This procedure should be undertaken only after approved training, supervised practice and competency assessment, and carried out in accordance with local policies and protocols. Sign in or Register a new account to join the discussion. You are here: Respiratory. Tracheostomy care: Part 1 — Using suction to remove respiratory secretions via a tracheostomy tube.
How to use suction to remove respiratory secretions via a tracheostomy tube. Department of Health Standard principles for preventing hospital-acquired infections. Journal of Hospital Infection ; 47 supplement : S Dougherty, L. Oxford: Blackwell Publishing.
Higgins, D. Nursing Times ; 8, Pryor, J. Edinburgh: Churchill Livingstone. 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. 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.
For all patients with a new tracheostomy a referral to a speech pathologist for assessment and provision of communication aids is recommended. 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.
One-way 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 vocal sounds or voice when the speaking valve is first used. One-way speaking valves are not suitable for all children with a tracheostomy. The child's tolerance to the one-way 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. Therefore, a joint assessment involving the Respiratory nurse consultant and a Speech pathologist is essential before the device is used to determine if the child has adequate airway patency.
All children with a tracheostomy tube should be referred to Complex Care Hub after discussion with the family. The referral should be made as soon as possible following tracheostomy tube insertion to allow adequate time for the planning of in-home health care support prior to the patients discharge. Following the referral a needs assessment will be undertaken by CCH team to determine the support required for the patient and their family. The referring team is responsible for ensuring appropriate equipment for discharge is organised in collaboration with the Complex Care Hub or Equipment Distribution Centre.
This should occur in consultation with the ward nursing staff, respiratory nurse consultants and the parent collaboration with the Complex Care Hub or Equipment Distribution Centre. Ensure all members of the medical, nursing and allied health teams are aware of the planned discharge date. 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.
These are located in the home care manuals provided by Complex care team. 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. If the child is unable to tolerate the downsizing and capping of the tracheostomy tube a medical review is required as the trial of decannulation may not proceed and the tube may be upsized.
Additional monitoring: Overnight oximetry monitoring downloadable and sleep diary are recorded throughout the night. The child is reviewed in the morning by the admitting team to determine whether the decannulation trial goes ahead or not. 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.
Note: 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 — ensure equipment is at bedside and remains with the child until the child is discharged. Monitor the patient's vital signs - respiratory rate, heart rate, oxygen saturation, colour and work of breathing continuously throughout the procedure then observe and document:.
Note: The child is to remain on the ward for 24 hours post decannulation and should not leave the ward without medical approval and supervised by nursing staff competent in tracheostomy care.
The child is usually discharged home when they're considered by the medical team to have a safe airway. The average hospital length of stay post decannulation is 36 - 48 hours, however this maybe longer if clinically indicated. Following a successful decannulation the family are able to return all tracheostomy and suctioning equipment on discharge from hospital but are encouraged to keep the pulse oximeter until seen at follow up outpatient appointment.
Note: If child having severe breathing problems call immediately and follow basic life support flowchart. 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.
If stoma site remains open the family are advised to carefully supervise their child around water to avoid aspiration. Ensure all written documentation related to the management of a patient with a tracheostomy is in accordance with the RCH documentation policy. Record the reason and type of the interventions performed relating to tracheostomy care and appropriate outcomes in the progress notes and flow sheets assessment.
Tracheostomy Management Evidence Table. Please remember to read the disclaimer. Updated April The Royal Children's Hospital Melbourne. Tracheostomy management. Tracheostomy management Note: this guideline is currently under review. Definition of terms Decannulation : removal of a tracheostomy tub Heat moisture exchangers HME : a hygroscopic material that retains the child's exhaled heat and moisture, which is then returned to subsequent inhaled air gas.
Humidification : the mechanical process of increasing the water vapour content of an inspired gas. Breaths are delivered by occluding a T piece. NeopuffTM is the resuscitation device used at the bedside in Neonatal Unit at RCH Stoma : a permanent opening between the surface of the body, and an underlying organ in this case, between the trachea and the anterior surface of the neck. Tracheostomy : a surgical opening between 2 - 3 or 3 - 4 tracheal rings into the trachea below the larynx Tracheal Suctioning : is a means of clearing the airway of secretions or mucus through the application of negative pressure via a suction catheter.
Trache or 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.
There are a variety of different tracheostomy tubes available. Related Documents Aseptic technique Emergency Procedures Tracheostomy Kit A tracheostomy kit is to accompany the patient at all times and this must be checked each shift by the nurse caring for the patient to ensure all equipment is available.
Download the flowchart PDF 21 KB Complications Complications can be classified by timing: intraoperative; early usually defined as the first postoperative week ; late; and post-decannulation. Ensure the tracheostomy equipment kit is present at the bedside with the patient. Patients return from theatre with stay sutures nylon sutures inserted on either side of the tracheal opening. The stay sutures are taped to the chest and labelled left and right.
Pulling the stay sutures up and out will apply traction to the stoma opening to assist with insertion of the replacement tube. The stay sutures should remain in situ and securely attached to the chest wall until the first or second successful tube change.
