Tracheostomy management

Note: This guideline is currently under review.

Introduction

A tracheostomy is a surgical opening into the trachea below the larynx through which an indwelling tube is placed
to overcome upper airway obstruction, facilitate mechanical ventilatory support and/or the removal of tracheo-
bronchial secretions.

Definition of terms

Decannulation: removal of a tracheostomy tube

Heat moisture exchangers (HME): a hygroscopic material that retains the child's exhaled heat and
moisture, which is then returned to subsequent inhaled air (gas).
Humidification: the mechanical process of increasing the water vapour content of an inspired gas.
Neopuff : is a flow controlled, pressure limited mechanical device specifically designed for neonatal
resuscitation. Breaths are delivered by occluding a T piece. Peek Inspiratory Pressure (PIP) is preset, and
PEEP can be adjusted using the valve on the T piece.1
Stoma: a permanent opening between the surface of the body, and an underlying organ (in this case,
between the trachea and the anterior surface of the neck).
Tracheostomy: a surgical opening between 2 - 3 ( 3- 4) tracheal rings into the trachea below the larynx
Tracheal Suctioning: is a means of clearing the airway of secretions or mucus through the application of
negative pressure via a suction catheter.
Tracheostomy tube: a curved hollow tube of rubber or plastic inserted into the trachea to relieve airway
obstruction, facilitate mechanical ventilation or the removal of tracheal secretions. See image below.
 Aim

The aim of the guideline is to outline the principles of management for patients with a new or existing tracheostomy
for clinicians at the Royal Childrens Hospital.

Tracheostomy kit

A blocked or partially blocked tracheostomy tube causes severe breathing difficulties. The key concept of
tracheostomy management is to ensure patency of the airway. A tracheostomy kit is to accompany the patient
at all times and be checked each shift by the nurse caring for the patient.

Tracheostomy kit
x1tracheostomy tube of the same size insitu (with introducer if available)
x1tracheostomy tube one size smaller (with introducer if applicable)
Spare inner tubes for double lumen trache tubes
Spare ties (cotton and velcro)
Scissors (or chain cutters as applicable)
Resuscitation bag and mask (appropriate size for patient)
One way valve (community use only)
Wall or portable suction
Appropriate size suction catheters
0.9% sodium chloride ampoule and 1 ml syringe
x1 HME or tracheostomy bib
Fenestrated gauze dressing
Cotton wool sticks
Water based lubricant for tube changes
Mucous trap-for emergency suction
Tape (ie sleek)

NB: NeopuffTM is the resuscitation device used at the bedside in Neonatal Unit at RCH.

Special considerations

All children 6 years and under are to have cotton ties only to secure tracheostomy tubes.
Children 6 years and over who are considered at risk of undoing velcro ties should have cotton ties.
For patients with a newly established tracheostomy it is recommended that tracheal dilators are available at
the patients bedside until after the first successful tube change.

Emergency management

The majority of children with a tracheostomy are dependent on the tube as their primary airway. Cardiorespiratory
arrest most commonly results from tracheostomy obstructions or accidental dislodgement of the tracheostomy tube
from the airway. Obstruction may be due to thick secretions, mucous plug, blood clot, foreign body, or kinking or
dislodgement of the tube.

Early warning signs of obstruction include tachypnoea, increased work of breathing, abnormal breath sounds,
tachycardia and a decrease in SpO2 levels . Cyanosis, bradycardia and apnoea are late signs - do not wait for
these to develop before intervening.
The resuscitation flowchart for a tracheostomy patient follows APLS principles.

It is recommended that a copy of this flow chart is readily available e.g. placed in a prominent
position at the bedside or in the patients bed chart folder.
Download the flowchart (PDF 21 KB)
 Complications

Immediate post-operative complications include:

Blocked tube
Bleeding from the airway/tracheostomy tube
Pneumothorax
Subcutaneous and/or mediastinal emphysema
Respiratory and/or cardiovascular collapse
Dislodged tube
Granulation tissue
Tracheo-oesophageal fistula

Long term complications include:

Acute airway obstruction
Blocked tube
Infection (localised to stoma or tracheo-bronchial)
Aspiration
Tracheal trauma
Dislodged tube
Stomal or tracheal granulomation tissue
Tracheal stenosis

Post operative management of a new tracheostomy

After a tracheostomy is inserted, the patient is managed in either the Paediatric Intensive Care (PICU - Rosella) or
Neonatal Unit (NNU - Butterfly) in the initial post-operative period.

Patients return from theatre with stay sutures in situ, which should be taped to the chest and labeled left and
right. The stay sutures should remain in situ and securely attached to the chest wall, , until the first
successful tube change. The stay sutures facilitate the opening of the stoma during reinsertion of the
tracheostomy tube.

The ENT team, in consultation with the parent medical team, will perform the first tube change, including the
removal of the stay sutures. This is usually done 5-7 days after insertion of the tracheostomy tube.

