FAQ – Tracheostomy

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 healthcare team.
• Observe your child attentively in order to detect any sign of respiratory distress (see that specific 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 healthcare team.
• Increase liquid intake to help liquify the secretions.
• Increase the humidity level.

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

• by a foreign object: change the cannula.
• by secretions:
  • Try suctioning the secretions and,
  • Instill a few drops of normal saline, if recommended by your healthcare team.
  • Repeat suctioning.

If the obstruction persists:

• Change the cannula.
• If needed, suction secretions.
• If needed, repeat instillation and suction up to 2 more times maximum.

If the problem is resolved:

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

If the symptoms persist:

• Call 911 immediately.
• If required, begin manual ventilation and CPR as instructed.

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):
  • Change the cannula.
  • Suction tracheal secretions if needed.
• If the problem is resolved:
  • Verify your child’s breathing to detect any signs of respiratory distress.
  • Inform your child’s healthcare team.
• If the symptoms persist:
  • Call 911 immediately.
  • If required, begin manual ventilation and CPR as instructed.

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 healthcare 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 healthcare team.

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 healthcare 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 healthcare 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 healthcare 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.

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 healthcare team to inform them of the situation.
• If the cannula has come out completely:
  • undo the tracheostomy ties;
  • insert a new cannula if available or reinsert the old one in the meantime;
  • replace the tracheostomy ties;
  • suction tracheal secretions;
  • once the cannula has been inserted, contact your child’s healthcare 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 healthcare 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 healthcare 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.

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 healthcare 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 healthcare team.

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 healthcare team.
• Increase the level of humidity.

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 healthcare team.
• Observe your child’s breathing to detect any signs of respiratory distress.

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 healthcare team;
  • try suctioning the tracheal secretions again.
• Rapidly contact your child’s healthcare team.

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 healthcare team.

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 healthcare team.
• Contact your child’s healthcare team for more recommendations if the skin is irritated (eg, application of an antibiotic cream).

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 healthcare team for more recommendations regarding skin protection under the tracheostomy ties.