What is an appropriate step for the nurse to take when providing tracheostomy care when the tracheostomy tube has a reusable inner cannula?

Use our resource to help you learn how to take care of your child’s tracheostomy (trach) at home. As you learn about the care your child needs, you may have a wide range of feelings. Please feel free to talk about your feelings or concerns with the nurses and doctors who are caring for your child.

Before you leave the hospital, you will have many chances to practice all of the things that you will need to do at home. A nurse will always be with you as you are learning. You may find that reading this page answers many of your questions. It may also help you to think of more questions. Please write down your questions so that you can ask your team when you see them. If anything in these pages is confusing, please ask your nurse to explain it. The more you understand about your child’s medical condition and care, the more comfortable you will feel at home.

Below you will find the following information: 

• Normal Breathing 
• The Tracheostomy
• Home Care vs. Hospital Care 
• Tracheostomy Skin Care 
• Changing Tracheostomy Ties 
• How to Suction the Tracheostomy
• How to Change a Tracheostomy Tube 
• Emergency Care
• Additional Information 

Please note: This information is for informational purposes only and is not intended to substitute in any way for medical education, training, treatment, advice, or diagnosis by a healthcare professional. Lurie Children’s makes no warranties related to the information in this document. A qualified healthcare professional should always be consulted before making any healthcare-related decision.

Home Care vs. Hospital Care

While your child is in the hospital, you will notice that the nurses will practice sterile technique versus the clean technique which you will be using at home.

Sterile technique includes:

• Hand washing
• Wearing sterile gloves
• Using a new trach tube and tie

Clean technique includes:

• Hand washing
• Using gloves is optional
• Re-using a trach tube that has been properly cleaned
• Re-using the same trach ties if they are not soiled or wet

Since the home environment has fewer germs and fewer sick contacts, the clean technique can be used. For this reason several adaptations have been made. At home you may reuse tracheostomy tubes by using the proper technique for cleaning trach tubes. You may also reuse suction catheters, but only in emergencies (for example, if your size suction catheter is on backorder from your home health company or if you are traveling and have underestimated the amount of catheters you would need while away).

Tracheostomy Skin Care

The skin around your child’s trach needs special care. Your nurse will also teach you how to clean the stoma in the hospital. Secretions (mucus) from the trach can cause the skin to become red and sore if allowed to remain on the skin for too long. As much as possible, the skin should be kept clean and dry. Several times a day, you should clean the skin around the trach tube.

The supplies needed are:

• Wash basin with warm water
• Mild soap
• 2-3 clean washcloths
• Clean velcro trach ties (if ties need to be changed)
• Scissors

Proceed as follows:

• Wash your hands thoroughly with soap and water before beginning
• Dip a corner of the washcloth in the warm water
• Squeeze the water out and apply a very small amount of the mild soap to the wet cloth.
• Rub the corners of the cloth together until the soap is absorbed into the cloth
• Remove soiled or wet trach ties and be sure to secure the trach tube with one hand
• Start as close to the stoma as possible
• Clean the skin with the soapy washcloth wiping away from the trach opening
• Wipe in one direction and never wipe in a back and forth motion
• Repeat the technique with another clean corner of the washcloth until all mucus or drainage has been removed
• Dip another corner of the dry washcloth into the warm water
• Squeeze dry and rinse soap from around the stoma (wipe in one direction)
• Take the second dry washcloth and dry the skin thoroughly
• You may now clean the rest of your child’s neck
• Avoid using baby oils, lotions or ointments unless ordered by your doctor
• Thread new velcro ties and fasten in back of neck
• Trach ties come in varying widths, so make sure that you have the appropriate size for your child

Changing Trach Ties

You will need to cut the trach ties to fit your child’s neck. You have a long end and a short end of the trach ties. You will be cutting the long end. Don’t be afraid to cut the tie. It should not be so long as to lie underneath the phlange (wings). You may also round the edges and cut off the label for your child’s comfort. It is a good idea to use a spare set of trach ties already cut to the correct size to use as a guide when cutting another set of trach ties.

