caring for the child/young person with a tracheostomy · healthcare professionals caring for a...
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Best Practice Statement ~ September 2008
Caring for the child/young personwith a tracheostomy
10906 Cover.qxp:9005 Cover 28/8/08 09:38 Page 1
© NHS Quality Improvement Scotland 2008
ISBN 1-84404-522-6
First published September 2008
You can copy or reproduce the information in this document for use within NHSScotland and foreducational purposes. You must not make a profit using information in this document.Commercial organisations must get our written permission before reproducing this document.
www.nhshealthquality.org
NHS Quality Improvement Scotland is committed to equality and diversity. We have assessed thisBest Practice Statement for likely impact on the six equality groups defined by age, disability,gender, race, religion/belief and sexual orientation. For a summary of the equality and diversityimpact assessment, please see our website (www.nhshealthquality.org). The full report inelectronic or paper form is available on request from the NHS QIS Equality and Diversity Officer.
10906 Cover.qxp:9005 Cover 28/8/08 09:38 Page 2
ContentsIntroduction 2
Key stages in the development of best practice statements 3
Best practice statement: caring for the child/young person with atracheostomy 4
Section 1: Education and training 5
Section 2: Communication 8
Section 3: Swallowing and nutrition 10
Section 4: Stoma care 12
Section 5: Tracheostomy tube management 14
Section 6: Suctioning 20
Section 7: Humidification 22
Section 8: Therapeutic Play Interventions 25
Appendix 1: Number of tracheostomies in children/young peoplein Scotland 27
Appendix 2: Contraindications for speaking valve use 28
Appendix 3: Factors which may affect communication 29
Appendix 4: Factors which may affect swallowing 30
Appendix 5: Tracheostomy tube table 31
Appendix 6: Sizing chart for paediatric airways 32
Appendix 7: Decannulation 33
Appendix 8: Discharge checklist 35
Appendix 9: Minimal occlusion technique 37
Appendix 10: Tracheostomy suction procedure in paediatrics 39
Appendix 11: Illustrations 41
Appendix 12: Audit tool 44
Glossary 50
References 54
Who was involved in developing and reviewing the statement? 63
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Caring for the child/young person with a tracheostomy
IntroductionNHS QIS’ vision is of an NHS that achieves excellence in the care of everypatient every time. It leads the use of knowledge to promote improvementin the quality of healthcare for the people of Scotland and performs threekey functions:
• providing advice and guidance on effective clinical practice, includingsetting standards
• driving and supporting implementation of improvements in quality, and
• assessing the performance of the NHS, reporting and publishing thefindings.
In addition, NHS QIS also has central responsibility for patient safety andclinical governance across NHSScotland.
A series of best practice statements has been produced within the PracticeDevelopment Unit of NHS QIS, designed to offer guidance on best andachievable practice in a specific area of care. These statements reflect thecurrent emphasis on delivering care that is patient-centred, cost-effectiveand fair. They reflect the commitment of NHS QIS to sharing localexcellence at a national level.
Best practice statements are produced by a systematic process, outlinedoverleaf, and underpinned by a number of key principles.
• They are intended to guide practice and promote a consistent, cohesiveand achievable approach to care. Their aims are realistic butchallenging.
• They are primarily intended for use by registered nurses, midwives,allied health professionals, and the staff who support them.
• They are developed where variation in practice exists and seek toestablish an agreed approach for practitioners.
• Responsibility for implementation of these statements rests at locallevel.
Best practice statements are reviewed, and, if necessary, updated after 3years in order to ensure the statements continue to reflect current thinkingwith regard to best practice.
2
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3
Topic selection and Scoping Process
Review literature on topic.Source grey literature.
Ascertain current policy and legislation.Seek information from manufacturers,voluntary groups and other relevant
sources.
Establish working group. Establish reference group toadvise on consultation
drafts.
Determine focus and contentof statement.
Review evidence forrelevance to practice.
Determine how patients’views will be incorporated.
Draft document sent to reference group. Wide consultation process.
Review and revisestatement in light of
consultation comments.
Publish and disseminatestatement.
Feedback on impact of statement is sought/ impact
evaluation.
Review and update process.Identify new research/findings
affecting topic. Consider challenges of using
statement in practice.
Key stages in the development of best practice statements
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Caring for the child/young person with a tracheostomy
Best Practice Statement: Caring for the child/young personwith a tracheostomyIn 2003, NHS QIS published the best practice statement caring for thepatient with a tracheostomy1, which was relevant to adults andchildren/young people with a tracheostomy. NHS QIS has a commitment toreview and, if necessary, update best practice statements every 3 years,therefore, an updated best practice statement of the same name waspublished in 20072. However, during the review process the working groupagreed that separate guidance for tracheostomy care was required for bothadult and children/young people as the two varied greatly. Therefore the2007 best practice statement focused on adult services only and a workinggroup was convened to develop a separate best practice statement forhealthcare professionals caring for a child/young person with atracheostomy. As with the original, this statement does not refer to care ofchildren/young people with a laryngectomy.
The reasons that children/young people may require a tracheostomy canbe put into three broad categories: airway obstruction, unsafeairway/airway compromise and need for long-term ventilation. Morespecifically this can be due to trauma, burns, birth defects, inability tobreath without a ventilator, neurological problems, neuromuscularproblems, problems with the lungs (broncho/trachea malacia,bronchopulmonary dysplasia), or spinal injury.
The care of a child/young person with a tracheostomy is a highly skilledprocess requiring the knowledge and expertise of a multidisciplinary teamincluding dietitians, physiotherapists, play specialists, specialist nurses,speech and language therapists and trained carers. The membership of theworking group convened to develop the statement reflects this.
The working group recognises that the best practice statement focuses onthe physical care of the child/young person with a tracheostomy and thatpsychological support for the child/young person and their parents/carersmay also be required.
A section has been included in this statement to highlight the importanceof play interventions, and although it is included in this best practicestatement for tracheostomy care, the group feels that it could be adaptedfor other specialties. An audit tool has also been developed to supporthealthcare professionals and organisations that would like to audit currentlocal practice and is included as an appendix and available on the NHS QISwebsite to download (www.nhshealthquality.org).
4
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5
Section1:Educationandtraining
Keypoints:
1Thereareanumberofchildren/youngpeoplewithatracheostomybothinhospitalandinthecommunity.NHSboardshavearesponsibility
towardsthesechildren/youngpeopleandtheirfamilies/carersandalsoforpreparinghealthcareprofessionalstocareforthem.
2Afamily-centredapproach,goodcommunicationskillsandtechnicalcompetencearerequiredtocarefor,assureandassistchildren/young
peopleandtheirfamilies/carersinadaptingto,andmanaging,atracheostomy.
3Children/youngpeopleandtheirfamilies/carersrequireeducationandsupportinadaptingto,andlivingwith,atracheostomy
Statement
Reasonsforstatement
Howtodemonstratestatementisbeingachieved
Hea
lthca
rep
rofe
ssio
nals
carin
gfo
ra
child
/you
ngp
erso
nw
itha
trac
heos
tom
yha
veac
cess
to:
•ed
ucat
ion
and
trai
ning
tom
eet
loca
lnee
d,an
d•
stan
dard
ised
loca
lpro
toco
lsor
guid
elin
esde
velo
ped
bylo
cals
pec
ialis
tsan
dth
em
ultid
isci
plin
ary
team
with
inp
utfr
omch
ildre
n/yo
ung
peo
ple
and
thei
rfa
mili
es/c
arer
s.
Hea
lthca
rep
rofe
ssio
nals
need
tobe
equi
pp
edw
ithth
eap
pro
pria
tekn
owle
dge
and
skill
sto
mee
tth
eun
ique
need
sof
thes
ech
ildre
n/yo
ung
peo
ple
and
thei
rfa
mili
es/c
arer
sco
mp
eten
tlyan
def
fect
ivel
y.
Ther
ear
elo
calt
rain
ing
and
educ
atio
nop
por
tuni
ties
for
heal
thca
rep
rofe
ssio
nals
tom
eet
loca
lnee
d.
Ther
ear
elo
calp
roto
cols
orgu
idel
ines
tosu
pp
ort
heal
thca
rep
rofe
ssio
nals
carin
gfo
rth
ech
ild/y
oung
per
son
with
atr
ache
osto
my.
Hea
lthca
rep
rofe
ssio
nals
who
com
ein
toco
ntac
tw
itha
child
/you
ngp
erso
nw
itha
trac
heos
tom
y(n
om
atte
rho
win
freq
uent
ly)
unde
rsta
nd:
•th
ep
artic
ular
indi
catio
nsfo
rtr
ache
osto
my
•ris
ksas
soci
ated
with
atr
ache
osto
my
•p
oten
tialc
omp
licat
ions
with
atr
ache
osto
my
•th
ety
pes
oftu
bes
and
equi
pm
ent
invo
lved
inea
chca
se,
and
•th
eim
por
tanc
eof
stan
dard
infe
ctio
nco
ntro
lpre
caut
ions
(SIC
Ps).
Itis
ap
rofe
ssio
nalr
esp
onsi
bilit
yto
beab
leto
addr
ess
child
ren/
youn
gp
eop
le’s
need
sco
mp
eten
tly.
Ther
eis
docu
men
ted
evid
ence
ofed
ucat
ion
pro
vide
dto
deve
lop
and
upda
tekn
owle
dge
ofhe
alth
care
pro
fess
iona
lsw
orki
ngw
ithch
ildre
n/yo
ung
peo
ple
with
atr
ache
osto
my.
Hea
lthca
rep
rofe
ssio
nals
and
par
ents
/car
ers
who
are
inco
ntac
tw
itha
child
/you
ngp
erso
nw
itha
trac
heos
tom
yha
veac
cess
to,
and
rece
ive,
trai
ning
onro
utin
ean
dem
erge
ncy
airw
aym
anag
emen
tfo
rch
ildre
n/yo
ung
peo
ple
with
atr
ache
osto
my.
Itis
the
pro
fess
iona
lres
pon
sibi
lity
ofhe
alth
care
pro
fess
iona
lsto
ensu
reth
eyan
dp
aren
ts/c
arer
sar
ep
rep
ared
and
com
pet
ent
tode
alw
ithem
erge
ncy
situ
atio
ns.
Aud
itof
resu
scita
tion
trai
ning
spec
ific
toch
ildre
n/yo
ung
peo
ple
with
atr
ache
osto
my
whi
chis
tailo
red
tolo
caln
eed.
Ther
eis
docu
men
ted
evid
ence
that
resu
scita
tion
trai
ning
spec
ific
toch
ildre
n/yo
ung
peo
ple
with
atr
ache
osto
my
isp
rovi
ded
tofa
mili
es/c
arer
s.
Staf
fp
erso
nald
evel
opm
ent
pla
nsid
entif
yre
susc
itatio
ntr
aini
ngre
qui
rem
ents
for
rele
vant
pro
fess
iona
ls.
Key
staf
fid
entif
ied
loca
llyas
com
pet
ent
are
read
ilyav
aila
ble
toat
tend
toem
erge
ncie
s.
10906 Text.qxp:9005 Text 4/9/08 01:09 Page 5
Caring for the child/young person with a tracheostomy
6
Statement
Reasonsforstatement
Howtodemonstratestatementisbeingachieved
Hea
lthca
rep
rofe
ssio
nals
know
whe
nto
seek
,an
dha
veac
cess
to,
pro
fess
iona
ladv
ice
and
assi
stan
cefr
omre
leva
ntsp
ecia
lists
on:
•co
mp
lex
nutr
ition
•ch
est
phy
siot
hera
py
•in
fect
ion
pre
vent
ion
and
cont
rol
•sp
eech
,la
ngua
gean
dco
mm
unic
atio
n•
resu
scita
tion
•sp
ecia
list
equi
pm
ent
req
uire
men
ts•
child
deve
lop
men
t•
airw
ay/r
esp
irato
rynu
rsin
g,an
d•
pla
y.
Prof
essi
onal
exp
ertis
e/ju
dgem
ent/
know
ledg
eis
req
uire
dto
iden
tify
the
poi
ntat
whi
chit
isap
pro
pria
teto
seek
spec
ialis
tad
vice
,fo
rex
amp
lefr
omp
hysi
othe
rap
ists
,di
etiti
ans,
and
spee
chan
dla
ngua
geth
erap
ists
base
don
the
indi
vidu
alch
ild/y
oung
per
son’
sne
eds.
Ther
eis
evid
ence
ofcl
ear
lines
ofco
mm
unic
atio
nan
dag
reed
arra
ngem
ents
betw
een
the
diffe
rent
heal
thca
rep
rofe
ssio
nals
who
may
bere
qui
red
top
rovi
deca
refo
rth
ech
ild/y
oung
per
son
with
atr
ache
osto
my.
Hea
lthca
rep
rofe
ssio
nals
mai
ntai
nco
mp
eten
cyin
carin
gfo
ra
child
/you
ngp
erso
nw
itha
trac
heos
tom
y.It
isa
pro
fess
iona
lcom
mitm
ent
tom
aint
ain
com
pet
ency
.3,4
Ther
eis
evid
ence
ofat
tend
ance
atco
mp
eten
cy-b
ased
trai
ning
and
educ
atio
np
rovi
sion
for
rele
vant
heal
thca
rep
rofe
ssio
nals
.
Pers
onal
deve
lop
men
tp
lans
refle
ctth
ele
velo
fco
mp
eten
cyac
hiev
edor
req
uire
d.
Prio
r(w
here
pos
sibl
e)to
atr
ache
osto
my
bein
gp
erfo
rmed
,ed
ucat
ion
and
reas
sura
nce
ofth
ech
ild/y
oung
per
son
and
thei
rp
aren
ts/c
arer
star
tsan
dco
ntin
ues
thro
ugh
the
pat
ient
jour
ney.
Inad
ditio
nto
care
,he
alth
care
pro
fess
iona
lsar
ein
stru
men
tal
inin
spiri
ngco
nfid
ence
and
offe
ring
sup
por
tto
child
ren/
youn
gp
eop
lew
itha
trac
heos
tom
yan
dth
eir
fam
ilies
/car
ers.
Reco
rds
ofin
form
atio
ngi
ven
toch
ildre
n/yo
ung
peo
ple
and
fam
ilies
/car
ers
atp
artic
ular
stag
esof
the
pat
ient
jour
ney
are
audi
ted
tode
mon
stra
teth
atap
pro
pria
tein
form
atio
nis
conv
eyed
effe
ctiv
ely.
The
educ
atio
nof
child
ren/
youn
gp
eop
lean
dth
eir
fam
ilies
/car
ers,
tokn
owho
wto
acce
ssre
ady
advi
cean
dsu
pp
ort,
isne
cess
ary
ifch
ildre
n/yo
ung
peo
ple
with
atr
ache
osto
my
are
toliv
esu
cces
sful
lyin
the
com
mun
ity.
Fam
ilies
/car
ers
ofa
child
/you
ngp
erso
nw
itha
trac
heos
tom
yw
hore
ceiv
ead
equa
teed
ucat
ion
and
sup
por
t,as
wel
las
equi
pm
ent,
sup
plie
s,fo
llow
up,
etc
can
besa
fely
care
dfo
rou
tof
hosp
italt
oliv
ein
the
com
mun
ity.5-
7
The
fam
ilies
/car
ers
ofch
ildre
n/yo
ung
peo
ple
with
atr
ache
osto
my
inth
eco
mm
unity
have
cont
act
deta
ilsof
the
loca
land
/or
spec
ialis
tte
am.
The
educ
atio
nof
fam
ilies
/car
ers
and
educ
atio
nst
aff
and
acce
ssto
read
yad
vice
and
sup
por
tis
nece
ssar
yif
child
ren/
youn
gp
eop
lew
itha
trac
heos
tom
yar
eto
safe
lyac
hiev
efu
ll-tim
eed
ucat
ion
insc
hool
.8
Chi
ldre
n/yo
ung
peo
ple
with
atr
ache
osto
my
have
the
right
toac
cess
full-
time
educ
atio
n.Th
ere
isev
iden
ceof
atte
ndan
ceat
loca
ltra
inin
gan
ded
ucat
ion
for
heal
thca
rep
rofe
ssio
nals
tom
eet
loca
lnee
d.
Reco
rds
ofin
form
atio
ngi
ven
toch
ildre
n/yo
ung
peo
ple
,fa
mili
es/c
arer
san
ded
ucat
ion
staf
fat
par
ticul
arst
ages
ofth
ep
atie
ntjo
urne
yar
eau
dite
dto
dem
onst
rate
that
app
rop
riate
info
rmat
ion
isco
nvey
edef
fect
ivel
y.
