B.

Pengertian
Trakeostomi adalah prosedur dimana dibuat lubang kedalam trakea. (Smeltzer & Bare, 2002)
Trakeostomi adalah insisi operasi dimana memasukkan selang ke dalam trakea agar klien
dapat bernafas dengan lebih mudah dan mengeluarkan sekretnya. ( Putriardhita, C, 2008)
Ketika selang indwelling dimasukkan kedalam trakea, maka istilah trakeostomi digunakan.
Trakeostomi dapat menetap atau permanent. Trakeostomi dilakukan untuk memintas suatu
obstuksi jalan nafas atas, untuk membuang sekresi trakeobronkial, untuk memungkinkan
penggunaan ventilasi mekanis jangka panjang, untuk mencegah aspirasi sekresi oral atau
lambung pada pasien tidak sadar atau paralise (dengan menutup trakea dari esophagus), dan
untuk mengganti selang endotrakea, ada banyak proses penyakit dan kondisi kedaruratan
yang membuat trakeostomi diperlukan.

C. Klasifikasi Trakeostomi
Menurut Sakura21 (2009), trakeostomi dibagi atas 2 (dua) macam, yaitu berdasarkan letak
trakeostomi dan waktu dilakukan tindakan. Berdasarkan letak trakeostomi terdiri atas letak
rendah dan letak tinggi dan batas letak ini adalah cincin trakea ketiga. Sedangkan berdasarkan
waktu dilakukan tindakan maka trakeostomi dibagi dalam 1). Trakeostomi darurat (dalam
waktu yang segera dan persiapan sarana sangat kurang) 2). Trakeostomi berencana (persiapan
sarana cukup) dan dapat dilakukan secara baik.

D. Fungsi
Menurut Masdanang (2008), Fungsi dilakukannya tindakan trakeostomi antara lain adalah :
1. Mengurangi jumlah ruang hampa dalam traktus trakheobronkial 70 sampai 100 ml.
Penurunan ruang hampa dapat berubah ubah dari 10% sampai 50% tergantung pada ruang
hampa fisiologik tiap individu
2. Mengurangi tahanan aliran udara pernafasan yang selanjutnya mengurangi kekuatan yang
diperlukan untuk memindahkan udara sehingga mengakibatkan peningkatan regangan total
dan ventilasi alveolus yang lebih efektif. Asal lubang trakheostomi cukup besar (paling
sedikit pipa 7)
3. Proteksi terhadap aspirasi
4. Memungkinkan pasien menelan tanpa reflek apnea, yang sangat penting pada pasien
dengan gangguan pernafasan
5. Memungkinkan jalan masuk langsung ke trachea untuk pembersihan
6. Memungkinkan pemberian obat-obatan dan humidifikasi ke traktus
7. Mengurangi kekuatan batuk sehingga mencegah pemindahan secret ke perifer oleh tekanan
negatif intra toraks yang tinggi pada fase inspirasi batuk yang normal

E. Indikasi
Menurut Ilham (2010), Indikasi trakeostomi termasuk sumbatan mekanis pada jalan nafas dan
gangguan non obstruksi yang mengubah ventilasi. Gejala-gejala yang mengindikasikan
adanya obstruksi pada jalan nafas :
1. timbulnya dispneu dan stridor eskpirasi yang khas pada obstruksi setinggi atau di bawah
rima glotis terjadinya retraksi pada insisura suprasternal dan supraklavikular.
2. Pasien tampak pucat atau sianotik
3. Disfagia
4. Pada anak-anak akan tampak gelisah

Gangguan yang mengindikasikan perlunya trakeostomi :

1. Terjadinya obstruksi jalan nafas atas
2. Sekret pada bronkus yang tidak dapat dikeluarkan secara fisiologis, misalnya pada pasien
dalam keadaan koma.
3. Untuk memasang alat bantu pernafasan (respirator).
4. Apabila terdapat benda asing di subglotis.
5. Penyakit inflamasi yang menyumbat jalan nafas ( misal angina ludwig), epiglotitis dan lesi
vaskuler, neoplastik atau traumatik yang timbul melalui mekanisme serupa
6. Mengurangi ruang rugi (dead air space) di saluran nafas atas seperti rongga mulut, sekitar
lidah dan faring.

F. Jenis Tindakan Trakeostomi

Menurut Ilham (2010), tindakan trakeostomi dapat dibagi atas 3 (tiga) jenis, yaitu :

1. Surgical trakeostomy
Tipe ini dapat sementara dan permanen dan dilakukan di dalam ruang operasi. Insisi dibuat
diantara cincin trakea kedua dan ketiga sepanjang 4-5 cm.
2. Percutaneous Tracheostomy
Tipe ini hanya bersifat sementara dan dilakukan pada unit gawat darurat. Dilakukan
pembuatan lubang diantara cincin trakea satu dan dua atau dua dan tiga. Karena lubang yang
dibuat lebih kecil, maka penyembuhan lukanya akan lebih cepat dan tidak meninggalkan scar.
Selain itu, kejadian timbulnya infeksi juga jauh lebih kecil.
3. Mini tracheostomy
Dilakukan insisi pada pertengahan membran krikotiroid dan trakeostomi mini ini dimasukan
menggunakan kawat dan dilator.

G. Komplikasi
Menurut Ilham (2010), komplikasi yang terjadi pada tindakan trakeostomi dibagi atas :
1. Komplikasi dini
a. Perdarahan
b. pneumothoraks terutama pada anak-anak
c. Aspirasi
d. Henti jantung sebagai rangsangan hipoksia terhadap respirasi
e. paralisis saraf rekuren
2. Komplikasi lanjut
a. Perdarahan lanjutan pada arteri inominata
b. Infeksi
c. fistula trakeoesofagus
d. stenosis trakea

H. Pemasangan Trakeostomi
1. Alat - Alat
Menurut Roni7iftitah (2010), Alat yang perlu dipersiapkan untuk melakukan trakeostomi
adalah :
a. Spuit yang berisi obat analgesia
b. Pisau bedah
c. Pinset anatomi
d. Gunting panjang tumpul
e. Sepasang pengait tumpul
f. Benang bedah
g. Klem arteri, gunting kecil yang tajam
h. Serta kanul trakea dengan ukuran yag sesuai

2. Ukuran Trakeostomi
Menurut Putriardhita, C (2008), Ukuran trakeostomi standar adalah 0 12 atau 24 44
French. Trakeostomi umumnya dibuat dari plastik, namun dari perak juga ada. Tabung dari
plastik mempunyai lumen lebih besar dan lebih lunak dari yang besi. Tabung dari plastik
melengkung lebih baik kedalam trakea sehingga iritasi lebih sedikitdan lebih nyaman bagi
klien.
3. Jenis Pipa Trakeostomi
Menurut Roni7iftitah (2010), Alat yang perlu dipersiapkan untuk melakukan trakeostomi
adalah :
a. Cuffed Tubes
Selang dilengkapi dengan balon yang dapat diatur sehingga memperkecil risiko timbulnya
aspirasi.
b. Uncufed Tubes
Digunakan pada tindakan trakeostomi dengan penderita yang tidak mempunyai risiko aspirasi
c. Trakeostomi dua cabang (dengan kanul dalam)
Dua bagian trakeostomi ini dapat dikembangkan dan dikempiskan sehingga kanul dalam
dapat dibersihkan dan diganti untuk mencegah terjadi obstruksi.
d. Silver Negus Tubes
Terdiri dari dua bagian pipa yang digunakan untuk trakeostomi jangka panjang. Tidak perlu
terlalu sering dibersihkan dan penderita dapat merawat sendiri.
e. Fenestrated Tubes
Trakeostomi ini mempunyai bagian yang terbuka di sebelah posteriornya, sehingga penderita
masih tetap merasa bernafas melewati hidungnya. Selain itu, bagian terbuka ini
memungkinkan penderita untuk dapat berbicara.

