TRACHEASTOMY CARE

Tracheotomy is a surgical procedure that is usually done in the operating room under general anesthesia. A tracheotomy is an incision into the trachea (windpipe) that forms a temporary or permanent opening which is called a tracheostomy.

Tracheostomy Care

Rubbing of the trach tube and secretions can irritate the skin around the stoma. Daily care of the trach site is needed to prevent infection and skin breakdown under the tracheostomy tube and ties. Care should be done at least once a day; more often if needed. Children with new trachs or children on ventilators may need trach care more often. Tracheostomy dressings are used if there is drainage from the tracheostomy site or irritation from the tube rubbing on the skin.

It may be helpful to set up a designated spot in your home for equipment and routine tracheostomy care.

Equipment

* Sterile cotton tipped applicators (Q-tips)
* Trach gauze and "unfilled" gauze
* Sterile water
* Hydrogen peroxide (1/2 strength with sterile water)
* Trach ties and scissors (if ties are to be changed)
* Two sterile cups or clean disposable paper cups
* Small blanket or towel roll

Procedure

* Wash your hands.
* Explain procedure in a way appropriate for the child's age and understanding.
* Lay your child in a comfortable position on his/her back with a small blanket or towel roll under his/her shoulders to extend the neck and allow easier visualization and trach care.
* Open Q-tips, trach gauze and regular gauze.
* Cut the trach ties to appropriate length (if trach ties are to be changed).
* Pour 1/2 strength hydrogen peroxide into one cup and sterile water into the other.
* Clean the skin around the trach tube with Q-tips soaked in 1/2 strength hydrogen peroxide. Using a rolling motion, work from the center outward using 4 swabs, one for each quarter around the stoma and under the flange of the tube. Do not allow any liquid to get into trach tube or stoma area under the tube. Note: Some doctors recommend cleaning with just soap and water in home care, using hydrogen peroxide only to remove encrusted secretions. This is because daily use of hydrogen peroxide might irritate the skin of some children.
* Rinse the area with Q-tip soaked in sterile water.
* Pat dry with gauze pad or dry Q-tips.
* Change the trach ties if needed (See Changing a Tracheostomy Tube).
* Check the skin under the trach ties.
* Tuck pre-cut trach gauze around and under the trach tube flush to skin. Do not cut the gauze or use gauze containing cotton because the child may inhale small particles. Use precut tracheostomy gauze or unfilled gauze opened full length and folded into a U shape or use two gauze pads, one placed under each wing of the tube. Be sure the trach dressing does not fold over and cover the trach tube opening. Change the dressing when moist, to prevent skin irritation. Tracheostomy dressings may not be needed for older tracheostomies when the skin is in good condition and the stoma is completely healed and free from rash or redness.
* For tracheostomy tubes with cuffs, check with your doctor for specific cuff orders. Check cuff pressure every 4 hours (usual pressure 15 - 20 mm Hg). In general, the cuff pressure should be as low as possible while still maintaining an adequate seal for ventilation.
* Monitor skin for signs of infection. If the stoma area becomes red, swollen, inflamed, warm to touch or has a foul odor, call your doctor.
* Check with the doctor before applying any salves or ointments near the trach. If an antibiotic or antifungal ointment is ordered by the doctor, apply the ointment lightly with a cotton swab in the direction away from the trach stoma.
* Wash your hands after trach care.

Care of the Inner Cannula

Some older children and teens have trach tubes with an inner cannula. Some inner cannulas are disposable (DIC: Disposable Inner Cannula). These should be changed daily, discarding the old cannula. Check with your equipment vendor regarding disposable cannulas.

For the reusable cannulas, the cannula should be cleaned 1 to 3 times a day and more often if needed. Do not leave the inner cannula out for more than 15 minutes.
Equipment

* 1/2 strength hydrogen peroxide
* Sterile water or normal saline
* Two clean or sterile containers (small bowl or cup)
* Inner cannula brush (tracheostomy brush or sterile pipe cleaner)
* Unfilled gauze pad

Cleaning kits are available for inner cannula trach care. Check with your supply vendor.

