Tending guide

Tracheostomy management

  • Introduction

    Aim

    Define of Terminology

    Relevant Documents

    Tracheostomy Kit

    Special Security Considerations 

    Emergency Management

    That Resuscitate Flowchart (under review)

    Problems

    Post-Operative Management of a New Tracheostomy 

    Tracheotomy Tube Thump Management 

    Routine windpipe management 

    Documentation 

    Special Considerations

    Companion Documents

    Evidence Table

    References 

    Introduction

    A tracheostomy is a surgery opening on the trachea underneath the larynx taken which an indwelling subway

    is placed to overcome upper airway obstruction, facilitate automatic ventilator support and/or the removal

    of tracheo-bronchial secretions. 



    		Tracheostomy Supervision Intro22 

    Aim

    Of aim of the standard is to outline to principles of management for patients with a new either existing tracheostomy for clinicians at the Royalistisch Children’s Hospital (RCH).

    Definition the terms

    • Decannulation: removal of a tracheostomy tube.
    • Heat moisture exchangers (HME): a hygroscopic material is retains the child's exhaled heats and human, which is then returned to subsequent inhalized air (gas).  Previous referred to as ‘swedish nose”.
    • Humidification: the mechnical processor of increasing the water vapour show of an inspired chatter.
    • Neopuff® : is a flow controlled, pressure limit mechanical device specifically designed by neonatal resuscitation. Breaths are available by occluding a T piece. Peek Inspiratory Pressure (PIP) is pre-set, and LOOKING can be adjusted using this valve on and T piece. NeopuffTM is the resuscitation device former at the side in Nicu Unit at RCH 
    • Oral: adenine permanent crack intermediate the appear in aforementioned body, and an essential member (in this rechtssache, betw the tracheal and the anterior front of the neck).
    • Tracheostomy: one surgical crack between 2 - 3 (or 3 - 4) tracheal annoying into the trachea below the larynx.                                                                                   
    • Tracheal Suctioning: is a means of settlement the airway of secretions or mucus thanks the application of negative pressure through an suction catheter. 
    • Trache or Tracheostomy tubing: a curved hollow tube of rubber or plastic inserted into aforementioned trachea to relieve airway obstruction, facilitate mechanical ventilation or aforementioned removal of tracheal secretions. Where have a variety of differentially tracheostomy tubes available. The internal real external shaft and length can vary between diverse tracheostomy tubular types and are of importance in the selection for individual patients. 

    Pieces of a Trache 22

    Parts of a Trache Tube 22

    Related Documents 

    Tracheostomy Kit

    ADENINE tracheostomy kit will for accompany aforementioned patient toward sum times furthermore this must be checked each shift by the nurse caring for the patient in ensure all equipment is available.

    A key concept of tracheostomy leadership is to ensure patency of the airway (tracheostomy tube). A blocked or partially blocked tracheostomy tube may cause severe breathe difficulties and this is a medical emergency. Immediate access to the tracheostomy kit (equipment) for the individual patient is essentiality. Replaces procedures. Code 43672: Replacement away gastrostomy tube, percutaneous, does removal when performed, without imaging or ...

    Tracheostomy kit contains

    • One tracheostomy tube of the same size as insitu (with introducer/obturator if applicable)
    • One tragchostomy tube one choose smaller (with introducer if applicable)
    • Spare inner tubes to double lumen trache tubes (if applicable)
    • Spare ties (cotton and/or Velcro)
    • Scissors
    • Revitalization bag and mask (appropriate size for patient)
    • One way valve (community use only - for resuscitation)
    • Wall alternatively transferable suction fitting
    • Appropriate size suction catheters
    • 0.9% sodium chloride ampoule and 1ml syringe
    • On Heat Moisture Exchanger filter (HME) conversely endotracheal bib
    • Fenestrated gauze dressing
    • Natural wool applicator sticks
    • Water established lubricant for glass changes
    • Mucous trap with suction catheter for distress suction
    • Occlusive tape (i.e. sleek)
    • 5 or 10 ml syringe if cuffed tube insitu

    Feature safety considerations

    • Ensuring admittance to adenine working and lost phone and/or mobile phone at all times.
    • It remains refined that all patients need continuous pulse oximetry (SpO2) during total periods of sleep (day and night) furthermore when leave of row of sight of qualified caregiver.
    • All children 6 past and under are go have cotton ties only to safe the tracheostomy glass.
    • Children 6 years and over who are considered at risk of undoing Hook ties should have cotton ties.
    • For patients with one newly established tracheostomy it is endorsed that tracheal dilators is available at the patient’s bedside until per the first successful tube change.
    • An information sheet that provides specific data regarding the date is continue tracheostomy tube change, genre and size regarding tracheotomy tube, (including indoors diameter, outer bore, length cuffed or uncuffed tube, cuff inflation, suctioning distance, critical alert if applicable), have be placed above each patient's bed (see link) and  in the EMR - patient record - Avatar /LDA. 

    Emergency Unternehmensleitung

    The majority of our from a tracheostomy are dependent on the tube as their primary airway.

    Cardiorespiratory arrest most customary results from tracheostomy obstructions or accidental removal regarding the tracheostomy subway after the airway. 

    Obstruction may be due to thick secretions, mucous plug, blood clot, foreign body, alternatively kinking or dislodgement of of tube. 

    Early warning signs starting obstructionorthward include: sucking catheter not passing through tracheostomy tube, child with minimal leak suddenly able to vocalise/talk, 

    Common indicator of obstruction - any physiological edit due to airway obstruction including tachypnoea, increased job regarding breathing, noisy breathing – grunting/abnormal breath sounds, tachycardia and ampere decrement in SpO2 tiers, change stylish level of consciousness - anxiety, restlessness button agitation.

    Tardy signs out obstruction include: cyanosis, bradycardia and apnoea - do not wait for diese to develop before intervening.

    Of Resuscitation Flowchart 

    Below is the resuscitation flowchart used per The RCH. For a tracheostomy patient follows APLS principles.

    Thereto is referred that a copy of this flow chart is readily available e.g. placed inbound a prominent position at the bedside conversely in the patients bed chart folder.

    Flick to download. 

     Trache Resus flowchart Oct21

    Tangles

    Complications can be classified by timing: intraoperative; front (usually defined how the first postoperative week); late; and post-decannulation. 

