Children with tracheostomy tubes can benefit from home care but require specialized nursing to prevent complications and emergencies. The artificial airway increases risk, especially in children with upper airway disorders. To provide safe and effective care, home care nurses must be skilled in respiratory assessment, routine tracheostomy management, and tracheostomy emergency response. They also need to apply proven strategies that help prevent complications and must be prepared to respond effectively to tracheostomy-related emergencies.
If you’re caring for a child with a tracheostomy, make sure you know the reason for the tracheostomy and the status of the child’s upper airway. Children commonly require tracheostomies to bypass airway obstructions or to allow chronic mechanical ventilation. Airway obstruction may stem from trauma, tumors, infections, or structural airway abnormalities. Neurologic or neuromuscular disorders put children with weak gag reflexes at risk for choking and aspiration, and progressive muscular weakness or degeneration may hamper their ability to breathe. These children may need tracheostomies to manage secretions, avoid aspiration, and allow mechanical ventilation. Premature infants and children with chronic lung disease may need tracheostomies for long-term mechanical ventilation.
Evidence-based tracheostomy management
The American Thoracic Society (ATS) and the American Academy of Otolaryngology (AAO) have published guidelines for tracheostomy management. Supported by nursing research, these guidelines replace harmful traditions with safe, effective practices. Two primary evidence-based practice changes are safer, more effective suctioning and discontinuation of saline instillation into the tracheostomy tube.
Current nursing and respiratory-care literature recommends a specific suctioning technique for children with tracheostomies—one that’s different from that used for adults. An infant’s airway diameter is 25% smaller than an adult’s. Also, an infant’s trachea is supported by soft cartilage that’s more pliable. In addition, small, collapsible air passages leave children vulnerable to respiratory distress.
Routine high-pressured, deep suctioning for long durations has detrimental effects for pediatric patients. Deep suctioning is defined as inserting the catheter until it meets resistance at the carina, followed by withdrawing the catheter slightly before applying suction. Studies have found damaged tracheal tissue and inflammation where deep suctioning has been performed. In children, harmful effects include tracheal edema, inflammation, ulceration, bleeding, necrotizing tracheobronchitis, and pneumothorax. Documented physiologic risks of deep suctioning in children include atelectasis, hypoxemia, laryngospasm, bronchospasm, infection, decreased lung compliance, increased intracranial pressure, hypertension, hypotension, and arrhythmias.
Be aware that applying high levels of negative pressure during suction may cause tissue damage, hypoxia, and atelectasis. Higher negative pressures don’t extract larger amounts of secretions, so negative pressure should be applied at the lowest level to prevent serious consequences. (See Suction pressure recommendations.)
Although suctioning traditionally is done every 2 hours for children with tracheostomies, evidence indicates it should be done only when secretions are present. Audible secretions, decreased oxygenation, or diminished breath sounds signal the need for suctioning. If the child doesn’t need suctioning during the day, the ATS recommends once-daily suctioning at bedtime to ensure patency of the tracheostomy tube. In children without secretions, it recommends minimal suctioning at morning and bedtime to check patency.
To ensure your suctioning practice for pediatric patients is based on the most recent evidence, follow these guidelines:
- Suction catheters must be premeasured to no more than 0.5 centimeters beyond the end of the tracheostomy tube.
- Use a multi-holed suction catheter with side holes close to the distal end to remove secretions from a greater surface area.
- A rapid technique is safer and more effective. When inserting and removing the suction catheter, apply suction for no more than 5 seconds to prevent atelectasis.
- Twirling the catheter between your fingers and thumb rather than stirring it with your hand and wrist reduces friction and removes secretions from all areas of the tube.
- A larger catheter removes secretions more effectively than a smaller one. Use the catheter that is closest in size to the diameter of the trach tube, yet is easy to insert.
Perils of instilling saline solution
Normal saline instillation involves instilling a bolus of 3 to 10 mL normal saline solution directly into the child’s trach tube before suctioning. It’s mistakenly advocated as a way to improve oxygenation, remove secretions by thinning them, and stimulating coughing to loosen secretions. Extensive research shows that this practice doesn’t thin or mobilize secretions; instead, it reduces oxygenation, increases airway-infection risk, and heightens patient anxiety, dread, dyspnea, or pain.
To help mobilize secretions, stimulate coughing, and improve oxygenation, use the following evidence-based practices:
- Maintain adequate airway humidification and systemic hydration, and administer prescribed respiratory medications and treatments to thin secretions.
- Replace bolus saline instillation with nebulized saline treatment for safer, more effective humidification of the bronchial tree.
- To mobilize secretions, use cough-assistive devices, vibration vests, and prescribed respiratory treatments and medications.
Dealing with tracheostomy emergencies
About 11% of pediatric patients with tracheostomies die at home. A child with a tracheostomy is at risk for a respiratory emergency at any time. To be prepared for an emergency, develop a prevention strategy and a planned response, and use your technical and critical-thinking skills to ensure a calm, stepped approach. Remember—in the patient’s home, you’re the child’s life-support system. (See Tracheostomy emergencies in the home: How to intervene.)
Home care nurses who are critical thinkers and use evidence-based protocols are invaluable to the pediatric patients who depend on them to stay safe and healthy. Consistent, effective, and intelligent nursing practice builds bridges of trust, respect, and confidence between you and the patient and family. As the child’s home care nurse, you can bridge the gap between the primary care provider and family caregivers. To promote safe, high-quality care and reduce hospital admissions, evaluate the learning needs of family caregivers (and the patient, if old enough to perform self-care) and provide education about tracheostomy care.
Boroughs D, Dougherty J. Evidence-based pediatric secretion management. (n.d.) http://ce.nurse.com/course/ce619/evidence-based-pediatric-secretion-management.
Cincinnati Children’s Hospital Medical Center. Best evidence statement (BESt). Basic pediatric tracheotomy care. Cincinnati: Author: 2011.
Downes JJ, Boroughs DS. Care of the child with a chronic tracheostomy. In: AAP Section on Home Health Care; Libby RC, Imaizumi SO, eds. Guidelines for Pediatric Home Health Care. 2nd ed. Chicago, IL: American Academy of Pediatrics. 2009:477-90.
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Deborah S. Boroughs is director of pediatric special programs at BAYADA Home Health Care, Inc. in Burlington, New Jersey. Joan M. Dougherty is administrator of the Pennsylvania Ventilator Assisted Children’s Home Program in Philadelphia.