OSTOMY for Babies

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OSTOMY for Babies
TRACHE

• Airway course with
• Michael Jackson RRT-NPS CPFT

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Reasons for Tracheostomy
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Contributing Factors to Airway Problems

• Environmental issues
• Trauma
• Disease entities

• Anatomical problems
• Birth disorders
• Infectious agents
• Foreign body

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BWH NICU babies may require trachs.
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Anatomy of Upper Airway
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Anatomical Position of Trach Tube
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EQUIPMENT STANDBY

• Ambu with Popoff and swival adaptor
• Spare tracheostomy tube
• Tracheostomy set on unit
• Suction
• Humidification
• Communication device

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Trach Care

• First tube change by Otolaryngology
• Tube data posted at bedside.
• Trach kit kept on unit
• Spare tube and spare of next lower size kept at
  bedside.

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• Do Not Change Ties On Patient With Fresh Trach
  Until First Change By MD has occurred.
• Measure length of tie to use and document
• Check every few hours if swelling from surgery,
  if positioning or loss of fluid is occurring
  width of neck may change and readjust ties
• Always check under ties for skin condition
• Be careful not to have velcro pressing against
  skin

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Trach Cleaning Materials

• cotton swabs
• 1/4 hydrogen peroxide / sterile water
• gauze pad/ trach sponge
• twill tape or velcro strap
• suture removal kit
• warming lights (optional)
• flash light (optional)
• spare trach 1 size smaller
• emergency O2 resuscitator bag

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Trach Cleaning Procedure

• Lay out equipment
• Assure infant warmth security (2 person)
• Auscultate bilaterally
• Inspect trach site redness, excoriation
• Note secretions suction as needed
• Swab with peroxide solution away from stoma with
  swirling motion
• Re-swab with sterile water
• Allow to air dry
• Change tube holder
• auscultate.

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Trach Cleaning Procedure
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• Trach-ties should be checked for tightness.
• Only one finger should fit under tie.
• Dont move the finger back forth too
• much as
• this will
• pull the
• trach.

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TRACHEOSTOMYTUBE PROFILE
In an Emergency Notify Respiratory (PAGE 11117)
COVERING MD Complete this form to identify the
patient's tracheostomy tube profile. Post the
completed form at the patient's
bedside. Tracheostomy tube (original)
size________ ID Neonatal Shiley
Portex Bivona Other
Special Length Tracheostomy tube change to
size________ ID Neonatal Shiley
Portex Bivona Other
Special Length
Suction slightly past end of tube
Suction to ____on a ____ catheter
CRITICAL ALERT Airway patent from above trach
Yes __ No __
First trach change due __/__/__ note 1st change
must be done by ORL Trach last changed __/__/__
Trach tie length ____cm
Standby equipment at bedside cardiac monitor,
oximeter, mapleson, suction, humidity, spare
trach and one size smaller (if available)
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trach tube change RN RT

• After day 7, remove external sutures only
• Remove tracheostomy tube
• Re-insert tube of same size (use water soluble
  lubricant, shoulder roll)
• Inform MD re. complications document change
• Consider replacing tube monthly

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Trach Collar
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Suctioning Tips
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Suction at least a few mm past the Length of
trach tube pre-measure distance to suction
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Suctioning
Suction at least slightly past end of the length
of the tracheostomy tube. Suction as ordered
check for patency q4h or at least once a shift by
inserting catheter slightly past full length of
trach tube. This will depend on the size of the
trach tube and potential for plugging Do not
suction down to the carina unless ordered This
will cause trauma
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Available Trach Sizes
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PMV (speaking valve)
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HME/Artifical Nose (Heat Moisture Exchanger)
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Humidification with HME

• Monitor of nosesused per day
• Check if patient is aspirating saliva
• Frequent coughing may be a clue

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Skin Care Issues

• cotton ties vs. velcro ties
• Skin integrity
• Ointments/ gauze
• Allevyn absorbant gauze
• Split gauze use
• Consults

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Role of the R.T.

• Gather required equipment 1. O2 Y connector
  2. Ambu bag 3. (2) O2 flowmeters(if on O2.) 4.
  Heated nebulizer 5.spare emergency equivalent
  tube. 6. Cont. pulse oximeter (if not in a
  monotored bed).
• Daily assessment done by R.T each shift ( seems
  to work best if coordinated together with R.N.)
• Equipment changed per policy
• Begin teaching with pt. family if needed.

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Role of the R.N.

• Check physician orders
• Contact Resp. Therapy inform them of any new
  trach pt.
• Ensure that the following items are set up in the
  room 1. Sx set-up 2. appropriate sized Sx
  catheters yankaur 3. sterile gloves 4.Sterile
  H20 5. normal saline 6. Hydrogen peroxide
  7.sterile bowl, Q-tips, drainage sponges .
• Participate in daily assessment and perform trach
  care with R.T. per protocol.

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Importance of History Physical

• Multisystem involvement with
• Patient having surgery
• Patient with medical illness
• Know WHY patient has a tracheostomy

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Issues Related to Infants Anatomy and Physiology

• Apnea
• Feeding issues
• Behavioral issues

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Feeding Issues
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• Ability to suck, swallow breathe
• Variables
• Testing swallowing ability after tracheostomy-
• usually after 5 days
• (but may be earlier)

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SIGNS OF RESP DISTRESS 1.Child who has no voice
suddenly vocalizes 2.Suction catheter cannot
easily pass into trach tube 3.Difficulty
breathing/Cyanosis 4.Child stops breathing
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• Unplanned Decannulation
• Fresh trach new stoma bag mask ventilate
• Old trach established stoma - try to replace tube
  with same size tube, next lower size tube, or ett
  tube.
• Re-place using obturator
• Do not force tube back into stoma
• If tube cannot be replaced easily, begin bag
  mask ventilation (gauze held over stoma leak).
• Prepare for oral intubation

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Airway Dysfunction

• In case of suspected tube plugging
• Attempt to pass a suction catheter through the
  tube.
• If obstructed, remove tube
• Assess airway after tube removal
• Provide alternative airway support

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Complications

• Bleeding
• Infection, Skin Breakdown Cellulitis
• Air Leak
• Obstruction

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Bleeding
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Infection
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Obstruction
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Other Complications

• Tracheoinnominate Fistula- (rare)An erosion of
  the tube into the Lg. Artery that runs in front
  of the trachea. Possible hemorrhage- could lead
  to death.
• Tracheoesophageal Fistula- An abnormal connection
  between the trachea the esophagus resulting
  from erosion of the back wall of the trach.
• Stenosis- Scar tissue at the site of the trach.
• Pressure Necrosis- Patients with long term trachs
  can develop pressure sores of the skin tissue
  around the site.( Very important to inspect site
  daily.)

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Granuloma
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Patient Education

• Replicating care
• Providing mobility

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Patient Education
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Changing a trach tubeHumidification

• Remove stitches On new trach
• Remove tracheostomy tube
• Insert new tube same size

• Monitor of nosesused per day
• Check if patient is aspirating saliva
• Frequent coughing may be a clue

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Larry Rhein MD friend
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