Tracheostomy Care

Front 1

How often are tracheostomy tubes changed? What is the max number of times a trach tube can be changed?

Back 1

Pediatric trachs without an inner cannula are changed at least once per week. Changes can be made up to a max of once per day if tolerated for family education.

Front 2

Why are tracheostomy tubes changed?

Back 2

To ensure tracheostomy tube patency and reduce the risk of infection.

Front 3

When should ENT (otolaryngology) be consulted to perform a trach tube change?

Back 3

1) It is a new trach (1 week post-op);
2) the length or diameter of trach tube is increased;
3) the type/style/brand has changed;
4) the previous change was complicated;
5) there are significant granulations that may require ablation

Front 4

If not routine, when else should a trach tube be changed?

Back 4

1) Respiratory distress due to blockage from mucous plug, emesis or foreign object
2) Accidental decannulation
3) Family education

Front 5

What precautions should be taken for a trach tube change?

Back 5

1) New trach: ensure sutures remain intact and ENT should perform
2) At least 30 min before feeding, or 90 min after feeding, to prevent aspiration
3) Type of tube being removed (cuffed ones used infrequently at sickkids)
4) Tube length
5) If cuffed, pressures above 30 mm Hg can cause ischemia of tracheal mucosa
6) Stoma check for granulation tissue (call ENT if significant)

Front 6

What are some complications associated with trach tube changes?

Back 6

1) Creating a false passage (fistula)
2) Infection
3) Inability to reinsert tracheostomy
4) Dehiscence of surgical wound (rupture of sutures)
5) GERD
6) Frequent changes can erode tracheal wall, hemorrhage from artery erosion, cause tracheal stsenosis, granulation tissue

Front 7

What do you need? (9)

Back 7

1) MAIN person + HELPER
2) Spare trach + obturator
3) ETT one size smaller than trach
4) Blanket to wrap child
5) Suction
6) BVM
7) Oxygen
8) Water-soluble lubricant or sterile NS
9) Cleaning supplies

Front 8

STEPS
1. Explain procedure

Back 8

STEPS
2. Hand hygiene and put on proper PPE

Front 9

STEPS
3. Prepare equipment (insert obturator into trach, lubricate with sterile NS; inspect supplies for damage/wear), place nearby

Back 9

STEPS
4. Lay patient flat with roll under shoulders, tilt head back and extend neck (remove loose clothing to observe respiratory status; older children can sit, infants can be bundled)

Front 10

STEPS
5) Tube suction

Back 10

STEPS
6) MAIN person holds trach with non-dominant hand while HELPER removes velcro ties

Front 11

STEPS
7) HELPER cleans skin/stoma area, monitors resp status and need for suctioning

Back 11

STEPS
8) MAIN person removes old trach with non-dominant hand and replaces with clean trach/obturator with dominant hand (avoiding passing over eyes)

Front 12

STEPS
9) MAIN person puts finger close to trach to check that air is flowing through, and looks for chest rise/fall, and skin/lip colour

Back 12

STEPS
10) HELPER finishes skin care and replaces velcro ties
- tip of pinky fingerunder trach ties
11) Clean and store used trach right away

Front 13

Why shouldn't petroleum-based ointments be used near trach?

Back 13

Risk of oil getting into airway and causing lipid pneumonia

Front 14

What do you document and where after the trach change?

Back 14

In the Progress Notes; Tracheostomy teaching checklist (if for family education)
patient's tolerance, assessment of patient status before/during/after, size/type of trach, any concerns for future tube changes

Front 15

What are signs/symptoms of a mucus plug?

Back 15

1) Increased resp effort
2) Whistling respirations
3) Any signs of resp difficulty
4) Tube partially/fully occluded

Front 16

What interventions do you take to address a mucus plug?

Back 16

Tube suction immediately to the appropriate distance
If unsuccessful, do trach change

Front 17

What interventions do you take to address loose ties?

Back 17

-Ensure they are tight enough at beginning of each shift or change in position and after a tube change
- See if they need to be replaced

Front 18

What interventions do you take to address an accidental decannulation

Back 18

Insert ETT into stoma (~1-2cm), call for help
Do trach change when help arrives

If patient deteriorates, manually resuscitate

Front 19

What interventions do you take to address an unsuccessful trach insert?

Back 19

STAT call RT
STAT call ENT resident/staff
Ensure tube is correct size, reposition, attempt to reinsert when stoma opens with next respiratory effort
If still unsuccessful, insert ETT

Front 20

What interventions do you take to address an unsuccessful ETT insert?

Back 20

Occlude stoma and attempt bag-valve-mask resuscitation and call CODE BLUE
Continue to attempt ETT insert