Steps

Rationale/Points of Emphasis

1 Perform hand hygiene.

Reduces transmission of microorganisms.

2a Gather all necessary supplies. Decontaminate and disinfect procedure tray/trolley/surface to create a “general aseptic field.” Assemble supplies on aseptic field near the child’s bed.

Promotes efficient time management and provides an organized approach to the procedure.

2b Based on healthcare prescriber’s orders, select appropriately sized tracheostomy tube.

Tracheostomy tubes must fit the airway and the functional needs of the child. Tube size is determined based on tracheal size and shape, indications for the tracheostomy, lung mechanics, upper airway resistance, and the needs of the child for speech, ventilation, and airway clearance. Length, curvature, flexibility, and composition of the tube are also considered. Because a stoma may become slightly smaller over time, a second replacement tube at the bedside should be the next smaller size from that of the patient.

caREminder

The indications for cuffed tracheostomy tubes in pediatrics are limited. Cuffed tracheostomy tubes may be used in children requiring ventilation with high pressures, children requiring only nocturnal ventilation, and those with chronic translaryngeal aspiration. The exact role of cuffed tracheostomy tubes in children has not been defined in the literature. Should a cuffed tube be present, ensure that secretions are cleared from above the tube cuff before deflating the cuff before removal.

3 Inspect tracheostomy tube for stiffness, cracks, and tears. Damaged tubes or flexible tubes that are becoming stiff should be discarded and replaced with new tubes.

Individual flexible polyvinyl chloride (PVC) tracheostomy tubes may be in intermittent use by the child for 6 months to 1 year before stiffening. With use, these tubes become progressively more rigid and may develop splits or cracks. Silicone tracheostomy tubes do not stiffen after repeated use or after cleaning and disinfection. Metal tracheostomy tubes can be used indefinitely. Metal tubes can occasionally crack at the soldered joint.

4 Attach securing device to opening on one end of tracheostomy tube (see Chapter 102 ). Ensure that the obturator is inserted in the new tube.

Use of obturator gives stability to the tracheostomy.

5 Lubricate the end of the new tracheostomy tube with water-based lubricant. Place back in open package nearby the child.

Lubrication decreases the trauma to tracheal tissue.

6 Position child in supine position with neck slightly extended. Place rolled towel or diaper under the child’s shoulders.

Straightens airway and optimizes path for removal and placement of tracheostomy. Slightly extends neck for optimal positioning, bringing tracheostomy tube forward. A second person is recommended to assist by holding the child’s shoulders to prevent movement.

7 Don appropriate PPE (optional) and gloves.

Face shield should be used if the child is infectious or has copious secretions that may come into contact with the caregiver. Reduces transmission of microorganisms.

8 Remove old securing device. The child, a family member, or another healthcare provider should hold the tracheostomy tube in place.

Self-fastening securing devices are softer, less irritating to the skin, and easily removed by releasing the self-fastening tabs. Care should be taken to prevent cutting the child’s skin when removing twill ties.

9 With one hand, remove old tracheostomy tube and tracheostomy set and move it to one side out of the way.

Tracheostomy tubes and sets may be cleaned and reused. Routine tracheostomy tube changes result in fewer complications from infection and formation of granulation tissue requiring surgical intervention.

10 Gently and quickly insert the new tube, pushing back and then down, in an arcing motion.

Back and downward motion follows the natural curve of the trachea. Tube should extend at least 2 cm beyond the stoma and no closer than 1 to 2 cm to the carina. Curvature should be such that the distal portion of the in situ tracheostomy tube should be concentric and collinear with the trachea.

11 Immediately remove the obturator (Figure 104-1).

Obturator occludes the patency of the tracheostomy.

Figure 104-1 Once the new tube has been inserted, stabilize the flanges of the outer cannula with the fingers of one hand while immediately withdrawing the obturator with the other hand.

12 Assess for patency of the tube by using stethoscope to listen for air movement.

If there is no air movement, the procedure will need to be repeated. A tracheostomy tube whose distal position is not collinear with the trachea may cause complications, such as esophageal obstruction or partial occlusion of the tracheostomy tube tip by the tracheal wall. Other complications include tracheal wall erosion, tracheoinnominate artery fistula, tracheoesophageal fistula, and stomal breakdown.

13 Hold the outer cannula of the tracheostomy tube in place and attach the tracheostomy securing device (see Chapter 102 ).

One person should hold the tube in place, while the assistant attaches the securing device.

14 If a cuffed tube is used, inflate the cuff to the proper volume using a syringe. Consult the healthcare prescriber for cuff pressure to be applied. In general, cuff pressures between 15 and 20 cm H₂O are well tolerated by children.

Cuff pressures should be kept as low as possible to protect the airway and prevent leaks. Tracheal mucosa damage may be caused by cuff pressures above 30 cm H₂O.

15 Provide oxygenation/ventilation breaths as needed using a manual ventilation bag if indicated based on child’s respiratory status.

If the child experiences respiratory distress during the procedure, extra breaths will assist in reestablishing the child to his or her baseline respiratory status.

16 Remove gloves and PPE and dispose of waste in appropriate trash receptacle. Turn off suction equipment. Return reusable supplies to safe storage area. Perform hand hygiene.

Reduces transmission of microorganisms. Suction equipment should not remain running when not in use.

caREminder

The tracheostomy tube may be cleansed for future use depending on institutional policy. Families should be encouraged to reuse the tubes when performing this procedure at home.

17 Remove shoulder roll and place the child in position of comfort with head elevated 30 degrees.

This position will facilitate the ease of breathing.