Procedure

* Wash your hands.
* Explain procedure in a way appropriate for the child's age and understanding.
* Pour 1/2 strength hydrogen peroxide into a bowl or cup and normal saline or sterile water into the other.
* Open the gauze pad
* Remove the inner cannula
* Place the inner cannula into 1/2 strength hydrogen peroxide. Soak it for a few seconds and use the brush to clean secretions on the inside and outside of cannula.
* Place the cannula into normal saline or sterile water solution, soak and rinse.
* Dry off excess water with clean or sterile gauze pad.
* Suction through the outer cannula if needed.
* Replace inner cannula. Be sure the cannula is secure or "locked" in place in the trach tube.
* Wash your hands.

Cuffed Tracheostomy Tubes

A cuff is a soft balloon around the distal end of the tube that can be inflated to seal the trachea for children needing ventilator support or to help prevent secretions from entering the lungs.

Avoid over inflating the tracheostomy tube cuff. The pressure of the cuff against the wall of the trachea can cause damage if it is too high. Two techniques that can be used to help avoid excess pressure are the minimal occluding volume technique and the minimal leak technique.

Suction the trach tube if needed. After suctioning the tube, suction the mouth and above the trach cuff so that secretions do not go into lungs when cuff is deflated.
Cuff Deflation Techniques

* Minimal Occluding Volume Technique: Deflate the cuff, then slowly begin re-injecting air (or sterile water depending on the type of tube) with a luer lock syringe. Place a stethoscope to the side of the child's neck near the trach tube. Inject air into the pilot line until you can no longer hear air going past the cuff. This means the airway is sealed. For children that are totally ventilation dependent, provide breaths with manual resuscitator.
* Minimal Leak Technique: The same procedure as Minimal Occluding Volume, except that after the airway is sealed, slowly withdraw a small amount (approximately 1cc), so that a slight leak is heard at the end of inspiration.

Periodic measurements of the cuff volume should be noted and any changes reported to the doctor. A pressure manometer may be used to check cuff pressure on balloons filled with air. Generally, cuff pressure should be below 25 cm H2O.

Suctioning a Tracheostomy

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

* Sterile Technique: sterile catheters and sterile gloves
* Modified Sterile Technique: sterile catheters and clean gloves
* Clean Technique: clean catheter and clean hands

The size of the suction catheter depends on the size of the tracheostomy tube. Size 6, 8 or 10 French are typical sizes for neonatal and pediatric trach tubes. The larger the number, the larger the diameter of the suction catheter. Use a catheter with an outer diameter that is about half the inner diameter of the artificial airway this will allow air to enter around it during suctioning. You can also compute the catheter size with this formula: Multiply the artificial airways diameter in millimeters by two. For example, 8 mm X 2 = 16, so a 16 French catheter. Also see Tracheostomy Sizing Chart for recommended catheter sizes for specific Bivona and Shiley pediatric tracheostomy tubes.

Older children may be taught to suction themselves.
Suction Depths

* Shallow Suctioning: Suction secretions at the opening of the trach tube that the child has coughed up.
* Pre-measured Suctioning: Suction the length of the trach tube. Suction depth varies depending on the size of the trach tube. The obturator can be used as a measuring guide.
* Deep Suctioning: Insert the catheter until resistance is felt. (Deep suctioning is usually not necessary. Be careful to avoid vigorous suctioning, as this may injure the lining of the airway).

