Percutaneous tracheostomy in patients with cervical spine fractures feasible and safe Abstract The aim of this study

y is to evaluate the short and long-term results of percutaneous tracheostomy in patients with documented cervical spine fracture. Between June 2000 and September 2005, 38 consecutive percutaneous tracheostomy procedures were performed on multi-trauma patients with cervical spine fracture. Modified Griggs technique was employed at the bedside in the general intensive care department. Staff thoracic surgeons and anesthesiologists performed all procedures. Demographics, anatomical conditions, presence of co-morbidities and complication rates were recorded. The average operative time was 10 min (615). Two patients had minor complications. One patients had minor bleeding (50 cc) and one had mild cellulitis. Nine patients had severe paraparesis or paraplegia prior to the PCT procedure and 29 were without neurological damage. There was no PCT related neurological deterioration. Twenty-eight patients were discharged from the hospital, 21 were decannulated. The average follow-up period was 18 months (148). There was no delayed, procedure related, complication. These results demonstrate that percutaneous tracheostomy is feasible and safe in patients with cervical spine fracture with minimal short and long-term morbidity. We believe that percutaneous tracheostomy is the procedure of choice for patients with cervical spine fracture who need prolonged ventilatory support. Key Words: Tracheostomy percutaneous; Fracture cervical spine 1. Introduction In the last decade, percutaneous tracheostomy (PCT) has become a routine practice in many hospitals. In the early publications, most authors considered adverse conditions such as short-fat neck, enlarged thyroid, inability to extend the neck, previous neck surgery, presence of a coagulopathy and suspected or documented cervical spine fracture as relative or absolute contraindications for PCT [18]. More recently, several reports demonstrated the feasibility and safety of PCT in patients with some of the above contraindications [915]. In a computerized search of the literature, the authors could not find articles addressing the safety and long-term results of PCT in trauma patients with documented cervical spine fracture (CSF). Reported herein is our experience with thirty-eight consecutive PCT procedures performed on multi-trauma patients with CSF.

2. Materials and methods

Between June 2000 and September 2005, 38 consecutive percutaneous tracheostomy procedures were performed on multi-trauma patients with documented cervical spine fracture. The indications for tracheostomy were prolonged mechanical ventilation, failure of extubation and need for intermittent respiratory support. A small group of qualified thoracic surgeons who had large experience with PCTs (more than 80 previous cases) performed the operations in the general intensive care department of a major tertiary care facility. The Helsinki Committee approved the procedure. Conscious patients signed the informed consent and in unconscious patients, the appointed legal guardian signed the informed consent. All PCTs were performed as a bedside operation using a modification of the Griggs' technique and a Portex set of instruments (SIMS Portex, Hythe-Kent, England) as was described previously [10,11]. The appropriate intensive care monitoring was used in all cases. The procedure was performed as described in the manual accompanying the Portex PCT kit, with some modifications. All patients were supine without neck extension. The available anatomical landmarks (thyroid cartilage, cricoid cartilage, tracheal cartilages and sternal notch) were identified. In ten patients, it was possible to palpate all of these landmarks. However, in twenty-eight patients only the sternal notch and the thyroid cartilage were clearly identifiable. A gentle rostral traction on the larynx was applied to gain better exposure of the surgical field. The neck was prepared and draped according to the cervical fixation apparatus (Philadelphia support device, Hallow apparatus, Internal fixation or Cranial traction). Local anesthesia was used in all patients (10 ml of 1% lidocaine solution). Horizontal skin incision was followed by a blunt dissection of the subcutaneous and pretracheal tissues, using a Pean clamp, to form a tract wide enough to accommodate the tip of the surgeon's finger. The anterior tracheal wall was palpated and the oro-tracheal tube was cautiously withdrawn with the surgeon's finger control. Thereafter, puncture of the tracheal wall was performed with the needle-cannula in the space between the first and second tracheal cartilages and the rest of the procedure was completed using the guide-wire and the dilating forceps as described in the manual accompanying the Portex PCT kit. The balloon on the tracheostomy cannula was over inflated (15 cc) for approximately 30 min as a preventative tamponade on the luminal surface of the trachea. If the skin incision was greater than the diameter of the tracheostomy cannula, simple cutaneous sutures were placed on either side of the cannula and the tissues approximated until the stoma fitted snugly around the cannula. The thoracic staff surgeons did the inhospital follow up until decannulation was accomplished. Long-term follow up was performed in the outpatients clinic and by telephone questionnaire. 3. Results Twenty-nine male and nine female patients with cervical spine fractures were included in this study. The average age was 47 years (range: 19 to 76) and the mean operation time was 10 min (615). Sixty percent of the patients had more than one fracture in the cervical spine. The most common sites were C2 and C6 (nine patients). Two patients had minor complications. One patient had minor bleeding (50 cc) and one had mild cellulitis around the stoma. Nine patients had severe paraparesis or paraplegia prior to the PCT procedure and 29 were without neurological damage. There was no PCT related neurological deterioration. The percutaneous operation was completed in all patients without conversion to the open technique. During the early (in-hospital) follow up, ten patients died of causes unrelated to the PCT. Twenty-eight patients were discharged from the hospital, 21

underwent uneventful decannulation. The average follow-up period was 18 months (148). There was no late, procedure related, morbidity or mortality. Twenty-four patients were available for long-term clinical evaluation in the outpatients clinic and four were lost to follow-up. Seventeen of these patients were followed for more than a year after the PCT. Fifteen patients underwent CT scan of the neck and/or the chest, which included the location of previous PCT, as part of their orthopedic, thoracic or maxillofacial follow-up. No tracheostomy-related complication was diagnosed although reduction of the tracheal diameter by less than 10% diameter was found in five patients, all were without any associated symptoms. Five of these patients also required fiber-optic bronchoscopy due to minor hemoptysis (2 patients), dyspnea (2 patients) and hoarseness (1 patient). In all cases there was no pathological finding at the PCT site. 4. Discussion In recent years, percutaneous tracheostomy has become a common practice in many hospitals throughout the world. Numerous studies assessed the safety of the procedure, length of operation and incidence of short- and long-term complications [18]. A number of clinical and anatomical conditions such as morbid obesity, short fat neck, enlarged thyroid, emergency loss of airway and cervical trauma, were considered as relative or absolute contraindications [15]. Recently, more than a few articles reported the safety and feasibility of PCT in these situations [11,13,14]. Ben Nun et al. reported their positive experience with PCT in emergency cases [11] and Mayberry and coauthors demonstrated the safety of the procedure in trauma patients without cervical-spine clearance [9]. Fracture in the cervical spine makes tracheostomy procedure more complex and demanding than the usual, no matter which technique is employed, open or percutaneous. The inability to extend the neck, the presence of recent surgical scar (internal fixation), or an external fixation device (hallow or Philadelphia) in the surgical field, makes the operation more complex and challenging. In the early phase of our learning curve, the complexity of the situation justified the classification of CSF as a contraindication for PCT. However, with the accumulation of experience the advantages of PCT became more apparent and our indications for PCT expanded gradually. We found that, no matter which device was used to treat the cervical spine fracture, a gentle rostral traction improved exposure of PCT site and made the procedure feasible and safe. Like us, O'Keeffe et al. [14] and others [15] had encouraging results with PCT in patients with CSF. They published their positive experience with PCT following anterior approach and internal fixation of the fracture. These studies, however, focused mainly on the feasibility of the procedure and the short-term outcome. In a computerized study of the literature, we could not find articles referring to the feasibility, safety and long-term results of PCT in patients with external or internal fixation of CSF. Reported herein are the encouraging results of a long-term follow-up in this unique subgroup of patients. In this series all PCT procedures were performed at the patient's bedside in the intensive care unit. There was no case of conversion to open surgery. We did not have PCT related neurological deterioration and only two cases of mild, early surgical complications were diagnosed. The long-term follow-up in this study is not perfect. Twenty-six percent of the patients died in the hospital and 14% of the survivors were lost to follow-up. The long-term follow-up included clinical data in all patients but only 63% underwent imaging of the PCT site using bronchoscopy and/or CT scan. Nevertheless, we did not find any significant PCT related complication. On the basis of these data, we conclude that PCT is feasible and safe in patients with CSF. Actually, in this clinical setting we believe that PCT is even easier when compared with open tracheostomy. Thus, we recommend that cervical spine fracture would not be considered a contraindication for PCT anymore. We do think, however, that experienced surgeons familiar with the technique and way beyond their learning curve should perform these procedures. References

1.Friedman Y, Fildes J, Mizock B, Patel S, Appavu S, Roberts R. Comparison of percutaneous and surgical tracheostomies. Chest 1996; 110:480485.[Abstract/Free Full Text] 2. Gysin C, Dulguerov P, Guyot JP, Perneger TV, Abajo B, Chevrolet JC. Percutaneous versus surgical tracheostomy a double-blind randomized trial. Annals Surgery 1999; 230:708714. Porter JM, Ivatury RR. Preferred route of tracheostomy-percutaneous versus open at the bedside: a randomized, prospective study in the surgical intensive care unit. Am Surgeon 1999; 65:142146.[Medline] Powell DM, Price PD, Forrest LA. Review of percutaneous tracheostomy. Laryngoscope 1998; 108:170177.[CrossRef][Medline] Suh RH, Margulies DR, Hopp ML, Ault M, Shabot MM. Percutaneous dilatational tracheostomy: still a surgical procedure. Am Surgeon 1999; 65:982986.[Medline] Vigliaroli L, DeVivo P, Mione C, Pretto G. Clinical experience with Ciaglia's percutaneous tracheostomy. Eur Arch Otorhinolaryngol 1999; 256:426428.[CrossRef][Medline] Atweh NA, Possenti PP, Caushaj PF, Burns G, Pineau MJ, Ivy M. Dilatational percutaneous tracheostomy: modification of technique. J Trauma 1999; 47:142144.[Medline]

3.

4. 5.

6.

7.

8.

Escarment J, Suppini A, Sallaberry M, Kaiser E, Cantais E, Palmier B, Quinot JF. Percutaneous tracheostomy by forceps dilation: report of 162 cases. Anaesthesia 2000; 55:125130.[CrossRef][Medline] Mayberry JC, Wu IC, Goldman R, Chestnut M. Cervical spine clearance and neck extension during percutaneous tracheostomy in trauma patients. Critical Care Medicine 2000; 28:34363440.[CrossRef][Medline]

9.

