Nottingham Neonatal Service – Clinical Guidelines
Title:
TRACHEOSTOMY CARE
Version:
Ratification
Date:
Review Date:
Approval:
Author:
3
(V1 JUNE 2009, V2 OCTOBER 2011))
August 2015
Job Title:
Consultation:
Guideline
Contact
Distribution:
Target
audience:
Patients to
whom this
applies:
Key Words:
Risk Managed:
Evidence used:
Guideline No. B17
August 2018
Nottingham Neonatal Service Clinical Guideline group
V1 Tracey Bateman ANNP, Dale Vizzard – Staff Nurse
V2 Anneli Wynn-Davies, Andy Marshall
Revised: June 2015 (minor changes: Dushyant Batra)
Consultant Neonatologist, Consultant Paediatric ENT surgeon
Nottingham Neonatal Service Staff and Clinical Guideline Meeting
Dr Stephen Wardle, Guideline Coordinator and Consultant Neonatologist
co/ Stephanie Tyrrell, Nottingham Neonatal Service
[email protected]
Nottingham Neonatal Service, Neonatal Intensive Care Units
Staff of the Nottingham Neonatal Service
Patients of the Nottingham Neonatal Service who fit the inclusion criteria
of the guideline below
Tracheostomy, Ventilation
Management of babies with tracheostomy tubes on the
neonatal units of the Nottingham Neonatal Service
The contemporary evidence base has been used to develop this guideline.
References to studies utilised in the preparation of this guideline are
given at its end.
Clinical guidelines are guidelines only. The interpretation and application of clinical
guidelines remain the responsibility of the individual clinician. If in doubt, contact a senior
colleague. Caution is advised when using guidelines after the review date. This guideline
has been registered with the Nottingham University Hospitals NHS Trust.
1. INTRODUCTION
A tracheostomy is an artificial opening made into the trachea through the anterior of the neck to
facilitate ventilation. The surgical stoma is created by making an incision at the level of the
second and third or third and fourth cartilaginous tracheal rings. The stoma created is maintained
by the use of a tracheostomy tube.
The tracheostomy considerably reduces the upper airway anatomical dead space significantly
reducing the effort required for breathing while significantly increasing alveolar ventilation
compared with nasopharyngeal or oropharyngeal routes (Pritchard 1994). However, the loss of
the upper airways also means warming, humidification and filtering of inspired gases before
reaching the trachea and lungs does not naturally occur. This results in the drying out of tracheal
and bronchial epithelium, frequently inducing tenacious mucus, plugs and/or dry crustation in
addition to paralysis of cilia (Russell & Matta 2004).
2. INDICATIONS
The indications are threefold.
a)
To restore airway by bypassing an obstruction in the upper respiratory tract.
e.g.
subglottic stenosis
laryngomalacia
vocal cord palsy
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Guideline No. B17
papillomas
laryngeal webs
Infection or trauma
b)
To ease the management of secretions and improve gaseous exchange for long term
ventilated infants.
e.g.
Severe respiratory distress
Heart failure
Cardiac or lung abnormalities.
c)
To aid assisted ventilation for medical or surgical conditions.
e.g.
cardiothoracic surgery
severe chronic lung disease.
Trauma.
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3. TYPES OF TRACHEOSTOMY TUBES.
The type and size of tube used initially will be dictated by the surgeon. In Nottingham, the Shiley
Paediatric and Neonatal tubes are used.
These are silastic and single patient use.
They consist of an outer tube and an introducer.
Neonatal tubes are shorter in length than paediatric tubes and the wings are also
shorter. The internal diameters are the same for corresponding sizes
i.e the diameter of a Neonatal 0 is the same as Paediatric 0.
(NB. Only sizes 6 or above have cuffs and would be used for older children)
SIZE CHART
Neonatal
Neonatal
Neonatal
3.0
3.5
4.0
Paediatric (PED)
3.0
3.5
4.0
4.5
5.0
5.5
4. TRACHEOSTOMY CARE FOR THE FIRST WEEK.
Prior to receiving the baby back form theatre, it is essential that the emergency tracheostomy
box is by the bedside;
The following items must be available at all times at the bedside of the patient;









Spare tracheostomy tube of the same size.
Spare tracheostomy tube of the next size down.
Tracheal dilators.
Spare inner tube/ cannula.
10ml syringe
Scissors
Stitch cutters
Tapes
Lubricant.
NB: In addition there must be functioning suction equipment and appropriate size
catheters along with a Neopuff and appropriate sized mask. Checked and working as per
daily checks.
The above emergency equipment must accompany the patient during transfer between
departments.
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Humidity
Normally, the upper airway ensures that inspired gases are filtered, warmed and moistened by
the ciliated cells lining the respiratory tract. Cold air inspired directly into the trachea can cause
paralysis of the cilia and formation of plugs which may result in blockage of the tube.
Tracheostomy formation bypasses the natural humidification of gases. Therefore, humidification
prevents tracheal secretions becoming hard and crusty, facilitating respiratory exchange thus
preventing obstruction, consolidation and atelectasis.
