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FAQ – Tracheostomy

When to consult your healthcare team

Breathing

Secretions

Tracheal cannula

Tracheostomy

Feedings

General condition

Your child’s health care team will take the opportunity during your child’s follow-up appointments to review your child’s care and equipment. Adjustments will be made as required.

Do not hesitate to refer to your child’s health care team for any questions or for specific advice related to your child’s condition.

WARNING: The information in this section is meant as a general guide for parents and caregivers with certain problems related to children with tracheostomy using a simple non-fenestrated, cuffless tracheal cannula.
It is not intended to replace the recommendations of your child’s health care team.

Discuss your child’s unique needs with the healthcare team, including WHO and WHEN to contact when problems arise.

 

One or more of these symptoms: coughing more frequently, yellow, green, pink or blood tinged secretions, secretions are thicker, secretions are more abundant than usual, secretions have a bad odor, labored breathing, breathing more quickly, chest pain, fever (≥ 38⁰C rectal or ≥ 37.5⁰C oral or ≥ 37.5⁰C underarm), irritability, loss of energy, loss of appetite/refusal to eat

Possible cause(s)

  • Respiratory tract infection
  • Incorrect placement of the tracheal cannula

What to do?

  • Suction the secretions if required.
  • Rapidly contact your child’s health care team.
  • Observe your child attentively in order to detect any sign of respiratory distress (see next problem).
  • In this case, call 911 immediately.
  • If required, begin manual ventilation and CPR as instructed.

If your child has increased secretions without respiratory distress, then:

  • Suction the secretions if required.
  • Raise the head of the bed at night and during naps.
  • Keep your child in a sitting and semi-sitting position if more comfortable this way.
  • Take your child’s temperature every 4 hours and give the medication recommended by your child’s health care team.
  • Increase liquid intake to help liquify the secretions.
  • Increase the humidity level.

One or more of these respiratory distress symptoms: labored breathing, more comfortable in a sitting position or with head elevated than in a lying down position, rapid, noisy or wheezy breathing, shallow breathing, secretions are more abundant than usual, weak cough, indrawing (retraction of the skin over, under and in between the ribs), use of accessory muscles to help with breathing, nasal flaring (enlargement of the nostrils during breathing), extension of the neck backwards to try to breathe in air, continuously crying, agitation, anxiety, irritability, scared look on your child’s face, marked sweating, pale skin, blue color of lips and nail beds

Possible cause(s)

  • Obstruction of the tracheal cannula by a foreign object or by secretions (mucus plug)
  • Accumulation of secretions or water in the artificial nose
  • Respiratory tract infection (eg, tracheitis, pneumonia)
  • Granulation tissue around the tracheal cannula site (thick soft scar tissue that sometimes forms around the tracheostomy)
  • Bronchospasm (eg, allergic reaction, exposure to smoke, dust, cold air)

What to do?

  • Remain calm and reassure your child.
  • Immediately identify the cause of the blockage (eg, secretions, mucus plug).

If the tracheal cannula is obstructed

If the obstruction persists:

If the problem is resolved:

  • Verify your child’s breathing to detect any signs of respiratory distress.
  • Inform your child’s health care team.

If the symptoms persist:

If there is an accumulation of secretions,
in the tracheostomy:

  • Try suctioning the secretions.
  • Instill a few drops of normal saline, if recommended by your healthcare team.
  • If you are able to suction the secretions: repeat instillation and suction up to 2 more times maximum, if needed.
  • If you are unable to suction the secretions (blockage of the tracheal cannula):
  • If the problem is resolved:
    • Verify your child’s breathing to detect any signs of respiratory distress.
    • Inform your child’s health care team.
  • If the symptoms persist:

in the artificial nose:

  • Remove the artificial nose.
  • Suction tracheal secretions.
  • Replace the artificial nose.
  • If the problem is resolved:
    • Verify your child’s breathing to detect any signs of respiratory distress.
    • Inform your child’s health care team.
  • If the problem persists: re-evaluate the cause of the obstruction.