Signs That a Child Needs Suctioning

* Rattling mucus sounds from the trach
* Fast breathing
* Bubbles of mucus in trach opening
* Dry raspy breathing or a whistling noise from trach
* Older children may vocalize or signal a need to be suctioned.
* Signs of respiratory distress under Tracheostomy Complications

Equipment

* Suction machine
* Suction connecting tubing
* Suction catheters
* Normal saline
* Sterile or clean cup
* 3cc saline ampules (“bullets”)
* Ambu bag
* Tissues
* Gloves (optional for home care, use powder-free gloves)

Suctioning a Tracheostomy
Procedure

* Explain procedure in a way appropriate for child's age and understanding.
* Wash hands.
* Set up equipment and connect suction catheter to machine tubing.
* Pour normal saline into cup.
* Put on gloves (optional).
* Turn on suction machine (suction machine pressure for small children 50-100mm Hg, for older children/adults 100-120mm Hg)
* Place tip of catheter into saline cup to moisten and test to see that suction is working.
* Instill sterile normal saline with plastic squeeze ampule into the trach tube if needed for thick or dry secretions. Excessive use of saline is not recommended. Use saline only if the mucus is very thick, hard to cough up or difficult to suction. Saline may also be instilled via a syringe or eye dropper, which is less expensive than single dose units. Recommended amount per instillation is approximately 1cc.
* Gently insert catheter into the trach tube without applying suction. (Suction only length of trach tube - premeasured suctioning. Deeper insertion may be needed if the child has an ineffective cough.)
* Put thumb over opening in catheter to create suction and use a circular motion (twirl catheter between thumb and index finger) while withdrawing the catheter so that the mucus is removed well from all areas. Avoid suctioning longer than 10 seconds because of oxygen loss. Note: Some research has shown that by applying suction both going in and then out of the tube takes less time and therefore results there is less hypoxia. Also, there are now holes on all sides of the suction catheters, so twirling is not necessary.
* Draw saline from cup through catheter to clear catheter.
* For trach tubes with cuffs, it may be necessary to deflate the cuff periodically for suctioning to prevent pooling of secretions above trach cuff.
* Let child rest and breathe, then repeat suction if needed until clear (allow at least 30 seconds between suctioning).
* Oxygenate as ordered (extra oxygen may be given before and after suction to prevent hypoxia).
* Some children need extra breaths with an Ambu bag (approximately 3 - 5 breaths). Purposes of bagging: hyperoxygenation, hyperinflation, and hyperventilation of the lungs. However, this is usually not needed for stable children with no additional respiratory problems.

* The child's mouth or nose may also be suctioned, if needed after suctioning the trach, then dispose of that catheter (do not put same catheter back into trach).
* Dispose of suction catheter, saline and gloves, turn off machine. In home care, catheters may sometimes be used more than once before disposal or cleaning if child need frequent suctioning. Keep tip of catheter sterile, and store into original package.
* A bulb syringe may be used between suctioning if the child is able to cough up some secretions on his/her own.
* Be aware of color, odor, amount and consistency of the secretions and notify doctor of changes in secretions.

Other Suctioning Devices

* A newer suction technique, which is used most often in hospitals for children on ventilator support is a closed multiuse catheter system, also called an "in-line" catheter. This closed system allows suctioning without disconnecting the ventilator. The catheter is protected inside a sleeve and is usually changed only once a day.

* In addition to a stationary suction machine, small, portable, battery-operated suction machines are available for travel. The batteries are rechargeable or the machine can be plugged into a car cigarette lighter.
* The DeLee suction trap is a small plastic suction device. The caregiver sucks on a tube to create a negative suction pressure. (The secretions are collected in a sputum trap and do not come in contact with the caregiver.)

DeLee Suction Trap

* Luer lock syringe with a suction catheter attached. Disconnect the suction catheter from the thumb hole apparatus and attach the end of the catheter to the syringe. (Use size 8 or 10 french suction catheter)
* Bulb syringes can be useful for removing mucus at the opening of the tube, but does not replace routine suctioning of the length of the trach tube.
* Bulb syringe can be modified by cutting off tip of bulb syringe and inserting suction catheter hub into opening. To use, squeeze bulb, insert catheter into trach tube and release bulb (always remove catheter before squeezing bulb).
* The CoughAssist is an alternative to traditional suctioning that is especially helpful for those with an ineffective ability to cough. The CoughAssist assists patients in the removal of bronchial secretions from the respiratory tract. This is a new, vacuum-like, non-invasive technique. (See: Respironics, Inc.)

