The amount of suctioning needed is different for each child. You will need to suction more often when your child has a respiratory infection. Normal mucus is clear to white in color and thin or slightly thick. It should not have an odor. Mucus builds up during sleep, so it is good to suction the trach when your child wakes up in the morning or after naps.
Suctioning before he eats helps prevent coughing episodes during a meal. If your child is on a ventilator vent , a catheter that is protected inside a sterile sleeve may be needed. Higher pressures may result in trauma to the tracheal tissue or hypoxia from aspirating oxygen. Blood stained secretions may indicate tracheal injury. Large quantities of blood or persistent bleeding should be investigated to determine the cause of the bleeding. The catheter should be introduced to the desired depth.
Do not apply suctioning while introducing the catheter as this can increase the risk of mucosal damage and hypoxemia. Occlude the suction port with a gloved thumb and suction upon removal of the catheter. Suctioning should be continuous, not intermittent. Intermittent suctioning does not reduce trauma and is less effective. Shallow suctioning is when the suction catheter is passed to the tip of the tracheostomy tube. This technique is often used if the patient has loose secretions that are able to be coughed to the end of the tube.
If the suction catheter is passed further than the end of the tracheostomy tube, this is considered deep suctioning. Deep suctioning may be required if shallow suctioning does not clear secretions adequately. For effective deep suctioning, many experts advocate advancing the suction catheter until the carina, where resistance is met. Once resistance is met, the suction catheter should be withdrawn slightly before suctioning is commenced. Brief, second suction duration is usually recommended to avoid mucosal damage and prolonged hypoxia.
If there is a need for repeated suctioning, care should be taken to maintain and normalize vital signs in between suction episodes with special attention to the heart rate and oxygen saturation levels. When performing closed suctioning, the tip of the catheter should always be in the withdrawn position when not being used.
The visible black marker indicates that the tube is withdrawn. Flush the closed suction tubing with clean water and empty the water receptacle as needed.
Reattach any oxygen to the patient if indicated. If using an open suction system for a patient receiving mechanical ventilation, reattach all equipment. If the patient has a fenestrated tracheostomy tube, the unfenestrated inner cannula must be in place before suctioning. The adequacy of suctioning can be assessed by the clearance of secretions, improved breath sounds, improved air entry, good pulse oximetry readings, and improvement in respiratory distress in a patient.
The importance of suctioning of both ventilated and non-ventilated patients with tracheostomy cannot be overstated. The presence of thick viscous secretions can lead to atelectasis, a decrease in oxygenation and even collapse of the lung lobe s. Closed tracheal suction systems versus open tracheal suction systems for mechanically ventilated adult patients. Cochrane Database of Systematic Reviews , Issue 4. DOI: All healthcare workers and individuals caring for those with tracheostomy should understand methods of preventing and controlling the transmission of infection.
The novel corona virus COVID pandemic has resulted in an increase in patients intubated and use of mechanical ventilation. The United States and globally, we are likely to see an increase in tracheostomy as well, as patients may have difficulty weaning and require longer periods of time on a vent. COVID also has implications for healthcare workers, as there are shortages with workers becoming ill from the virus.
Infection control is paramount in controlling the outbreak and protecting patients, healthcare workers and the community. Although tracheostomy tube changes are relatively simple and easy procedures, it should only be changed by someone who is trained and competent to do so. Assessment, trouble-shooting and advanced placement techniques of a speaking valve in-line with mechanical ventilation. Review the different types of speaking valves and benefits for those with tracheostomy and mechanical ventilation: Passy-Muir, Shiley, Shikani, and Montgomery.
This information has been collected and designed to help in clinical management, the authors do not accept any responsibility for any harm, loss or damage arising from actions or decisions based on the information contained within this website and associated publications.
The opinions expressed are those of the authors. It is preferable to secure new ties before removing the old ties As there is a potential risk for tracheostomy tube dislodgment when attending to tie changes a minimum of two people who are competent in tracheostomy care are required to undertake tracheostomy tie changes.