If your child has difficulty breathing that is not related to the issues above:

  • Contact your child’s healthcare team immediately.
  • If your child has medications that have been previously prescribed for these symptoms (eg, Ventolin), administer them as prescribed or according to your child’s health care team.

Resistance or impossibility of tracheal cannula reinsertion

Possible cause(s)

  • Spasm, irritation or inflammation of the trachea
  • Complete or partial obstruction of the trachea (eg, laryngospasm)
  • Incorrect positioning of your child’s head
  • Granulation tissue around the tracheal cannula site

What to do?

  • Do not force insertion of the cannula into the trachea.
  • Remain calm and reassure your child, he may still be able to breathe through his tracheostomy.
  • If the new cannula is partially inserted:
    • hold the cannula in place and remove the obturator;
    • allow your child to calm down and breathe through the cannula;
    • reposition your child’s head so that it is slightly tilted backwards by replacing the rolled towel under the shoulders;
    • try again to insert the rest of the cannula without forcing, as your child takes a breath in, while gently pulling on the  neck skin just below the tracheostomy;
    • if you are able to insert the cannula completely, secure it with ties and immediately contact your child’s health care team to inform them of the situation.
  • If the cannula is impossible to insert:
    • remove the cannula and lubricate it again;
    • try re-inserting the cannula with the obturator in place;
    • if this does not work: try again with a smaller size cannula with the obturator;
    • if this also does not work: try again by replacing the obturator with a suction catheter to serve as an insertion guide;
    • observe your child’s breathing to detect any signs of respiratory distress;
    • if you are able to insert the cannula completely, secure it with ties and immediately contact your child’s health care team to inform them of the situation.
  • If you are unable to insert the new cannula call 911 immediately.
  • While waiting for help, if your child is not breathing on his own, begin manual ventilation and CPR as instructed.
  • While waiting for help, if your child is breathing on his own through the tracheostomy and if you have been trained to do so by your child’s health care team:
    • insert a suction catheter into the tracheostomy to maintain an open airway;
    • hold on to the catheter so that it does not slide into the trachea;
    • verify if your child is in respiratory distress (see that specific problem);
    • if your child is in respiratory distress, remove the suction catheter and begin manual ventilation and CPR as instructed.

Tracheal cannula falls out, partially or completely, accidental decannulation: cuffless tracheal cannula partially or completely out

Possible cause(s)

  • Accident
  • Incorrect manipulation of the cannula
  • Tracheostomy ties (ribbons or Velcro® band) are too loose or poorly secured around the neck
  • Excessive cough

What to do?

  • Remain calm and reassure your child, he may still be able to breathe through his tracheostomy.
  • If the cannula has come out partially:
    • gently push it back down even if the conditions are not ideal;
    • immediately contact your child’s health care team to inform them of the situation.
  • If the cannula has come out completely:
  • If the cannula is impossible to insert:
    • remove the cannula and lubricate it again;
    • try re-inserting the cannula with the obturator in place;
    • if this does not work: try again with a smaller size cannula with the obturator;
    • if this also does not work: try again by replacing the obturator with a suction catheter to serve as an insertion guide;
    • observe your child’s breathing to detect any signs of respiratory distress;
    • if you are able to insert the cannula completely: secure it with ties and immediately contact your child’s health care team to inform them of the situation.
  • If you are unable to insert the new cannula: call 911 immediately.
  • While waiting for help, if your child is not breathing on his own, begin manual ventilation and CPR as instructed.
  • While waiting for help, if your child is breathing on his own through the tracheostomy and if you have been trained to do so by your child’s health care team:
    • insert a suction catheter into the tracheostomy to maintain an open airway;
    • hold on to the catheter so that it does not slide into the trachea;
    • verify if your child is in respiratory distress (see that specific problem);
    • if your child is in respiratory distress, remove the suction catheter and begin manual ventilation and CPR as instructed.

Blood-tinged secretions

Possible cause(s)

  • Irritation of the trachea by:
    • incorrect suctioning technique (too frequent, too deep or using a suction pressure that is too high)
    • injury due to the rubbing of the tracheal cannula
  • Respiratory tract infection
  • Granulation tissue around the tracheal cannula site
  • Insufficient humidification
  • Insufficient hydration

What to do?

