What is a tracheostomy?
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A tracheostomy is a surgical opening made in the neck into the trachea (windpipe) that allows a child to breathe without using the nose or mouth.
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A tracheostomy tube is inserted into the opening to allow breathing and removal of secretions. There are several different types.
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Single cannula. This type is generally seen in infants and small children. These may or may not have acuff to hold them in place. -
Double cannula. This type has an inner lining and an outer, removable piece. It is usually held to the child by laces or a Velcro-fastened neck band calledtrach (pronounced “trake”)ties. -
Cuffed. A cuffed tube has a soft balloon around the distal (far) end that can be inflated to seal the space around the tube against the trachea to allow for mechanical ventilation (use of a respirator) in patients with respiratory failure. The cuff is inflated with air, foam, or sterile water. -
Fenestrated. A fenestrated tube has an opening in the tube that permits speech when the external opening of the tracheostomy tube is blocked with a finger or special speaking valve. The opening in the part of the tube that is inside the trachea allows air to pass into the upper airway across the vocal folds to make speech sounds. These tubes are usually not used in younger children
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How common is it?
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A tracheostomy tube is placed in children for many reasons, including birth defects, complications of prematurity, feeding problems, and brain disorders.
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More children are receiving tracheostomies because lifesaving medical treatments are now available that allow children to survive serious medical conditions.
Who is the treatment team?
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Primary care provider in the medical home.
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A pediatric pulmonologist and surgeon may be involved in the child’s care.
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A respiratory therapist may also be involved if the child is on a ventilator.
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Some children have home nurses who may accompany them to school or child care.
What are some elements of a Care Plan for a child with a tracheostomy?
The Care Plan should address
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Suctioning of the tracheostomy
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A clean disposable suction tube placed in the child’s tracheostomy tube is hooked up to a suction machine to remove any of the child’s secretions that have built up and might block the child’s breathing.
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This may be done up to every 4 hours and is usually done by the child’s nurse.
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Eating
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Children with tracheostomies generally can eat by mouth. A few children also have eating or swallowing problems that will be addressed in the Care Plan.
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Most children do require suctioning prior to eating and may require suctioning after eating if any food slips down into the airway.
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Plenty of fluids are recommended to keep secretions thin and moist.
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Speech
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There are many ways in which a child with a tracheostomy can speak.
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Certain types of tracheostomy tubes.
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Special speaking valves that allow air into the tube, but block air from going out except through the upper airway (eg, Passy-Muir valve).
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Plugging the trachea with a finger temporarily will encourage speech.
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Children younger than 3 years may receive speech therapy through
early intervention services. Early intervention is a system of services to support infants and toddlers with disabilities and their families. -
For children 3 years and older,
special education and related services are available through the public school to provide the therapies necessary for school achievement.
What adaptations may be needed?
Physical environment
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When holding a child with a tracheostomy, be sure the chin is up and the tube opening is unobstructed.
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Prevent foreign objects from entering the tracheostomy tube, such as water, sand, dust, and small toy pieces.
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Avoid sandboxes and beaches.
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Avoid chalk dust.
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Watch play with other children so that toys, fingers, and food are not put into the tracheostomy tube and that other children don’t pull on the tube.
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Avoid clothing that blocks the tracheostomy tube, such as crewnecks, turtlenecks, and shirts that button in the back.
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No plastic bibs.
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No necklaces.
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No fuzzy or fur clothing or stuffed toys.
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Do not allow anyone to smoke near the child.
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No latex balloons—these are dangerous for all children. Latex over any airway will block breathing.
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Avoid exposure to people with colds or other contagious illnesses to the extent possible.
What should be considered an emergency?
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Call emergency medical services/911 for
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Difficulty breathing, especially if accompanied by noisy breathing (grunting or whistling from the tube) or cyanosis (pale, blue color of lips and skin).
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Increased respiratory rate or effort.
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Sweaty, clammy skin.
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Retractions—extra work of breathing that involves pulling in of the skin between the ribs, below the breastbone, above the collarbones, or in the hollow of the neck.
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Tracheostomy tube comes out and cannot be replaced.
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Extreme restlessness or change in level of consciousness (eg, sudden lethargy, not responding).
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Notify parents/guardians for
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Fever and increased secretions
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Redness, rash, or foul odor at the tracheostomy site
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What types of training or policies are advised?
There must be a trained person with the child at all times who is able to identify an emergency and
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Suction and replace a tracheostomy tube that is blocked with secretions.
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Ventilate the child using an oxygen bag.
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Perform CPR.
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For children who are transported, there should be a trained person (preferably a registered nurse or licensed practical nurse) with the child at school and on the bus to and from the program.
What are some resources?
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Cynthia Bissell, RN, Aaron’s Tracheostomy Page,www.tracheostomy.com
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American Thoracic Society, 212/315-8600,www.thoracic.org
Source: Managing Chronic Health Needs in Child Care and Schools: A Quick Reference Guide.
Products are mentioned for informational purposes only. Inclusion in this publication does not imply endorsement by the American Academy of Pediatrics.
Listing of resources does not imply an endorsement by the American Academy of Pediatrics (AAP). The AAP is not responsible for the content of external resources. Information was current at the time of publication.
The information contained in this publication should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.