How can the nurse best minimize the patients risk for infection during tracheostomy care?

Rehabil Nurs. Author manuscript; available in PMC 2022 Jan 1.

Published in final edited form as:

PMCID: PMC8365473

NIHMSID: NIHMS1732150

Patricia R. Lawrence, MSN, RN, APRN, CPNP-AC, Rebecca Chambers, RN, BSN, Melissa Spezia Faulkner, PhD, RN, FAAN, and Regena Spratling, PhD, RN, APRN, CPNP

Abstract

Routine tracheostomy care in children maintains airway patency, minimizes infection, and ensures skin integrity around the tracheostomy stoma to prevent complications. Using evidence-based recommendations for care of the mature tracheostomy limits variation in practice and leads to better patient outcomes in all care settings. Incorporating evidence-based care into practice is especially important because children with tracheostomies are at high risk for morbidity and mortality. The purpose of this review is to summarize the most current, evidence-based literature for pediatric tracheostomy care, including stoma care and tracheostomy suctioning. Rehabilitation nurses can then include these best practices when caring for children with tracheostomies and when educating caregivers who provide tracheostomy care to children at home.

Keywords: Pediatric, stoma, suctioning, tracheostomy

Evidence-Based Care of Children With Tracheostomies: Hospitalization to Home Care

Tracheostomies are increasingly performed in children with complex medical conditions that were once seen as life-limiting, including children with congenital heart disease, lung disease, and neurologic impairment (Watters, 2017). Although the exact number of children who require medical technology at home and tracheostomies in particular is unclear, over 4,800 pediatric tracheostomies are performed each year (Mahida et al., 2016). Children who require medical technology, including tracheostomies, ventilators, feeding tubes, and other medical devices, require complex care not only during hospitalization and rehabilitation but also at home by family caregivers. Improving the evidence-based knowledge and skills of nurses, other healthcare providers and family caregivers can improve the outcomes for patients requiring tracheostomy care (Mitchell et al., 2013; Watters, 2017). However, there is a lack of empirical research in the area of tracheostomy care that limits evidence-based practice to primarily relying on guidelines that have been developed by expert consensus (Bolsega & Sole, 2018; Mitchell et al., 2013; Sherman et al., 2000). It is important to note that the pediatric tracheostomy expert consensus guidelines developed by the American Thoracic Society (ATS) in 2000 (Sherman et al., 2000) have not been updated since its original publication yet remains relevant and is frequently cited in the literature when describing current, evidence-based pediatric tracheostomy care. The purpose of this review is to provide the best evidence currently available on optimal tracheostomy care in children.

Tracheostomy Tube Care

Knowing how to properly care for children with a tracheostomy is critical because inappropriate care can lead to serious complications, including death, making tracheostomy care a high-risk procedure (Everitt, 2016; Schreiber, 2015). Many episodes of tube obstruction can be prevented simply by inspecting a patient’s tracheostomy, with some sources recommending inspection of the tube three times a day, depending on the volume and thickness of a patient’s secretions (Morris, Whitmer, & McIntosh, 2013). Because the tracheostomy tube bypasses the parts of the airway that naturally humidify and filter the air, secretions tend to be thicker and drier (Watters, 2017). Therefore, tracheostomy care, which includes inspection and suctioning, is usually provided every 4–8 hours to prevent tube obstruction (Morris et al., 2013; Watters, 2017). Younger infants and toddlers who have smaller airways may require more frequent assessment and suctioning to ensure airway patency.

Tube Replacement

Pediatric tracheostomy tubes lack the disposable inner cannula often found in adult tracheostomy tubes, requiring that clinicians and caregivers replace the entire tracheostomy tube more often than adult tracheostomies (Smolar et al., 2017). Replacing the tracheostomy tube is done on a regular basis, although there is no scientific evidence supporting the frequency with which this should be done. In addition, there is a lack of expert consensus on how often tracheostomy tubes should be changed (Mitchell et al., 2013; Sherman et al., 2000). However, most tracheostomy tube changes occur weekly (Sherman et al., 2000). Tube changes may need to be done more frequently with respiratory tract infections (Watters, 2017) and as often as needed if tube malfunction or a clogged tube is suspected (Mitchell et al., 2013). Prior to replacing the tracheostomy tube, there are several things that should be done in preparation. First, make sure that there is proper lighting so that the patient and their tracheostomy site can be well visualized and ensure that the patient is positioned so that the tracheostomy area can be well seen (Schreiber, 2015). A small towel roll or pillow placed under the shoulders can hyperextend the neck, making visualization easier. Be certain that all supplies and emergency equipment are available at the bedside (Mitchell et al., 2013). This should include an additional tracheostomy tube that is the same size as the current tube, as well as a tracheostomy tube that is one size smaller. Available emergency equipment should also include oxygen, suction and suction catheters, pulse oximetry, a ventilation bag, an obturator, and water-soluble lubricant (Everitt, 2016; Mitchell et al., 2013; Schreiber, 2015). Schreiber also suggests mental preparation for tracheostomy care, which allows clinicians and caregivers the time needed to review a mental checklist to confirm complete readiness and safety. A full assessment of the patient should be performed, including a time-out, listening to breath sounds, and documenting all vital sign parameters. Consider using a two-person technique when changing the tube or anything that secures the tube in place. Prior to the tracheostomy tube change, the stoma and tracheostomy tube should be suctioned, especially before the cuff is deflated (Mitchell et al., 2013). The tracheostomy tube should be replaced using a clean, nonsterile technique (Mitchell et al., 2013). Once the tube has been replaced and secured, the tracheostomy tube should be suctioned again.

