Caring for Children and Young People with a Tracheostomy

1
Caring for Children and Young People with a
Tracheostomy

• Coventry and Warwickshire
• Education pack 1
• Liz Herd

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Introduction
What do you know about tracheostomy?
3
Do you have any concerns

• About caring for a child with a tracheostomy?

4
Ground rules

• We value the young people we care for we would
  never put them or you at risk
• Always ask any questions when they occur to you,
  weve all asked questions that may seem
  silly-there is no such thing as a silly question!
• Stop me if you dont understand- the chances are
  others dont either
• Tell me if you need a break

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110

• The children and young people rely on the
  assessors to ensure we deliver high standards of
  care-the assessors take this responsibility very
  seriously
• These high standards protect you as well as the
  young people
• We are incredibly privileged to be part of their
  lives we owe them 110

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Parent Experts

• All parents know their child/young person best
  They care for them daily
• Listen to them-act on what they say!!
• As a resource they are second to none Use
  Them-get to know the child as the parent does

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Patient dignity

• Always ask child/young person for consent when
  considering interventions
• Ask how they would like it done
• To be near and work with a tracheostomy is up
  close and personal- remember personal space where
  possible
• Where appropriate and safe care to be given at a
  time suitable to family

8
Hand hygiene

• As with all care hand hygiene is extremely
  important
• Please follow the 8 point plan and repeat steps 5
  times
• Wash hands as required through out the procedure

9
Hand hygiene

• You may use alco gel if required but this must be
  on clinically clean hands only!

10
Patient Privacy

• Tracheostomy requires a lot of input from various
  professionals.
• Privacy means that the family including the child
  may not be discussed with people who do not need
  to know or with whom you have no consent to share
  information.

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Definition of a tracheostomy

• A tracheostomy is a surgical opening in the
  trachea between the second and fourth rings
  (Campbell d Glasper 1995)

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Anatomy and Physiology of respiration

• Normal Respiration
• What gas do we breath?
• Where does gaseous exchange take place?
• Name the differences between inspired and expired
  air

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Functions of structures within upper respiratory
tract

• Mouth
• Nose
• Pharynx
• Larynx
• Epiglottis
• Voice box/Vocal cords

14
Tracheostomy

• Temporary
• (Not longer than 6 months)
• Permanent
• (Longer than 6 months but may be removed if
  appropriate to treatment)

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Common Reasons for tracheostomy

• Temporary
• Inflammation-following allergy burn or scald
• Acute infection-causing swelling and difficulty
  in breathing
• Facial trauma-to bypass upper respiratory tract
  infection
• Foreign body lodged in upper respiratory tract

• Permanent
• Tracheo-bronchomalacia- a condition where the
  trachea and bronchus are narrowed at birth and
  rings are floppy
• Trauma-Following spinal Damage
• Long term ventilation

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Reasons for tracheostomy

• Congenital
• Tumours
• Cystic Hygromas
• Abnormal craniofacial anatomy
• Tracheal Malacia
• Degenerative Diseases
• Sleep disorders
• Vocal cord palsy

• Acquired
• Foreign object
• Epiglotitis
• Croup
• Tracheo-malacia
• Facial trauma
• Spinal Trauma
• Vocal cord palsy

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Management of tracheostomy

• Priorities
• To maintain and protect the child/young persons
  airway
• To ensure the air breathed is warm and moist
• To promote speech where possible if not possible
  to support child/young persons method of
  communication

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Methods of protecting the airway

• Filters-humicoils, Swedish noses, T vents
• Use of nebulisers
• Suction using correct equipment-in child
  appropriate way
• Being able to replace tracheostomy tubes
  immediately, if it is blocked

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Psychosocial aspects of care

• Body Image
• Different from peers
• Who will baby-sit?
• Will I be able to speak?
• If no speaking tube will I be ignored?

