Background
More children with chronic medical conditions are surviving, largely because of advances in medical and tracheostomy care and technology support. The vast majority of these children are now being cared for in their own homes and at school.
Tracheostomy is one of the oldest surgical procedures and was first successfully performed on children in the late 19th century. Today, it is a common procedure and is life saving for many infants and children requiring airway and respiratory support. However, despite providing a safe and ‘protected’ airway, paediatric tracheostomy is often associated with significant morbidity and mortality.
A tracheostomy is an artificial opening in the trachea, usually between the third and fourth tracheal rings (see Figure 9.1) into which a tube is inserted and through which the child breathes. A tracheostomy is initially a life-saving operation, but is also a life-threatening one unless the airway is kept clear from secretions and blockages 24 h a day.
Children with tracheostomies require constant supervision from those trained fully in their care.
Indications for tracheostomy in a child
The following are the most common indications for tracheostomy in children include.
Differences between adult and paediatric airways
There are a number of important anatomical and physiological differences between the adult and paediatric airways (Figure 9.2). Clearly, there are emotional, psychological and practical differences to also address, including the additional relationships that must be forged between the tracheostomy teams and the child and the parents.
Figure 9.2 (a) Relative differences between adult and paediatric airways. Note the relative sizes of the tongue and the angle of the epiglottis and (b) The laryngeal aperture of a child is relatively (and physically) smaller than the adult.
The child’s cervical spine is more flexed than that of an adult and this combined with the relatively larger head and tongue, predisposes to airway obstruction. The larynx itself is situated higher in the neck than in the adult and the epiglottis is longer and less flexible. Intubation is performed in a slightly modified way in the child, often using a straight blade to elevate the epiglottis from ‘behind’. A more conventional (adult) blade can usually be employed from 12–18 months of age depending on the child and operator preferences. By the age of 8, most children can be considered to have an adult larynx, although of much smaller calibre.
The narrowest part of a child’s airway is at the level of the cricoid (see Figure 9.3). This can be as small as 4 mm in the neonate. A minor degree of swelling or airway obstruction will cause a significant increase in resistance to airflow.
Figure 9.3 In the child’s larynx (a), the airway is narrowest at the cricoid in contrast to that of the adult (b).
Nursing and general care of the paediatric tracheostomy patient
Preparation of essential equipment and environment
The child’s bed area must always be made easily accessible from both sides without obstruction, as the child’s airway is at risk and may need immediate attention. All bedside equipment must be checked whenever a practitioner takes over the care of a ‘tracheostomised’ child, including breaks and transfers to another ward/department. The child MUST NEVER be left alone.
The accompanying carer (including parents, where applicable), as a minimum, must be able to:
- recognise signs of airway obstruction
- initiate suctioning of tracheostomy tube.
The child should have a dedicated tracheostomy trolley by the bedside containing:
- oxygen saturation monitoring—if oxygen therapy is required
- suction catheters—correct size to safely suction tracheostomy tube
- clean gloves to minimise the risk of cross-contamination
- clean gauze to clean stoma/secretions
- clean receiver with tap water to flush through suction tubing after use
- 2 ml syringe
- ampoules of 0.9% sodium chloride for irrigation
- yellow waste bag ‘for incineration’
- goggles/protective eye wear should be available
- an ‘emergency trachi box’ with the following contents:
- a spare tracheostomy tube (same size and make)
- a tracheostomy tube (one size smaller)
- a water-based lubricant, such as Aqualube ® or KY Jelly®
- round-ended scissors (safer cutting of tapes)
- spare tracheostomy tapes
- a suction catheter (same ID as the suction catheter) to ‘railroad’ a new tube into the stoma (Seldinger technique).