10. Ben-nun A, Altman E, Best LA. Emergency percutaneous tracheostomy in trauma patients. Ann Thorac Surg 2004; 77:1045 1047.[Abstract/Free Full Text] 11. Ben-nun A, Altman E, Best LA. Extended indications for percutaneous tracheostomy. Ann Thorac Surg 2005; 80:1276 1279.[Abstract/Free Full Text] 12. Mansharamani NG, Kaziel H, Garland R, LoCicero J, Ernst A, Critchlow JA. Safety of bedside dilatational tracheostomy in obese patients in the ICU. Chest 2000; 117:14261429.[Abstract/Free Full Text] 13. Urwin S, Short S, Hunt P. Percutaneous dilational tracheostomy in the morbidly obese. Anaesthesia 2000; 55:393394.[Medline] 14. O'Keeffe T, Goldman RK, Mayberry JC, Rehm CG, Hart RA. Tracheostomy after anterior cervical spine fixation. J Trauma Oct 2004; 57:855860.[Medline] 15. Harrop JS, Sharan AD, Scheid EH Jr, Vaccaro AR, Przybylski GJ. Tracheostomy placement in patients with complete cervical spinal cord injuries: American Spinal Injury Association Grade A. J Neurosurg Jan 2004; 100:1 Suppl Spine2023.[Medline] http://icvts.ctsnetjournals.org/cgi/content/full/5/4/427

Percutaneous Tracheostomy Practice Management Guideline Division of Trauma and Surgical Critical Care Vanderbilt University Medical Center Revised 2005 PREPARATION: 1. Consent should be obtained for "tracheostomy" (See Bedside Surgery protocol). 2. Medication pack: Fentanyl 500 mcg Vecuronium 20 mg Versed 10 mg Diprivan 50 cc vial (esp. CHI pts.) The patient should be sedated with Versed / Diprivan and Fentanyl, followed by Vecuronium, inducing a general anesthesia. NOTE: The ventilator must be adjusted appropriately when paralytics are administered, usually a rate of 12, and a FiO2 of 100%. Caution should be used when PEEP > 15. 3. Equipment: a. Indications for Perc. Trach with Bronchoscopy: Attending should be scrubbed for High Risk Case. 1. Multiple Facial Fractures 2. Morbid Obesity 3. Surgeons preference b. Trauma cart, to include: Ciaglia percutaneous tracheostomy kit 1 pair - scissors 2 pair - curved hemostats 1 - Needle holder 1 - Scalpel 2 - Weitelanders Trach tubes: (1) #8 Shiley and (1) Big boy Sterile towels Gowns, gloves Syringes Betadine solution Suture 1 - large drape Intubation set Chemical CO2 detector Continuous BP monitor

PROCEDURE: 1. Medicate the patient. 2. After medications are administered, the neck is prepped and draped. The area is infiltrated with 1% Lidocaine with Epinephrine and a vertical incision is made. Dissection is carried down to the level of the trachea. Percutaneous Tracheostomy Practice Management Guideline Division of Trauma and Surgical Critical Care Vanderbilt University Medical Center Revised 2005 Page 2 3. The tapes holding the endotracheal tube are cut and the person at the head of the bed manipulates the ET tube while the surgeon palpates for its presence within the trachea. Tidal volumes should be closely monitored during this time. The tube is slowly withdrawn until the balloon can be palpated, and then withdrawn further until its tip is palpated at the level of the second tracheal ring. Note: An air leak may be noted around the ET tube; however, as long as minute volumes measured on the expiratory limb of the ventilator are acceptable, this should not cause alarm. 4. The percutaneous tracheostomy is completed in the standard fashion. 5. The CO2 monitor is connected to the tracheostomy tube and, once color change occurs and tidal volume is confirmed, the ET tube may be fully withdrawn. The tracheostomy tube is, then, sutured to the neck. 6. Chest x-ray is always obtained. 7. Ventilator settings are returned to prior levels after sedation and paralytics have worn off. http://www.traumaburn.com/Protocols/Tracheostomy.pdf Safety of Bedside Percutaneous Dilatational Tracheostomy in Obese Patients in the ICU* 1. 2. 3. 4. 5. 6. Naresh G. Mansharamani, MD, Henry Koziel, MD, Robert Garland, RRT, Joseph LoCicero III, MD, FCCP, Jonathan Critchlow, MD and Armin Ernst, MD

+ Author Affiliations

1.

*From

the Division of Pulmonary and Critical Care Medicine, Department of Medicine (Drs. Mansharamani, Koziel, Ernst, and Mr. Garland) and Department of Surgery (Drs. LoCicero and Critchlow), Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA.
Correspondence to: Armin Ernst, MD, Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, One Deaconess Rd, Boston, MA 02115; e-mail: aernst@caregroup.harvard.edu

1.

Next Section Abstract

Study objective: To examine the safety of bedside percutaneous dilatational tracheostomy in obese patients. Design: Case series of consecutive obese patients (body mass index 27 kg/m2) with acute respiratory failure in a
medical, cardiac, or surgical ICU unit who required tracheostomy for failure to wean and continued mechanical ventilatory support.

Results: Thirteen obese patients were identified and consented to the procedure. Bedside percutaneous dilatational
tracheostomy was successfully performed in the ICU for all 13 patients. Procedural complications were limited to paratracheal tracheostomy tube placement in one patient, with immediate identification and appropriate correction. Postprocedural complications were limited to a cuff leak in one patient.

Conclusion: Bedside percutaneous tracheostomy can be safely performed in obese patients.

Percutaneous dilatational tracheostomy (PDT) has been recognized as a reliable alternative to the surgical placement of an artificial airway in patients with persistent respiratory failure due to various medical conditions. 1 PDT may offer several advantages over conventional surgical tracheostomy placement, as PDT is associated with lower periprocedural and postprocedural complication rates,2 and PDT can be performed at the bedside, thus avoiding the scheduling, time commitments, and costs associated with surgical operating facilities. Among the relative contraindications for PDT include patients with altered neck anatomy due to severe neck burns, and scarring from a previous tracheostomy.34 In addition, obese patients with large and thick necks are considered poor candidates for PDT, and are commonly referred for surgical tracheostomy placement. However, the feasibility and safety of bedside PDT in obese patients has not been extensively investigated. In this report, we describe our experience for bedside PDT in obese patients at a tertiary-care referral hospital. Previous SectionNext Section Materials and Methods Setting The Beth Israel Deaconess Medical Center (BIDMC) is a tertiary-care facility with a medical ICU, surgical ICU, cardiac care unit, and cardiothoracic ICU. The BIDMC includes extensive general medical and surgical services. In addition, the BIDMC has a large population of obese patients enrolled in medical weight reduction programs and referred for surgical gastric bypass surgery. Patients During the period of December 1996 to January 1999, consecutive obese patients referred for PDT were identified for this report. All patients were 18 years old, experienced acute respiratory failure requiring endotracheal tube (ETT) intubation and mechanical ventilation, and were referred for tracheostomy placement for persistent respiratory failure and prolonged weaning from mechanical ventilation. Only patients with a body mass index (BMI) 27 kg/m 2 (considered obese, > 50% of ideal body weight) were included in the study. None of these patients had absolute contraindications for PDT. Absolute contraindications included the following: uncontrolled bleeding disorders; high ventilatory demands (minute ventilation > 15 L/min), high oxygenation needs (positive end-expiratory pressure > 15 cm H2O or fraction of inspired oxygen of 0.7); and active cutaneous infection over the proposed tracheostomy site.4 PDT PDT is the procedure of choice at our institution for medical and surgical patients with respiratory failure requiring tracheostomies for prolonged mechanical ventilatory support. All PDT procedures were performed by specially trained general surgeons, thoracic surgeons, and pulmonologists. All PDT procedures are performed at the bedside in the ICU in which the patient resided, with continuous monitoring of BP, heart rate, respiratory rate, oxygen saturation, and cardiac rhythm strip. Mechanical ventilatory support was maintained throughout the procedure, the fraction of inspired oxygen was increased to 1.0, and all patients were placed on mandatory mechanical ventilation mode. Most procedures were attended by an anesthesiologist to assist in the management of the airway in the event of complications. Informed consent was obtained from each patient, or from a designated power of attorney or family member, if the patient was unable to provide informed consent. All patients received short-acting IV midazolam or propofol, and a short-acting paralytic agent such as vecuronium if necessary. PDT was performed as previously described in detail,4 with few modifications dictated by the patients body habitus. Briefly, a 1.5- to 2.0-cm vertical or horizontal skin incision was performed, the pretracheal tissue was bluntly dissected with a hemostat, and the tracheal rings or cricoid cartilage were identified by palpation. Employing the Seldinger technique, a guidewire was then placed below the first tracheal ring, a stoma created by sequential dilatation, followed by placement of a # 8 Portex Perfit (Sims-Portex; Keene, NH) tracheostomy tube, a # 9 Portex Perfit (Sims-Portex) tracheostomy tube, or an extralong # 8 Portex (Sims-Portex) tracheostomy tube (sizes depict the inner diameter [ID] in millimeters). Extralong tubes were chosen for the additional horizontal tube length if the pretracheal tissue and fat plane was too thick for a regular-sized tracheal tube.

Flexible fiberoptic bronchoscopy was not routinely performed during the procedure, but was immediately available. Previous SectionNext Section Results A total of 13 consecutive obese patients with acute respiratory failure and dependence on mechanical ventilatory support were referred for PDT. None of the patients were excluded. The patient characteristics and demographics are presented in Table 1 . The 13 patients included 8 men and 5 women with a mean SD age of 55 14.8 years (range, 37 to 82 years). The mean weight was 132 40.8 kg (range, 76.8 to 206 kg), and the mean BMI was 45.9 12.4 kg/m2 (range 28.1 to 61.8 kg/m2). All required intubation for acute respiratory failure attributed to a variety of underlying medical conditions. The mean duration of endotracheal intubation prior to request for PDT was 18.7 7.46 days (range, 10 to 35 days). Patient Characteristics and Demographics* Bedside PDT was successfully performed in all 13 cases. Twelve of the patients received an 8-mm ID tracheostomy tube, (3 of these patients required an extra long 8-mm ID tracheostomy tube), and 1 patient had a 9-mm ID tracheostomy tube placed. Procedural complications included the paratracheal placement of the tracheostomy tube in one case (patient 8). For this case, the tracheostomy tube initially dissected along a tissue plane adjacent to the trachea, but was immediately identified prior to ETT extubation. The tracheostomy tube was properly repositioned without clinical consequence to the patient, and proper tracheostomy position was verified by direct bronchoscopic visualization. Postprocedural complications included a cuff leak in one patient (patient 5) on day 2 following the initial PDT. The tracheostomy tube was exchanged at the bedside with a changing kit. There were no serious bleeding complications during the procedures and no cardiopulmonary complications. None of the patients for whom PDT was performed required conversion to emergent surgical tracheostomy placement. There were no deaths associated with bedside PDT. Previous SectionNext Section Discussion This report demonstrates that PDT is a feasible alternative to surgical tracheostomy placement in the obese patient with persistent respiratory failure requiring continued mechanical ventilatory support. Performed at the bedside in the ICU, with appropriate monitoring of vital function, bedside PDT can be safely performed in obese patients by experienced personnel. The care of the obese patient in the ICU poses many challenges, and establishing an artificial airway in this patient population can be technically difficult. In most institutions, obese patients in need of a tracheostomy are referred for surgical tracheostomy placement. However, even the surgical approach can be challenging, and may require tracheostomy with cervical lipectomy to overcome the technical barriers.5 PDT, first described in its current form in 1985,3 has increasingly evolved as a viable alternative to surgical tracheostomy placement.6 However, prior reported experience of PDT in obese patients has been limited. The current report suggests that obesity may not be a relative contraindication to PDT, and that in the absence of other anatomic abnormalities, PDT can be safely performed in these patients requiring prolonged maintenance of an artificial airway. In general, PDT is considered very safe, with a complication rate of 4 to 17% in experienced hands.2 The most common complications include bleeding, subcutaneous emphysema, aspiration, and stomal infection. 278 These complication rates are similar to those reported for surgical tracheostomies, and the postprocedural complication rate for PDT may be lower than surgically placed tracheostomy.269 The observed complication rate for obese patients in the current study is consistent with rates reported for other patients undergoing PDT. In this report, the complications were limited and included paratracheal placement of the tracheostomy tube in one patient (7.7%) and a postprocedure cuff-leak in one patient (7.7%). Of note, the paratracheal insertion was performed by a resident in training under close supervision by

the attending surgeon. Due to this close supervision, the misplacement was immediately identified and corrected. In both cases, the tracheostomy tube was replaced with a new tracheostomy tube without further complications and without clinical consequences to the patients. Several important features may have contributed to the success of bedside PDT placement in the obese patient population included in this report. Due to the high case load at the BIDMC ICUs, all operators have a large cumulative experience with bedside PDT. The cumulative number of PDT procedures performed by the operators in this report is > 400. Furthermore, all procedures were performed in an ICU setting, with the appropriate monitoring and with the appropriate facilities to appropriately manage adverse events. Anesthesiologists were present for most procedures in this patient population, although no complications in airway management were experienced. Additionally, it is necessary to adapt the inserted tracheostomy tube to the anatomic requirements. Thus, in patients with very large necks, we had extralong tubes available for insertion if necessary. Finally, the availability of fiberoptic bronchoscopy facilitated the proper positioning of a tracheostomy tube in one case. These safeguards should be considered for complex PDT procedures. The findings in this report are limited by the relatively small number of patients included. However, this report represents the largest reported experience for PDT in obese patients. The experience of successful PDT in obese patients at the BIDMC may not represent patients at other institutions in various medical centers in this country and the world. However, the underlying medical conditions were quite diverse, and likely represent various medical and surgical patients encountered in other practices. Clearly, as successful PDT placement in obese patients requires specialized skill, this procedure may not be appropriate in centers with less experience. Our experience suggests that PDT is a feasible, well-tolerated, and safe procedure for the obese patient requiring prolonged mechanical ventilatory support for persistent respiratory failure. When performed by experienced surgeons and interventional pulmonologists at the bedside of the patient in the ICU of a tertiary-care medical center, PDT may be associated with a high success rate and low complication rate in the obese patient, and may offer a significant cost advantage. Previous SectionNext Section Footnotes

Abbreviations: BIDMC = Beth Israel Deaconess Medical Center; BMI = body mass index; ETT = endotracheal tube; ID = inner diameter; PDT = percutaneous dilatational tracheostomy; TT = tracheostomy tube

o o

Received June 3, 1999. Accepted November 23, 1999.