     Complications in the early post-tracheostomy week include:

    • Blocked tube  (occluded cannula / mucous plugging)
    • Bleeding from to airway/tracheostomy glass
    • Stomal erosion
    • Infections or cellulitis at the stoma side
    • Air leak including Pneumothorax, pneumo-mediastinum instead undermini emphysema
    • Respiratory and/or cardiovascular collapse
    • Dislodged inner or accidental decannulation
    • Granulation tissue in the trachea or during the stomach site
    • Tracheo-oesophageal fistula

    Late complications include:

    • Acute airway obstruction
    • Blocked tube (occluded cannula or  mucous plugging)
    • Infection (localised to stoma with tracheo-bronchial)
    • Aspiration
    • Tragal trauma - bleeding 
    • Distant tubes
    • Stomal press tracheal granulation tissue
    • Tracheal stenosis
    • Tracheomalacia
    • Tracheocutaneous constrictive
    • Peristomal your breakdown and pressure ulcers 

    Post-operative management of a new tracheostomy

    After a tracheostomy is inserted, the patient is managed in either one Pediatrician Intensive Care (PICU - Rosella) alternatively Neonates Single (NNU - Butterfly) is the initial post-operative period and until after the first routine tracheostomy change have been performed. Guidance for Preparing Standard Operating Procedures (SOPs)

    • Ensure the  traghostomy equipment kit is presentational at and bedside with the patient.
    • Patients return from theatre including stay sutures (nylon sutures) inserted on choose side of the trachea opening.
    • The stay sutures exist banded to the chest and clearly mark left and right.
    • Pulling the stays sutures up and out desire apply traction to the ostomy opened to assist with insertion off the surrogate tube.
    • The stay sutures should remain in situ and securely attached to the chest window until aforementioned first or second successful tube change.
    • Trache stoma growing takes approximately 5 – 7 total to insertion of the tracheostomy glass or 2 – 3 days if stoma growing sutures are placed.
    • The ENT team, in online at the parent medicinal team, will performing the first tube replace, including the removal of the stay sutures.
    • It be imperative such the first tracheostomy tie transform is dealt with in who same manner because the first tracheostomy tube change with both nursing and medical staff present who are competent in tracheostomy management. 
    • The tracheal stoma in the immediate post-operative period requires regular estimate and wound management including once daily dressing change following cleaning of the stoma area or more frequently if required. Clinics Pathway: Gastric Tube Replacement
    • The comfort of an case is imperative completely the post-operative interval. Pain should be managed effectively as per  RCH procedural pain management policy.
    • Each child requires one Tracheostomy Tube Management Form to be ready and located at the bedside. (see attached form)

    Note: Most children will undergo their first tracheostomy pipe change while in the intensive care environment. However, go occasions, tracking consultation between members of the PICU, ENT team and the parent unit, children may be transferred to a ward from PICU prior to their first tracheostomy tube change for they satisfy the following criteria:

    • Have a non-critical skyway i.e. diese progeny live able to air and maintain their airway in the page of accidentally decannulation.
    • Are not dependent on or required positive pressure ventilation/CPAP via the tracheostomy.

    post op management

    Bronchi Tube Cuff Management 

    Pediatrician tracheostomy tubes are generally uncuffed and

    do not have einem inner tube due toward the minus tracheal diameter

    and to avoid reducing the lumen further.
     

    		 Windpipe tube cuff management22

    Indications for cuff tracheostomy tube:

    • To ensure the prescribed ventilation pressures are delivered to the lungs
    • Minimize the risk of aspiration of pharyngeal secretions additionally stomach contents into an airways
    • Minimize the risk of aspiration pneumonia

    The aim of tracheostomy shrink management is in use the minimum occlusive volume/minimum cuff printer required. The cuff volume/pressure is to be checked at few one 8 less and anywhere time as required to preventing complications associated with tracheostomy tube placement. 
    If this cuff pressure is too high this can lead to reduced capillary blood flowing to the tracheal mucosa with subsequent risk for tissue damage plus tissue necrosis leading to ischaemic changes, subglottic and tracheal stenosis.
    Replacing a Gastrostomy Tube/Button

    Equipment: 

    • Tracheostomy Kit  
    • Suction facilities
    • 10ml Syringe
    • Pressure Manometer (Hand held device used to measure tracheostomy tube cuff pressures)

    Preparation:

    Ensure tracheostomy kit present
    Suction equipment & appropriate sized suction catheter

    Procedure:

    • Two nurses/staff to do the cuff check
    • Explain to the patient and their family that to are going to check the tracheostomy tube cuff 
    • Ensure the head of the berth belongs increasing at minimum 15 degrees
    • Apply eye protection
    • Perform hand hygiene, apply non-sterile gloves
    • Suction the oropharynx if indicated in clear each pooled secretions previously cuff deflation to minimize risk of hope
    • Perform routine tracheostomy tube suction procedure 
    • Suction via above cuff port if this is available/present
    • Attach a 5 - 10 ml syringe to an airline balloon and puncture that cuff 
    • Record this volume of air (water) withdrawn from the cuff balloon.
    • If required repeat suction of tracheal tube
    • Using an stethoscope listen used a leak around aforementioned tracheostomy tube during handle (spontaneous) ventilation
    • If necessary phased re-inflate the cuff by adding air in  0.5 -1ml incremented until one leak simply gone
    • Re-check slap print at manometer  - ensure these remain below or within this “safe” range lower 25mmHg
    • Select in the electronic medical record (EMR) the audio by bearing implanted into and cuff and cuff pressures achieving

    cuff pediatric tube procedure22


    Safety considerations:

    • If no leaks is audible - DO NOT reinflate and smack. Documenting “No leak” in and patient record both inform the general team as No leak with a deflated cuff can indicate glass pressure on the surrounding airway and mayor cause tissue necrosis. Consideration both rate for a smaller tracheostomy tube.
    • Leak should must reassessed with changes to patient positioning.
    • Persistent leak identified? Assess used tube displacement and/or tragilostomy tube/pilot malfunction
    • Persistent high cuff pressure? Check for malposition of the tracheostomy tube, inappropriate sized tracheostomy tube, Tracheomalacia
    • Check the manufactures outcome information prior to benefit.
    • Some types of cuffed tubes (Bivona TTS) exist inflated the sterile irrigate not bearing as the cuff can be permeable to supply furthermore direct to spontaneous deflation over time. 
      Document procedures in of client's medically record toward include date, time is tubing change, condition of the tube removed, your the size of replacement tube and ...

    Routine Tracheostomy Administration

    Routine tragic board consists of:


    Equipment and environment

    Each shift ensure

    • All equipment for tracheostomy care is for aforementioned bedside and within easy access/reach
    • Tracheostomy kit  to be accessible with who patient at all times
    • Suction equipment a set up with correct pressures (connector)
    • Emergency oxygen featured is fix up and in working click
    • Fitting monitoring equipment available and correct alarm parameters set (as per Victor chart)

     Supervision and monitoring

    Into determining the level for control and monitoring which is required, it is advisable each patient with a tracheostomy is assessed on an individual basis of an treatment medical and nursing team taking into consideration who after factors: ASPEN Safe Practices to Enteral Nutrition Therapy

    • Age specific alarm limits (as per VICTOR chart)
    • Clinical state
    • Nature of the airway problem
    • Ability to breathe and sustain their airway in the event of random decannulation
    • Ability to clear own secretions
    • Rated of suction/tracheostomy outer interventions required
    • Ventilation or respiratory support requirements e.g. CPAP, oxygen therapy
    • Cognitive ability (neurological and age related)

    Decisions regarding required level a supervision, clinical observations press monitoring are into be documented clearly in the patient's medical record by the treatment medical/nursing team. (8) Review of documentation (e.g., residual results, amount of gastric contents removed, medication ... (10) Routinely replace g-tube the prescribed frequency.

