caring for your child's tracheostomy - rt connection · caring for your child's...

Caring for Your Child's Tracheostomy


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Table of Contents

The Definition and Purpose of a Tracheostomy .............................................................................. 3

What to Expect During Your Stay ......................................................................................................... 4

Weekly Goals

Week 1 .........................................................................................................................5

Week 2 ........................................................................................................................5

Week 3 ........................................................................................................................6

Week 4 ......................................................................................................................... 6

Background Information

Types of Tracheostomy Tubes ................................................................................................ 7

Parts of the Tracheostomy Tube……………………………………………………………..7

Tracheostomy Care

Stoma Care ..................................................................................................................8

Changing Trach Ties ............................................................................................................ 11

Trach Suctioning ......................................................................................................................... 15

Changing the Trach Tube ..................................................................................................... 19

Cleaning the Used Trach ...................................................................................................... 23

Humidification/Speaking Valves ........................................................................................... 24

Mucous Plugs/Ambu Bag Use ............................................................................................. 26

Trach CPR ................................................................................................................... 27

Daily Life ................................................................................................................................................. 29

Travel/Emergency Kit .............................................................................................................................. 30

Important Phone Numbers/Helpful Website ................................................................................ 31

Appendix 1 ...................................................................................................................................................... 32


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The Definition and Purpose of a Tracheostomy

A tracheostomy is a surgical opening (stoma) in the neck and into the windpipe (trachea) that will allow

your child to breathe better.

Children receive a tracheostomy ("trach") for many different reasons: airway defects, breathing problems,

accidents or other injuries or problems. The length of time your child will need the trach will depend on

many factors that will be discussed between you and your doctor.

The reason my child has a tracheostomy is:


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What to Expect During Your Stay

Before going home, you will learn to provide complete care of your child's trach. You will be taught

everything you need to know to keep your child safe at home and will work closely with nurses and

respiratory therapists to make sure all of your questions are answered.

We require that you and one other caregiver are both trained in all proper and necessary care for

your child's tracheostomy. This will mean that you are both required to perform necessary skills in

caring for the tracheostomy before you go home from the hospital. These skills include:

Stoma care

Trach suctioning

Trach changes

Trach Cardiopulmonary Resuscitation (CPR)

Oxygen home therapy, Nebulizer treatment, Ventilator, Home monitor, Use of ambu bag,

Emergency checklist

These skills will be discussed individually later in this manual,

You and the second caregiver will also be required to "room in" with your child for a 24-hour period

independently before you go home, where you will be responsible for providing all necessary care, but will

have nursing and respiratory staff available for questions or concerns


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Weekly Goals

Although it is impossible to predict how long your child will be in the hospital, we have outlined

weekly goals for you as you learn to take care of your child's tracheostomy. These are guidelines. Your child's situation may not follow these time lines exactly.

Education Week 1

1. Read handouts regarding your child's diagnosis, medications, equipment and the teaching plan for discharge

2. Identify the primary and secondary caregivers 3. Observe care performed by the nurse and the respiratory therapist (RT):

a. Trach cleaning/trach change b. Trach suctioning c. G-button care/feeding (if applicable)

d. Medication administration e. Nebulizer treatment (RT) f. Use of Ambu bag (RT)

4. Perform these Care Steps under the guidance of the nurse and the RT. This will be called Care Set #1.

a. Trach cleaning/stoma care b. Trach suctioning

c. G-button care/feeding (if applicable) d. Medication administration e. Nebulizer treatment (with RT)

f. Use of Ambu bag (with RT)

5. Begin planning with the case manager and the social worker for home care needs and

equipment. Please provide your questions and concerns to the case manager and social worker.

6. Questions/Concerns I would like addressed: .___________________________________________________ .___________________________________________________

.___________________________________________________

Education Week 2

1. The primary and secondary caregiver will perform Care Sets #2 and #3 under the guidance of the nurse and the RT:

a. Trach cleaning/stoma care

b. Trach suctioning c. G-button care/feeding (if applicable)

d. Medication administration e. Nebulizer treatment (with RT) f. Use of Ambu bag (with RT)

2. Parent to change trach 3. Attend Trach CPR. Schedule after 1st trach change is complete.


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Education Week 3 1. The primary and secondary caregivers will Perform Care Sets when needed.