Previous Section References 1.

Ciaglia, P, Graniero, KD (1992) Percutaneous dilatational tracheostomy: results and long-term followup. Chest 101,464-467
Abstract/FREE Full Text 2.

Friedman, Y, Fildes, J, Mizock, B, et al Comparison of percutaneous and surgical tracheostomies. Chest 1996;110,480-485
Abstract/FREE Full Text 3.

Ciaglia, P, Firsching, R, Syniec, C Elective percutaneous dilatational tracheostomy. Chest 1985;87,715719

Abstract/FREE Full Text 4. 5.

Ernst, A, Garland, R, Zibrak, J Percutaneous tracheostomy. J Bronchol 1998;5,247-250

Clayman, GL, Adams, GL Permanent tracheostomy with cervical lipectomy. Laryngoscope 1990;100,422424
Medline 6.

Hazard, P, Jones, C, Benitone, J Comparative clinical trial of standard operative tracheostomy with percutaneous tracheostomy. Crit Care Med 1991;19,1018-1024
MedlineWeb of Science 7.

Petros, S, Engleman, L Percutaneous dilatational tracheostomy in a medical ICU. Intensive Care Med 1997;23,630-634
CrossRefMedlineWeb of Science 8.

Bobo, M, McKenna, S The current status of percutaneous dilational tracheostomy: an alternative to open tracheostomy. J Oral Maxillofac Surg 1988;56,681-685
9.

Griggs, WM, Myburgh, JA, Worthley, LI A prospective comparison of percutaneous tracheostomy technique with standard surgical tracheostomy. Intensive Care Med 1991;17,261-263
CrossRefMedlineWeb of Science http://chestjournal.chestpubs.org/content/117/5/1426.full

Tracheostomy: care and management review Introduction These guidelines are intended to support practitioners looking after children with tracheostomies to improve the care and safety of this group of children. While not intended to replace formal teaching, there are quick reference algorithms included in these guidelines for practitioner use. All practitioners should have appropriate clinical experience in dealing with a child with a tracheostomy and should not rely solely on these guidelines for their practice. Sections: 1. Formation

Preparation of equipment and environment Initial care observations initial observations and complications post-procedural safety check other initial complications feeding humidification other care requirements

Management suctioning tape changes (cotton)

tube changes (planned)

Carer competency sheets Resuscitation of a child with a tracheostomy Subsequent care stoma care investigations complications

Discharge General information (link)

Background More children with chronic medical conditions are surviving, largely due to advances in tracheostomy care and technology support. The vast majority of these children are now being cared for in their own homes and at school. Tracheostomy is one of the oldest surgical procedures and was first successfully performed on children in the late 19th century. Today it is a common procedure and is life saving for many infants and children requiring airway and respiratory support. However, despite providing a safe and protective airway paediatric tracheostomy is often associated with significant morbidity and mortality (Midwinter et al, 2002). A tracheostomy is an artificial opening in the trachea, usually between the 3rd and 4th tracheal rings (see Figure 1) into which a tube is inserted and through which tube the child breathes. A tracheostomy is initially a life saving operation but is also a life threatening one unless the airway is kept clear from secretions and blockages 24 hours a day. Children with tracheostomies require constant supervision from those trained fully in its care.

Figure 1: Tracheostomy positioning Section 1 - Formation Tracheostomy: preparation of equipment and environment The childs bed area must be made easily accessible from both sides without obstruction, e.g. patient luggage, chairs, etc (Rationale 1). Appropriate resuscitation and suction equipment with correct tracheostomy fittings (15mm Smiths Medical (Portex) swivel connector and a male Smiths Medical (Portex) adaptor for GOS, Silver & Montgomery tubes) checked and in full working order (Rationale 2). Note: All equipment must be checked whenever a practitioner takes over the care of a tracheostomised child, including breaks and transfers to another ward/department. The child MUST NEVER be left alone. The accompanying carer (including parents where applicable), as a minimum, must be able to:

Recognise signs of airway obstruction Initiate suctioning of tracheostomy tube

The child should have a dedicated tracheostomy trolley by the bedside containing:

Oxygen saturation monitoring - if oxygen therapy is required (Rationale 3) Suction catheters - correct size (Rationale 4)

Clean gloves (Rationale 5) Clean gauze (Rationale 6) Clean receiver with tap water (Rationale 7) 2 ml syringe Ampoule 0.9% sodium chloride for irrigation (Rationale 8) Yellow waste bag for incineration (Rationale 9) An emergency trachi box with the following contents: A spare tracheostomy tube (same size and make) (Rationale 10) A tracheostomy tube (one size smaller) (Rationale 11) A water based lubricant such as Aqua lube or KY jelly (Rationale 12) Round ended scissors (Rationale 13) Spare tracheostomy tapes (Rationale 14) A suction catheter (same ID as the suction catheter) (Rationale 15)

Goggles/protective eye wear should be available (Rationale 9). A tube with a 15mm termination requires a Smiths Medical (Portex) swivel connector which can be added to the resuscitator and must be available at the child's bedside. A flat-ended tube requires an appropriately sized tracheal tube adapter and a Smiths Medical (Portex) swivel connector that will slip into the tube as required to create a 15mm termination that will be compatible with resuscitation equipment. Following an audit of use and competence tracheal dilators are now to be kept in the Resuscitation Trolley (not at the child's bedside) and only used by competent practitioners (Rationale 16). Practitioners should use the seldinger technique when reinserting a tube. Initial care Nursing actions during the first seven days following formation of the tracheostomy centre on maintaining the correct positioning and patency of the new tube, stoma maintenance and parental teaching (if appropriate)(Rationale 17). Communication between the hospital and community health carers must be commenced following surgery (Rationale 18). The initial nursing care of a child with a tracheostomy is very different from that for an established stoma. At Great Ormond Street Hospital (GOSH), the first tube change occurs after one week (Rationale 19); other units advocate changing the tube after 3 days (Deutsch, 1998). The Tracheostomy Nurse Practitioner (TNP) or ENT Surgeons will perform the first tube change. To ensure the safety of the airway, the trachea is sometimes sutured onto the childs skin with tiny interrupted disposable sutures these are called maturation sutures (Rationale 20). In addition, two long looped stay sutures extend from inside the stoma and are taped to the childs chest. These sutures are attached to the tracheal wall on either side of the stoma (Rationale 21). Tape on the childs chest will be labelled DO NOT REMOVE (Rationale 22). These will be removed after the first tube change. Figure 2: Position of Stay Sutures Observations The childs vital signs should be recorded in accordance with local policy, with the frequency reducing as the childs condition dictates (Rationale 23). Initial observations and complications Practitioners should also carry out routine non-invasive observations to rule out the following potential initial complications:

check that the tape tension is correct and able to support the tracheostomy tube observe any neck swelling (surgical emphysema - see below) check for air entry through tube - place finger above tube opening & feel for a passage of air inspect the chest for bilateral chest movement auscultate the chest for equal air entry (pneumothorax/ tube position)

A flexible endoscopy may be performed post operatively if the child is distressed and or coughing. Post-procedural tube check For the majority of children a chest x-ray is performed in theatre, if this has not happened then a portable post-operative chest Xray must be performed within one hour or soon after the child has returned to the ward to confirm tube position and to rule out a pnuemothorax and surgical emphysema (Tarnoff et al, 1998). Other Initial Complications Initial complications are largely avoidable if the procedure is carefully performed together with careful and effective post-operative management. Other initial complications include:

Haemorrhage: May be primary, reactionary or secondary. A large haemorrhage may be fatal (Rationale 24). Secretions may initially be blood stained but will settle within a few hours, if it continues then practitioners should contact the TNP, CSP or ENT team. Tube Blockage (Rationale 26) At least: - hourly suction for the first 12 24 hours regular suction until first tube change (as required)(Yaremchuck, 2003; Onakoya et al, 2003; Friedman et al 2003; Seay et al, 2002; Park et al, 1999)

Accidental decannulation/tube displacement (Rationale 27) The tube may visibly come out of the stoma or can be pulled out of the trachea and sit in the pre-tracheal tissues. Tube can be reinserted but must not be forced. On reinsertion, air entry must be checked and confirmed. ENT team / TNP or clinical emergency team must be contacted immediately to review tube position. Common causes for this include: chubby infant neck, incorrectly chosen tube, loose trachy tapes or the child pulling at the tube. Care must be taken to ensure that the tube is correctly secured and does not become displaced. If it does, early recognition is essential as this could be life-threatening. Practitioners must contact the ENT team/ TNP or clinical emergency team for immediate assistance.

Infection (chest/stoma site) (Rationale 25) Surgical emphysema Air may leak around the tube into the surrounding tissue - this is particularly problematic if the child has had neck sutures inserted (Rationale 28, 29 and 30). Checking tape tension not only confirms that the tube is secured correctly but also if they appear tighter may indicate swelling. Contact the ENT team, TNP or CSP's.

The child, where possible, should not leave the ward during the first week unless medically indicated (Rationale 31). Feeding If there have been no previous feeding concerns, the child may recommence their normal feeds after a specified time of being nil orally. This is normally 3 hours post-operation, but practitioners must confirm this with the anaesthetic chart (Rationale 32, 33, 34). For a child that has had feeding difficulties or has never orally fed, consultation with the Speech and Language Therapist (SALT)

should be sought before the commencement of oral feeding. Begin with water. If the child shows signs of aspiration, for example, if there is coughing after/ during drinking, or visible drink coming out of the tracheostomy, then maintain nil orally and contact ENT team and the SALT. Humidification

DO NOT USE a Heat and Moisture Exchanger (HME) during the first week (Rationale 35). Administer humidity via sterile water and elephant tubing continuously for 1 week as far as is practicable. The child may come off for short periods, i.e. to feed, play, bathe, mobilise, etc. Small and vulnerable infants under one year must have continuous warmed humidity. Change humidity apparatus when the bottled water needs changing (usually 24hrs) or earlier if contaminated with secretions or if the mask comes into contact with the floor. When not in use, the mask should be covered).

Other care needs

Change the tapes at least daily or when soiled or wet (Rationale 36). A suitable dressing, such as Trachi-dress, should be inserted behind the flanges to protect the skin (shiny side to skin). Avoid using bulky substitutes as these may pull the tube away from the neck presipitating accidental decannulation. Never use cotton wool or cut gauze dressings (keyhole)(Rationale 37). The tracheostomy tube should be changed for the first time 7 days after surgery. The tracheostomy tube should normally be changed for the first time by the ENT surgeon or the TNP. The stay sutures will be removed at this time.