4. Tehnik Melakukan Trakeostomi

Menurut Sakura21 (2009), Penderita tidur terlentang, bahu diganjal dengan bantalan kecil
sehingga memudahkan kepala diekstensikan pada persendian atlanto oksipital. Dengan posisi
seperti ini leher akan lurus dan trakea akan terletak digaris median dekat permukaan leher.
Kulit dibersihkan dengan antiseptik dan ditutup dengan kain steril. Obat anastesikum
(Novokain) disuntikkan diantara krikoid dengan fossa supra sternal secara infiltrasi. Sayatan
kulit dapat vertikal di garis tengah leher mulai di bawah krikoid sampai fossa supra sternal
atau jika membuat sayatan horizontal dilakukan pada pertengahan jarak antara kartilago
krikoid dengan fossa supra sternal atau kira-kira 2 jari dibawah krikoid orang dewasa.
Sayatan dibuat kira-kira 5 cm.
Dengan gunting panjang yang tumpul, kulit serta jaringan dibawahnya dipisahkan lapis demi
lapis dan ditarik ke lateral dengan pengait tumpul, sampai tampak trakea yang berupa pipa
dengan susunan cincin-cincin tulang rawan yang berwarna putih. Bila lapisan kulit dan
jaringan dibawahnya dibuka tepat ditengah maka trakea ini mudah ditemukan. Pembuluh
darah yang tampak ditarik ke lateral. Isthmus tiroid yang ditemukan ditarik keatas supaya
cincin trakea jelas terlihat. Jika tidak mungkin, isthmus tiroid di klem pada dua tempat dan di
potong di tengahnya sebelum klem dilepaskan isthmus tiroid diikat kedua tepinya dan
disisihkan ke lateral. Perdarahan dihentikan dan jika perlu diikat. Lakukan aspirasi dengan
cara menusukkan jarum pada membran antara cincin trakea dan akan terasa ringan waktu
ditarik. Buat stoma dengan memotong cincing trakea ke-3 dengan gunting yang tajam.
Kemudian dipasang kanul trakea dengan ukuran yang sesuai. Kanul difiksasi dengan tali pada
leher penderita dan luka operasi ditutup dengan kassa.
Hal yang perlu diperhatikan sebelum membuat lubang pada trakea perlu dibuktikan dulu yang
akan dipotong itu benar-benar trakea dengan cara mengaspirasi dengan semprit yang berisi
novokain. Bila yang ditusuk itu adalah trakea maka pada waktu dilakukan aspirasi terasa
ringan dan udara yang terisap akan menimbulkan gelembung udara. Untuk mengurangi reflek
batuk dapat disuntikkan novokain sebnyak 1 cc ke dalam trakea. Untuk menghindari
terjadinya komplikasi perlu juga diperhatikan insisi kulit jangan terlalu pendek agar tidak
sukar mencari trakea dan mencegah terjadinya emfisema kulit.
Ukuran kanul harus sesuai dengan diameter lumen trakea. Bila kanul terlalu kecil, akan
menyebabkan kanul bergerak-gerak sehingga terjadi rangsangan pada mukosa trakea dan
mudah terlepas keluar. Bila kanul terlalu besar, sulit untuk memasukkannya kedalam lumen
dan ujung kanul akan menekan mukosa trakea dan menyebabkan nekrosis dinding trakea.
Panjang kanul harus sesuai pula. Bila terlalu pendek akan mudah keluar dari lumen trakea
dan masuk kedalam jaringan subkutis sehingga penderita asfiksia. Bila kanul terlalu panjang
maka mukosa trakea akan teriritasi dan mudah timbul jaringan granulasi.

5. Perawatan Pasca Trakeostomi

Menurut Ilham (2010), Secera setelah trakeostomi dilakukan :
a. Rontgen dada untuk menilai posisi tube dan melihat timbul atau tidaknya komplikasi
b. Antibiotik untuk menurunkan risiko timbulnya infeksi
c. Mengajari pihak keluarga dan penderita sendiri cara merawat pipa trakeostomi

Menurut Roni7iftitah (2010), langkah-langkah tindakan perawatan trakeostomi adalah :

