“NICU to Nursery – Tracheostomy Care in the Home Setting” by Janelle Nobrega for OPENPediatrics

a nurse is caring for a patient who has a tracheostomy tube with an inner cannula in place
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NICU to Nursery: Tracheostomy Care in the Home Setting by Janelle Nobrega. Healthcare workers in all healthcare settings should always adhere to the latest World Health Organization guidelines on hand hygiene and barrier precautions before and after contact with a patient, bodily fluids, or patient surroundings. For more information, please watch our video entitled Hand Hygiene. Part 1: Introduction to Tracheostomy Tubes. Tracheostomy tubes are available in a number of types, sizes, styles, and come in adult and pediatric sizes. Adult tracheostomy tubes usually have a locking inner canula, whereas pediatric tracheostomy tubes do not. For the purpose of this video, we will be focusing on tracheostomy tubes used in pediatric patients, including infants. Pediatric tubes are either cuffed or uncuffed. Cuffed tubes have an inflatable cuff that can be filled with air. This allows for a tight seal during ventilation support or to prevent aspiration of stomach contents into the lungs. Uncuffed tubes do not have an inflatable cuff and are most commonly used to encourage spontaneous breathing in patients or to improve air flow around the tube, allowing for improved vocalization. Both the cuffed and uncuffed tubes have an obturator within the tube to aid with insertion. Additionally, tubes can have straight or V-shaped flanges. Shiley and Bivona tubes are the most commonly used brands in pediatrics. The Bivona trach tubes are available with or without the cuff. Bivona trach tubes have what is called a tight-to-shaft technology so that the balloon appears when it is inflated with air and disappears completely when deflated. The Bivona FlexTend provides extra tube length externally, which is helpful for patients on ventilators, and in infants, as they have very little chin space. The extra tube length reduces irritation and erosion of the chin and upper neck area. Shiley trach tubes also come with and without cuffs. The cuff of the Shiley trach protrudes slightly into the airway when deflated. This may make it slightly harder to pass through the stoma and may block some air from passing around

the tube, making vocalization difficult. Advantages of the Shiley include a low-flange angle, which is said to improve fit for infant patients. And the Shiley pediatric trach tubes come in longer lengths to bypass airway obstructions. Part 2. Tracheostomy Care General Care Concepts. Safety checks. All supplies that may be needed to change a tracheostomy tube should be readily available at the bedside or within reach. Your bedside safety check should include a pulse oximetry monitor, a cardiac monitor if clinically indicated, a spare tracheostomy tube the same size currently in place, a spare tracheostomy tube one size smaller than currently in place, water soluble lubricant and a syringe for cuffed tubes, humidification, oxygen setup if clinically indicated, suction equipment and supplies, bandage scissors, and a self-inflating Ambu bag with a pop-off valve. An easy way to remember these items is the acronym MASHTT. M stands for monitor, cardiac, and pulse oximeter. A stands for Ambu bag with pop-off. S stands for suction. H stands for humidity. And the two Ts at the end stand for your spare trach the same size and your spare trach one size smaller. Suctioning. Suctioning a tracheostomy should be done at a minimum of every eight hours and as needed when clinically indicated by clinical assessment to ensure patency of the artificial airway. Depth of suction is determined by adding the shaft length of the tracheostomy tube to the adapter FlexTend length and then adding one centimeter so that you can suction just below the end of the tracheostomy tube. Apply suction while withdrawing the catheter for no more than five to 10 seconds per pass. Installation of saline is not routine practice and should only be utilized for thick secretions. We use clean technique for suctioning a tracheostomy. Humidification. All patients with a tracheostomy tube have either an active or a passive humidification device. Use an active humidification device while sleeping. Do not use a passive device when the patient is unattended or unable to remove the device him or

