Manual of Care for the Pediatric Trach
"Hello, I'm Parker, and I have a trach!"
Click here for a printable version, PDF format (Acrobat Reader required)
A tracheostomy is an opening in the windpipe (trachea) that your baby breathes through instead of breathing through his nose and mouth. Often the tracheostomy is not permanent and can be removed after the problem has been corrected or the baby grows and no longer needs the tracheostomy. Babies with the following problems may get tracheostomy:
1. Birth defects that affect the baby's breathing, such as a small jaw, vocal cord paralysis, or large tongue.
2. Tracheomalacia: noisy breathing caused by a soft or weak breathing tube.
3. Need for prolonged respiratory support (i.e., on ventilation), such as BPD.
4. Scarred or narrowed larynx: subglottic stenosis.
5. Neuromuscular diseases.
7. Respiratory control problems, such as central hypoventilation or central apnea.
1. A small opening is made from the skin to the windpipe (trachea) by a cut in the neck for a tracheostomy.
2. A tracheostomy tube is a short piece of plastic that is placed into the trachea through a surgical hole in the neck. It does not reach into the lung.
3. The baby breathes through this plastic tube instead of through his nose and mouth.
4. You will not be able to hear the baby cry or talk with the tracheostomy tube in at first. After some time, an air leak usually develops around the trach tube. Some of the air escapes through the voice box, permitting some return of voice.
1. Surgery takes approximately one hour. It is not the surgery, but the immediate post-op course that is frightening to most parents. Many families have not seen a mist-collar, and the monitors, the trach "stay stitches", and even bloody secretions seem overwhelming. The child or infant is usually sedated at first and the parents or family must wait a few days even to hold their child, for reasons of safety.
2. The baby spends the first week in the ICU for recovery.
3. Hand-on teaching follows the first trach change. Many parents need everything they can to prepare for caring for a child with a trach, and there are a number of available handbooks and articles directed at the caregiver (see end of article on literature).
3. Trach plugging.
4. Granulation (scar) tissue.
5. Skin necrosis.
1. The baby will go home on a home apnea and cardiac monitor. The monitor counts the baby's breathing rate and heart rate.
2. The monitor alarms to tell you if the baby is not breathing (apnea) or if the heart beat is too slow (bradycardia) or fast (tachycardia).
3. A pulse oximeter provides the oxygen saturation information and is routinely used early on.
2. Suctioning the trach tube: Suctioning is done to clear the trach tube of mucus, so that the trach tube will not become blocked. Suctioning is done to a premeasured depth that just allows the tip of the suction catheter to come out the end of the trach tube. Suctioning more deeply may injure the lining of the windpipe. Your child's nurse will show you how far the catheter should be inserted. You can check this depth by passing a catheter through an extra clean trach tube until the side holes close to the tip just clear the end of the tube and measuring the distance from the end of the catheter.
a. Wash your
a. Twill tape
or bias seam tape or shoe laces or Velcro holder
2. Changing the
ties: Do not change the tracheostomy ties by yourself unless
a. Change ties
daily or when:
before changing ties. Suctioning decreases chances of the baby's
ties requires two people - one person to hold tube in place and
blanket roll under shoulders to expose the tracheostomy area.
e. Slide old
ties from center of hole to top on both sides of the tracheostomy
f. Insert new
ties under old ones.
g. Secure new
ties with a square knot. Ties should be tight enough to easily slip
h. Cut off old
ties and remove. Guard tips of scissors with your fingers.
i. Examine neck daily for redness, skin breakdown, or rashes.
If using trach
holder or Velcro trach tie:
a. Tap water
a. Clean area
around tracheostomy opening in neck (stoma) daily and when the area is
3. Place gauze trach dressing around trach tube. Change dressing as often as necessary to keep skin dry.
a. May use
pre-cut trach dressings (more expensive)
4. Clean stoma 2-3 times a day if an odor is present (or more often, if there is drainage present).
5. Powders and lotions must not be used around the trach stoma.
6. If ordered by the baby's doctor to treat irritations or rashes, apply ointments in a thin layer. (Ointments under the trach collar can make the skin irritations worse. Sometimes clean and dry is best.)
tube with obturator (guide)
2. Changing the tracheostomy tube
a. Do not
change the tracheostomy tube by yourself unless absolutely necessary.
3. Your baby
may cough, cry, turn red, or sweat. He is OK. This does not hurt the
4. Change the trach tube every 1-2 weeks (as directed by your baby's doctor) or for:
infant who does not respond to suctioning or usual calming methods.
5. Change tube
before feeding or at least 2 hours after feeding. Avoid changing just
6. Inspect the removed tube for color change, mucus plugs, or odor.
The medical equipment supply company will teach you how to clean the tracheostomy tubes and what to use for cleaning.
A humidifier and tracheostomy collar (trach collar) are used to filter and moisten air entering the windpipe (trachea) because the baby does not breathe through his nose or mouth.