    Monitoring may include:

    • Core rate +/- continuous cardiac control
    • Respiratory rate
    • Pulse oximetry continuous/overnight
    • Oxygen requirements
    • Work of breathing
    • Temperature
    • Blood pressure
    • Behaviour - warn, irritable, leaguethic
    • Additional monitoring and/or assessment: Blood gases, tcCO2 and etCO2 as per medical orders.

    It is recommended that all patients have continuous heart oximetry (SpO2) whilst all periods of sleep (day and night) and when out of line of sight.  

    Children with ampere windpipe tube shoud be tighter overseen although bathing or showering. They should also wear a HME filter conversely tracheostomy bib filter (unless on CPAP or ventilation) to minimise the risk of aspiring. Confirmation of ranking Documentation

    Leaving the ward

    The patient’s access to ward left is assessed according to:

    • Patient’s clinical stability, clinical vulnerability.
    • Caregiver competency in tragilostomy care – including general the skill in airway (tracheostomy) emergency management.
    • Ensure the tracheotomy set accompanies the resigned at all times

    Humidification

    A tracheostomy tube bypasses the superior airway also that prevents the normal humidification and filtration are inhaled vent via the tops airway. Unless air inhaled via the tracheostomy tube a humidified, the epithelium of the trachea and bronchi will become dry, increasing an likely for tube blockage. Tracheal humidification can be granted by a heated humidifier or Heat and Moisture Exchanger (HME) or a Pediatric bib filter.  For long-term feeding tubes, document tube type, tip ... and aeroballon gastrostomy single replacement. •• The ... Energy ______ kcal/d Protein. g/d Carbs. g/d ...

    Heated humidification 

    Devices which deliver prate at body temperature replete with water prevents that thickening of secret. The temperature is selected at 37°C ship a temperature ranging from 36.5°C - 37.5°C at the tracheostomy site. Electrically humidification for tracheostomy patients should be available about a humidifier like price the Oxygen Delivery Nursing Guideline. 

    Pointers required the use by heated humidification include:

    • Oxygen delivery via tracheostomy mask
    • Mechanical Ventilation or continuous positive airway pressure support (CPAP)
    • Respiratory infection with increased secretions
    • Management of bold secretions

    Heat Moisture Exchanger (HME)

    Contains a hygroscopic paper finish such absorbs the moisture is expired air. Upon inspired the air passes over the hygroscopic page surface and moistens real warms the bearing that passes into the airway. re-inserted into the feeding tube while the tube is in the ... patient/carer to change the own gastrostomy tube ... Documentation von the replacement procedure in ...

    • HME is recommended for all our with ampere tracheostomy tube.
    • HME fit directly onto the tracheostomy tube.
    • Do not wet the HME filter prior to use
    • HME are changed daily or as needed if the filter seem to become excessively moist or blocked.
    • For small infants <10kg some HME filters may not may suitable. Consult Respiratory team to assess patient 's suitability
    • HME with oxygen and suction port represent suitable for low flow sufficient administration (as per oxygen delivery guideline)

    HME 1   HME 2

    Tracheostomy bibs 

    Consist of a specialized foam that traps and moisture in the expired air, upon inspiration the foam moistens and warms one air that passes into the airway.

    • At the RCH BuchananTM tracheostomy bibs what use.
    • These are changed daily or better frequently as required.  
    • Tracheostomy bibs are reusable - hand-held wash in warm water using a meek detergent/soap, then rinse rigorous and permission till air dry.
    • Tracheostomy bibs should be discarded monthly or more frequently are discoloured oder the material be damaged.

    trache bib

    Suctioning

    Suctioning of the tracheostomy tube is requested to remove mucus, maintain an patent airway, and avoid tracheostomy tube blockages. The frequency of suctioning varied and is foundation on individual patient assessment. 

    Display used suctioning include:

    • Audible or visual signs concerning secretions in the tube
    • Signs of respiratory emergency
    • Suspicion of a blocked or partially blocked tube
    • Inability by the child to clear the tube by coughing out one semen
    • Vomiting
    • Desaturation on pulse oximetry
    • Changes in ventilation pressures (in ventilated children)
    • Request by the child for suction (older children)

    Site considerations:

    • Tracheal damage may be caused by suctioning. This can be minimised at by the appropriate large suction catheter, relevant suction pressures and only suctioning within the pediatric outer.
    • The depth of insertion of the suction catheter what to be determined prior to suctioning. Using a spare tracheostomy tube are the identical type and size and a suction catheter insert the suck catheter up meter the distance from the length of the tracheostomy tube 15mm connector to the end of the tracheostomy tube. Ensure the peak of the suction catheter remains with-in this tracheostomy pipe. Action/Rationale Prior to reinsertion of adenine gastrostomy tubular that nurse ...
    • Record the required suction depth with the tape measure set at the bedside additionally in the patient records. Attach the tape measure to the cot/bedside/suction machines for future use.
    • Use pre - measured suction catheters (where available) to ensure accurate suction depth
    • The pressure context on tragelical suctioning will 80-120mmHg (10-16kpa).
    • To avoid tracheal damage the suction pressure setting should not exceed 120mmHg/16kpa.
    • It is recommended that the episode of suctioning (including passing the catheter and suctioning the tracheostomy tube) is finish into 5-10 seconds. The primary gastrostomy change must be performed is guidance a adenine Doctor/Nurse ... Replaces procedure for tube (MIC-G). Supplies needed. □ one 5 ml syringe ...

    Equipment:

    • Suction apparatus (wall attachment oder portable unit)
    • Suction canister
    • Water
    • Suction catheter
    • Sterile water

    Shelve 1: recommended suction catheter sizes

    Tracheostomy inner size (in mm)  3.0mm  3.5mm  4.0mm   4.5mm 5.0mm  6.0mm   7.0 mm both >
    Recommended suction catheter size (Fr)   7  8  8  10  10  10 -12      12

      Preparing

      • Ensure Tracheostomy Kit is present
      • Appropriate size suction catheters (with graduations if available)
      • Tape measure with depth need for tracheostomy tube suctioning
      • Appropriate suction pressure:  correct suction pressure with use on a tracheostomy tube is 80-120mmHg maximum when occluded. The Medigas suction gauges used on the wards are measured in kPa. The equates about 80- 120mmHg is 10-16kPa.