CoughAssist

* Hand-operated suction systems such as the RES-Q-VAC provides suction anywhere and anytime and is totally portable.
Encourage your child to cough; this also helps to clear the airway and lungs. Using chest P.T., postural drainage and percussion as needed to maximize airway clearance.

Changing a Tracheostomy Tube

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

* Same size trach tube with obturator
* Size smaller trach tube with obturator
* Trach ties
* Small blanket or towel roll
* Blanket for mummy restraint (if needed)
* Sterile water soluble lubricant
* Blunt ended scissors
* Tweezers or hemostats
* Suction machine
* O2 blow-by (if ordered)
* Good light source
* The kitchen or dining room table covered with a pad or blanket may be a good place for a trach change.

Procedure

* Explain the procedure in a way appropriate for a child's age and understanding. Use a calm gentle approach. If you are anxious, the child may sense this.
* Wash hands.
* Cut trach ties to the appropriate length, cut the ends of the tape at an angle to make it easier to thread through the hole in the trach wing (flange) and to prevent fraying. Or wrap a piece of tape around the end of the tie similar to the end of a shoe lace to make it easier to thread.
* Inspect all tubes for cracks, tears, or decreased flexibility before use, especially if tubes are reused. For cuff tubes, inflate cuff to check function and check for leaks (deflate completely before inserting).
Bring trach tie through one end of new trach tube. Avoid touching the part of the tube that is inserted into the trachea. Try to keep it sterile.
* Insert obturator into new tube; be sure it slides in and out easily. The obturator helps to guide the tube, and the rounded tip adds protection to the stoma during insertion.
* Place a small amount of sterile water soluble lubricant (surgilube or KY Jelly) on the end of the new trach tube and place the tube in sterile tray or clean surface until ready to insert. Note: Never use Vaseline or petroleum as a lubricant. Some doctors do not recommend using lubricant, because of the danger of aspiration. If you do use a lubricant, use it sparingly and wipe off excess.
* Have a suction machine and O2 handy if needed.
* Place the child on his/her back with a small blanket or towel roll under his/her shoulders to help with hyperextension. It might be helpful to wrap the child in a blanket mummy-style, if he/she is not cooperative. The child may also sit up for the trach change.
* Administer oxygen if ordered.
* Cut the old trach ties while holding onto trach tube. Always hold the tube when ties are not secure; a cough can dislodge the tube.
* Gently remove the old trach tube (follow angle of the tube, an upward and outward arc).
* Insert the new tube in a smooth curving motion directing the tip of the tube toward the back of the neck in a downward and inward arc (like inserting a suction catheter).
* Do not force the tube!
* Remove the obturator immediately while holding the tube securely with the other hand. Remember that the child cannot breath with the obturator in place.
* Changing the trach tube will cause the child to cough; do not let go of the tube.
* Thread the trach tie through other end of tube and tie, allowing one finger between the neck and the ties. Tweezers or hemostats may be needed to thread ties through the hole of the wing of tracheostomy tube. Once the ties are properly adjusted, secure with a double or triple square knot and cut off the excess tape (Never tie in a bow).
* Inspect old tube for color, mucus plugs or odor, then discard. Most plastic pediatric trach tubes are disposable and are not washed and reused. Metal tracheostomy tubes are washed, then boiled to sterilize and reused.
* When changing trach tube, observe for skin irritation, breakdown, and signs of infection.
* Remember to praise the child. A trach change can be emotionally difficult for some children.