10906 Text.qxp:9005 Text 4/9/08 01:09 Page 6
7
Statement
Reasonsforstatement
Howtodemonstratestatementisbeingachieved
An
addi
tiona
lsup
por
tp
lan
shou
ldbe
deve
lop
edfo
rnu
rser
yan
dsc
hool
pup
ilsto
iden
tify
the
leve
lof
sup
por
tth
atis
req
uire
din
thos
een
viro
nmen
ts.
This
will
incl
ude
emer
genc
ygu
idel
ines
.
Itis
imp
orta
ntto
ensu
reth
atev
eryo
neco
min
gin
toco
ntac
tw
ithth
ech
ild/y
oung
per
son
with
atr
ache
osto
my
isaw
are
ofth
eir
need
s.
Add
ition
alsu
pp
ort
pla
nsar
eau
dite
dto
ensu
reth
atap
pro
pria
tesu
pp
ort
for
the
child
/you
ngp
erso
nis
pro
vide
d.
Keychallenges:
1Developmentoflocalpolicies/guidelinesrelatingtotracheostomyeducationandtraining.
2Sharingeducationandtraininginformationwiththeacuteandcommunitymultidisciplinaryteam.
3Identificationoftheeducationandtrainingneedsofadiversegroupofhealthcareprofessionals,children/youngpeople,families/carersand
othersinhospitalandthecommunityandaddressingtheseneedswithinresourceconstraints.
4Raisingawarenessofthespecificresuscitationrequirementsofchildren/youngpeoplewithatracheostomy.
5Closerliaison/workingbetweenhealthandeducationandsocialwork(ifappropriate).
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Caring for the child/young person with a tracheostomy
8
Section2:Communication
Keypoints:
1Theimpactofthelossofnormalvoicefollowingtracheostomyshouldnotbeunder-estimatedandwheneverpossiblechildren/youngpeopleand
theirfamilies/carersshouldbepreparedforthis.
2Thespeechandlanguagetherapisthasakeyroleinthecareofchildren/youngpeoplewithatracheostomy.9
Statement
Reasonsforstatement
Howtodemonstratestatementisbeingachieved
Hea
lthca
rep
rofe
ssio
nals
need
tobe
know
ledg
eabl
eab
out
com
mun
icat
ion
pro
blem
sas
soci
ated
with
child
ren/
youn
gp
eop
lew
itha
trac
heos
tom
y.
Chi
ldre
n/yo
ung
peo
ple
with
atr
ache
osto
my
may
have
com
mun
icat
ion
pro
blem
sth
ataf
fect
thei
rab
ility
toin
tera
ctan
dbe
invo
lved
inth
eir
own
care
.
Invo
lvem
ent
ofch
ildre
n/yo
ung
peo
ple
/car
ers
isvi
tali
nsu
pp
ortin
gth
ech
ild/y
oung
per
son.
Ther
eis
docu
men
ted
evid
ence
ofin
-ser
vice
educ
atio
nto
deve
lop
and
upda
tekn
owle
dge
ofhe
alth
care
pro
fess
iona
lsw
orki
ngw
ithch
ildre
n/yo
ung
peo
ple
with
atr
ache
osto
my,
incl
udin
gco
mm
unic
atio
n.
The
child
/you
ngp
erso
n’s
key
wor
ker
invo
lves
the
spee
chan
dla
ngua
geth
erap
ist.
Idea
llyas
sess
men
tst
arts
pre
-op
erat
ivel
yfo
rel
ectiv
etr
ache
osto
mie
s.
Spee
chan
dla
ngua
geth
erap
ists
have
clin
ical
exp
ertis
ein
asse
ssm
ent
and
man
agem
ent
ofco
mm
unic
atio
ndi
fficu
lties
.Th
ere
isdo
cum
ente
dre
ferr
alto
the
spee
chan
dla
ngua
geth
erap
ist.
The
spee
chan
dla
ngua
geth
erap
ist
will
asse
ssth
eco
mm
unic
atio
nsk
ills
ofth
ech
ild/y
oung
per
son,
dep
ende
nton
the
age
and
abili
tyof
the
child
/you
ngp
erso
n.
Tim
ely
asse
ssm
ent
allo
ws
for
early
inte
rven
tion
pla
nnin
gto
faci
litat
eth
ebe
stm
eans
ofco
mm
unic
atio
nan
dto
redu
ceth
eris
kof
pos
sibl
efu
ture
diffi
culti
esin
clud
ing
the
acq
uisi
tion
and
deve
lop
men
tof
spee
ch,
lang
uage
and
com
mun
icat
ion
skill
s.
Ther
eis
docu
men
ted
evid
ence
ofsp
ecifi
cre
cord
sp
rovi
ded
byth
esp
eech
and
lang
uage
ther
apis
tfo
llow
ing
asse
ssm
ent
toal
low
the
child
/you
ngp
erso
nto
deve
lop
the
best
way
toco
mm
unic
ate
tom
eet
thei
rne
eds.
The
spee
chan
dla
ngua
geth
erap
ist
imp
lem
ents
and
eval
uate
sth
eco
mm
unic
atio
nre
cord
spec
ific
toa
child
/you
ngp
erso
n’s
need
san
dre
view
sit
atre
gula
rin
terv
als
orw
hen
heal
thne
eds
chan
ge.
Equi
pm
ent
and
trai
ning
shou
ldbe
avai
labl
efo
rho
spita
land
hom
eto
assi
stw
ithco
mm
unic
atio
nif
age
and
abili
tyap
pro
pria
te,
egba
byin
terc
oms,
sign
lang
uage
.
Chi
ldre
n/yo
ung
peo
ple
with
atr
ache
osto
my
may
have
com
ple
xco
mm
unic
atio
nne
eds
whi
chre
qui
rea
com
bina
tion
ofap
pro
ache
sto
min
imis
ep
robl
ems.
This
may
incl
ude
app
rop
riate
alte
rnat
ive
orau
gmen
tativ
eco
mm
unic
atio
nsy
stem
s.10
The
spee
chan
dla
ngua
geth
erap
ist
uses
ongo
ing
asse
ssm
ent
toup
date
com
mun
icat
ion
pro
gram
mes
inth
ech
ild/y
oung
per
son’
sre
cord
.
10906 Text.qxp:9005 Text 4/9/08 01:09 Page 8
9
Statement
Reasonsforstatement
Howtodemonstratestatementisbeingachieved
The
acut
esp
eech
and
lang
uage
ther
apis
tis
resp
onsi
ble
for
refe
rrin
gth
ech
ild/y
oung
per
son
toth
eco
mm
unity
spee
chan
dla
ngua
geth
erap
yse
rvic
e.
Toen
sure
cont
inui
tyof
com
mun
icat
ion
sup
por
tby
givi
ngtim
eous
refe
rral
toal
low
loca
lser
vice
sto
pla
nah
ead.
Refe
rral
isdo
cum
ente
din
the
child
/you
ngp
erso
n’s
reco
rd.
Ifcl
inic
ally
indi
cate
d11(s
eeA
pp
endi
x2)
,sp
eaki
ngva
lves
/tra
cheo
stom
yva
lves
shou
ldbe
cons
ider
edfo
rch
ildre
n/yo
ung
peo
ple
,an
dev
enyo
ung
babi
es.11
,12
The
deci
sion
toco
nsid
era
spea
king
valv
esh
ould
bea
mul
tidis
cip
linar
yon
e,as
not
allc
hild
ren/
youn
gp
eop
lew
illto
lera
teits
use.
11,1
3
Spea
king
valv
es/t
rach
eost
omy
valv
esca
nbe
extr
emel
yef
fect
ive
with
child
ren/
youn
gp
eop
leto
imp
rove
voic
ing
and
inba
bies
byen
cour
agin
gvo
calis
atio
nat
the
pre
-sp
eech
deve
lop
men
tst
age.
11
The
use
ofa
one
way
-sp
eaki
ngva
lve
allo
ws
air
tobe
inha
led
via
the
valv
ebu
tex
hale
dup
over
the
lary
nxal
low
ing
for
voic
eto
bep
rodu
ced.
The
pre
senc
eof
air
leak
arou
ndan
dab
ove
the
trac
heos
tom
ytu
beis
nece
ssar
yfo
rth
isto
hap
pen
.
Spea
king
valv
essh
ould
not
beus
edw
itha
cuffe
dtr
ache
osto
my
tube
orw
hils
tas
leep
.
Afo
rmal
asse
ssm
ent
isca
rrie
dou
tby
asp
eech
and
lang
uage
ther
apis
tal
ong
with
the
child
/you
ngp
erso
nscl
inic
alnu
rse
spec
ialis
tan
dth
ere
sults
docu
men
ted
inth
ech
ild/y
oung
per
son’
sre
cord
.
Ther
eis
ado
cum
ente
dp
roto
colw
ithin
the
mul
tidis
cip
linar
yte
amon
the
use
ofsp
eaki
ngva
lves
/tra
cheo
stom
yva
lves
.A
nin
divi
dual
ised
advi
cesh
eet
isgi
ven
toea
chch
ild/y
oung
per
son,
par
ent/
care
ran
dis
incl
uded
inth
ech
ild/y
oung
per
sons
reco
rd.
Keychallenges:
1Developmentofguidelinesandprotocolsrelatingtocommunicationofchildren/youngpeoplewithatracheostomy,toencompassthespecificneeds
ofchildren/youngpeople.
2Sharingofinformationwiththeacuteandcommunitymultidisciplinaryteamaboutthechild/youngperson’scommunication.
3Provisionofin-serviceeducationwiththesupportoflocalspeechandlanguagetherapiststodevelopknowledgeoftracheostomycommunication
issues.
4Amultidisciplinaryapproachwiththeinvolvementoffamiliesandcarersandsecondaryandtertiarycentresisrequiredtomanage
communicationissuesforchildren/youngpeoplewithatracheostomy.
5Additionalresourcesarerequiredtoprovideanycommunicationaidsthatmaybeneeded,toprovidesupportinthecommunity/homeandat
nursery/schoolandtoprovidecontinuingeducationtoallinvolvedinthecareofchildren/youngpeoplewithatracheostomy.
6Assessmentbyappropriatelyskilledhealthcareprofessionalsneedstobeongoingaschildren/youngpeople’sneedschangewithdevelopment.
7Ensuringthataccesstospecialistadviceandsupportisavailableparticularlyforthosechildren/youngpeoplewithcomplexcommunicationneeds.
8Effectivedischargeplanningisneededtofacilitateasmoothtransitionintothecommunity.
10906 Text.qxp:9005 Text 4/9/08 01:09 Page 9
Caring for the child/young person with a tracheostomy
10
Section3:Swallowingandnutrition
Keypoints:
1Thepresenceofatracheostomytubemayimpairswallowingwithincreasedriskofaspiration.
2Animpairedswallowmaycompromisethechild/youngperson’snutritionalstatus.Healthcareprofessionalshaveanimportantroleinthe
provisionofgoodnutritionalcareforchildren/youngpeoplewithtracheostomies.
3Swallowingdifficultiesmaybeduetomanyfactors(Appendix4).
4Children/youngpeoplewithatracheostomymayexperiencelossofappetiteduetothealteredairway,whichcausesreductionintheabilityto
smellandtaste.
5Thespeechandlanguagetherapistshouldimplementanoro-motorprogrammeforthechild/youngpersonwhoisnon-orallyfedinorderto
normalisesensationandmaintainandpromoteskills.10Achild/youngpersonwhoisnon-orallyfedcanbecomeorallyhypersensitiveresulting
inpossiblefuturebehaviouralfeedingdifficulties.14
Statement
Reasonsforstatement
Howtodemonstratestatementisbeingachieved
Hea
lthca
rep
rofe
ssio
nals
and
par
ents
/car
ers,
wor
king
toge
ther
top
rovi
dea
mul
tidis
cip
linar
yte
amap
pro
ach,
are
know
ledg
eabl
eab
out
nutr
ition
alan
dsw
allo
win
gp
robl
ems
asso
ciat
edw
ithch
ildre
n/yo
ung
peo
ple
with
atr
ache
osto
my.
Mul
tidis
cip
linar
ym
anag
emen
tof
fers
anef
ficie
ntan
dco
-ord
inat
edw
ayof
deal
ing
with
any
nutr
ition
alor
swal
low
ing
diffi
culty
.
Ther
eis
docu
men
ted
evid
ence
ofth
ein
-ser
vice
educ
atio
n,in
clud
ing
nutr
ition
issu
es,
pro
vide
dto
deve
lop
and
upda
teth
ekn
owle
dge
ofhe
alth
care
pro
fess
iona
lsan
dp
aren
ts/c
arer
sw
orki
ngw
ithch
ildre
n/yo
ung
peo
ple
with
atr
ache
osto
my.
Spee
chan
dla
ngua
geth
erap
ists
unde
rtak
ean
initi
alas
sess
men
tof
swal
low
ing
func
tion,
incl
udin
gfir
stga
ther
ing
rele
vant
info
rmat
ion
from
the
mul
tidis
cip
linar
yte
am,
and
reco
gnis
ew
hen
toin
volv
eth
edi
etiti
an.
The
asse
ssm
ent
shou
ldbe
carr
ied
out
alon
gw
ithth
ech
ild/y
oung
per
son’
snu
rse.
Ifdi
fficu
ltyw
ithsw
allo
win
gis
iden
tifie
d,ea
rlyp
oten
tial
pro
blem
sca
nbe
min
imis
ed.
Spee
chan
dla
ngua
geth
erap
ists
are
know
ledg
eabl
ein
the
asse
ssm
ent
ofth
esw
allo
w.
Itis
esse
ntia
lto
carr
you
tth
eas
sess
men
tal
ong
with
the
nurs
ew
hois
know
ledg
eabl
ein
suct
ioni
ngan
dem
erge
ncy
pro
cedu
res.
Whe
rean
imp
aire
dsw
allo
wis
iden
tifie
d,ad
ditio
nal
app
rop
riate
inve
stig
atio
nsm
aybe
unde
rtak
enfo
llow
ing
Roya
lCol
lege
ofSp
eech
and
Lang
uage
Ther
apis
ts(R
CSL
T)cl
inic
algu
idel
ines
.10
The
refe
rral
and
outc
ome
ofth
esp
eech
and
lang
uage
ther
apy
asse
ssm
ent
isre
cord
edin
the
child
/you
ngp
erso
n’s
reco
rd.
Die
titia
nsun
dert
ake
the
nutr
ition
alas
sess
men
tof
the
child
/you
ngp
erso
nw
ithid
entif
ied
imp
aire
dsw
allo
w.
Chi
ldre
n/yo
ung
peo
ple
have
par
ticul
arne
eds
that
req
uire
exp
ert
inte
rven
tion
tom
aint
ain
nutr
ition
alst
atus
.C
hild
ren/
youn
gp
eop
le’s
need
sw
illch
ange
asth
eyde
velo
p.
The
refe
rral
and
outc
ome
ofth
enu
triti
onal
asse
ssm
ent
isre
cord
edin
the
child
/you
ngp
erso
n’s
reco
rd.
Follo
win
gas
sess
men
ts,
heal
thca
rep
rofe
ssio
nals
pla
n,im
ple
men
tan
dev
alua
tea
nutr
ition
alre
cord
spec
ific
toth
ech
ild/y
oung
per
son’
sne
eds
and
pro
vide
ongo
ing
revi
ews.
Acl
ear
pre
scrip
tion
ofnu
triti
onal
req
uire
men
tssp
ecifi
cto
each
indi
vidu
alch
ild/y
oung
per
son
isre
qui
red
toen
sure
that
adeq
uate
nutr
ition
isre
ceiv
edsa
fely
.
The
indi
vidu
alis
ednu
triti
onal
pla
nis
docu
men
ted
inth
ech
ild/y
oung
per
son’
sre
cord
.
For
naso
gast
rican
dga
stro
stom
yfe
edin
g,be
stp
ract
ice
guid
elin
essh
ould
befo
llow
ed.14
10906 Text.qxp:9005 Text 4/9/08 01:09 Page 10
11
Statement
Reasonsforstatement
Howtodemonstratestatementisbeingachieved
Ora
lhyg
iene
shou
ldbe
mai
ntai
ned
thro
ugh
regu
lar
oral
care
.G
ood
oral
heal
thw
illas
sist
effe
ctiv
enu
triti
on.15
,16
Ora
lbac
teria
and
poo
ror
alhy
gien
ese
emto
influ
ence
the
inci
denc
eof
pul
mon
ary
infe
ctio
ns.17
Chi
ldre
nw
hore
ceiv
ere
duce
dor
noor
alfe
eds
req
uire
moi
stur
eto
pre
vent
thei
rm
outh
beco
min
gdr
y.14
Evid
ence
ofgo
odor
alhe
alth
isdo
cum
ente
din
the
child
/you
ngp
erso
n’s
reco
rd.