Immediately on return to the neonatal unit, the baby must receive humidified air or oxygen from a
Fisher Paykal® Humidifying Unit. If the baby is ventilated, then this shall be delivered by the
normal humidifying system within the ventilator set up.
If ventilated-
standard humidification settings apply as per ventilator.
If not ventilated-
a tracheostomy mask should be attached to the Fisher Paykal® Humidifier
system and set at 34 degrees Celsius. However, in the
event of thick or
copious secretions, the humidity may be increased to 35 degrees Celsius.
(To set the right temperature by this system the base should be set at
37degrees Celsius and the heater wire at –3oC)
Humidification should be maintained for the first 7days post-op until the first tracheostomy
change has been performed, after which a Swedish nose (Thermovent T) may be used in the
non-ventilated infant. If the infant remains still ventilated, the same ventilator humidification
settings should apply.
If secretions become a problem with the use of the Swedish nose then the infant should revert
back to the humidification system above and the temperature be gradually weaned as the baby
tolerates.
Suctioning
The frequency of suctioning will depend upon the individual baby’s needs and should not be
considered a routine procedure. Tracheostomy formation reduces the effectiveness of the cough
reflex and ciliary clearance. Therefore, the baby will need help to clear mucous from the upper
airways.
Set the suction pressure to max 10-20 kPa
Select the right size catheter; it should be no more than half the diameter of the tube;
Tracheostomy size in mm x3 = catheter size Fg/ CH
2
Suctioning should not exceed 15secs to prevent hypoxia
NB:
If secretions are particularly thick despite humidity sterile 0.9% Sodium Chloride 0.5mls
can be instilled prior to suctioning.
Cleaning the site and changing the tapes
Secretions from around the tracheostomy tube can irritate, macerate or breakdown skin near the
stoma. Babies with a new tracheostomy or on mechanical ventilation may require more frequent
care of the site.
Tracheostomy dressings are not routinely used on neonates unless there are specific issues
relating to non-healing of the stoma. However the site still needs regular attention.
The site can be cleaned with sterile saline (normasol) and gauze and must be thoroughly dried.
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Changing the tapes
If the tapes need changing due to soiling, it is important that 2 persons are present to perform
the procedure during this first week. One nurse/ person to secure the tracheostomy tube, and
another to remove old tapes and apply the new should be present. Care must be taken not to
allow the tube to dislodge.
In the event of a blocked or dislodged tube during the first week after insertion
This is an emergency situation and as such medical help must be summoned
immediately. If possible the ENT surgeon on call must be summoned.
The emergency tracheostomy box should be opened in anticipation and the intubation trolley
made ready.
Within the first week, the tracheostomy stoma is unlikely to be properly formed so only an
ENT surgeon should attempt to re-insert the tracheostomy tube as there is a great danger
of making a false passage.
Therefore, in the event of having to remove the tube the baby should be intubated orally and
stabilised awaiting the ENT specialists.
The First Routine Tube Change.
This will be performed between 5-7days post-op.
An ENT Specialist ONLY performs this.
It may be carried out on the neonatal unit or in theatre depending on the circumstances;
generally if they anticipate problems the baby will go to theatre.
Feeding
Feeding is not contraindicated after tracheostomy formation but will be under the advice of the
ENT team involved.
Usually oral feeds are withheld for 24-48hrs post-op.
Generally babies can receive naso-gastric tube feeds with no ill effects. However, oral feeds may
need strict supervision by experienced neonatal and/or speech therapy staff depending on
circumstances. The risk of aspiration can be very high.
5. CHANGING A TRACHEOSTOMY TUBE.
The tracheostomy tube should be changed safely and effectively by a Registered nurse or carer
who is competent in the procedure. This can be a one or two person procedure.
Equipment:
New tracheostomy tube – designated size (new tapes attached)
Spare tube of smaller size.
Tracheal dilators
Suction
Rolled towel/ sheet for positioning
Scissors (blunt ended)
Dressings if required.
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Process:
1. Wash hands and apply lubricant jelly to the new tracheostomy tube with applicator. Attach
the ties to one side of the new tube.
2. Switch on suction ready for use.
3. Position baby on their back with a small rolled sheet/ towel under shoulders if required to
extend the neck slightly and ensure a good view of the tube and stoma.
4. Cut ties holding the tube and support the tube whilst doing so thus preventing the tube
dislodging too soon
5. Remove tracheostomy tube with one hand and immediately insert the new tube with the
other smoothly following the walls of the stoma.
6. Once in place remove the introducer whilst supporting the tube in place. Be aware that
the baby will cough at this point and supporting the tube will prevent it dislodging.
7. Tie tapes around the neck to secure the tube. Test the tightness- you should be able to
just slip 2 fingers under the tapes if correct. Trim the excess off the tapes.
6. SUCTIONING VIA TRACHEOSTOMY TUBE
Suctioning should be carried out by a registered nurse or carer who is competent in applying
suction to a tracheostomy tube
Equipment:
Suction and appropriate size catheters.