There are two sides to the trach ties. There is a dull side which lies next to your child’s neck. The fluffy side lies outward and is the side where the Velcro side will stick. You should not be able to place more than one finger’s width between the trach tie and your child’s neck.

You may place a dry gauze trach dressing between the skin and the trach tube if a lot of tracheal secretions are present. These dressings need to be checked for drainage and changed at least every 2 hours. Make sure the dressing does not cover the trach opening. This would make it difficult for your child to breathe.

Call your doctor if you see any skin breakdown.

How to Suction the Tracheostomy

In our review of the importance of suctioning, we will cover:

• Signs and symptoms that indicate the need for suctioning.
• Supplies needed to suction.
• Step by step instructions on how to complete the suctioning process.

Keeping the trach free of secretions is very important. However, mucus is a normal part of every person’s airway. It helps protect the respiratory system by filtering out dust, dirt and some germs which are inhaled with the air we breathe. Sometimes we have more mucus than usual, such as when we have a cold.

The tracheostomized child cannot close off their airway to create enough pressure when coughing to remove secretions. By inserting a small catheter into the trach tube, mucus is removed and the child can breathe more easily. Effective suctioning can decrease the possibility of upper airway infections, pneumonia and a possible oxygen requirement.

At first, your child may pull away or cry when you try to suction. Suctioning is a little uncomfortable because it causes coughing, but it should not hurt your child. Try to remember that you are helping your child to breathe easier when you suction. Also think about what you are doing, rather than how your child is acting when you suction.

Signs that Indicate a Need for Suctioning

• Seeing mucus in the opening of the trach tube or hearing mucus in the airway
• Increased respiratory rate or effort
• Retractions (which is seen when the skin between the ribs pulls in while breathing)
• Nasal flaring (which is seen when the nostril flares out when your child breaths in)
• Change in skin color from normal to pale or blue
• Changes in activity, such as if your child is upset or inconsolable, or appears to be sleepy
• Increased coughing

Other times to suction include before eating or before and after sleeping. Be aware that every sound your child makes does not mean they need to be suctioned. Do not get stuck in the suction cycle, where the more you suction the more secretions you create.

Call your doctor if you notice thick secretions that are yellow or green in color.

Supplies Needed for Suctioning

• Self-inflating bag (if your child is on oxygen or on a ventilator)
• Normal saline
• Sterile suction catheter kit
• Suction source
• Oxygen (if your child requires it)

Steps for Suctioning

• Wash your hands thoroughly with soap and water before beginning
• Open suction catheter kit and open saline
• Put on sterile gloves
• Attach suction source to the catheter
• Test the force of the catheter by drawing up sterile water through the suction catheter
• Measure a pre-set length of the catheter that you will insert into the trach tube
• Make this measurement by inserting a catheter into a trach tube that is the same size as your child’s tube and extend it approximately 1 – 1½ mm past the tip of the tube (this is how far you will insert the catheter for suctioning)
• Keeping your thumb off the valve, gently insert the catheter into the trach tube
• Make sure that you are only inserting the pre-set length
• If your child does not clear his airway, you may have to insert the tube a little farther (DO NOT FORCE THE CATHETER.)
• Place your thumb on the suction control as you pull the catheter out
• Roll the catheter between your fingers as you withdraw
• The catheter should only stay in the trach tube for 5-10 seconds at a time because your child cannot breathe during suctioning
• Squirt 2-3 drops of saline down the tube if the mucus appears thick (this will make your child cough, so suction immediately; this should not be done routinely and should only be done if needed)
• Between suctioning, give your child 2-3 breaths with the self-inflating bag if needed
• If your child still sounds noisy, suction 2-3 more times until your child sounds clear
• Once your child sounds clear, do not suction again
• Suction a small amount of water through the suction catheter to clear the mucus from the connective tubing

How to Change a Tracheostomy Tube

This section will cover:

• When to change the trach tube
• Supplies needed for the change

Changing your child’s trach may seem difficult at first. However, after watching the nurse change the trach and practicing the procedure yourself, you will soon be comfortable enough to do it independently. It is always a good idea to have another person available to assist in trach changing. One person will change the tube and the other will assist in keeping the child occupied so that the tube change goes smoothly.