Most children will undergo their first tracheostomy tube change while in the intensive care environment.
However, on occasions, following 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 if they
meet the following criteria:
Have a non critical airway i.e. these children are able to breathe and maintain their airway in the
event of accidental decannulation.
Are not dependent on positive pressure ventilation/CPAP via the tracheostomy.

It is imperative that the first tracheostomy tie change is dealt with in the same manner as the first
tracheostomy tube change with both nursing and medical staff present who are competent in
tracheostomy management. The tracheostomy kit should be present at the bedside.

The tracheal stoma in the immediate post operative period requires regular assessment and management
including once daily dressing change following cleaning of the stoma area with 0.9% normal saline, or more
frequently if required.

The comfort of patients is imperative throughout the post-operative period. Pain should be managed
effectively as per RCH procedural pain management policy.
 Each child requires a Tracheostomy Tube Management Form to be completed and placed at the bedside.
(see attached form)

Routine management

Routine tracheostomy management consists of:

Equipment & environment

Activities of daily living
Supervision and Monitoring
Humidification
Suctioning
Management of abnormal secretions
Tracheostomy tube tie changes
Tracheostomy tube changes
Stoma Care
Feeding and Nutrition
Oral Care
Communication

Video of tracheostomy management

Equipment and environment

Each shift ensure emergency oxygen and suction equipment is set up and in working order
Ensure appropriate equipment is accessible at the bedside and accompanies the patient

Activities of daily living

Maintain and review as required the childs PUPPS and falls risk assessment
Children with tracheostomy tube should wear a HME filter (unless ventilated) and be closely supervised
when bathing or showering.

Supervision and monitoring

In determining the level of supervision and monitoring which is required, it is recommended each patient with a
tracheostomy is assessed on an individual basis by the treating medical/surgical and nursing team4 taking into
consideration the following factors:

Age specific alarm limits

Clinical state
 Nature of the airway problem
Ability to breathe and maintain their airway in the event of accidental decannulation
Ability to clear own secretions
Frequency of suction/tracheostomy tube interventions required
Ventilation requirements
Cognitive ability

It is recommended decisions regarding required level of supervision and required clinical

observations/monitoring are documented clearly in the patient's medical record by the treating team.

Monitoring may include:

Heart rate +/- continuous cardiac monitoring

Respiratory rate
Pulse oximetry continuous/overnight
Oxygen requirements
Work of breathing
Temperature
Blood pressure
Behaviour - alert, irritable, lethargic

Additional tests/assessments

Measurement of blood gases, tcCO2 and etCO2 as per medical orders.

Leaving the ward

The patients access to ward leave needs to be assessed according to the patients stability, vulnerability
and the level of patient/caregiver knowledge and skill in airway (tracheostomy) and/or ventilation
management

Humidification
A tracheostomy bypasses the upper airway and therefore prevents normal humidification and filtration of inhaled
air. Therefore, unless air inhaled via the tracheostomy tube is humidified, the epithelium of the trachea and bronchi
will become dry which increases the potential for tube blockage. Tracheal humidification can be provided by a
heated humidifier or Heat and Moisture Exchanger (HME) or a Tracheostomy bib.

Heated humidification: delivers gas at body temperature saturated with water which prevents the thickening of
secretions. The temperature is set at 37C delivering a temperature ranging from 36.5C - 37.5C at the
tracheostomy site. Heated humidification for tracheostomy patients should be delivered via a humidifier as per the
Oxygen clinical guideline (nursing). Indications for the use of heated humidification include:

Oxygen delivery via tracheostomy mask

Mechanical Ventilation
Respiratory infection with increased secretions
Management of thick secretions

Heat Moisture Exchanger (HME): contains a hygroscopic paper surface that absorbs the moisture in expired air.
Upon inspiration the air passes over the hygroscopic paper surface and moistens and warms the air that passes
into the airway.

HME is recommended for all patients with a tracheostomy tube.

HME fit directly onto the tracheostomy tube.
HME are changed daily or as needed if the filter appears to be excessively moist or blocked.
For small infants <10kg HME filters may not be suitable. Consult Respiratory team to assess patient's
 suitability
HME with oxygen port are suitable for low flow oxygen administration (as per oxygen guideline)
Do not wet the HME filter prior to use.

Tracheostomy bibs: are a specialized foam that traps the moisture in the expired air, upon inspiration the
foam moistens and warms the air that passes into the airway.

At the RCH BuchananTM tracheostomy bibs are used.

Tracheostomy bibs are reusable. They are changed daily or more frequently as required.
Hand wash in warm water using a mild detergent/soap, then rinse thoroughly and allowed to air dry.
Tracheostomy bibs should be discarded monthly or more frequently if discoloured or the material is
damaged..