a. Kaji pernapasan klien, termasuk kebutuhan klien akan pengisapan dan pembersihan
trakeostomi
b. Letakkan alat-alat di atas meja
c. Tinggikan tempat tidur sampai ketinggian yang nyaman untuk bekerja
d. Bantu klien untuk mengambil posisi semi fowler atau terlentang
e. Jika diperlukan, hubungkan selang pengisap ke aparatus penghisap. Letakkan ujung selang
di tempat yang mudah di jangkau dan hidupkan penghisap
f. Letakkan handuk melintang di dada klien
g. Buka set atau peralatan penghisap. Buka juga bungkus alat-alat yang diperlukan unruk
pembersihan trakheostomi
i. Letakkan perlak paling bawah dan atur peralatan penghisap
ii. Atur mangkuk steril kedua dekat. Jangan sentuh bagian dalam mangkuk
iii. Tuangkan 50 ml hidrogen peroksida ke mangkuk kedua. Jangan sampai menetes ke
perlak.
iv. Buka sikat steril dan letakkan di sebelah mangkuk yang berisi hidrogen peroksida
v. Buka ketiga bungkus kasa 10 x 10 cm. pertahankan sterilitas kasa. Tuangkan hidrogen
peroksida di atas kasa pertama dan normal salin di kasa kedua. Biarkan kasa ketiga tetap
kering.
vi. Buka swab berujung kapas. Tuangkan hidrogen peroksida pada satu paket swab dan
normal salin pada paket swab lainnya.
vii. Jika anda menggunakan kanul dalam sekali pakai, buka bungkusnya sehingga kanul dapat
dengan mudah diambil. Pertahankan sterilsasi kanula dalam.
viii. Tetapkan panjang tali pengikat trakheostomi yang diperlukan dengan menggandakan
lingkar leher dan menambah 5 cm dan gunting tali pada panjang tersebut.
h. Lakukan prosedur pengisapan. Pastikan bahwa anda telah menggunakan mantel pelindung
dan sarung tangan steril
i. Lepaskan bib trakheostomi dari keliling pipa trakheostomi dan buang bib tersebut.
j. Lepaskan sarung tangan yang sudah basah dan kenakan sarung tangan steril yang baru.
Tangan dominan anda harus tetap steril sepanjang prosedur dilakukan. Bersihkan kanul
dalam.
k. Mangganti kanul dalam sekali pakai ( dispossible inner-canula).
i. Buka dan dengan hati-hati lepaskan kanul dengan menggunakan tangan tak dominan anda.
ii. Lakukan pengiapan dengan teknik steril, jika diperlukan.
iii. Keluarkan kanul dalam baru steril dalam bungkusnya dan siramkan sejumlah normal salin
steril pada kanul baru tersebut. Biarkan normal salin menetes dari kanul dalam.
iv. Bantalan kasa pertama di gunakan untuk membersihkan kulit di sektar trakheostomi. Kasa
kedua digunakan untuk mengangkat debris yang dilunakkan oleh hidrogen peroksida, dan
kasa ketiga digunakan untuk mengeringkan kulit.
v. Swab digunakan untuk membersihkan sekitar trakheostomi.
vi. Kanul dalam steril harus sudah siap dipasang setelah anda membersihkan kulit.
vii. Tali menahan trakheostomi di tempatnya tanpa menghambat sirkulasi.
l. Membersihkan jalan udara sehingga pembersihan trakheostomi menjadi lebih efisien.
Pengisapan merupakan prosedur steril. Mantel pelindung mencegah kontak dengan cairan
tubuh klien.
m. Kulit harus dibersihkan untuk mencegah kerusakan kulit.
n. Menurunkan penyebaran mikroorganisme.
i. Kanul dalam harus dilepaskan dan diganti untuk mengurangi penyebaran mikroorganisme
dan untuk meningkatkan pernapasan.
ii. Melepaskan kanul dalam dapat menstimulasi batuk dan klien mungkin membutuhkan
pengisapan.
iii. Normal salin yang menetes ke dalam trakheostomi dapat menyebabkan klien batuk.
iv. Dengan hati-hati dan cermat pasang kanul dalam ke dalam bagian luar kanul dan kunci
kembali agar tetap berada di tempatnya.
v. Hubungkan kembali klien dengan sumber oksigen.
o. Membersihkan kanul dalam tak disposible
i. Lapaskan kanul dalam menggunakan tangan tak dominan anda dan letakkan kanul tersebut
dalam mangkuk yang berisi hidrogen peroksida.
ii. Bersihkan kanul dalam dengan sikat ( tangan dominan anda memegang sikat dan tangan
tak dominan anda memegang kanul dalam).
iii. Pegang kanul di atas magkuk yang berisi hidrogen peroksida dan tuangkan normal salin
pada kanul tersebut sampai semua kanul terbilas dengan baik. Biarkan normal salin memetes
dari kanul dalam.
iv. Pasang kembali kanul dalam ke dalam kanul luar dan kunci agar tidak berubah letaknya.
v. Hubungkan kembali ke sumber oksigen.
p. Gunakan kasa dan swab berujung kapas yang dibasahi dengan hidrogen peroksida untuk
membersihkan permukaan luar dari kanul luar dan area kulit sekitarnya.bersihkan juga area
 kulit tepat di bawah kanul. Lalu bilas menggunakan kasa dan swab yang dibasahi dengan
normal salin. Kemudian keringkan dengan menggunakan kasa kering.
q. Ganti tali pengikat trakheostomi. Biarkan tali yang lama tetap di tempatnya sementara anda
memasang tali yang baru. Sisipkan tali yang baru pada salah satu sisi dari faceplate.
Lingkarkan kedua ujung bebasnya mengelilingi bagian belakang leher lain ke sisi lainnya dari
faceplate. Sisipkan salah satu ujung bebasnya pada salah satu sisi faceplate dan ikat dengan
kuat tetapi tidak ketat. Gunting tali yang lama.
r. Letakkan bib trakheostomi atau balutan bersih mengelilingi kanul luar di bawah tali
pengikat faceplate. Periksa untuk memastikan bahwa tali pengikat tidak terlalu ketat tetapi
pipa trakheostomi telah dengan aman tertahan di tempatnya.
s. Mengempiskan dan mengembangkan manset (cuff) pipa trakheostomi.
i. Pakai sarung tangan steril
ii. Lakukan pengisap jalan udara orofaring klien

Tracheostomy management

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

Aim
The aim of the guideline is to outline the principles of management for patients with a new or
existing tracheostomy for clinicians at the Royal Childrens Hospital.
Tracheostomy kit
A blocked or partially blocked tracheostomy tube causes severe breathing difficulties. The
key concept of tracheostomy management is to ensure patency of the airway. A
tracheostomy kit is to accompany the patient at all times and be checked each shift by
the nurse caring for the patient.
Tracheostomy kit
9. x1tracheostomy tube of the same size insitu (with introducer if available)
10. x1tracheostomy tube one size smaller (with introducer if applicable)
11. Spare inner tubes for double lumen trache tubes
12. Spare ties (cotton and velcro)
13. Scissors (or chain cutters as applicable)
14. Resuscitation bag and mask (appropriate size for patient)
15. One way valve (community use only)
16. Wall or portable suction
17. Appropriate size suction catheters
18. 0.9% sodium chloride ampoule and 1 ml syringe
19. x1 HME or tracheostomy bib
20. Fenestrated gauze dressing
21. Cotton wool sticks
22. Water based lubricant for tube changes
23. Mucous trap-for emergency suction
24. Tape (ie sleek)
NB: NeopuffTM is the resuscitation device used at the bedside in Neonatal Unit at RCH.
Special considerations
25. All children 6 years and under are to have cotton ties only to secure
tracheostomy tubes.
26. Children 6 years and over who are considered at risk of undoing velcro ties
should have cotton ties.
27. For patients with a newly established tracheostomy it is recommended that
tracheal dilators are available at the patients bedside until after the first successful tube
change.
Emergency management
The majority of children with a tracheostomy are dependent on the tube as their primary
airway. Cardiorespiratory arrest most commonly results from tracheostomy obstructions or
accidental dislodgement of the tracheostomy tube from the airway. Obstruction may be due to
thick secretions, mucous plug, blood clot, foreign body, or kinking or dislodgement of the
tube.
Early warning signs of obstruction include tachypnoea, increased work of breathing,
abnormal breath sounds, tachycardia and a decrease in SpO2 levels . Cyanosis, bradycardia
and apnoea are late signs - do not wait for these to develop before intervening.

The resuscitation flowchart for a tracheostomy patient follows APLS principles.