Once the stability of the tracheostomy stoma and tract has been verified the child may be allowed off the ward with a person appropriately trained in routine and emergency tracheostomy skills. Section 2 - Management Suctioning Airway suctioning is a common practice practice in the care of a child with a tracheostomy, and is undertaken to remove secretions from the childs respiratory tract. A child with a tracheostomy may find it difficult to clear their secretions effectively therefore suction is an essential aspect of their care. Suctioning is associated with many potential complications and is now only recommended when there are clear indications that the patency or ventilation of the children could be compromised (Pritchard et al, 2001; Czarnik et al, 1991; Fiorentini, 1992; Raymond, 1995; Gemma et al, 2002; Dellinger, 2001; Spence et al, 2003; Ahn & Hwang, 2003; Prasad & Hussey, 1995). Main complications requiring suction interventions:

Hypoxia Formation of distal granulation tissue/ ulceration Cardiovascular changes Pnuemothorax Atelectasis Bacterial infection Intracranial changes

The GOSH Guideline on Suctioning Techniques (Simpson, 2009) is a useful resource. Practitioners trained in the skill should perform tracheostomy suctioning to minimise complications and maximise treatment (NMC, 2002). The child and family must be informed of the reasons for suctioning, positioning, risks and outcomes as appropriate. A 'clean' technique must be used and the catheter should be discarded if the tip is contaminated with hands, cot sides, etc. Suction equipment must accompany the child at all times, regardless of the nature of the journey or the distance to be travelled.

Equipment The following equipment should be prepared:

Suction catheters of the correct size Suction unit with variable vacuum control Gloves Apron (don if there is time - a child should never wait for suctioning) Tap water (in clean container) 2ml syringe with 0.9% sodium chloride for irrigation (not for routine suctioning) Yellow waste bag for incineration

Practitioners must be aware that some pre-term, vulnerable infants and especially those who are requiring > 40% inspired oxygen, may require pre-oxygenation prior to suctioning to minimise a potential hypoxic event (Sigler & Willis, 1985; Odell et al, 1993; Pritchard et al, 2001). Distal tracheal damage and hypoxia are very real and potential complications especially in the vulnerable paediatric airway. These complications may be reduced by having:

The correct size catheter, as a guide, practitioners should double the size of the tracheostomy tube to obtain the appropriate catheter size, e.g., 4.0 ID tracheostomy tube = size 8fg catheter . A suction catheter diameter should be less than half of the size of the tracheostomy tube to reduce potential for hypoxia and allow the child to breathe throughout the procedure (Odell et al, 1993; Glass & Grap, 1995; Wood, 1998; Ahn & Hwang, 2003). 1 distal and 2 lateral ports with rounded ends allows secretions to be collected both distally and from the sides of the tube to minimise tube occlusion (Ahn & Twang, 2003). Any more than three lateral holes then the catheter wall would be too weak. A Lateral port that is smaller than the distal port so that mucosal adhesion and biopsy does not occur (Fiorentini, 1992; Luce et al, 1998). An integrated valve for vacuum control, as suction should only be applied on removal. Catheters should not be kinked prior to insertion in an effort to control the vacuum (Prasad & Hussey, 1995). It is preferable to use suction catheters with graduations, so that practitioners can measure the exact depth to be suctioned. Suctioning should not occur distal to the tube tip. Catheters should only be inserted so that the distal hole sits at the end of the tube. This allows collection of secretions but not trauma to the distal tracheal mucosa (Brodsky et al 1987; Runton, 1992). Suction pressures should be kept to a minimum; as a general guide pressures should not exceed 60-80mmHg (8-10kPa) for neonates/ small infants and up to 120mmHg < 16kPa for older children, below is an approximate but more specific guide (Dean 1997; McElery 1996; Mowery, 2002; Simpson, 2001;.Billau, 2004; Young, 1984). Excessive pressures can cause trauma, hypoxaemia and atelectasis (Czarnik et al, 1991).

Age of child

Approx tube size

Suction Pressures 8 - 10 Kpa

Pre-term - 1 month

3.0 60 - 75 mmHg 10 - 12 Kpa

0 - 3 yrs

3.5 - 5.0 75 - 90 mmHg 12 - 15 Kpa

3 - 10 yrs

5.0 - 6.0 90 - 112 mmHG

15 - 20 Kpa 10 - 16 yrs 6.0 - 7.0 112 - 150 mmHG Suctioning is not a painful or distressing procedure; in fact most infants will remain asleep throughout. If the child becomes distressed during suctioning then practitioners should revise their technique. Note: Suctioning a paediatric tracheostomy is very different from suctioning an adult tube, so adult practitioners will need to adapt their practice. Constant observation of the child during suctioning is essential; practitioners should observe for an improvement or deterioration in respiratory rate and quality, child's colour, and oxygen saturations (if being monitored). Technique

Perform a clinical hand wash (if there is time)(Rationale 9). Put on a minimum of gloves (Rationale 9). Turn suction unit on and check the vacuum pressure and set to the appropriate level, according to the child's age. The carer MUST know the length of the tracheostomy tube. If the tube is fenestrated then an un-fenestrated inner tube should be inserted to prevent the catheter going through the fenestration and causing trauma. Insert catheter gently into the tracheostomy tube, enough to ensure that the lateral and distal holes just pass through the tip of the tube, use the graduations on the catheter as a guide. Adult literature suggests longer distances (Luce et al, 1998), however the distance between the tube tip and a childs carina could only be a matter of millimetres. Handle only the proximal end of the catheter. Catheters should be discarded if the end has been touched before insertion. Apply suction by placing thumb over the valve, found either on catheter or suction tubing. Do not kink the catheter (Czarnik et al, 1991). Do not employ an intermittent suction technique, as previously though intermittent suctioning does not reduce trauma and is less effective, (Luce et al, 1993). Slowly withdraw the catheter straight out of the tube maintaining the vacuum. Do not apply suction on insertion as this may cause mucosal irritation, damage and hypoxia. There is absolutely no need to rotate the suction catheter on withdrawal, as both the distal and lateral holes on the new style of catheter allows for circumferential suctioning. Suctioning should be quick but effective and should not exceed 5-10 seconds (Sumner, 1990; Young, 1984; Toiles and Stone, 1990), most of this literature is based on the adult population. In paediatrics, maximum durations should be based on the child's underlying medical condition and current clinical condition and practitioners should adjust timings accordingly, for example 10 seconds is a long time for a neonate with underlying lung disease (Rationale 38). The catheter may be re-used if immediate suction is required, as long as secretions have not occluded the suction ports (Scoble et al, 2001)(Rationale 39). Wrap the catheter around the gloved hand, remove the glove by inserting it over the used catheter and discard in yellow waste bag according to Waste Policy. Flush suction tubing with tap water (Rationale 40) and connect a new catheter to the tubing. Wash hands (Rationale 9).

Record if the secretions are bloody, purulent, foul smelling or unusually thick in the childs health care records. Take samples as required. Note: Deep suctioning may be required in certain circumstances - for example during broncho-alveolar lavage - but this should not be routine practice (Bailey et al, 1988). Instillation of saline - Saline should not be used routinely (Blackwood, 1999; Hudak & Bond-Domb, 1996; Pritchard et al, 2001; Ackerman & Mick, 1990; Scoble et al, 2001; Neill, 2001).

Tape changes (cotton) Note: Velcro ties are not routinely used at GOSH following a two severe untoward incidents in other centres. If children arrive in GOSH with Velcro ties then it must be explained to their parents that cotton tapes will be used for the duration of their stay. If Velcro ties are used then a risk assessment must be completed in accordance with Trust policy and documented in the local and Trust Risk Registers. A tracheostomy tube is held in place with cotton tapes around the neck. It is essential that the ties are secure and the tension of the ties is correct. The tapes are secured with knots tied either side of the tracheostomy tube. All staff/parents should be taught to tie the tapes in the same way (Rationale 41). Parents may prefer to adopt another method of securing the tapes once they have established a routine at home. This method may be continued when the child is re-admitted to hospital but will need individual assessment. Tracheostomy tape changes are normally performed daily. Only Personnel trained and competent in the techniques involved must change tracheostomy tapes and two people are required (NMC, 2002). Equipment The following equipment should be prepared and be readily available:

Appropriate emergency equipment readily available (Rationale 42) Gauze swabs and saline sachets Two lengths of inch cotton tape with short plastic backing. The backing can be made from appropriately sized available tubing, e.g.24hr Urine or O2 tubing. Cut the ends of the tapes to a point (Rationale 43) Round ended scissors A rolled up towel (Rationale 44) A blanket to swaddle a baby or uncooperative toddler (Rationale 45) Suction equipment available (see suction guidelines) Non-sterile gloves and an apron Goggles/protective eye wear Childs own comforter, e.g. dummy, as appropriate An older child may not require swaddling. Some children may assist with the procedure by holding the tracheostomy tube in place and some may even prefer to sit during a change. These options must be discussed with the child and parents/carers as swaddling the child may cause increased distress.

To change the tracheostomy tapes:

Perform a clinical hand wash, put on gloves, apron and protective eye wear (parents do not need to wear the protective clothing) The warmed water should be poured onto the gauze swabs Assistant to swaddle baby, exposing shoulders and above Place baby/child in supine position, with a rolled up towel under shoulders; (as mentioned above, some older children may wish to sit) Place clean tapes behind the baby/childs neck

Assistant should hold tube in position using either their thumb and index finger, or index and middle finger; see figure below (Rationale 46). Minimal pressure should be applied.

Figure 3: Positioning for a tape/tube change

Tape changer should cut the tapes between the knot and the flange and remove dirty ties. The stoma site (above, below and under each flange) and back of the neck should be cleaned and thoroughly dried with the water and gauze using a clean technique. Thread the new tape through the flange on the side furthest away from the tape changer. Tie the tapes using three knots ensuring the tape is flat to the childs skin. Thread tape through near side flange, tie once and make a bow. Check tape tension by: Raising baby/child to a sitting position whilst assistant continues to hold tube in position. With the baby/childs head bent forward it should be possible to slip one finger comfortably between the ties and the baby/childs neck. See Figure 4.

Figure 4: Tape tension If the ties are too tight or loose lay the baby/child back down, undo the bow and readjust.

If the tension is correct, lie the baby/child down and change the bow into three knots by pulling the loops of the bow through to create a second knot. Tie one further knot to secure the ties. Cut off excess tape to leave inch remaining. Assistant may release tube ONLY when instructed to do so. Ensure baby/child is made comfortable. Clear away equipment according to the Waste Policy. Wash hands. Record the tape change in the baby/childs health care records. Check all equipment is replaced and restocked as necessary.

Tube changes (planned) Tracheostomy tubes can be changed weekly or monthly (refer to tube information sheets above). Ask the TNP or childs doctor if unsure. Only personnel trained and competent in the techniques involved must perform a tracheostomy tube change and two people are required (NMC, 2002). An older child should not require swaddling. Some children may assist with the procedure, such as cleaning the stoma site, holding the tracheostomy tube, etc. Some children may need to be swaddled to maintain their safety during the change; assess each child individually. Equipment The following equipment should be prepared:

Emergency equipment, oxygen and suction A tracheostomy tube of the same size A tracheostomy tube that is a size smaller

A water based lubricant such as Aqualube or KY jelly Gauze swabs Saline sachets Two lengths of inch cotton tape Round ended scissors A rolled up towel Gloves and an apron Goggles/protective eye wear Two syringes may be required if the child has a cuffed tube (Rationale 47)

To change a tracheostomy tube:

Perform a clinical hand wash Put on gloves, apron and protective eye wear Assistant to swaddle baby, exposing shoulders and above (baby in supine position) if appropriate Lubricate new tube with a dot of water-based lubricant on the outside bend of the tube Insert obturator into the tube Position the rolled up towel under the childs shoulders, as per tape changes. Place clean tapes behind the baby/childs neck Assistant should hold the tube in position using either their thumb and index finger, or index and middle finger. Tube changer should cut the ties between knot and flange Remove the dirty ties Remove the tube from the stoma with a curved action Quickly insert new tube with a curved action Remove obturator The assistant should take over and hold the tube in position The stomal area and back of the neck should be cleaned and dried with the water and gauze using a clean technique The ties are then tied using the method previously described

Carer Competency Guide Staff and carers should be trained and assessed in the following competencies: 1. 2. 3. 4. Staff competency - home preparation (PDF, 434 KB) Staff competency - ventilated child Carer competency - home preparation (PDF, 434 KB) Carer competency - ventilated child (PDF, 468 KB)

Figure 5: 'Trache' Poster

Resuscitation The basics of cardio-pulmonary resuscitation (CPR) and Basic Life Support (BLS) are universal to all protocols for emergency care:

Airway management Rescue breathing Circulatory support

The airway element of BLS will require modification in children with tracheostomies, it is therefore essential that practitioners have received training in both routine and tracheostomy BLS. BLS is similar in the sequence of skills to be performed for those with a tracheostomy:
Safety

Stimulate

Shout

Suction*

Airway

Breathing

Circulation

TRACHEOSTOMY RESUSCITATION ALGORITHM (PDF, 153 KB) When applied to a patient with a tracheostomy, CPR may be more difficult to teach and to learn because additional processes are required to determine and correct the cause of the collapse. Practitioners caring for a child with a tracheostomy must familiarise themselves with the tracheostomy resuscitation algorithm. Patients with a tracheostomy must always have their specific emergency equipment correctly assembled and easily accessible (as already discussed). Starting BLS quickly is extremely important (Rationale 48):

Ensure safety of yourself and the child Stimulate the child and call their name, taking care to support their head and body (Rationale 49) Call for assistance from colleagues (Rationale 50) If you are by yourself DO NOT leave the patient at this stage. Open and check the childs airway by placing supine on a flat firm surface (Rationale 51) It may be helpful to put a folded towel under the shoulders, only if this is immediately available. Do not waste time by collecting this equipment. Gently tilt the tip of the chin upward, taking care not to press on soft tissue underneath. Inspect tube for obvious problems, ie signs of blockage: crusts, kinks or dislodgement. IF IN ANY DOUBT ABOUT CHILDS CONDITION SUMMON THE CLINICAL EMERGENCY TEAM IMMEDIATELY (2222) Suction the tracheostomy tube. In most circumstances suctioning will clear the obstruction.