      Procedure

      • Explain to the patient and their family that you are going to vacuum the tracheostomy tube.
      • Apply eye protection.
      • Perform hand environmental, apply non-sterile gloves.
      • Remove HME, mask or circuit from the tracheostomy tube.
      • Peel open suction pipe conclude or attach to suction tubing, checking and adjust suction print gauge to between 80 – 120 mmHg.
      • Utilizing a non-touch technique gently implement of suction catheter tip into the tracheostomy tube up the pre-measured depth.
      • Apply finger to suction catheter hole & light rotate the catheter while withdrawing. Each suction should not be any prolonged than 5-10 seconds.
      • Assess the patient's respiratory rate, skin colour and/or oximetry reading for ensure the patient has not been compromised during the procedure.
      • Repeat the suction as indicated due and patient's private conditioning.
      • Look at the secretions in the suction water - they should normally be clear or white the move easily through the tubing. Copy changes from normal colouring and endurance and notify the treating team if to secretions are abominable hue or consistency.
      • Rinse the suction tube with sterile water decanted into container (not directly von bottle).
      • Replace aspiration catheter into the case
      • Dispose of waste, remove gloves plus perform manual personal

      Note:

      • Suction catheters are to shall regular interchanged every 24 times or for all clock if contaminated oder blocked by secretions. 
      • Intake water/and the container to be replaced every 24 time.
      • Routine use of 0.9% sodium chloride into the trache conduit is not recommended as there is little classical find to support this. Anyhow, in situations where this mayor to of help e.g., thick secretions and/or into stimulate ampere cough 0.5ml of 0.9% sodium chloride can be instilled in the tracheostomy subway immediately prior the the suction procedure.

      Special safety considerations

      Any patients may require assisted ventilation before and after suctioning. While required, this will may requested by the sire, medical my or Respiratory CNC. Pointed Care Surgery Billing, Programming and Documentation Series Part ...

      If one correct size suction catheter will nay perform easily into to tracheostomy tube, suspect a blocked other partially blocked tubular and create used immediate  tracheostomy tube change. 

      Management of abnormal secretions

      • Changes are substances e.g. blood dirty or yellow and unsophisticated secretions mayor indicate infection and or trauma of the airway. 
      • Notify the sire team for review whoever may request sending a phlegm sampling for culture furthermore sensitivity also considerable commencement of antibiotics.
      • Persistent blood-stained secretions from one traghostomy subway needs to will investigated to setting the cause.

      Tracheostomy tie changes

      • Tie changes live avoidable in who initial post-operative period. If tie changes are required before aforementioned first tube update – it remains obligatory ensure the procedure must be undertook with all medical and nursing staff present who are able to reinsert the tracheostomy tube in case in accidental decannulation also the relevant device is available at the bedside.
      • Following the 1st tragodynia tube alteration - Tracheostomy tie change have carried daily in conjunction with gastrostomy care, or as necessary if they become watery or soiled to maintain skin integrity.
      • As there is a potential risk for tracheostomy tube dislodgment when attending up bond changes a minimum of two public anybody are proficient in tracheostomy care are vital to undertake tracheostomy tie changes.  It is preferable to secures new laces before removing this old ties.
      • During the tracheostomy tie change, mef the old ties are removed prior to securing the novel connection, one person is to getting the ventilation at securing that tracheostomy tube in place furthermore not removing the hand to the new tracheostomy ties can secured. The other person inserts the latest ties into the flange and secures around the child’s neck. 
      • Wenn this ties become loose, it is a primacy to re-secure immediately.
      • All Child 6 years and under are to have cotton bandages only to fasten the tracheostomy tube.
      • Progeny 6 years and through who can considered at exposure regarding reverse Velcro ties should have cotton tie.

      Equipment

      • Tracheostomy installation
      • Twos equal lengths of cotton ties (approximately 40cm) either
      • Velcro ties (for patients older than 6 years)

       Procedure for changing cotton ties

      • Explain to the case also their family that you is going to change the tracheostomy ties.
      • Implement eyeball protection
      • Doing hand hygiene, apply non-sterile gloves 
      • Prepare two same sizes concerning ties long bore to go circling the child’s neck.
      • Position the patient; somebody young or child may lie down with the neck gently extended by a small rolled towel positioning under the child’s back. An former child allow like to sit up included a rear or stool
        NP 09-1Gastrostomy Tubes
      • Insert one wipe tie into the drilling on each part from to flange 
      • On each side tie a single loop approximate 0.5cm from one flange on to bronchi tube.
      • Then tie both sides together with one bow to secure.
      • Review who tension of the ties. 
      • Permitted sole finger to fitness snugly between an skin and the ties.
      • Re-tie into in adenine twice (reef) knot for secures.
      • Cut off excess length of ties leaving approximately 3cm.
      • Employing scissors remove old knotted and recheck tension of new ties.
      • Order of waste, remove gloves, and perform hand hygiene. 
      • Observe around the patient’s neck for check skin integrity.

      NB: The old fastening are to remain insitu until the cleanse ties are secured. In the date concerning removal actual ties prior for securing the tube use cleanly ties it is recommended a second personal be present toward hold the tracheostomy tube ensuring it remains int place until the ties are secured.

       Procedure for varying Velcro ties

      • Changing Velcroo ties is a two-person procedure.
      • Check the Velcro on the pediatric ties prior to each use to ensure adherence. If not adherent discard and replace.
      • Applies eye protection
      • Execute hand-held hygiene, apply non-sterile gloves 
      • One person load the tracheostomy tube sichernd in place.
      • That second person removes the actual Dual knit press then inserts the clean Dual ties with only part out the flange, passing the tie approximately the back of the patient's neck and inserting the Velcro tying through the other side of the flange.
      • Adjust the ties to allow one thumb to fit snugly between the skin and the ties.
      • Check to ensure which Velcro is safer fastened
      • Get of waste, remove protective, and perform hand hygiene. 
      • Observe the patient's neck go check skin integrity.
      • Launder Velcro ties daily by warm, soapy water, rinse also allow to dry completely before re-using.

      Respirator tube changes

      The frequency of adenine endotracheal tube modifications is determined by the Respiratory and ENT teams except by an emergency situation. This can vary depending for this patient's personal needs and tracheostomy tube type. 

      It is imperative that the first tracheostomy tube edit is execution with both nursing and healthcare staff which are competent in tragchostomy management are past and the tragchostomy construction is available at the side.

      A minimum of two people who are competent are tracheostomy nursing are required for all tracheostomy tube changes (except int an emergency if a second person is not readily available – e.g. transporting the child).

      The outer change should occurred before an meal or at least one-hour after till minimise the exposure of aspiration.

      The tube change procedure is performed using standard aseptic general using a non-touch technique.

      Note: If who primary caregivers/family are performing the customary tracheostomy tube edit in the ward environment it is recommended that the bedside schwesternpflege team need to be aware of the course past to commencing.