Ifth
ech
ild/y
oung
per
son
has
acu
ffed
tube
,sw
allo
win
gsh
ould
beas
sess
edw
ithth
ecu
ffde
flate
dan
don
lyfo
llow
ing
med
ical
clea
ranc
eto
doso
.18
Ass
essm
ent
shou
ldbe
done
alon
gw
ithm
ultid
isci
plin
ary
team
mem
bers
able
tode
flate
/inf
late
tube
,su
ctio
n,m
odify
vent
ilatio
nse
ttin
gs,
etc.
19
Indi
catio
nsfo
rcu
ffed
tube
sar
elim
ited
inp
aedi
atric
san
dm
aybe
used
tom
anag
ese
vere
asp
iratio
nof
secr
etio
nsor
sign
ifica
ntdi
fficu
lties
with
vent
ilatio
n.20
Ther
em
aybe
dysp
hagi
ap
rese
ntse
cond
ary
toth
ep
rimar
ym
edic
aldi
agno
sis.
21
Ifth
em
edic
alco
nditi
onre
qui
res
acu
ffed
tube
beca
use
ofth
eda
nger
ofse
vere
asp
iratio
nth
enor
alfe
edin
gsh
ould
not
beco
nsid
ered
.22
Ther
eis
docu
men
ted
evid
ence
ofa
pro
toco
lfor
the
mul
tidis
cip
linar
yte
amto
follo
win
mak
ing
any
deci
sion
toas
sess
the
swal
low
ifa
cuffe
dtu
beis
pre
sent
whi
chsh
ould
bere
cord
edin
the
child
/you
ngp
erso
n’s
reco
rd.
Ther
eis
ade
taile
dp
roto
colf
orcu
ffde
flatio
nto
follo
ww
hen
asse
ssin
gth
esw
allo
was
wel
las
are
cord
ofth
ero
utin
esw
allo
was
sess
men
tre
cord
edin
the
child
/you
ngp
erso
n’s
reco
rd.
Keychallenges:
1Developmentofguidelinesandprotocolsrelatingtonutritionofchildren/youngpeoplewithatracheostomy,andmultidisciplinaryreferrals.
2Sharingswallowingandnutritioninformationwiththeacuteandcommunitymultidisciplinaryteam.
3Provisionofin-serviceeducationandwritteninformation(withthesupportofthespeechandlanguagetherapyanddieteticsdepartments)to
developknowledgeoftracheostomynutritionissuesforallhealthcareprofessionalsandparents/carers.
4Developmentofreadilyaccessibleswallowingassessmentservices,includingaccesstovideofluoroscopy.
5Developmentofguidelinesandinformationtosupporttransitionfrom
hospitaltocommunitycare.
10906 Text.qxp:9005 Text 4/9/08 01:09 Page 11
Caring for the child/young person with a tracheostomy
12
Section4:Stomacare
Keypoints:
1Children/youngpeoplewithatracheostomyareatincreasedriskofinfectionandgranulationtissueformationofthestomasite.
2Effectivenursingmanagementofthestomawillaidthepreventionofperistomalinfectionandirritation.
3Awell-formedtrachealtractwillbeevidentabout5dayspostoperatively;suturescanusuallyberemoved5–10daysaftertheprocedure.23,24
Statement
Reasonsforstatement
Howtodemonstratestatementisbeingachieved
All
heal
thca
rep
rofe
ssio
nals
invo
lved
intr
ache
osto
my
man
agem
ent
are
pro
vide
dw
ithed
ucat
ion
onst
oma
man
agem
ent.
Toin
crea
secl
inic
alsk
illan
dkn
owle
dge
ofst
oma
man
agem
ent.
Doc
umen
ted
pro
gram
mes
rele
vant
tocl
inic
alne
edan
dto
indi
vidu
alre
qui
rem
ents
are
avai
labl
e.
Hea
lthca
rep
rofe
ssio
nals
are
able
tode
mon
stra
tecl
ean
stom
aca
re.
All
child
ren/
youn
gp
eop
lew
itha
trac
heos
tom
yst
oma
shou
ldha
vefr
eque
ncy
ofst
oma
care
indi
vidu
ally
asse
ssed
with
care
unde
rtak
enat
leas
tda
ily25
usin
gcl
ean
tech
niq
ue.
Trac
heos
tom
yst
omas
are
ap
oten
tiala
venu
efo
rre
spira
tory
trac
tin
fect
ion.
Cle
ante
chni
que
isad
voca
ted
asth
esk
inis
cont
amin
ated
with
orga
nism
s.26
Inci
denc
eof
per
isto
mal
infe
ctio
nin
child
ren/
youn
gp
eop
lew
itha
trac
heos
tom
yis
kep
tto
am
inim
um.
All
child
ren/
youn
gp
eop
lesh
ould
have
anev
alua
tion
ofst
omal
cond
ition
docu
men
ted
inth
eir
reco
rdan
dan
app
rop
riate
pla
nof
care
initi
ated
.
Toal
low
ongo
ing
asse
ssm
ent
ofth
est
oma.
Toas
sist
shar
ing
clin
ical
findi
ngs.
Ther
eis
docu
men
ted
evid
ence
ofst
omal
cond
ition
inth
ech
ild/y
oung
per
son’
sre
cord
and
loca
lpol
icie
s/gu
idel
ines
are
avai
labl
e.
The
stom
ash
ould
becl
eane
das
per
loca
lpol
icy.
Aba
rrie
rfil
msh
ould
beap
plie
dto
the
surr
ound
ing
skin
ifcl
inic
ally
indi
cate
d.
Cot
ton
woo
lmus
tno
tbe
used
tocl
eans
ear
ound
the
stom
a.
Ano
n-irr
itant
solu
tion
isus
edto
clea
nth
esk
inan
dtr
ache
alm
ucos
a.
Top
rote
ctth
esk
infr
omtr
ache
alse
cret
ions
and
enco
urag
emen
tof
wou
ndhe
alin
g.
Risk
ofin
hala
tion
from
fibre
s.
Evid
ence
that
heal
thca
rep
rofe
ssio
nals
are
awar
eof
whe
nto
app
lyba
rrie
rfil
man
dm
etho
dsto
enco
urag
ew
ound
heal
ing.
Use
ofdr
essi
ngs
arou
ndth
ehe
alth
yst
oma
site
isun
nece
ssar
y,un
less
clin
ical
lyin
dica
ted,
inw
hich
case
ther
ear
esp
ecifi
cally
desi
gned
trac
heos
tom
ydr
essi
ngs
avai
labl
e.
Trac
heos
tom
ytu
bes
have
soft
flang
es(e
xcep
tsi
lver
tube
s)th
atdo
not
req
uire
adr
essi
ngbe
twee
nth
etu
bean
dth
esk
in.
Dre
ssin
gsp
rovi
dean
idea
lenv
ironm
ent
for
bact
eria
lco
loni
satio
n.
Doc
umen
ted
evid
ence
that
heal
thca
rep
rofe
ssio
nals
are
know
ledg
eabl
ein
the
typ
esof
dres
sing
sav
aila
ble
and
able
toid
entif
yth
em
ost
app
rop
riate
one
base
don
clin
ical
need
.
Dev
ices
secu
ring
the
trac
heos
tom
ytu
besh
ould
bech
ecke
dre
gula
rlyfo
rse
curit
y.To
redu
ceth
ein
cide
nce
ofac
cide
ntal
tube
disl
odge
men
t.Ev
iden
ceof
secu
ring
devi
cebe
ing
chec
ked
isdo
cum
ente
din
the
child
/you
ngp
erso
n’s
reco
rd.
10906 Text.qxp:9005 Text 4/9/08 01:09 Page 12
13
Statement
Reasonsforstatement
Howtodemonstratestatementisbeingachieved
Pare
nts/
care
rsan
dch
ildre
n/yo
ung
peo
ple
(age
app
rop
riate
)ar
eta
ught
tom
anag
est
oma
care
prio
rto
disc
harg
e.Pa
rent
s/ca
rers
/chi
ldre
n/yo
ung
peo
ple
are
awar
eof
imp
orta
nce
ofke
epin
gst
oma
clea
n.
Con
fiden
cein
par
ents
/car
ers
and
inde
pen
denc
ein
child
ren/
youn
gp
eop
lew
itha
trac
heos
tom
y.
Loca
lpol
icie
san
dgu
idel
ines
are
avai
labl
eon
how
tote
ach
par
ents
/car
ers/
child
ren/
youn
gp
eop
le(a
geap
pro
pria
te)
tom
anag
est
oma
care
.
Ther
eis
docu
men
ted
evid
ence
that
the
par
ent/
care
r/ch
ild/y
oung
per
son
has
been
taug
htto
care
for
thei
rst
oma.
Obs
erve
trac
heos
tom
ysi
tefo
rsi
gns
ofov
ergr
anul
atio
n.Tr
eat
over
gran
ulat
ion
app
rop
riate
ly.
•an
tibio
ticoi
ntm
ent/
antif
unga
l/st
eroi
dalc
ream
•si
lver
nitr
ate
stic
k,an
d•
lase
r.
Min
imis
eris
kof
exte
rnal
obst
ruct
ion
ofth
est
oma.
Redu
ceris
kof
loca
lble
edin
gan
din
fect
ion.
Op
timis
ep
oten
tiald
ecan
nula
tion.
Educ
atio
nof
heal
thca
rep
rofe
ssio
nals
and
par
ents
/car
ers
tore
cogn
ise
gran
ulat
ion.
Loca
lgui
delin
es.
Doc
umen
tof
affe
cted
area
,tr
eatm
ent
and
resu
lt.
Hea
lthca
rep
rofe
ssio
nals
and
par
ents
/car
ers
unde
rsta
ndth
ep
oten
tials
ourc
esof
mic
ro-o
rgan
ism
san
dth
ene
edfo
rgo
odha
ndhy
gien
ebe
fore
and
afte
rto
uchi
ngth
esi
te.
Han
dhy
gien
eis
cons
ider
edto
beth
esi
ngle
mos
tim
por
tant
pra
ctic
ein
redu
cing
the
tran
smis
sion
ofin
fect
ious
agen
ts.27
Loca
linf
ectio
nco
ntro
lpol
icie
san
dgu
idel
ines
are
avai
labl
eto
teac
hp
aren
ts/c
arer
s/ch
ildre
n/yo
ung
peo
ple
(age
app
rop
riate
)th
ep
oten
tials
ourc
esof
infe
ctio
n.
Evid
ence
ofin
fect
ion
cont
rolt
rain
ing
pac
kage
s/m
ater
ials
.
Keychallenges:
1Developmentoflocalpolicies/guidelinesrelatingtotracheostomystomacare.
2Sharingstomacareinformationwiththeacuteandcommunitymulti-disciplinaryteam.
3Provisionofeducationalresourcestodevelopnewskillsandteach/superviselessexperiencedstaff/carers.
4Developmentofevidencetosupportcurrentpractice.
10906 Text.qxp:9005 Text 4/9/08 01:09 Page 13
Caring for the child/young person with a tracheostomy
14
Section5:Tracheostomytubemanagement
Keypoints~Generaltubemanagement
1Thereisavarietyoftracheostomytubesavailable.Tracheostomytubesaremadefrom
eitherpolyvinylchloride(PVC),siliconeorsilver.Allfit
intothefollowingcategories:neonatal;paediatricandadultsizes;cuffed/uncuffed;fenestrated/unfenestrated;double/singlecannula;
minitracheostomy;andthosewithanadjustableflange.Eachtubetyperequiresspecificmanagement.*
2Somestylesofadulttracheostomytubeshaveinnercannulae(seeAppendix11).
3Effectivetubemanagementcombinedwithsuctionandhumidificationcanreducetheincidenceofcomplicationsinthechild/youngperson
withatracheostomyandisintegraltothereductionofclinicalrisk.
4Parents/carersandthechild/youngperson(age/abilityappropriate)shouldbeconfidentandcompetentintubemanagementpriortodischarge
from
hospital.
Statement
Reasonsforstatement
Howtodemonstratestatementisbeingachieved
Indi
vidu
alas
sess
men
tof
the
mos
tap
pro
pria
tetu
besh
ould
bem
ade
byth
em
ultid
isci
plin
ary
team
.C
onsi
dera
tion
need
sto
begi
ven
to:
•th
ecl
inic
alne
ed/r
easo
nfo
rtr
ache
osto
my
•th
eam
ount
ofse
cret
ions
•w
heth
erra
diot
hera
py
isre
qui
red,
and
•w
heth
erm
agne
ticre
sona
nce
imag
ing
(MRI
)is
req
uire
d(s
eeA
pp
endi
x5)
Ther
ear
elo
calp
olic
ies
and
guid
elin
eson
app
rop
riate
tube
sele
ctio
nav
aila
ble.
Trai
ning
and
educ
atio
non
tube
sele
ctio
nis
pro
vide
dan
dre
cord
ed.
Itis
esse
ntia
lpra
ctic
efo
rth
ech
ild/y
oung
per
son
toha
vean
othe
rtu
be,
ofth
esa
me
size
and
typ
eas
wel
las
atu
beon
esi
zesm
alle
rav
aila
ble
atal
ltim
es.
Tofa
cilit
ate
ach
ild/y
oung
per
son’
sai
rway
inth
eev
ent
ofan
obst
ruct
edor
acci
dent
ally
deca
nnul
ated
tube
.Th
ere
are
loca
lpol
icie
san
dgu
idel
ines
onem
erge
ncy
airw
aym
anag
emen
t.
Doc
umen
tatio
nof
tube
sav
aila
ble
reco
rded
inth
ech
ild/y
oung
per
son’
sre
cord
s.
Ong
oing
educ
atio
non
emer
genc
yai
rway
man
agem
ent
isp
rovi
ded
and
docu
men
ted.
Ifth
ech
ild/y
oung
per
son
isus
ing
asi
ngle
cann
ula
tube
itsh
ould
bech
ange
dat
leas
ton
cea
wee
k.Th
issh
ould
beas
sess
edon
anin
divi
dual
basi
sas
child
ren/
youn
gp
eop
lem
ayre
qui
rem
ore
orle
ssfr
eque
ntch
ange
s.28
Tom
inim
ise
the
risk
ofai
rway
obst
ruct
ion
and
infe
ctio
n.Lo
calp
olic
ies/
guid
elin
esar
eav
aila
ble
ontr
ache
osto
my
tube
rep
lace
men
tin
line
with
man
ufac
ture
r’sgu
idel
ines
and
aw
ritte
nre
cord
ofse
rialn
umbe
rsan
dda
tes
rep
lace
d.Th
issh
ould
bedo
cum
ente
din
child
/you
ngp
erso
n’s
reco
rd.
Ong
oing
educ
atio
non
trac
heos
tom
ytu
bere
pla
cem
ent
isp
rovi
ded
tohe
alth
care
pro
fess
iona
lsan
ddo
cum
ente
d.
*Tracheostomytubesarecommonlyreferredtobythenameofthemanufacturer,egShiley,PortexorKapitex.
IllustrationsofavailabletubesareprovidedinAppendix11.
10906 Text.qxp:9005 Text 4/9/08 01:09 Page 14
15
Statement
Reasonsforstatement
Howtodemonstratestatementisbeingachieved
Rout
ine
trac
heos
tom
ytu
bech
ange
ssh
ould
not
occu
rim
med
iate
lybe
fore
oraf
ter
eatin
g.Th
etr
ache
osto
my
tube
chan
gep
roce
dure
may
caus
eco
ughi
ng/g
agre
flex/
vom
iting
.D
ocum
ente
dev
iden
ceof
educ
atio
nof
heal
thca
rep
rofe
ssio
nals
and
par
ents
/car
ers
insa
fero
utin
etr
ache
osto
my
tube
man
agem
ent.
Thefirsttubechangeisahighriskprocedure
and
shou
ldbe
unde
rtak
enun
der
med
ical
dire
ctio
n.Th
ista
kes
pla
ce5–
7da
ysaf
ter
the
surg
ical
pro
cedu
re.23
The
time
dela
yal
low
sa
trac
tto
beco
me
esta
blis
hed
with
inth
etr
ache
a,th
eref
ore,
min
imis
ing
the
risk
ofst
omal
clos
ure
ontu
bere
mov
al.
Ther
ear
elo
calg
uide
lines
and
pol
icie
son
man
agem
ent
ofth
etu
bein
clud
ing
info
rmat
ion
onth
efr
eque
ncy
oftu
bech
angi
ng.