Change the tracheostomy tube immediately if the tube appears blocked or any resistance is felt and the child is in distress. Exercise caution if the stoma is less than one week old; if time, contact the TNP/ ENT team/ Emergency team first. However, if the childs condition is unstable, summon the Clinical Emergency Team (2222) immediately. The same size tube should be inserted. If unable to insert the same size tube try to insert the one that is a size smaller. If the stoma closes and the smaller tube cannot be replaced, remove the Obturator from the smaller tube and pass a suction catheter through the tube. Then attempt to insert the end of the catheter through the stomal opening. Then attempt to guide the tracheostomy tube along the catheter and through the stoma (Seldinger technique). If this is also unsuccessful, ventilation can be attempted via the catheter threaded in to the stoma (as described previously) or by conventional rescue breaths (e.g. mouth-to-mouth or bag and mask over the mouth & nose). These options may not be appropriate for some children due to their underlying airway problem; practitioners must therefore always be aware of the underlying disease/ anatomy.

The Seldinger technique should be practised as a first line attempt at reinserting a tracheostomy tube. Tracheal dilators should only be used by practitioners familiar and practised in their use. Tracheal dilators are currently kept in the resuscitation trolley for use on request from experienced practitioners (Lyons and Cooke et al, 2007). Assess breathing:

Supporting the new tube, place the side of your face over the tracheostomy tube to listen and feel for any breathing. At the same time look at the childs chest to observe any breathing movement. Take up to a maximum of ten seconds to do this. If the child is breathing adequately, give oxygen and keep their airway open by regular suction and await for the clinical emergency team/ENT/TNP and/or CSPs to arrive (practitioners should decide on whom best to call). If the child is not breathing (or only making agonal gasps), commence artificial respiration with a bag-valve system directly connected to the tracheostomy tube and administer 5 breaths. This is best achieved with a Smiths Medical (Portex) 15mm swivel connector attached to the ambu bag. Ensure that the breaths are effective by observing chest movement. Oxygen should be set at a minimum of 10 litres/minute for a paediatric system and 15 litres/minute for the adult system. Parents will be taught mouth to trachy resuscitation for going home, in addition to the other equipment required they must be given a Smiths Medical (Portex) catheter mount 15mm female, and two emergency Velcro tapes.

Further BLS instructions (PDF, 18 KB) Although community teams will supply the equipment for the child's discharge home, after emergency care from a suitably qualified BLS instructor with trachesostomy experience, they should give the parents two pairs of velcro tapes, two disconnection wedges, and two tracheostomy extensions from Smiths Medical (Portex) +/- male to female adapters depending on tube chosen. Practitioners should seek advice from the TNP; these items should be added to their emergency boxes when they get home. Parents require both theoretical and practical teaching / practice of both emergency algorithms, namely action to take on a blocked tube and action to take if the tracheostomy tube cannot be replaced (Seldinger technique). Practitioners teaching parents/ carers must have appropriate knowledge and experience in both areas. At GOSH, a modified 'Resus baby' and 'Little Junior' is used for BLS and a Smiths Medical (Portex) percutaneous tracheostomy manikin for parents to practice the Seldinger technique. Discharge TRACHEOSTOMY DISHARGE ALGORITHM The formation of a tracheostomy must be confirmed by telephone with the childs Health Visitor (HV), GP, Paediatric Community Nurse (PCN), School Nurse & local Hospital on the day the tracheostomy is inserted. An equipment list and introductory letter must be sent so that equipment can be ordered immediately - New Equipment Form (PDF, 227 KB)(Rationale 38). The community team must be contacted after one week to confirm tube style/ size, which may have had to be changed during the first week. The progress of supply orders should also be checked. Discussion of respite and carer support should be broached with community team. Most children will be discharged back via their local hospital, which will allow local services and support to be activated. Negotiations to do this should begin as soon as the tracheostomy is formed. However some children, such as those who have had a planned tracheostomy or who have been in hospital for a long time may be discharged home straight from hospital. Some equipment may have to be provided to facilitate this; this should be discussed individually with the communities involved. All appropriate documentation and medicines should be ordered/ completed.

Ensure that the portable suction unit has been collected from the community team before the day of discharge and bought to the hospital for the transfer home and parents are aware of how it works. The childs parents, or two main carers, must be taught and be deemed as competent in the following: (sometimes it is not possible to complete all the training at GOSH and local teams may have to complete this)

Tracheostomy tube changes (minimum of two) Tracheostomy tape changes Stoma care Suctioning Resuscitation skills/ emergency care Carer must stay and do an overnight stay with their child and carry out all care overnight Feel confident in themselves taking the child out of the hospital

They must be given the appropriate GOSH tracheostomy and resuscitation booklets to support their training. All training received must be recorded on the childs discharge planner and kept in their health record for future reference. An eight-week ENT outpatient appointment must be arranged prior to discharge (unless indicated otherwise by the medical team). Confirm discharge of patient with HV and/or PCN and GP as appropriate. Although community teams will supply the equipment for the child's discharge home, after emergency care training from a suitably qualified BLS instructor with trachesostomy experience, they should give the parents two pairs of velcro tapes, two disconnection wedges and two tracheostomy extensions from Smith Medical (Portex)+/- male to female adapters, depending on tube chosen (Rationale 52). Practitioners should seek further advice from the TNP as required. Parents require both theoretical and practical teaching/ practice of both both emergency algorithms, namely: action to take on a blocked tube and action to take if the tracheostomy tube cannot be replaced (Seldinger technique), therefore practtioners teaching parents/ carers must have appropriate knowledge and experience in both areas. At GOSH we use a modified 'Resus baby' and 'Little Junior' for the BLS aspect and the percutaneous tracheostomy manikin from Smiths Medical for parents to practice the Seldinger technique. General Information IMPORTANT: GENERAL INFORMATION ON TRACHEOSTOMY FORMATION, TYPES OF TRACHEOSTOMY TUBE WITH TUBE INFORMATION SHEETS, HUMIDIFICATION METHODS AND HME'S PLEASE REFER TO THIS SEPERATE PDF DOCUMENT.(PDF, 44 KB) Rationale Rationale 1: Child's airway is at risk and they may need immediate attention Rationale 2: To enable effective emergency attention if required Rationale 3: To enable continual assessment of oxygen requirements Rationale 4: To safely suction tracheostomy tube Rationale 5: To minimise the risk of cross-contamination Rationale 6: To clean stoma/secretions Rationale 7: To flush through suction tubing after use Rationale 8: To draw up saline for instillation Rationale 9: To meet hospital Waste Disposal guidelines

Rationale 10: To replace a blocked tube Rationale 11: If the stoma opening shrinks and the normal size tube cannot be inserted Rationale 12: Smoother insertion of the tracheostomy tube Rationale 13: To prevent trauma to the neck, when cutting the ties Rationale 14: To secure the tube Rationale 15: To 'railroad' the tube into the stoma (Seldinger technique) Rationale 16: To be used only on request by practitioners able and competent to use Rationale 17: To maximise safety. Replacing tubes in the first week may be problematic where the stoma has not yet been established. Rationale 18: To ensure effective discharge planning Rationale 19: It is essential that the tube stay in situ long enough for the tract to form avoiding a difficult and possibly dangerous first tube change Rationale 20: To form a more permanent and safer stoma, if the tube requires changing in the first week. Rationale 21: To assist with the opening of the stoma during the first week, by raising the trachea to the skins surface and pulling the stoma apart so that a tube can be inserted Rationale 22: Stay sutures will be removed AFTER the first tube change Rationale 23: To ensure safe recovery from effects of anaesthesia Rationale 24: Expect small amounts of bloodstained secretions in the first few hours. Any concerns call the ENT or emergency teams as required. Rationale 25: The stoma site must be cleaned daily or when soiled. Using a clean technique and sterile gauze/saline. The wound must be inspected for signs of inflammation/ and or infection. Observe colour and nature of secretions Rationale 26: Although children should only be suctioned when required, it is imperative that this trachy tube is kept clear at all times. Children must be nursed in continuous humidity for the first week (may come off for short periods only) Rationale 27: Check correct tension of the tapes, ensuring that only one finger between the neck and tapes. Close observation of respiratory rate, effort, chest movements and air entry on return to the ward Rationale 28: Contact ENT team as stomal sutures may need to be removed Rationale 29: Observe for neck/face swelling or if the child complains of discomfort, pain or difficulty with breathing Rationale 30: Regularly check tape tension for increased tightness Rationale 31: Their airway is at risk and they must remain in an environment that can cope with any complications Rationale 32: The vocal cords are sprayed during procedure, making them less responsive/effective in protecting the airway from aspiration Rationale 33: The effect of the paralysing agent continues for up to 3 hours Rationale 34: Other physical complications accompanied with post surgical oedema, restricted laryngeal elevation preventing complete and safe closure of the lower respiratory tract may cause aspiration and/or regurgitation of food Rationale 35: The HME does not provide enough humidity in the initial phase, children require extra humidity to prevent tube occlusion in the first week

Rationale 36: To monitor stoma/ healing Rationale 37: Flecks of displaced cotton may enter the respiratory tract Rationale 38: Although where possible secretions should be cleared on the first attempt. Adult literature suggests that episodes should be limited to three, to limit potential side effects and maximise the recovery period, (Luce et al, 1993) Rationale 39: If the distal end of the catheter has not been contaminated prior to the suctioning episode then there is no evidence to suggest that by using the same catheter up to three times at the same suctioning episode, increases the risk of infection (Scoble et al, 2001). In fact with effective re-training on technique, some institutions have repeatedly used the same catheter on the same patient for a 24-hour period and have reported no increase in infection Rationale 40: To clear the tubing from secretions Rationale 41: To ensure continuity of training Rationale 42: In case of accidental decannulation Rationale 43: To allow insertion into the tube flanges Rationale 44: To place under the childs shoulders, which will hyper extend the neck, making observation and cleaning of the stoma easier Rationale 45: If a child is moving during the procedure there is potential of accidental decannulation. Involve the play specialist where possible. Most children will settle once they get used to the procedure and especially when parents begin to carry it out Rationale 46: To support the tracheostomy tube and preventing an accidental decannulation Rationale 47: To facilitate deflation and inflation of the cuff Rationale 48: To prevent/minimise hypoxia and subsequent tissue death. Early intervention may prevent progression into full cardiorespiratory arrest Rationale 49: This may be sufficient to rouse the child Rationale 50: Always summon more help, to assist in tube changes, bring other equipment etc Rationale 51: To tilt head and expose airway Rationale 52: Parents/carers can add these items to the emergency box when they get home. References/Bibliography Reference 1: Ackerman MH, Gugerty BP (1990) The effects of normal saline bolus instillation on artificial airways. The Journal of the Society of Otolaryngology Nursing Spring : 14-17. Reference 2: Ackerman MH, Mick DJ (1998) Instillation of normal saline before suctioning in patients with pulmonary infections: a prospective randomized controlled trial. Am J Crit Care 7 (4): 261-6. Reference 3: Ahn Y, Hwang T (2003) The effects of shallow versus deep endotracheal suctioning on the cytological components of respiratory aspirates in high-risk infants. Respiration 70 (2): 172-8. Reference 4: Akgul S, Akycolcu N (2002) Effects of normal saline on endotracheal suctioning. J Clin Nurs 11: 826-30.

