Other complications of suction include haemodynamic instability related to hypoxia and vagal stimulation. Undesirable fluctuations in intracranial pressure may also occur as a result of a reduction in cerebral venous return.
The decision to perform suction must be based on a comprehensive patient assessment rather than at regimented frequencies. This assessment should include a review of respiratory characteristics, chest excursion, palpation and auscultation.
Introduce the catheter no further than the carina. All nurses who perform suction must have received approved training and demonstrated competence under supervision. They should ensure that their knowledge and skills are maintained. This article has been double-blind peer-reviewed. For related articles on this subject and links to relevant websites see www.
Sign in or Register a new account to join the discussion. You are here: Respiratory. Tracheal suction. This procedure should be undertaken only after approved training, supervised practice and competency assessment, and carried out in accordance with local policies and protocols.
Sign in or Register a new account to join the discussion. You are here: Respiratory. Tracheostomy care: Part 1 — Using suction to remove respiratory secretions via a tracheostomy tube. How to use suction to remove respiratory secretions via a tracheostomy tube.
Department of Health Standard principles for preventing hospital-acquired infections. Journal of Hospital Infection ; 47 supplement : S Dougherty, L. Oxford: Blackwell Publishing. Higgins, D. Nursing Times ; 8, Pryor, J. Edinburgh: Churchill Livingstone. Routine use of 0. However, in situations where this may be of benefit e. Special safety considerations Some patients may require assisted ventilation before and after suctioning.
Management of abnormal secretions Changes in secretions e. Tracheostomy tie changes If tie changes are required before the first tube change — it is imperative that the procedure must be undertaken with both medical and nursing staff present who are able to reinsert the tracheostomy tube in case of accidental decannulation and the appropriate equipment is available at the bedside. Tracheostomy tie changes are performed daily in conjunction with stoma care, or as required if they become wet or soiled to maintain skin integrity.
It is preferable to secure new ties before removing the old ties As there is a potential risk for tracheostomy tube dislodgment when attending to tie changes a minimum of two people who are competent in tracheostomy care are required to undertake tracheostomy tie changes. During the tracheostomy tie change, if the old ties are removed prior to securing the new ties, one person is to maintain the airway by securing the tracheostomy tube in place and not removing the hand until the new tracheostomy ties are secured.
If the ties become loose it is a priority to re-secure immediately. All Children 6 years and under are to have cotton ties only to secure the tracheostomy tube. Children 6 years and over who are considered at risk of undoing Velcro ties should have cotton ties. Equipment Tracheostomy kit Two equal lengths of cotton ties approximately 40cm or Velcro ties for patients older than 6 years Procedure for changing cotton ties Explain to the patient and their family that you are going to change the tracheostomy ties.
An older child may like to sit up in a bed or chair Insert a clean tie into the holes on each side of the flange On each side tie a single loop approximately 0. Then tie both sides together in a bow to secure.
Check the tension of the ties. Allow one finger to fit snugly between the skin and the ties. Re-tie into in a double reef knot to secure. Cut off excess length of ties leaving approximately 3cm. Using scissors remove old ties and recheck tension of new ties. Dispose of waste, remove gloves, and perform hand hygiene.
Procedure for changing Velcro ties Changing Velcro ties is a two person procedure. Check the Velcro on the tracheostomy ties prior to each use to ensure adhesiveness. If not adherent discard and replace. Apply eye protection Perform hand hygiene, apply non-sterile gloves One person holds the tracheostomy tube securely in place. The second person removes the existing Velcro ties and then inserts the clean Velcro ties through one side of the flange, passing the tie around the back of the patient's neck and inserting the Velcro tie through the other side of the flange.
Adjust the ties to allow one finger to fit snugly between the skin and the ties. Check to ensure the Velcro is securely fastened Dispose of waste, remove gloves, and perform hand hygiene. Observe the patient's neck to check skin integrity. Wash Velcro ties daily in warm, soapy water, rinse and allow to dry completely before re-using. Tracheostomy tube changes The frequency of a tracheostomy tube changes is determined by the Respiratory and ENT teams except in an emergency situation.
Consider distraction techniques and or procedural sedation. Swaddle the patient if age appropriate by wrapping the arms and containing them in the sheet. Place the rolled towel under the patient's shoulders to extend their neck unless contraindicated. The older child may find it more comfortable to sit upright with their head tilted back.