• Fear of Blockage
• Parental Concerns-re letting go
• Extra equipment must be carried
• How do I transport this equipment

Task!
List 10 More psychosocial issues raised with
having a tracheostomy
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Planned tube changeRequirements

• Planned at a time to suit the child-i.e. after
  school
• A clean environment offering privacy with hand
  washing facilities
• Child to have neck extended in the position/young
  person chooses
• Always ask child/young persons consent and listen
  to and take account of child/young persons
  requests!
• 2 Staff, or parent and one competent staff member
  to be present at all planned tube changes!!
• Take this opportunity to observe the stoma and
  the neck for signs of infection
• Always offer suction prior to tube changes

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Equipment Required for routine tube change

• Tray
• Alco-wipes
• Hand washing facilities
• Alcogel
• Normal saline/warm water (for cleaning)
• Galipot
• Scissors
• Oxygen (if required)
• Ambubag

• Working suction machine set at appropriate
  pressure
• Gloves
• Suction catheters
• Child tube size
• Plus new tube, smaller size
• Tapes or velcros
• Oxygen Saturation monitor (If required)
• Gauze swabs/Trachy applicators

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Equipment Tray
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System for changing tube

• Tube should be changed using 1/2/3 method
• 1 unties and removes used tube-ensuring the tube
  does not fall out accidentally
• 2 places clean tube in stoma and holds it there
  until tube is secured by carer number 1
• 3 ensure tube is secure whilst cleaning of stoma
  and neck take place

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Practical Demo on doll
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Important
ALWAYS Ensure child/young Person is comfortable
and breathing comfortably and well following
tracheostomy tube change!!
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Emergency tube change

• 2 failed suction attempts-child not improving
• Shout for help
• Tube out
• Tube in - introducer out
• Tube secure
• Ensure adequate respiration
• Reassure child/young person throughout

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Neck care

• Extremely important we only get one neck
• Do NOT tie tapes too tight
• Do NOT leave wet tapes on
• Ensure edge of velcro cannot scratch skin
• Tie using reef knot-flat knot
• Always have 2 competent people to change tapes
  because of the risk of de-cannulation

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Cleaning Neck
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Get Knotted!

• Tapes should be secured with a reef knot
• This is what you do!
• Right over left and under then left over right
  and under and then pull

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Stoma care

• The stoma should be cleaned as required
• This may be done with the tapes tied
• LOOK FOR
• Signs of infection
• Signs of trauma
• Signs of granulation
• Signs of bleeding

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Record Keeping

• All usual record keeping rules apply

current
consistant
accurate
concise
fit for purpose
ledgible
consecutive
factual
contemporanious

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Tracheostomy Specific Records

• Should include
• How often child/young person has required suction
  throughout shift
• Describe colour, consistency and smell of
  secretions
• Describe breathing or change in patterns of
  breathing
• Any thing different for that child/young person

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Tube change records should include

• Good or difficult change
• Reason for change
• Condition of stoma
• Condition of neck
• Who changed the tube
• Who witnessed the change

• Consistency and colour of secretions
• Batch number of tube
• If tube is to be reused
• number of days used
• Condition of tube when removed

Child/young persons condition following tube
change
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Rules!

• Carer will need to do 2 good tracheostomy changes
  with the child/young person
• Carer will need to do 3 changes throughout the
  year to maintain competency
• So far in 12 years of this training we have had
  to do an emergency tube changes 3 times but they
  have been in the last 2 years
• Carer must do Tracheostomy suction training and
  competency in conjunction with this training

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Dont Worry!

• In 10 years of delivering this training we have
  never had to do an emergency tracheostomy tube
  change
• Time is not an issue-safety is

• You will always have support phone numbers
• These children are very important to us we will
  not sign you off as competent till we are sure
  you can care for the child/young person safely

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References

• References
• Coventry Teaching Primary Care Trust Hand
  Hygiene Policy February 2006.
• Coventry Teaching Primary Care Trust Clinical
  Waste Disposal Policy 2003
• Coventry Teaching Primary Care Trust
  Tracheostomy Tube Cleaning Policy March 2006.
• Coventry Teaching Primary Care Trust Consent for
  treatment Policy April 2004
• Essence of Care D.O.H 2001 Standards 10
  Record Keeping
• 
  11 - Privacy and Dignity
• Wilson M (2005) Paediatric tracheostomy.
  Paediatric Nursing. 17,3, 38-44.
• Barnett M (2005) Tracheostomy management and
  care. Journal of Community Nursing 19 1 4-8