Introduction
Tracheostomy is required in children with compromised airway due to various conditions. The tracheostomy is inserted surgically in a tertiary 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 hospital and community setting.1 Children and infants with tracheostomies have an increased vulnerability to a range of life threatening complications, and therefore require someone trained in their care with them at all times.2 We have created as easy to remember acronym for tracheostomy care which can be followed by the health care professionals, nursing staff and the care giver involved with the children who needs tracheostomy care support.
Materials and Methods
The acronym Tracheostomy was created to teach and train the care giver and nursing staff for better post tracheostomy care. All the aspects of tracheostomy care have been included in this as mentioned below
Tube change-when to change?
Regular cleaning-how to perform?
Airway protection-what is required?
Complication awareness-how to prevent?
Home kit requirement-things to keep ready bedside.
Emergency situations-when to call your doctor?
Oral hygiene- why it is important?
Stoma/skin care-what to look for?
Ties care-too tight or too loose?
Outer & inner tube cleaning-how to perform?
Mucous problems-suctioning tips
Your safety-what all you must know.
Discussion
Tube change-when to change?
First tube change should be performed on 7th post-operative day.
Second tube change can be done before discharging the child from the hospital.
Regular interval between tube change should be 4 to 6 weeks.
It can be performed as a planned or emergency procedure if the tube is blocked/dislodged/soiled/broken. 3
Keep the tube change kit ready before performing the procedure.
Always keep same size tube & one down size tube ready.
Always check the cuff for any leak or damage.
Lubricate the tube before insertion.
Tube change should be done quickly.
Never perform this procedure alone. Arrange the help before performing tube change.
Neck extension gives better exposure of tracheostomy site.
If unable to insert the tube, keep towel roll under the shoulder to extend the neck. 4
Regular cleaning-how to perform?
Wash your hands before changing the tube.
Clean your tracheostomy equipment as directed.
Clean your stoma site as directed.
4Do not use hydrogen peroxide solution near stoma site. 5
Airway protection-what is required?
You can protect your child’s lower airway by covering the tracheostomy tube opening via one of the following
Deep breathing exercises and coughing exercises 10 times in an hour to prevent lung infections. 6
Complication awareness-how to prevent?
Hand hygiene.
Regular cleaning of tube and stoma site to prevent infections.
Avoid water entering in your child’s tube while bathing or showering.
Keep your child away from smoke, dust, pollutants.
Do not allow them to swim.
Use HME filters.
Plenty of fluids for drinking to keep the secretion thin & loose.
Regular suctioning to prevent tube block.
Always keep the emergency tracheostomy kit handy or bedside.
Home kit requirement-things to keep ready bedside.
Appropriate size AMBU bang & AMBU Mask.
Tracheostomy tube- same size & one size smaller (arrange obturator for both if possible).
Adequate size suction catheter.
Suction apparatus- electric & foot operated.
Oxygen- cylinder & concentrator.
Pulse oximeter.
Humid-vent
Nebulizer
Hand care gloves
100 ml NS
Water for injection
Water soluble lubricant
Empty 10cc syringe
Extra pair of ties
Hydrogen peroxide solution
Pack of gauze pieces
Hand sanitizer
Brush for cleaning
Q tips or cotton applicators
Scissors
Roller towel or blanket.7
Emergency situations-when to call your child’s doctor?
If child develops breathing difficulties in spite of suctioning/cleaning/tube changing
If child gets fresh blood in suction catheter while suctioning or bleeding stoma
If you notice yellowish/ greenish or foul smell secretions
If child complains of severe pain while breathing or swallowing
If you can-not insert the new tracheostomy tube in spite of smaller size trial
If you notice liquids or food particles in suction catheter while suctioning
If child develops high grade fever or fast breathing
If your child has troubled breathing and lips turning blue. 8
Stoma/skin care-what to look for?
Check skin around the stoma for signs of infection-redness, bumps, thick crusting, foul smell discharge, excessive secretions
Check for skin breakdown due to flange pressure
Keep the stoma dry and clean
Always wash your hands before cleaning stoma site or tube
Clean around stoma & flange with Q tips soaked in normal saline.
Clean with betadine solution followed by normal saline soaked gauze piece
Apply new dressing every day or change as required. 9
Ties care-too tight or too loose?
Can be changed once
In a week or as soon as it gets soiled.
Do not use Velcro ties as it can come off accidently so always use cotton double ties for your child’s tube
Do not change immediately after food as slight movement of tube can cause gag reflex which can induce vomiting.
Ask for the help before changing the ties
Ties should not be too tight or too loose
Keep one finger between ties and neck skin to get adequate fitting while tying
Outer & inner tube cleaning-how to perform?
Inner cannula can be removed & clean with brush and water.
If mucous secretions are dried up then soak the inner cannula in diluted hydrogen peroxide solution & brush it off.
In case of excessive secretion, clean the inner cannula three times in a day to prevent infections.
Outer cannula (tube) cleaning can be done monthly during the tube change.
Tube without inner cannula needs frequent cleaning.
Always ask for the help before tube change.
Tube should be cleaned under running tap water followed by soakage for 15-20 minutes in diluted hydrogen peroxide solution. Clean the tube with small brush or pipe cleaner and keep it for drying. Once dried, tube can be kept in paper bag for further usage. Bivona tube can be used up to 5 times 10
Mucous problems-suctioning tips
Whenever needed
Perform quick suctioning -o2 desaturation/abnormal breath sounds/copious secretions/ increased work of breathing/audible secretions
Routinely done -after waking up
Do not perform suction while inserting the catheter
Preoxygenate your child before and after suctioning.
Use appropriate size suction catheter
Each suction session should be performed in less than 10 seconds
Wait for 30 seconds in between suction sessions.
Only three attempts at a time
Wait for 5 -10 minutes if further suctioning required.
Ask your child to take deep breath before suctioning.
Keep suction pressure to less that 120mmhg for open system suctioning.
To keep the secretion thin- ask your child to drink plenty of wate
Your child will need more humidity- during winter season11
Your child’s safety-what all you must know.
If your child has trouble breathing-do not get panic
Tell your child to Take deep breath & cough
Remove your child’s inner cannula
Try to clean outer tube with suctioning
Use soda bicarb to loosen the secretion and perform suction
Still trouble then change the tracheostomy tube
Ask for help urgently
Always make sure that tube should be mucous free.
Always keep tracheostomy kit with you
Always cover tracheostomy tube with moist gauze or HME to prevent infection
Seek medical advice if you have any doubt 12
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