Tracheostomy Ties

Tracheostomy ties will need to be changed more often than the tube if they become soiled, wet, loose or cause pressure on the child's skin. Some specialists recommend changing ties daily, although this is usually not necessary in home care. However, infants with short fat necks, overweight children, and children on high humidification will probably need daily tie changes. Trach tie changes should also be done with two people. Twill tape comes with the tracheostomy tube or by the roll. If possible, secure new ties before removing old ties to decrease chances of the trach tube dislodging. There are several different techniques for securing the tracheostomy ties. The important things to remember are to use a knot, not a bow, and to be sure the ties are snug, but not too tight. You should be able to slip one finger under the ties. Change the position of the knot slightly with each change to avoid skin breakdown from the knot. If skin irritation does occur, place a gauze pad under the ties or use soft Velcro ties instead.

Check tension of trach ties several times a day, because ties may loosen.
Some Ways to Secure Trach Ties

* Use one long piece of twill tape and thread half the length through one side of trach tube. Then bring one end around the back of the neck and through the other side of the trach tube and tie the two ends in a triple knot in the back of the neck.
* Mallinckrodt (maker of Shiley Tracheostomy Tubes) recommends cutting two lengths of twill tape, each long enough to fold in half and still reach around the child's neck. Thread the folded end of one of the ties through one of the holes on the trach tube, going from skin side out. Pull the tie through until it forms a loop. Draw the ends through the loop until the tie is secured to the tube. Repeat on the other side of the trach tube. Bring the loose ends of both ties around to the back of the neck and tie them together using a square knot.
* Cut two pieces of twill tape long enough to fit around the neck and tie. Cut the tie at an angle to prevent fraying. Cut a 1/4 inch slit in each tape about 1 inch from the end. Insert the cut end of the tape through the neck plate hole from back to front. Pull the other end of the tape through the hole in the tape using tweezers or hemostats. Pull tightly while holding the tube. Repeat this on other the other side. Bring both ties together and tie in a triple square knot.
* Velcro straps, such as the Dale tracheostomy tube holder. Note: Velcro holders are comfortable and easy to adjust; however, keep in mind that toddlers and children with developmental disabilities may be able to release Velcro. If you clean and reuse Velcro ties, be sure the Velcro still holds securely after washing.
* Cotton shoe laces can be fun, as they come in many different colors and designs and are easy to thread.
* Umbilical cord tape or hemming tape from a sewing store can also make good trach ties.
* Metal trach holders are good because they do not trap moisture and they are reusable. However, they are also hard to find. Some parents have had these custom made by jewelers. Note: Keep wire cutters handy incase of an emergency when using metal trach holders.

Risk Factor Associated with Difficult Tracheostomy Tube Changes

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

Techniques for a Difficult Trach Change

* The obturator helps make insertion easy and trauma-free. Always keep an obturator on hand should the tube need an emergency change.
* Reposition the child if needed
* If the tube cannot be completely inserted, hold the tube in place, remove the obturator to let the child breathe, then continue to insert to tube.
* If still unable to insert tube, remove the tube, re-lubricate and try again.
* If this is unsuccessful, try to insert the one size smaller tube.
* Try spreading the skin around stoma and try to insert tube as the child is breathing in.
* If needed, insert a suction catheter through the smaller tube and guide the suction catheter into the trach stoma. Then slide the trach tube over the suction catheter and into the stoma. Remove the suction catheter. Click on thumbnail
* If all else fails, cut a section of suction catheter to place it into the stoma in order to keep the stoma open and maintain an airway. Be sure to cut the catheter long enough so that it cannot be aspirated! Hold on to the catheter and call emergency services.
* Give supplemental oxygen if needed and available

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

Tracheostomy Humidification

The nose and mouth provide warmth, filtering and moisture for the air we breath. A tracheostomy tube by-passes these mechanisms. Humidification must be provided to keep secretions thin and to avoid mucus plugs. Children with tracheostomies do best in an environment of 50% humidity or higher.
Equipment