- a spare tracheostomy tube (same size and make)
Appropriate resuscitation and suction equipment with correct tracheostomy fittings (15 mm swivel connector and a male adaptor for GOS, Silver & Montgomery tubes) checked and in full working order. A tube with a 15 mm termination requires a Smiths Medical (Portex©) swivel connector, which can be added to the resuscitator and must be available at the child’s bedside. A flat-ended tube requires an appropriately sized tracheal tube adapter and a Smiths Medical (Portex) swivel connector that will ‘slip into’ the tube as required to create a 15 mm termination that will be compatible with resuscitation equipment.
As with adult patients, tracheal dilators are not automatically recommended as essential bedside equipment. They should be available in the immediate area but not necessarily at the bedside unless specifically required. They should only be used by staff who are competent to do so.
Initial care following tracheostomy
Nursing actions during the first 7 days following formation of the tracheostomy centre on maintaining the correct positioning and patency of the new tube, stoma maintenance and parental teaching (if appropriate). As with newly formed adult tracheostomies, replacing a paediatric tracheostomy tube within the first week can be problematic and so the focus of care is ensuring the existing tube remains patent. Communication between the hospital and community health carers must be commenced following surgery to ensure effective and timely discharge planning.
The initial nursing care of a child with a tracheostomy is very different from that for an established stoma. At GOSH, the first tube change occurs after 1 week, which allows sufficient time for the stoma tract to mature. Other units have advocated changing the tube after as little as 3 days. The Tracheostomy Nurse Practitioner (TNP) or an appropriate head and neck surgeon will perform the first tube change.
To ensure the safety of the airway, the trachea is sometimes sutured onto the child’s skin with tiny interrupted disposable sutures—these are called ‘maturation sutures’. These ‘maturation sutures’ will help to form a more permanent and safer stoma, especially if the tube requires changing in the first week. In addition, two long-looped ‘stay’ sutures extend from inside the stoma and are taped to the child’s chest (Figure 9.4). These sutures are attached to the tracheal wall on either side of the stoma. These ‘stay sutures’ will assist with the opening of the stoma during the first week, by raising the trachea to the skin surface and pulling the stoma apart so that a tube can be inserted. The tape on the child’s chest will be labeled ‘DO NOT REMOVE’ (for the first 7 days following the procedure) and will be removed after the first tube change.
Observations
The child’s vital signs should be recorded in accordance with local policy, with the frequency reducing as the child’s condition dictates. Practitioners should also carry out routine non-invasive observations to rule out the following potential initial complications.
- Check that the tape tension is correct and able to support the tracheostomy tube.
- Observe if there is any neck swelling (surgical emphysema—see subsequent text).
- Check for air entry through tube—place finger above tube opening and feel for the flow of air against your finger.
- Inspect the chest for bilateral chest movement.
- Auscultate the chest for equal air entry (pneumothorax/tube position).
A flexible endoscopy may be performed post-operatively if the child is distressed and or coughing.
Post-procedural tube check
For the majority of children, a chest radiograph is performed in the theatre; if this has not happened, then a portable post-operative chest radiograph must be performed within 1 h or soon after the child has returned to the ward to confirm tube position and to rule out a pneumothorax and surgical emphysema (Figure 9.5).
Other initial complications
Initial complications are largely avoidable if the procedure is carefully performed together with careful and effective post-operative management.
Listed here are the other initial complications.
Haemorrhage
May be primary, reactionary or secondary. A large haemorrhage may be fatal. Secretions may initially be blood stained but will settle within a few hours. If it continues, practitioners should contact the appropriate specialist tracheostomy or surgical team.
Tube blockage
Although children should only be suctioned when required, it is imperative that a new tracheostomy tube is kept patent at all times. Children must be nursed in continuous humidity for the first week (may come off for short periods only). To reduce the incidence of tube occlusions, suction should be performed:
- at least half—hourly suction for the first 12–24 h
- as required until the first tube change.
