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Caring for Children with Tracheostomies

young boy with a trach blowing a pinwheel

Nurses and doctors in the Center provide teaching and instruction for families of patients with tracheostomies. Parents and guardians must demonstrate appropriate and effective tracheostomy care for the child, including suctioning and changing, prior to discharge. It is imperative for them to be involved with tracheostomy care as soon as possible and to demonstrate comfort and confidence before leaving the hospital. A PDF of all instructions is located here. Mass. Eye and Ear and MGHfC have also produced a book, "A Parent's Guide to Caring for a Child with a Tracheostomy at Home," which you may find helpful. Please note: it's a large file and may take a moment to open. If you have any questions on the book, or this section of our website, please contact your physician.

Supplies
Nurses in the Center will arrange for a medical supply company to provide the required equipment and supplies for at-home care for children with new tracheostomies. A representative from the medical supply company will then come to the child's home to provide additional teaching for the home equipment/supplies.  Many children with new tracheostomies will have a representative from VNA (Visiting Nurse Association) set up to provide nursing care at home.

The most common tracheostomy tubes are Shileys and Bivonas.  You will need to carry spare tubes and a suction machine and catheters with you at all times, including the same size tracheostomy tube that is currently in place and one size smaller.  

Additional supplies include tracheostomy ties, saline bullets, sterile water-soluble lubricant, a humidification machine, and an oxygen tank. You will also need sterile water, hydrogen peroxide, gauze, and cotton swabs for cleaning around tracheostomy site. 

Spare tracheostomy tubes and a suction machine and catheters must be with the child at all times.

Humidification 

Humidification is used to prevent airway obstruction that can result from an accumulation of mucus in the tracheostomy tube. A tracheostomy collar is used to provide humidification, typically while the child is sleeping. For some children, an "HME" (heat and moisture exchanger) or "swedish nose" is put on end of the tracheostomy to provide humidification while awake.  Humidification may be either cool or warm.  Cool is used more often; however, if you child is not tolerating or responding well to the current humidification provided, please speak with your VNA, physician, and/or medical supply company about potentially changing the temperature used.

Suction

If your child’s breathing appears rapid, noisy, rattling, or congested, suctioning is needed to make them more comfortable. Suctioning is used to remove any tracheal secretions and to check for patency of the tracheostomy tube.

How often suctioning is needed will vary and depend on your child's ability to cough and clear own secretions. Tracheostomy tubes will most likely need to be suctioned when the child wakes up, prior to eating, and when changing the tracheostomy tube.  When the child has a cold, he/she will produce more secretions and thus may require more frequent suctioning. Try to only suction when necessary, as suctioning too often may cause an increase in production of secretions and damage to the trachea. The tracheostomy should be suctioned when a gurgling/bubbling/congested sound is heard, visible mucus is present in the tracheostomy, increased coughing is noted, or if the child becomes restless and appears to have difficulty breathing or clearing his/her own secretions.  

Call your physician if secretions from the tracheostomy become bloody, green, yellow, foul smelling, or increase in thickness. Clear or white tracheal secretions are normal.  

Steps for suctioning a tracheostomy tube:

  1. Wash your hands first and put on gloves
  2. Connect a suction catheter to tubing from the suction machine
  3. Turn the machine on
  4. Insert the catheter into the tracheostomy tube to designated length
  5. Cover the vent on catheter with your thumb.  With your other thumb and finger, slowly remove the catheter in a rolling motion
  6. Allow time for the child to recover after suctioning.  If the child continues with signs of respiratory distress despite attempts to suction, the tracheostomy may need to be replaced

Cleaning

The tracheostomy site should be cleaned twice a day. You will need the following supplies: hydrogen peroxide, sterile water (mixed together makes half strength hydrogen peroxide), cotton swabs, and gauze.
 