2. Training is completed by a Durable Medical Equipment representative. Utilize Home

Equipment for care

3. Trach Change #2

4. Complete Home Ventilator Teaching with RT (if applicable)

5. Plan for home care needs with the case manager and/or the social worker Questions/Concerns I would like addressed:

__________________________________________________ _____________________________________________________ _____________________________________________________

6. Complete the 24 – hour “Rooming In”

Both the Primary and the Secondary caregiver must complete a full "Rooming In" experience independently.

Education Week 4 1. The primary and secondary Caregiver Perform Care Sets when

needed 2. Trach Change #3 3. Finalize home care needs with the case manager and/or the social worker

Questions/Concerns I would like addressed:


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Background Information

Types of Tracheostomy Tubes

There are different types and brands of trachs. Your doctor will determine what type of trach and the appropriate size to meet your child's needs.

Your child's trach is a:

Type: _____________________ Size: _______________

Parts of the Tracheostomy Tube

Connector: the part of the trach tube that sticks out of the neck that can connect to the ventilator and the Ambu bag

Cannula: the part of the trach tube that goes inside the windpipe (trachea)

Cuff: a small balloon filled with air that helps to hold the trach in place and prevent air from escaping around it; the side port allows the balloon to be filled or emptied. Not all trachs have a cuff

Neck plate: the part of the trach tubes where the ties are attached; also called "the wings" of the tube

Obturator: placed inside the tube to guide the tube into the trachea during insertion


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Cuffed Trach: Uncuffed Trach:

Neck Plate Side Port

Tracheostomy Care

Stoma Care

It is important to clean the area around the trach tube at least twice a day. You may have to do

this more often right after your child's trach is established because of increased secretions and

moisture. The site should be kept as clean and dry as possible.

Be watchful for signs of infection around the stoma, including:

Redness O d o r Pus or discharge Skin breakdown

Supplies

Towel roll Sterile water (see Appendix 1, pg. 37)

Cotton tipped applicators Absorbent dressing Trach ties

Obturator Inner Cannula


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Procedure

1. Wash hands with soap and water.

Dry with clean towel.

2. Gather supplies.

3. Place a towel roll under your child's 4. Remove the old dressing.

shoulders. Inspect the site for any skin

breakdown, signs of infection or

rashes.


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5. Use wet cotton tipped applicator to clean around stoma site. Swab should be dipped in sterile water. If crusty drainage is present, use 1/2 strength peroxide. Begin at the top of the stoma

and wipe in one straight line away from the opening. Discard this swab. With a new wet swab,

start again the top of the stoma on the opposite side and repeat. Discard this swab and continue

this procedure along the border of the stoma until all areas are cleaned. Remember to wipe the

wings as well.

6.Use dry cotton tipped applicator to dry area around the stoma site. Use the same procedure

outlined above, but with dry cotton swabs. Be careful not to allow small pieces of cotton to be breathed into the stoma.

Sterile Water


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7.Apply the absorbent dressing or gauze and replace the old trach ties with a clean set

(See Trach Tie Change). If using Polymem®, place This side out" away from your child's skin. If using gauze, never cut it because pieces of the gauze can be breathed in.

Key Points:

Do not apply lotions or powders near the stoma.

Only apply ointment to your child's neck as directed by your doctor.

Report any breakdown in the skin, foul odor, drainage or rashes to your nurse or doctor.

The skin around your child's stoma should be the same color as the rest of their skin.

The stoma should be pink, like the inside of your child's mouth.

Trach Tie Change

Trach ties hold the trach tube in place and must be attached to the trach at all times unless you are

performing a trach tie change. You should change the trach ties at least once a day and whenever they

become wet or dirty, regardless of the last time they were changed.

Supplies

Another person

Towel roll

Sterile water

Cotton tipped applicator

Clean trach ties Absorbent dressing

Soap and water

Clean washcloths Nystatin powder if ordered


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Procedure


Dry with clean towel. 2. Gather supplies.

3. Place a towel roll under your child's 4. Remove the old dressing.

shoulders. Inspect the site for any skin breakdown, sign of infection or

rashes.