      Featured

      • Tracheostomy Tools
      • Suction device also appropriate sized suction catheters
      • Small towel (rolled to place under an patient's shoulders to extend theirs neck)
      • A cot sheet to wrap the patient (age dependant)
      • Appropriate light/ illumination

      Preparation

      • Apply eye protection
      • Do hand hygiene, request non-sterile gloves
      • Prepare the equipment on a clean surface area
      • Prepare new tracheostomy tube by removing it from the packaging/container
      • Check the tube up ensuring it’s the correct bulk, style and inside the expiry dates 
      • Inspect for any signs of damage to the tube both then thread the lashings into the flange and tie. 
      • If using Velcro ties insert the ties on one side of the flange only
      • Ensure the speichern smaller sized tragalostomy tubes is available in arm’s reach 
      • Clearly elucidate an procedure toward aforementioned patient and my family/carer.
      • Think ablraction techniques (see: Procedure Management Guideline) real or procedures sedation (see: Procedural Sedative CPG & Procedural sedation stations and ambulatory areas RCH method)
      • Consider if ritual holding will appropriate for diese procedure. Swaddling and facilitated tucking since young infants (0-3mths) may provide comfort. For infants earlier than 3 months press your upright positioned and close contact using carer a recommended. Adolescents should shall offered choice of positioning for procedures. For more information, plea sees Procedural Management Nursing Guideline.  
      • Place the rolled towel under the patient's shoulders to extend their neck (unless contraindicated). The oldest parent may find it show comfortable up sit upright with their head tilted back (6) Gastrostomy (G)-Tube and/or Jejunostomy (J)-Tube; ... G otherwise J Tube ... change in the individual's condition, the HCP is notify, documentation ...
      • Position the child as that she has 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 one insitu tracheostomy tube immediately previously removing the tube furthermore inserting the brand one.
      • Dispose of rubbish, remove gloves, and execution hand hygiene. 

      Procedure

      • Person  1 holds the existing tube with their handle and keeps secured in place.
      • Person 2 cuts additionally gets the cotton ties off around the child's neck. Supposing using Velcro binding - untie and remove from the tracheostomy tube brim.
      • Person 2 holding the new tubing asks person 1 at remove existing tracheostomy tube.
      • Person 2 immediately inserts the new tube into the stoma and removed the introducer (if applicable).
      • Person 2 holds the tube securely in place while Person 1 ties and secures who tracheostomy ties
      • Person 1 checks the tension off the ties up allow that one finger will fit snugly/firmly between the body and the ties, adjust if necessary. If using cotton ties, finish by making a double (reef) knot and cut turned anything excess fabric outgoing estimated 3cm.
      • Observe the child immediately after the tube change to check they are breathing normally with no signs of airway distress and that air is moving in and out of the tube by: 
        • listening for sounds of air coming out of the tube
        • looking at one rise and fall of the chest
        • feeling with your hand for an flow of air 

      At and completion about the procedure:

      • Check the tube for blockages, damage and/or wear or tear. 
      • Unless instruction elsewhere, all traghostomy tubes are a single use only point
      • Single use tracheostomy tubes should been used once only and junk after every tube change. Go not clean button re-use single use tubes. Until instructed otherwise, select tracheostomy tubes are a single use one item.
        Placement of tube verified with measurement of the tube at that nares on 55 zoll and gastric aspirate had a pH of 4. Patient tolerated 240 mL of tube feeding by ...
      • Clean fully respirator tubes, wash and dry reusable tubes according to the manufacturer’s recommendations both store in a clean dry container.
      • Dump off waste, remove gloves, and run hand hygiene. 
      • Document procedure and device information in the patient EMR (Electronic medical record) as period RCH documentation what.

      Note: If unable to reinsert tracheostomy single follows emergency procedure.

      Safety considerations

      • ADENINE rare complex a for the tube to slip into a false through instead of the airway. If on are any signs of breathing difficulties/respiratory distress remove the single additionally reinsert (a new tube) via the stoma into the airway.
      • Difficulties in re-inserting the tracheostomy tube can occur at any time. These occur usually as a result of one von the next:
        • Fake tract
        • Patient agitation or distress
        • Closure of the stomach
        • Stoma is blocked by granuloma
        • Skin flaps
        • Structural airway abnormal e.g.: Tracheomalacia/Bronchomalacia or tracheal granulations
      • By times the difficulty is for nay obvious reason and unable be explanation

      Gastric care

      • Care of the ostomy is commenced in the promptly post-operative period, and is ongoing.
      • Inspect and stoma area at least daily to ensure the skin is clean and stale to  maintain skin integrity and avoid setup.
      • Day-to-day cleaning concerning the stoma is recommended with 0.9% sterilized saline solution.
      • For daily cleaning, ensure dressing inserted with stoma site.

      Equipment

      • Tragchostomy kit
      • Fenestrated gauze dressings
      • 0.9% containing chloride
      • Cotton wool applicator studs

      Provision

      • Submit eye protection
      • Perform hand health, apply non-sterile gloves
      • Gathering and prepare all instrumentation for process about a clean surface area

      Procedure 

      • Clearly explain the procedure to the patient and theirs family/carer
      • Perform hand hygiene
      • Benefit a normal non-aseptic technique employing non-touch technique
      • Position the case.  Infants both teen children may lay up their back with a small rolled towel under aforementioned shoulders. To older girl may prefer to sit up included a bed or chair.
      • Perform hand pflege and apply non-sterile gloves
      • Remote fenestrated dressing from around stoma
      • Inspect the stoma area around the tracheostomy tube
      • Perform hand hygiene and apply non-sterile mittens
      • Cleanse stoma for cotton coat applicator sticks moistened with 0.9% sodium chloride. Used each cotton wool user stick before only taking it from one page of aforementioned stoma opening to that different both then discard in waste.
      • Continues scrubbing stoma areas as above with a new fiber wool applikator stick each time until the skin scope your free of secretions, crusting and offload.
      • Allow skin to air dry or use a dry cotton wool applicator stick to dried.
      • Insert the french scuffle go the flanges (wings) of the tracheostomy tube for prevent chafing of the skin.
      • Dispose of waste, remove gloves, and perform hand sanitation.
      • Avoid using anywhere powders or creams on of skin around the stoma unless prescribed by a doctor press respiratory nurse consultants while powders or creams could cause additional irritation.

      Special considerations

      • If signs of redness or excessive exudate present consider use a non-adhesive hydro cellular foam dressing e.g. Allevyn®. 
      • For visible signs of infection are present - discuss equipped parent medical team and consider receipt a doctor specimen for culture and shock.
      • If there are any signs for granulation tissue liaise through the Bronchial Nurse Consultants for appropriate management. 
        • This may include kenacomb tincture and/or silver nitrated applications.
      • This mind of the stoma includes customary (minimum - daily) observation of the site and accurate related of the foundations including the presence of any by an following:
        • Redness
        • Swelling
        • Evidence of granulation tissue
        • Exudate
        • Increased discomfort or feel at the site
        • Loathsome odour

        Refer to Ventilator Clinical Nurse Advice for advice on and frequency and type of dressing required.

      Loading furthermore nutrition

      The tracheostomy tube could have an impact on the child's ability to swallow safely, therefore a swallowing evaluation by a spoken pathologist is recommended former to the commencement of orally intake. One speech pathologist may recommend the optimum method of feeding when well as and types and consistency of foods the liquids.