During the tracheostomy tie change, if the old ties are removed prior to securing the new ties, one person is to maintain the airway by securing the tracheostomy tube in place and not removing the hand until the new tracheostomy ties are secured. If the ties become loose it is a priority to re-secure immediately. All Children 6 years and under are to have cotton ties only to secure the tracheostomy tube. Children 6 years and over who are considered at risk of undoing Velcro ties should have cotton ties.
Equipment Tracheostomy kit Two equal lengths of cotton ties approximately 40cm or Velcro ties for patients older than 6 years Procedure for changing cotton ties Explain to the patient and their family that you are going to change the tracheostomy ties. An older child may like to sit up in a bed or chair Insert a clean tie into the holes on each side of the flange On each side tie a single loop approximately 0.
Then tie both sides together in a bow to secure. Check the tension of the ties. Allow one finger to fit snugly between the skin and the ties. Re-tie into in a double reef knot to secure. Cut off excess length of ties leaving approximately 3cm.
Using scissors remove old ties and recheck tension of new ties. Dispose of waste, remove gloves, and perform hand hygiene. Procedure for changing Velcro ties Changing Velcro ties is a two person procedure. Check the Velcro on the tracheostomy ties prior to each use to ensure adhesiveness.
If not adherent discard and replace. Apply eye protection Perform hand hygiene, apply non-sterile gloves One person holds the tracheostomy tube securely in place. The second person removes the existing Velcro ties and then inserts the clean Velcro ties through one side of the flange, passing the tie around the back of the patient's neck and inserting the Velcro tie through the other side of the flange.
Adjust the ties to allow one finger to fit snugly between the skin and the ties. Check to ensure the Velcro is securely fastened Dispose of waste, remove gloves, and perform hand hygiene.
Observe the patient's neck to check skin integrity. Wash Velcro ties daily in warm, soapy water, rinse and allow to dry completely before re-using. Tracheostomy tube changes The frequency of a tracheostomy tube changes is determined by the Respiratory and ENT teams except in an emergency situation. Consider distraction techniques and or procedural sedation. Swaddle the patient if age appropriate by wrapping the arms and containing them in the sheet.
Place the rolled towel under the patient's shoulders to extend their neck unless contraindicated. The older child may find it more comfortable to sit upright with their head tilted back. Position the child so that you have good visibility and access to the stoma.
If necessary extend the neck further and open the stoma wider by using your thumb and forefinger. Suction the existing tracheostomy tube immediately before removing the existing tube and inserting the new one. Procedure Person 1 holds the existing tube with their hand and keeps secured in place Person 2 cuts and removes the cotton ties from around the child's neck.
If using Velcro ties - undo and remove from the tracheostomy tube flange. Person 2 holding the new tube asks person 1 to remove existing tracheostomy tube Person 2 immediately inserts the new tube into the stoma and removes the introducer if applicable.
If using cotton ties, finish by making a double reef knot and cut off any excess fabric leaving approximately 3cm. Do not clean or re-use single use tubes. Document procedure and device information in the patient medical record as per requirements stated below. Safety considerations A rare complication is for the tube to slip into a false passage instead of the airway. Difficulties in re-inserting the tracheostomy tube can occur at any time. These occur usually as a result of one of the following: False tract Patient agitation or distress Closure of the stoma Spasm of the trachea Stoma is blocked by scar tissue granuloma Skin flaps Structural airway abnormalities e.
Inspect the stoma area at least daily to ensure the skin is clean and dry to maintain skin integrity and avoid breakdown Daily cleaning of the stoma is recommended using 0.
After daily cleaning, ensure dressing inserted at stoma site Equipment Tracheostomy kit Fenestrated gauze dressing 0. Infants and young children may lay on their back with a small rolled towel under the shoulders. An older child may prefer to sit up in a bed or chair.
Perform hand hygiene and apply non-sterile gloves Remove fenestrated dressing from around stoma Inspect the stoma area around the tracheostomy tube Perform hand hygiene and apply non-sterile gloves Clean stoma with cotton wool applicator sticks moistened with 0. Use each cotton wool applicator stick once only taking it from one side of the stoma opening to the other and then discard in waste.