Suctioning
Suctioning of the tracheostomy tube is necessary to remove mucus, maintain a patent airway, and avoid
tracheostomy tube blockages. Indications for suctioning include:

Audible or visual signs of secretions in the tube

Signs of respiratory distress
Suspicion of a blocked or partially blocked tube
Inability by the child to clear the tube by coughing out the secretions
Vomiting
Changes in ventilation pressures (in ventilated children)
Request by the child for suction (older children)
Tracheal suctioning should be carried out regularly for patients with a tracheostomy tube. However the
frequency varies between patients and is based on individual assessment.3
Tracheal damage may be caused by suctioning. This can be minimised by using the appropriate sized
suction catheter and only suctioning within the tracheostomy tube.

Table 1: recommended suction catheter sizes

Tracheostomy tube size (in mm) 3.0mm 3.5mm 4.0mm 4.5mm5.0mm 6.0mm 7.0mm

Recommended suction catheter size (Fr) 7 8 8 10 10 10-12 12

The suction depth is determined by the length of the individual tracheostomy tube.
The depth of insertion of the suction catheter needs to be determined prior to suctioning to avoid airway
trauma.3
Using a spare tracheostomy tube of the same size and a measuring tape:
measure the distance from the length of the tracheostomy tube connector to the end of the
tracheostomy tube.
record the suction depth on the tape measure and the patients observations chart.
attach the tape measure to the cot/bedside/suction machine for future use.
Use pre - measured suction catheters(where available) to ensure accurate suction depth

The pressure setting for tracheal suctioning is 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 completed within 5-10 seconds.3
Suction catheters can be used for a 24hour period and then discarded unless indicated earlier.
Routine use of 0.9% sodium chloride is not recommended however, In situations where this may be of
benefit e.g., thick secretions and to stimulate a cough 0.2 - 0.5ml of 0.9% sodium chloride can be used.2,3

Suctioning equipment:
Suction apparatus (wall attachment or portable unit)
 Suction canister
Tubing
Suction catheter
Sterile water

Suctioning checks:
Ensure tracheostomy kit is present
Appropriate size suction catheter
Depth required for tracheostomy tube suctioning3
Appropriate suction pressure.

The correct suction pressure for use on a tracheostomy tube is 80-120mmHg maximum when occluded. The
Medigas suction gauges on the ward are measured on kPa. The equivalent of 80- 120mmHg is 10-16kPa.

Suctioning: Procedure
1. Explain to the patient and their family that you are going to suction the tracheostomy tube.
2. Hand hygiene - ABHR
3. Use personal protective equipment including non sterile gloves and safety glasses.
4. Suction using a clean, non touch technique.
5. Attach suction catheter to suction tubing
6. Gently introduce the suction catheter into the tracheostomy tube to the pre-measured depth.3
7. Apply suction & gently rotate the catheter while withdrawing. Each suction should not be any longer than
5-10 seconds.3
8. Assess the patient's respiratory rate, skin colour and/or oximetry reading to ensure the patient has not been
compromised during the procedure. Repeat the suction as indicated by the patient's individual condition.
9. Rinse the suction catheter with sterile water decanted into bowl, not directly from bottle.
10. Look at the secretions in the suction tubing - they should be clear or white and move easily through the
tubing.
11. Notify the parent team if the secretions are abnormal, and consider sending a specimen for culture and
sensitivity.

Suctioning: Special considerations

Some patients may require assisted ventilation before and after suctioning. If required, this will be requested
by the parent medical team or Respiratory Nurse.
If the correct size suction catheter does not pass easily into the tracheostomy tube, suspect a blocked or
partially blocked tube and prepare for immediate tracheostomy tube change

Suction catheters are to be routinely replaced every 24hours or at any time if contaminated or blocked by
secretions. Suction water/and the container to be replaced every 24 hours.

Management of abnormal secretions

Changes in secretions e.g. blood stained or yellow/green secretions may indicate infection and/ or trauma of the
airway. Notify the parent team, send a specimen for culture and sensitivity and consider commencement of
antibiotics.

Persistant blood stained secretions from the tracheostomy tube need to be investigated to determine the cause.

Tracheostomy tube tie changes

If tie changes are required before the 1st tube change It is imperative that the procedure must be
undertaken with both medical and nursing staff present who are able to reinsert the tracheostomy tube in
 case of accidental decannulation.
The first tracheostomy tube tie change and the appropriate equipment available at the bedside.
It is preferable to secure new ties before removing the old ties
There is a potential risk for tracheostomy tube dislodgment when attending to tie changes, therefore 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 The other person inserts the new ties into the flange and
secures around the childs neck. Tracheostomy tie changes are performed daily in conjunction with stoma
care, or as required if they become wet or soiled to maintain skin integrity.
If the ties become loose it is a priority to re-secure immediately.
Tracheal chains these can remain insitu and are changed with routine trache tube changes. The chains
need to be checked every shift to ensure the correct tension and that the clasp is secure.
All Children 6 years and under are to have cotton ties only to secure tracheostomy tubes.
Children 6 years and over who are considered at risk of undoing velcro ties should have cotton ties.

