTIVATE EMERGENCY SERVICES


        SUCTION / CHANGE
       TRACHEOSTOMY TUBE
                                      IF BREATHING


                                                         GET HELP,
         CHECK BREATHING
                                                     RECHECK BREATHING
       LOOK, LISTEN AND FEEL
IF NOT BREATHING/NOT
BREATHING NORMALLY


                       BREATHE                             IF NO CHEST RISE:
        5 EFFECTIVE RESCUE BREATHS                       SUCTION & RE-ATTEMPT
            (Via Tracheostomy Tube)                      BREATHS UP TO 5 TIMES

                                                             IF NO SUCCESS:
                                                         REMOVE TRACHEOSTOMY
    ASSESS FOR SIGNS OF CIRCULATION*
                                                        PUT FINGERS OVER STOMA
           LOOK FOR SIGNS OF LIFE:
                                                              OPEN AIRWAY
     (Moving / Breathing - MAX. 10 SECONDS)
                                                           SNIFFING POSITION
NO SIGNS OF LIFE
                                                                 BREATHE
              COMPRESS CHEST                            PINCH NOSE COVER MOUTH
       15 COMPRESSIONS TO 2 BREATH                           IF NO SUCCESS:
        100 COMPRESSIONS / MINUTE                       BREATHE THROUGH STOMA

                                                         WHEN GET CHEST RISE…
       CONTINUE - UNTIL HELP ARRIVES                          ASSESS FOR
        OR … IF ALONE … AFTER 1 MIN …                   *SIGNS OF CIRCULATION*
        ACTIVATE EMERGENCY SERVICES
        Tracheostomy Group         Page 22                   March 2009
                        Tracheostomy Resuscitation for CHILDREN
                                 Large Child/ Teenager

      CHANGE IN COLOUR/
     DIFFICULTY BREATHING


    CHECK RESPONSIVENESS                   IF NOT
                                         RESPONSIVE


                SHOUT FOR HELP
  IF 2ND PERSON:ACTIVATE EMERGENCY SERVICES


      SUCTION / CHANGE
     TRACHEOSTOMY TUBE
                                     IF BREATHING


                                                          GET HELP,
       CHECK BREATHING
                                                      RECHECK BREATHING
     LOOK, LISTEN AND FEEL
IF NOT BREATHING/ NOT
BREATHING NORMALLY


                    BREATHE                                IF NO CHEST RISE:
    5 EFFECTIVE RESCUE BREATHS                           SUCTION & RE-ATTEMPT
        (Via Tracheostomy Tube)                          BREATHS UP TO 5 TIMES

                                                             IF NO SUCCESS:
                                                         REMOVE TRACHEOSTOMY
ASSESS FOR SIGNS OF CIRCULATION*
                                                        PUT FINGERS OVER STOMA
       LOOK FOR SIGNS OF LIFE:
                                                              OPEN AIRWAY
 (Moving / Breathing - MAX. 10 SECONDS)
                                                           HEAD TILT CHIN LIFT
NO SIGNS OF LIFE
                                                                 BREATHE
              COMPRESS CHEST                            PINCH NOSE COVER MOUTH
      30 COMPRESSIONS TO 2 BREATHS                           IF NO SUCCESS:
        100 COMPRESSIONS / MINUTE                       BREATHE THROUGH STOMA

                                                         WHEN GET CHEST RISE…
     CONTINUE - UNTIL HELP ARRIVES
                                                              ASSESS FOR
      OR … IF ALONE … AFTER 1 MIN …
                                                        *SIGNS OF CIRCULATION*
      ACTIVATE EMERGENCY SERVICES
      Tracheostomy Group            Page 23                   March 2009
                                               References

Addenbrooke’s Hospital NHS Trust (2007) Tracheostomy Nursing Service, Living with a
Tracheostomy. Internal Publication.

ATS - American Thoracic Society (1999) Care of a child with a tracheostomy.
www.thoracic.org/sections/eduction/care-of -the-child-with-a-chronic-tracheostomy

Great Ormond Street Hospital for Children NHS Trust (2001) Living with a tracheostomy: Information
for Families. Internal Publication.

Great Ormond Street Hospital for Children NHS Trust (2004) Tracheostomy Management: Tape
Changes. Internal Publication.

Ireton, J. (2007) Tracheostomy Suction: a protocol for practice. Paediatric Nursing, Vol. 19, No 10,
pp14-18

Leeds Teaching Hospitals NHS Trust (2007) Infection control policy. Policy No 20. Internal Publication.

Nursing and Midwifery Council (2008) The Code - Standards for conduct, performance and ethics for
nurses and midwives, London. www.nmc-uk.org

Oxford Radcliffe NHS Hospitals Trust (2005) Adult Tracheostomy Management: Guidelines for best
practice. Internal Publication.

Ridling, D., Martin, L., Bratton, S. (2003) Endotracheal suctioning with or without instillation of isotonic
sodium chloride solution in critically ill children. American Journal of Critical Care, Vol 12, No 3, pp212-
219

Royal Liverpool Children’s NHS Trust (2006) Tracheostomy Competencies. Internal Publication.

St Mary’s NHS Trust (2006) Having a Tracheostomy. Internal Publication.

Wilson, M. (2005) Tracheostomy Management. Paediatric Nursing, Vol 17, No 3, pp38-43

Yorkhill NHS Trust. Managing a Tracheostomy: A guide for carers and families. Internal Publication.

www.tracheostomy.com




Tracheostomy Group                      Page 24                              March 2009

								
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