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Tracheostomy: care and management review Introduction These guidelines are intended to support practitioners looking after children with tracheostomies to improve the care and safety of this group of children. While not intended to replace formal teaching, there are quick reference algorithms included in these guidelines for practitioner use. All practitioners should have appropriate clinical experience in dealing with a child with a tracheostomy and should not rely solely on these guidelines for their practice. Sections: 1. Formation

Preparation of equipment and environment Initial care

o o o

observations initial observations and complications post-procedural safety check other initial complications feeding humidification other care requirements

Management o suctioning o tape changes (cotton) o tube changes (planned) Carer competency sheets Resuscitation of a child with a tracheostomy Subsequent care o stoma care o investigations o complications Discharge General information (link)

Background More children with chronic medical conditions are surviving, largely due to advances in tracheostomy care and technology support. The vast majority of these children are now being cared for in their own homes and at school. Tracheostomy is one of the oldest surgical procedures and was first successfully performed on children in the late 19 th century. Today it is a common procedure and is life saving for many infants and children requiring airway and respiratory support. However, despite providing a safe and protective airway paediatric tracheostomy is often associated with significant morbidity and mortality (Midwinter et al, 2002). A tracheostomy is an artificial opening in the trachea, usually between the 3rd and 4th tracheal rings (see Figure 1) into which a tube is inserted and through which tube the child breathes. A tracheostomy is initially a life saving operation but is also a life threatening one unless the airway is kept clear from secretions and blockages 24 hours a day. Children with tracheostomies require constant supervision from those trained fully in its care. Figure 1: Tracheostomy positioning

Section 1 - Formation

Tracheostomy: preparation of equipment and environment The childs bed area must be made easily accessible from both sides without obstruction, e.g. patient luggage, chairs, etc (Rationale 1). Appropriate resuscitation and suction equipment with correct tracheostomy fittings (15mm Smiths Medical (Portex ) swivel connector and a male Smiths Medical (Portex) adaptor for GOS, Silver & Montgomery tubes) checked and in full working order (Rationale 2). Note: All equipment must be checked whenever a practitioner takes over the care of a tracheostomised child, including breaks and transfers to another ward/department. The child MUST NEVER be left alone. The accompanying carer (including parents where applicable), as a minimum, must be able to:

Recognise signs of airway obstruction Initiate suctioning of tracheostomy tube

The child should have a dedicated tracheostomy trolley by the bedside containing:

Oxygen saturation monitoring - if oxygen therapy is required (Rationale 3) Suction catheters - correct size (Rationale 4) Clean gloves (Rationale 5) Clean gauze (Rationale 6) Clean receiver with tap water (Rationale 7) 2 ml syringe Ampoule 0.9% sodium chloride for irrigation (Rationale 8) Yellow waste bag for incineration (Rationale 9) An emergency trachi box with the following contents: o A spare tracheostomy tube (same size and make) (Rationale 10) o A tracheostomy tube (one size smaller) (Rationale 11) o A water based lubricant such as Aqua lube or KY jelly (Rationale 12) o Round ended scissors (Rationale 13) o Spare tracheostomy tapes (Rationale 14) o A suction catheter (same ID as the suction catheter) (Rationale 15)

Goggles/protective eye wear should be available (Rationale 9). A tube with a 15mm termination requires a Smiths Medical (Portex) swivel connector which can be added to the resuscitator and must be available at the child's bedside. A flat-ended tube requires an appropriately sized tracheal tube adapter and a Smiths Medical (Portex) swivel connector that will slip into the tube as required to create a 15mm termination that will be compatible with resuscitation equipment. Following an audit of use and competence tracheal dilators are now to be kept in the Resuscitation Trolley (not at the child's bedside) and only used by competent practitioners (Rationale 16). Practitioners should use the seldinger technique when reinserting a tube. Initial care Nursing actions during the first seven days following formation of the tracheostomy centre on maintaining the correct positioning and patency of the new tube, stoma maintenance and parental teaching (if appropriate)(Rationale 17). Communication between the hospital and community health carers must be commenced following surgery (Rationale 18). The initial nursing care of a child with a tracheostomy is very different from that for an established stoma. At Great Ormond Street Hospital (GOSH), the first tube change occurs after one week (Rationale 19); other units advocate changing the tube after 3 days (Deutsch, 1998). The Tracheostomy Nurse Practitioner (TNP) or ENT Surgeons will perform the first tube change. To ensure the safety of the airway, the trachea is sometimes sutured onto the childs skin with tiny interrupted disposable sutures - these are called maturation sutures (Rationale 20). In addition, two long looped stay sutures extend from inside the stoma and are taped to the childs

chest. These sutures are attached to the tracheal wall on either side of the stoma (Rationale 21). Tape on the childs chest will be labelled DO NOT REMOVE (Rationale 22). These will be removed after the first tube change. Figure 2: Position of Stay Sutures Observations The childs vital signs should be recorded in accordance with local policy, with the frequency reducing as the childs condition dictates (Rationale 23). Initial observations and complications Practitioners should also carry out routine non-invasive observations to rule out the following potential initial complications:

check that the tape tension is correct and able to support the tracheostomy tube observe any neck swelling (surgical emphysema - see below) check for air entry through tube - place finger above tube opening & feel for a passage of air inspect the chest for bilateral chest movement auscultate the chest for equal air entry (pneumothorax/ tube position)

A flexible endoscopy may be performed post operatively if the child is distressed and or coughing. Post-procedural tube check For the majority of children a chest x-ray is performed in theatre, if this has not happened then a portable post-operative chest X-ray must be performed within one hour or soon after the child has returned to the ward to confirm tube position and to rule out a pnuemothorax and surgical emphysema (Tarnoff et al, 1998). Other Initial Complications Initial complications are largely avoidable if the procedure is carefully performed together with careful and effective post-operative management. Other initial complications include:

Haemorrhage: May be primary, reactionary or secondary. A large haemorrhage may be fatal (Rationale 24). Secretions may initially be blood stained but will settle within a few hours, if it continues then practitioners should contact the TNP, CSP or ENT team. Tube Blockage (Rationale 26) At least: o - hourly suction for the first 12 24 hours o regular suction until first tube change (as required)(Yaremchuck, 2003; Onakoya et al, 2003; Friedman et al 2003; Seay et al, 2002; Park et al, 1999) Accidental decannulation/tube displacement (Rationale 27) o The tube may visibly come out of the stoma or can be pulled out of the trachea and sit in the pre-tracheal tissues. o Tube can be reinserted but must not be forced. On reinsertion, air entry must be checked and confirmed. o ENT team / TNP or clinical emergency team must be contacted immediately to review tube position. o Common causes for this include: chubby infant neck, incorrectly chosen tube, loose trachy tapes or the child pulling at the tube. o Care must be taken to ensure that the tube is correctly secured and does not become displaced. If it does, early recognition is essential as this could be life-threatening. Practitioners must contact the ENT team/ TNP or clinical emergency team for immediate assistance. Infection (chest/stoma site) (Rationale 25) Surgical emphysema Air may leak around the tube into the surrounding tissue - this is particularly problematic if the child has had neck sutures inserted (Rationale 28, 29 and 30). Checking tape tension not only confirms that the tube is secured correctly but also if they appear tighter may indicate swelling. Contact the ENT team, TNP or CSP's.

The child, where possible, should not leave the ward during the first week unless medically indicated (Rationale 31).

Feeding If there have been no previous feeding concerns, the child may recommence their normal feeds after a specified time of being nil orally. This is normally 3 hours post-operation, but practitioners must confirm this with the anaesthetic chart (Rationale 32, 33, 34). For a child that has had feeding difficulties or has never orally fed, consultation with the Speech and Language Therapist (SALT) should be sought before the commencement of oral feeding. Begin with water. If the child shows signs of aspiration, for example, if there is coughing after/ during drinking, or visible drink coming out of the tracheostomy, then maintain nil orally and contact ENT team and the SALT. Humidification

DO NOT USE a Heat and Moisture Exchanger (HME) during the first week (Rationale 35). Administer humidity via sterile water and elephant tubing continuously for 1 week as far as is practicable. The child may come off for short periods, i.e. to feed, play, bathe, mobilise, etc. Small and vulnerable infants under one year must have continuous warmed humidity. Change humidity apparatus when the bottled water needs changing (usually 24hrs) or earlier if contaminated with secretions or if the mask comes into contact with the floor. When not in use, the mask should be covered).

Other care needs

Change the tapes at least daily or when soiled or wet (Rationale 36). A suitable dressing, such as Trachi-dress, should be inserted behind the flanges to protect the skin (shiny side to skin). Avoid using bulky substitutes as these may pull the tube away from the neck presipitating accidental decannulation. Never use cotton wool or cut gauze dressings (keyhole)(Rationale 37). The tracheostomy tube should be changed for the first time 7 days after surgery. The tracheostomy tube should normally be changed for the first time by the ENT surgeon or the TNP. The stay sutures will be removed at this time.

Once the stability of the tracheostomy stoma and tract has been verified the child may be allowed off the ward with a person appropriately trained in routine and emergency tracheostomy skills. Section 2 - Management Suctioning Airway suctioning is a common practice practice in the care of a child with a tracheostomy, and is undertaken to remove secretions from the childs respiratory tract. A child with a tracheostomy may find it difficult to clear their secretions effectively therefore suction is an essential aspect of their care. Suctioning is associated with many potential complications and is now only recommended when there are clear indications that the patency or ventilation of the children could be compromised (Pritchard et al, 2001; Czarnik et al, 1991; Fiorentini, 1992; Raymond, 1995; Gemma et al, 2002; Dellinger, 2001; Spence et al, 2003; Ahn & Hwang, 2003; Prasad & Hussey, 1995). Main complications requiring suction interventions:

Hypoxia Formation of distal granulation tissue/ ulceration Cardiovascular changes Pnuemothorax Atelectasis Bacterial infection Intracranial changes

The GOSH Guideline on Suctioning Techniques (Simpson, 2009) is a useful resource. Practitioners trained in the skill should perform tracheostomy suctioning to minimise complications and maximise treatment (NMC, 2002). The child and family must be informed of the reasons for suctioning, positioning, risks and outcomes as appropriate. A 'clean' technique must be used and the catheter should be discarded if the tip is contaminated with hands, cot sides, etc. Suction equipment must accompany the child at all times, regardless of the nature of the journey or the distance to be travelled.