* Air compressor
* Nebulizer bottle
* Aerosol tubing
* Trach mask
* Sterile water
* Saline ampules (“bullets”)
* Heat Moisture Exchanger (HME) Also known by several other terms including: Thermal Humidifying Filters, Swedish nose, Artificial nose, Filter, Thermovent T.
* Room humidifiers

Humidity should be delivered while sleeping. Attach a mist collar (trach mask) with aerosol tubing over the trach with the other end of tubing attached to the nebulizer bottle and air compressor. Sterile water goes into the nebulizer bottle (do not overfill, note line guide). Oxygen can also be delivered via the mist collar if needed.
Heated mist may be ordered. Heated mist is accomplished by an electric heating rod that fits into the nebulizer bottle. Extra care should be taken to be sure the bottle does not go dry, which could melt plastic. Many of these heating elements do not have automatic shut-offs and this could be a potential fire hazard. Also, more moisture will accumulate in the aerosol tubing with heated mist. Moisture that accumulates in the aerosol tubing must be removed frequently to prevent occlusion of the tube and/or accidental aspiration. Disconnect tubing at the trach end, empty into a container and discard. Do not drain fluid into the humidifying unit. Fluid traps (or drainage bags) are helpful in preventing occlusion and aspiration. These collection devices also need to be emptied frequently. Position the air compressor and tubing lower than the child to help prevent aspiration from moisture in the tubing. A mist collar can also be worn during the day when mucus is thick or blood tinged. Sterile saline drops can be instilled into the trach tube if secretions become thick and difficult to suction. A saline nebulizer treatment is also helpful to loosen secretions if the child has a nebulizer machine. Additional fluid intake can also helps to keep secretions thinner.

Secretions can be kept thin during the day by applying a Heat Moisture Exchanger (HME) to the trach tube. An HME is a humidifying filter that fits onto the end of the trach tube and comes in several shapes and sizes (all styles fit over the standard trach tube opening). There are also HME’s available for portable ventilators. Bedside ventilators have built-in humidifiers. HME’s also help prevent small particles from entering the trach tube. Change HME daily and as needed if soiled or wet.
Although room humidifiers are also helpful, it is vital that these machines be cleaned regularly to prevent bacterial growth. Warm mist humidifiers are especially prone to bacterial growth. Bacteria, mold and mildew grow best in warm, wet environments. Use caution with ultrasonic humidifiers because they can produce ‘white dust,’ which can be harmful when inhaled. The higher the mineral content (the harder your water is), the greater the potential for white dust. Using distilled water can help prevent white dust. The regular cool mist humidifiers are often the best choice, unless otherwise directed by your doctor. Clean and refill room humidifiers daily.

Precautions For Parents

A child with a tracheostomy can do most things that other children do. Try to treat your child as normally as possible. It is important not to be overly protective. However, children with trachs must be watched very closely, since they may not be able to verbally indicate discomfort. Water represents a particularly serious threat, as drowning can easily occur if the tube is submerged in water.

Here are some precautions for children with tracheostomies. Remember that each child is different and that common sense goes a long way when caring for a child with a trach.

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

Emergency Plan for a Child with a Tracheostomy

* Post CPR instructions at the child’s bedside.
* Have emergency telephone numbers posted near each telephone.
* If possible, have a phone within reach of the child's bedside.
* A cordless telephone may be helpful to have access at all times.
* A mobile phone for travel if possible
* Notify electric, gas and telephone company that you have a child with a tracheostomy and whatever other medical issues he/she might have, so that your home is a priority in resuming service in the event of a power outage.
* Notify Police and Ambulance services that you have a child with a trach in your home.
* Notify the Fire Department if you have oxygen in your home.
* If snow is a problem in your area, notify your Department of Public Works for snow removal priority. Road repairs could also be a potential problem.
* Always have an extra trach tube with obturator, ties and scissors handy both at home and away from home. You may want to keep ties in place on the tube in order to save time in an emergency.
* Medic-Alert bracelet may be helpful.
* Develop an emergency plan and train all family members.
* Pack an emergency bag to take with you whenever you take your child away from home ("Travel Kit" under Equipment Needs).