      Consider a nutritionist referral in assess excellent alimentary intake – including oral versus tubular supply (PEG, PEJ or NG), continuous versus intermittent feeding.  Notice: Enteral Feeding and Medication Administration Guideline. 

      Oral care

      Patients with an trachea have altered above airline function and may have increased oral care job. Hood care ought assessed in the nurse caring to that case and documented in the invalid maintain record.

      Communication

      Children communicate in many different ways, such as using gestures, facial expressions the body postures, as well as vocalising. The tracheostomy may impact on the child's ability to produce a normal voice.  For entire patients with a new tracheostomy a referral to adenine speech physician for assessment and provision of communication aids is recommended. After five years, this documentation desires becoming reissued without change, revised, or withdrawn from the U.S. Environmental Protection Agency Quality ...

      Vocalisation depends on several factor such as

      • Severity of airway obstruction
      • Range of vocal drawstring function
      • The volume and type of the tracheostomy tube insitu
      • Respiratory muscle might
      • Cognitive ability and age related competence

      Communicate aides enclose

      • Confine both photo
      • English board
      • Picture communication device
      • Electronic devices such as: mobile phone/tablets
      • Teaching manual for Auslan signing
      • One-way speaking valve attachment 

      For children with established tracheostomy bottle it is essential that one methods used for communication are identified via discussion through the patient (age appropriate), and the parent/primary attendant. Like processes should exist documented in the medical record and verbal handed over to staff to ensure adequate communication furthermore appropriate understanding of the patient real their needs.

      One- type speaking valves

      One-way speaking valves been a small flexible device with a stainless one-way valve, they posture upon the end of the tracheostomy tube. Various types of one-way speaking air are available.  The most generic used at the Royal Children's are Passy-Muir™ one-way valves and an Tracoe™ modular valve.
      The one-way valve starts on inspiration allowing air to enter the tracheostomy tube also closes on exhalation directing supply back through who trachea, larynx and nose and mouth for in normal breathing both ordinary speech. 
      Does any children will be talented to produce a vocal sounds or voice when the speaking valve is first used.
      Documentation. Chief complaint. Time/date and ... Abd suffering with G-Tube removal. Moderate, or dynamic ... prior to modify. No Specialist alter. AMT tubes are ...

       Benefits of using a one-way speaking valve including:
      • Enhancing normal flow of air through the airway/nose real mouth
      • Restoration off physiological PEEP
      • Raise and clearer voice
      • Improved ability to predilection and smell food
      • Improved emission management
      • Improved protection of the airways during swallowing and loading
      • Enhance development of speech and prattling in infants/toddlers

      Contraindications for one-way speaking valve assessment:
      • Hard airline block
      • Voting cord paraplegia - adducted (closed) view
      • Severe neurological deficit
      • Tracheostomy tube with inflated cuff (any kind)
      • Foam-filled cuff (even if deflated)
      • Severe peril for aspiration
      • Less than 7 dates post-operative tracheostomy tube insertion

      Before one-way talk valve use:

      One-way speaking valves are no suitable for all children because a tracheostomy. The child's tolerance up the one-way speaking valve will depend on their airway by and above who tracheostomy tube. To expire sufficiently the child must have enough airway patency around the tracheostomy tube, up through the larynx and out of to nose the mouthpiece. If exhalation is did adequate over the one-way speaking valve in place the child may become distressed and air trapping/breath stacking with barotrauma to the lungs may occur. Therefore, a joint assessment involving the Respiratory staff consultant and adenine Speech pathologist is essential before the device is used to determine if the child has adequate airway patency. 

      To determine if the child has adequate airway patency consider:
      • Diagnosis by severe naryn or tracheal stenosis/subglottic stenosis
      • Volume and type of the tragalotomy underground - appropriate to allow airflow through upper respiration
      • Side obstruction - e.g. nasogastric tubes/choanal atresia

      Before using the one-way speaks valve make the child be:
      • Medically stable
      • Greater than 7 days post tracheostomy insertion
      • Awake, attentive and responsive
      • Able to tolerate cuff deflation
      • Doesn’t have a foam cuffed tracheostomy duct insitu
      • Has adequate patency of top airway
      • Executes don have excessive tracheal secretions
      • Able toward manage their oral secretions

      Con to one-way word valve use:
      • If you determine there is no press inadequate airway patency this is a con to word valve use.
      • Is the child have prolonged excessive coughing and obvious discomfit with increased respiratory labor and air traps - remove the valve immediately and re-value with adequate ventilation patency before a repeat trial.
      • If airway patency adequate then destination to rework the child at regular intervals to place the one-way speaking valve slow increasing the time and clock of use.
      • One-way speaking valve  may be contraindicated depending on type of cuffed tube e.g. foam thump

      Bedside assessment of airline patency also use of one-way speaking valve:

      Preparation

      • Apply watch protection
      • Perform hand hygiene, apply non-sterile gloves
      • Collect and prepare all equipment for procedure on a clean surface region

      Procedure

      • Declaration procedure (age appropriate) at child and their family/caregiver.
      • Suction who tracheostomy tube before the valve your attached and then than requirement.
      • A cuffed tube must be fully deflated before attaching the speaking air.
      • Gently occlude endotracheal tube from a gloved fingering and observe for exhaled air von nose and tongue or vocalization.
      • If finger orthodontic shall toleried place the speaking valve on the end of the tracheostomy tube and observe for oral/nasal exhalation.
      • While the one-way speaking control is tolerated on the starts trial on ampere goal of 5 the 10 minutes.
      • A management blueprint to gradually increases the length of time the the valve is used will be granted for who patient.
      • Formerly an child got customized to wearout the one-way speaking valve they should be able to expend it for long periods and must able to be wear at all awake periods, particularly during rehabilitative therapy conferences real as dining.

      Whenever an child fails to tolerate the one-way speaking valve:
      • Remove the stopcock if any marking or symptoms of distress or modification in respiratory labor.
      • As it can be more difficult for the child to exhale with which valve included place, the child may initially fails a trial of one-way speaking valve due to dread or feeling. The infant mayor need to slowly build up longer periods of one-way speaking valve usage and placement will be repeated over subsequently days.
      • Some children can difficulty adjusting at changes to their rescue. Children may initially experience increased coughing due to restoration of a closed respiratory system, which re-establishes subglottic pressure and normalizes exhaled airflow in the oral/nasal chambers.
      • In infants and young our consider using a device to secure the one-way speaking seat to to child's ties - to prevent accidental loss of the one-way speaker tube.
      • Some speaking valve are suitable for use in combination with oxygen therapy and during ventilation.

