Guidelines for the care of a child with an established tracheostomy

• Introduction
• What is a tracheostomy?
• Reasons for a tracheostomy
• Types of Tracheostomy Tubes
• Communication
• Discharge Planning
• Emergency and Bedside Equipment
• Emergency Box
• Criteria for competence
• New tracheostomy
• Humidification
• Suction via a Tracheostomy Tube
• Changing Tracheostomy tapes / Care of the Stoma
• Planned Tracheostomy Tubes Change
• Emergency Tracheostomy Tube Change
• Troubleshooting Guide
• Appendix 1 - Guide to Discharge
• Appendix 2 - Hospital Bedhead sign - New Tracheostomy
• Appendix 3 - Hospital Bedhead sign - Existing tracheostomy
• Appendix 4 - Emergency Paediatric Tracheostomy Management
• Appendix 5 - Daily Tracheostomy Checklist
• Appendix 6 - Basic Life Support Flow chart
• Appendix 7 - Tracheostomy Transfer Checklist
• Appendix 8 - Bivona Information Sheet
• References

Introduction

Children with a compromised airway may 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 a 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 and proficient in their tracheostomy cares with them at all times. This means they should be continuously supervised 24 hours a day by an adult who is tracheostomy trained and proficient in all tracheostomy skills, and has completed basic life support training.

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 Trust Infection Control Policy. These guidelines have been developed by a multidisciplinary group from The Leeds Teaching Hospitals NHS Trust and The Leeds NHS Community Trust.

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What is a tracheostomy?

A tracheostomy is an artificial opening in the airway in which a tracheostomy tube is placed. A tracheostomy may be temporary or permanent depending on the reason it is required. The opening the tube is placed in to is called a stoma. The tracheostomy tube allows the passage of air and the removal of secretions.

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Reasons for a tracheostomy

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Types of Tracheostomy Tubes

There are several different types of tracheostomy tubes and below is a description of the most commonly used at LTHT. Be aware that shiley and bivona make paediatric and neonatal tubes that come in the same size. The PED tubes are longer than the NEO tubes.

Single lumen disposable tubes - e.g. Shiley. These are most frequently used in infants and children under 8 years old. They are replaced weekly but can stay for a maximum of 28 days. The smallest size is a 3.0mm and the largest 7.0mm. Use once and dispose.
Reusable tubes - e.g. Bivona tubes. These are softer, flexible and more comfortable. They are changed weekly to 4 weekly and can be used 5 times. They should be washed in hot soapy water after removal and sterilised the day of insertion. Sterilisation can be completed in an electric steam steriliser or placing in boiling water and removing once the water is hand hot. They should be carefully inspected before insertion to check they have been cleaned thoroughly and there is no damage. (Appendix 8) The bivona flextend (pictured) contains a metal coil and care should be taken during MRI’s, CT’s and X-Rays. Tubes can be changed to Shileys for the scans if needed. Discuss with the Consultant or WellChild Tracheostomy Nurse for advice.
Double lumen disposable - e.g. Shiley, Kapitex These are only used in older children / adolescents. They consist of inner and outer tubes to aid clearance of secretions without the need for a complete tube change should the inner lumen become blocked. They are changed weekly up to 4 weekly. Fenestrated tubes - These are double lumen tubes with additional holes built into the shaft of the tube to allow air flow through the vocal cords to facilitate vocalisation. Do not suction through a fenestrated tracheostomy if the inner tube is also fenestrated, swap it to a solid inner tube to prevent trauma.
Cuffed tubes eg. Shiley, Kapitex and Bivona These use a low pressure air, water or foam filled cuff around the distal end of the tube. This inflates to fill any gap between the tube and the trachea, sealing the airway. They are used to aid ventilation and / or prevent aspiration of secretions into the airways. The foam cuff tube is used increasingly less in paediatrics but it is one to be aware of. It self inflates and the cuff exerts a low pressure on the trachea reducing the risk of tracheal scarring. However, the deflated cuff remains quite bulky and can cause trauma on insertion and removal. If tolerated, cuffed tubes should be deflated at regular intervals throughout the day to avoid trauma. E.g. 10 minutes every 2-4 hours. The cuff pressure should be monitored and recorded at regular intervals with an appropriate manometer.