The best time to change the trach is when your child is comfortable and when you do not feel hurried. This may be when your other children are sleeping or when your child is distracted. It is important to incorporate the trach change as part of your child’s routine. Never change the tube when your child is sleepy, hungry or irritable. They will not be cooperative. It is not a good idea to change the trach after eating because this may cause your child to vomit.

Supplies Needed

• Sterile trach tube with obturator while in the hospital (clean tube when at home) Individual saline droppers
• Wash basin with warm water
• Two washcloths
• Mild soap
• Surgilube
• Sterile suction catheter
• Rolled blanket
• Blunt tipped scissors
• Clean velcro trach ties

Once you have gathered your supplies you are ready to begin. First, review the parts of the trach tube:

• The wings
• The obturator
• The cannula

Then, you can begin with the trach change:

• First, wash your hands thoroughly with soap and water before beginning
• Using the rolled blanket, position your child so their chin is pointing to the ceiling and their head is tilted back
• It is important not to tilt the head too far back because this will make it more difficult to insert the tube
• The head should be tilted in a natural position
• If you have a small child or baby, it is easier to change the trach while he is lying down An older child can sit in a chair or stand if physically able
• Put on your gloves and suction the child prior to preparing for the trach change Depending on your child’s needs you may have to ventilate them with the self-inflating bag
• Get your sterile or clean trach tube ready by inserting the obturator into the cannula and attaching the velcro ties to the tube
• Cut the trach ties to fit your child’s neck
• Lubricate the end of the trach and place it back on to your working area
• If your child is wearing a cuffed tube, inflate and deflate the cuff to make sure that the cuff is working properly
• Have your helper hold the old trach firmly in place while you undo the Velcro ties Whenever the ties are not fastened your child may be able to cough the trach out

Be careful not to touch the trach cannula while changing the tube. You do not want to contaminate the cannula. If at any time your child needs suctioning before the procedure is completed, have your helper hold the tube by keeping their hand on the wings. Then, suction as needed. When finished, continue with the tube change.

• On the count of three, have your assistant remove the old trach and lay it to the side
• Your child will be able to breathe for a few seconds while you reach for the new trach tube
• Pick up the new trach and make sure to hold the obturator firmly in place
• The curve of the tube should be inserted downward toward the trachea
• Insert the new tube removing the obturator as quickly as possible with your free hand while still holding the new trach in place
• Next, secure the ties around your child’s neck
• Check to make sure you can get no more than one finger under the trach ties
• Never let go of the trach until the ties are secure
• If the trach leans to the left or right, the ties are too tight
• Disinfect the old trach tube and wash your hands
• If you decide to disinfect the trach at a later time, it is important to immediately rinse the tube under running water to prevent the drying of any secretions
• Let the tube completely air dry before putting it into a container to properly sanitize at a later time

Cleaning & Sanitizing the Trach Tubes

There are two different kinds of tracheostomy tubes used at Lurie Children’s:

• Plastic trach tubes, also known as Shiley tracheostomy tubes
• Silicone trach tubes, also known as Bivona tracheostomy tubes

If your child has a customized tube, it can be used for 3-4 months before ordering new tubes. Talk to your ENT doctor about how many times you can reuse the trach tubes before throwing them away.