herself. An example of an active humidification device is a large volume nebulizer. If no supplemental oxygen is required and optimal aerosol output is desired, a large volume nebulizer can be operated. An example of a passive humidification device is a heat moisture exchange or an HME device. When utilizing an HME, check periodically and assure that it is clear of secretions. Replace the HME if secretions are visualized. After applying an HME, assess for changes in respiratory status, including work of breathing and tachypnea. Consider decreasing the use of an HME or changing to an active humidification device if there is an increase in the viscosity of airway secretions. If supplemental oxygen is required, you may utilize a large volume nebulizer or an HME. When utilizing a large volume nebulizer, ensure use of an oxygen flow meter and adjust the FD02 dial accordingly to maintain acceptable oxygen saturations for your patient per prescriber order. If supplemental oxygen is required with an HME, you must utilize an HME with an oxygen adapter. Connect the side port to oxygen via oxygen tubing. Adjust the flow accordingly to the patients oxygen requirement per prescriber orders. Consult your HME device manual to review the appropriate adjustment range of oxygen flow through an HME, as this may vary according to the manufacturer of the device. Point of clarification. An HME should not be worn at night or when the child is unattended because there is a possibility that an HME could become occluded with secretions. This may cause increased work of breathing and respiratory distress. Site care. Tracheostomy site care should be performed daily at a minimum. And tracheostomy times should be changed daily to allow for assessment of the tracheostomy stoma and the paristomal skin as well as the surrounding skin of the neck. Tracheostomy site care can be performed with sterile saline. Consider 1/4 strength hydrogen peroxide for sites with drainage. And consult your institutional experts for assessment as needed. Neck care can be performed with mild soap water.

Removing tracheostomy ties is always a two-person procedure. This procedure can be performed by any combination of nurses or caregivers. Ensure that only one small finger thickness can be inserted between the neck and the tracheostomy ties in the sitting or side lying position. The inner cannula of a double-lumen tracheostomy tube is cleaned or replaced at least once a day and as needed. A nurse or caregiver can change the inner cannula. Now we will review cleaning a tracheostomy site. The trach ties can stay on during this procedure. If the trach ties are intact, only one person is required to clean the trach site. However, if the ties are loose or if you are changing the trach ties, two people will be required to complete this procedure. The first step is to remove the soiled dressing by gently lifting up on the flanges and pulling out the soiled dressing. Next, in one hand, take a cotton tipped swab that is moistened with either normal saline or diluted hydrogen peroxide solution as prescribed. Gently lift the trach ties and flanges exposing the edges of the tracheostomy site. Clean the tracheostomy site with the moistened cotton tip swab. Twist the moistened cotton tipped swab in your fingers as you move around the edges of the tracheostomy site. At this point, while the trace site is exposed, you want to check the skin surrounding this area for any signs of redness, pus, granulomas, blood, or secretions. If signs of infection or bleeding are present, a discussion with the health care provider is warranted. Point of clarification. To prevent skin irritation and breakdown, ensure the site is dry prior to placing the dressing over the tracheostomy site. Once the tracheostomy site is clean, a new dressing can be applied to the tracheostomy site. To do this, take your new dressing and gently put it under the flanges and trach ties so that the dressing is directly against the skin. Use a new cotton tipped swab to aid in positioning

around the flanges of the tracheostomy tube. Emergency response. In the event of an unplanned decannulation, a tracheostomy obstruction, or if the patient is in any distress, call for help immediately and activate the emergency response. Attempt to replace the tracheostomy tube. Direct responders to your safety supplies, including the spare tracheostomy tubes present at the bedside. Institute basic life support measures as indicated until help arrives. Part 3: Home Care, Changing a Tracheostomy Tube. Equipment. All supplies that may be needed to change a tracheostomy tube should be readily available at the bedside or within reach. Preparation. Open the new tube package. If present, check to see that the cuff inflates properly. Practice removing the obturator from the new trach tube. Cut new trach ties and prepare the stoma dressing. Put the ties on the new trach. Apply water-soluble lubricant to the end of the new trach tube. Give or increase supplemental oxygen for five minutes before changing the trach tube if your doctor recommends to do so. Procedure. Have your child lie on his or her back, and place a blanket roll behind their shoulders so that the stoma site is visible. Suction if there is a buildup of secretions present. You will need two people to change the trach tube. Unfasten the trach ties on your child and take off the dressing. Deflate the cuff if present. Take out the trach tube. Wipe the stoma with a moistened gauze, and then wipe dry. Place the new tube with obturator in the stoma following the curve of the airway. Right away, take out the obturator while holding the tube in place. Place the child back on baseline support and replace the dressing and secure the trach ties. Make sure that one finger fits comfortably underneath the ties. Check to make sure your child is breathing comfortably after the trach change. Thank you very much for watching this video on our patient with a tracheostomy. Please help us improve the content by providing us with some feedback.

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Boston Childrens Hospital, OPENPediatrics, Nursing, NICU to Nursery: Tracheostomy Care in the Home Setting, Janelle Nobrega, Stoma, Trach, Bivona, Shiley, Fl…
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