Infection Control

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

What is RSV?

RSV stands for respiratory syncytial virus, the most frequent cause of serious respiratory tract infections in infants and young children. This is such a common virus that virtually all children have been infected by RSV by the age of 3. In most children and adults, RSV results in a respiratory infection that is not distinguishable from a common cold. However, for infants and children with underlying conditions, such as prematurity, lung, heart and immune deficiency diseases, RSV can be a very serious respiratory illness requiring hospitalization.

Avoid crowded places and avoid contact with people who have cold symptoms. When a family member is sick, extra precautions must be taken by washing hands often and preventing the spread of infectious secretions on tissues and objects.

Ask your doctor if Respigam would be helpful for your child. Respigam is an immune globulin that is given in injections throughout the RSV season for children at risk.


Tracheostomy Complications
Respiratory Distress and Tube Obstruction

Mucus plugs are the most common cause of respiratory distress for children with tracheostomies. Symptoms of a mucus plug include resistance when trying to suction or bag and/or signs of respiratory distress.
Symptoms of Respiratory Distress

* Difficulty breathing
* Increased respiratory rate
* Increased heart rate
* Grunting, noisy breathing
* Stridor (audio file) (video file)
* Whistling noise when breathing
* Cyanosis (pale, blue color around lips, nail beds, eyes)
* Restlessness
* Sweaty, clammy skin
* Retractions (pulling in of the skin between the ribs, and below the breast bone, above collar bones or in the hollow of the neck)
* Anxiety, frightened look
* Flared nostrils
* Change in pulse or blood pressure
* Infants may have trouble sucking
* Difficulty or refusing to eating
* Inability to wake the child
* Head bobbing due to use of strap muscles for breathing
* Reduced airflow through the tube
* More comfortable with head elevated or sitting up
* Low O2 saturations for children with a home pulse oximeter
Suction trach or change trach tube as needed for respiratory distress. The tube may have become blocked with dried secretions or blood. If symptoms do not clear with suction or trach change, call the doctor or 911, go directly to the emergency room, or call an ambulance.
Bleeding

Very small amounts of bleeding (pink or red streaked mucus) often occurs as a result of routine suctioning. This bleeding can be managed with close observation and by modifying the care that might have caused the problem.
Possible Causes of Minor Bleeding

* Irritation to the fragile tissue around the stoma
* Insufficient humidity to the airway
* Too frequent, deep or vigorous suctioning
* Suction pressure that is too high (Suction machine pressure for small children 50-100mm Hg, for older children/adults 100-120mm Hg)
* Infection
* Trauma, manipulation of trach
* Foreign object in the airway
* Excessive coughing

Call your doctor, emergency services, or go directly to your local emergency room for a significant amount of bright red bleeding from the tracheostomy.
Infection

Children with tracheostomies are at high risk for respiratory infections. The trach tube bypasses the natural defenses (nasal hair and mucus membranes) of the upper airway that filter out dust and bacteria. Also, monitor for local infections at the stoma site. Hand washing before any trach care is one of the best defenses against infection.
Symptoms of Infection

* Yellow or green secretions (may be pink/blood tinged)
* Thicker mucus
* Increased amount of mucus
* Redness, rash and/or inflamed at stoma site
* Bleeding at stoma site
* Foul odor
* Elevated temperature (fever)
* Congested lung sounds
* Increased respiratory effort or change in respiratory rate
* Listlessness
* Discomfort with trach care, tender at stoma site

Tracheitis
A dry tracheitis is an infection in the trachea that may develop if humidification of the airway is inadequate.

Call the doctor for symptoms of infection.
Other Complications

Tracheal Stenosis
Scar tissue at the site of the tracheostomy tube, often from excessive trach cuff pressure.

