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Tracheostomy

Background

A tracheostomy is the opening, or stoma, resulting from a surgically performed tracheotomy to provide an airway that bypasses the upper airway. The procedure can be life saving for many children with chronic medical conditions. A tracheostomy is typically placed in children who have either significant lung disease requiring ongoing ventilation, or some form of airway obstruction. After working with care team members and the family to determine if a tracheostomy is appropriate, the otolaryngologist (Ear-Nose-Throat/ENT specialist) creates an incision in the trachea and inserts a metal or plastic tracheostomy tube to act as an artificial airway. Once the support settings are stable in the hospital, the child’s care can be transitioned to the home or a care center.
Tracheostomy
Children with tracheostomies rely on daily medical maintenance that is performed primarily by families who will have differing needs for ongoing support. When the child leaves the hospital, an outpatient plan should be developed in coordination with the child’s primary care provider and include information for obtaining medical supplies and scheduling follow-up appointments with specialists such as ENT and pulmonology, respiratory therapy, speech and feeding therapy, and/or early intervention, and home health care. The child’s family and care team must be able to manage routine care as well as complications and emergencies. A Physician Orders for Life Sustaining Treatments (POLST forms) may be appropriate.



Tracheostomy Care

Changing Tracheostomy Tubes
Recommended frequencies for tube changes range from daily to monthly. [Lichtenstein: 1986] [Fitton: 1994] [Mitchell: 2013] Advantages of frequent tube changes include the potential of decreasing airway infection, granulomas, and the incidence of tube blockage by trapped secretions. [Sherman: 2000] Disadvantages of frequent tube changes include patient discomfort and the potential of stretching the stoma site when cuffed tubes are changed. [Sherman: 2000] All tubes should be inspected for cracking or splitting prior to re-insertion. Duration of use prior to splitting or cracking is dependent of tube composition. Metal tubes can be used indefinitely if no cracking is observed. Silicone tubes do not stiffen after repeated use, although cracks and tears can occasionally develop. Since PVC tubes stiffen over time, they need to be replaced more frequently. [Sherman: 2000] Changing a tracheostomy tube does not need to be performed under sterile conditions, but should be performed using a clean technique. [Mitchell: 2013] Trach Change (Breath of Life) provides a five-minute video for caregivers on changing trachs.

Tracheostomy Tube Size
The diameter of the tube should be small enough that it does not put significant pressure on the tracheal wall, but large enough to allow effective airflow and clearance of secretions. The tube should be long enough that it comfortably fits into the trachea, but not so long that it contacts the carina.

Tracheostomy Ties
Tracheostomy ties are made from twill tape, Velcro, and stainless steel (bearded chain form). The American Thoracic Society Committee on trach care has found no superiority of a particular type of tie material. Tension on the tie is correct when one finger can be placed snuggly beneath the tie without difficulty. Ties should be kept clean and dry. Skin breakdown has been seen more with narrow ties than wide ties. [Sherman: 2000]

Suctioning
Encourage coughing to clear secretions; this strengthens muscles, prevents complications that can come with suctioning, and allows patients to be independent in their own mucous mobilization.

Suctioning depth: Epithelial damage and inflammation of the trachea distal to the end of the trach tube have been demonstrated with routine deep suctioning. [Runton: 1992] [Hodge: 1991] A pre-measured technique is recommended for suctioning. Pre-marked catheters are strongly recommended to ensure proper depth of suctioning. [Sherman: 2000]
  • Measure the length of a trach tube cannula that is the same size as currently used in the child.
  • Insert the catheter to the measured length.
  • Routine use of saline installation in not recommended. Slowly remove the catheter with a twirling or rotation motion to reduce friction and increase the surface area of the cannula that is being suctioned.

Suctioning frequency: Routine suctioning frequency depends on the clinical status of the child and the amount of secretions produced. For children with little or no secretions, suctioning is still recommended at morning and bedtime to check for tube patency. [Sherman: 2000]

Cleaning the suction catheter: The American Thoracic Society recommends a four-step cleaning process for suction catheters. This cleaning procedure demonstrated sterility in 98% of all suction catheter exteriors and 91% of all suction catheter interiors up to 20 days after cleaning: [American: 1993]
  • Wash and flush the catheter with hot, soapy water.
  • Soak the catheter in a vinegar-and-water solution or a commercial disinfectant.
  • Rinse catheter inside and out with clean water.
  • Allow the catheter to air dry.
All caregivers should wash their hands before and after suctioning. Non-sterile, disposable gloves may be worn during suctioning. Trach Suctioning (Breath of Life) provides a short video about how to suction a trach.