Communication

Children with tracheostomies can find communication difficult. This is because, if the child has an age appropriate tracheostomy, air needed for producing voice will be exhaled from the tracheostomy rather than directed up through the voice box and vocal cords where voice is produced. However, there are strategies that can be put in place to encourage voice production.  A referral to Speech and Language Therapy (SALT) should be considered.

If the child’s condition allows, a one way valve (speaking valve) can be trialled. This allows the child to breathe in through the tracheostomy but as the child exhales the valve closes. This forces all the air to exit via the upper airway through the voice box and vocal cords allowing vocalisation. Not all children will tolerate a valve and they are assessed by our SALT team to see if and when it is appropriate to trial a one way valve.

In addition the SALT team may consider alternative and augmentative communication aids (AAC) such as Makaton, picture communication symbols, low tech aids and high tech aids as appropriate.  It may be that an onward referral to the Leeds Communication Aid Service (LCAS) is appropriate.

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Discharge Planning

Discharge planning should begin as soon as possible. Families caring for children with tracheostomies at home will need considerable support and creating a care package for these children can take many months. Timely referrals to Community Teams, Continuing Care and other local services will help prevent any delays to this process.

It is helpful for the child to have a named nurse/nurses on the ward to help coordinated discharge.

The guide in Appendix 1 can help direct a child’s journey home. Ideally the family will be trained within 4 weeks but this must not be rushed and a family should only be discharged once they feel confident in tracheostomy cares and they have the correct support at home. Once the family have completed their tracheostomy training and basic life support training they should be encouraged to take their child for walks off the ward unaccompanied to build up their confidence.

If the child is to be transferred to another hospital, this must not be done until the child has had their first tube change. It must also be checked that the receiving hospital have enough tracheostomy trained staff and are happy to train the family for discharge home.

Travelling to hospital regularly can have a financial impact and families should be directed to charitable funds where required. Families will also be entitled to additional benefits and they should be supported with these applications. The parent booklet has information about benefits and charitable funds that may be helpful for families.

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Emergency and Bedside Equipment

All children with tracheostomy tubes should have an oxygen saturation monitor made available to them, e.g. If the child is asleep, unwell or not being directly supervised (at home). There should always be a working suction unit and appropriately sized suction catheters available to the child wherever they may be. In hospital the bedside must have a high flow oxygen flow-meter and a Bag-Valve-Mask within reach. Children will not be provided with a BVM for home unless they are deemed high risk. A one way valve (pictured across) can be added to the emergency box to help facilitate mouth to trache for carers/parents in the home setting.

(Above: One way laerdal valve - Order Ref No 820410)

Children in hospital must have a bed head sign printed in colour. This displays the vital airway information that may be required in an emergency. The ‘new tracheostomy’ sign (a) should be used until the first change has been completed. After this the ‘tracheostomy’ (b) bedhead sign should be displayed.

These signs are recognised nationally and can be printed from http://www.tracheostomy.org.uk/resources

The Emergency Paediatric Tracheostomy Management should also be available at the bedside. Both hospital and community nurses/carers should be able to perform the basic response. This can also be found at http://www.tracheostomy.org.uk/resources

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Emergency Box

The emergency box for a child with a tracheostomy must be kept with the child at all times and should consist of the following items:

• Tracheostomy tube the same size and make as their current tube. It should have tapes attached and be stored in a sealed container.
• Tracheostomy tube one size smaller with tapes attached and stored in a clean container.
• Spare tracheostomy tapes
• Appropriate sized suction catheter (for Seldinger technique)
• Lubricating gel
• Round ended scissors
• Disconnection wedge if using a Bivona tube
• Spare inner tube for double lumen tubes
• 5ml Syringe if cuffed tube or 2ml if 0.9% Saline required)
• 0.9% Saline (If part of treatment plan or child in PICU/HDU/NICU)
• One way valve (if BVM not issued for home)

If any other equipment is needed it should be carried separately to ensure ease of access to the emergency equipment.
A bedside checklist must be completed at the beginning of every shift (See Appendix 5). This identifies what equipment should be at the bedside and what equipment must be included in the emergency box. The emergency box should be checked at least once per shift and before and after every trip out. If the child is being transferred to another ward or going to theatre there is a transfer checklist that helps to ensure you have all the emergency equipment you would need to safely transfer the child. See Appendix 7.

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Criteria for competence

All staff undertaking care of a tracheostomy should be:

• Registered nurses
• Registered medical staff
• Trained Carers (e.g. Clinical Support Workers / School Teaching Assistants / Play Specialists)

Staff must have undertaken a period of supervised practice in the management of a tracheostomy tube and be able to 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.