Trache stoma maturation takes approximately 5 — 7 days after insertion of the tracheostomy tube or 2 — 3 days if stoma maturation sutures are placed.
The ENT team, in consultation with the parent medical team, will perform the first tube change, including the removal of the stay sutures.
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 tracheal stoma in the immediate post-operative period requires regular assessment and wound management including once daily dressing change following cleaning of the stoma area or more frequently if required.
The comfort of the patient is imperative throughout the post-operative period. Pain should be managed effectively as per RCH procedural pain management policy. Each child requires a Tracheostomy Tube Management Form to be completed and placed at the bedside. 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.
Caregiver competency in tracheostomy care — including knowledge and skill in airway tracheostomy emergency management. Ensure the tracheostomy kit accompanies the patient at all times Humidification A tracheostomy tube bypasses the upper airway and therefore prevents the normal humidification and filtration of inhaled air via the upper airway.
Heated humidification Delivers gas at body temperature saturated with water which prevents the thickening of secretions. Indications for the use of heated humidification include: Oxygen delivery via tracheostomy mask Mechanical Ventilation Respiratory infection with increased secretions Management of thick secretions Heat Moisture Exchanger HME Contains a hygroscopic paper surface that absorbs the moisture in expired air.
HME is recommended for all patients with a tracheostomy tube. HME fit directly onto the tracheostomy tube. Do not wet the HME filter prior to use HME are changed daily or as needed if the filter appears to be excessively moist or blocked. Consult Respiratory team to assess patient 's suitability HME with oxygen and suction port are suitable for low flow oxygen administration as per oxygen guideline Tracheostomy bibs Consist of 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.
Tracheostomy bibs should be discarded monthly or more frequently if discoloured or the material is damaged. Suctioning Suctioning of the tracheostomy tube is necessary to remove mucus, maintain a patent airway, and avoid tracheostomy tube blockages.
Indications for suctioning include: Audible or visual signs of secretions in the tube Signs of respiratory distress Suspicion of a blocked or partially blocked tube Inability by the child to clear the tube by coughing out the secretions Vomiting Desaturation on pulse oximetry Changes in ventilation pressures in ventilated children Request by the child for suction older children Safety considerations: Tracheal damage may be caused by suctioning.
This can be minimised by using the appropriate sized suction catheter, appropriate suction pressures and only suctioning within the tracheostomy tube. The depth of insertion of the suction catheter needs to be determined prior to suctioning.
Using a spare tracheostomy tube of the same type and size and a suction catheter insert the suction catheter to measure the distance from the length of the tracheostomy tube 15mm connector to the end of the tracheostomy tube. Ensure the tip of the suction catheter remains with-in the tracheostomy tube. Record the required suction depth on the tape measure placed at the bedside and in the patient records. Use pre - measured suction catheters where available to ensure accurate suction depth The pressure setting for tracheal suctioning is mmHg kpa.
It is recommended that the episode of suctioning including passing the catheter and suctioning the tracheostomy tube is completed within seconds. Equipment: Suction apparatus wall attachment or portable unit Suction canister Tubing Suction catheter Sterile water Table 1: recommended suction catheter sizes Tracheostomy tube size in mm 3. The Medigas suction gauges used on the wards are measured in kPa. The equivalent of mmHg is kPa. Procedure Explain to the patient and their family that you are going to suction the tracheostomy tube.
Apply eye protection Perform hand hygiene, apply non-sterile gloves Remove HME, mask or circuit Peel open suction catheter end and attach to suction tubing, check and adjust suction pressure gauge to between 80 — mmHg. Utilizing a non-touch technique gently introduce the suction catheter tip into the tracheostomy tube to the pre-measured depth.
Each suction should not be any longer than seconds. Repeat the suction as indicated by the patient's individual condition. Look at the secretions in the suction tubing - they should normally be clear or white and move easily through the tubing. Document changes from normal colour and consistency and notify the treating team if the secretions are abnormal colour or consistency.
Rinse the suction catheter with sterile water decanted into container not directly from bottle. Replace suction catheter into the packaging Dispose of waste, remove gloves and perform hand hygiene Note: Suction catheters are to be routinely replaced every 24 hours or at any time if contaminated or blocked by secretions.
Routine use of 0. However, in situations where this may be of benefit e. Special safety considerations Some patients may require assisted ventilation before and after suctioning. Management of abnormal secretions Changes in secretions e. Tracheostomy tie changes If tie changes are required before the first 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 and the appropriate equipment is available at the bedside.
Tracheostomy tie changes are performed daily in conjunction with stoma care, or as required if they become wet or soiled to maintain skin integrity. Do not suction for more than 10 seconds each time. Turn or twist the suction catheter as it is taken out. Remove your thumb from the suction control vent if you feel the catheter pull during suctioning. Wait 20 to 30 seconds between each suction try.
After 3 tries, wait 5 to 10 minutes before suctioning again. Put the suction catheter into the trachestomy tube. Cleaning and storing suction supplies Rinse the suction catheter and connection tubing with clean tap water after each use. Last reviewed:. September Interested in using our health content?
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