2. How to use:
nebulizer jar with sterile water to line on jar
2. Fill clean nebulizer jar with sterile distilled water.
3. Check to make sure suction machine is working.
4. Check suction tubing as well.
2. Clean using solution recommended by the home equipment supply company.
After use or
1. Your baby may have trach collar and humidity off during the day if allowed by your baby's doctor. An "artificial nose" type humidification device may be adequate.
2. Use trach collar and humidity during naps and at night to keep trach moist and prevent mucus plugs.
3. If humidifier is not available (during long trips or power failure), place one drop of saline every hour or two into the trach tube to moisten trach tube and windpipe.
4. The windpipe (trachea) of your baby is small and easily plugged with mucus, so the humidifier with trach collar provides a direct source of moisture that a vaporizer cannot.
5. If mucus becomes thick, move the numbered ring on the humidifier to a lower number. The usual setting is 50%. Increasing the baby's fluid intake may help thin the mucus.
1. Restlessness or increased irritability.
2. Increased breathing (respiratory) rate.
3. Heavy, hard breathing.
4. Grunting, noisy breathing.
5. Nasal flaring (sides of nostrils move in and out with breathing).
6. Retraction (sinking in of breastbone and skin between the ribs with each breath).
7. Blue or pale color.
8. Whistling from the trach tube.
10. Change in pattern of heart rate (less than 80 or more than 210 beats/minute).
11. Bleeding from trach tube.
a. Report to
You will take a basic CPR class. We will teach you how to do CPR with the trach and how to use an ambu bag to breathe for the baby.
If the baby stops breathing:
1. SUCTION TRACH TUBE AT ONCE.
2. Replace trach tube if it has come out, is blocked with mucus, or your baby does not improve with suctioning. Tie trach ties!!!
3. Begin CPR if baby does not breathe when trach tube is clear.
Call for help!!
1. Stimulate baby by gently shaking.
2. Position baby on a hard flat surface with his nose pointed straight up.
3. Suction tracheostomy. Replace if blocked.
4. Listen and feel for breath by placing ear over tracheostomy. Look at chest to see if baby is breathing.
5. Place mouth or attach ambu bag over trach tube to form a seal.
6. Give 2 quick puffs. Observe to see if chest moves like an easy breath.
7. Feel for brachial heart rate (pulse) in the bend of the arm for 5 seconds and check to see if baby is breathing on his own (look, feel, and listen for air movement).
8. If you feel a pulse, breathe with mouth or ambu bag on tube. Count 1-2 breathe, 1-2 breathe.
9. If air is leaking from the nose and mouth, close them with your hand.
10. If you do not feel a heart rate in 5 seconds or if the heart rate is less than 60 bpm, do chest compressions and breathe for baby with mouth or ambu bag on trach tube. Press ½ to 1 inch with each compression. It is a little tricky to use the ambu bag and do chest compression, but you will learn how. Count:
1 2 3 4 5
This rate is about 100 times a minute. The breath is about 1 to 1 ½ seconds long.
11. Check heart rate and breathing about every minute. Do what the baby is not doing.
12. Call your local Emergency number or ambulance team for help if your baby does not respond.
13. Have baby taken to the nearest hospital.
1. Food or liquid comes though the trach.
2. There is a rash, drainage, or unusual odor around the trach opening.
3. Mucus becomes green or foul smelling (normal color is clear or whitish).
4. Bleeding occurs from the trach tube.
5. Difficult breathing not relieved by suctioning or changing trach.
6. Unable to replace trach tube.
7. Baby stops breathing.
1. Plugged trach:
a. Suction and
use ambu bag.
2. Coughing out trach tube:
a. Insert new
clean trach tube as soon as possible.
a. Suction if
you think vomit has gone down tube.
4. Unable to replace trach tube:
a. Try to
insert smaller trach tube.
2. Burp well and place on right side or in infant seat after feeding.
3. DO NOT PROP THE BOTTLE.
4. Do not let your baby have a bottle unless you are present (in case choking occurs).
2. NEVER LEAVE YOUR BABY ALONE IN THE TUB.
3. Baby's head must be held during hair washing so that water does not enter the trach.
4. Change the trach ties after the bath if they get wet.
2. Clothing that covers the trach should not be worn. Also avoid plastic bibs.
strings, fuzzy clothing, fuzzy blankets, and stuffed animals should be
4. Purchasing a
portable intercom system so you can hear the baby when you are in
2. He will learn to talk around the trach tube.
3. It is important that you talk to him as you would any other baby.
valves such as the Passé-Muir valve can aid in talking when it is
2. It is important that parents be able to rest and go out without the baby!
3. Some parents use a TV monitor, which they find helpful in watching the child.
2. Animals with fine hair should not be in the house.
3. Keep home as free from lint and dirt as possible.
4. Do not use powders, chlorine bleach, ammonia, or aerosol sprays in the same room as the baby. Particles and fumes get into the lungs through the trach. This will cause a "burning feeling" and breathing problems.