Parent/Carers/Guardians - i.e. relatives, or other individuals involved in the child's daily care at home. Carers can undertake the management of a tracheostomy provided they have been signed off by a recognised practitioner, who is competent in management of a tracheostomy, and completed a competency pack a copy of which is kept in the child’s notes.

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.

None of the procedures in these guidelines should be attempted unless a competent individual is present (with their training maintained). The professional practitioner should accept accountability for maintaining their own practice and competence.

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New tracheostomy

All newly formed tracheostomies will be cared for in PICU/NICU/HDU in the immediate postoperative period. The family should be provided with a parent/carer information booklet and competencies (Parent Booklet Link) within the first 24 hours and a referral made to the WellChild Tracheostomy Nurse Specialist if it has not already been done. Discharge planning should be commenced.

A new tracheostomy will have stay sutures in place for the first week. These are used only if a tracheostomy tube change is required within the first week. The sutures aid the opening of the stoma. The stay sutures are taped to the chest and should not be removed until the first planned tube change after a week.

Some tracheostomy tubes are also sutured in place. For these children a stitch cutter should be added to the emergency equipment so the tracheostomy tube can be removed in the event of a blockage.

All children should have continuous artificial humidification for a minimum of 24-48 hours post op and then weaned to nebulisers as appropriate. This is to reduce the risk of the tracheostomy tube becoming blocked and an “emergency tube change” being required. Neonates may require this for the first week as they have much smaller tubes which are liable to block more easily. Frequent suctioning is also required in the first 24-48 hours for the same reason.

The first elective tube change usually happens around the 7th post-operative day and is performed by the child’s Surgical or ENT Team. Should an emergency tracheostomy change become necessary before this time then the stay sutures should be used to maintain the patency of the stoma. By pulling forward and laterally on these sutures the stoma should open and will help with placement of a new tube. If the tube becomes dislodged and the patient is struggling to breathe then it may be safer to intubate the child rather than re-insert the tracheostomy tube because of the risk of creating a false passage. This is assessed on an individual basis, as on day 6 it may well be safe to re-insert the tracheostomy tube whereas on day 1 or 2 post op the patient will almost certainly need re - intubation with an ET tube. 

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Humidification

Breathing through a tracheostomy tube bypasses your natural mechanism for adding humidity and filtering the air. An Heat and Moisture Exchanger, HME, is added to the tracheostomy to help aid these mechanisms. The paper or foam ends capture dirt before it enters the tracheostomy. It also collects moisture from the exhaled breath allowing it to be inhaled next time. HME’s should be changed a minimum of daily - more often if it becomes saturated, blocked with secretions or dirty.
 
There are several different HME’s available. The age, weight and oxygen requirements all help to direct towards the most appropriate option for the child. The WellChild Tracheostomy Nurse or Children’s Home Ventilation Nurse Specialists can help with this.

Oxygen delivery sets via the tracheostomy should be available at the bedside in hospital.
If a child needs greater than 2-3l/min then this it should be humidified.

Nebulisers - The use of 0.9% sodium chloride nebulisers can be helpful to loosen thick and sticky secretions. If required, they can be given at regular intervals throughout the day to help loosen secretions and reduce the risk of tube blockages.

0.9% Sodium Chloride Instillation is not recommended for regular use. It involves instilling 0.2-0.5mls directly into the tracheostomy immediately prior to suction to promote a cough and loosen secretions. Evidence of its effectiveness is limited and it can be potentially hazardous, causing a drop in oxygen saturations and an increase in work of breathing.

It should only be used by an experienced practitioner if all other options have been tried.

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Suction via a Tracheostomy Tube

Indications

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

When is suction required?

• Only when necessary to avoid damage and over production of secretions. Suction should never be done routinely - other than during the first 24 hours post new tracheostomy formation 
• Bubbling / rattling sounds from the tracheostomy 
• Coughing 
• Increased work of breathing
• Drop in oxygen saturations
• If the child is restless 
• Unexplained crying 
• Anxious looking 
• Pale colour 
• cyanosed 

An increase in suctioning 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

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

(Evelina London Children’s Hospital, 2016)

Suction pressures may vary from these according to each individual child and the recommended pressures for each child will be recorded in their notes

Equipment

• Suction unit in working order
• 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)
• Small bowl/bottle (filled with sterile / cooled boiled water)
• Bag for waste
• Emergency equipment
• Professional carers - gloves / apron / goggles

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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 they are healthy and to ensure that neither is red nor sore.