Equipment The following equipment should be prepared:

Suction catheters of the correct size Suction unit with variable vacuum control Gloves Apron (don if there is time - a child should never wait for suctioning) Tap water (in clean container) 2ml syringe with 0.9% sodium chloride for irrigation (not for routine suctioning) Yellow waste bag for incineration

Practitioners must be aware that some pre-term, vulnerable infants and especially those who are requiring > 40% inspired oxygen, may require pre-oxygenation prior to suctioning to minimise a potential hypoxic event (Sigler & Willis, 1985; Odell et al, 1993; Pritchard et al, 2001). Distal tracheal damage and hypoxia are very real and potential complications especially in the vulnerable paediatric airway. These complications may be reduced by having:

The correct size catheter, as a guide, practitioners should double the size of the tracheostomy tube to obtain the appropriate catheter size, e.g., 4.0 ID tracheostomy tube = size 8fg catheter . A suction catheter diameter should be less than half of the size of the tracheostomy tube to reduce potential for hypoxia and allow the child to breathe throughout the procedure (Odell et al, 1993; Glass & Grap, 1995; Wood, 1998; Ahn & Hwang, 2003). 1 distal and 2 lateral ports with rounded ends allows secretions to be collected both distally and from the sides of the tube to minimise tube occlusion (Ahn & Twang, 2003). Any more than three lateral holes then the catheter wall would be too weak. A Lateral port that is smaller than the distal port so that mucosal adhesion and biopsy does not occur (Fiorentini, 1992; Luce et al, 1998). An integrated valve for vacuum control, as suction should only be applied on removal. Catheters should not be kinked prior to insertion in an effort to control the vacuum (Prasad & Hussey, 1995). It is preferable to use suction catheters with graduations, so that practitioners can measure the exact depth to be suctioned. Suctioning should not occur distal to the tube tip. Catheters should only be inserted so that the distal hole sits at the end of the tube. This allows collection of secretions but not trauma to the distal tracheal mucosa (Brodsky et al 1987; Runton, 1992). Suction pressures should be kept to a minimum; as a general guide pressures should not exceed 60-80mmHg (8-10kPa) for neonates/ small infants and up to 120mmHg < 16kPa for older children, below is an approximate but more specific guide (Dean 1997; McElery 1996; Mowery, 2002; Simpson, 2001;.Billau, 2004; Young, 1984). Excessive pressures can cause trauma, hypoxaemia and atelectasis (Czarnik et al, 1991).

Age of child Pre-term - 1 month

Approx tube size Suction Pressures 8 - 10 Kpa 3.0 60 - 75 mmHg 10 - 12 Kpa

0 - 3 yrs

3.5 - 5.0 75 - 90 mmHg 12 - 15 Kpa

3 - 10 yrs

5.0 - 6.0 90 - 112 mmHG 15 - 20 Kpa

10 - 16 yrs

6.0 - 7.0 112 - 150 mmHG

Suctioning is not a painful or distressing procedure; in fact most infants will remain asleep throughout. If the child becomes distressed during suctioning then practitioners should revise their technique. Note: Suctioning a paediatric tracheostomy is very different from suctioning an adult tube, so adult practitioners will need to adapt their practice.

Constant observation of the child during suctioning is essential; practitioners should observe for an improvement or deterioration in respiratory rate and quality, child's colour, and oxygen saturations (if being monitored). Technique

Perform a clinical hand wash (if there is time)(Rationale 9). Put on a minimum of gloves (Rationale 9). Turn suction unit on and check the vacuum pressure and set to the appropriate level, according to the child's age. The carer MUST know the length of the tracheostomy tube. If the tube is fenestrated then an un-fenestrated inner tube should be inserted to prevent the catheter going through the fenestration and causing trauma. Insert catheter gently into the tracheostomy tube, enough to ensure that the lateral and distal holes just pass through the tip of the tube, use the graduations on the catheter as a guide. Adult literature suggests longer distances (Luce et al, 1998), however the distance between the tube tip and a childs carina could only be a matter of millimetres. Handle only the proximal end of the catheter. Catheters should be discarded if the end has been touched before insertion. Apply suction by placing thumb over the valve, found either on catheter or suction tubing. Do not kink the catheter (Czarnik et al, 1991). Do not employ an intermittent suction technique, as previously though intermittent suctioning does not reduce trauma and is less effective, (Luce et al, 1993). Slowly withdraw the catheter straight out of the tube maintaining the vacuum. Do not apply suction on insertion as this may cause mucosal irritation, damage and hypoxia. There is absolutely no need to rotate the suction catheter on withdrawal, as both the distal and lateral holes on the new style of catheter allows for circumferential suctioning. Suctioning should be quick but effective and should not exceed 5-10 seconds (Sumner, 1990; Young, 1984; Toiles and Stone, 1990), most of this literature is based on the adult population. In paediatrics, maximum durations should be based on the child's underlying medical condition and current clinical condition and practitioners should adjust timings accordingly, for example 10 seconds is a long time for a neonate with underlying lung disease (Rationale 38). The catheter may be re-used if immediate suction is required, as long as secretions have not occluded the suction ports (Scoble et al, 2001)(Rationale 39). Wrap the catheter around the gloved hand, remove the glove by inserting it over the used catheter and discard in yellow waste bag according to Waste Policy. Flush suction tubing with tap water (Rationale 40) and connect a new catheter to the tubing. Wash hands (Rationale 9).

Record if the secretions are bloody, purulent, foul smelling or unusually thick in the childs health care records. Take samples as required. Note: Deep suctioning may be required in certain circumstances - for example during broncho-alveolar lavage - but this should not be routine practice (Bailey et al, 1988). Instillation of saline - Saline should not be used routinely (Blackwood, 1999; Hudak & Bond-Domb, 1996; Pritchard et al, 2001; Ackerman & Mick, 1990; Scoble et al, 2001; Neill, 2001). Tape changes (cotton) Note: Velcro ties are not routinely used at GOSH following a two severe untoward incidents in other centres. If children arrive in GOSH with Velcro ties then it must be explained to their parents that cotton tapes will be used for the duration of their stay. If Velcro ties are used then a risk assessment must be completed in accordance with Trust policy and documented in the local and Trust Risk Registers. A tracheostomy tube is held in place with cotton tapes around the neck. It is essential that the ties are secure and the tension of the ties is correct. The tapes are secured with knots tied either side of the tracheostomy tube. All staff/parents should be taught to tie the tapes in the same way (Rationale 41). Parents may prefer to adopt another method of securing the tapes once they have established a routine at home. This method may be continued when the child is re-admitted to hospital but will need individual assessment. Tracheostomy tape changes are normally performed daily. Only Personnel trained and competent in the techniques involved must change tracheostomy tapes and two people are required (NMC, 2002).

Equipment The following equipment should be prepared and be readily available:

Appropriate emergency equipment readily available (Rationale 42) Gauze swabs and saline sachets Two lengths of inch cotton tape with short plastic backing. The backing can be made from appropriately sized available tubing, e.g.24hr Urine or O2 tubing. Cut the ends of the tapes to a point (Rationale 43) Round ended scissors A rolled up towel (Rationale 44) A blanket to swaddle a baby or uncooperative toddler (Rationale 45) Suction equipment available (see suction guidelines) Non-sterile gloves and an apron Goggles/protective eye wear Childs own comforter, e.g. dummy, as appropriate An older child may not require swaddling. Some children may assist with the procedure by holding the tracheostomy tube in place and some may even prefer to sit during a change. These options must be discussed with the child and parents/carers as swaddling the child may cause increased distress.

To change the tracheostomy tapes:

Perform a clinical hand wash, put on gloves, apron and protective eye wear (parents do not need to wear the protective clothing) The warmed water should be poured onto the gauze swabs Assistant to swaddle baby, exposing shoulders and above Place baby/child in supine position, with a rolled up towel under shoulders; (as mentioned above, some older children may wish to sit) Place clean tapes behind the baby/childs neck Assistant should hold tube in position using either their thumb and index finger, or index and middle finger; see figure below (Rationale 46). Minimal pressure should be applied.

Figure 3: Positioning for a tape/tube change

Tape changer should cut the tapes between the knot and the flange and remove dirty ties. The stoma site (above, below and under each flange) and back of the neck should be cleaned and thoroughly dried with the water and gauze using a clean technique. Thread the new tape through the flange on the side furthest away from the tape changer. Tie the tapes using three knots ensuring the tape is flat to the childs skin. Thread tape through near side flange, tie once and make a bow. Check tape tension by: o Raising baby/child to a sitting position whilst assistant continues to hold tube in position. o With the baby/childs head bent forward it should be possible to slip one finger comfortably between the ties and the baby/childs neck. See Figure 4.

Figure 4: Tape tension

If the ties are too tight or loose lay the baby/child back down, undo the bow and readjust.

If the tension is correct, lie the baby/child down and change the bow into three knots by pulling the loops of the bow through to create a second knot. Tie one further knot to secure the ties. Cut off excess tape to leave inch remaining. Assistant may release tube ONLY when instructed to do so. Ensure baby/child is made comfortable. Clear away equipment according to the Waste Policy.

Wash hands. Record the tape change in the baby/childs health care records. Check all equipment is replaced and restocked as necessary.

Tube changes (planned) Tracheostomy tubes can be changed weekly or monthly (refer to tube information sheets above). Ask the TNP or childs doctor if unsure. Only personnel trained and competent in the techniques involved must perform a tracheostomy tube change and two people are required (NMC, 2002). An older child should not require swaddling. Some children may assist with the procedure, such as cleaning the stoma site, holding the tracheostomy tube, etc. Some children may need to be swaddled to maintain their safety during the change; assess each child individually. Equipment The following equipment should be prepared:

Emergency equipment, oxygen and suction A tracheostomy tube of the same size A tracheostomy tube that is a size smaller A water based lubricant such as Aqualube or KY jelly Gauze swabs Saline sachets Two lengths of inch cotton tape Round ended scissors A rolled up towel Gloves and an apron Goggles/protective eye wear Two syringes may be required if the child has a cuffed tube (Rationale 47)

To change a tracheostomy tube:

Perform a clinical hand wash Put on gloves, apron and protective eye wear Assistant to swaddle baby, exposing shoulders and above (baby in supine position) if appropriate Lubricate new tube with a dot of water-based lubricant on the outside bend of the tube Insert obturator into the tube Position the rolled up towel under the childs shoulders, as per tape changes. Place clean tapes behind the baby/childs neck Assistant should hold the tube in position using either their thumb and index finger, or index and middle finger. Tube changer should cut the ties between knot and flange Remove the dirty ties Remove the tube from the stoma with a curved action Quickly insert new tube with a curved action Remove obturator The assistant should take over and hold the tube in position The stomal area and back of the neck should be cleaned and dried with the water and gauze using a clean technique The ties are then tied using the method previously described

Carer Competency Guide Staff and carers should be trained and assessed in the following competencies:

1. 2. 3. 4.

Staff competency - home preparation (PDF, 434 KB) Staff competency - ventilated child Carer competency - home preparation (PDF, 434 KB) Carer competency - ventilated child (PDF, 468 KB)

Resuscitation The basics of cardio-pulmonary resuscitation (CPR) and Basic Life Support (BLS) are universal to all protocols for emergency care:

Airway management Rescue breathing Circulatory support

The airway element of BLS will require modification in children with tracheostomies, it is therefore essential that practitioners have received training in both routine and tracheostomy BLS. BLS is similar in the sequence of skills to be performed for those with a tracheostomy: Safety, Stimulate, Shout, Suction* , Airway, Breathing, Circulation TRACHEOSTOMY RESUSCITATION ALGORITHM (PDF, 153 KB) When applied to a patient with a tracheostomy, CPR may be more difficult to teach and to learn because additional processes are required to determine and correct the cause of the collapse. Practitioners caring for a child with a tracheostomy must familiarise themselves with the tracheostomy resuscitation algorithm. Patients with a tracheostomy must always have their specific emergency equipment correctly assembled and easily accessible (as already discussed). Starting BLS quickly is extremely important (Rationale 48):

Ensure safety of yourself and the child Stimulate the child and call their name, taking care to support their head and body (Rationale 49) Call for assistance from colleagues (Rationale 50) If you are by yourself DO NOT leave the patient at this stage. Open and check the childs airway by placing supine on a flat firm surface (Rationale 51) It may be helpful to put a folded towel under the shoulders, only if this is immediately available. Do not waste time by collecting this equipment. Gently tilt the tip of the chin upward, taking care not to press on soft tissue underneath. Inspect tube for obvious problems, ie signs of blockage: crusts, kinks or dislodgement. IF IN ANY DOUBT ABOUT CHILDS CONDITION SUMMON THE CLINICAL EMERGENCY TEAM IMMEDIATELY (2222) Suction the tracheostomy tube. In most circumstances suctioning will clear the obstruction. Change the tracheostomy tube immediately if the tube appears blocked or any resistance is felt and the child is in distress. Exercise caution if the stoma is less than one week old; if time, contact the TNP/ ENT team/ Emergency team first. However, if the childs condition is unstable, summon the Clinical Emergency Team (2222) immediately. The same size tube should be inserted. If unable to insert the same size tube try to insert the one that is a size smaller. If the stoma closes and the smaller tube cannot be replaced, remove the Obturator from the smaller tube and pass a suction catheter through the tube. Then attempt to insert the end of the catheter through the stomal opening. Then attempt to guide the tracheostomy tube along the catheter and through the stoma (Seldinger technique). If this is also unsuccessful, ventilation can be attempted via the catheter threaded in to the stoma (as described previously) or by conventional rescue breaths (e.g. mouth-to-mouth or bag and mask over the mouth & nose). These options may not be appropriate for some children due to their underlying airway problem; practitioners must therefore always be aware of the underlying disease/ anatomy.