Cleaning the Trach Site (Stoma Care)
Cleaning around the stoma typically is recommended twice daily, but may need to be done three times daily if there is increased discharge or odor. Caregivers can prepare a mixture of ½ hydrogen peroxide and ½ water. Swabs dipped in this solution are gently rolled from the tube outwards in a radial pattern around the stoma. Clean swabs should be used for each pass. This should be followed by a rinse using swabs dipped in clean water, then the area should be allowed to air dry. [Coviden: 2014] Cleaning the Stoma (Breath of Life) is a short video about cleaning the stoma.

Supplies

There are multiple on-line commercial medical supply vendors. Home health companies are also excellent resources for supplies.

Humidification
Bypassing the upper airway can lead to a humidity deficit of inspired air. This lack of humidity can lead to pathologic airway changes including loss of ciliary action, thickening of mucous secretions, and cellular desquamation. Passive humidifier use in adults with tracheostomy correlates with improved secretion viscosity, lung function, and sputum production. [Vitacca: 1994] The American Thoracic Society recommends the humidification of inspired air through a tracheostomy with the following recommendations: [Sherman: 2000]
  • The air temperature should be 32-34 degrees Celsius.
  • The relative humidity should be 100%.
  • The absolute humidity should be 33 to 37 mg of H2O / L.
Humidity (Breath of Life) provides a 4-minute video on humidification with a trach.

Complications

Up to 50% of children with tracheostomy will experience complications. Risk factors for complications include younger age (< 3 years of age), prematurity, emergent vs. elective tracheotomy, and duration of cannulation (11% with tracheostomy < 100 days, 55% for 100-500 days, and 80% for > 500 days). [Arcand: 1988] [Kenna: 1987] [Ward: 1995] [Wetmore: 1982] [Gianoli: 1990] Known complications include:

Mucous Plugs
: Mucous that significantly obstructs air movement through the trach tube will result in respiratory distress. Resistance against the plug can sometimes be felt when attempting to suction. Unsuccessful removal of the plug and continued respiratory distress requires immediate medical evaluation. If there is any concern about a persistent mucous plug, the tube should be replaced.

Accidental Decannulation: Accidental decannulation occurs particularly in children who can pull on their trach or roll onto connected tubing. Advance preparation for accidental decannulation is essential to be able to recannulate in a timely manner. Parents might choose to have a trach tube of one-size smaller available in case a same-sized trach tube will not advance. If replacement of a trach tube is unsuccessful, then immediate medical evaluation is necessary. In some cases, the child can breathe through the stoma until the trach tube is replaced; however, the stoma may close quickly. Occasionally a tracheostomy tube will be reinserted into a false passage in the neck and not actually into the trachea. If a tracheostomy tube cannot be reinserted and the child cannot ventilate or oxygenate effectively, it is a life-threatening event and endotracheal intubation through the oral or nasal cavity should be performed.

Blood in Tracheal Secretions
: Lightly streaked bloody secretions can be common and caused by many things including pneumonia, hard coughing, or trauma while playing. Frank blood in the tracheal secretions could be indicative of a critical issue that requires immediate medical evaluation.

Skin Breakdown
: The Medical Home Portal is developing an Ostomy Care section in a Wound Care module. Please check back for a link to this information.

Aspiration
: A number of children with tracheostomies are at risk for aspiration of ingested food or liquids, meaning the swallowed materials accidentally enter the airway. This may be evident when food or colored drinks reappear during trach suctioning. Some people test for this by checking for colored food dye during suctioning after a child has sucked on a brightly colored candy or lollipop. If aspiration is noted, a swallow evaluation can help determine what substances are safe (if any) for continued oral ingestion.

Decannulation Readiness

Decannulation usually is performed because the child no longer needs the tracheostomy. The decision to decannulate should be made in conjunction with the child, his or her family, the child’s ENT, and other relevant specialists or therapists. The procedure may require hospitalization and/or surgery. A follow-up sleep study and additional speech therapy may be needed as the child readjusts to his or her healing airway.