Tracheostomy Ties

Tracheostomies can be secured with a variety of materials, including cotton twill, Velcro straps, and stainless-steel beaded metal chains to prevent accidental decannulation (Sherman et al., 2000). Skin breakdown from tracheostomy ties has been described as a complication, and therefore, special attention must be given to regularly assessing the skin at and underneath all tracheostomy ties. Tracheostomy ties should not be too tight or too loose. Therefore, it is generally recommended that tracheostomy ties be secure enough to allow for slipping one finger beneath the tie (Sherman et al., 2000). All three materials have advantages and disadvantages (Sherman et al., 2000). For example, twill ties must be cut if they become tight, whereas Velcro ties can be adjusted more easily. Wire cutters need to be available when beaded metal chains are used to secure tracheostomy tubes. Twill ties are narrower and not as soft as Velcro (Schreiber, 2015). Cotton twill has also been described as retaining more moisture and may increase the risk of skin irritation and breakdown. The most important aspect of a tracheostomy tie is that it secures the tracheostomy well (Sherman et al., 2000). However, a recent retrospective study (n = 109) supported the use of Velcro ties over cotton twill ties, demonstrating significantly less skin irritation and no accidental decannulation events (Bitners, Burton, & Yang, 2019). Although the rate of skin breakdown was also lower in patients using Velcro in the study, the results were not statistically significant.

Tube Cleaning

After changing out the tracheostomy tube, the recently removed tube can be cleaned for reuse, when applicable. After cleaning the recently removed tube, air dry the tube completely before storing away. There is a growing demand for custom pediatric tubes due to the increase in survival of children with complex airways (Watters, 2017). Therefore, it is important to check the manufacturer’s instructions for cleaning tracheostomy tubes. Smolar et al. (2017) acknowledged that some manufacturers provide little guidance on tube cleaning. Some tubes and inner cannulas are now single use only (Everitt, 2016). For instance, the Shiley pediatric tracheostomy tube package inserts used to recommend soaking in a variety of different solutions including saline or half-strength hydrogen peroxide but now recommend disposal after each use (Smolar et al., 2017). Soaking has been shown to be in effective in removing bio films and associated bacteria, which led researchers to study the effects of machine dishwashing as an alternative method for cleaning. Smolar et al. concluded that machine dishwashing of tracheostomy tubes can lead to changes in tube hardness and tube chemical composition, which can lead to tube dysfunction, and therefore do not recommend machine dishwashing as a safe cleaning method.

Use of adult-sized tracheostomy tubes may be used in some adolescents and therefore may have reusable inner cannulas. No studies have been done to determine the ideal frequency for cleaning the inner cannula, but it should be inspected regularly. Reusable inner cannulas require careful cleaning and should be removed and cleaned approximately every 2–4 hours, depending on the type and amount of secretions, and cleaned according to the manufacturer’s recommendations (Everitt, 2016).

Tracheostomy Tube Suctioning

The goal of suctioning is to maximize secretion removal while minimizing desaturation and tissue damage (McClean, 2012). Tracheostomy tubes bypass the natural mechanisms of both humidifying and filtering the air that occurs in a child’s upper airway. Therefore, children with tracheostomies may have thicker secretions, requiring humidification and more frequent suctioning to decrease the incidence of tracheal tube blockages (Watters, 2017). Suctioning should only be done when secretions are audible or are visibly present, or if an obstruction is suspected (Boroughs & Dougherty, 2015; Mitchell et al., 2013; Sherman et al., 2000). Other reasons for suctioning include diminished breath sounds and/or decreased oxygenation (Mitchell et al., 2013). Rather than relying on a set schedule, the need for suctioning should be tailored to the individual patient. Suctioning may be required more frequently during respiratory tract infections or illness (Watters, 2017).

Recommendations for hyperoxygenating before suctioning vary, with the majority of studies occurring in adult critical care settings. The ATS guidelines (Sherman et al., 2000) state that stable children with a tracheostomy who do not require a ventilator, continuous positive airway pressure, or high oxygen levels do not require hyperoxygenation or hyperventilation. Children requiring a higher level of support may require hyperoxygenation. The use of saline to loosen secretions is a common practice, but it is no longer routinely recommended because saline may flush particles into the lower respiratory tract and lead to decreased oxygenation after suctioning (Sherman et al., 2000). Inhalation of nebulized saline is not effective in liquefying secretions. Rather, the best way to keep secretions loose and easy to remove with suctioning is by keeping the patient hydrated and by keeping the secretions humidified (Everitt, 2016). Secretions can be better mobilized by maintaining adequate patient hydration, humidification, and administering prescribed respiratory medications (Boroughs & Dougherty, 2015). Suctioning after respiratory medication treatments is therefore sometimes necessary. Cough-assisted devices and vibration vests can also help with mobilizing secretions, if they are available.