Continue cleaning stoma area as above with a new cotton wool applicator stick each time until the skin area is free of secretions, crusting and discharge. Allow skin to air dry or use a dry cotton wool applicator stick to dry. Insert the fenestrated gauze under the flanges wings of the tracheostomy tube to prevent chafing of the skin.
Avoid using any powders or creams on the skin around the stoma unless prescribed by a doctor or respiratory nurse consultants as powders or creams could cause further irritation. Special considerations If signs of redness or excessive exudate present consider using a non-adhesive hydro cellular foam dressing e. If visible signs of infection are present - discuss with parent medical team and consider obtaining a swab specimen for culture and sensitivity. If there are any signs of granulation tissue liaise with the Respiratory Nurse Consultants for appropriate management.
The care of the stoma includes routine minimum - daily observation of the site and accurate documentation of the findings including the presence of any of the following: Redness Swelling Evidence of granulation tissue Exudate Increased discomfort or pain at the site Offensive odour Refer to Respiratory Clinical Nurse Consultant for advice on the frequency and type of dressing required.
Feeding and nutrition The tracheostomy tube may have an impact on the child's ability to swallow safely, therefore a swallowing evaluation by a speech pathologist is recommended prior to the commencement of oral intake.
Oral care Patients with a tracheostomy have altered upper airway function and may have increased oral care requirements. Communication Children communicate in many different ways, such as using gestures, facial expressions and body postures, as well as vocalising. One- way speaking valves One-way speaking valves are a small plastic device with a silicone one-way valve, they sit on the end of the tracheostomy tube.
Various types of one-way speaking valves are available. If the child has prolonged excessive coughing and obvious discomfit with increased respiratory effort and air trapping - remove the valve immediately and reassess for adequate airway patency before a repeat trial. If airway patency adequate then aim to reassess the child at regular intervals to place the one-way speaking valve gradually increasing the time and frequency of use.
A cuffed tube must be fully deflated before attaching the speaking valve. Gently occlude tracheostomy tube with a gloved finger and observe for exhaled air from nose and mouth or vocalization. If the one-way speaking valve is tolerated on the initial trial for a goal of 5 to 10 minutes. A management plan to gradually increase the length of time which the valve is used will be provided for the patient Once the child has adjusted to wearing the one-way speaking valve they should be able to wear it for long periods and be able to be wear at all awake periods, particularly during rehabilitative therapy sessions and when eating.
If the child fails to tolerate the one-way speaking valve: Remove the valve if any signs or symptoms of distress or changes in respiratory effort. As it can be more difficult for the child to exhale with the valve in place, the child may initially fail a trial of one-way speaking valve due to anxiety or discomfort. The child may need to slowly build up longer periods of one-way speaking valve use and placement will be repeated on subsequent days.
Some children have difficulty adjusting to changes to their airways. In infants and young children consider using a device to secure the one-way speaking valve to the child's ties - to prevent accidental loss of the one-way speaking valve.
Some speaking valves are suitable for use in combination with oxygen therapy and during ventilation. Safety precautions when using one-way speaking valves: If the child has severe airway obstruction the speaking valve should not be used. In cuffed tracheostomy tubes - ensure cuff is completely deflated. The young child should always be supervised when wearing the speaking valve. The one-way speaking valve should not be worn when the child is sleeping.
One-way speaking valves do not humidify the air - therefore may be unsuitable for children with copious thick secretions. If the one-way speaking valve is not functioning properly i. The consistency of respiratory secretions is also affected by the tracheostomy as the mechanism of warming and humidifying air through the upper airway is lost.
Secretions become thick and dry, which inhibits mucociliary transport. They can build up and may block the tracheostomy tube. Endotracheal suctioning is performed to maintain a clear airway and optimise respiratory function Dougherty and Lister, It can be performed via a tracheostomy tube. A number of risks are associated with it. These include:.
The decision to perform suction must be based on a comprehensive patient assessment rather than using set times. This assessment will include a review of characteristics such as respiratory rate and pattern, chest excursion and palpation and auscultation of the chest Higgins, There appears to be some controversy over the use of sterile or non-sterile gloves.
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