Position the child so that you have good visibility and access to the stoma. If necessary extend the neck further and open the stoma wider by using your thumb and forefinger.
Suction the existing tracheostomy tube immediately before removing the existing tube and inserting the new one. Procedure Person 1 holds the existing tube with their hand and keeps secured in place Person 2 cuts and removes the cotton ties from around the child's neck. If using Velcro ties - undo and remove from the tracheostomy tube flange. Person 2 holding the new tube asks person 1 to remove existing tracheostomy tube Person 2 immediately inserts the new tube into the stoma and removes the introducer if applicable.
If using cotton ties, finish by making a double reef knot and cut off any excess fabric leaving approximately 3cm. Do not clean or re-use single use tubes. Document procedure and device information in the patient medical record as per requirements stated below. Safety considerations A rare complication is for the tube to slip into a false passage instead of the airway.
Difficulties in re-inserting the tracheostomy tube can occur at any time. These occur usually as a result of one of the following: False tract Patient agitation or distress Closure of the stoma Spasm of the trachea Stoma is blocked by scar tissue granuloma Skin flaps Structural airway abnormalities e. Inspect the stoma area at least daily to ensure the skin is clean and dry to maintain skin integrity and avoid breakdown Daily cleaning of the stoma is recommended using 0.
After daily cleaning, ensure dressing inserted at stoma site Equipment Tracheostomy kit Fenestrated gauze dressing 0. Infants and young children may lay on their back with a small rolled towel under the shoulders. An older child may prefer to sit up in a bed or chair. Perform hand hygiene and apply non-sterile gloves Remove fenestrated dressing from around stoma Inspect the stoma area around the tracheostomy tube Perform hand hygiene and apply non-sterile gloves Clean stoma with cotton wool applicator sticks moistened with 0.
Use each cotton wool applicator stick once only taking it from one side of the stoma opening to the other and then discard in waste. Continue cleaning stoma area as above with a new cotton wool applicator stick each time until the skin area is free of secretions, crusting and discharge.
Allow skin to air dry or use a dry cotton wool applicator stick to dry. Insert the fenestrated gauze under the flanges wings of the tracheostomy tube to prevent chafing of the skin.
Avoid using any powders or creams on the skin around the stoma unless prescribed by a doctor or respiratory nurse consultants as powders or creams could cause further irritation.
Special considerations If signs of redness or excessive exudate present consider using a non-adhesive hydro cellular foam dressing e. If visible signs of infection are present - discuss with parent medical team and consider obtaining a swab specimen for culture and sensitivity. If there are any signs of granulation tissue liaise with the Respiratory Nurse Consultants for appropriate management.
The care of the stoma includes routine minimum - daily observation of the site and accurate documentation of the findings including the presence of any of the following: Redness Swelling Evidence of granulation tissue Exudate Increased discomfort or pain at the site Offensive odour Refer to Respiratory Clinical Nurse Consultant for advice on the frequency and type of dressing required. Feeding and nutrition The tracheostomy tube may have an impact on the child's ability to swallow safely, therefore a swallowing evaluation by a speech pathologist is recommended prior to the commencement of oral intake.
Oral care Patients with a tracheostomy have altered upper airway function and may have increased oral care requirements. Communication Children communicate in many different ways, such as using gestures, facial expressions and body postures, as well as vocalising. One- way speaking valves One-way speaking valves are a small plastic device with a silicone one-way valve, they sit on the end of the tracheostomy tube. Various types of one-way speaking valves are available.
If the child has prolonged excessive coughing and obvious discomfit with increased respiratory effort and air trapping - remove the valve immediately and reassess for adequate airway patency before a repeat trial.
If airway patency adequate then aim to reassess the child at regular intervals to place the one-way speaking valve gradually increasing the time and frequency of use. A cuffed tube must be fully deflated before attaching the speaking valve. Gently occlude tracheostomy tube with a gloved finger and observe for exhaled air from nose and mouth or vocalization. If the one-way speaking valve is tolerated on the initial trial for a goal of 5 to 10 minutes.
A management plan to gradually increase the length of time which the valve is used will be provided for the patient Once the child has adjusted to wearing the one-way speaking valve they should be able to wear it for long periods and be able to be wear at all awake periods, particularly during rehabilitative therapy sessions and when eating.