Tube tie change: Equipment

Tracheostomy kit
Two equal lengths of cotton ties or Velcro ties (for patients older than 6 years)

Tube tie change: Procedure for changing cotton ties

1. Explain to the patient and their family that you are going to change the tracheostomy ties.
2. Hand hygiene ABHR & use personal protective equipment including non sterile gloves and safety glasses.
3. Prepare two equal lengths of ties long enough to go around the child's neck.
4. Lie the child/infant down with the neck gently extended by a small rolled towel placed under the child's
shoulders. An older child may like to sit up in a bed or chair
5. Insert a clean tie on each side of the flange into the holes
6. On each side tie a single loop approximately 0.5cm from the flange on the tracheostomy tube.
7. Then tie both sides together in a bow to secure.
8. Check the tension of the ties. Allow one finger to fit snugly between the skin and the ties.
9. Re-tie into in a reef (double) knot to secure.
10. Cut off excess length of ties leaving approximately 3cm.
11. Remove old ties and recheck tension of new ties.
12. NB: The old ties are to remain insitu until the clean ties are secured. In the event of removing existing
ties prior to securing the tube with clean ties it is recommended a second person is present to hold
the tracheostomy tube ensuring it remains in place until the ties are secured.
13. Observe the patient's neck to ensure skin integrity.

Tube tie change: Procedure for changing velcro ties

1. Changing velcro ties is a two person procedure.

2. Check the velcro on the tracheostomy ties prior to each use to ensure adhesiveness. If not adherent discard
and replace.
3. One person holds the tracheostomy tube securely in place.
4. 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.
5. Adjust the ties to allow one finger to fit snugly between the skin and the ties.
6. Observe the patient's neck to ensure skin integrity.
7. Wash velcro ties daily in warm, soapy water, rinse and dry completely before re-using.
Tracheostomy tube changes

At The Royal Children's Hospital the frequency of a tracheostomy tube change is determined by the Respiratory
and ENT teams except in an emergency situation. This can vary from weekly to monthly depending on the
patient's individual needs and tracheostomy tube type. Tracoe, Portex, Shiley and Bivonna tracheostomy
tubes are used at RCH.

It is imperative that the first tracheostomy tube change is performed with both nursing and medical staff
who are competent in tracheostomy management present and the tracheostomy kit is available at the
bedside.

A minimum of two people who are competent in tracheostomy care are required for all tracheostomy tube
changes (except in an emergency if a second person is not readily available eg. Transporting the child).

The tube change should occur before a meal or at least one-hour after to minimise the risk of aspiration.
Utilise personal protective equipment including non sterile gloves and safety glasses.
The tube change is a clean, non touch technique.

Tracheostomy tube changes: Equipment

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

Tracheostomy tube changes: Procedure

1. Hand hygiene ABHR & use personal protective equipment including non sterile gloves and safety glasses.
2. Prepare the new tracheostomy tube by removing it from the packaging/container, check the expiry dates
and inspect for any signs of damage to the tube and then thread the ties into the flange and tie.
3. If using velcro ties- insert the ties on one side of the flange only
4. Clearly explain the procedure to the patient and their family/carer.
5. Consider distraction techniques and or procedural sedation.
6. Swaddle the patient if age appropriate by wrapping the arms and containing them in the sheet.
7. 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.
8. 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.
9. Suction the existing tracheostomy tube immediately before removing the existing tube and inserting the new
one.
10. Person 1 holds the existing tube with their hand, person 2 cuts and removes the cotton ties from around
the child's neck. If using Velcro ties - undo and remove from the flange.
11. Person 1 removes the existing tube. Person 2 immediately inserts the new tube into the stoma and
removes the introducer (if applicable).
12. Person 2 holds the tube in place while Person 1 ties and secures the tracheostomy ties.
13. Check the tension of the ties to allow - one finger to fit snugly between the skin and the ties, adjust if
necessary. If using cotton ties, finish by making a reef double knot and cut off any excess fabric leaving
approximately3cm.
14. Observe the child immediately after the tube change to:
15. ensure they are breathing normally with no signs of respiratory distress.
16. Check that air is moving in and out of the tube by:
17. listening for sounds of air coming out of the tube
18. looking at the rise and fall of the chest
 19. feeling with your hand for a flow of air
20. Check the old tube for blockages and or wear and tear.
21. Discard single use tubes or wash and dry reusable tubes tubes according to the manufacturers
recommendations.

Note: If unable to reinsert tracheostomy tube follow emergency procedure.

Tracheostomy tube changes: Special considerations

A rare complication is for the tube to slip into a false passage instead of the airway. If there are any signs of
breathing difficulties/respiratory distress remove the tube and reinsert (a new tube) via the stoma into the
airway.
Unless instructed otherwise, all single use tracheostomy tubes should be used once only and discarded
after every tube change, do not clean or re-use single use tubes.
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 eg: Tracheo/bronchomalaca.
At times the difficulty is for no obvious reason and cannot be explained

Stoma care
Care of the stoma is commenced in the immediate post-operative period, and is ongoing.
Daily cleaning of the stoma is recommended using 0.9% sterile saline solution. After cleaning, ensure the
skin is clean and dry to avoid breakdown.