Steps for cleaning a tracheostomy:

  1. Wash hands first and put on gloves. Have supplies and suction ready.
  2. Suction the tracheostomy.
  3. Lay the child flat with towel roll under the shoulders.
  4. Dip cotton swab in half strength hydrogen peroxide.
  5. In a rolling motion, clean from the stoma site outward.
  6. Repeat steps but using only sterile water now.
  7. Pat dry area with gauze.
  8. Check skin for redness, green or yellow drainage, foul odor or rash.  Call VNA and /or your physician if this occurs.

Changing Tubes

The tracheostomy tube should be changed approximately every 1-2 weeks, but this may vary depending on the child. If a child is experiencing respiratory distress and suctioning is not effective, it is time to change the tube.

young girl with trachIt will also need to be replaced if tracheostomy tube is accidentally removed. When this occurs, attempt to reinsert the currently used tracheostomy tube. If you are unable to reinsert the tracheostomy tube, try to insert a smaller sized tube. If you are ever unable to insert the tracheostomy tube or if your child appears to be experiencing respiratory distress, call 911 immediately.

When preparing to change a tracheostomy, you will need the spare tracheostomy (same size as child currently has in and one size smaller) with new tracheostomy ties already in place and cut to appropriate length, the suctioning machine/catheter, lubricant, and humidification/oxygen supply.  The child should be lying down with a towel or blanket roll under the shoulders to promote hyperextension of the neck.  The child may need to be swaddled in a blanket to maintain proper positioning during the tracheostomy change. If possible, two adults should be present when changing the tracheostomy.
 
Steps for changing a tracheostomy tube:

  1. Wash hands first and wear gloves.  Have the suction and humidification/oxygen machines at the ready.
  2. Open the tracheostomy package and inspect for cracks/damage, insert obturator into the new tube and make sure that it can slide easily in and out of tube. The obturator will guide the tube during insertion. Apply a small amount of sterile water-soluble lubricant to tip of the tracheostomy and place it back in original package.
  3. Suction the tracheostomy.
  4. With the child lying down, with a blanket roll under the shoulders and with one hand securing the tracheostomy, remove the tracheostomy ties and then gently remove the tracheostomy in an up/outward motion.
  5. With the obturator in place, insert the new tracheostomy tube in a down/inward motion. Secure the tracheostomy with one hand while immediately removing the obturator with your other hand.
  6. Secure the tracheostomy ties, sit the child up and allow time to recover.

Changing a tracheostomy will often cause coughing, require suctioning and supplemental humidification or possible oxygen. One finger should fit between the child's neck and the tracheostomy ties. Tracheostomy ties that are too tight may cause skin breakdown; but if too loose, the tracheostomy is at risk for becoming dislodged.  If possible, do not suction or change the tracheostomy during or immediately after eating, as this may cause excessive coughing or vomiting.  If you are unable to insert the tracheostomy, try using the smaller size tracheostomy.  If unable to insert smaller size, call 911 immediately.

Changing Ties

Tracheostomy ties should be changed daily and during cleaning to help prevent skin breakdown.  The spare tracheostomy ties should be pre-measured and cut to an appropriate length.
 
Steps for changing tracheostomy ties:

  1. Wash hands first and put on gloves. Have spare tracheostomy ties at the ready.
  2. With the child lying down and a towel roll under the shoulders, secure the tracheostomy with one hand while removing Velcro.
  3. Clean and inspect the skin while always securing the tracheostomy.
  4. Insert the narrow, pointed velcro end into the tracheostomy tube wing and fold it back onto the soft cloth of neck band.
  5. Repeat on the other side.
  6. Secure the two ends of the tie at back of neck.  If too much material is present, the extra may be cut off.
  7. Check to be sure that one finger can fit snuggly under the tie.
     

Eating

Children with tracheotomies are usually able to eat normally. They are encouraged to take small bites and to drink plenty of fluid.

Suctioning the tubes prior to eating is encouraged, because suctioning during or immediately after meals may result in uncomfortable complications such as excessive coughing and/or vomiting.

Bathing

A child with a tracheostomy should not submerge under water or be unsupervised while bathing.  Use an HME on the tracheostomy during the bath time, and do not allow water to enter the tracheostomy.  If water does enter the tracheostomy, you must suction it out.