Ano
tesh
ould
bem
ade
ofth
ete
chni
que
used
tofo
rmth
etr
ache
osto
my,
size
and
styl
eof
tube
and,
inp
artic
ular
,w
heth
erth
etr
ache
ais
stitc
hed
upto
the
skin
.
Stitc
hes
and
typ
eof
sutu
ring
will
affe
ctca
re.
Doc
umen
ted
evid
ence
ofst
itchi
ngan
dty
pe
ofsu
turin
gin
the
child
/you
ngp
erso
n’s
reco
rd.
All
child
ren/
youn
gp
eop
lew
itha
trac
heos
tom
yha
vetu
bes
clea
ned
orre
pla
ced
asap
pro
pria
tefo
llow
ing
man
ufac
ture
r’sgu
idel
ines
and
inlin
ew
ithin
fect
ion
cont
rolp
olic
ies.
Tube
sin
situ
are
ap
oten
tialr
eser
voir
for
pat
hoge
nic
bact
eria
.Lo
calp
olic
ies/
guid
elin
esar
eav
aila
ble
onho
wtr
ache
osto
my
tube
sar
ecl
eane
d.Th
ese
are
inlin
ew
ithm
anuf
actu
rer’s
guid
elin
es,
loca
linf
ectio
nco
ntro
land
deco
ntam
inat
ion
pol
icie
s.
Loca
lpol
icie
s/gu
idel
ines
are
avai
labl
eon
trac
heos
tom
ytu
bere
pla
cem
ent
inlin
ew
ithm
anuf
actu
rer’s
guid
elin
esan
da
writ
ten
reco
rdof
seria
lnum
bers
and
date
sre
pla
ced.
Brus
hes
are
not
used
onp
last
ictu
bes
unle
sssp
ecifi
cally
reco
mm
ende
dby
the
man
ufac
ture
r.Br
ushe
sm
ayca
use
dam
age
toth
elin
ing
ofth
etu
be.
Doc
umen
ted
the
child
/you
ngp
erso
n’s
reco
rd.
10906 Text.qxp:9005 Text 4/9/08 01:09 Page 15
Caring for the child/young person with a tracheostomy
16
Statement
Reasonsforstatement
Howtodemonstratestatementisbeingachieved
Inad
ditio
nto
stan
dard
resu
scita
tion
equi
pm
ent,
all
child
ren/
youn
gp
eop
lew
itha
trac
heos
tom
yre
qui
reth
efo
llow
ing
equi
pm
ent
(whi
chis
chec
ked
atle
ast
daily
)to
bere
adily
acce
ssib
lefo
rem
erge
ncy
pro
cedu
res:
•a
trac
heos
tom
ytu
beth
esa
me
size
asth
ech
ild/y
oung
per
son
has
insi
tu•
atr
ache
osto
my
tube
asi
zesm
alle
rth
anth
atin
situ
•ifacuffedtubeinsitu
-a
cuffe
dtr
ache
osto
my
tube
and
anun
cuffe
dtr
ache
osto
my
tube
the
sam
esi
zeas
insi
tup
lus
a10
mls
yrin
ge•
secu
ring
devi
ses
•st
itch
cutt
ers
(prio
rto
first
tube
chan
ge)
•sc
isso
rs•
man
ualr
esus
cita
tion
bag
•ap
pro
pria
tely
size
dfa
cem
ask
(to
fitm
anua
lres
usci
tatio
nba
g)if
clin
ical
lyin
dica
ted
•ai
r-tig
htw
ater
pro
ofta
pe
(to
occl
ude
trac
heos
tom
yst
oma
ifun
able
toin
sert
tube
and
need
top
erfo
rmba
sic
life
sup
por
tvi
afa
cem
ask)
•su
ctio
nm
achi
ne•
app
rop
riate
lysi
zed
suct
ion
cath
eter
s•
glov
es•
trac
heal
dila
tors
prio
rto
first
tube
chan
gein
anIT
Use
ttin
g,an
d•
alco
holb
ased
hand
rub.
Toen
sure
app
rop
riate
equi
pm
ent
isav
aila
ble
inan
emer
genc
y.
Use
ofa
larg
ersy
ringe
asp
art
ofth
ere
susc
itatio
neq
uip
men
tm
ayp
ose
aris
kof
over
infla
tion
ofa
cuffe
dtr
ache
osto
my
tube
and
subs
eque
ntda
mag
eto
the
trac
hea.
Chi
ldre
n/yo
ung
peo
ple
with
atr
ache
osto
my
have
thei
row
nem
erge
ncy
equi
pm
ent
with
them
atal
ltim
es.
Loca
lpol
icy/
guid
elin
esar
eav
aila
ble
oneq
uip
men
tw
hich
isto
bere
adily
acce
ssib
lein
anem
erge
ncy.
Acc
essi
bilit
yof
equi
pm
ent
req
uire
din
anem
erge
ncy
isdo
cum
ente
din
the
child
/you
ngp
erso
n’s
reco
rd.
All
child
ren/
youn
gp
eop
lefo
rw
hom
deca
nnul
atio
nis
cons
ider
edsh
ould
bein
divi
dual
lyas
sess
edby
the
mul
tidis
cip
linar
yte
am.
Tofa
cilit
ate
safe
and
effe
ctiv
ede
cann
ulat
ion.
Ther
ear
elo
calp
olic
ies
and
guid
elin
eson
the
deca
nnul
atio
np
roce
dure
.
Clo
sem
onito
ring
and
obse
rvat
ion
ofth
ech
ild/y
oung
per
son’
sai
rway
and
resp
irato
ryst
atus
occu
rsth
roug
hout
the
deca
nnul
atio
np
roce
ss.
Toal
low
early
dete
ctio
nof
any
diffi
culti
esth
roug
hout
the
pro
cess
.Th
ere
are
loca
lpol
icie
san
dgu
idel
ines
onth
ede
cann
ulat
ion
pro
cedu
reav
aila
ble.
The
deca
nnul
atio
np
roce
dure
isdo
cum
ente
din
the
child
/you
ngp
erso
n’s
reco
rd.
All
child
ren/
youn
gp
eop
lem
ust
have
thei
rem
erge
ncy
equi
pm
ent
with
them
atal
ltim
esdu
ring
the
deca
nnul
atio
np
roce
ss.
Toen
sure
that
emer
genc
yeq
uip
men
tis
avai
labl
eto
man
age
any
airw
ayan
dre
spira
tory
diffi
culti
es.
Ther
ear
elo
calp
olic
ies
and
guid
elin
eson
the
deca
nnul
atio
np
roce
dure
avai
labl
e.
The
deca
nnul
atio
np
roce
dure
isdo
cum
ente
din
the
child
/you
ngp
erso
n’s
reco
rd.
10906 Text.qxp:9005 Text 4/9/08 01:09 Page 16
17
Keypoints~Cuffedtracheostomytubes
1Cuffedtubesareusefulforreducingaspirationandminimisingairleakageduringventilation.
2Cuffedtubescomeinavarietyofstyles–aircuff,watercuff,foamcuff.Eachcufftyperequiresspecificmanagement.
3Appropriatemanagementofacuffedtubecanpreventdamagetothetrachealmucosa.
4Tracheostomytubeshavealow-pressurecuffthatremovestheneedtodeflatethecuffonaregularbasis.
5Insomestylesofcuffedtubesamanometershouldbeusedtomeasurecuffpressure,bystaffcompetentinmanometeruse.
Statement
Reasonsforstatement
Howtodemonstratestatementisbeingachieved
Mos
ttr
ache
osto
my
tube
sw
itha
cuff
have
high
volu
me,
low
pre
ssur
ecu
ffs.
The
cuff
shou
ldbe
infla
ted
toth
em
inim
alde
sire
doc
clus
ion
volu
me.
The
pre
ssur
eof
the
cuff
isdi
ssip
ated
over
aw
ider
surf
ace
area
.
Top
reve
nttr
aum
ato
the
muc
osal
wal
l.29
Loca
lpro
toco
lsor
guid
elin
eson
reco
rdin
gof
cuff
pre
ssur
ear
eav
aila
ble.
Com
pet
ency
ofst
aff
toun
dert
ake
the
tech
niq
ueof
min
imal
occl
usio
nvo
lum
e(M
OV)
(see
Ap
pen
dix
9).
Cuf
fed
trac
heos
tom
ytu
bes
that
have
air
cuffs
shou
ldha
vecu
ffp
ress
ure
chec
ked
atle
ast
once
daily
mai
ntai
ning
pre
ssur
ebe
twee
n15
–25c
mH
2 Ous
ing
am
anom
eter
.30
Cuf
fp
ress
ure
abov
e30
cmH
2 Om
ayca
use
dam
age
toth
etr
ache
alm
ucos
a.If
the
pre
ssur
eis
belo
w15
cmH
2 O,
asp
iratio
nm
ayoc
cur.
Loca
lpro
toco
lsor
guid
elin
eson
reco
rdin
gof
cuff
pre
ssur
ear
eav
aila
ble.
Com
pet
ency
ofhe
alth
care
pro
fess
iona
lsto
unde
rtak
eth
ero
leis
asse
ssed
.
Pres
sure
isdo
cum
ente
dw
ithin
the
child
/you
ngp
erso
n’s
reco
rd.
10906 Text.qxp:9005 Text 4/9/08 01:10 Page 17
Caring for the child/young person with a tracheostomy
18
Keypoints~Innercannulamanagement
1Innercannulaereducethelumenoftheoutertracheostomytubeincreasingrespiratoryeffort.
2Innercannulaearedesignedtoalloweasyremovalforcleaningwithouthavingtoremovetheoutertube.
3Provisionoftrainingtorecogniseadisplacedtube.
Statement
Reasonsforstatement
Howtodemonstratestatementisbeingachieved
All
child
ren/
youn
gp
eop
lew
itha
trac
heos
tom
ytu
bew
ithan
inne
rca
nnul
are
qui
rein
divi
dual
asse
ssm
ent
ofth
efr
eque
ncy
ofin
ner
cann
ula
care
.
Tom
inim
ise
the
risk
ofob
stru
ctio
n.D
ocum
enta
tion
iden
tifie
sth
e:•
typ
eof
tube
insi
tu•
amou
ntof
secr
etio
nsth
ech
ild/y
oung
per
son
pro
duce
s,an
d•
freq
uenc
yof
clea
ning
.
Loca
lpol
icie
s/gu
idel
ines
are
avai
labl
eon
how
trac
heos
tom
yin
ner
cann
ulas
are
clea
ned.
Thes
ear
ein
line
with
man
ufac
ture
r’sgu
idel
ines
,lo
cali
nfec
tion
cont
rola
ndde
cont
amin
atio
np
olic
ies.
10906 Text.qxp:9005 Text 4/9/08 01:10 Page 18
19
Keypoints~Fenestratedtubes
1Fenestratedtubesarerarelyusedinchildrenandyoungpeople.
2Fenestratedtubesmaybecuffedoruncuffed.
3Fenestratedtubesareusedtoencourageweaningfrom
thetracheostomyandalsoforvoicing.
4Fenestratedtubesaresuppliedwithtwoinnercannulae;oneisfenestratedandoneisnot.
Statement
Reasonsforstatement
Howtodemonstratestatementisbeingachieved
All
child
ren/
youn
gp
eop
lew
itha
fene
stra
ted
trac
heos
tom
ytu
beha
veth
efe
nest
rate
din
ner
cann
ula
rem
oved
prio
rto
trac
heal
suct
ion
and
rep
lace
dw
ithan
unfe
nest
rate
din
ner
cann
ula.
Itis
pos
sibl
eto
inse
rtth
esu
ctio
nca
thet
erth
roug
hth
efe
nest
ratio
nca
usin
gda
mag
eto
the
trac
heal
wal
l.D
ocum
ente
dev
iden
ceth
athe
alth
care
pro
fess
iona
lsha
vere
ceiv
edtr
aini
ngin
the
use
offe
nest
rate
dtr
ache
osto
my
tube
s.
Loca
lpol
icie
s/p
roce
dure
son
the
man
agem
ent
offe
nest
rate
dtu
bes
are
avai
labl
e.
Man
agem
ent
offe
nest
rate
dtu
bes
isdo
cum
ente
din
the
child
/you
ngp
erso
n’s
reco
rd.
All
child
ren/
youn
gp
eop
lew
itha
fene
stra
ted
tube
req
uire
anun
fene
stra
ted
tube
tobe
read
ilyac
cess
ible
for
use
inan
emer
genc
y.
Toal
low
vent
ilatio
nw
ithem
erge
ncy
equi
pm
ent
asai
rw
illex
itvi
ath
efe
nest
ratio
n.In
form
atio
nis
reco
rded
inth
ech
ild/y
oung
per
son’
sre
cord
.
Keychallenges:
1Developmentoflocalpolicies/guidelinesrelatingtoallaspectsoftracheostomytubecare.
2Sharingtracheostomytubemanagementinformationwiththeacuteandcommunitymultidisciplinaryteam.
3Provisionofeducationalresourcestodevelopnewskillsandteach/superviselessexperiencedhealthcareprofessionals.
4Developmentofevidencetosupportcurrentpractice.
5Assessingthecompetenceofhealthcareprofessionalstoundertakeallaspectsoftracheostomytubemanagement.
6Ensuringparents/carersandchildren/youngpeople(ifageappropriate)areeducatedinallaspectsoftubemanagementandareconfident
andcompetentinmanagingthetubepriortothechild/youngperson’sdischargefrom
hospital.
10906 Text.qxp:9005 Text 4/9/08 01:10 Page 19
Caring for the child/young person with a tracheostomy
20
Section6:Suctioning
Keypoints:
1Thefrequencyoftrachealsuctioningshouldbeassessedforeachchild/youngpersononanindividualbasisandshouldonlybecarriedout
whenthechild/youngpersonisunabletocleartheirownairwayeffectively.
2Suctioningshouldmaximiseremovalofsecretionswithminimaltissuedamageandhypoxia.
3Standardinfectioncontrolprecautionsshouldbeapplied,includinggoodhandhygieneanduseofpersonalprotectiveequipment.
4Suctionequipmentshouldbeeasilyaccessibleandmustbecheckeddaily.
5Children/youngpeoplewhohavedifficultyclearingsecretionsmayrequirereferraltoarespiratoryphysiotherapist.
6Individualassessmentofthechild/youngpersonwilldeterminewhatequipmentisrequiredathome.
Statement
Reasonsforstatement
Howtodemonstratestatementisbeingachieved
Whe
rep
ossi
ble,
the
low
est
effe
ctiv
ep
ress
ure
shou
ldbe
used
whe
nsu
ctio
ning
,us
ing
equi
pm
ent
with
anad
just
able
and
mea
sura
ble
dial
.Th
ere
com
men
ded
pre
ssur
esar
e:•
60–8
0mm
Hg
(8–1
0kPa
)fo
rne
onat
es,31
,32
•80
–100
mm
Hg
(10–
13kP
a)fo
rch
ildre
n,33
and
•80
–120
mm
Hg
(10–
16kP
a)fo
rad
oles
cent
s34
Ther
eis
are
qui
rem
ent
tose
tsu
ctio
nle
vels
whi
char
esa
fean
def
fect
ive.
35
Pres
sure
sin
exce
ssof
26.7
kPa
(200
mm
Hg)
can
resu
ltin
grea
ter
muc
osal
trau
ma.
36,3
7
Ther
eis
aris
kof
atel
acta
sis
ifsu
ctio
np
ress
ure
isto
ohi
gh.38
,39
Low
pre
ssur
esar
ele
ssef
fect
ive
and
pro
long
suct
ion
time.
40
Ther
eis
evid
ence
that
suct
ioni
ngtr
aini
ngsp
ecifi
cto
child
ren
and
youn
gp
eop
lew
itha
trac
heos
tom
yis
pro
vide
dto
fam
ilies
/car
ers
and
heal
thca
rep
rofe
ssio
nals
.
Suct
ioni
ngsh
ould
last
nolo
nger
than
5se
cond
sat
atim
e.5
Ap
pro
pria
tely
size
d,si
ngle
-use
mul
ti-ey
edor
clos
edsy
stem
,m
ulti-
use
cath
eter
ssh
ould
beus
ed.
Suct
ion
cath
eter
diam
eter
mus
tno
tex
ceed
half
the
inte
rnal
diam
eter
ofth
ech
ild/y
oung
per
son’
str
ache
osto
my
tube
size
.38,
41
Prol
onge
dsu
ctio
ning
resu
ltsin
hyp
oxia
.