How to Clean the Uncuffed Plastic Shiley Trach Tubes
Supplies needed:

• Dirty trach tube and its obturator
• Mild soap and water
• White vinegar
• Clean container or a new zip lock plastic bag
• Paper towels
• Pen and tape

Directions:

• Clean the tube and obturator with soap and water
• Using the obturator clean any mucus from inside the tube
• While cleaning, look for cracks or sharp edges (if you find any, discard the tube)
• Rinse the tube and obturator well in water
• Soak in ½ strength vinegar and water for 2-3 hours in a clean container
• Rinse the vinegar solution off and place the trach on a clean, dry paper towel to air dry
• Place a clean paper towel over the wet tube and obturator to protect from dust and let dry overnight
• Once the tube is dry, handle it by the wings only Inspect it again for any damage
• Store in a clean container or zip lock bag
• Label with the size of the trach tube and the date cleaned on the outside of the container or bag

Cleaning the Silicone Bivona & the Cuffed Shiley Trach Tubes

Refer to section above for Uncuffed Shiley trach tube cleaning directions.

• Supplies needed:
• Dirty trach tube and obturator
• Mild soap and water
• Pot or container for boiling water
• New zip lock plastic bag
• Paper towels
• Pen and tape

Directions:

• Clean the tube and obturator with mild soap and water using the obturator to clean any mucus from inside the tube
• While cleaning, look for any cracks or sharp edges (if you find any, discard the tube) Rinse well with water
• Boil water in a pot and remove from direct heat or microwave water until it is boiling hot Place the trach tube and obturator into the hot water
• Leave the tube and obturator in hot water until the water is cool enough to pull the trach out using your bare hands (never boil tracheostomy tubes over direct heat)
• Allow water, tube, and obturator to cool
• Place on a clean dry surface such as a paper towel
• Place a clean paper towel over the wet trach to protect from dust and let dry overnight Store in a clean container or zip lock plastic bag
• Label the container with the size of the tube and date cleaned

Emergency Care

Learn about prevention of an emergency situation, and what to do if:

• Your child has trouble breathing or stops breathing
• You cannot insert a trach tube
• The trach falls out

These preventive measures may help to avoid some problems:

• Make sure your child is getting enough humidity – humidity will keep the mucus loose and decrease the chances of a mucus plug (if you hear a whistling sound from the trach, this might mean that your child’s airway is dry)
• Always make sure the trach ties are securely fastened and are tight enough around your child’s neck
• Make sure that the trach is open to air and that nothing is blocking it such as clothing or bedding
• Always have your child nap or sleep with their apnea monitor or pulse oximeter on  and do not discontinue their use unless discussed with your ENT doctor

If Your Child Has Trouble Breathing

Signs and symptoms of difficulty breathing are:

Retractions: Pulling of the skin between the ribs, under the breastbone or around the trach itself
Sweaty and pale skin: Your child is sweaty and pale and seems to be working hard to breathe while at rest.
Dusky lips or nail beds: Your child’s lips or nail beds look dark, dusky or blue
Feeling restless or frightened: Your child is restless or looks frightened for no apparent reason

The most common reason for breathing problems, other than an illness, is that the trach tube becomes plugged with dried mucus. Making sure your child is getting enough humidity can help prevent this problem. However, if the trach does become plugged, try to remove the plug by suctioning.

If you have trouble passing the catheter into the trach and it feels tight, put a few drops of saline into the tube and try to suction again. Do not force the catheter; it may push the plug in further. If you are unable to remove the mucus plug, change the trach tube and try to suction again.

If Your Child Stops Breathing

Remember the ABCs of CPR

• A-AIRWAY – Check to make sure that the tube is open to air. Look, listen and feel for air coming from the trach and watch the chest for movement. Position your child’s head so that the neck is exposed.
• B-BREATHING – Use your mouth or self-inflating bag to give your child two breaths through the trach. Feel for air leaking from the nose and mouth. If this happens, cover the mouth and nose with your hand. If you cannot pass air through the trach, change the tube. You should squeeze the bag slowly and gently with only enough force to see the chest rise.
• C-CIRCULATION – Check for signs of movement such as coughing or signs of breathing after giving 2 breaths. After giving the two initial breaths, start compressions.