Sterile plastic gloves (non-sterile for long standing stoma)
2ml syringe
Sterile saline ampoule for irrigation
Yellow waste bag
Process:
1. Assess need for suction i.e. increased work of breathing, noisy breathing,
desaturations.
2. Position the baby comfortably with good view of tube.
3. check suction pressure does not exceed 20Kpa
4. Alcohol gel hands and apply glove to the hand with which you will be holding the
sterile catheter.
5. Use a fresh catheter for each insertion; this should be no greater than half the
diameter of the tube (see pg 4).
6. If required due to thick secretions instil 0.5ml sterile sodium chloride before inserting
catheter.
7. Insert catheter only until resistance is felt, pull back slightly then apply suction.
8. Rotate catheter whilst withdrawing. Suctioning must not exceed 15secs.
9. Document the effectiveness of suction and the type/amount of secretions aspirated.
7. PARENTAL TEACHING AND DISCHARGE PLANNING.
Our aim is to teach parents and carers the required skills to care for their baby at an appropriate
pace using appropriate language. A registered nurse who is experienced and is competent in
tracheostomy care will carry out teaching. The teaching tick list for parents and the “breath of
fresh air” booklet are useful aids.
The baby is nursed on the Neonatal Intensive Care Unit both pre and post operatively. In
general, the baby is likely to be discharged directly from the unit but on occasions may be
transferred to a paediatric ward after the first tube change has been performed.
The teaching tick list for tracheostomy care and suctioning are used to document parental
teaching that has taken place. This in turn acts as a guide for staff to know what the learning
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needs of the parents/carers are and also guidance to the parents of what they need to achieve in
order to prepare for discharge home. It is important that when it is time to discharge home the
parents/carers have achieved all the required skills to care for their baby with a tracheostomy.
Initially, all equipment needed to take the baby home will be supplied by the hospital. However,
all subsequent equipment and prescriptions will come directly from the community paediatric
nurses or GP.
Discharge should be planned carefully, ideally for Monday or Tuesday. This will ensure that the
community team responsible will be available to support the family during the important first few
days. The first home appointment with the community nurse must be made PRIOR to discharge.
The following 7 Step approach may be of help;
1)
Confirm with the ENT and Neonatal Consultants that discharge should be prepared
for including preparation for home Oxygen therapy if required.
2)
Contact the community paediatric team. A referral letter will need to be faxed to
them. Contact also the health Visitor and GP and if required organise a discharge
planning meeting. This meeting should take place at least 2weeks before discharge.
The community nurse must meet with the family on the unit prior to discharge, this will
enable them to assess the need of the family and put in place any further support they
may need.
3)
Ask community nurse to arrange for 2 portable suction machines to be ordered. They
will be responsible for any subsequent orders of gloves/ saline/ syringes/ catheters so
it will be helpful to supply a list. Remember that not all community nurses will have
supported families where a baby has a tracheostomy and they may need support
themselves from the unit.
4)
The unit is responsible for the order and supply of all other items, a comprehensive
list can be found at the end of this guideline. The unit should provide 4 weeks supply
of these items to allow the community team to put their orders in and deliver to the
parents.
5)
Support parents carers and indeed anyone who will be caring for the baby through the
tracheostomy teaching tick list and suctioning competency. This is extremely
important as anyone entrusted with the baby’s care should be competent to care for
the tracheostomy and this should be impressed on the family.
6)
All families should participate in the resuscitation training. However, this is compulsory
for carers of a baby with a tracheostomy. Any person should be taught who is likely to
be caring for the baby.
7)
These key issues are paramount at all times.
a) equipment for suctioning and emergency tube changes accompany baby at all
times
b) swimming is never allowed
c) all carers undergo relevant training by ward staff prior to discharge.
d) The parent/carer must be able to respond immediately if the baby has difficulties
with their airway.
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APPENDIX 1
EQUIPMENT NEEDED FOR DISCHARGE
The following items should be ordered and provided from the neonatal unit;
 20 sachets normasol (for cleaning stoma site
 20 packets of gauze swabs (for cleaning stoma site)
 20x 10ml ampoules of Saline
 6 sachets of Aqua Gel or 2 tubes of Aqua Gel
 3x tracheostomy tubes of correct size.
 1x Tracheostomy tube in smaller size
 1x Tracheostomy tube in bigger size
 Roll of tracheostomy ties
 Tracheal dilators
 Round ended scissors
 2x boxes sterile gloves
 Yellow waste bags
 600 appropriately sized suction catheters
 1x box smaller sized catheters.
The community nurses should supply:


2x portable suction machines
Saturation monitors if applicable.
Teaching tick lists and the “Breath of Fresh Air” booklets are currently located in the filing
cabinets at the nurses station. Both parents and anyone who is likely to be left as a sole carer
for the baby should complete these.
A list of community nurses and their contact details can be found in the baby info folder.
Alternatively you can contact the Nottingham Community Paediatric Nurses. They can often help
in contacting the correct community nurse for the baby.
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