Trac
heal
suct
ioni
ngca
nca
use
trac
heal
muc
osal
dam
age.
Mul
ti-ey
edca
thet
ers
caus
ele
ast
trau
ma.
39
Toen
able
gas
flow
betw
een
suct
ion
cath
eter
and
airw
ayw
allt
hus
pre
vent
ing
atel
ecte
sis.
42
Loca
lpol
icie
sp
rovi
degu
idan
ceon
app
rop
riate
suct
ioni
ngte
chni
que
.
Doc
umen
ted
reco
rdof
cath
eter
use
with
inth
ech
ild/y
oung
per
son’
sre
cord
.
Ap
pro
pria
tesu
ctio
nca
thet
ersi
zesh
ould
bedo
cum
ente
din
the
child
/you
ngp
erso
n’s
reco
rd.
Suct
ioni
ngsh
ould
beca
rrie
dou
tus
ing
the
‘pre
-mea
sure
dte
chni
que
’.44,
33Th
esu
ctio
nca
thet
ersh
ould
not
bein
sert
edm
ore
than
half
ace
ntim
etre
beyo
ndth
een
dof
the
trac
heos
tom
ytu
be.28
(See
Ap
pen
dix
10).
Ani
mal
mod
elst
udie
s45an
dp
ost
mor
tem
stud
ies46
clea
rlyde
mon
stra
teep
ithel
iald
amag
ew
here
deep
suct
ion
isro
utin
ely
per
form
ed.47
Doc
umen
ted
reco
rdw
ithin
the
child
/you
ngp
erso
n’s
reco
rdth
atp
re-m
easu
red
tech
niq
ueis
used
.
The
need
for
hyp
erox
ygen
atio
np
rior
top
roce
dure
shou
ldbe
asse
ssed
onan
indi
vidu
alba
sis
inlin
ew
ithho
spita
l/co
mm
unity
pol
icy
Tom
inim
ise
risk
ofhy
pox
iaas
soci
ated
with
suct
ioni
ngfo
rid
entif
ied
child
ren/
youn
gp
eop
le.
Doc
umen
ted
with
inth
ech
ild/y
oung
per
son’
sre
cord
.
Hos
pita
l/co
mm
unity
pol
icy
inp
lace
.
10906 Text.qxp:9005 Text 4/9/08 01:10 Page 20
21
Statement
Reasonsforstatement
Howtodemonstratestatementisbeingachieved
Ifa
fene
stra
ted
tube
isin
situ
,a
pla
inin
ner
tube
shou
ldbe
inse
rted
prio
rto
suct
ioni
ng.
Itis
pos
sibl
eto
inse
rtth
esu
ctio
nca
thet
erth
roug
hth
efe
nest
ratio
nca
usin
gda
mag
eto
the
trac
heal
wal
l.D
ocum
ente
dw
ithin
the
child
/you
ngp
erso
n’s
reco
rd.
Hea
lthca
rep
rofe
ssio
nals
are
awar
eof
the
psy
chol
ogic
alef
fect
ofsu
ctio
ning
onch
ildre
n/yo
ung
peo
ple
.Su
ctio
nca
nbe
atr
aum
atic
exp
erie
nce
for
the
child
/you
ngp
erso
nan
dth
eir
par
ents
/car
ers.
Info
rmat
ion
isav
aila
ble
ina
varie
tyof
acce
ssib
lefo
rmat
sto
pro
mot
ech
ild/y
oung
per
son/
par
ent/
care
run
ders
tand
ing
and
redu
cean
xiet
y.
Loca
linf
ectio
nco
ntro
lpol
icy
mus
tbe
adhe
red
toth
roug
hout
the
trac
heal
suct
ioni
ngp
roce
ssin
clud
ing
the
use
ofp
erso
nalp
rote
ctiv
eeq
uip
men
t(P
PE)
and
per
form
ing
hand
hygi
ene.
Ther
em
ust
beus
eof
inta
ctst
erile
equi
pm
ent
and
safe
disp
osal
ofw
aste
.
Isot
onic
sodi
umch
lorid
eso
lutio
nsh
ould
not
bein
still
edro
utin
ely.
48
Ther
eis
aris
kof
cont
amin
atio
nof
equi
pm
ent,
cros
sin
fect
ion
toth
ech
ild/y
oung
per
son
and
exp
osur
eof
heal
thca
rep
rofe
ssio
nals
totr
ache
alse
cret
ions
.
Inst
illat
ion
ofso
dium
chlo
ride
can
have
anad
vers
eef
fect
onox
ygen
satu
ratio
ns.49
Alo
cali
nfec
tion
cont
rolp
olic
yad
dres
ses
issu
esan
dp
reca
utio
nsre
qui
red
inre
latio
nto
trac
heal
suct
ioni
ngan
ddi
spos
alof
equi
pm
ent.
Doc
umen
ted
with
inth
ech
ild/y
oung
per
son’
sre
cord
.
Keychallenges:
1Developmentoflocalpolicies/guidelinesforchildren/youngpeoplerelatingtosuctioningofatracheostomy.
2Sharingsuctioninginformationwiththeacuteandcommunitymulti-disciplinaryteam.
3Ensuringappropriateequipmentisreadilyavailable,includingcorrectcathetersizeandtype.
4Providingregularin-servicetraining/communicationforhealthcareprofessionalsworkingwithchildren/youngpeoplewithatracheostomy.
5Providingsupportandteachingofsuctioningtechniqueforchildren/youngpeopleandfamilies/carersandensuringthatthefamily/carers
understandtheprocedure.
10906 Text.qxp:9005 Text 4/9/08 01:10 Page 21
Caring for the child/young person with a tracheostomy
22
Section7:Humidification
Keypoints:
1Thenormalhumidificationandfiltrationsystem
isbypassedinchildren/youngpeoplewithatracheostomy.Breathingunhumidifiedaircan
thickensecretionsandincreasetheriskofmucousplugging.Humidificationmustbeartificiallysupplementedtominimisethisriskofthickened
secretionsandmucousplugging.50
2Theneedforhumidificationinchildren/youngpeoplewithatracheostomyisongoing.Arangeofproductsareavailableforproviding
humidificationinthechild/youngperson’shomeenvironment.Thechoiceofartificialhumidificationsystem
isdependentonthechild/young
person’sageandcondition(seeAppendix11).
An
idea
ld
evic
efo
rev
ery
chil
d/y
oun
gpe
rson
isn
ota
vail
abl
e28a
nd
itm
ay
ben
eces
sary
tou
sea
com
bin
ati
onof
hum
idif
ica
tion
syst
ems.
3Maintenanceofsafetyisakeyconsiderationinchildren/youngpeoplewithatracheostomywhenusinganyhumidificationproduct.
Statement
Reasonsforstatement
Howtodemonstratestatementisbeingachieved
Hea
lthca
rep
rofe
ssio
nals
unde
rtak
eas
sess
men
tof
hum
idifi
catio
nne
eds
inch
ildre
n/yo
ung
peo
ple
with
atr
ache
osto
my.
The
norm
alhu
mid
ifica
tion
and
filtr
atio
nsy
stem
isby
pas
sed
inch
ildre
n/yo
ung
peo
ple
with
atr
ache
osto
my.
Ther
eis
docu
men
ted
evid
ence
ofhu
mid
ifica
tion
asse
ssm
ent
inth
ech
ild/y
oung
per
son’
sre
cord
s.
Chi
ldre
n/yo
ung
peo
ple
with
atr
ache
osto
my
req
uire
hum
idifi
catio
nto
mai
ntai
nm
ucoc
illar
ycl
eara
nce
and
tore
duce
the
risk
ofp
ulm
onar
yin
fect
ion.
51
Hea
tan
dm
oist
ure
exch
ange
r(H
ME)
filte
rshe
atai
rto
the
child
/you
ngp
erso
nsbo
dyte
mp
erat
ure.
28
Itis
desi
rabl
eto
heat
and
hum
idify
insp
ired
gas
tom
atch
the
norm
alp
hysi
olog
ical
cond
ition
sat
the
leve
lof
the
carin
a.9
Hum
idifi
catio
nis
nece
ssar
yto
pre
vent
:•
obst
ruct
ion/
occl
usio
nof
trac
heos
tom
ytu
be•
atel
ecta
sis
•p
ulm
onar
yin
fect
ion
•p
oor
vent
ilatio
n/p
erfu
sion
coup
ling,
and
•tr
ache
itis.
51,5
2
Ther
eis
asy
stem
tom
onito
rin
spire
dga
ste
mp
erat
ures
.
Hea
lthca
rep
rofe
ssio
nals
are
awar
eof
the
bene
fits
asso
ciat
edw
ithth
eva
rious
hum
idifi
catio
nde
vice
sav
aila
ble
for
child
ren/
youn
gp
eop
lew
itha
trac
heos
tom
y.
HM
Efil
ters
are
effic
ient
whe
nus
edw
ithch
ildre
n/yo
ung
peo
ple
with
‘nor
mal
’am
ount
sof
thin
secr
etio
ns.
HM
Efil
ters
are
sim
ple
tous
ean
dar
eco
stef
fect
ive.
28
HM
Efil
ters
shou
ldbe
chan
ged
ever
y24
hour
s,or
mor
eof
ten
asin
dica
ted.
6
Hea
ted
syst
ems
are
very
effic
ient
and
tem
per
atur
eca
nbe
cont
rolle
dat
reco
mm
ende
dhu
mid
ityle
vels
.D
eliv
ery
ofin
spire
dai
rat
37ºC
and
100%
rela
tive
hum
idity
mai
ntai
nsth
ebo
dy’s
norm
alde
fenc
em
echa
nism
s.51
,53
Neb
ulis
ers
are
safe
and
effic
ient
.28
Doc
umen
ted
evid
ence
oftr
aini
ngan
ded
ucat
ion
pro
gram
mes
toin
form
heal
thca
rep
rofe
ssio
nals
ofth
ety
pes
ofhu
mid
ifica
tion
syst
ems
avai
labl
ean
dth
esa
feus
eof
syst
ems
whi
char
eem
plo
yed
loca
lly.
10906 Text.qxp:9005 Text 4/9/08 01:10 Page 22
23
Statement
Reasonsforstatement
Howtodemonstratestatementisbeingachieved
Hea
lthca
rep
rofe
ssio
nals
are
awar
eof
par
ticul
arp
robl
ems
asso
ciat
edw
ithar
tific
ialh
umid
ifica
tion
inch
ildre
n/yo
ung
peo
ple
with
atr
ache
osto
my.
Exce
ssiv
ear
tific
ialh
umid
ifica
tion
ofin
spire
dga
ses
may
pro
duce
asm
uch
harm
asun
der
hum
idifi
catio
n.5
HM
Efil
ters
(art
ifici
alno
ses)
incr
ease
the
dead
spac
e,re
sist
ance
and
the
wei
ght
onth
etr
ache
osto
my
tube
.Th
eH
ME
filte
rm
aybe
com
ebl
ocke
d.6
Hea
ted
syst
ems
are
pron
eto
rain
out
(con
dens
atio
nin
the
tubi
ng)
whe
nw
ater
vapo
urco
ols
and
colle
cts
inth
etu
bing
.28
Dis
tille
dw
ater
and
salin
ere
serv
oirs
inhu
mid
ifica
tion
syst
ems
have
been
show
nto
bea
sour
ceof
infe
ctio
n.54
Neb
ulis
ers
may
beto
oco
ol28
and
they
req
uire
aga
sflo
wge
nera
tor
and
tubi
ngm
akin
gth
emin
conv
enie
ntfo
rac
tive
child
ren/
youn
gp
eop
le.6,
20
Ap
pro
pria
tesi
zed
HM
Edo
cum
ente
din
the
child
/you
ngp
erso
n’s
reco
rd.
Hum
idifi
catio
nsy
stem
sar
em
anag
edin
acco
rdan
cew
ithth
em
anuf
actu
rer’s
inst
ruct
ions
,lo
calg
uide
lines
orp
roto
cols
and
infe
ctio
nco
ntro
lpol
icy.
Hum
idifi
catio
nsy
stem
sva
ryan
dhe
alth
care
pro
fess
iona
lsm
ust
beaw
are
ofdi
ffere
nces
ineq
uip
men
t.Lo
calg
uide
lines
and
pro
toco
lsar
ein
pla
ce.
10906 Text.qxp:9005 Text 4/9/08 01:10 Page 23
Caring for the child/young person with a tracheostomy
24
Statement
Reasonsforstatement
Howtodemonstratestatementisbeingachieved
The
child
/you
ngp
erso
nan
dp
aren
ts/c
arer
ssh
ould
befu
llyaw
are
ofth
ene
edfo
ran
dap
pro
pria
teus
eof
hum
idifi
catio
neq
uip
men
t.
Prov
isio
nof
app
rop
riate
info
rmat
ion
may
imp
rove
par
ent/
care
r/ch
ild/y
oung
per
son
com
plia
nce
and,
ther
efor
e,m
inim
ise
long
-ter
mp
robl
ems.
Doc
umen
ted
disc
ussi
onw
ithth
ep
aren
ts/c
arer
s.
Info
rmat
ion
pro
vide
dto
par
ents
/car
ers
inth
elo
calp
aren
tal
info
rmat
ion
and
trea
tmen
tp
ack
ontr
ache
osto
my
care
and
man
agem
ent.
Keychallenges:
1Developmentoflocalpolicies/guidelinesrelatingtohumidificationofatracheostomyforchildren/youngpeople.
2Sharinghumidificationinformationwiththeacuteandcommunitymultidisciplinaryteam.
3Provisionoftrainingandeducationtodeveloptheknowledgeofparents/carerswhosechild/youngpersonrequiresartificialhumidification.
4Provisionoftrainingandeducationtodevelopknowledgeofhealthcareprofessionalscaringforchildren/youngpeoplewhorequireartificial
humidification.
5Developmentandimplementationofevidence-basedprotocolsandproceduresforallhealthcareprofessionalsandparents/carers.
6Localprovisionandaccesstoarangeofhumidificationsystemsandequipment.
10906 Text.qxp:9005 Text 4/9/08 01:10 Page 24
25
Section8:Therapeuticplayinterventions
Keypoints:
1Playisanessentialpartofachild/youngperson’snormalhealthydevelopmentwhichenableschildren/youngpeopletolearn,communicate
anddevelop.
2Playprogrammesassistintheachievementsofdevelopmentalgoalsforchildren/youngpeople.Whendevelopmentisimpairedordelayed,
areferralshouldbemadetoaphysiotherapistskilledinneuro-developmentaltherapy.
3Playservicesinhospitalhelpfamilies/carersadjusttopotentiallystressfulsituationsandeventsandunderstandillnessandtreatments.
Statement
Reasonsforstatement
Howtodemonstratestatementisbeingachieved
All
child
ren/
youn
gp
eop
lest
ayin
gin
hosp
itals
houl
dha
veac
cess
toa
qua
lifie
dp
lay
spec
ialis
t.55
Play
ises
sent
ialt
oth
eov
eral
lhea
lthy
deve
lop
men
tof
child
ren/
youn
gp
eop
le.
Med
ical
cond
ition
sm
ust
not
limit
the
child
/you
ngp
erso
n’s
soci
alan
dem
otio
nal
deve
lop
men
t.
Aud
itof
pla
yse
rvic
es.56
,57
Hea
lthca
rep
rofe
ssio
nals
have
know
ledg
eof
child
hood
deve
lop
men
tan
dsh
ould
reco
gnis
eth
eim
por
tanc
eof
safe
pla
yte
chni
que
sfo
ra
child
/you
ngp
erso
nw
itha
trac
heos
tom
yan
dre
fer
toth
ep
lay
spec
ialis
t.
Inor
der
tosu
pp
ort
the
par
ents
/car
ers’
ago
odun
ders
tand
ing
ofch
ildde
velo
pm
ent
ises
sent
ial.
Play
/toy
sof
othe
rch
ildre
n/yo
ung
peo
ple
can
bea
risk
for
child
ren/
youn
gp
eop
lew
ithtr
ache
osto
my,
egsa
ndp
lay.
Ther
eis
docu
men
ted
evid
ence
oflo
calt
rain
ing
and
educ
atio
nor
gani
sed
byth
ep
lay
spec
ialis
t.
Ther
eis
docu
men
ted
refe
rral
toth
ep
lay
spec
ialis
t.
Risk
asse
ssm
ents
are
carr
ied
out
and
docu
men
ted.
Play
spec
ialis
tssh
ould
mee
tth
ede
velo
pm
enta
l,m
edic
alan
dem
otio
naln
eeds
ofin
divi
dual
child
ren/
youn
gp
eop
lean
dfa
mili
es/c
arer
sas
par
tof
the
mul
tidis
cip
linar
yte
amlia
isin
gw
ithal
ldis
cip
lines
tom
eet
the
over
alln
eeds
ofth
ech
ild/y
oung
per
son.
