Caring for your Child’s Tracheostomy - Connection · 2017-06-22 · Caring for Your Child’s Tracheostomy Page 3 The Definition and Purpose of a Tracheostomy A tracheostomy is

Caring for yourChild’s Tracheostomy

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...............................................................................................................................................13

Changing the Trach Tube......................................................................................................................... 17

Cleaning the Used Trach.......................................................................................................................... 21

Humidification .......................................................................................................................................... 22

Speaking Valves ………………………………………………………………………………......23

Mucous Plugs............................................................................................................................................ 23

AMBU Bag Use & Trach CPR.................................................................................................... 24

Daily Life ........................................................................................................................................................................26

Travel/Emergency Kit.....................................................................................................................................................27

Important Phone Numbers/Helpful Website ..................................................................................................28

Appendix 1 ................................................................................................................................................................................29


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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) thatwill allow your child to breathe better.

Children receive a tracheostomy “trach” for many different reasons: airway defects, breathingproblems, accident or other injuries or problems. The length of time your child will need thetrach 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 taughteverything you need to know to keep your child safe at home and will work closely with nurses andrespiratory 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 necessarycare for your child's tracheostomy. This will mean that you are both required to performnecessary skills in caring for the tracheostomy before you go home from the hospital. These skillsinclude:

Stoma care

Trach suctioning

Trach changes

Trach Cardiopulmonary Resuscitation (CPR)

Oxygen home therapy, Nebulizer treatment, Ventilator, Home monitor, Use of artificialmanual breathingunit (AMBU) bag, Emergency checklist

These skills will be discussed individually in this manual.

You and the second caregiver will also be required to “room in” with your child for a 24-hourperiod. You will be responsible for independently providing all necessary care, but will havenursing 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 weeklygoals for you as you learn to take care of your child's tracheostomy. These are guidelines. Yourchild's situation may not follow these time lines exactly.

Education Week 11. Read handouts regarding your child's diagnosis, medications, equipment and the teaching plan for

discharge

2. Identify the primary and secondary caregivers3. Observe care performed by the nurse and the respiratory therapist (RT):

a. Trach cleaning/trach changeb. Trach suctioningc. G-button care/feeding (if applicable)d. Medication administratione. 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 becalled Care Set #1.

a. Trach cleaning/stoma careb. Trach suctioningc. G-button care/feeding (if applicable)d. Medication administratione. 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.

Questions/Concerns I would like addressed:

1. ____________________________________________________________________2. ____________________________________________________________________3. ____________________________________________________________________

Education Week 21. 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 careb. Trach suctioningc. G-button care/feeding (if applicable)d. Medication administratione. Nebulizer treatment (with RT)f. Use of AMBU bag (with RT)

2. Parent to change trach3. 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.

1. Training is completed by a Durable Medical Equipment representative. Utilize HomeEquipment for care

2. Trach Change #23. Complete Home Ventilator Teaching with RT (if applicable)4. Plan for home care needs with the case manager and/or the social worker


1. ____________________________________________________________________2. ____________________________________________________________________3. ____________________________________________________________________

5. Complete the 24 – hour “Rooming In”

Both the Primary and Secondary caregiver must complete a full “Rooming In”experience independently

Education Week 41. The primary and secondary caregiver will Perform Care Sets when needed.2. Trach Change #33. Finalize home care needs with the case manager and/or social worker


1. ____________________________________________________________________2. ____________________________________________________________________3. ____________________________________________________________________


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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 trachand the appropriate size to meet your child's needs.

Your child's trach is a:

Type: _______________________ Size: ____________ Custom: Yes / No

Parts of the Tracheostomy Tube

1. Connector: the part of the trach tube that sticks out of the neck that can connect to theventilator and the AMBU bag

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

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

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

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

6. Inner Cannula: a replaceable cannula that fits inside the tracheal tube (used on largertrachs)

Cuffed Trach Trach

5

1

2

46

3


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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

Blanket or Towel roll

Sterile water (see Appendix 1, pg. 32)

Liquid containers

Hydrogen peroxide (if needed)

Cotton tipped applicators (swab)

Absorbent gauze pad

Trach ties (if changing the trach ties at the same time as stoma care)

Procedure

1. Wash hands with soap & waterDry with a clean towel

2. Gather supplies


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3. Place blanket or towel roll underyour child’s shoulders

4. Remove the old absorbent gauzepad if presentInspect the stoma site for any skinbreakdown, signs of infection orrashes

5. Use wet cotton tipped applicator to clean around stoma siteSwab should be dipped into sterile water. If crusty drainage is present, use ½strength hydrogen peroxide (mix equal parts sterile water and hydrogen 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 at the top of the stoma on theopposite side and repeat. Discard this swab, and continue this procedure along theborder of the stoma until all areas are cleaned. Remember to wipe down the neckplate “wings” as well.