5. Do not smoke or allow others to smoke around your baby. It's irritating to the baby's airways.
6. Watch play with other children so that toys, fingers, and food are not put into the trach tube.
7. Do not buy toys with small parts that can easily be removed.
8. Always carry your GO BAG supplies when you leave home.
9. No swimming.
2. Protect the tracheostomy on dusty windy days when dust particles may enter the trachea and cause drying or crusting mucus.
2. This is usually a frightening situation for older brothers/sisters and requires parents' support and teaching to ease their initial discomfort and fear.
3. It may be helpful to involve brother and sister's help in small tasks such as holding the baby still, helping clean equipment, etc.
4. Watch young brothers and sisters around the baby!
1. You may want to count the baby's breathing rate twice a day when the baby is quiet or asleep. You can write the number in a record book you bring to the doctor.
2. One count is a breath in and out. Sometimes the baby holds his breath briefly, breathes fast then slow, stretches or moves. Count the breathing as best you can.
3. Call the doctor if the breathing rate is 15-20 counts higher than usual or your baby is working hard to breathe. Make sure the baby is not too warm or does not have mucus in his trach.
1. You will be very busy at home.
2. It helps to have a calendar with your day's activities clearly marked.
3. Some things you will do several times a day and some things you do several times a week. Organization and a schedule are important. So is help from family members.
4. It is important to teach several people to care for the baby so you can have a break and get out by yourself.
a. 1-2 times a
day, or more if necessary.
2. Wash suction bottle in hot soapy water.
3. Chest Physiotherapy (or CPT):
a. 2-3 times a
day (if recommended by the baby's doctor)
4. Change trach collar and tubing.
5. Change water bottle for humidifier.
6. Check to make sure suction machine is working.
2. Clean suction bottle and tubing in solution recommended by home equipment supply company.
3. Clean trach collar and tubing in solution recommended by home equipment supply company.
Weekly (or as
1. De Lee suction catheter.
2. Bulb syringe.
3. Suction catheters - disposable.
4. Trach tube with tie (same size and size smaller).
6. Water soluble lubricant (sterile single use packets).
7. Saline (two or three 5 cc vials).
8. 4 x 4's or trach sponges.
9. Portable suction machine.
10. Emergency phone numbers.
11. HME devices (heat moisture exchanger)
12. Ambu bag.
13. Portable oxygen.
14. Hospital, insurance, and pharmacy cards available in baby's own "wallet"
a. ½ teaspoon
of table salt added to 8 ounces of boiled water
2. Sterile distilled water
a. Boil tap or
bottled water 10 minutes after water begins to roll.
a. Must buy.
1. All of the home supplies you need will be provided through a home equipment and supply company. The hospital makes these arrangements with a company near where you live.
2. The supply company will contact you at home or while you room-in with your baby.
3. The supply company will tell you when and how to order supplies. They will give you a phone number to call if you have equipment problems. Call them if your equipment breaks or to reorder supplies.
programs are available to help provide medical and financial care of
your baby. The Child Services Coordinator in your community or a
social worker can help find out if you are eligible for the programs.
Babies are eligible for different reasons and some may not be eligible
or approved. Information can be obtained from your baby's social
worker during the hospital stay.
2. It is a lot of hard work to care for a baby with a trach. Yet most parents still prefer to have the baby at home.
3. We ask several family members to learn the care so everyone can get some rest.
4. Some insurance companies approve home-nursing care for a baby with a trach. We contact your insurance company to find out if they provide this service.
5. Home health agencies or public health services are used for short visits. These visits are an hour or less. The nurses answer questions, help with special treatments and help with medications. They may weigh the baby or watch a feeding. They work with your doctor to follow the baby's condition and progress.
6. Even though it is difficult to find people to babysit, it is important to teach other people to care for the baby so you can go out.
7. Respite services which provide relief for parents may not be available in all communities or for babies with trachs.
8. If you get too tired or frustrated, call the doctor or social worker. We will try to help.
1. Your baby returns to the hospital clinic to follow his breathing problems and trach.
2. If you see more than one doctor (eye, surgery, breathing, x-ray, lab, development), check to see if the appointment can be made for the same day.
3. At first it seems you spend most of your time going to the doctor.
4. As the baby's health gets better, the visits become less frequent and some doctors will not need to see him.
5. You will take the baby to a local baby doctor for routine baby care and shots. Make an appointment to see him the first week the baby is home.
6. We mail your doctor a report of your visits to the hospital clinics.
1. The home equipment company will call and write the following agencies to inform them that your baby has a serious medical problem:
2. The letter asks that you be placed on the priority list for notification of anticipated interruptions of service.
3. The letter asks that you be placed on the priority list for service reinstitution in the event of unexpected interruption of service.
The American Thoracic Society: Care of the Child with a Chronic Tracheostomy. American Journal of Respiratory and Critical Care Medicine, Volume 161, pp. 297-308, 2000. Internet address: www.atsjournals.org
Fitton C, Myer
C. Home care of the child with a tracheostomy. In: H.B. Othersen,
editor. The Pediatric Airway: An Interdisciplinary Approach. J.B.
Lippincott, Philadelphia, 1995. pp. 171-179.