Stru
ctur
edp
lay
and
deve
lop
men
tal
pla
yp
rogr
amm
esar
ep
lann
ed,
deve
lop
edan
dev
alua
ted
bya
qua
lifie
dp
lay
spec
ialis
t.
Play
can
bean
imp
orta
ntfa
ctor
inre
duci
ngan
yha
rmfu
lef
fect
ofst
ress
and
hosp
italis
atio
n.It
isth
roug
hp
lay
that
child
ren/
youn
gp
eop
leca
nbe
emp
ower
edto
com
mun
icat
ean
dha
vean
outle
tfo
rbe
havi
ours
.
Play
spec
ialis
tsha
vesp
ecifi
ctr
aini
ngin
pro
vidi
ngp
lay
for
child
ren/
youn
gp
eop
lean
dfa
mili
es/c
arer
sin
the
hosp
ital
and
com
mun
ityse
ttin
g.
This
isdo
cum
ente
din
child
/you
ngp
erso
n’s
reco
rd/d
evel
opm
enta
lass
essm
ent.
Loca
lgui
delin
esfo
rp
rofe
ssio
nalp
ract
ice
base
don
the
Nat
iona
lAss
ocia
tion
ofH
osp
italP
lay
Staf
fG
uide
lines
for
Prof
essi
onal
Prac
tice.
58
Pers
onal
deve
lop
men
tp
lan
(PD
P)fo
rp
lay
spec
ialis
tan
dte
am.
Educ
atio
n/in
form
atio
np
acks
shou
ldin
corp
orat
ead
vice
onap
pro
pria
tean
dsa
fep
lay
for
child
ren/
youn
gp
eop
lew
ithtr
ache
osto
my.
Thes
ep
acks
will
bedi
strib
uted
toth
ech
ild/y
oung
per
son’
snu
rser
y/sc
hool
.Pl
aysp
ecia
lists
will
liais
ew
ithco
mm
unity
team
s.
Not
allm
ater
ials
/act
iviti
esar
esu
itabl
efo
rch
ildre
n/yo
ung
peo
ple
with
atr
ache
osto
my.
59
Doc
umen
ted
evid
ence
oflo
calg
uida
nce.
Reco
rdof
info
rmat
ion
give
nto
par
ents
/car
ers/
scho
ol/n
urse
ryon
the
disc
harg
ech
eckl
ist.
Loca
lpar
ent/
care
rsin
form
atio
nan
dte
achi
ngp
ack
ontr
ache
osto
my
care
and
man
agem
ent
isgi
ven
top
aren
ts/c
arer
snu
rser
ies
and
scho
ols.
10906 Text.qxp:9005 Text 4/9/08 01:10 Page 25
Caring for the child/young person with a tracheostomy
26
Statement
Reasonsforstatement
Howtodemonstratestatementisbeingachieved
All
child
ren/
youn
gp
eop
lesh
ould
beof
fere
dp
sych
olog
ical
pre
par
atio
n/p
ost
pro
cedu
ralp
lay
pro
gram
mes
.Re
sear
chde
mon
stra
tes
that
psy
chol
ogic
alp
rep
arat
ion
has
been
foun
dto
beef
fect
ive
inre
duci
ngdi
stre
ssan
den
hanc
ing
cop
ing.
57,6
0
Post
pro
cedu
ralp
lay
sess
ions
can
help
fam
ilies
unde
rsta
ndth
etr
eatm
ent/
cond
ition
.61
Doc
umen
ted
evid
ence
inth
ech
ild/y
oung
per
son’
sre
cord
that
psy
chol
ogic
alp
rep
arat
ion
has
been
offe
red.
Doc
umen
ted
evid
ence
oflo
calg
uida
nce.
Risk
asse
ssm
ents
are
carr
ied
out
and
docu
men
ted.
All
child
ren/
youn
gp
eop
lesh
ould
beof
fere
ddi
stra
ctio
nth
erap
yfo
ran
ytr
eatm
ent
orp
roce
dure
unde
rtak
en,
egtu
bech
ange
s,su
ctio
n.
Pare
nts/
care
rssh
ould
beta
ught
dist
ract
ion
tech
niq
ues.
Dis
trac
tion
isan
effe
ctiv
eco
pin
gst
rate
gy.62
The
pla
ysp
ecia
list
isa
faci
litat
orw
how
orks
inp
artn
ersh
ipw
ithp
aren
tsan
dot
her
staf
f.63
Doc
umen
tatio
nof
use
ofdi
stra
ctio
nth
erap
ies,
obse
rvat
ion
and
fam
ilies
feed
back
.
Keychallenges:
1Developmentoflocalpolicies/guidelinesrelatingtotherapeuticplayinterventionsforchildren/youngpeoplewithatracheostomy.
2Sharingtherapeuticplayinterventioninformationwiththeacuteandcommunitymultidisciplinaryteam.
3Developmentofanationalparent/carersinformationandtreatmentpackontracheostomycareandmanagementforchildren/youngpeople.
10906 Text.qxp:9005 Text 4/9/08 01:10 Page 26
27
Total Number of tracheostomies (excluding laryngectomies) inchildren/young people.
Years ending 31 December 1997–2006
Year ofmain
operationAgegroup
Totalnumber of
tracheostomies
Rate per100,000population Population
19970–12 13 1.58 822,181
13–17 10 3.14 318,166
19980–12 21 2.58 813,307
13–17 6 1.89 317,491
19990–12 24 2.99 802,755
13–17 7 2.21 316,627
20000–12 21 2.66 789,128
13–17 19 5.96 318,872
20010–12 18 2.32 774,409
13–17 5 1.55 323,196
20020–12 35 4.60 761,434
13–17 4 1.23 324,364
20030–12 16 2.13 750,795
13–17 9 2.79 322,877
20040–12 23 3.10 742,572
13–17 6 1.85 324,074
20050–12 24 3.27 734,015
13–17 8 2.46 325,012
20060–12 18 2.47 727,633
13–17 5 1.55 322,557
Appendix 1: Total number of tracheostomies inchildren/young people in Scotland
Source: Information Services Division (ISD), SMR01 dataBased on all operations during the patients’ stay.ICD10 codes - E42 (excluding E425, E426 and E427).Population figures taken from the Scottish GRO mid-year population estimates.
10906 Text.qxp:9005 Text 4/9/08 01:10 Page 27
Appendix 2: Contraindications for speaking valve use11
• Severe stenosis
• Severe tracheomalacia
• Excessive granulation tissue
• Tracheal oedema
• Bilateral vocal cord palsy (adducted)
• Medical instability
• Severely reduced lung capacity
• Copious thick secretions
• Cuffed tracheal tube
• Laryngeal papillomatosis (aggressive)
Caring for the child/young person with a tracheostomy
28
10906 Text.qxp:9005 Text 4/9/08 01:10 Page 28
29
Appendix 3: Factors which may affect communication
• The position of the tracheostomy tube changes the diversion of theairflow with the majority of the outgoing breath passing out throughthe tracheostomy tube as opposed to the normal flow up and over thevocal cords and out of the mouth, resulting in the decreased ability tovocalise.
• The time from birth to five years is a critical period for acquiringspeech, language and communication skills and the impact of not beingable to vocalise can affect the development of these skills.5
• Children/young people who had a tracheostomy as babies anddecannulated between the age of one and four can have significantdelay of expressive language use. In addition the longer the period ofthe tracheostomy, the more likely there will be impairment of speechsound production.64
• Babies use both vocalisation, crying and non-verbal communicationsuch as facial expression and eye contact to communicate. Decreasedability to vocalise can have an impact on the child/youngperson/parent/carer interactions at this early stage as well as possiblefuture impact on communication development and social interaction.5
• There may be other medical, neurological, sensory disorders orstructural abnormalities involved which can have a direct affect on theability to communicate.10
• Good air leak around the tracheostomy tube and evidence of being ableto make voice can allow for the use of a speech valve by creating an oralair stream and allow voicing on the outgoing breath. Using a speechvalve can create a louder voice as well as impacting on speech andlanguage development in the younger child.65
• Some children/young people will have had normal speech and languageuse prior to the tracheostomy and their communication needs will bedifferent. Frustration at not being able to communicate needs, feelingsand opinions is an added factor. Speech and language therapy input asearly as possible will allow for decisions to be made for developing anappropriate communication system for the child/young person to allowthem a means of expression even if it is only required for a short time.64
This may involve alternative communication systems using low or hightech aids.66
10906 Text.qxp:9005 Text 4/9/08 01:10 Page 29
Appendix 4: Factors which may affect swallowing
Adult literature on swallowing with a tracheostomy has suggestedassociated difficulties relating to the pharyngeal stage of the swallow.21 Alsowell documented, is that aspiration is the major swallowing difficultyassociated with tracheostomy in the adult population.19 There is howeverlittle data available for the paediatric population21 but a number of factorsare suggested which may impact on swallowing.
• Swallowing difficulties may be present secondary to the primary medicaldiagnosis.21
• Children/young people with isolated airway problems are not likely tohave any swallowing problems.67
• Children/young people with long-term tracheostomies may havepharyngeal stage difficulties.62
• Restriction of upward laryngeal movement can limit laryngeal closurenecessary for complete epiglottic closure.68
• Air diversion through the tracheostomy tube may lead to laryngealdesensitisation due to lack of airflow in the upper respiratory airway.This may also have an effect on co-ordinated laryngeal closure.69
• In ventilated children, the co-ordination of sucking, swallowing andbreathing is altered and may lead to swallow dysfunction.69
• Cuffed tube use is limited in paediatrics but if required oral feedingshould not be considered.21
• Presence of infantile gastro oesophageal reflux commonly affectsbehaviour, swallowing and food intake.70
Caring for the child/young person with a tracheostomy
30
10906 Text.qxp:9005 Text 4/9/08 01:10 Page 30
31
Manufactureranddescription
Sizes
Comments
SHILEY
Op
aque
,th
erm
osen
sitiv
ep
olyv
inyl
chlo
ride
(PVC
)(la
tex-
free
)
Neo
nata
lCuf
fless
Trac
heos
tom
yTu
be:
size
s3.
0–4.
5mm
Paed
iatr
icC
uffle
ssTr
ache
osto
my
Tube
:si
zes
3.0–
5.5m
mPa
edia
tric
Cuf
fless
Long
Trac
heos
tom
yTu
be:
size
s5.
0–6.
5mm
Paed
iatr
icC
uffe
dTr
ache
osto
my
Tube
:si
zes
4.0–
5.5m
mPa
edia
tric
Cuf
fed
Long
Trac
heos
tom
yTu
be:
size
s5.
0–6.
5mm
Shile
ytu
bes
can
bele
ftin
situ
for
upto
28da
ys.
They
can
bere
used
seve
ralt
imes
,su
bjec
tto
the
inte
grity
ofth
etu
be.
Follo
wm
anuf
actu
rer’s
advi
cere
gard
ing
clea
ning
tube
s.
TRACOEMini
Radi
opaq
uep
olyv
inyl
chlo
ride
(PVC
)N
eona
tal(
350
serie
s)C
uffle
ssTr
ache
osto
my
Tube
:si
zes
2.5–
4.0m
mPa
edia
tric
(355
serie
s)C
uffle
ssTr
ache
osto
my
Tube
:si
zes
2.5–
6.0m
mTu
bes
not
reus
able
,bu
tm
ayre
mai
nin
situ
for
upto
28da
ys.
How
ever
,at
leas
tw
eekl
ych
ange
sar
ere
com
men
ded,
asth
etu
bem
aybe
com
eco
ated
and
bloc
ked
with
secr
etio
ns.
SIMSPORTEXBivona
Op
aque
,si
lcon
ised
pol
yvin
ylch
lorid
e(P
VC)
(late
x-fr
ee)
Neo
nata
lCuf
fless
Trac
heos
tom
yTu
be:
size
s2.
5–4.
0mm
Paed
iatr
icC
uffle
ssTr
ache
osto
my
Tube
:si
zes
2.5–
5.5m
m
Neo
nata
lAire
–cu
fTr
ache
osto
my
Tube
:si
zes
2.5–
4.5m
mPa
edia
tric
Aire
–cu
fTr
ache
osto
my
Tube
:si
zes
2.5–
5.5m
m
Neo
nata
lTig
htto
the
Shaf
t(T
TS)
Cuf
fed
Trac
heos
tom
yTu
be:
size
s2.
5–4.
5mm
Paed
iatr
icTi
ght
toth
eSh
aft
(TTS
)C
uffe
dTr
ache
osto
my
Tube
:si
zes
2.5–
5.5m
m
Neo
nata
lFom
e-cu
fTr
ache
osto
my
Tube
:si
zes
2.5–
4.5m
mPa
edia
tric
Fom
e-cu
fTr
ache
osto
my
Tube
:si
zes
2.5–
5.5m
m
Bivo
natu
bes
can
bele
ftin
situ
for
upto
28da
ys.
Unl
ike
mos
tot
her
pla
stic
pro
duct
s,th
eyca
nbe
reus
edse
vera
ltim
es,
subj
ect
toth
ein
tegr
ityof
the
tube
.Fo
llow
man
ufac
ture
rsad
vice
rega
rdin
gcl
eani
ngtu
bes.
The
silic
one
tube
isre
info
rced
with
wire
–th
ew
ireis
not
com
pat
ible
with
use
durin
gM
RI
Aire
–cu
ffha
san
air-
fille
dcu
ffTT
SC
uff
has
aw
ater
-fill
edcu
ffFo
me-
cuf
has
aru
bber
foam
-fill
edcu
ff.Th
efo
amis
self-
exp
andi
ng.
GreatOrmondStreet
Poly
viny
lchl
orid
e(P
VC)
Avai
labl
ein
size
s3.
0–7.
0mm
Tube
sno
tre
usab
le.
Not
com
pat
ible
with
stan
dard
vent
ilato
rtu
bing
and/
orH
MEs
and/
orre
susc
itatio
neq
uip
men
t.Musthaveaccesstoaportex
male/femaleadaptorofappropriatesizefor
emergencysituations.
SILVERtracheostomytubes
Silv
erAv
aila
ble
ina
rang
eof
size
s–
mea
sure
din
the
Fren
chga
uge
and
not
com
pat
ible
toth
em
etric
mea
sure
men
tsof
pla
stic
tube
s.Th
inw
alle
dtu
be,
allo
win
gfo
rin
ner
cann
ula.
Silv
ertu
bes
can
bele
ftin
situ
for
28da
ys.
Follo
wm
anuf
actu
rer’s
advi
cere
gard
ing
clea
ning
tube
s.NotcompatiblewithuseduringMRI.
All
size
sst
ated
are
for
the
inte
rnal
diam
eter
.
For
info
rmat
ion
onad
ult
tube
s,p
leas
ese
eth
eca
ring
for
the
pat
ient
with
atr
ache
osto
my
best
pra
ctic
est
atem
ent.
2
Appendix5:Tracheostomytubetable
10906 Text.qxp:9005 Text 4/9/08 01:10 Page 31
Appendix 6: Sizing chart for paediatric airways71
Updated Great Ormond Street Hospital sizing chart for paediatric airways
Tweedie DJ, Skilbeck CJ, Cochrane LA, Cooke J, Wyatt ME. Choosing a paediatrictracheostomy tube: an update on current practice. J Laryngol Otol. 2008;122(2):161-9 , page9 © JLO (1984) Limited, reproduced with permission.