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5. Clean the stoma as directed under "Stoma Care" (pg. 8)

6. Agree on who is the "Holder." This person is responsible for holding the trach in place while

the other person replaces the ties.

The Holder must hold the trach in place throughout the entire tie change!

7. Remove the trach tie from one side. While the "Holder" holds the trach in place, unattach one

side and bring it around the back of the neck to where the other side is still attached.

8. Wash the neck. Use mild soap and water, rinse and then dry thoroughly with a washcloth. Look

for signs of skin breakdown or rash around the neck; pay special attention to the back of the

neck. If needed for skin break down, use Nystatin powder. Use away from child to avoid

aspiration. Put powder into hand and apply to neck.


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9. Attach clean trach tie to the empty wing. Bring it around the back of the neck to the other side.

Place a clean dressing under the trach.

10. Remove the old tie; attach the new one. Make sure the trach tie is securely attached to the

wings, but not too tight around your child's neck. You should be able to insert your little finger

between the tie and the back of your child's neck.

Key Points:

Clean dirty or used trach ties with mild soap and water and hang them to dry. Do not put trach

ties in the dryer.

Check trach ties before each use. If they become stiff, frayed, hard or the velcro is not sticking,

then replace them with new trach ties.

Report any breakdown in the skin or rashes to your nurse or doctor.


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Trach Suctioning

Suctioning removes mucous from your child's trach. The amount of suctioning needed is different for

each child. Suction only as needed but at least once in the morning and once in the evening to check

patency. Mucous builds up during sleep. It is good to suction the trach when your child wakes up.

Suctioning before eating will help prevent coughing during meals. Try to avoid suctioning after meals to

prevent vomiting.

Normal mucous looks clear to white in color and can be thin to slightly thick. Mucous should not look

yellow or green in color or have an odor.

You should suction when your child has any of the following:

Mucous at the opening of the trach causing bubbling or gurgling sounds

Coughing and bringing up mucous

Breathing faster or harder than usual

Restless or scared Chest is not moving because of a mucous plug

Mouth or lips are pale or blue in color

As your child gets older, they may be able to tell you when they need to be suctioned.

Determine length of catheter for suctioning

Suction catheters should not be inserted any deeper than needed. Suction catheters have numbers of

lines at the end of the catheter, Measure one catheter for the correct length for insertion against a spare

trach tube. Write this number down and keep with your suction machine.

Suction machine with tubing Suction catheters Sterile water (See Appendix 1, pg. 32)

Clean gloves

Saline drops, if needed for thick secretions

Ambu bag and mask Extra trach tube Obturator nearby

Your child's suction depth is: ____________

Supplies


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Procedure

1. Wash hands with soap and water. 2. Gather supplies.


3. Turn on the suction machine and set 4. Put on clean gloves and attach suction

the pressure to 80-120 mm Hg. catheter to suction tubing. Make sure not to touch the last 2-3 inches of the catheter.


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5. Hold the catheter with fingers slightly above the measured mark for suctioning.

This technique will help prevent the catheter from going in too deep.

6. Insert the tip of the catheter into the trach while continuing to hold the catheter at the

pre-measured mark.

7. Apply quick suction as you enter to the connector then release as you go down the tube. This

will catch any mucous sitting there that may have been coughed up into the connector.


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8. Apply suction while twirling (not stirring) catheter between your fingers as you remove the

catheter. Each suction period should take 3-5 seconds. Allow for recovery time or give 3-5 breath with

the Ambu bag, as needed. Repeat steps 6 & 7 until mucous is cleared. You may have to use saline

drops here only for very thick secretions.

9. After you have finished suctioning, clean the catheter by suctioning sterile water through the tubing.


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Tract, Tube Change

Change the trach tube once a week and as needed. Using two people to change the trach tube is best,

but in an emergency you MUST be prepared to do this alone.

You will not be hurting your child when you change the trach

Your child may cough and/or cry while you change out the trach

It is usually best to change the tube prior to meals or at least 2 hours after eating

Do not touch the end of the trach cannula that goes into the windpipe Always have the same size trach and one size smaller within reach during trach change!

