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Tracheostomy Care For School Nurses
Tracheostomy Care For School Nurses
Jo Anne Wright, RN, MSN, CNS Pediatric Pulmonary and ENT Trach Nurse Specialist Childrens Hospital/UHHSC
What is a tracheostomy?
Tracheostomy is a surgical procedure that is usually done in the OR under general anesthesia. A tracheostomy is an incision into the trachea that forms a temporary or permanent opening. The terms tracheotomy and tracheostomy are interchangeable. The opening is called a stoma.
Tracheostomy Complications
Mucus plugs are the most common cause of respiratory distress for children with tracheostomies. Symptoms of mucus plug include resistance when trying to suction or bag and/or signs of respiratory distress.
Complications, continued
Bleeding R/T infection, suctioning: too deeply, too aggressively, too much pressure, lack of humidity
Infection R/T pseudomonas, staph, strep, fungus
Suctioning a Tracheostomy
The upper airway warms, cleans and moistens the air we breathe. The trach tube bypasses these mechanisms, so that the air via the tube is cooler, dryer and not as clean. In response to these changes, the body produces more mucus. The trach tube is suctioned to remove mucus from the tube and trachea to allow for easier breathing. Generally, the child should be suctioned every 4-6 hrs and as needed.
Suctioning a Tracheostomy
The size of the suction catheter depends on the size of the tracheostomy tube. Size 8 Fr or 10 Fr are typical sizes for pediatric trach tubes.
The catheter should be the largest that fits the trach tube size. Suction pressure: >1 yr = 100-120 mmHg
Deep Suctioning: Insert the catheter until resistance is felt (Deep suctioning is usually not necessary). Be careful to avoid vigorous suctioning, as this may injure the lining of the airway.
More symptoms
Difficulty or refusing to eat Reduced airflow through the tube Low O2 saturations
Tracheostomy Humidification
The nose and mouth provide warmth, filtering and moisture for the air we breathe. A trach tube by-passes these mechanisms. Humidification must be provided to keep secretions thin and to avoid mucus plugs. Children with trachs do best in an environment of 50% humidity or higher. Having humidification is important during sleep. And since we live in the desert, the kids need extra moisture.
Heat Moisture Exchange (HME) or artificial nose Can be worn 3-4 hrs a day, at least twice a day. Discard them after use
Tracheostomy Care
Rubbing of the trach tube and secretions can irritate the skin around the stoma. Trach dressings are used if there is drainage from the trach site or irritation from the tube rubbing on the skin.
Accidental Decannulation
Try to stay calm Reinsert tube immediately even if conditions are not ideal There should always be two spare trachs with the child at all times; the childs size and one size smaller. If the regular size doesnt fit, then the smaller one will keep the airway patent.
Accidental Decannulation
Opening the airway is always the first priority. If a spare trach tube is not handy, replace the one that came out. You can replace with a clean one later.
Accidental Decannulation
If you cant reinsert the tube, observe the child to see if he/she can breathe through the stoma itself. This may be possible if the stoma is well healed and fairly large. The child may also be able to breathe through the nose and mouth if there is no severe obstruction above the trach site.
After Decannulation
The stoma begins closing as soon as the trach tube is removed. This may take months to achieve final closure. Until closed by nature or surgery, need to keep opening covered. Bandaids work nicely for this; change as needed.
Child may still have mucus coming from the tracheocutaneous fistula. Must avoid contact with water as this leads directly to the lungs as when the trach tube was in place. Usually the child will need to have ENT surgery to close the layers if not closed by 1 year.
Trach Ties (may be velcro, may be twill tape or metal chain) Water to rinse tubing after suctioning Pre cut 2x2 or 4x4 gauze Extra artificial noses (HMEs) Normal saline bullets (for suctioning)
When the child is discharged from the University Hospital with a trach tube, I generally set up this first bag of goodies.
Its then up to the parents or caregivers to replace used items.
If these items are not with child, ask parent to send them daily. You need to have equipment available to care for this child. Schools are not responsible for buying this stuff.
If the child is oxygen dependent, should have portable oxygen and a portable pulse oximeter with them. The oximeter doesnt need to be a constant monitor unless there are concerns for resp. distress. Periodically, check the O2 sat. It should be >92%.
Newport HT 50 Is an older model, less able to fine tune for vent settings.
Some children are totally vent dependent and cant breathe without support. These kids dont do well off the vent. These kids need immediate action. Some children are able to breathe on their own and use the vent for supplemental support. These kids may be off the vent for short periods of time. You have time to figure things out.
Alarms may be heard for a variety of reasons, but always check the child. Press Silence/Reset button
After the intervention, press Silence/Reset button, again. This resets the alarms.
HIGH PRES occurs when circuit pressure is > high pressure alarm check for kinks and occlusions
LOW PRES occurs when circuit pressure is < low pressure alarm check for disconnect
POWER LOST or POWER LOW external power and voltage drops to low level or is operating on external power and the voltage drops below a useable level and switches to the internal battery. unplug from current outlet and replug somewhere else
Resource Nurse
Jo Anne Wright, RN, MSN, CNS Pediatric Pulmonary/Pediatric ENT Trach Nurse Specialist (505) 925-4330 (505) 951-3351