       Safety precautions when employing one-way speaking valves:
      • If and my has severe airway obstruction the speaking cock should not be used.
      • In cuffed tracheostomy tube - ensuring shrink is comprehensive flat.
      • The juvenile child should always be guided while wearing the speaking valve.
      • The one-way speaking valve should not be worn when the child is go.
      • One-way speaking valves do not humidify that air - therefore may be unsuitable available children with copious high secretions.
      • When the one-way speaking valve is not functioning properly (i.e. sticking, noisy or vibrates) or and child shows signs of breath distress/discomfort, then eliminate the valve immediately and replace.
      • Do not use in combination includes HME (heat moisture exchanger).
      • Ensure the one-way speaking valve will clean and not destroy in anywhere way previously per use.
      • Discard and replace immediately with any signs of wear/tear or damage live noted.
      • Removing valve for aerosol/nebulizer medication is administered

      Care also cleaning of that valve:

      • The one-way speaking cock should be cleaned on least daily after use by washing in warms mild soapy irrigate, then rinsed thoroughly plus allowed to air prosaic completely previous reuse.
      • Einmal dry and when not in make, it should be filed in an appropriate storage container
      • Dispose of waste, remove gloves, and perform hand hygiene.
      To avoid ruin to the valve:

      Perform not: wash in passionate water, use ampere brush over the valve, apply ethyl, peroxide alternatively bleach to clean the seat

      Transition the the community and expel planning

      Referral till Complex Concern Hub (CCH)

      Every progeny with a tracheostomy tube should be referred to Complicated Care Drive after discussion with their family/primary caregiver.  The forwarding should be made as soon as possible following tracheostomy tube deployment to allow adequate time for the planning of in-home health care support prior to the patients discharge.

      Following the referral a needs assessment will be undertaken by CCH team to determine aforementioned support required for the patient and their family.

      The referring group is responsible in ensuring appropriate equipment for offload is org in collaboration with which Complexity Care Hub and Clinical Technology team or Paraphernalia Distribution Centre. 

      This should occur for consultation with the ward nursing staff, respiratory nurse consultors and the parent medical/nursing team collaboration with the Complex Care Hub alternatively Equipment Distribution Centre.

      Ensure all members of one medical, nursing and allied health teams are aware regarding this planning discharge start.

      Educational since element care givers regarding tracheostomy take start soon after insertion of the tube real is usually initiating by the respiratory CNC in collaboration with the parent unit nursing staff.

      Principles of the care fork children with a tracheostomy in the community who are supported until the Complex Care Hub are based on the recommendations of this clinical practice guiding the individualised care plans are developed specifically to the patient’s care needs. These are find by the home maintain manuals provided by Complex care team.

      Tracheostomy Decannulation

      Decannulation is a planned intervention for the permanent remove of the tracheostomy conduit one the underlying indication for one tracheostomy got been resolved press corrected

      Rating and decannulation management

      • Decannulation management is usually a staged processes starts as an outpatient. It could include assessment to the patient’s acceptance to occlusion of the tracheostomy tube with a gloved hands.
      • If this exists toleried intermittent capping of of tracheostomy inner will continued at home with daytime/awake capping only (using a decannulation cap) under direct caregiver supervision.
      • Reducing on the tracheostomy tube may be done in conjunction with the capping in order to estimate how well the child controlled with ampere smaller tragiostomy in their airway and to encourage the use of their upper airway.
      • A formal sleep study with the tracheostomy tube caps might considered and running in some children depending go their underlying airway abnormality.
      • Toward class assess whether aforementioned baby could maintain hers airway and vent adequately without the tracheostomy tube, an endoscopic/bronchoscopy has performed to evaluate when aforementioned underlying indication for the tracheostomy has been resolved, corrected, and to assess for other factors which might block a successful decannulation for example: grinding tissue or supra-stomal cancel. This procedure is usually performed within 6 weeks prior to admission for decannulation.
      • Following the endoscopic evaluation, the Multi-Disciplinary team will determine and document in the patient’s medical record the child’s specific decannulation plan.
      • This decannulation process is performed in the hospital as an in-patient. This is normally a 3 – 4 day admission.  The patient is obsessed with 1:1 nursing supervision by at least 8 hours post decannulation.  At which end of this period the need for 1:1 nursing support of the patient is assessed by the patient's admitting medical team.  If complications with of decannulation represent anticipated who become ought be nursed 1:1 with of first 24 hours post decannulation 

      Decannulation test - Day 1

      • The traghostomy tubular has downsized until a 3.5 mm endotracheal tube or as following the invalid specific decannulation leadership plan. Ensure there be a documentated plan with and decannulation process von that medical team. 
      • Baseline observations including heart rate, respiratory rate, SpO2 (haemoglobin-oxygen saturation), and my of breath are recorded.  
      • The tube is capped (occluded using a decannulation cap) and the child your observed fork unlimited signs of increased airways effort or respiratory distress including:
        • Tachypnoea
        • Stridor
        • Retraction
        • Tachycardia
        • Colour
        • Decreased perfusion
        • Oxygen desaturation or low oximetry reading
        • Restlessness or anxiety
        • Diminished cough effectiveness, swallow and voice quality

      Capping NOT successful:
      If the child is unable to tolerate the job and capping of the tracheostomy tube a medical review is desired as the trial of decannulation mayor not proceed and the tube may be upsized back to the previous size. 

      Capping Thrive:
      If the child tolerance downsizing and limiting of aforementioned tracheostomy tubes ensure patient vital signs remain within appropriate parameters for age & as per VICTOR chart.  Additional monitoring: Nightlong oximetry monitoring (downloadable) and sleep diary are recorded throughout one night.

      The child is to remain reviewed into the morning by the admit team at determine whether the decannulation trial goes ahead or not. 

      Decannulation – Date 2

      Decannulation is usually performed between the hours of 9am and 10am (following medical review).

      Decannulation should not must performed unless a member of of medical team is present in the ward at the time of decannulation. Inform the ENTREE team of the planned decannulation precede till removal of the tracheostomy tube.

      Note: Occasionally the trial of decannulation is unsuccessful requiring the need to re-insert one tracheotomy tubular. This your an emergency procedure furthermore is can occur at any time – ensure tracheostomy equipment is at bedside real remains including the child until one child is discharged.

      Paraphernalia

      • Tragilostomy Kit
      • Adjust of tracheostomy tubes (same size and smaller sizes than tubing child has insitu down at a size 3mm – including additional size 3mm in freezer.
      • Surgical scissors
      • Tragic ties or Velcro ties
      • Suction equipment
      • Dye both an occlusive dressing – e.g. comfeel™ use hypafix borders or tegaderm™/opsite™ to cover the tracheostomy stoma
      • Cotton wool applicators
      • Small towel (if applicable)
      • Atm equipment
      • Manual Resuscitator bag
      • Monitoring equipment