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Key Points

Do not apply lotions or powders near the stoma

Only apply ointment as instructed 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

6. Use dry cotton tipped applicatorto dry area around the stoma site.Use the same procedure as outlinedabove, but with dry swabs.

Be careful not to allow small piecesof cotton to be breathed into thestoma

7. Place a clean absorbent gauze padaround the cannula and under theneck plate “wings” as needed.Replace the trach ties as needed(refer to Trach Tie Change p. 11)

Be careful not to cut the gauze, thesmall pieces can be breathed in


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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

Blanket or Towel roll


Clean trach ties

Soap & water

Cotton tipped applicators (swab)

Clean washcloths

Nystatin power (if ordered by the physician)

Procedure

**Follow steps 1-6 as illustrated with Stoma Care (pages 8-10)

7. Agree on who the “Holder” isThis person is responsible forholding the trach in place while theother person replaces the ties.

The Holder must hold the trach inplace throughout the entire tiechange!

8. Remove the trach side from oneside (wing).While the Holder ensures the trachremains in place, unattach one sideand bring the around the back of theneck to the other side that is stillattached.


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Key Points

Clean dirty or used trach ties with mild soap and water and hang them to dry. Do not puttrach ties in the dryer.

Check trach ties before each use. If they become stiff, frayed, hard, or the Velcro is not sticking,replace them with new trach ties.

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

9. Wash the neck.Use mild soap and water, rinse and then dry thoroughly with a washcloth. Look forsigns of skin breakdown or rash around the neck; pay special attention to the back of theneck.

*If needed for skin breakdown, use Nystatin powder (as ordered by the physician). Useaway from the stoma to avoid aspiration. Put the powder in your hand and apply to theneck.

10. Attach clean trach tie to the emptywing.Bring the rest of the trach tie aroundthe back of the neck to the other side.Place a clean dressing under thetrach as needed (step #7 of stomacare pg. 10)

11. Remove the rest of the old trach tieand attach the new one to the openwing.Make sure the trach tie is securelyattached to the wings, but not tootight around your child’s neck. Youshould be able to insert your littlefinger between the tie and the backof your child’s neck


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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

Suctioning 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.

Your child’s suction depth is:

_____________


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Supplies

Suction machine with tubing

Suction catheters


Clean gloves

Saline drops, if needed for thick secretions

AMBU bag and mask

Extra trach tube

Obturator nearby

Procedure


2. Gather supplies

3. Turn on the suction machine andset the pressure to 80 – 120 mmHg


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4. Put on clean gloves and attachsuction catheter to suction tubing.Make sure not to touch the last 2-3inches of the catheter.

5. Hold the catheter with fingersslightly above the measured markfor suctioning.This technique will help prevent thecatheter from going too deep

6. Insert the tip of the catheter intothe trach while continuing to holdthe catheter at the pre-measuredmark.

7. Apply quick suction as you enter tothe trach opening, then release asyou go down the tube.This will suction any mucous sittingthere that may have been coughed upthe trach by your child


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8. Apply suction while twisting (notstirring) the catheter betweenyour fingers as you remove thecatheter.Each suction period should take 3-5seconds. Allow for recovery timeor give 3-5 breaths with the AMBUbag, as needed. Repeat steps 6&7(pg. 15) until the mucous iscleared. For very thick secretionsyou may have to use saline drops

9. After you have finishedsuctioning, clean the catheter bysuctioning sterile water throughthe tubing.


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Trach 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 trachchange!

Supplies

Another person Towel roll Clean gloves One current size trach tube One size smaller trach tube Clean trach ties

Water soluble lubricant Suctioning supplies Clean dressing

AMBU bag

Procedure


2. Gather supplies


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3. Apply clean gloves. Attach oneside of the trach tie to the wing,and place the obturator into thenew/clean trach.Lubricate the tip of the trach, but becareful to avoid touching the tip ofthe cannula or allow anything else totouch it

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

5. Suction your child’s trachSee (Trach Suctioning pgs. 14-16)

6. The first person removes the trachties while holding the trach inplaceThis is a good time to do trach care ifthe trach change is non-emergent


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7. Make sure the second person isready with the new trach beforethe first person removes the oldtrach

8. The first person removes the old trach and the second person inserts the newone in one curving motionKeep the child’s neck extended by holding their chin up; this should makeinsertion easier and you can also fully visualize the stoma

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

Do not let go of the trach!