If someone is available, have them call 911. If no one is available, perform CPR for one minute then call 911. Continue CPR as you were taught until help arrives. You will not be sent home without learning CPR. This will be taught to you while your child is here in the hospital.

When You Cannot Insert a New Trach Tube

If you are having difficulty inserting a new trach tube, make sure your child’s head is in the correct position and try to insert the new tube again. If it still will not go in, try to put the old tube back in. The old tube that was removed should be able to go back in without difficulty.

Emergency steps to follow if the new or old tube cannot be inserted:

• Use smaller step-down tube (1/2 size smaller than the original tube) and notify your doctor if the smaller tube is used
• The longer the smaller tube is in, the more difficult it will be to insert the original size tube
• If you are unable to insert the step down tube, have someone call for emergency help
• Do not panic if your child passes out
• If your child passes out, the neck muscles will relax, and you may find it easier to insert the trach tube at this time

If the Trach Tube Falls Out

If the trach tube comes out accidentally, you will need to act quickly and calmly. Remember that you have changed the trach many times before.

• Always have a clean tube and ties available
• If you do not, quickly put the old trach back in until you can get a clean tube
• Put the obturator in the tube and lubricate
• Insert the tube and quickly remove the obturator
• Secure the tube and ties

Daily activities

Bathing

Give your child a bath in a shallow tub. Never leave them alone in the bathtub. When bathing, never allow water to enter the trach tube. If it does, suction immediately.

Do not use powder or aerosol sprays around a tracheostomy. These products may cause irritation or breathing problems.

Clothing

You may dress your child according to your taste. However, avoid clothes that could cover the trach opening such as turtlenecks. Avoid necklaces, beads, strings or fuzzy clothes because the fibers or tiny beads could get into the trach and cause breathing problems.

Play

Older children should avoid contact sports. Sand boxes and water sports are allowed with close supervision. Physical education is allowed if age appropriate and not too strenuous.

• When playing or traveling outdoors wear an artificial nose over the trach tube (never sleep in the artificial nose)
• Use the trach collar with heated humidity
• Never leave your child alone
• Anyone taking care of your child must be trained in the care of a child with a tracheostomy and be CPR certified

Sleep

All children with trachs go home with either a pulse oximeter or apnea monitor. They should be placed on the monitor when their activity is not being directly supervised. Use the monitor any time your child is asleep, whether for a nap or for the night.

Additional Information

Case management is available at Lurie Children’s to assist you in obtaining all the supplies needed for home care. Before your child is discharged from the hospital, a nurse case manager will meet with you to discuss your family’s needs. They will assist you in managing hospital and community services.

In addition, you and your secondary care giver will be asked participate in a 24-hour stay before you take your child home. This means you will be responsible for doing all of your child’s care for a 24-hour period while in the hospital. The nurses will be available to answer questions during this time as you become independent in providing your child’s care.

Your child will need a wide variety of supplies and equipment at home. These will be provided by a durable medical equipment (DME) company. The selection of this company will be made by you, assisted by the case manager. You will meet with a representative from the company prior to discharge. Instructions on use of the equipment, delivery and reordering of supplies will be reviewed prior to discharge. When your supplies are delivered to your home, you will find it helpful to keep everything organized and within reach.

When leaving the house with your child, you must bring all emergency equipment and portable suction. Refer to the transport bag supply list that your nurse has given you. When traveling in a car, it is very important to have a person knowledgeable in your child’s care sitting next to your child in case there is an emergency while driving.

 If you are traveling alone with your child, attach him to his pulse oximeter and drive in a lane such that it is easy for you to pull out of traffic if the alarm goes off and you have to attend to your child.

Note:  These pages have been adapted for the website from materials developed by contributors Linda Downs, RN; Ann Beland, RN, BSN; Pat Reamer, RN, BSN; Lindsay Hird, RN; and the 9 West Education Committee. Editors Suma Rao-Gupta, MPH, and illustrator Adrienne Boutwell also contributed to the effort.

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