Stoma care: Equipment

Fenestrated dressing
0.9% sodium chloride
Cotton buds/sticks

Stoma care: Procedure for stoma care

1. Clearly explain the procedure to the patient and their family/carer
2. Perform hand hygiene ABHR or Wash hands.
3. Use a clean non-touch technique and personal protective equipment e.g. safety glasses and gloves.
4. Lay the child on their back with a small rolled towel under the shoulders. An older child may prefer to sit up
in a bed or chair.
5. Remove fenestrated dressing from around stoma.
6. Inspect the stoma area around the tracheostomy tube.
7. Clean stoma with cotton buds moistened with 0.9% sodium chloride. Use each cotton bud once only taking
it from one side of the stoma opening to the other and then discard.
8. Continue cleaning with new cotton buds until the skin area is free of secretions, crusting and discharge.
9. Allow skin to air dry or use a dry cotton bud to dry.
10. 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 stomal
therapist as powders or creams could cause further irritation.
If signs of redness or excessive exudate consider using a non adhesive hydrocellular foam dressing e.g.
Allevyn. Discuss with parent medical team and consider obtaining a specimen for culture and sensitivity.
If there are any signs of granulation tissue liaise with the respiratory nurse consultants and/or stomal
therapists for appropriate management.

The care of the stoma includes routine observation of the site and accurate documentation of the findings
including:

Redness
Swelling
Evidence of granulation tissue
Exudate
Increased discomfort during care
Stomal odour.

If visible signs of infection are present obtain a specimen for culture/sensitivity.

Refer to stomal therapy/respiratory CNC for advice on the frequency and type of dressing required.

Feeding and nutrition

A tracheostomy may have an impact on the child's ability to swallow safely. It may also influence how the child
feels about eating and drinking. Prior to commencing nasogatric or oral intake of food or drinks it is
recommended that speech pathologist assesses the child's ability to swallow.

Consider a dietician referral to assess optimal nutritional intake including oral versus tube feeding (PEG, PEJ or
NG), continuous versus intermittent feeding.

Oral care
Patients with a tracheostomy have altered upper airway function and may have increased oral care requirements.
Mouth care should assessed by the nurse caring for the patient and documented in the patient care record

Communication
Children communicate in many different ways, such as using gestures, facial expressions and body postures, as
well as vocalising. The tracheostomy may impact on the child's ability to produce a normal voice.

Vocalisation depends on several factors such as:

Severity of airway obstruction
Extent of vocal cord function
The size and type of the tracheostomy tube insitu
Respiratory muscle strength
Cognitive ability and age related ability

For patients with a new tracheostomy, refer to a speech pathologist for assessment and provision of
communication aids such as:
Pen and paper
Alphabet board
Picture communication device
Teaching manual for Auslan signing
 Electronic devices
Assessment for suitablility of speaking valve attachement

For children with established tracheostomy tubes it is essential that the methods used for communication
are identified via discussion with the patient (age appropriate), and the parent/carers. These methods
should be documented in the medical record and verbally handed over to staff to ensure adequate
communication and appropriate understanding of the patient and their needs.
Speaking valves are a small plastic device with a silicone one-way valve, they sit on the end of the
tracheostomy tube. The one-way valve opens on inspiration allowing air to enter the tracheostomy tube and
closes on exhalation directing air up through the trachea, larynx and nose and mouth as in normal breathing
and normal speech. Not all children will be able to produce a voice when the speaking valve is first used.

Speaking valves:

Various types of speaking valves are available. The most commonly used at the Royal Children's are Passy-Muir
one-way valves.

Benefits of using a speaking valve include:

Enhancing normal flow of air through the airway/nose and mouth

Restoration of physiological PEEP
Louder and clear voice
Improved ability to taste and smell foods
Improved secretions
Improved protection of the airways during swallowing and feeding
Improves development of speech and babbling in infants/toddlers

Contraindications for PMV assessment:

Severe airway obstruction

Vocal cord paralysis - adducted position
Severe neurological deficit
tracheostomy tube with inflated cuff (any kind)
Foam-filled cuff (even if deflated)
Severe risk for aspiration
< 7 days post-operative tracheostomy tube insertion

Before speaking valve use:

A joint assessment involving the respiratory nurse consultant and a speech pathologist is essential before the
device is used. While some children can use speaking valves without any difficulties Speaking valves are not
suitable for all children with a tracheostomy.

The child's tolerance to the speaking valve will depend on their airway around and above the tracheostomy tube.
To exhale sufficiently the child must have enough airway patency around the tracheostomy tube, up through the
larynx and out of the nose and mouth. If exhalation is not adequate with the speaking valve in place the child may
become distressed and air trapping/breath stacking or barotrauma to the lungs may occur.