Frequency of cleaning can alter if the stoma / skin are not clean and dry. The stoma / skin can be assessed as:

1. Healthy: clean and dry skin.
2. Infected: inflamed skin with infected/serous exudate.
3. 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 for parents in the child’s home, e.g. single parent families. However, in all but emergency cases staff both in and out of hospital must ensure two people are available.

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. Within a hospital setting ribbon tie tapes should be first choice. Any change to Velcro should be risk assessed as they have a greater risk of accidental decannulation. Considerations should include:

Childs age, awareness and ability -    Can they reach to undo the tapes?
Environment - Are there other children who can undo the tapes or pull on the tracheostomy?
Excessive secretions - Excessive secretions can result in the tapes becoming loose
Family - Are the family aware of the risks and happy to proceed?

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.

Ties:                Usual method of securing a tracheostomy tube. Marpac ties by CCMed are available on prescription and are easy to secure with a foam backing for comfort. They are available in neonate 106, child 107 and adult 108 sizes.

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.

Equipment:

• Clean tapes
• Neck roll/ Sheet to swaddle (if under 1 year, older children may wish to sit up with back support)
• Gauze (sterile) - X2 packs of 5
• To moisten gauze:
  • Hospital    - 0.9% Sodium Chloride
  • Home       - cooled boiled water (< 1 year) 
                    - tap water (> 1 year)

• Dressing and barrier cream (if needed)
• Round ended scissors
• Professional Carers - gloves / apron / goggles
• Suction equipment
• Emergency equipment

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Planned Tracheostomy Tubes Change

Indications

It is advisable to change a tracheostomy tube regularly to prevent the gradual build-up of secretions which can block the tube, make suction difficult and cause respiratory distress. The frequency with which a tracheostomy 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:

• Clean / New tracheostomy of the correct size and make
• Emergency Smaller Tracheostomy Tube within reach
• Clean tapes
• Neck roll/ Sheet to swaddle (if under 1 year, older children may wish to sit up)
• Gauze (sterile) - X2 packs of 5
• To moisten gauze:
  • Hospital  - 0.9% Sodium Chloride
  • Home      - cooled boiled water (< 1 year) 
                  - tap water (> 1 year)

• Dressing and Barrier Cream (if needed)
• Round ended scissors
• Professional Carers - gloves / apron / goggles
• Lubrication jelly (water soluble e.g. Optilube)
• Suction equipment: see tracheostomy suction guideline
• Emergency equipment
  • Bag Valve Mask if in hospital or high risk in the community (not all tracheostomy children will need a BVM for home)

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Emergency Tracheostomy Tube Change

There is a risk the tracheostomy tube can block, become dislodged or accidentally decannulated at any time

It is imperative that staff caring for the child can perform an emergency tube change to prevent the risk of respiratory arrest.

Signs of a blocked tube

• Unable to pass the suction catheter to the premeasured depth 
• Absent or reduced expired air from the tracheostomy 
• Coughing 
• Increased work of breathing - stridor, use of accessory muscles
• Drop in oxygen saturations
• If the child is restless or agitated 
• Unexplained crying 
• Anxious looking 
• Pale colour 
• Cyanosed 

If there are signs of a blocked tube, suction the tracheostomy to establish patency of the tracheostomy. If this is unsuccessful, the tracheostomy must be removed immediately and a new tracheostomy tube the same size inserted. If you are unable to pass the same size tracheostomy, the smaller size should be used and the child should be reviewed in hospital and upsized again as soon as possible.

There may be times when the tracheostomy appears patent upon suction but the child’s condition does not improve or continues to deteriorate. In these instances change the tracheostomy tube. If there is ever any doubt about the patency of the tube always change the tracheostomy.

Seldinger technique

If unsuccessful the seldinger technique can be used to try and insert the smaller size tube. The step should not delay basic life support initiation if it is required.

Remove the introducer from the smaller tube and pass a suction catheter through the tube.

Then attempt to insert the end of the catheter through the stoma opening and guide the tracheostomy tube along the catheter and through the stoma.

Lyons, MJ, Cooke, J, Cochrane, LA and Albert, DM (2007)

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Troubleshooting Guide

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