It is recommended that a copy of this flow chart is readily available e.g. placed in a
prominent position at the bedside or in the patients bed chart folder.
Download the flowchart (PDF 21 KB)
Complications
Immediate post-operative complications include:
28. Blocked tube
29. Bleeding from the airway/tracheostomy tube
30. Pneumothorax
31. Subcutaneous and/or mediastinal emphysema
32. Respiratory and/or cardiovascular collapse
33. Dislodged tube
34. Granulation tissue
35. Tracheo-oesophageal fistula
Long term complications include:
36. Acute airway obstruction
37. Blocked tube
38. Infection (localised to stoma or tracheo-bronchial)
39. Aspiration
40. Tracheal trauma
41. Dislodged tube
42. Stomal or tracheal granulomation tissue
43. Tracheal stenosis
Post operative management of a new tracheostomy
After a tracheostomy is inserted, the patient is managed in either the Paediatric Intensive Care
(PICU - Rosella) or Neonatal Unit (NNU - Butterfly) in the initial post-operative period.
44. Patients return from theatre with stay sutures in situ, which should be taped to
the chest and labeled left and right. The stay sutures should remain in situ and securely
attached to the chest wall, , until the first successful tube change. The stay sutures facilitate
the opening of the stoma during reinsertion of the tracheostomy tube.
45. The ENT team, in consultation with the parent medical team, will perform the
first tube change, including the removal of the stay sutures. This is usually done 5-7 days
after insertion of the tracheostomy tube.
46. Most children will undergo their first tracheostomy tube change while in the
intensive care environment. However, on occasions, following consultation between
members of the PICU, ENT team and the parent unit, children may be transferred to a ward
from PICU prior to their first tracheostomy tube change if they meet the following criteria:
Have a non critical airway i.e. these children are able to breathe and
maintain their airway in the event of accidental decannulation.
 Are not dependent on positive pressure ventilation/CPAP via the
tracheostomy.
47. It is imperative that the first tracheostomy tie change is dealt with in the same
manner as the first tracheostomy tube change with both nursing and medical staff present
who are competent in tracheostomy management. The tracheostomy kit should be present
at the bedside.
48. The tracheal stoma in the immediate post operative period requires regular
assessment and management including once daily dressing change following cleaning of the
stoma area with 0.9% normal saline, or more frequently if required.
49. The comfort of patients is imperative throughout the post-operative period.
Pain should be managed effectively as per RCH procedural pain management policy.
50. Each child requires a Tracheostomy Tube Management Form to be completed
and placed at the bedside. (see attached form)
Routine management
Routine tracheostomy management consists of:
51. Equipment & environment
52. Activities of daily living
53. Supervision and Monitoring
54. Humidification
55. Suctioning
56. Management of abnormal secretions
57. Tracheostomy tube tie changes
58. Tracheostomy tube changes
59. Stoma Care
60. Feeding and Nutrition
61. Oral Care
62. Communication
 Video of tracheostomy management

Equipment and environment

63. Each shift ensure emergency oxygen and suction equipment is set up and in
working order
64. Ensure appropriate equipment is accessible at the bedside and accompanies the
patient
Activities of daily living
65. Maintain and review as required the childs PUPPS and falls risk assessment
66. Children with tracheostomy tube should wear a HME filter (unless ventilated)
and be closely supervised when bathing or showering.
Supervision and monitoring
In determining the level of supervision and monitoring which is required, it is recommended
each patient with a tracheostomy is assessed on an individual basis by the treating
medical/surgical and nursing team4 taking into consideration the following factors:
67. Age specific alarm limits
68. Clinical state
69. Nature of the airway problem
70. Ability to breathe and maintain their airway in the event of accidental
decannulation
71. Ability to clear own secretions
72. Frequency of suction/tracheostomy tube interventions required
73. Ventilation requirements
74. Cognitive ability
It is recommended decisions regarding required level of supervision and required
clinical observations/monitoring are documented clearly in the patient's medical record
by the treating team.

Monitoring may include:

75. Heart rate +/- continuous cardiac monitoring
76. Respiratory rate
77. Pulse oximetry continuous/overnight
78. Oxygen requirements
79. Work of breathing
80. Temperature
81. Blood pressure
82. Behaviour - alert, irritable, lethargic
Additional tests/assessments
83. Measurement of blood gases, tcCO2 and etCO2 as per medical orders.
Leaving the ward
84. The patients access to ward leave needs to be assessed according to the
patients stability, vulnerability and the level of patient/caregiver knowledge and skill in
airway (tracheostomy) and/or ventilation management
Humidification
A tracheostomy bypasses the upper airway and therefore prevents normal humidification and
filtration of inhaled air. Therefore, unless air inhaled via the tracheostomy tube is humidified,
the epithelium of the trachea and bronchi will become dry which increases the potential for
tube blockage. Tracheal humidification can be provided by a heated humidifier or Heat and
Moisture Exchanger (HME) or a Tracheostomy bib.

Heated humidification: delivers gas at body temperature saturated with water which
prevents the thickening of secretions. The temperature is set at 37C delivering a temperature
ranging from 36.5C - 37.5C at the tracheostomy site. Heated humidification for
tracheostomy patients should be delivered via a humidifier as per the Oxygen clinical
guideline (nursing). Indications for the use of heated humidification include:
85. Oxygen delivery via tracheostomy mask
86. Mechanical Ventilation
87. Respiratory infection with increased secretions
88. Management of thick secretions
Heat Moisture Exchanger (HME): contains a hygroscopic paper surface that absorbs the
moisture in expired air. Upon inspiration the air passes over the hygroscopic paper surface
and moistens and warms the air that passes into the airway.
89. HME is recommended for all patients with a tracheostomy tube.
90. HME fit directly onto the tracheostomy tube.
91. HME are changed daily or as needed if the filter appears to be excessively
moist or blocked.
92. For small infants <10kg HME filters may not be suitable. Consult Respiratory
team to assess patient's suitability
93. HME with oxygen port are suitable for low flow oxygen administration (as per
oxygen guideline)
94. Do not wet the HME filter prior to use.