Tracheoesophageal Fistula
An abnormal connection between the trachea and the esophagus resulting from erosion of the back wall of the trachea.

Granuloma (common)
A growth of inflammatory tissue, which is caused by the irritation of the airway by the tracheostomy tube.

Pressure Necrosis
Infants with short, fat necks or children on mechanical ventilation may develop infections or pressure sores of the skin and soft tissue around the trach site. Inspect skin daily.

Tracheoinnominate Fistula (rare)
An erosion of the tube into a large artery that runs in front of the trachea. Hemorrhage could lead to death if not stopped.
Accidental Decannulation (What to Do If the Trach Tube Comes Out Accidentally)

* Try to Stay calm
* Reinsert tube immediately even if conditions are not ideal.
* There should always be two spare trachs with the child at all times, the child’s size and one size smaller for emergency replacement. If the regular size does not fit, then the smaller size will keep the airway patent (open). Keep two trach tubes taped at the head of the child’s bed and in your travel bag. Always keep blunt-nosed scissors handy to cut trach ties.
* Opening the airway is always the first priority. If a spare trach tube is not handy, replace the one that came out. Later, when the situation is under control, you can replace it with a clean trach tube.
* If you cannot reinsert the tube, observe the child to see if he/she can breathe through the stoma itself. This may be possible if the stoma is well healed and fairly large. The child may also be able to breathe through the nose and mouth if there is no severe obstruction above the trach site. Go immediately to the emergency room.
* Comfort the child when situation is under control.
* See Changing Tracheostomy Tube, which includes, "Techniques for a Difficult Trach Change."
* Children with trachs are often on some type of monitoring device (apnea monitors or pulse oximeters) when not directly supervised (naps and bedtime), to alert caretakers in the event of a problem such as accidental decannulation or a mucus plug. Ask your physician about these devices and if they would be appropriate for your child.
* A less sophisticated but useful alarm is to attach bells to the child's legs and/or arms. However, be sure that the bells cannot be removed or swallowed!
* It may be comforting to have the child sleep in the same room with you for closer monitoring, particularly infants and young children.

What to Do If Your Child Pulls on the Trach Tube

* Caring for a child with a tracheostomy may cause anxiety. Try not to let the child see that you are anxious.
* Try not to make a big deal about the trach, particularly if the child touches the trach tube. They will learn very quickly that by touching or pulling the trach tube, they receive attention, which tends to reinforce the behavior.
* Once children develop a pattern of pulling on the trach tube, it is more difficult to control, especially for young children and children with developmental disabilities. A Tracheostomy Collar may be helpful in preventing the child from pulling out the tracheostomy tube. A trach collar is like a belt with a hole in the center for the trach tube opening, then it fastens in the back of the neck. Check with your doctor or medical supply vendor.

CPR with a Tracheostomy

All parents and caregivers should be trained in cardiopulmonary resuscitation (CPR). In fact, infant and child CPR classes for parents are required before a baby can be discharged from many Neonatal Intensive Care Units (NICU). Although it is not the purpose site to teach CPR, I would like to point out some important differences when delivering CPR to an infant or child with a tracheostomy tube.
If the Child is Not Breathing

* Open the airway using the chin lift, but do not hyperextend the neck.
* Suction the trach tube.
* If the trach has an inner cannula, remove the inner cannula and suction slightly past (mm) the length of the trach tube.
* Change the trach tube if plugged or dislodged.
* Give two gentle puffs of air into the trach tube using an Ambu bag (breathing bag) with trach adapter or mouth to trach technique.
* If air leaks from nose and mouth, hold them closed.
* If the tube is obstructed or lost, it may be possible to give ventilation by sealing your mouth over the stoma and blowing or place the face mask of ambu bag over the stoma (gently, just enough to cause the child’s chest to expand).
* If the child's airway is not obstructed, you can use mouth to mouth resuscitation by closing the stoma with your finger.
* Give CPR as indicated.