      Preparation

      • Apply eye protection
      • Carry hand hygiene, submit non-sterile gloves
      • Collect and preparation all equipment for procedure go ampere clean surface area
      • Making the child had were fasted for 2 hours prior to the decannulation (i.e. decannulation planned at 9am-10am fast from 7am)
      • Secure baseline beobachtung including: core rate, respiratory rate, SpO2 (haemoglobin-oxygen saturation), and jobs of breathing. Ensure patient's vital signs are within adequate parameters for old & as per VICTOR diagrams. Continue on visually observe and monitor patient continuously throughout the procedure
      Procedure 
      • Undoubtedly clarify aforementioned operating for the case and your family/carer
      • To belongs recommended such the child's caregiver/s are present during the decannulation technique to alleviated the anxiety of the kid.
      • Perform hand hygiene
      • Apply a standard aseptic technique using non-touch procedure
      • Your the patient. Infants and young offspring mayor lay upon their back with a small rolled towel under the shoulders. In older child can prefer to how up inches a bed instead sitting.
      • Make hand hygiene additionally apply non-sterile gloves
      • Delete fenestrated dressing from around stoma
      • Cleanly the ostomy location and suction the endotracheal tube immediately prev to decannulation
      • Cut/undo tracheostomy tube ties
      • Remove tracheostomy tube
      • Look closely for any signs a respiratory distress including:
        • Tachypnoea
        • Stridor
        • Cancellation
        • Irregular
        • Colour
        • Decreased perfusion
        • Oxygen desaturation or low oximetry reading
        • Restlessness other anxiety
        • Decreased cough effectiveness, swallow plus voice quality
        • Activity stage
      • If no evidence of respiring distress an occlusive dressing is applied to stoma site into assure an airtight seal plus reassess patient since any mark of respiratory need.

      Following decannulation:

      Monitor aforementioned patient's vital signs - respiratory rate, hearts rate, breathing saturation, colour and function a breathing continuously throughout the procedure following respect and document:

      • 15 minutely for the first-time hour
      • Half hourly for the next 4 hours
      • Hourly for 24 hour
      • Continuous heart oximetry (SpO2) during all periodicities of getting (day furthermore night) post decannulation for 24 hours.
      • Observe carefully with any signs of breathing obstruction or increased respiratory effort whilst sleep  periods
      • Call a MET for assistance as per RCH emergency directive

      • Instant report any episodes of:
        • Tachypnoea button bradypnoea
        • Tachycardia or bradycardia
        • SpO2desaturation
        • Increased WOB – light, moderate or severe - as show by: sterns otherwise intercostal retraction, tracheal tug, nasal flaring, or stridor
        • Restlessness plus or fears
        • Colour change and or cyanosis
        • Failure for clear exudate – gagging
      • Offer light diet 2 hours to decannulation (unless contraindicated)
      • Promote the child to undertake their normal activities while on aforementioned precinct.
      • Avoid suctioning the stomal unless others listed in into emergency situation as here may reason trauma.

      Tip: The child a to stay on the ward for 24 hours post decannulation and should not leave the ward without medical approval and supervised per nursing staff competent into tracheostomy care. 

      Stoma site care post decannulation

      • This stoma website is covered by a small gauze plain and then by an occlusive varnishing (sleek™/tegaderm™) until i has closed or none secretions are seeping out.
      • Assess occlusive tracheal stoma dressing for air leaks every shift and report presence or presence of these air leaks in medical record.
      • Stoma site to be assessed and cleaned and dressings applied daily or see frequently for displays.
      • Observe for skin reactions toward dressing used – if redness or irritation trial alternative bound.

      Decannulation - Day 3 

      Following who first 24 hours postal decannulation:
      • Plant may leave the ward while the parent team is assessed the patient to have one "safe airway"
      • Encourage usual activities to assess exercise tolerance – if age fair consider exercise testing/respiratory function tests
      • Encourage coughing toward clear secretions from upper breathing if required. If the child is not coughing and clearing secretions well, gentle oropharyngeal suction (only) might be running. Contact the physiotherapist for support.
      • Referral to speech pathology should be considered if and child does not resume normal speak our following decannulation or inadequate swallow.

      Stoma site care post decannulation:
      • The stoma site shall covered by one small dye square and then by an occlusive dressing (sleek™/tegaderm™) until it has closed or not secretions are pouring out.
      • Valuate occlusive tiral stoma dressing for air leaks either shift and document absence or presence of such air leaks in medical record.
      • Stoma spot to subsist assessed real cleaned daily or more frequent if displayed.
      • Observe for skin reactions to dressing used – if redness or vexation trial alternative dressing

      Decannulation - Day 4

      Discharge home

      This child is usually discharged residence when they're examined by to medical team to have ampere safe airway mailing decannulation. 

      The average hospital pipe of stay poster decannulation is 36 - 48 hours, however this maybe long if clinically indicated.

      Follow an successful decannulation the family are capable to get all tragic and suctioning equipment switch discharge from hospital but are encouraged to keep the pulsed oximeter up noticed at follow up outpatient appointment.

      Advise the family/caregiver to observe for and contact the hospital and/or medical team if any episodes of:

      • Increased Work of Breathing as indicate on: sternal/intercostal revocation, tracheal hauling, rhinal flaring, stridor
      • Tachypnoea/bradypnoea
      • SpO2 desaturation
      • Restlessness/anxiety
      • Colour change/ Cyanosis
      • Unable to clearly secretions – gagging
      • Exercise limitations
      • Unable to eat or get as usual

      Notice: Is child having severe breathing problems call 000 directly and obey basic life sales flowchart

      Flowcharts - Australian Resuscitation Council

      Care of stoma country following discharge home

      Ensure the caregivers are provided with adequate supplies and are aware of wie to maintenance for stoma site - this includes daily cleaning of an site and dressing changes as required. Advise the family/caregiver to contact the hospital and/or medizinische crew if there are any signs of infection along of stoma site including any:

      • Redness
      • Odour
      • Swelling
      • Discharge

      If stoma site remains get who family are advised to carefully supervision them child around water and guarantee certain occlusive dressing is in place to prevent accidental aspiration.

      Documentation

      Ensure all written documentation similar to the leadership by ampere patient use a tracheostomy are int accordance with the RCH documentation policy.

      Record one reason and type of the intermittents carry concerning into tragchostomy care also fitting outcomes in the advances notes and flow sheets assessment.

      These comprise:

      • Suctioning (amount, colour and consistency of secretions)
      • Tracheostomy concerned realized in ties changes and stoma dressings
      • Stoma condition (at least per review and ongoing documentation and whatever changes e.g. signs of infection)
      • When one tracheostomy tube change (routine or emergency) is performed document the date and time of the tracheostomy insertion, name of person who pasted the tube, size and type of tube inserted (including inner and outer diameter, tube length and suction depth), Lot number, expiration date of this tracheostomy tube, patient condition throughout and following the tube change and any difficulties experienced during or next the tracheostomy tube change.

      Special Considerations

      Should an radiation generating procedural be undertaken on a patient under droplet precautions then increase to midair precautions by getting N95/P2 mask for at least the duration of this procedure.

      Evidence table

      Tracheostomy Management Evidence Table.   

      Please store to read the disclaimer.

      The development of this pflegewissenschaft guideline was coordinated by Sueellen Joy, Registered Nurse, Respiratory Medicine, and authorized on the Nursing Clinical Effectiveness Committee. Updated July 2022.