If the child fails to tolerate the one-way speaking valve: Remove the valve if any signs or symptoms of distress or changes in respiratory effort. As it can be more difficult for the child to exhale with the valve in place, the child may initially fail a trial of one-way speaking valve due to anxiety or discomfort. The child may need to slowly build up longer periods of one-way speaking valve use and placement will be repeated on subsequent days.
Some children have difficulty adjusting to changes to their airways. In infants and young children consider using a device to secure the one-way speaking valve to the child's ties - to prevent accidental loss of the one-way speaking valve. Some speaking valves are suitable for use in combination with oxygen therapy and during ventilation.
Safety precautions when using one-way speaking valves: If the child has severe airway obstruction the speaking valve should not be used. In cuffed tracheostomy tubes - ensure cuff is completely deflated.
The young child should always be supervised when wearing the speaking valve. The one-way speaking valve should not be worn when the child is sleeping. One-way speaking valves do not humidify the air - therefore may be unsuitable for children with copious thick secretions. If the one-way speaking valve is not functioning properly i. Do not use in combination with HME heat moisture exchanger Ensure the one-way speaking valve is clean and not damaged in any way before each use.
Once dry and when not in use, it should be stored in an appropriate storage container Dispose of waste, remove gloves, and perform hand hygiene. To avoid damage to the valve: do not wash in hot water do not use a brush on the valve do not use alcohol, peroxide or bleach to clean the valve Transition to the community and discharge planning Referral to Complex Care Hub CCH All children with a tracheostomy tube should be referred to Complex Care Hub after discussion with the family.
Internal referral to EPIC External referral form The referring team is responsible for ensuring appropriate equipment for discharge is organised in collaboration with the Complex Care Hub or Equipment Distribution Centre. This procedure is performed within 6 weeks prior to admission for decannulation. Preparation Decannulation management is usually a staged process commenced as an outpatient clinic with assessment following capping of the tracheostomy tube.
Downsizing of the tracheostomy tube may be done in conjunction with the capping in order to assess how well the child manages with a smaller tracheostomy in their airway and to encourage the use of their upper airway.
The decannulation process is performed in the hospital as an in-patient. This is usually a 3 — 4 day admission.
The patient is nursed for at least 8 hours post decannulation. At the end of this period the need for nursing supervision of the patient is assessed by the patient's parent medical team. If complications with the decannulation are anticipated the patient should be nursed for the first 24 hours post decannulation Decannulation - Day 1 The tracheostomy tube is downsized to a 3.
Ensure documented plan for the decannulation process from the parent medical team Baseline observations including heart rate, respiratory rate, SpO2 haemoglobin-oxygen saturation , and work of breathing are recorded.
The tube is capped occluded using a decannulation cap and the child is observed for any signs of increased respiratory effort or respiratory distress including: Tachypnoea Stridor Retraction Tachycardia Colour Decreased perfusion Oxygen desaturation or low oximetry reading Restlessness or anxiety Decreased cough effectiveness, swallow and voice quality If the child is unable to tolerate the downsizing and capping of the tracheostomy tube a medical review is required as the trial of decannulation may not proceed and the tube may be upsized.
Decannulation — Day 2 Decannulation is usually performed between the hours of 9am and 10am following medical review. Equipment Tracheostomy Kit Set of tracheostomy tubes same size and smaller sizes than tube child has insitu down to a size 3mm — including additional size 3mm in freezer.
Surgical scissors Tracheostomy ties or Velcro ties Suction equipment Gauze and an occlusive dressing — e. Perform hand hygiene Use a standard aseptic technique using non-touch technique Position the patient. Following decannulation: Monitor the patient's vital signs - respiratory rate, heart rate, oxygen saturation, colour and work of breathing continuously throughout the procedure then observe and document: 15 minutely for the first hour Half hourly for the next 4 hours Hourly for 24 hours Continuous pulse oximetry SpO 2 during all periods of sleep day and night post decannulation for 24 hours.
Observe carefully for any signs of airway obstruction or increased respiratory effort during sleep periods Call a MET for assistance as per RCH emergency guidelines Immediately report any episodes of: Tachypnoea or bradypnoea Tachycardia or bradycardia SpO 2 desaturation Increased WOB — mild, moderate or severe - as evidenced by: sternal or intercostal retraction, tracheal tug, nasal flaring, or stridor Restlessness and or anxiety Colour change and or cyanosis Failure to clear secretions — gagging Offer light diet 2 hours after decannulation unless contraindicated Encourage the child to undertake their normal activities while on the ward.
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