To determine if the child has adequate airway patency consider:

Diagnosis of severe laryngeal or tracheal stenosis/subglottic stenosis

Size and type of the tracheostomy tube - appropriate to allow airflow through upper airway
Nasal obstruction - e.g. nasogastric tubes/choanal atresia etc

Before trail of speaking valve ensure the child:

Post-operative tracheostomy 7 days or greater
 Medically stable
Awake and responsive
Doesn't have excessive tracheal secretions and is able to manage oral secretions
Able to tolerate cuff deflation
Has adequate patency of upper airway

Perform bedside assessment of airway patency:

Explain procedure (age appropriate) to child and their family

Suction the tracheostomy tube before the valve is attached and then as required.
A cuffed tube must be 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 finger occlusion is tolerated place the speaking valve on the end of the tracheostomy tube and observe
for oral/nasal exhalation.
If the PMV is tolerated on the initial trial for a goal of 5 to 10 minutes, then a plan to improve consistency and
length of tolerance is developed and provided to the child and their care-givers.
Once the child has adjusted to wearing the valve they should be able to wear it for long periods and the
PMV can and should be worn at all awake times, particularly during rehabilitative therapy sessions and
when eating.

If the child fails to tolerate the PMV:

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
PMV due to anxiety, discomfort.
Children may need to slowly build up longer periods of valve use and PMV placement will be repeated on
subsequent days.
Many children however, have difficulty adjusting to changes to their airways. 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 children consider using an device to secure the PMV to the child's ties - to prevent
accidental loss of the PMV.
Some speaking valves are suitable for use in combination with oxygen therapy and during ventilation.

Contraindication to PMV use:

If you determine there is no airway patency then the degree of stenosis is a contraindication to speaking
valve use.
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 PMV gradually
increasing the time and frequency of use.
PMV may be contraindicated depending on type of cuffed tube e.g. foam cuff

Precautions when using 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 speaking valve should not be worn when the child is sleeping.
Speaking valves do not humidify the air - therefore may be unsuitable for children with copious thick
secretions.
If the speaking valve is not functioning properly (i.e. sticking, noisy or vibrates) or the child shows signs of
respiratory distress/discomfort, then remove the valve immediately and replace.
Do not use in combination with HME (heat moisture exchanger)
 Remove valve before aerosol/nebulizer medication is administered

Care and cleaning of the Valve:

The speaking valve should be cleaned daily by washing the valve in warm mild soapy water, then rinsed
thoroughly and allowed to air dry completely before reuse.
Once dry and when not in use, it should be stored in the appropriate storage container.
Ensure the valve is clean and not damaged in any way before each use.
Replace the valve immediately if any signs of wear/tear or damage are noted.

To avoid damage to the valve:

do not wash in hot water

do not brush the valve
do not use alcohol, peroxide or bleach to clean the valve

Transition to the community and discharge planning

All children with a tracheostomy tube in situ require a referral to Family Choice Program to identify if support
is required either for the patient or their family. The referral should be made as soon as possible following
tracheostomy tube insertion to allow adequate time for planning home support services.
The referring team is responsible for ensuring appropriate equipment is organised in collaboration with the
Equipment Distribution Centre. This should occur in consultation with the nursing staff, respiratory nurse
consultants and the parent medical team.
Ensure all members of the medical, nursing and allied health teams are aware of the planned discharge.
Prior to discharge an intervention chart is required to be completed to provide detailed information about
the interventions required for the patient over a past 24-48 hour period including:
Frequency of care the patient required including the amount of suctioning the child has required.
Level of dependency the patient has on their tracheostomy.

Assessment will be made in accordance to the above information as to the child's eligibility for assistance
required at home and for discharge.
Education for primary care givers regarding tracheostomy care commences soon after insertion of the tube
and is usually initiated by the respiratory CNC in collaboration with the parent unit nursing staff.
Principles of the care for children with a tracheostomy in the community who are managed by FCP are
based on the recommendations of this clinical practice guideline. However individualised care plans are
developed specifically to their care needs. These are located in the home care manuals in FCP department.