Caring for the child/young person with a tracheostomy
32
Preterm-1 month1-6
months6-18
months18 mths - 3 yrs
3-6years
6-9years
9-12 years
12-14 years
Trachea (Transverse
Diameter mm)5 5-6 6-7 7-8 8-9 9-10 10-13 13
PLA
ST
IC
Great Ormond Street
ID (mm) 3.0 3.5 4.0 4.5 5.0 5.5 6.0 7.0
OD (mm) 4.5 5.0 6.0 6.7 7.5 8.0 8.7 10.7
Shiley
*Cuffed Tube Available
Size 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5
ID (mm) 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5
OD (mm) 4.5 5.2 5.9 6.5 7.1 7.7 8.3 9.0
Length (mm)Neonatal 30 32 34 36
Paediatric 39 40 41* 42* 44* 46*
54* 56*Long Paediatric 50* 52*
Portex (Blue Line)
ID (mm) 3.0 3.5 4.0 4.5 5.0 5.0 6.0 7.0
OD (mm) 4.2 4.9 5.5 6.2 6.9 6.9 8.3 9.7
Portex (555) Size 2.5 3.0 3.5 4.0 4.5 5.0 5.5
ID (mm) 2.5 3.0 3.5 4.0 4.5 5.0 5.5
OD (mm) 4.5 5.2 5.8 6.5 7.1 7.7 8.3
LengthNeonatal 30 32 34 36
Paediatric 30 36 40 44 48 50 52
Bivona
All sizes avail-able with Fome Cuff, Aire Cuff &
TTS Cuff
Size 2.5 3.0 3.5 4.0 4.5 5.0 5.5
ID (mm) 2.5 3.0 3.5 4.0 4.5 5.0 5.5
OD (mm) 4.0 4.7 5.3 6.0 6.7 7.3 8.0
LengthNeonatal 30 32 34 36
Paediatric 38 39 40 41 42 44 46
Bivona ID (mm) 2.5 3.0 3.5 4.0 4.5 5.0 5.5
Usable Length (mm)
55 60 65 70 75 80 85
Bivona Flextend ID (mm) 2.5 3.0 3.5 4.0 4.5 5.0 5.5
Shaft Length (mm) 38 39 40 41 42 44 46
Flextend Length (mm)
10 10 15 15 17.5 20 20
TracoeMini ID (mm) 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0
OD (mm) 3.6 4.3 5.0 5.6 6.3 7.0 7.6 8.4
Length (mm) Neonatal (350)
30 32 34 36 36
Paediatric (355) 32 36 40 44 48 50 55 62
SIL
VE
R
Alder Hey FG 12-14 16 18 20 22 24
Negus FG 16 18 20 22 24 26 28
Chevalier Jackson
FG 14 16 18 20 22 24 26 28
FG 12-14 16 18 20 22 24 26
ID (mm) 2.9-3.6 4.2 4.9 6.0 6.3 7.0 7.6
Cricoid (AP Diameter)
ID (mm) 3.6-4.8 4.8-5.8 5.8-6.5 6.5-7.4 7.4-8.2 8.2-9.09.0-10.7
10.7
Bronchoscope (Storz)
Size 2.5 3.0 3.5 4.0 4.5 5.0 6.0 6.0
ID (mm) 3.5 4.3 5.0 6.0 6.6 7.1 7.5 7.5
OD (mm) 4.2 5.0 5.7 6.7 7.3 7.8 8.2 8.2
Endotracheal Tube (Portex)
ID (mm) 2.5 3.0 3.5 4.0 4.5 5.0 6.0 7.0 8.0
OD (mm) 3.4 4.2 4.8 5.4 6.2 6.8 8.2 9.6 10.8
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Appendix 7: Decannulation
Decannulation involves removal of the tracheostomy tube allowing‘normal’ respiration to occur. The following steps should be taken.
Pre admission
Physical and psychological assessment is essential and will involve thefollowing assessments:
• Swallowing and cough: this can be carried out by medical staff and or aspeech and language therapist, it may be necessary to perform avideofluoroscopy.
• Secretions: consider how often is suction required? Are oral secretionsstill evident? Do they increase during activity?
• Airway assessment: this could include an microlaryngobronchoscopy(MLB) and can be carried out as a pre admission or on day one. Thiswill enable a view of the airway and if the tracheostomy has beeninserted due to a primary airway cause, this will be assessed. If thetracheostomy has been inserted to facilitate treatment, it is stilladvisable to review through an MLB, as the tracheostomy tube cancause airway complication.
• Psychological: it is not always necessary to have a professionalpsychologist available. However, discussing and listening with theparents, and the child if appropriate, is essential.
Admission
Day one following airway assessment by ear, nose and throat (ENT)consultant, undertake an MLB if necessary.
Downsize to size 3.mm tracheostomy tube.
Day two cover with decannulation cap if available, or occlude withairtight tape for 12 hours, then uncover overnight.
Day three cover for 24 hours from 8am.
Day four decannulate. Occlude stoma with airtight dressing andcontinue observations.
Day five child/young person is able to go off the ward.
Day six discharge, with outpatient department appointment in 6weeks.
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Throughout the process, the child/young person should be observed forclinical signs of respiratory distress/fatigue. The child/young person mayexperience a feeling of panic at each stage initially. It is vital to alleviate thispanic, while being vigilant for any signs of respiratory distress. Theparents/carers may experience anxiety as their child/young person will bebreathing through a smaller tube, before it is occluded and removed. Thismay feel like they are losing a safe airway. Reassurance of both thechild/young person and parents/carers is essential to maximise the safety ofthis procedure.
If this is unsuccessful, the child/young person’s original tube is reinserted.The child/young person’s condition will be reassessed, with the possibilityof returning to the decannulation process at a later date.
Following a successful decannulation, it may take a number of weeks forthe stoma to close. Sometimes a surgical closure is necessary after 6months.
It is necessary to inform the disability living allowance (DLA) office of thesuccessful decannulation.
Observations
The child/young person will be continually observed for:
• breathing pattern
• respiratory distress
• restlessness
• agitation
• colour
• oxygen saturations, and
• vital signs.
If there any concerns, medical staff must be informed immediately.
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Action Achieved/signature Date
Ear, nose, throat (ENT)/respiratory consultant to make clinical decision that thechild/young person requires long-term tracheostomy airway
Specialist nurse to discuss and answer questions with child/young person(age/ability appropriate) and parents/carers regarding the management oftracheostomy, and training schedule post tracheostomy surgery. Writteninformation given
Referral to speech and language therapy service
Referral to play specialist
Specialist nurse/named nurse to liaise with discharge planning service
Referral to the relevant community children’s nursing (CCN) service if available
Inform relevant children’s nursing service regarding equipment required fordischarge
Equipment delivered direct to the ward for parental/carer training
All supplies and sundries required for tracheostomy management to bedocumented and listed with order codes to be faxed to relevant communitychildren’s nursing service
Parents/carers and child/young person (where appropriate) to be given training -practical demonstration and supervised practice regarding tracheostomymanagement and troubleshooting – see individual child/young person’stracheostomy information.
• Why the individual child/young person has a tracheostomy airway?
• What size/type of tracheostomy tube is in situ?
• Tracheal suction technique
• What is pre-measured tracheal suction depth?
• Set-up of portable suction equipment
• Portable suction negative pressure setting?
• Tracheal stoma care
• Tracheostomy tube change technique
• Troubleshooting
- Recognition and management of airway obstruction/respiratory distress
- Emergency airway management and use of Ambu Bag
- Stoma over-grannulation management
- Equipment breakdown
- Accessing replacement equipment/supplies
- Management of respiratory infections
• Basic life support and tracheostomy resuscitation training
• Written information regarding child/young persons tracheostomy managementand completed parent/carer tracheostomy teaching guideline
• Relevant contact telephone numbers
• Written information regarding readmission criteria
• Information on how to dispose of clinical waste
Appendix 8: Discharge checklist
Name_________________ DOB_________________Date_____________
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Action Achieved/signature Date
Outreach training by specialist nurse regarding tracheostomy management/basiclife support and tracheostomy resuscitation training for child/young persons localhospital (nursing and medical staff), community team – GP, CCN, health visitor,community paediatric physiotherapist, respite/hospice services and education(nursery/school) to be arranged, as required
Tracheostomy sundries/supplies for discharge• Portable suction unit• Appropriate sized resuscitation bag• Apnoea monitor (for child <1 year) and sensors• Tracheostomy tube - same size• Tracheostomy tube - smaller size
• Tracheostomy securing devices (ie collars/tape, relevant size)• Suction catheters (relevant size)• Suction tubing• Non-sterile gloves• HME filters• Airtight waterproof tape
Parent/identified carer(s) to be competent in all aspects of tracheostomymanagement, essential tracheostomy supplies, basic life support and emergencyairway management and use of Ambu Bag prior to discharge
Document names and relationship to child/young person of all peopletracheostomy trained/competent, with completed parent/carer tracheostomyteaching guidelines
1
2
3
4
5
6
7
8
9
Follow-up with respiratory service and/or ENT service – outpatient clinicappointment to be arranged, prior to discharge. Parent/carer to be informed
Inform local hospital, Children’s Community Nurse, GP regarding discharge date.Discharge letter and relevant written tracheostomy information to be sent timeously
Telephone follow-up by specialist nurse within week of discharge – date arrangedwith parent/carer
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Appendix 9: Minimal occlusion technique72,73
Cuff inflation
It is very important that care is taken not to over inflate the cuff on atracheostomy tube. The tracheostomy cuff has several important functions(to prevent aspiration of upper airway secretions and/or prevent loss ofairway pressure in the ventilated child/young person), however, it can alsocause damage to the tracheal mucosa. An over inflated cuff can reduceperfusion to the tracheal mucosa, which may lead to ulceration, dilationand stenosis of the trachea.
Most cuffed tracheostomy tubes have a high volume, low pressure cuff –thereby, reducing the risk of trauma due to pressure. This style of cuffallows the pressure of the cuff to be diffused over a wider surface area.However, this does not eliminate the risks entirely. Therefore, the cuffshould be inflated to the minimal desired occlusion volume to preventtrauma to the mucosal wall.
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Minimal occlusion volume (MOV) technique
This technique requires two people.
• When the cuff is inflated with volume (air or water depending on styleof tracheostomy cuff), it is gradually inserted in 0.2–0.5mls incrementswith a 5ml syringe into the tracheostomy tube cuff (for paediatric cuffedtubes – adult cuff volumes will require a 10ml syringe).
• A stethoscope is positioned just below the thyroid cartilage, enabling airleaks to be heard.
• One person inserts the volume, while the second person listens forabsence of an air leak as the volume is inserted.
• When no air leak is heard, the cuff is inflated to the minimal occlusionvolume and, no further increments of volume are required.
• It is important that the volume inserted is documented in thechild/young person’s record for reference.
• For greater accuracy, the first person withdraws 0.5–1.0ml of air until anair leak is heard by the second person.
• The first person re-inflates the cuff until no air leak is heard by thesecond person, thereby confirming the amount of volume required toachieve a minimal occlusion volume.
DO NOT EXCEED THE MANUFACTURER’S RECOMMENDED CUFFVOLUME.
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Oralpharynx
Larynx
Vocal cords
Trachea
Oesophagus
Epiglotis
Cricothyroidmembrane
Cricoldcartilage
Stethoscope
Thyroidcartilage
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Action Rationale
Preoxygenate child/young person for oneminute prior to procedure and continue untilchild/young person is clinically stable if:• child/young person is at risk of
desaturation• child/young person routinely requires
>40% oxygen• child/young person has experienced
detrimental effect of suctioning on aprevious occasion74
• To minimise hypoxia
Universal precautions must be used.• Clinical hand wash must be performed• Non-sterile gloves must be worn• Non-touch techniques should be adopted
• To minimise risk of infection• To minimise risk of contamination
Suction catheter should be attached to thesuction tubing without touching the end ofthe suction catheter
• To minimise risk of contamination
Suction catheter should be inserted usingpre-measured technique
Tube length should be pre-determined byinserting a suction catheter into atracheostomy the same size as thechild/young person’s. This measurementshould be recorded in the child/youngpersons record75
• As a point of reference for healthcareprofessionals
Deep suctioning is not recommended.However, it may be necessary in particularcircumstances, eg during broncho-alveolarlavage, or for airway clearance in acutely illchild/young person with lung consolidationand/or collapse
• Animal model studies45 and post mortemstudies46 clearly demonstrate epithelialdamage where deep suction is routinelyperformed
• Deep suction should never be usedroutinely, however in selected situations itcan be necessary for clearance ofsecretions located beyond the tube20
Suction should be applied to therecommended pressure (see Section 6)
Negative pressure should be applied for therecommended duration
Healthcare professionals must use theirclinical judgement to assess if a child/youngperson can only tolerate shorter duration ofsuction based on clinical symptoms
Suction catheter should be withdrawn asnegative pressure is applied
Assess child/young person’s condition afterfirst suction attempt
• There is increased risk of hypoxia andatelectasis in children/young people andinfants due to smaller residual lungvolume76
• Children/young people with impairedrespiratory or cardiac function may be atincreased risk of hypoxia77
To determine whether child/young personrequires further suctioning
Appendix 10: Tracheostomy suction procedure in paediatrics34
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Action Rationale
If further suction is required, a new suctioncatheter should be used as suction cathetersare licensed for single use only
• To minimise infection• To comply with licensing laws
If secretions are thick and offensive, a samplespecimen should be collected and sent forscreening
• To establish if the child/young person hasan infection or requires additionaltreatment
If the child/young person has thick or drysecretions the healthcare professional must:• assess the child/young persons hydration
status, and• provide additional methods of airway
humidification, eg a humidified air systemor saline nebulisers78
Routine instillation of saline is not advised
• Dehydration affects secretion viscosity• Nebulised solutions decrease secretion
viscosity79
• Research concludes that saline instillationcan have detrimental effects for thechild/young person
During the entire suction procedure, thechild/young person must be continuallymonitored/observed for changes inrespiratory rate, oxygenation, colour, heartrate, respiratory effort
Any changes during the suction procedureshould be documented in the child/youngpersons record
• To ensure patient safety• To note deterioration in the child/young
person’s condition• So that appropriate action can be taken if
necessary• To influence future suction practices
Table adapted from Ireton J. 2007. Tracheostomy Suction: a protocol for practice.Paediatric Nursing, 19(10), 14-1834 with permission from RCN Publishing.
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Appendix 11: Illustrations
1. Humid-vent 2. Trach phone 3. Swedish Nose
4. Thermovent 5. Portex Thermovent HME 6. Tyco healthcare tracheolife
7. Catheter with side holes 8. Velcro tracheostomy collar 9. Humidification Bib
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10. Heated humidifier andwater chamber
11. Ultrasonic Nebuliser 12. Great Ormond Street tubes,flat and extended versions
13. Cuffed tracheostomy tube 14. Portex blue line uncuffedtracheostomy tube
15. Single cannulated tube
16. Uncuffed fenestrated tube 17. Speaking valve 18. Passy Muir speaking valve
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19. Passy Muir speaking valve withoxygen connector
20. Smiths medical biovonafome-cuf paediatric/neonataltracheostomy tube
21. Smiths medical biovonauncuffed paediatric/neonataltracheostomy tube
22. Smiths medical biovona aire-cuf paediatric/neonataltracheostomy tube
23. Shiley paediatric uncuffedtracheostomy tube
24. Pharma neo port
25. Pharma neo basic
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Section Y NDonotknow
Action andcomments
Section 1: Education and training
a Healthcare professionals have access to:
• Education
• Training
• Standardised local policies or guidelines
bAll healthcare professionals who come into contact with achild/young person with a tracheostomy (no matter howinfrequently) understand:
• Indications for the tracheostomy
• Risks associated with a tracheostomy
• Potential complications with a tracheostomy
• Types of tubes and equipment for each case
• Importance of standard infection control precautions
cHealthcare professionals and parents/carers receive training onroutine and emergency airway management for children/youngpeople with a tracheostomy
dHealthcare professionals demonstrate knowledge of when to seek,and have access to, professional advice and assistance fromrelevant specialists
eHealthcare professionals have a record of maintaining competencyin caring for a child/young person with a tracheostomy
fEducation and reassurance of the child/young person and theirparents/carers starts (where possible) prior to a tracheostomybeing performed
gEducation of family/carers and education staff, and access to readyadvice and support, is provided
hAn additional support plan including emergency guidelines isdeveloped for nursery/school and other agencies
Appendix 12: Audit toolPlease see the NHS QIS website (www.nhshealthquality.org) to download a Word version of this audit toolto save and use electronically or print to use by hand.