Tracheostomy bibs: are a specialized foam that traps the moisture in the expired air,
upon inspiration the foam moistens and warms the air that passes into the airway.
95. At the RCH BuchananTM tracheostomy bibs are used.
96. Tracheostomy bibs are reusable. They are changed daily or more frequently as
required.
97. Hand wash in warm water using a mild detergent/soap, then rinse thoroughly
and allowed to air dry.
98. Tracheostomy bibs should be discarded monthly or more frequently if
discoloured or the material is damaged..
Suctioning
Suctioning of the tracheostomy tube is necessary to remove mucus, maintain a patent airway,
and avoid tracheostomy tube blockages. Indications for suctioning include:
99. Audible or visual signs of secretions in the tube
100. Signs of respiratory distress
101. Suspicion of a blocked or partially blocked tube
102. Inability by the child to clear the tube by coughing out the secretions
103. Vomiting
104. Changes in ventilation pressures (in ventilated children)
105. Request by the child for suction (older children)
106. Tracheal suctioning should be carried out regularly for patients with a
tracheostomy tube. However the frequency varies between patients and is based on individual
assessment.3
107. Tracheal damage may be caused by suctioning. This can be minimised by
using the appropriate sized suction catheter and only suctioning within the tracheostomy tube.
Table 1: recommended suction catheter sizes
 Tracheostomy tube size (in mm) 3.0mm 3.5mm 4.0mm 4.5mm 5.0mm 6.0mm 7.0mm
Recommended suction catheter 7 8 8 10 10 10-12 12
size (Fr)
108. The suction depth is determined by the length of the individual tracheostomy
tube.
109. The depth of insertion of the suction catheter needs to be determined prior to
suctioning to avoid airway trauma.3
110. Using a spare tracheostomy tube of the same size and a measuring tape:
measure the distance from the length of the tracheostomy tube
connector to the end of the tracheostomy tube.
record the suction depth on the tape measure and the patients
observations chart.
attach the tape measure to the cot/bedside/suction machine for future
use.
Use pre - measured suction catheters(where available) to ensure
accurate suction depth
111. The pressure setting for tracheal suctioning is 80-120mmHg (10-16kpa) to
avoid tracheal damage. The suction pressure setting should not exceed 120mmHg/16kpa.
112. It is recommended that the episode of suctioning (including passing the
catheter and suctioning the tracheostomy tube) is completed within 5-10 seconds.3
113. Suction catheters can be used for a 24hour period and then discarded unless
indicated earlier.
114. Routine use of 0.9% sodium chloride is not recommended however, In
situations where this may be of benefit e.g., thick secretions and to stimulate a cough 0.2 -
0.5ml of 0.9% sodium chloride can be used.2,3
Suctioning equipment:
115. Suction apparatus (wall attachment or portable unit)
116. Suction canister
117. Tubing
118. Suction catheter
119. Sterile water
Suctioning checks:
120. Ensure tracheostomy kit is present
121. Appropriate size suction catheter
122. Depth required for tracheostomy tube suctioning3
123. Appropriate suction pressure.
The correct suction pressure for use on a tracheostomy tube is 80-120mmHg maximum
when occluded. The Medigas suction gauges on the ward are measured on kPa. The
equivalent of 80- 120mmHg is 10-16kPa.
Suctioning: Procedure
1. Explain to the patient and their family that you are going to suction the
tracheostomy tube.
2. Hand hygiene - ABHR
3. Use personal protective equipment including non sterile gloves and safety
glasses.
4. Suction using a clean, non touch technique.
5. Attach suction catheter to suction tubing
6. Gently introduce the suction catheter into the tracheostomy tube to the pre-
measured depth.3
7. Apply suction & gently rotate the catheter while withdrawing. Each suction
should not be any longer than 5-10 seconds.3
8. Assess the patient's respiratory rate, skin colour and/or oximetry reading to
ensure the patient has not been compromised during the procedure. Repeat the suction as
indicated by the patient's individual condition.
9. Rinse the suction catheter with sterile water decanted into bowl, not directly
from bottle.
10. Look at the secretions in the suction tubing - they should be clear or white and
move easily through the tubing.
11. Notify the parent team if the secretions are abnormal, and consider sending a
specimen for culture and sensitivity.
Suctioning: Special considerations
1. Some patients may require assisted ventilation before and after suctioning. If
required, this will be requested by the parent medical team or Respiratory Nurse.
2. If the correct size suction catheter does not pass easily into the tracheostomy
tube, suspect a blocked or partially blocked tube and prepare for immediate tracheostomy
tube change
 Suction catheters are to be routinely replaced every 24hours or at any time if
contaminated or blocked by secretions. Suction water/and the container to be replaced
every 24 hours.
Management of abnormal secretions
Changes in secretions e.g. blood stained or yellow/green secretions may indicate infection
and/ or trauma of the airway. Notify the parent team, send a specimen for culture and
sensitivity and consider commencement of antibiotics.

Persistant blood stained secretions from the tracheostomy tube need to be investigated to
determine the cause.
Tracheostomy tube tie changes
3. If tie changes are required before the 1st tube change It is imperative that the
procedure must be undertaken with both medical and nursing staff present who are able to
reinsert the tracheostomy tube in case of accidental decannulation.
4. The first tracheostomy tube tie change and the appropriate equipment
available at the bedside.
5. It is preferable to secure new ties before removing the old ties
6. There is a potential risk for tracheostomy tube dislodgment when attending to
tie changes, therefore a minimum of two people who are competent in tracheostomy care are
required to undertake tracheostomy tie changes. During the tracheostomy tie change, if the
old ties are removed prior to securing the new ties, one person is to maintain the airway by
securing the tracheostomy tube in place and not removing the hand until the new
tracheostomy ties are secured The other person inserts the new ties into the flange and secures
around the childs neck. Tracheostomy tie changes are performed daily in conjunction with
stoma care, or as required if they become wet or soiled to maintain skin integrity.
7. If the ties become loose it is a priority to re-secure immediately.
8. Tracheal chains these can remain insitu and are changed with routine trache
tube changes. The chains need to be checked every shift to ensure the correct tension and that
the clasp is secure.
9. All Children 6 years and under are to have cotton ties only to secure
tracheostomy tubes.
10. Children 6 years and over who are considered at risk of undoing velcro ties
should have cotton ties.
Tube tie change: Equipment
11. Tracheostomy kit
12. Two equal lengths of cotton ties or Velcro ties (for patients older than 6 years)
Tube tie change: Procedure for changing cotton ties
1. Explain to the patient and their family that you are going to change the
tracheostomy ties.
2. Hand hygiene ABHR & use personal protective equipment including non
sterile gloves and safety glasses.
3. Prepare two equal lengths of ties long enough to go around the child's neck.
4. Lie the child/infant down with the neck gently extended by a small rolled
towel placed under the child's shoulders. An older child may like to sit up in a bed or chair
5. Insert a clean tie on each side of the flange into the holes
6. On each side tie a single loop approximately 0.5cm from the flange on the
tracheostomy tube.
7. Then tie both sides together in a bow to secure.
8. Check the tension of the ties. Allow one finger to fit snugly between the skin
and the ties.
9. Re-tie into in a reef (double) knot to secure.
10. Cut off excess length of ties leaving approximately 3cm.
11. Remove old ties and recheck tension of new ties.
12. NB: The old ties are to remain insitu until the clean ties are secured. In
the event of removing existing ties prior to securing the tube with clean ties it is
recommended a second person is present to hold the tracheostomy tube ensuring it
remains in place until the ties are secured.
13. Observe the patient's neck to ensure skin integrity.
Tube tie change: Procedure for changing velcro ties

14. Changing velcro ties is a two person procedure.

15. Check the velcro on the tracheostomy ties prior to each use to ensure
adhesiveness. If not adherent discard and replace.
16. One person holds the tracheostomy tube securely in place.
17. The second person removes the existing velcro ties and then inserts the clean
velcro ties through one side of the flange, passing the tie around the back of the patient's neck
and inserting the velcro tie through the other side of the flange.
18. Adjust the ties to allow one finger to fit snugly between the skin and the ties.
19. Observe the patient's neck to ensure skin integrity.
20. Wash velcro ties daily in warm, soapy water, rinse and dry completely before
re-using.
Tracheostomy tube changes

At The Royal Children's Hospital the frequency of a tracheostomy tube change is determined
by the Respiratory and ENT teams except in an emergency situation. This can vary from
weekly to monthly depending on the patient's individual needs and tracheostomy tube type.
Tracoe , Portex , Shiley and Bivonna tracheostomy tubes are used at RCH.
1. It is imperative that the first tracheostomy tube change is performed with both
nursing and medical staff who are competent in tracheostomy management present and the
tracheostomy kit is available at the bedside.
2. A minimum of two people who are competent in tracheostomy care are
required for all tracheostomy tube changes (except in an emergency if a second person is not
readily available eg. Transporting the child).
3. The tube change should occur before a meal or at least one-hour after to
minimise the risk of aspiration.
Utilise personal protective equipment including non sterile gloves and
safety glasses.
The tube change is a clean, non touch technique.
Tracheostomy tube changes: Equipment
4. Tracheostomy Kit
5. Suction device and appropriate sized suction catheters
6. Small towel (rolled to place under the patient's shoulders to extend their neck)
7. A cot sheet to wrap the patient (age dependant)
8. Appropriate light/ illumination
Tracheostomy tube changes: Procedure