Decannulation

Decannulation is a planned intervention for the permanent removal of the tracheostomy tube once the
underlying indication for the tracheostomy has been resolved or corrected.
The patient is admitted to hospital for the procedure.
Bronchoscopy evaluation is usually performed prior to planned decannulation to evaluate airway stability,
assess possible granulation or suprastomal collapse, to assess whether the child can maintain their airway
and ventilation adequately without the tracheostomy tube.
Decannulation planning can also include a staged process with downsizing and capping of the
tracheostomy tube in order to assess how the child would cope with a smaller tracheostomy in the airway
and to encourage the use of the upper airway.
The tracheostomy is usually blocked off using a decannulation cap if tolerated the child is monitored
overnight (downloadable oximetry) with the tube occluded.
To ensure the patient and the caregivers are prepared for the decannulation ensure the procedure has been
 explained.
Decannulation is usually performed between the hours of 9am and 6pm.
There should be a clearly documented plan for the decannulation process from the parent medical team
Decannulation should not be performed unless a member of the parent medical team is present in the
ward at the time of decannulation. Inform the ENT team of the planned decannulation prior to removal of
the tracheostomy tube.
It is recommended that the child's caregiver/s are present to alleviate the anxiety of the child.
The child should be fasted for 2 hours prior to the decannulation.
Post decannulation, the patient is ideally nursed 1:1 for 24 hours and should not leave the ward unless
supervised by nursing staff. At the end of this 24 hour period the need for nursing supervision of the patient
(away from the ward area) is assessed by the patient's parent medical team.3
Occasionally the trial of decannulation is unsuccessful requiring the need to re-insert the tracheostomy
tube. This is an emergency procedure and it can occur at any time

Decannulation: Equipment
Equipment - to stay at bedside until the child is discharged:
Tracheostomy Kit
Set of tracheostomy tubes (same size and smaller sizes than tube child has insitu down to a size 3mm -
keep a size 3mm in freezer).
Surgical scissors
Tracheostomy ties or velcro ties
Gauze dressing and an occlusive dressing - Comfeel with hypafix borders or tegaderm/opsite to
cover the tracheostomy stoma
Oxygen and suction
Cotton tipped applicators
Small towel (if applicable)
Oxygen and suction equipment
Laerdal Resuscitator kit

Decannulation: Procedure
Obtain baseline observations including heart rate, respiratory rate, haemoglobin-oxygen saturation, and
work of breathing. Ensure patient vital signs are within appropriate parameters forage
Monitor patient continuously throughout the procedure.
Clean the stoma and suction the tracheostomy tube immediately prior to decannulation.
Cut/undo tracheostomy tube ties.
Remove tracheostomy tube.
Observe for any signs of respiratory distress including:
Tachypnoea
Stridor
Retraction
Tachycardia
Colour
Decreased perfusion
Haemoglobin-oxygen desaturation or low oximetry reading.
Restlessness
cough effectiveness swallow and voice quality
activity levels

Apply occlusive dressing to stoma site post decannulation if no evidence of respiratory distress.
Patient should again be assessed for signs of respiratory distress after applying occlusive dressing to
stoma site.
Patient should be nursed 1:1 for the first 24 hours post decannulation if complications with the
decannulation are anticipated.
Following decannulation:
Monitor the patient's respiratory rate, heart rate, oxygen saturation, colour and work of breathing
continuously throughout the procedure then:
15 minutely for the first hour
Half hourly for the next 4 hours
Hourly for 24 hours
Continuous pulse oximetry (SpO2) for patients during all periods of sleep (day and night) post
decannulation for 24 hours.
Call a MET for assistance as per RCH guidelines

Report any episodes of:

Tachypnoea/bradypnoea
Tachycardia/bradycardia
SpO2 desaturation
Increased WOB - as evidenced by: sternal/intercostal retraction, tracheal tug, nasal flaring, stridor
Restlessness/anxiety
Colour change/ Cyanosis
Failure to clear secretions - gagging
Offer light diet 2 hours after decannulation unless contraindicated by increased respiratory effort
Encourage the child to undertake normal activities while on the ward.
Continuous pulse oximetry (SpO2) during sleep
Observe carefully for signs of any airway obstruction during sleep.
The child should not leave the ward for 24 hours following decannulation.
Following the first 24 hours post decannulation the patient may leave the ward if the admitting team has
assessed the patient to have a "safe airway" unless supervised by nursing/medical staff competent in
emergency tracheostomy care.
Encourage coughing to clear secretions from upper airway if required. If the child is not coughing and
clearing secretions well, gentle oropharyngeal suction (only) may be performed. Contact the
physiotherapist for support.
Avoid suctioning the stoma unless otherwise indicated in an emergency situation as this may cause
trauma.
Referral to speech pathology should be considered if the child does not resume normal voice production
following decannulation.

Stoma site care post decannulation:

Dressings:
The stoma site is covered by a small gauze square and then by an occlusive dressing (sleek/tegaderm)
until it has closed or no secretions are seeping out.
Assess occlusive tracheal stoma dressing for air leaks every shift and document absence or presence of
these in medical record.
Stoma site to be assessed daily and cleaned (as per tracheostomy CPG) or more frequently if indicated.