The Seldinger technique should be practised as a first line attempt at reinserting a tracheostomy tube. Tracheal dilators should only be used by practitioners familiar and practised in their use. Tracheal dilators are currently kept in the resuscitation trolley for use on request from experienced practitioners (Lyons and Cooke et al, 2007).

Assess breathing:

Supporting the new tube, place the side of your face over the tracheostomy tube to listen and feel for any breathing. At the same time look at the childs chest to observe any breathing movement. Take up to a maximum of ten seconds to do this. If the child is breathing adequately, give oxygen and keep their airway open by regular suction and await for the clinical emergency team/ENT/TNP and/or CSPs to arrive (practitioners should decide on whom best to call). If the child is not breathing (or only making agonal gasps), commence artificial respiration with a bag-valve system directly connected to the tracheostomy tube and administer 5 breaths. This is best achieved with a Smiths Medical (Portex) 15mm swivel connector attached to the ambu bag. Ensure that the breaths are effective by observing chest movement. Oxygen should be set at a minimum of 10 litres/minute for a paediatric system and 15 litres/minute for the adult system. Parents will be taught mouth to trachy resuscitation for going home, in addition to the other equipment required they must be given a Smiths Medical (Portex) catheter mount 15mm female, and two emergency Velcro tapes.

Further BLS instructions (PDF, 18 KB) Although community teams will supply the equipment for the child's discharge home, after emergency care from a suitably qualified BLS instructor with trachesostomy experience, they should give the parents two pairs of velcro tapes, two disconnection wedges, and two tracheostomy extensions from Smiths Medical (Portex) +/- male to female adapters depending on tube chosen. Practitioners should seek advice from the TNP; these items should be added to their emergency boxes when they get home. Parents require both theoretical and practical teaching / practice of both emergency algorithms, namely action to take on a blocked tube and action to take if the tracheostomy tube cannot be replaced (Seldinger technique). Practitioners teaching parents/ carers must have appropriate knowledge and experience in both areas. At GOSH, a modified 'Resus baby' and 'Little Junior' is used for BLS and a Smiths Medical (Portex) percutaneous tracheostomy manikin for parents to practice the Seldinger technique. Discharge TRACHEOSTOMY DISHARGE ALGORITHM The formation of a tracheostomy must be confirmed by telephone with the childs Health Visitor (HV), GP, Paediatric Community Nurse (PCN), School Nurse & local Hospital on the day the tracheostomy is inserted. An equipment list and introductory letter must be sent so that equipment can be ordered immediately - New Equipment Form (PDF, 227 KB)(Rationale 38). The community team must be contacted after one week to confirm tube style/ size, which may have had to be changed during the first week. The progress of supply orders should also be checked. Discussion of respite and carer support should be broached with community team. Most children will be discharged back via their local hospital, which will allow local services and support to be activated. Negotiations to do this should begin as soon as the tracheostomy is formed. However some children, such as those who have had a planned tracheostomy or who have been in hospital for a long time may be discharged home straight from hospital. Some equipment may have to be provided to facilitate this; this should be discussed individually with the communities involved. All appropriate documentation and medicines should be ordered/ completed. Ensure that the portable suction unit has been collected from the community team before the day of discharge and bought to the hospital for the transfer home and parents are aware of how it works. The childs parents, or two main carers, must be taught and be deemed as competent in the following: (sometimes it is not possible to complete all the training at GOSH and local teams may have to complete this)

Tracheostomy tube changes (minimum of two) Tracheostomy tape changes Stoma care Suctioning Resuscitation skills/ emergency care Carer must stay and do an overnight stay with their child and carry out all care overnight Feel confident in themselves taking the child out of the hospital

They must be given the appropriate GOSH tracheostomy and resuscitation booklets to support their training. All training received must be recorded on the childs discharge planner and kept in their health record for future reference. An eight-week ENT outpatient appointment must be arranged prior to discharge (unless indicated otherwise by the medical team).

Confirm discharge of patient with HV and/or PCN and GP as appropriate. Although community teams will supply the equipment for the child's discharge home, after emergency care training from a suitably qualified BLS instructor with trachesostomy experience, they should give the parents two pairs of velcro tapes, two disconnection wedges and two tracheostomy extensions from Smith Medical (Portex)+/- male to female adapters, depending on tube chosen (Rationale 52). Practitioners should seek further advice from the TNP as required. Parents require both theoretical and practical teaching/ practice of both both emergency algorithms, namely: action to take on a blocked tube and action to take if the tracheostomy tube cannot be replaced (Seldinger technique), therefore practtioners teaching parents/ carers must have appropriate knowledge and experience in both areas. At GOSH we use a modified 'Resus baby' and 'Little Junior' for the BLS aspect and the percutaneous tracheostomy manikin from Smiths Medical for parents to practice the Seldinger technique. General Information IMPORTANT: GENERAL INFORMATION ON TRACHEOSTOMY FORMATION, TYPES OF TRACHEOSTOMY TUBE WITH TUBE INFORMATION SHEETS, HUMIDIFICATION METHODS AND HME'S PLEASE REFER TO THIS SEPERATE PDF DOCUMENT.(PDF, 44 KB) Rationale Rationale 1: Child's airway is at risk and they may need immediate attention Rationale 2: To enable effective emergency attention if required Rationale 3: To enable continual assessment of oxygen requirements Rationale 4: To safely suction tracheostomy tube Rationale 5: To minimise the risk of cross-contamination Rationale 6: To clean stoma/secretions Rationale 7: To flush through suction tubing after use Rationale 8: To draw up saline for instillation Rationale 9: To meet hospital Waste Disposal guidelines Rationale 10: To replace a blocked tube Rationale 11: If the stoma opening shrinks and the normal size tube cannot be inserted Rationale 12: Smoother insertion of the tracheostomy tube Rationale 13: To prevent trauma to the neck, when cutting the ties Rationale 14: To secure the tube Rationale 15: To 'railroad' the tube into the stoma (Seldinger technique) Rationale 16: To be used only on request by practitioners able and competent to use Rationale 17: To maximise safety. Replacing tubes in the first week may be problematic where the stoma has not yet been established. Rationale 18: To ensure effective discharge planning Rationale 19: It is essential that the tube stay in situ long enough for the tract to form avoiding a difficult and possibly dangerous first tube change Rationale 20: To form a more permanent and safer stoma, if the tube requires changing in the first week.

Rationale 21: To assist with the opening of the stoma during the first week, by raising the trachea to the skins surface and pulling the stoma apart so that a tube can be inserted Rationale 22: Stay sutures will be removed AFTER the first tube change Rationale 23: To ensure safe recovery from effects of anaesthesia Rationale 24: Expect small amounts of bloodstained secretions in the first few hours. Any concerns call the ENT or emergency teams as required. Rationale 25: The stoma site must be cleaned daily or when soiled. Using a clean technique and sterile gauze/saline. The wound must be inspected for signs of inflammation/ and or infection. Observe colour and nature of secretions Rationale 26: Although children should only be suctioned when required, it is imperative that this trachy tube is kept clear at all times. Children must be nursed in continuous humidity for the first week (may come off for short periods only) Rationale 27: Check correct tension of the tapes, ensuring that only one finger between the neck and tapes. Close observation of respiratory rate, effort, chest movements and air entry on return to the ward Rationale 28: Contact ENT team as stomal sutures may need to be removed Rationale 29: Observe for neck/face swelling or if the child complains of discomfort, pain or difficulty with breathing Rationale 30: Regularly check tape tension for increased tightness Rationale 31: Their airway is at risk and they must remain in an environment that can cope with any complications Rationale 32: The vocal cords are sprayed during procedure, making them less responsive/effective in protecting the airway from aspiration Rationale 33: The effect of the paralysing agent continues for up to 3 hours Rationale 34: Other physical complications accompanied with post surgical oedema, restricted laryngeal elevation preventing complete and safe closure of the lower respiratory tract may cause aspiration and/or regurgitation of food Rationale 35: The HME does not provide enough humidity in the initial phase, children require extra humidity to prevent tube occlusion in the first week Rationale 36: To monitor stoma/ healing Rationale 37: Flecks of displaced cotton may enter the respiratory tract Rationale 38: Although where possible secretions should be cleared on the first attempt. Adult literature suggests that episodes should be limited to three, to limit potential side effects and maximise the recovery period, (Luce et al, 1993) Rationale 39: If the distal end of the catheter has not been contaminated prior to the suctioning episode then there is no evidence to suggest that by using the same catheter up to three times at the same suctioning episode, increases the risk of infection (Scoble et al, 2001). In fact with effective re-training on technique, some institutions have repeatedly used the same catheter on the same patient for a 24-hour period and have reported no increase in infection Rationale 40: To clear the tubing from secretions Rationale 41: To ensure continuity of training Rationale 42: In case of accidental decannulation Rationale 43: To allow insertion into the tube flanges Rationale 44: To place under the childs shoulders, which will hyper extend the neck, making observation and cleaning of the stoma easier

Rationale 45: If a child is moving during the procedure there is potential of accidental decannulation. Involve the play specialist where possible. Most children will settle once they get used to the procedure and especially when parents begin to carry it out Rationale 46: To support the tracheostomy tube and preventing an accidental decannulation Rationale 47: To facilitate deflation and inflation of the cuff Rationale 48: To prevent/minimise hypoxia and subsequent tissue death. Early intervention may prevent progression into full cardio-respiratory arrest Rationale 49: This may be sufficient to rouse the child Rationale 50: Always summon more help, to assist in tube changes, bring other equipment etc Rationale 51: To tilt head and expose airway Rationale 52: Parents/carers can add these items to the emergency box when they get home. References/Bibliography Reference 1: Ackerman MH, Gugerty BP (1990) The effects of normal saline bolus instillation on artificial airways. The Journal of the Society of Otolaryngology Nursing Spring : 14-17. Reference 2: Ackerman MH, Mick DJ (1998) Instillation of normal saline before suctioning in patients with pulmonary infections: a prospective randomized controlled trial. Am J Crit Care 7 (4): 261-6. Reference 3: Ahn Y, Hwang T (2003) The effects of shallow versus deep endotracheal suctioning on the cytological components of respiratory aspirates in high-risk infants. Respiration 70 (2): 172-8. Reference 4: Akgul S, Akycolcu N (2002) Effects of normal saline on endotracheal suctioning. J Clin Nurs 11: 826-30. Reference 5: Albarzangi L, Murphy A, Browning ST (2003) A novel method of managing a critical airway. Laryngoscope 113 (9): 1564-5. Reference 6: Avena MJ, de Carvalho WB, Beppu OS (2003) [Evaluation of oxygenation, ventilation and respiratory mechanics before and after endotracheal suction in mechanically ventilated children]. Rev Assoc Med Bras 49 (2): 156-61. Reference 7: Billau C (2004) Chapter 9 Suctioning in Russell C and Matta B Tracheostomy a multi professional handbook. Cambridge, Cambridge University Press Reference 8: Blackwood B (1999) Normal saline instillation with endotracheal suctioning: primum non nocere (first do no harm). J Adv Nurs 29 (4): 928-34. Reference 9: Bloggs RL (1993) Airway management in AACN Procedural Manual for Critical Care (3rd edition). Philadelphia, WB Saunders Co

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