If fresh blood in the secretions:

  • remain calm and reassure your child;
  • if bleeding continues, immediately contact your child’s health care team;
  • observe your child’s breathing to detect any signs of respiratory distress (see that specific problem);
  • if your child is in respiratory distress, remove the suction catheter and begin manual ventilation and CPR as instructed.

If blood streaks or pink secretions:

  • observe your child’s breathing to detect any signs of respiratory distress;
  • check the pressure of the suction device;
  • review suctioning technique; be sure to respect the length and the depth of insertion of the suction catheter that is recommended;
  • gently suction tracheal secretions;
  • increase the level of humidity;
  • contact your child’s health care team.

Bleeding from inside the tracheostomy or around the tracheostomy

Possible cause(s)

  • Irritation of the trachea
  • Ulceration of the trachea
  • Granulation tissue around the tracheal cannula site
  • Infection
  • Insufficient humidity
  • Cannula replacement

What to do?

  • Immediately contact your child’s health care team.
  • Increase the level of humidity.

Introduction of water into the tracheostomy

Possible cause(s)

  • Accident during a bath, while washing hair or splashing
  • Accumulation of water in the tubing of a heated humidifier or air compressor humidifier system

What to do?

  • Suction tracheal secretions.
  • Immediately contact your child’s health care team.
  • Observe your child’s breathing to detect any signs of respiratory distress.

One or more of these symptoms: coughs and /or choking during meals, saliva more abundant than usual, secretions are more abundant after meals, secretions resemble the liquids or food that was recently ingested, traces of food are found during suctioning of tracheal secretions, vomiting right after a meal

Possible cause(s)

  • Dysphagia (difficulty in swallowing)
  • Gastric reflux (stomach contents rise up through esophagus)

What to do?

  • Stop feeding your child food and liquids immediately.
  • Suction tracheal secretions.
  • If solid food or thick liquid bits are present in the secretions:
    • instill a few drops of saline solution according to the recommendations of your child’s health care team;
    • try suctioning the tracheal secretions again.
  • Rapidly contact your child’s health care team.

Vomiting

Possible cause(s)

Various

What to do?

  • Turn your child’s head to the side so as to avoid vomit from entering the tracheostomy.
  • If you think that vomit has entered the tracheostomy, suction tracheal secretions.
  • Clean your child’s mouth.
  • Observe your child’s breathing to detect any signs of respiratory distress (see that specific problem).
  • Rapidly contact your child’s health care team.

Skin around the tracheostomy site irritated (redness, edema, itchiness, burns, bad odor, oozing, presence of red pimples, small sores or bleeding and/or tracheostomy dressing is wet and soiled)

Possible cause(s)

  • Infection
  • Dampness of the skin (from secretions, or a soiled tracheostomy dressing)
  • Use of products that irritate the skin

What to do?

  • The skin around the tracheostomy site should look the same as the skin on the rest of your child’s neck.
  • Review the technique for cleaning of the skin around the tracheostomy.
  • Keep the tracheostomy site clean and dry by increasing the frequency of cleaning around the tracheostomy and by changing the tracheostomy dressing.
  • There are many types of products that can be used to protect the skin such as foam dressings and liquid skin protectors; speak with your child’s health care team.
  • Contact your child’s health care team for more recommendations if the skin is irritated (eg, application of an antibiotic cream).

Skin around the neck irritated (redness, edema, itchiness, burns, bad odor, oozing, presence of red pimples, small sores or bleeding)

Possible cause(s)

Tracheostomy ties are too tight

What to do?

  • The space between the skin of your child’s neck and the tracheostomy ties (Velcro® or cotton ribbons) should be the thickness of the tip of a finger. Individuals with large fingers should use their small finger. This space can sometimes be reduced particularly when the child is overweight.
  • Verify the space between the neck and the tracheostomy tie and adjust, if needed.
  • Contact your child’s health care team for more recommendations regarding skin protection under the tracheostomy ties.

Do not hesitate to contact your child’s health care team for any questions or for specific advice related to your child’s condition.


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