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Section Y NDonotknow
Action andcomments
Section 2: Communication
aHealthcare professionals can demonstrate they are knowledgeableabout communication problems associated with children/youngpeople with a tracheostomy
bThe key worker involves the speech and language therapist(ideally pre-operatively)
cThe speech and language therapist assesses the communicationskills of the child/young person.
dThe speech and language therapist implements, evaluates andreviews the specific communication record
eThe acute speech and language therapist refers the child/youngperson to the community speech and language therapist
fClinical indicators are reviewed to ascertain whether speakingvalves/tracheostomy valves should be considered
Section 3: Swallowing and nutrition
aHealthcare professionals and parents/carers are knowledgeableabout nutritional and swallowing problems associated withchildren/young people with a tracheostomy
bSpeech and language therapists undertake the initial swallowingassessment and recognise when to involve the dietitian
cDietitians undertake the nutritional assessment of the child/youngperson with identified impaired swallowing
dFollowing assessments, healthcare professionals plan, implement,evaluate and review a specific nutritional record
e Regular oral care is provided
fIf the child/young person has a cuffed tube, swallowing should beassessed with the cuff deflated following medical clearance to do so
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Section Y NDonotknow
Action andcomments
Section 4: Stoma care
aAll healthcare professionals involved in stoma managementundertake training on it
bThe child/young person with a tracheostomy stoma has frequencyof stoma care individually assessed
cAn evaluation of stomal condition is documented in thechild/young person’s record and an appropriate plan of careinitiated
dThe stoma is cleaned as per local guidelines/policies and nocotton wool used around the stoma. If clinically indicated, barrierfilm is applied
eNo dressings are used around the healthy stoma site unlessclinically indicated
f Devises securing the tracheostomy tube are checked for security
gParents/carers and children/young people (age appropriate) aretaught to manage stoma care prior to discharge
h Tracheostomy site is observed for signs of granulation
iHealthcare professionals and parents/carers follow hand hygieneprocedures
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Section Y NDonotknow
Action andcomments
Section 5: Tracheostomy tube management
General tube management
aThe multidisciplinary team individually assesses the mostappropriate tube to be used
bThe child/young person has another tube of the same size andtype and one size smaller at all times
cIf the child/young person is using a single cannula tube, it ischanged at least once a week and assessed on an individual basis
dRoutine tube changes do not occur immediately before or aftereating
eThe first tube change takes place 5–7 days after the surgicalprocedure and under medical direction
fA note is made of the technique used to perform thetracheostomy, size and style of tube and whether it is stitched upto the skin
g The tracheostomy tube is cleaned or replaced as appropriate
hBrushes are not used on plastic tubes unless specificallyrecommended by the manufacturer
iIn addition to standard resuscitation equipment, allchildren/young people with a tracheostomy require theequipment listed on page 16 of the best practice statement
jIf decannulation is considered, the child/young person isindividually assessed by the multidisciplinary team
kClose monitoring and observation of the child/young person’sairway and respiratory status occurs throughout the decannulationprocess
lThe child/young person has their emergency equipment withthem at all times during the decanulation process
Cuffed tracheostomy tubes
aThe cuff should be inflated to the minimal desired occlusionvolume
bCuffed tracheostomy tubes that have air cuffs should have cuffpressure checked at least once daily maintaining pressure between15–25cmH20 using a manometer
Inner cannula management
aIndividual assessment of the frequency of inner cannula care isundertaken
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Section Y NDonotknow
Action andcomments
Fenestrated tubes
aThe fenestrated inner cannula is removed prior to tracheal suctionand replaced with an unfenestrated inner cannula
bAll children/young people with a fenestrated tube require anunfenestrated tube readily accessible
Section 6: Suctioning
aThe lowest effective pressure is used when suctioning usingequipment with an adjustable and measurable dial. See page 20 ofthe best practice statement for recommended pressures
bSuctioning lasts no longer than 5 seconds at a time and anappropriate catheter is used
c Suctioning is carried out using the pre-measured technique
dThe need for hyperoxygenation prior to the procedure is assessedon an individual basis in line with local policies
eA plain inner tube is inserted prior to suctioning if a fenestratedtube is in situ
fHealthcare professionals are aware of the psychological effect ofsuctioning on children/young people
gThe local infection control policy is adhered to throughout thetracheal suctioning process
Section 7: Humidification
aAn assessment of humidification needs is undertaken by healthcareprofessionals
bMucocillary clearance and reduction in the risk of pulmonaryinfection is achieved with humidification
cHealthcare professionals are aware of the benefits associated withhumidification device
dHealthcare professionals are aware of the particular problemsassociated with artificial humidification in children/young peoplewith a tracheostomy
eHumidification systems are managed in accordance withmanufacturers instructions and local policies and guidelines
fThe child/young person and parents/carers are aware of the needfor and appropriate use of humidification equipment
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Section Y NDonotknow
Action andcomments
Section 8: Therapeutic play interventions
aThe child/young person in hospital has access to a qualified playspecialist
bHealthcare professionals have knowledge of childhood developmentand refer to the play specialist
cPlay specialists are part of the multidisciplinary team caring for thechild/young person with a tracheostomy and plan, develop andevaluate structured play and developmental programmes
dEducation/information packs include advice on appropriate and safeplay for children/young people with a tracheostomy
eParents/carers are offered psychological preparation/post proceduralplay programmes
fParents/carers are offered distraction therapy for any treatmentundertaken
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Glossaryaspiration The entry of gastric secretions, oropharyngeal
secretions or food and fluid into thetracheobronchial passages (airways) caused bydysfunction or absence of normal protectivemechanisms.
atelectasis Collapse of lung tissue preventing the exchange ofcarbon dioxide and oxygen as part of normalrespiration.
barrier film A protective barrier which may look like plastic skinand protects the skin from becoming red and sore.
basic life support A sequence of events needed to try to revive acollapsed person. Basic life support for babies andchildren is mainly required for a breathingemergency. As damage to vital organs starts to occurafter just a few minutes of oxygen shortage, it isessential that when needed basic life support isstarted quickly.
‘blue dye’ test Tracheal suctioning at set intervals following theintroduction of blue dye on to the tongue or bymixing dye with foods or liquids as a supplementaryswallow assessment technique (the Modified EvansBlue Dye Test).
catheter Hollow tube for removing secretions.
cross transmission The transmission of an infectious agent from oneindividual to another via direct or indirect exposure.
cuffed tube A tube with a balloon on the end which can beinflated with air to hold the tube in position andprevent secretions entering the respiratory tract.
decannulation Removal of the tracheostomy tube allowing ‘normal’respiration to occur.
fenestrated tube A tube which has an opening cut into the tube wallto allow the passage of air.
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fibreoptic A flexible endoscope is placed above the epiglottisevaluation and laryngeal function is assessed before, duringof swallowing and after swallowing.(FEES)
gastrostomy A feeding tube that is inserted surgically through theabdominal wall into the stomach allowing liquid feedto be delivered directly into the stomach.
hand hygiene The process of cleaning hands by performing handwashing or using alcohol hand rub solutions.
heat and moisture Device to increase moisture content of inspiredexchanger (HME) (breathed in) air.
humidification Equipment for maintaining moisture when givingsystem ventilation (not necessarily always oxygen).
hyperoxygenation The use of high concentrations of oxygen before andafter endotracheal suction.
leaked air Space between the trachea and tracheostomy tubeallows expiratory air to leak up round the tube andover the vocal cords allowing voice to be producedand speech if developed to be used.
minimal occlusion The gradual inflation of the tracheostomy tube cuffvolume by 0.5ml increments of air until no air leak is heard -
using a stethoscope held just below the thyroidcartilage.
mucociliary Lining of the respiratory tract.
multi-eyed Catheter with numerous holes around tip.catheter
nasogastric Liquid feed delivered directly into the stomach by afeeding narrow tube that is passed into the nose and down
the oesophagus (food pipe) into the stomach.
oral feeding Food and drink taken by mouth.
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passy muir valve Referred to as ‘Passy Muir (Tracheostomy) Valves’ not‘speaking’ valves as the valve only enables voicing tohappen through expired air escaping over the vocalcords.
perfusion coupling The ability to match ventilation and perfusion toeach other.
peristomal The area surrounding the stoma.
rain out Where moisture in a gas passing through a tube ordevice condenses through contact with coolsurfaces. Drainage or technical preventive measuresmay be needed since droplets can build up andreduce gas flow.
single patient use Can be used more than once but on one patientonly.
single use Use once only and then discard.
sleep apnoea A sleep disorder characterised by periods of absenceof breathing.
speaking valve A valve that has a one way mechanism that allows airto enter through the tracheostomy tube but closeson expiration to redirect the airflow past the vocalcords to produce voice provided that air leak ispresent (see passy muir valve).
standard infection Formally agreed steps that must be used by all healthcontrol precautions and social care workers to prevent the spread of(SICPs) micro-organisms that may cause infection.
SICPs should be used appropriately at all times in thecare setting whether an infection is known to bepresent or not, when dealing with blood, excretions,secretions, and other body fluids.
stoma The artificial opening in the patient’s neck formed bythe tracheostomy.
suctioning The process of removing secretions.
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tracheal tract The tract formed by the presence of a tracheostomytube.
tracheostomy A surgical opening in the anterior wall of the trachea(front of neck) to facilitate breathing.
T-Tube A device to connect a cuffed tracheostomy tube to ahumidifier.
ventilator A machine used to assist breathing.
videofluoroscopy An investigation that provides a comprehensiveexamination of swallowing function at differentlevels. A radiographic investigation to evaluate thestatus and safety of the pharyngeal swallow wheresmall amounts of barium is mixed with food or drinkand given in the normal feeding position.
weaning process Attempt to help patients breathe without the aid ofthe tracheostomy tube or ventilator.
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tracheostomy: best practice statement. 2003 [cited 2008 June 6];Available from:http://www.nhshealthquality.org/nhsqis/files/tracheostomy.doc
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5 Fiske E. Effective strategies to prepare infants and families for hometracheostomy care. Adv Neonatal Care. 2004;4(1):42-53.
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11 Engleman SG, Turnage-Carrier C. Continuing education series.Tolerance of the PASSY-MUIR SPEAKING VALVE in infants and childrenless than 2 years of age. Pediatr Nurs. 1997;23(6):571-5.
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72 Dartford and Gravesham NHS Trust. Guidelines for cuff inflation anddeflation of a tracheostomy tube. 2003 [cited 2008 June 9]; Availablefrom: http://www.dvh.nhs.uk/downloads/documents/EPSUO5GAZN_Guidelines_for_Cuff_Inflation_and_Deflation_of_a_Tracheostomy_Tube.pdf
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Additional reading/further reading
Abdullah VJ, Mok JSW, Chan HB, Chan KM, van Hasselt CA.Paediatric tracheostomy. Hong Kong J Paediatr. 2003;8(4):283-9.
American Thoracic Society. Patient information series: use of atracheostomy with a child. Am J Respir Crit Care Med. 2006;174(11):11-2.
Clark L, Clarke K, Hardy C, MacAulay F, Magorrian A-M, McGowan S, et al.Speech and language therapy in adult critical care: position statement.London: Royal College of Speech and Language Therapists; 2006 [cited2008 June 9]; Available from: http://www.rcslt.org/docs/free-pub/critical_care_Jan_17_07.pdf
Cochrane LA, Bailey CM. Surgical aspects of tracheostomy in children.Paediatr Respir Rev. 2006;7(3):169-74.
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Day T, Farnell S, Haynes S, Wainwright S, Wilson-Barnett J. Trachealsuctioning: an exploration of nurses’ knowledge and competence in acuteand high dependency ward areas. J Adv Nurs. 2002;39(1):35-45.
DeRowe A, Fishman G, Leor A, Kornecki A. Improving children’s co-operation with tracheotomy care by performing and caring for atracheostomy in the child’s doll – a case analysis. Int J PediatrOtorhinolaryngol. 2003;67:807-9.
Edwards EA, Hsiao K, Nixon GM. Paediatric home ventilatory support:the Auckland experience. J Paediatr Child Health. 2005;41(12):652-8.
Fiske E. Tracheostomy home care guide. Adv Neonat Care. 2005;4(1):54-5.
MacAulay F, McIntosh A. Swallowing with tracheostomy: an assessmentprotocol. London: Royal College of Speech and Language Therapists;2005. Bulletin, January 2005.
Middleton DB, ed. Tricks of the trade [online]. 2006 [cited 2008 June 9];Available from: http://www.emedmag.com/html/pre/tri/0506.asp
Noyes J, Lewis M. From hospital to home: guidance on dischargemanagement and community support for children using long-termventilation. Ilford: Barnardo’s; 2005.
Greenville Hospital System University Medical Centre. Trach care requiresintensive education. Focus on Pediatrics Spring 2003. Upstate, USA:Greenville Hospital System; 2003.
Sisk EA, Kim TB, Schumacher R, Dechert R, Driver L, Ramsay AM, et al.Tracheostomy in very low birth weight neonates: indications andoutcomes. Laryngoscope. 2006;116(6):928-33.
Simon BM, McGowman JS. Tracheostomy in young children: implicationsfor assessment and treatment of communication and feeding disorders.Infants Young Child. 1989;1(3):1-9.
Spence K, Gillies D, Waterworth L. Deep versus shallow suction ofendotracheal tubes in ventilated neonates and young infants. CochraneDatabase of Systematic Reviews 2003, Issue 3.
Torres LY, Sirbegovic DJ. Problems caused by tracheostomy tubeplacement. Neonat Intensive Care. 2004;17(1):52-4.
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Torres LY, Sirbegovic DJ. Clinical benefits of the Passy-Muir tracheostomyand ventilator speaking valves in the NICU. Neonat Intensive Care.2004;17(4):20-3.
Trachsel D, Hammer J. Indications for tracheostomy in children. PaediatrRespir Rev. 2006;7(3):162-8.
Wilson M. Tracheostomy management. Paediatr Nurs. 2005;17(3):38-44.
Woodnorth GH. Assessing and managing medically fragile children:tracheostomy and ventilatory support. Lang Speech Hear Serv Schools.2004;35(4):363-72.
Wootten CT, French LC, Thomas RG, Neblett WW, Werkhaven AJ, Cofer SA.Tracheostomy in the first year of life: outcomes in term infants, theVanderbilt experience. Otolaryngol Head Neck Surg. 2006;134(3):365-9.
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Heather Beattie Play Service Co-ordinatorNHS Grampian
Dawn Carnie Respiratory PhysiotherapistNHS Lothian
Kathryn Cowie Clinical Educator, Long Term Ventilation ServiceNHS Greater Glasgow and Clyde
Fiona Dagge-Bell Professional Practice Development OfficerNHS Quality Improvement Scotland
Catriona Don Children’s Community Nurse, Team LeaderNHS Tayside
Karen Graham Speech and Language TherapistNHS Greater Glasgow and Clyde
Sylvia Harrison Tracheostomy Nurse SpecialistNHS Greater Glasgow and Clyde
Pamela Joannidis Lead Nurse Infection ControlNHS Greater Glasgow and Clyde
Linda McCarthy Specialist Nurse Respiratory SupportNHS Lothian
Nicola Nunn Community Staff Nurse/Staff Nurse HDUNHS Grampian
Karen Riddell Community Paediatric DietitianNHS Greater Glasgow and Clyde
Dr Mark Bloch Consultant AnaesthetistNHS Grampian
Lynne Coltart Head and Neck Clinical Nurse SpecialistNHS Dumfries and Galloway
Marie Elen Child Health LecturerNapier University
Neil Geddes ENT SurgeonNHS Greater Glasgow and Clyde
Joyce Henderson PhysiotherapistNHS Fife
Elspeth Jardine Ventilation Service Co-ordinatorNHS Greater Glasgow and Clyde
Elinor Johnson Respiratory PhysiotherapistNHS Greater Glasgow and Clyde
Sara Jones Specialist Speech and Language TherapistNHS Grampian
Haytham Kubba ENT SurgeonNHS Greater Glasgow and Clyde
Toby Mohammed Head of Research and Practice Development Acute ServiceNHS Greater Glasgow and Clyde
Dr Mary-Louise Montague Consultant ENT SurgeonNHS Lothian
Gail Robertson Speech and Language TherapistNHS Lothian
Who was involved in developing and reviewing the statement?
Working Group
Reference Group
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Networks and organisations consultedAid for Children with Tracheostomies
Chartered Society of PhysiotherapyChild Health Commissioners ScotlandCommunity and Health Visitors Network
NHS Education for ScotlandNHS Health ScotlandNHS National Services ScotlandNHS QIS Dietetics NetworkNHS QIS Occupational Therapy NetworkNHS QIS Physiotherapy NetworkNHS QIS Speech and Language Therapy NetworkNHSScotland medical directorsNHSScotland nurse directors
Higher Academic Institute Speech and Language Therapists TrainingDepartments (QMUC, Strathclyde)
Paediatric Group of the British Dietetic Association
Royal College of NursingRoyal College of Paediatrics and Child Health
Scottish Colleges Committee on Children’s Surgical ServicesScottish Government Directorate of Health and WellbeingScottish Neonatal Nurses Group
NHS QIS support teamFiona Dagge-Bell Professional Practice Development OfficerJoanne McDonald Practice Development Project Co-ordinator
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NHS Quality Improvement Scotland
Edinburgh Office
Elliott House, 8-10 Hillside Crescent, Edinburgh, EH7 5EA
Phone 0131 623 4300
Glasgow Office
Delta House, 50 West Nile Street, Glasgow G1 2NP
Phone 0141 225 6999
Email: [email protected] Website: www.nhshealthquality.org
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