Supplies

Another person

Towel roll Clean gloves

One current size trach tubes

One size smaller trach tube

Clean trach ties

Water soluble lubricant Suctioning supplies

Clean dressing

Ambu bag

Procedure



2. Gather supplies and set up within reach.


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3. Apply clean gloves. Attach one side of the trach tie to the clean trach and place the obturator

into the new/clean trach.

Lubricate the tip of the new trach, but be careful to avoid touching the tip of the cannula or allow

anything to touch it.

4. Place your child on his/her back with a roll under their shoulders.

5. Suction your child's trach (See "Trach Suctioning", pg. 15)


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6. The first person removes the trach ties while holding the trach in place. This is a good time to do

trach care if needed (see trach care).

7. Make sure the second person is ready with the new trach before the first person removes the

old trach.

8. The first person removes the old trach and the second person inserts the new one in one

curving motion. Keep the child's neck extended by holding their chin up; this will make insertion easier.


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9. Once the new trach is inserted, immediately remove the obturator to allow your child to

breathe. Do not let go of the trach! (Save obturator in case of accidental decannulization)

10. Listen or feel for air movement from the track

11. Secure the trach in place with new trach ties and dressing. Suction if necessary.


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Key Points:

If the trach does not go in easily:

Do not force the trach into the windpipe

Reposition your child, lift their chin

Remember you have time to place the new trach in

Re-lubricate the tip of the trach tube and try again

If still unable to insert the trach, try one size smaller

If unable to insert the smaller trach, call 911

If your child is not breathing, begin CPR and call 911

Cleaning the used trach

Inspect for cracks, tears or stiffness. You will be given a limited number of trach tubes. The Shiley trach

has a 30 day use. The Bivona trach can be cleaned a maximum of 5 times. Your nurse will teach you how to clean the trach.

Shiley Trach

1. Wash hands with soap and water; dry with a clean towel. 2. Wash trach and obturator in mild soap and water, then rinse with hot water. 3. Prepare 1/2 strength hydrogen peroxide solution in a clean container

(The solution is made by mixing 1 Tbsp. hydrogen peroxide with 1 Tbsp. sterile water. Do not pre-mix the solution; it will not be effective. Discard the old, used solution when finished cleaning.)

4. Wash the trach in the solution.

5. Rinse with sterile water. 6. Let the trach and obturator air dry on a clean paper towel. 7. Store the trach in a clean zippered plastic bag. If any moisture is noticed in the bag, the

trach must be cleaned again. 8. Do not leave the trach soaking in the peroxide mixture.

Bivona Trach

1. Wash hands with soap and water; dry with a clean towel. 2. Gently wash trach and obturator with mild soap scrubbing with a soft bristled brush. Rinse

thoroughly with water. 3. Bring distilled water to a boil in a clean pot and remove from heat. 4. Place trach and obturator side-by-side in the pot. 5. Cover the pot with the lid and allow water to cool. 6. Handle trach by the wings and obturator handle; air dry on a clean paper towel. 7. Store the trach in a clean zippered plastic bag. If any moisture is noticed in the bag, the

trach must be cleaned again.


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Humidification

Humidification is very important for your child's trach. Your nose helps you breathe air into your lungs.

As the air passes through your nose, it is warmed and humidified. When air is breathed through the

trach, the nose cannot provide the warmth and humidification needed to keep your child's secretions thin

and moist. Humidification for the trach helps prevent thickening of your child's mucous which can plug

the trach.

There are two ways to provide humidification:

Mist Collar

The mist collar is an aerosol mask placed over your child's trach that allows your child to breathe

humidified air. This method is used most often when at home, awake or asleep. The humidified air may

also be heated if directed by your doctor.

Heat and Moisture Exchanger (HME)/"Artificial Nose"

The artifical nose is placed directly on the end of the trach to provide continuous humidification of air. It

may be used for short periods of time when your child is awake and active. Your child's doctor will decide

when your child is ready for an HME. Insurance supplies 1 per day.


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Speaking Valves (Passy Muir Valve)

When your child breathes through the trach, no air passes up through their vocal cords. The vocal cords

need air to make them vibrate, which enables you to talk. A "speaking valve" can help your child make

noises, allowing them to talk. Your pulmonologist, ENT, respiratory therapist and speech therapist will

help determine when your child is ready to begin using a speaking valve. Many children need time to

adjust to this new way of breathing; therefore, it is necessary that you gradually increase the time your

child is using the speaking valve.