Accidental decannulation/tube displacement
This is always a risk with a new tracheostomy. Common causes include chubby infant neck, incorrectly chosen tube, loose tapes or the child pulling at the tube. Risks can be minimised by appropriate choice of tube size and type, careful insertion technique and careful nursing. Check correct tension of the tapes securing the tube, ensuring that only one finger slips between the neck and tapes (Figure 9.6). Close observation is required: respiratory rate, effort, chest movements and air entry on return to the ward, coupled with direct observation of the tube itself. The tube may visibly come out of the stoma or can be pulled out of the trachea and sit in the pre-tracheal tissues. In this situation, the tube can be re-inserted by an appropriately trained person, but must not be forced. On reinsertion, air entry must be checked and confirmed and the appropriate clinical team must be contacted immediately to review tube position.
Infection (chest/stoma site)
The stoma site must be cleaned daily or when soiled using a clean technique and sterile gauze/saline. The wound must be inspected for signs of inflammation and/or infection. Observe colour and nature of secretions.
Surgical emphysema
Air may leak around the tube into the surrounding tissue—this is particularly problematic if the child has had neck sutures inserted. Checking tape tension not only confirms that the tube is secured correctly but may also be an indication of swelling if they appear tighter. Contact the appropriate clinical team for review.
The child, where possible, should not leave the ward during the first week unless medically indicated as the airway is at risk, and must remain in an environment that can manage any complications.
Feeding
If there have been no previous feeding concerns, the child may recommence normal feeds after a specified time of being ‘nil orally’. This is normally 3 hours post operation, but practitioners must confirm this with the anaesthetic chart or team. The vocal cords are often sprayed during the procedure, making them less responsive/effective in protecting the airway from aspiration. Other (sometimes pre-existing) physical complications accompanied by post-surgical oedema, restrict laryngeal elevation. This prevents the complete and safe closure of the lower respiratory tract and may cause aspiration and/or regurgitation of food.
For a child who has had feeding difficulties or has never been orally fed, consultation with the SALT should be sought before the commencement of oral feeding. Begin with water. If the child shows signs of aspiration, for example, if there is coughing after/during drinking, or visible drink coming out of the tracheostomy, then maintain nil orally and contact the ENT team and the SALT.
Humidification
GOSH do not use an HME in the first week following a new tracheostomy. The HME does not provide enough humidity in the initial phase to prevent tube occlusion in the first week. Administer humidity via sterile water and elephant tubing continuously for 1 week, as far as is practicable. The child may come off for short periods, that is, to feed, play, bathe, mobilise, and so on. Small and vulnerable infants under 1 year must have continuous warmed humidity.
Change humidity apparatus when the bottled water needs changing (usually 24 h) or earlier if contaminated with secretions or if the mask comes into contact with the floor. When not in use, the mask should be covered.
Other care needs
Given here is a list of other care needs.
- Change the tapes at least daily or when soiled or wet.
- A suitable dressing, such as Trachi-dress®, should be inserted behind the flanges to protect the skin (shiny side to skin; Figure 9.7). Avoid using bulky substitutes as these may pull the tube away from the neck precipitating accidental decannulation.
- Never use cotton wool or cut gauze dressings (keyhole) as flecks of displaced cotton may enter the respiratory tract.
- At GOSH, the first tube change occurs after 1 week, which allows sufficient time for the stoma tract to mature. The TNP or an appropriate head and neck surgeon will perform the first tube change. The ‘stay sutures’ will be removed at this time.
Once the stability of the tracheostomy stoma and tract has been verified the child may be allowed off the ward with a person appropriately trained in routine and emergency tracheostomy skills.
Routine management of the paediatric tracheostomy patient
Suctioning
Airway suctioning is a common practice in the care of a child with a tracheostomy, and is undertaken to remove secretions from the child’s respiratory tract. A child with a tracheostomy may find it difficult to clear the secretions effectively; therefore, suction is an essential aspect of their care. Suctioning is associated with many potential complications and is now only recommended when there are clear indications that the patency or ventilation of the children could be compromised. Suctioning a paediatric tracheostomy is very different from suctioning an adult tube, so adult practitioners will need to adapt their practice.