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

Tracheostomy tube changes: Special considerations

1. A rare complication is for the tube to slip into a false passage instead of the
airway. If there are any signs of breathing difficulties/respiratory distress remove the tube and
reinsert (a new tube) via the stoma into the airway.
2. Unless instructed otherwise, all single use tracheostomy tubes should be used
once only and discarded after every tube change, do not clean or re-use single use tubes.
3. Difficulties in re-inserting the tracheostomy tube can occur at any time. These
occur usually as a result of one of the following:
False tract
Patient agitation or distress
Closure of the stoma
Spasm of the trachea
Stoma is blocked by scar tissue (granuloma)
Skin flaps
Structural airway abnormalities eg: Tracheo/bronchomalaca.
At times the difficulty is for no obvious reason and cannot be
explained
Stoma care
4. Care of the stoma is commenced in the immediate post-operative period, and
is ongoing.
5. Daily cleaning of the stoma is recommended using 0.9% sterile saline
solution. After cleaning, ensure the skin is clean and dry to avoid breakdown.
Stoma care: Equipment
6. Fenestrated dressing
7. 0.9% sodium chloride
8. Cotton buds/sticks
Stoma care: Procedure for stoma care
1. Clearly explain the procedure to the patient and their family/carer
2. Perform hand hygiene ABHR or Wash hands.
3. Use a clean non-touch technique and personal protective equipment e.g. safety
glasses and gloves.
4. Lay the child on their back with a small rolled towel under the shoulders. An
older child may prefer to sit up in a bed or chair.
5. Remove fenestrated dressing from around stoma.
6. Inspect the stoma area around the tracheostomy tube.
7. Clean stoma with cotton buds moistened with 0.9% sodium chloride. Use each
cotton bud once only taking it from one side of the stoma opening to the other and then
discard.
8. Continue cleaning with new cotton buds until the skin area is free of
secretions, crusting and discharge.
9. Allow skin to air dry or use a dry cotton bud to dry.
10. Insert the fenestrated gauze under the flanges (wings) of the tracheostomy tube
to prevent chafing of the skin.

1. Avoid using any powders or creams on the skin around the stoma unless
prescribed by a doctor or stomal therapist as powders or creams could cause further irritation.
2. If signs of redness or excessive exudate consider using a non adhesive
hydrocellular foam dressing e.g. Allevyn. Discuss with parent medical team and consider
obtaining a specimen for culture and sensitivity.
3. If there are any signs of granulation tissue liaise with the respiratory nurse
consultants and/or stomal therapists for appropriate management.
The care of the stoma includes routine observation of the site and accurate documentation of
the findings including:
4. Redness
5. Swelling
6. Evidence of granulation tissue
7. Exudate
8. Increased discomfort during care
9. Stomal odour.
If visible signs of infection are present obtain a specimen for culture/sensitivity.
 Refer to stomal therapy/respiratory CNC for advice on the frequency and type of dressing
required.

Feeding and nutrition

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

Consider a dietician referral to assess optimal nutritional intake including oral versus tube
feeding (PEG, PEJ or NG), continuous versus intermittent feeding.
Oral care
Patients with a tracheostomy have altered upper airway function and may have increased oral
care requirements. Mouth care should assessed by the nurse caring for the patient and
documented in the patient care record
Communication
Children communicate in many different ways, such as using gestures, facial expressions and
body postures, as well as vocalising. The tracheostomy may impact on the child's ability to
produce a normal voice.
10. Vocalisation depends on several factors such as:
Severity of airway obstruction
Extent of vocal cord function
The size and type of the tracheostomy tube insitu
Respiratory muscle strength
Cognitive ability and age related ability
11. For patients with a new tracheostomy, refer to a speech pathologist for
assessment and provision of communication aids such as:
Pen and paper
Alphabet board
Picture communication device
Teaching manual for Auslan signing
 Electronic devices
Assessment for suitablility of speaking valve attachement
12. For children with established tracheostomy tubes it is essential that the
methods used for communication are identified via discussion with the patient (age
appropriate), and the parent/carers. These methods should be documented in the medical
record and verbally handed over to staff to ensure adequate communication and appropriate
understanding of the patient and their needs.
13. Speaking valves are a small plastic device with a silicone one-way valve, they
sit on the end of the tracheostomy tube. The one-way valve opens on inspiration allowing air
to enter the tracheostomy tube and closes on exhalation directing air up through the trachea,
larynx and nose and mouth as in normal breathing and normal speech. Not all children will be
able to produce a voice when the speaking valve is first used.
Speaking valves:
Various types of speaking valves are available. The most commonly used at the Royal
Children's are Passy-Muir one-way valves.

Benefits of using a speaking valve include:

14. Enhancing normal flow of air through the airway/nose and mouth
15. Restoration of physiological PEEP
16. Louder and clear voice
17. Improved ability to taste and smell foods
18. Improved secretions
19. Improved protection of the airways during swallowing and feeding
20. Improves development of speech and babbling in infants/toddlers
Contraindications for PMV assessment:
21. Severe airway obstruction
22. Vocal cord paralysis - adducted position
23. Severe neurological deficit
24. tracheostomy tube with inflated cuff (any kind)
25. Foam-filled cuff (even if deflated)
26. Severe risk for aspiration
27. < 7 days post-operative tracheostomy tube insertion
 Before speaking valve use:
A joint assessment involving the respiratory nurse consultant and a speech pathologist is
essential before the device is used. While some children can use speaking valves without any
difficulties Speaking valves are not suitable for all children with a tracheostomy.
The child's tolerance to the speaking valve will depend on their airway around and above the
tracheostomy tube. To exhale sufficiently the child must have enough airway patency around
the tracheostomy tube, up through the larynx and out of the nose and mouth. If exhalation is
not adequate with the speaking valve in place the child may become distressed and air
trapping/breath stacking or barotrauma to the lungs may occur.
To determine if the child has adequate airway patency consider:
28. Diagnosis of severe laryngeal or tracheal stenosis/subglottic stenosis
29. Size and type of the tracheostomy tube - appropriate to allow airflow through
upper airway
30. Nasal obstruction - e.g. nasogastric tubes/choanal atresia etc
Before trail of speaking valve ensure the child:
31. Post-operative tracheostomy 7 days or greater
Medically stable
Awake and responsive
Doesn't have excessive tracheal secretions and is able to manage oral secretions
Able to tolerate cuff deflation
Has adequate patency of upper airway
Perform bedside assessment of airway patency:
32. Explain procedure (age appropriate) to child and their family
33. Suction the tracheostomy tube before the valve is attached and then as
required.
34. A cuffed tube must be deflated before attaching the speaking valve.
35. Gently occlude tracheostomy tube with a gloved finger and observe for
exhaled air from nose and mouth or vocalization.
36. If finger occlusion is tolerated place the speaking valve on the end of the
tracheostomy tube and observe for oral/nasal exhalation.
37. If the PMV is tolerated on the initial trial for a goal of 5 to 10 minutes, then a
plan to improve consistency and length of tolerance is developed and provided to the child
and their care-givers.
38. Once the child has adjusted to wearing the valve they should be able to wear it
for long periods and the PMV can and should be worn at all awake times, particularly during
rehabilitative therapy sessions and when eating.
If the child fails to tolerate the PMV:
39. Remove the valve if any signs or symptoms of distress or changes in
respiratory effort.
40. As it can be more difficult for the child to exhale with the valve in place, the
child may initially fail a trial of PMV due to anxiety, discomfort.
41. Children may need to slowly build up longer periods of valve use and PMV
placement will be repeated on subsequent days.
42. Many children however, have difficulty adjusting to changes to their airways.
Children may initially experience increased coughing due to restoration of a closed
respiratory system, which re-establishes subglottic pressure and normalizes exhaled airflow
in the oral/nasal chambers.
43. In infants and young children consider using an device to secure the PMV to
the child's ties - to prevent accidental loss of the PMV.
44. Some speaking valves are suitable for use in combination with oxygen therapy
and during ventilation.
Contraindication to PMV use:
45. If you determine there is no airway patency then the degree of stenosis is a
contraindication to speaking valve use.
46. If the child has prolonged excessive coughing and obvious discomfit with
increased respiratory effort and air trapping - remove the valve immediately and reassess for
adequate airway patency before a repeat trial.
47. If airway patency adequate then aim to reassess the child at regular intervals to
place the PMV gradually increasing the time and frequency of use.
48. PMV may be contraindicated depending on type of cuffed tube e.g. foam cuff