A speaking valve is no the same as an HME. It does not humidify the air breathed in. Always continue to

humidify the air while your child is using the speaking valve.


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Mucous Plugs

Mucous can become thick and "plug" the tracheostomy tube. When this happens, no air flow will be able

to pass through the tube.

Signs of a possible mucous plug:

No sound of air passing through the trach

Blue coloration around the mouth or fingernail beds

Child is having difficulty breathing with nasal flaring

A "whistling" sound with breathing

Inability to pass a suction catheter through the trach tube

What to do if a mucous plug is present:

Instill saline drops to try to loosen up the mucous; then attempt to suction the trach

Repeat the saline drops and give breaths with the Ambu bag to push the saline drops down to the

plug. Attempt to suction again.

If still unable to pass the suction catheter, then remove the trach and replace with a new/clean

one.

Ways to help prevent mucous plugs:

US A a mis t col la r

Perform routine trach changes

Suctioning

Saline drops with thick secretions

Provide enough fluids with feedings

How to use the Ambu Bag

Connect the valve end of the bag to your child's trach.

Squeeze the Ambu bag slowly with one hand; squeeze enough air so that your child's chest

gently rises.

Let go of the bag and allow it to refill. Your child's chest will go down.

Squeeze and release the bag at the rate your child normally breathes, one breath every 3

seconds.

Do not leave the bag attache to your child's trach without squeezing it to give breaths!

Oxygen may be attached to the Ambu bag as needed.


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Trach CPR (Cardiopulmonary Resuscitation)

During your stay, you will be taught how to perform CPR with the trach and how to use an Ambu bag to

breathe for your child.

If you find your child unconscious and not breathing:

1. SUCTION THE TRACH AT ONCE. Then use the Ambu bag to give breaths.

2. IF YOU ARE NOT ABLE TO GIVE BREATHS WITH THE AMBU BAG AFTER SUCTIONING, REPLACE THE TRACH WITH A NEW/CLEAN TRACH IMMEDIATELY.

Begin CPR if the child does not breathe when the trach tube is clear:

1. Call for help and stimulate the child by gently shaking or tapping the baby's foot.

2. Position the child on a hard fiat surface with his nose pointed straight up.

3. Look, listen and feel for breath by placing your ear over the tracheostomy opening for about 3-5

seconds. Look at the chest to see if the child is breathing.

4. If your child is not breathing, attach the Ambu bag to the trach, or you can place your mouth over the

trach tube to form a seal.

5. Gently squeeze on the Ambu bag or blow gently into the trach, giving 2 slow breaths. Observe to see

if chest moves like an easy breath.

6. Look for signs of circulation (breathing, cough, movement) for 5-10 seconds and check to see if child

is breathing on his own (look, feel and listen for air movement).

7. If you see signs of circulation, give "rescue breathing" — breathe with mouth or Ambu bag on tube.

Count: 1-2 breathe; 1-2 breathe.

8. If air is leaking from the nose and mouth, close them with your hand.

9. If you do not see any signs of circulation such as the infant opening their eyes, moving, or

crying/coughing, begin chest compressions at a rate of at least 100 times a minute. Give 30

compressions, press down 1/2-1 inch for infants, and 1-1% inches for children with each compression.


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Then give 30 chest compressions and two breaths in cycles as you continue CPR for 5 cycles. This

should take about 2 minutes.

10. Call 911 for an ambulance if the child does not respond after the 2 minutes of CPR.

11. Check for signs of circulation and breathing every 2-3 minutes. Do what the child is not doing.

If no breathing, but has signs of circulation, give rescue breathing with Ambu bag or mouth-to-

trach.

If no breathing an no signs of circulation, give compressions and breathe with mouth-to-mouth

12. If the trach has come out and you can not get it back tin—Put your hand over the hole and give

mouth to mouth/mouth to nose breathing—You will be able to give air this way as long as you cover the trach hole.