Sometimes the decision to decannulate stems from concerns about the child’s quality of life, discomfort, or lack of favorable long-term prognosis. Emotional support is critical during this time; the regular medical team, a palliative care specialist, social worker, trusted nurse, chaplain, or other people may help the family make this decision. In some cases, the decannulation may occur outside of the hospital setting, for example, in conjunction with hospice care.

Descriptive Terms

  • Tracheostomy - the stoma or opening that results from a tracheotomy procedure.
  • Tracheotomy - a surgical incision in the trachea designed to provide an airway that bypasses the larynx.
  • Decannulation - the process of removing or weaning the patient from tracheostomy dependence. Without the presence of the tracheostomy tube, the stoma will spontaneously close within hours or days.
Parts of a Tracheostomy Tube (commonly abbreviated to "trach" or "trach tube")
  • Inner Cannula - the "sleeve" inside of the tracheostomy tube that can be removed for cleaning. Most tracheostomy tubes used in young children do not have an inner cannula.
  • Neck Plate (Flange) - site for ties; prevents movement and skin-breakdown secondary to pressure points.
  • Obturator - a guide used when inserting the actual trach tube.
  • Cuff - inflates with air inside the trachea to seal the tracheal airway, decreasing aspiration and potential air leak around the cannula. Cuffed trach tubes are used primarily for patients who require mechanical ventilation with high pressures to minimize risk of aspiration and aid management of airway pressures. [Sherman: 2000] For patients requiring only nocturnal ventilation, the cuff can be deflated during the day. Uncuffed trach tubes are preferred over cuffed tubes in most cases to prevent irritation to the tracheal wall.
  • Speaking Valve - a one-way valve placed over the external opening of the trach that allows air to pass through the trach only during inhalation. During exhalation, the valve closes and air is forced around the trach tube into the oropharynx to permit phonation and speech. The Passy-Muir is a popular choice for a speaking valve and can be securely placed. Note: Cuff must be deflated.
  • Trach-Nose or Heat and Moisture Exchanger (HME) – a cap that can be placed over the trach tube for use when away from mechanical supply of humidification. Can be easily dislodged, such as during a forceful cough.
Types of Cannulas
  • Double-Cannula Tube - contains a removable, inner cannula. Double-cannula tubes are used mostly for children with thick, copious secretions. [Sherman: 2000] Cleaning the inner cannula avoids frequent tracheostomy tube (outer cannula) changes; can be cuffed or un-cuffed depending on the indication.
  • Single-Cannula Tube - used mostly for infants and small children. Single-tubes are typically plastic and uncuffed.
  • Fenestrated Tube - contains an opening on the superior portion of the cannula where air can travel from the lungs, into the cannula, and up through the fenestration to the oropharynx. This augments vocalization.

Materials for Tracheostomy Tubes

Desired flexibility determines the choice of tube material. Metal tubes, (e.g., Jackson) are rigid. Silicone tubes (e.g., Bivona) are very flexible. Polyvinyl chloride, or PVC tubes (e.g., Shiley), may be flexible or rigid.

Resources

Information & Support

Little current research exists on tracheostomies in children.

For Professionals

Care of the Child with a Chronic Tracheostomy (ATS)
Pictures, recommendations, and guidelines from the 1999 Consensus Panel Statement on Tracheostomy Care for Children; American Thoracic Society.

For Parents and Patients

Aaron's Tracheostomy Page
Great reference for parents with easy-to-understand descriptions without heavy medical terminology; created by Cynthia Bissell, RN.

Patient Education

Cleaning the Stoma (Breath of Life)
Three-minute YouTube video about cleaning the stoma; commercially produced by Creative Force Video Productions - full-length video for a fee.

Humidity (Breath of Life)
Four-minute YouTube video on humidification with a trach.; commercially produced by Creative Force Video Productions - full-length video available for a fee.

Pediatric Tracheostomy Handbook (MUSC) (PDF Document 2.9 MB)
Care instructions and information about recognizing emergencies involving tracheostomies; Medical University of South Carolina.

Shiley Tracheostomy Tube Pediatric Homecare Guide (Coviden) (Spanish & English)(PDF Document 715 KB)
Information on how to care for your tracheostomy tube. Includes tips on how to suction, change ties, change tubes, and care for the skin around the neck opening.

Trach Change (Breath of Life)
Five-minute YouTube video showing how to change a trach. Includes close-ups of the trach parts; commercially produced by Creative Force Video Productions - full-length video for a fee.