Precautions when using speaking valves:

49. If the child has severe airway obstruction the speaking valve should not be
used.
50. In cuffed tracheostomy tubes - ensure cuff is completely deflated.
51. The young child should always be supervised when wearing the speaking
valve.
52. The speaking valve should not be worn when the child is sleeping.
53. Speaking valves do not humidify the air - therefore may be unsuitable for
children with copious thick secretions.
54. If the speaking valve is not functioning properly (i.e. sticking, noisy or
vibrates) or the child shows signs of respiratory distress/discomfort, then remove the valve
immediately and replace.
55. Do not use in combination with HME (heat moisture exchanger)
56. Remove valve before aerosol/nebulizer medication is administered
Care and cleaning of the Valve:
57. The speaking valve should be cleaned daily by washing the valve in warm
mild soapy water, then rinsed thoroughly and allowed to air dry completely before reuse.
58. Once dry and when not in use, it should be stored in the appropriate storage
container.
59. Ensure the valve is clean and not damaged in any way before each use.
60. Replace the valve immediately if any signs of wear/tear or damage are noted.
To avoid damage to the valve:
61. do not wash in hot water
62. do not brush the valve
63. do not use alcohol, peroxide or bleach to clean the valve

Transition to the community and discharge planning

64. All children with a tracheostomy tube in situ require a referral to Family
Choice Program to identify if support is required either for the patient or their family. The
referral should be made as soon as possible following tracheostomy tube insertion to allow
adequate time for planning home support services.
65. The referring team is responsible for ensuring appropriate equipment is
organised in collaboration with the Equipment Distribution Centre. This should occur in
consultation with the nursing staff, respiratory nurse consultants and the parent medical team.
66. Ensure all members of the medical, nursing and allied health teams are aware
of the planned discharge.
67. Prior to discharge an intervention chart is required to be completed to provide
detailed information about the interventions required for the patient over a past 24-48 hour
period including:
 Frequency of care the patient required including the amount of
suctioning the child has required.
Level of dependency the patient has on their tracheostomy.
68. Assessment will be made in accordance to the above information as to the
child's eligibility for assistance required at home and for discharge.
69. Education for primary care givers regarding tracheostomy care commences
soon after insertion of the tube and is usually initiated by the respiratory CNC in
collaboration with the parent unit nursing staff.
70. Principles of the care for children with a tracheostomy in the community who
are managed by FCP are based on the recommendations of this clinical practice guideline.
However individualised care plans are developed specifically to their care needs. These are
located in the home care manuals in FCP department.
Decannulation
71. Decannulation is a planned intervention for the permanent removal of the
tracheostomy tube once the underlying indication for the tracheostomy has been resolved or
corrected.
72. The patient is admitted to hospital for the procedure.
73. Bronchoscopy evaluation is usually performed prior to planned decannulation
to evaluate airway stability, assess possible granulation or suprastomal collapse, to assess
whether the child can maintain their airway and ventilation adequately without the
tracheostomy tube.
74. Decannulation planning can also include a staged process with downsizing and
capping of the tracheostomy tube in order to assess how the child would cope with a smaller
tracheostomy in the airway and to encourage the use of the upper airway.
75. The tracheostomy is usually blocked off using a decannulation cap if tolerated
the child is monitored overnight (downloadable oximetry) with the tube occluded.
76. To ensure the patient and the caregivers are prepared for the decannulation
ensure the procedure has been explained.
77. Decannulation is usually performed between the hours of 9am and 6pm.
78. There should be a clearly documented plan for the decannulation process from
the parent medical team
79. Decannulation should not be performed unless a member of the parent
medical team is present in the ward at the time of decannulation. Inform the ENT team of
the planned decannulation prior to removal of the tracheostomy tube.
80. It is recommended that the child's caregiver/s are present to alleviate the
anxiety of the child.
81. The child should be fasted for 2 hours prior to the decannulation.
82. Post decannulation, the patient is ideally nursed 1:1 for 24 hours and should
not leave the ward unless supervised by nursing staff. At the end of this 24 hour period the
need for nursing supervision of the patient (away from the ward area) is assessed by the
patient's parent medical team.3
83. Occasionally the trial of decannulation is unsuccessful requiring the need to
re-insert the tracheostomy tube. This is an emergency procedure and it can occur at any time
Decannulation: Equipment
Equipment - to stay at bedside until the child is discharged:
84. Tracheostomy Kit
85. Set of tracheostomy tubes (same size and smaller sizes than tube child has
insitu down to a size 3mm - keep a size 3mm in freezer).
86. Surgical scissors
87. Tracheostomy ties or velcro ties
88. Gauze dressing and an occlusive dressing - Comfeel with hypafix borders or
tegaderm/opsite to cover the tracheostomy stoma
89. Oxygen and suction
90. Cotton tipped applicators
91. Small towel (if applicable)
92. Oxygen and suction equipment
93. Laerdal Resuscitator kit
Decannulation: Procedure
94. Obtain baseline observations including heart rate, respiratory rate,
haemoglobin-oxygen saturation, and work of breathing. Ensure patient vital signs are within
appropriate parameters forage
95. Monitor patient continuously throughout the procedure.
96. Clean the stoma and suction the tracheostomy tube immediately prior to
decannulation.
97. Cut/undo tracheostomy tube ties.
98. Remove tracheostomy tube.
99. Observe for any signs of respiratory distress including:
Tachypnoea
Stridor
Retraction
Tachycardia
Colour
Decreased perfusion
Haemoglobin-oxygen desaturation or low oximetry reading.
Restlessness
cough effectiveness swallow and voice quality
activity levels
100. Apply occlusive dressing to stoma site post decannulation if no evidence of
respiratory distress.
101. Patient should again be assessed for signs of respiratory distress after applying
occlusive dressing to stoma site.
102. Patient should be nursed 1:1 for the first 24 hours post decannulation if
complications with the decannulation are anticipated.
Following decannulation:
103. Monitor the patient's respiratory rate, heart rate, oxygen saturation, colour and