Save the obturator in case of accidentaldecannulation

2

1

1

2


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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

10. Listen or feel for air movementfrom the trach

11. Secure the trach in place withnew trach ties and dressing.Repeat suctioning as needed


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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 (clean and reuse for trach changes over a

one month period). The Bivona trach can be cleaned a maximum of 5 times. Your

nurse will teach you how to clean the trach

Shiley Trach1. Wash hands with soap and water; dry with aclean towel.2. Wash trach and obturator in mild soap andwater, then rinse with hot water.3. Prepare 1/2 strength hydrogen peroxide solutionin a clean container(The solution is made by mixing 1 Tbsp. hydrogenperoxide with 1 Tbsp. sterile water. Do not pre-mix the solution; it will not be effective. Discardthe 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, thetrach must be cleaned again.8. Do not leave the trach soaking in the peroxide mixture.

Bivona Trach1. Wash hands with soap and water; dry with aclean towel.2. Gently wash trach and obturator with mild soapand scrubbing with a soft bristled brush. Rinsethoroughly with water3. Bring distilled water to a boil in a clean pot andremove from the heat4. Place trach and obturator side-by-side in the pot5. Cover the pot with the lid and allow water tocool6. 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, thetrach 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 overyour child's trach that allows your child tobreathe aerosolized moisture in the air. Thismethod is used most often when at home, awakeor asleep. The moist air may also be heated ifdirected by your doctor.

Heat and Moisture Exchanger (HME)“Artificial Nose”

The artificial nose is placed directly on the end ofthe trach to provide continuous humidification ofair. It may be used for short periods of time whenyour child is awake and active. Your child'sdoctor will decide when your child is ready foran HME. Insurance supplies 1 per day.


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Mucous Plugs

Mucous can become thick and "plug" the tracheostomy tube. When this happens, no air flow willbe 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 clear with suction, then remove & replace the trach with a new/clean

one.

Ways to help prevent mucous plugs: Use an aerosol mist collar Perform routine trach changes Suctioning as needed Saline drops with thick secretions Provide enough fluids with feedings

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, allowingthem to talk. Your pulmonologist, ENT,respiratory therapist and speech therapist willhelp determine when your child is ready tobegin using a speaking valve. Many childrenneed time to adjust to this new way of breathing;therefore, it is necessary that you gradually increase the time your child is using thespeaking valve.

A speaking valve is not 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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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 attached to your child's trach without squeezing it to give breaths! Oxygen may be attached to the AMBU bag as needed.

Trach CPR (Cardiopulmonary Resuscitation)

During your stay, you will be taught how to perform CPR to a child with the trach and learn howto 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 AFTERSUCTIONING, 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 flat 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 mouthover 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 seeif child is breathing on his own (look, feel and listen for air movement).


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7. If you see signs of circulation, give "rescue breathing" — breathe with mouth or AMBU bagon 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, orcrying/coughing, begin chest compressions at a rate of at least 100 times a minute. Give 30compressions, press down 1 ½ inches for infants, and 2 inches for children with eachcompression.

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 notdoing.

If no breathing, but has signs of circulation, give rescue breathing with AMBU bag ormouth-to-trach.

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

12. If the trach has come out and you cannot get it back in—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 equipmentneeded (example: ventilator, portable suction machine, supply bag, etc.)

Always prepare the room so that your child will spend time in with the suction machine,as well as an emergency kit (See pg. 35). This included going outdoors or leaving yourhome

Preparing to go home:o Power, phone, smoke detectorso Set up the room with supplieso Travel with 2 caregiverso Have oxygen availableo 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 mayenter

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 toilet paper roll is too small and can blockthe 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 matterwhere 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)

Portable suction machine & suction catheters

Bulb syringe

Normal saline

Trach ties & clean dressing

Clean gloves

Cotton tipped applicator

Hydrogen peroxide & small cup to make 1/2 strength hydrogen peroxide (if necessary)

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 ventilatorconnections

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


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Important Phone Numbers

Primary Care Provider

Home Health Nurse

DME Company

Trach Clinic

OT/PT/Speech

Specialty Doctor

Specialty Doctor

Local EMS/Fire Station

Nearest Police Station

Telephone Company

Gas Company

Electric Company

Other

Other

Helpful WebsiteAaron's Tracheostomy Page: http://www.tracheostomy.com

*MCCH does not endorse the information on this page but it may be a useful resource in

cooperation with your healthcare provider.


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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 boil3. Cover pot with lid end let boil for 10 minutes*4. Let the water cool with lid on5. Pour water into containers and cover with lid6. Write the date and "Sterile Water" on masking tape and stick on to each container7. Place the containers in the refrigerator8. Throw the water away after 3 days9. 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.

Caring for your Child’s Tracheostomy - Connection · 2017-06-22 · Caring for Your Child’s Tracheostomy Page 3 The Definition and Purpose of a Tracheostomy A tracheostomy is

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