What is a tracheostomy? A tracheostomy is an opening in the trachea, held open by a tracheostomy tube. Children who require a tracheostomy cannot maintain a patent airway without it, therefore, they need 24-hour care to prevent blockages and other care, including tape/tube changes, care of the stoma and emergency procedures. More and more children with chronic and life-threatening illnesses are surviving each day due to advances in tracheostomy support.

A child with a tracheostomy often finds it hard to clear their own secretions. Suctioning of the tracheostomy tube is an essential part of everyday care to clear secretions from the child’s respiratory tract. Airway suctioning can cause serious complications, therefore it should only be carried out when the patency of the airway could be compromised, so you may hear secretions in the tube or see that the child is coughing or having difficulty in breathing.

Suctioning of the tracheostomy tube should be performed as a ‘clean technique’, wearing gloves. It is essential to remember that children of different ages and sizes will have different sizes of tracheostomy tubes. As a guide, the correct size suction catheter is double the size of their tracheostomy tube, e.g. size 3.5 tracheostomy tube = size 7 fr suction catheter. You also need to know the length of the tracheostomy.

Connect the suction catheter to the suction unit and turn on the suction pressure. Remove the suction catheter without touching the tip of the catheter to keep it sterile. Insert the suction catheter into the tracheostomy tube to the correct depth, indicated by the graduated numbers on the catheter. Once inserted to the correct depth, hold the valve on the suction catheter and slowly withdraw the catheter, while maintaining the vacuum. Once removed, dispose of gloves and the suction catheter appropriately. Suctioning should be a quick and effective procedure of around 5–10 seconds. Ensure you observe the child throughout for any breathing distress or colour change.

Tapes are used to hold the tracheostomy securely in place. Tapes can either be cotton ties or Velcro, different types are used in different hospitals. Tape changes should be carried out daily, with a minimum of two people to carry out the procedure. Infants and some younger children may need to be swaddled, and a rolled-up towel placed under the shoulders to position the airway. It is important to ensure all the equipment is prepared before the procedure begins. Remember to ensure you know where your oxygen and suction are, and have them prepared as they may be needed during the procedure.

One person should be responsible for holding the tracheostomy in place throughout the entire procedure. The other person should be the tape changer. The tape changer should begin by placing clean ties behind the child’s neck and cutting the dirty ties off. Then it is important to clean around the tracheostomy site using saline and gauze and dry it thoroughly. While doing this, inspect the condition of the stoma. Sometimes granulation can form where the stoma site is trying to heal, which is often a lump of tissue and this may need treatment. Taking hold of the clean tapes, thread them through and either tie in a bow or Velcro them securely. The ‘tension’ of the ties must then be checked, by sitting the child up and putting an index finger through the tapes, to make sure they are not too tight or too loose. Readjust them as necessary and then double-bow the cotton tapes and cut the excess so there is 1.25 cm left. The person responsible for holding the tracheostomy MUST NOT let go until told to do so by the tape changer.

Planned tube changes can be done weekly or monthly, depending on the type of tracheostomy tube, and with a minimum of two people. The child should be positioned the same as for the tape change procedure, and all the equipment should be prepared before starting, including oxygen and suction. It is important to know whether the child has a cuffed tube, as this must be deflated prior to removing it. Place clean ties behind the child’s neck, and cut the dirty ties, with the assistant holding the tracheostomy secure. The tube changer should have the new tracheostomy to hand, then remove the old one and quickly insert the new one with the obturator in place, in a curved motion. Once inserted, remove the obturator. The assistant should take over holding the tracheostomy in place. The tube changer can then clean the stoma and secure the tracheostomy using the tape change procedure.

All children with a tracheostomy will have an emergency box, which must be kept with them at all times. Most boxes contain a list of what should be included. With an understanding of Basic Life Support (BLS), it can be adapted for a child with a tracheostomy. When checking the airway, check for signs of obstructions like secretions, and suction if necessary. If an obstruction is felt when trying to pass the suction catheter, an emergency tube change may be required. When assessing breathing, if rescue breaths are required, you can deliver them directly to the tracheostomy or by using a bag valve mask (BVM). Another complication in these children can be accidental decannulation, meaning the child could have accidentally removed the tracheostomy or it could have been dislodged. This is when an emergency tube change is required, so use the same size tracheostomy if possible; if not, use the smaller size. Remember to ALWAYS know where the emergency box, oxygen and suction are when caring for a child with a tracheostomy.