Twirling the catheter between the thumb and forefinger during suctioning removes secretions from all areas of the tracheostomy tube (Sherman et al., 2000). Suctioning should be applied when the catheter enters the tracheostomy tube, as well as when removing it from the artificial airway (Sherman et al., 2000). A rapid technique is safer and more effective (Boroughs & Dougherty, 2015). Therefore, apply suction for no more than 5 seconds during the insertion and removal of the catheter to prevent atelectasis and desaturation. McClean (2012) compared two methods of tracheal suctioning in a pilot study with 18 children with tracheostomies. Traditional suctioning, where suctioning was applied only during catheter removal, was compared with applying suctioning during insertion and removal; the application of suctioning during insertion and removal was more effective in clearing secretions. In addition, there were no differences in the children’s heart rate and pulse oximetry values between the two methods.

Measuring the suction catheter is important for preventing catheter over advancement into the airway. Tracheitis and tracheal ulceration can occur if the suction catheter is advanced too far into the tracheostomy tube (Everitt, 2016; Schreiber, 2015). The suction catheter should be premeasured using the same-sized tracheostomy tube as a guide and passed to the predetermined length to minimize the risk of mucosal inflammation and damage that can occur with deep suctioning. Premarked catheters are most helpful for accurately and consistently choosing the proper depth and are therefore strongly recommended (Sherman et al., 2000).

Heat and moisture exchangers are inline filter devices that are attached directly to the tracheostomy tube hub to help keep secretions thin by depositing heat and moisture into the filter during exhalation, which is returned to the lungs during inhalation (Watters, 2017). By keeping secretions thin, mucous production and coughing can be minimized. However, heat and moisture exchangers may not be suitable for all patients, such as those patients who cannot tolerate an increase in work of breathing or patients with a large amount of secretions. In these cases, a tracheostomy heated mist collar can be used (Watters, 2017).

Tracheal Stoma Care

Stoma care, sometimes referred to as “trach care,” is important for keeping the skin around the stoma healthy. Routine care helps with the prevention of infection at the insertion site and into the respiratory system, and it can be used as a time to apply other prescribed skincare products to the stoma when directed. Neither the ATS nor the American Academy of Otolaryngology—Head and Neck Surgery consensus documents describe any aspects of stoma care other than suctioning (Mitchell et al., 2013; Sherman et al., 2000). Although there is no evidence supporting a particular schedule around stoma care and dressing changes, secretions can lead to skin breakdown, which can lead to infection risk. Absorbing secretions helps prevent skin breakdown.

The stoma should be cleaned with saline alone, because hydrogen peroxide can be irritating to the skin (Schreiber, 2015). When cleaning the stoma with saline, use a clean gauze with each wipe. Always use a prepackaged sterile tracheostomy dressing that is already split rather than cutting a gauze pad to provide a cushion and absorb secretions, because loose fibers can cause irritation of the stoma. Schreiber (2015) also cautioned that frayed fibers from cutting a gauze can be inhaled into the respiratory tract, further supporting the use of prepackaged split gauze for absorbing moisture between cleaning sessions of the stoma. The rest of the neck and underneath the tracheostomy ties can be cleaned with soap and water.

Discussion and Conclusions

Nurses and other healthcare providers who care for children with tracheostomies must rely on available, evidence-based care recommendations to minimize practice variability to optimize patient outcomes. Research has demonstrated that standardizing tracheostomy care and caregiver education reduces hospital readmission (Wellsetal., 2018). Based on the growing need for a standardized process for preparing pediatric caregivers for tracheostomy care at home, attention has focused on developing a competency checklist that includes the knowledge and skills necessary for safely caring for pediatric tracheostomy patients at home (Amin et al., 2017). However, further research is needed in all aspects of pediatric tracheostomy care to determine which care practices lead to the best patient care outcomes.

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Key Practice Points

• Routine pediatric tracheostomy care includes cleaning the inner cannula if applicable, changing the tube, suctioning the tracheostomy, and providing stoma care.

• Using evidence-based recommendations for tracheostomy care limits variation in practice and therefore leads to better patient outcomes in all care settings.

• Rehabilitation nurses are instrumental in providing safe and effective care to these children and are responsible for preparing caregivers to provide tracheostomy care at home through education and demonstration.

• Knowing how to properly care for a pediatric patient with a tracheostomy is critical becaues inappropriate care can lead to serious complications, including death, making tracheostomy care and suctioning a set of high-risk procedures.

Acknowledgments

Funding

Funding was provided by the National Institute of Nursing Research, National Institutes of Health Grant Number 1R15NR018037–01.

Footnotes

Conflict of Interest

The authors declare there are no conflicts of interest.

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