Potential complications of suctioning include:
- hypoxia
- formation of distal granulation tissue/ulceration
- cardiovascular changes
- pneumothorax
- atelectasis
- bacterial infection
- intracranial changes.
Practitioners trained in the skill should perform tracheostomy suctioning to minimise complications and maximise treatment. The child and family must be informed of the reasons for suctioning, positioning, risks and outcomes as appropriate. A ‘clean’ technique must be used and the catheter should be discarded if the tip is contaminated with hands, cot sides, and so on. Suction equipment must accompany the child at all times, regardless of the nature of the journey or the distance to be travelled.
Suctioning equipment
The following equipment should be prepared.
- Suction catheters of the correct size
- Suction unit with variable vacuum control
- Gloves
- Apron (don if there is time—a child should never wait for suctioning)
- Tap water (in clean container)
- A 2 ml syringe with 0.9% sodium chloride for irrigation (not for routine suctioning)
- Yellow waste bag ‘for incineration’.
Practitioners must be aware that some pre-term, vulnerable infants and especially those who are requiring >40% inspired oxygen, may require pre-oxygenation prior to suctioning to minimise the potential for hypoxia following suction. Distal tracheal damage and hypoxia are very real potential complications in the vulnerable paediatric airway. These complications may be reduced in the following manner.
- The correct size catheter; as a guide, practitioners should double the size of the tracheostomy tube to obtain the appropriate catheter size (e.g. 4.0 ID tracheostomy tube = size 8F catheter). A suction catheter diameter should be less than half of the size of the tracheostomy tube to reduce potential for hypoxia and allow the child to breathe throughout the procedure.
- One distal and two lateral ports with rounded ends allow secretions to be collected both distally and from the sides of the tube to minimise tube occlusion. Catheters with more than three lateral holes may render the wall too weak (Figure 9.8).
- The lateral port should be smaller than the distal port so that mucosal adhesion and biopsy does not occur.
- An integrated valve for vacuum control, as suction should only be applied on removal. Catheters should not be kinked prior to insertion in an effort to control the vacuum.
- It is preferable to use suction catheters with graduations, so that practitioners can measure the exact depth to be suctioned. Suctioning should not occur distal to the tube tip. Catheters should only be inserted so that the distal hole sits at the end of the tube. This allows collection of secretions but not trauma to the distal tracheal mucosa.
- Suction pressures should be kept to a minimum as excessive pressures can cause trauma, hypoxaemia and atelectasis. As a general guide, pressures should not exceed:
- 60–80 mmHg (8–10 kPa) for neonates/small infants
- up to 120 mmHg < 16 kPa for older children.
- 60–80 mmHg (8–10 kPa) for neonates/small infants
Table 9.1 offers a more specific guide to suction pressures required with different sized paediatric tracheostomy tubes.
Table 9.1 A guide to tube sizes and suction pressures in paediatric patients.
| Age of child | Approximate tube size | Suction pressures |
| Pre-term—1 month | 3.0 | 8–10 kPa |
| 60–75 mmHg | ||
| 0–3 years | 3.5–5.0 | 10–12 kPa |
| 75–90 mmHg | ||
| 3–10 years | 5.0–6.0 | 12–15 kPa |
| 90–112 mmHg | ||
| 10–16 years | 6.0–7.0 | 15–20 kPa |
| 112–150 mmHg |
Adapted from GOSH guidelines, Billau (2004), Dean( 1997), Mowery (2002), Simpson (2009) and Young (1984).
Suctioning is not a painful or distressing procedure; in fact, most infants will remain asleep throughout. If the child becomes distressed during suctioning then practitioners should review their technique. Constant observation of the child during suctioning is essential; practitioners should observe for an improvement or deterioration in respiratory rate and quality, the child’s colour and oxygen saturations (if monitored).
Paediatric suctioning technique
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