Discharge:

The child is usually discharged home when they're considered to have a safe airway. The average length of
stay post decannulation is 24 -48 hours but this maybe longer if required.
Ensure the caregivers are provided with adequate supplies and are aware of how to care for stoma site -
this includes daily cleaning of the site and dressing changes as required.
Advise the family/caregiver to contact the hospital and/or medical team if any episodes of:
Tachypnoea/bradypnoea
SpO2 desaturation
Increased WOB - as evidenced by: sternal/intercostal retraction, tracheal tug, nasal flaring, stridor
Restlessness/anxiety
Colour change/ Cyanosis
 Unable to clear secretions - gagging

Advise the family/caregiver to contact the hospital and/or medical team if there are any signs of infection at
the stoma site including any
Redness
Odour
Swelling
Discharge

Following a successful decannulation the family are able to return all tracheostomy and suctioning
equipment but are encouraged to keep the pulse oximeter until seen at follow up outpatient appointment

Documentation

All written documentation related to the management of a patient with a tracheostomy is in accordance with
the RCH documentation policy.
Record the reason and type of the interventions performed relating to tracheostomy care and appropriate
outcomes in the progress notes. These include:
Suctioning (amount, colour and consistency of aspirates)
Tracheostomy cares including tie changes and stoma dressings
Stoma condition (ongoing documentation and any changes eg: signs of infection)
Significant changes in patient's condition

In the event of a tube change (routine or emergency), the following should be documented in the progress
notes:
The size and type of tube inserted
Lot number
Expiry date of the tracheostomy tube
Name of person who inserted the tube
Patient condition throughout the tube change
Any difficulties experienced during changing the tracheostomy tube.

Evidence table

Tracheostomy Management Evidence Table.

References

1. Hussey, S.G, Ryan, C.A and Murphy, B.P. (2007) "Comparison of three manual ventilation devices using an
intubated mannequin". Arch Dis. Child. Fetal Neonatal Ed. (2004); 89; 490-93.
2. Raymond SJ. Normal Saline Instillation Before suctioning: Helpful or Harmful? A review of the Literature".
American Journal of Critical Care July 1995 Volume 4, No. 4 267-271.
3. Gray JE, MacIntyre NR, Kronenberger WG. The effects of bolus normal saline instillation in conjunction with
endotracheal suctioning.
4. respir. Care. 1990;35:785-790.
5. Choate, K and Snadford, M (2003) "Tracheostomy: Clinical Practoce and the formation of policy and
guidelines" Australian Nursing Journal, 10, 8 p:CU1.
6. Scoble M, Copnell, B. Taylor, A. Kinney, S and Shann, F. (2001) "Effect of reusing suction catheters on the
occurence of pneumonia in children" Heart and Lung vol 30, 3 p: 225-233.
7. Celik, S and Kanan, N (2006) " A current conflict use of Isotonic Sodium Chloride Solution on the
Endotracheal Suctioning in Critically Ill Patients" Dimensions of Critical Care Nursing vol 25/No1 pp:11-14.
 8. Ridling, D. Martin, LD and Bratton, S. (2003) "Endotracheal Suctioing With or Without Instillation of Isotonic
Sodium Chloride Solution in Critically Ill Children". American Journal of Critical Care vol 12, no 3 pp:212-219.
9. Griggs, A. (1998) "Tracheostomy suctioning and humidification". Nursing Standard vol 13 (2) pp: 49-53, 55-
56.
10. Woodrow, P. (2002) "Managing patients with a tracheostomy in acute care". Nursing Standard vol 16 (44)
pp: 39-48.
11. Carr, M. Poje, C.P. Kingston, L. Kielma, D. Heard, C. (2001) "Complications in Pediatric Tracheostomies"
Laryngoscope 111: November 2001.
12. Edwards, E.A. Byrnes, C.A (1999) " Humidification Difficulties in Two Tracheostomized Children" Anaesthesia
and Intensive Care, 27, 6, pp: 656-58.
13. Wyatt, M.E. Bailey, C.M. Whiteside, R.N (1999) "Update on paediatric tracheostomy tubes" The Journal of
Laryngology and Otology , 113, 1, Health and Medical Complete pp:35-40.
14. Wetmore, R.F. Marsh, R.R. Thompson, M.E. Tom, L.W. (1999) "Pediatric Tracheostomy: A Changing
Procedure". The Annals pf Otology, Rhinology and Laryngology, 108, 7, pp:695-699.
15. Dixon, L.and Wasson, D. (1998) "Comparing Use and Cost Effectiveness of Tracheostomy Tube Securing
Devices. Medsurg Nursing, 7, 5 pp: 270-274
16. Tamburri, L.M. (2000) "Care of the Patient with a Tracheostomy". Orthopedic Nursing, 19, 2 pp:49-60.
17. Oberwaldner, B. Eber, E. (2006) "Tracheostomy care in the home". Paediatric Respiratory Reviews, 7, 185-
190.
18. O'Toole, EA. Wallis, C. (2004) "Sending children home on tracheostomy dependent ventilation:pitfalls and
outcomes". BMJ vol 89 (3) pp: 251-255.

Please remember to read the disclaimer.

The development of this clinical guideline was coordinated by Sueellen Jones, Registered Nurse, Respiratory
Medicine. Approved by the Clinical Effectiveness Committee. Authorised by Bernadette Twomey, Executive
Director Nursing Services. First published March 2008, reviewed February 2013 and most recently May 2014.

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