Definition of the Case/ Background of Disease

What is a tracheostomy?

A tracheostomy is a medical procedure — either temporary or permanent — that involves creating

The tube is inserted through a cut in the neck below the vocal cords. This allows air to enter the
lungs. Breathing is then done through the tube, bypassing the mouth, nose, and throat.

A tracheostomy is commonly referred to as a stoma. This is the name for the hole in the neck that
the tube passes through.

What is a tracheostomy tube?

Tracheostomy tubes are available in several sizes and materials including semi-flexible plastic, rigid
plastic or metal. The tubes are disposable or reusable. They may have an inner cannula that is either
disposable or reusable. The tracheostomy tube may or may not have a cuff. Cuffed trach tubes are
generally used for patients who have swallowing difficulties or who are receiving mechanical
ventilation. Non-cuffed trach tubes are used to maintain the patient’s airway when a ventilator is not
needed. The choice of tube is based on your condition, neck shape and size and purpose of the
tracheostomy.

All trach tubes have an outer cannula (main shaft) and a neck-plate (flange). The flange rests on your
neck over the stoma (opening). Holes on each side of the neck-plate allow you to insert trach tube
ties to secure the trach tube in place.
Postoperative considerations

Nursing care post op

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 and until after the
first routine tracheostomy change.

 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. (see attached form)

Note: 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 or require positive pressure ventilation/CPAP via the tracheostomy.

Drug study accrdg to case

Etomidine

Ketamine

Propofol

Atropine

Lidocaine

fentanyl

Health teachings

What do I need to know after going home with a tracheostomy?

 Immediately after the tracheostomy, you will communicate with others by writing until your
healthcare provider gives you instruction for communication techniques.
  Do not remove the outer cannula unless your healthcare provider has instructed you to do
so.
 Use tracheostomy covers to protect your airway from outside elements (such as dust, cold
air, etc.) Ask your healthcare provider for more information about tracheostomy covers and
where to purchase them.

Contact your healthcare provider or physician immediately when:

 If you have an irregular heart rate.

 If you have difficulty breathing and it is not relieved by your usual method of clearing
secretions.
 When secretions become thick, if crusting occurs or mucus plugs are present. Your physician
may recommend increasing your fluids or using cool mist humidification.
 If you have any other problems or concerns.

How do I take care of my tracheostomy tube?

The nurse will teach the proper way to care for your tracheostomy tube before you go home.
Routine tracheostomy care should be done at least once a day after you are discharged from the
hospital.

Gather the following supplies:

* Two non-sterile gloves

* A clean basin (or sink)

* Hydrogen peroxide

* Clean 4 x 4 fine mesh gauze pads

* Normal saline or tap water (Use distilled water if you have a septic tank or well water)

* Clean cotton-tipped swabs

* Clean pipe cleaners or small brush

* Clean washcloth

* Clean towel
* Trach tube ties

* Clean scissors

Wash your hands thoroughly with soap and water.

Stand or sit in a comfortable position in front of a mirror (in the bathroom over the sink is a good
place to care for your trach tube).

Put on the gloves.

Suction the trach tube. (Your healthcare provider will give you more information about the
suctioning procedure).

If your tube has an inner cannula, remove it. (If the trach tube does not have an inner cannula, go to
step 12.)

Hold the inner cannula over the basin and pour the hydrogen peroxide over and into it. Use as much
hydrogen peroxide as you need to clean the inner cannula thoroughly.

Clean the inner cannula with pipe cleaners or a small brush.

Thoroughly rinse the inner cannula with normal saline, tap water or distilled water (if you have a
septic tank or well water).

Dry the inside and outside of the inner cannula completely with a clean 4 x 4 fine mesh gauze pad.

Reinsert the inner cannula and lock it in place.

Remove the soiled gauze dressing around your neck and throw it away.

Inspect the skin around the stoma for redness, hardness, tenderness, drainage or a foul smell. If you
notice any of these conditions, call your nurse or physician after you finish routine care.

Soak the cotton-tipped swabs in a solution of half hydrogen peroxide and half water. Use the swabs
to clean the exposed parts of the outer cannula and the skin around the stoma.

Wet the wash cloth with normal saline, tap water or distilled water. Use the wash cloth to wipe away
the hydrogen peroxide and clean the skin.

Dry the exposed outer cannula and the skin around the stoma with a clean towel.

Change the trach tube ties.

* Measure and cut a piece of tie long enough to go around your neck twice. Cut the tie at an angle
(Illustration 17c.) so it is easier to insert the tie into the neck-plate.

* Untie one side of the old tie and remove that side from the neck-plate. Do not completely remove
the old tie until the new one is in place and is securely fastened.

* Holding the trach tube in place, lace the tie through one hole of the neck-plate, around the back
of your neck, through the other hole of neck-plate, and again around the back of your neck.
* Pull the tie snugly and tie a square knot on the side of your neck. There should be enough space
for no more than two fingers between the tie and your neck. (Illustration 17d.)

* Cut, remove and discard the old tie. If you have a cuffed trach tube, be careful not to cut the cuff
balloon when removing the old trach tube tie.

Place a fine mesh gauze under the tracheostomy tie and neck-plate by folding it or cutting a slit in it.

*Note: Some brands of mesh gauze are pre-cut.

Important: Do not use 4 x 4 gauze or toppers – they contain cotton fibers which could clog your
airway. *

Remove your gloves and throw them away.

Wash your hands with soap and warm water.

Wash the basin and small brush with soap and warm water. Dry them and put them away.

Put the used washcloth and towel in the laundry.

Wash your hands again with soap and warm water.