Trach Suctioning (Breath of Life)
Short video that helps improve knowledge and self-confidence while suctioning the trach. Commercially produced by Creative Force Video Productions.

Tracheostomy Care (St. Jude Children's Research Hospital)
Extensive information on care of trachs; includes changing, cleaning, suctioning, and traveling.

Tracheostomy: Parent Talk (Nemours)
A video of three parents who share their tips and experiences on raising a child with a tracheostomy.

Services

Early Intervention Programs

See all Early Intervention Programs services providers (53) in our database.

Home Health

See all Home Health services providers (73) in our database.

Pediatric Otolaryngology

See all Pediatric Otolaryngology services providers (9) in our database.

Pediatric Pulmonology

See all Pediatric Pulmonology services providers (5) in our database.

Respiratory Therapy

See all Respiratory Therapy services providers (10) in our database.

Speech/Language Therapy

See all Speech/Language Therapy services providers (48) in our database.

For other services related to this condition, browse our Services categories or search our database.

Studies

Clinical Trials on Tracheostomies (clinicaltrials.gov)
Lists current studies related to tracheostomy and children; sponsored by the U.S. National Institute of Health.

Authors

Reviewing Authors: Christine Hartling, BS, RRT-NPS, CPFT - 4/2014
Jeremy Meier, MD - 4/2014

Page Bibliography

American Association for Respiratory Care.
AARC clinical practice guideline. Endotracheal suctioning of mechanically ventilated adults and children with artificial airways. .
Respir Care. 1993;38(5):500-4. PubMed abstract

Arcand P, Granger J.
Pediatric tracheostomies: changing trends.
J Otolaryngol. 1988;17(2):121-4. PubMed abstract

Coviden.
Tracheostomy Tube Pediatric Homecare Guide.
Care Manual. 2014; http://lgdata.s3-website-us-east-1.amazonaws.com/docs/1310/598783/206-...

Fitton CM.
Nursing management of the child with a tracheotomy.
Pediatr Clin North Am. 1994;41(3):513-23. PubMed abstract

Gianoli GJ, Miller RH, Guarisco JL.
Tracheotomy in the first year of life.
Ann Otol Rhinol Laryngol. 1990;99(11):896-901. PubMed abstract

Hodge D.
Endotracheal suctioning and the infant: a nursing care protocol to decrease complications.
Neonatal Netw. 1991;9(5):7-15. PubMed abstract

Kenna MA, Reilly JS, Stool SE.
Tracheotomy in the preterm infant.
Ann Otol Rhinol Laryngol. 1987;96(1 Pt 1):68-71. PubMed abstract

Lichtenstein MA.
Pediatric home tracheostomy care: a parent's guide.
Pediatr Nurs. 1986;12(1):41-8, 69. PubMed abstract

Mitchell RB, Hussey HM, Setzen G, Jacobs IN, Nussenbaum B, Dawson C, Brown CA 3rd, Brandt C, Deakins K, Hartnick C, Merati A.
Clinical consensus statement: tracheostomy care.
Otolaryngol Head Neck Surg. 2013;148(1):6-20. PubMed abstract / Full Text

Runton N.
Suctioning artificial airways in children: appropriate technique.
Pediatr Nurs. 1992;18(2):115-8. PubMed abstract

Sherman JM, Davis S, Albamonte-Petrick S, Chatburn RL, Fitton C, Green C, Johnston J, Lyrene RK, Myer C 3rd, Othersen HB, Wood R, Zach M, Zander J, Zinman R.
Care of the child with a chronic tracheostomy. This official statement of the American Thoracic Society was adopted by the ATS Board of Directors, July 1999.
Am J Respir Crit Care Med. 2000;161(1):297-308. PubMed abstract

Vitacca M, Clini E, Foglio K, Scalvini S, Marangoni S, Quadri A, Ambrosino N.
Hygroscopic condenser humidifiers in chronically tracheostomized patients who breathe spontaneously.
Eur Respir J. 1994;7(11):2026-32. PubMed abstract

Ward RF, Jones J, Carew JF.
Current trends in pediatric tracheotomy.
Int J Pediatr Otorhinolaryngol. 1995;32(3):233-9. PubMed abstract

Wetmore RF, Handler SD, Potsic WP.
Pediatric tracheostomy. Experience during the past decade.
Ann Otol Rhinol Laryngol. 1982;91(6 Pt 1):628-32. PubMed abstract