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Daily Life

Helpful tips prior to going home:

Practice strolling your child around before leaving the hospital with all the equipment needed (ex.

ventilator, portable suction machine, etc.)

Always prepare the room that your child will spend time in with suction machine, as well as an

emergency kit (See pg. 35). This includes going outdoors or leaving your home.

Preparing your home:

o Power, phone, smoke detectors

o Set up room and supplies

o Travel with 2 caregivers

o Oxygen in the home

o Notify your Electrical Company

Meals:

Eat age-appropriate foods

Always eat or drink in an upright position, even when bottle feeding

Leave your child upright after feeding to reduce the risk of aspiration

Remember to make sure the trach opening is properly protected so no food particles may enter

Bathing:

Always prepare a shallow bath

Use care to prevent bath water entering the trach

Lean your child back when washing/rinsing head so that water does not go into the trach

Getting Dressed:

Do not block the trach with clothing such as crew necks or turtle necks

If cold or dusty, then use a loose scarf, mask or artificial nose/HME

Avoid clothes that shed fibers of lint or material with sequins and/or small beading

V-necks and clothing with buttons in front are recommended

Playtime:

Avoid small toys or toys with many detachable parts, sandboxes, contact sports and swimming

(Anything that can fit through an tolit paper roll is too small and can block the airway)

Other Important Items:

Do not use perfumes, powders, or aerosol sprays around your child

Do not smoke around your child

Keep your child away from allergens such as dust and mold


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Travel/Emergency Kit

Whenever you leave the house you will need to have trach supplies with you at all times. Emergencies

can happen anywhere. You must be prepared to handle any emergency no matter where you are.

Supplies:

Extra trach (one same size and one smaller) with obturator

Ambu bag and mask

An extra oxygen tank (if applicable and necessary) Suction catheters Portable suction machine Bulb syr inge Normal saline

Trach ties Clean gloves

Clean dressing

Cotton tipped applicator

Small cup to make 1/2 strength hydrogen peroxide

Hydrogen peroxide Sterile water Neck roll

Blunt-nose scissors Water-soluble lubricant Extra humidification (artificial nose/HME)

Important phone numbers

Safety & Troubleshooting

When to call the doctor:

Temperature greater than 100.0°F

Bleeding at the trach site

Redness, swelling at the stoma site

Increased amount of mucous/secretions

Change in color of secretions

Foul-smelling secretions

If your child is on a ventilator:

Routinely check the ventilator safety and auditory alarms

Have the key-lock "ON" if other children are around your child

Check proper ventilator tube and connector placement

Remember to hold the trach in place when connecting/disconnecting ventilator connections

Call your Durable Medical Equipment (DME) Company for any questions/issues with any medical

equipment.


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Important Phone Numbers

Primary Care Provider _____________________________________________________________

Home Health Nurse _________________________________________________________________

DME Company _______________________________________________________________

Trach Clinic _______________________________________________________________

OT/PT/Speech Service _______________________________________________________________

Specialty Doctor ________________________________________________________________

Specialty Doctor ________________________________________________________________

Local EMS/Fire Station ________________________________________________________________

Nearest Police Station _____________________________________________________________

Telephone Company ___________________________________________________________

Gas Company ________________________________________________________________

Electric Company ________________________________________________________________

Other ______________________________________________________________ Other ______________________________________________________________

Helpful Website

Aaron's Tracheostomy Page: http://www.tracheostomy.com *DCMC does not endorse the information on this page but it may be a useful resource in cooperation with your healthcare provider.

http://www.tracheostomy.com/


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Appendix 1

Recipe for Sterile Water

Supplies:

Large pot with lid Clean containers with lids Pen or marker Masking tape to write on Water

Procedure:

1. Wash hands with soap and water; dry with a clean towel.

2. Fill pot with water and bring to a boil

3. Cover pot with lid end let boil for 10 minutes*

4. Let the water cool with lid on

5. Pour water into containers and cover with lid 6. Write the date and "Sterile Water" on masking tape and stick on to each container

7. Place the containers in the refrigerator

8. Throw the water away after 3 days

9. May leave one container out at room temperature, but only good for 24 hours.

* If using sterile water for feeding/nutrition, see different instructions about how to make sterile water or

ask your nurse.

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