work of breathing continuously throughout the procedure then:
15 minutely for the first hour
Half hourly for the next 4 hours
Hourly for 24 hours
Continuous pulse oximetry (SpO2) for patients during all periods
of sleep (day and night) post decannulation for 24 hours.
Call a MET for assistance as per RCH guidelines
Report any episodes of:
104. Tachypnoea/bradypnoea
105. Tachycardia/bradycardia
106. SpO2 desaturation
107. Increased WOB - as evidenced by: sternal/intercostal retraction, tracheal tug,
nasal flaring, stridor
108. Restlessness/anxiety
109. Colour change/ Cyanosis
110. Failure to clear secretions - gagging
111. Offer light diet 2 hours after decannulation unless contraindicated by increased
respiratory effort
112. Encourage the child to undertake normal activities while on the ward.
113. Continuous pulse oximetry (SpO2) during sleep
114. Observe carefully for signs of any airway obstruction during sleep.
115. The child should not leave the ward for 24 hours following decannulation.
116. Following the first 24 hours post decannulation the patient may leave the ward
if the admitting team has assessed the patient to have a "safe airway" unless supervised by
nursing/medical staff competent in emergency tracheostomy care.
117. Encourage coughing to clear secretions from upper airway if required. If the
child is not coughing and clearing secretions well, gentle oropharyngeal suction (only) may
be performed. Contact the physiotherapist for support.
118. Avoid suctioning the stoma unless otherwise indicated in an emergency
situation as this may cause trauma.
119. Referral to speech pathology should be considered if the child does not resume
normal voice production following decannulation.
Stoma site care post decannulation:
Dressings:
120. The stoma site is covered by a small gauze square and then by an occlusive
dressing (sleek/tegaderm) until it has closed or no secretions are seeping out.
121. Assess occlusive tracheal stoma dressing for air leaks every shift and
document absence or presence of these in medical record.
122. Stoma site to be assessed daily and cleaned (as per tracheostomy CPG) or
more frequently if indicated.
Discharge:
123. The child is usually discharged home when they're considered to have a safe
airway. The average length of stay post decannulation is 24 -48 hours but this maybe longer if
required.
124. Ensure the caregivers are provided with adequate supplies and are aware of
how to care for stoma site - this includes daily cleaning of the site and dressing changes as
required.
125. Advise the family/caregiver to contact the hospital and/or medical team if any
episodes of:
Tachypnoea/bradypnoea
SpO2 desaturation
Increased WOB - as evidenced by: sternal/intercostal retraction,
tracheal tug, nasal flaring, stridor
Restlessness/anxiety
Colour change/ Cyanosis
Unable to clear secretions - gagging
126. Advise the family/caregiver to contact the hospital and/or medical team if
there are any signs of infection at the stoma site including any
Redness
Odour
Swelling
Discharge
127. Following a successful decannulation the family are able to return all
tracheostomy and suctioning equipment but are encouraged to keep the pulse oximeter until
seen at follow up outpatient appointment
Documentation
128. All written documentation related to the management of a patient with a
tracheostomy is in accordance with the RCH documentation policy.
129. Record the reason and type of the interventions performed relating to
tracheostomy care and appropriate outcomes in the progress notes. These include:
Suctioning (amount, colour and consistency of aspirates)
Tracheostomy cares including tie changes and stoma dressings
Stoma condition (ongoing documentation and any changes eg: signs of
infection)
Significant changes in patient's condition
130. In the event of a tube change (routine or emergency), the following should be
documented in the progress notes:
The size and type of tube inserted
Lot number
Expiry date of the tracheostomy tube
Name of person who inserted the tube
Patient condition throughout the tube change
Any difficulties experienced during changing the tracheostomy tube.
Evidence table
Tracheostomy Management Evidence Table.
References
1. Hussey, S.G, Ryan, C.A and Murphy, B.P. (2007) "Comparison of three
manual ventilation devices using an intubated mannequin". Arch Dis. Child. Fetal Neonatal
Ed. (2004); 89; 490-93.
2. Raymond SJ. Normal Saline Instillation Before suctioning: Helpful or
Harmful? A review of the Literature". American Journal of Critical Care July 1995 Volume 4,
No. 4 267-271.
3. Gray JE, MacIntyre NR, Kronenberger WG. The effects of bolus normal saline
instillation in conjunction with endotracheal suctioning.
4. respir. Care. 1990;35:785-790.
5. Choate, K and Snadford, M (2003) "Tracheostomy: Clinical Practoce and the
formation of policy and guidelines" Australian Nursing Journal, 10, 8 p:CU1.
6. Scoble M, Copnell, B. Taylor, A. Kinney, S and Shann, F. (2001) "Effect of
reusing suction catheters on the occurence of pneumonia in children" Heart and Lung vol 30,
3 p: 225-233.
7. Celik, S and Kanan, N (2006) " A current conflict use of Isotonic Sodium
Chloride Solution on the Endotracheal Suctioning in Critically Ill Patients" Dimensions of
Critical Care Nursing vol 25/No1 pp:11-14.
8. Ridling, D. Martin, LD and Bratton, S. (2003) "Endotracheal Suctioing With
or Without Instillation of Isotonic Sodium Chloride Solution in Critically Ill Children".
American Journal of Critical Care vol 12, no 3 pp:212-219.
9. Griggs, A. (1998) "Tracheostomy suctioning and humidification". Nursing
Standard vol 13 (2) pp: 49-53, 55-56.
10. Woodrow, P. (2002) "Managing patients with a tracheostomy in acute care".
Nursing Standard vol 16 (44) pp: 39-48.
11. Carr, M. Poje, C.P. Kingston, L. Kielma, D. Heard, C. (2001) "Complications
in Pediatric Tracheostomies" Laryngoscope 111: November 2001.
12. Edwards, E.A. Byrnes, C.A (1999) " Humidification Difficulties in Two
Tracheostomized Children" Anaesthesia and Intensive Care, 27, 6, pp: 656-58.
13. Wyatt, M.E. Bailey, C.M. Whiteside, R.N (1999) "Update on paediatric
tracheostomy tubes" The Journal of Laryngology and Otology , 113, 1, Health and Medical
Complete pp:35-40.
14. Wetmore, R.F. Marsh, R.R. Thompson, M.E. Tom, L.W. (1999) "Pediatric
Tracheostomy: A Changing Procedure". The Annals pf Otology, Rhinology and Laryngology,
108, 7, pp:695-699.
15. Dixon, L.and Wasson, D. (1998) "Comparing Use and Cost Effectiveness of
Tracheostomy Tube Securing Devices. Medsurg Nursing, 7, 5 pp: 270-274
16. Tamburri, L.M. (2000) "Care of the Patient with a Tracheostomy". Orthopedic
Nursing, 19, 2 pp:49-60.
17. Oberwaldner, B. Eber, E. (2006) "Tracheostomy care in the home". Paediatric
Respiratory Reviews, 7, 185-190.
18. O'Toole, EA. Wallis, C. (2004) "Sending children home on tracheostomy
dependent ventilation:pitfalls and outcomes". BMJ vol 89 (3) pp: 251-255.