Tracheostomy Tie Change

Purpose

Tie changes are done to prevent the tracheostomy tube from falling out, and to prevent skin breakdown and rashes on the neck.

When

Ties are changed at least daily or when ties are wet or dirty.

Supplies

You will need the following supplies for suctioning your child’s tracheostomy tube:

• Scissors
• Hemostats
• Extra tracheostomy ties
• Optional self-fastening ties

How to Change Twill Ties

Here are the steps you need to know for changing the twill tie for your child’s tracheotomy tube:

• Ask a second person to help with tie change. The second person will hold the tracheotomy tube in place while the first person is changing the ties.
• If possible during the tie change, do not cut the old ties until the new ties are secured. Slide the soiled ties up or down to allow you to put the new ties on the flange at the same time.
• Cut two pieces of cotton twill tape long enough to fit around the neck and be tied.
• Cut at an angle to prevent fraying. Fold the angled end over about 1/2 inch and poke a small hole into the doubled end about 1/4 inch from the fold.
• Thread the tape through the hole of the tracheotomy tube flange from back to front. Pull the other end of the tie through the hole using the hemostats’ or tweezers. Pull tightly while holding the tube. (This secures the tie to the tube without using knots and does not tug the tracheotomy tube from the child’s neck.)
• Repeat the process for the other side of the tube. Bring both pieces of tie together and tie a square knot
• Check the new ties and see that only one finger can slide under the ties. The location of the knot should be moved each time it is tied to prevent skin breakdown. Flex the child’s head slightly while tying to ensure the ties are secure in all positions. If irritation is noted on the neck, protection can be applied. This involves either placing a gauze pad at the point of rubbing or using different ties.
• Cut the old ties and remove them. Re-check the new ties to be sure that only one finger can slide between the ties and the neck. The second person must hold the tracheotomy in place as the first person secures the new ties. Secure the ties by tying three square knots.

Self-Fastening Ties

Some children are switched to self fastening ties following their tracheotomy tube change on the 5th POD, because they are easier to use and less irritating to most necks. However, they are not for every child. Style and fit is very important for safe use. Some children’s skin is sensitive to the material in the neck tape. They are expensive, and some insurances limit the number used. If your doctor permits you child to use them, a prescription will be sent to your equipment company. There are several brands from which to choose that may help fit your child’s needs.

How To Change Self-Fastening Ties

Here are the steps you need to know for changing the twill tie for your child’s tracheotomy tube:

• Remove the old ties, while the second person holds the flange of the tracheotomy tube.
• Slip the self-fastening tab through the opening of the tracheotomy flange, folding it back onto the cloth material to fasten it securely.

Tips

Your Child Should Have Emergency Equipment With Them At All Times!

• Same size tracheotomy tube with ties already in place
• One size smaller tracheotomy tube with the ties already in
• Suction machine (unit should be fully charged)
• Suction catheters
• Breathing bag, with adaptors if indicated
• Normal saline
• Extra tracheotomy ties
• Scissors
• Hemostats
• Water-based lubricant
• Phone list

Suctioning a Tracheostomy Tube

Purpose

To remove mucus from your child’s tracheostomy tube and windpipe, and to allow easier breathing. Mucus is the body’s normal method of cleaning the airway. During the first few weeks after a tracheotomy, your child may form a large amount of mucus because of the surgery on the airway, and the tissue’s normal response to the new tube. In many children, the amount of mucus should decrease over time.

When to Suction

You should learn your child’s breathing pattern so that you know what you see, feel, and hear when he or she needs suctioning. Signs which may indicate the need to suction may include:

• Rattling mucus not cleared with coughing
• Fast rattling
• Bubbles of mucus at tracheostomy opening

Advanced signs that your child need to suction may include:

• Frightened look
• Flared nostrils
• Restlessness
• Pale or bluish color (over skin, nails, mouth)
• Clammy skin
• Fast, noisy, hard breathing
• Dry, whistling sound

Supplies Needed

You will need the following supplies for suctioning your child’s tracheostomy tube:

• Saline bottles or disposable vials – side effects may occur with saline use, only instill saline when secretions are thick or blood tinged. These side effects include lower oxygen levels, changes in heart rate, or infection.
• Suction machine – pressure gauges vary with suction machines; check with your equipment company about setting the pressure limit.
• Suction catheter – the ideal size suction catheter is 1/2 the opening of the tracheostomy tube. You may need to adjust the size if the mucus is thick.
• Eye dropper / syringe – if using bottles of saline.
• Paper cups
• Breathing bag – with optional tracheostomy adapter for metal trach tube.
• Tissue
• Gloves – optional, suctioning is a clean procedure at home.
• Rinse water – If rinsing catheters in water instead of saline.

How to Suction

Here are the steps you need to take when suctioning a tracheostomy tube:

• Wash and dry hands
• Set up equipment
• Pour rinse water into paper cup
• Connect suction catheter to suction machine tubing
• Turn on suction machine
• Place tip of suction catheter into water to moisten it and test to see if suction machine works
• Put small drops of normal saline into tracheostomy tube. You do not have to use normal saline if mucus is thin and loose.
• Using a tissue, wipe away any mucus which is coughed out
• Ask your child to take three deep breaths or with a breathing bag, give the child 3-5 breaths
• Using the obturator as a guide, measure how far to insert the suction catheter. Many catheters have markings on them to make measuring easier.
• Without applying suction pressure, gently insert the suction catheter into the tracheostomy tube just past the end of the tracheostomy tube. Deeper suctioning may be needed and can be done safely if your child has a poor cough or is not clearing the mucus from the airway. Your nurse will review when and how to use deeper suctioning.
• Put your thumb over the opening of the suction catheter to create a vacuum.
• Use a gentle circular motion while removing the suction catheter so that the mucus is removed well from all areas. This step should take 5-10 seconds.
• Rinse the suction catheter
• Watch your child’s color and breathing effort
• Let the child catch his breath or repeat bag breathing between suctioning attempts
• Repeat suctioning until your child’s respiration’s sound clear and the suction catheter returns with little or no mucus. Limit the passes of the suction catheter to 3 times whenever possible to prevent tissue trauma.
• Dispose of suctioning supplies and turn off suction machine
• Wash and dry hands

Tips on Suctioning a Tracheostomy Tube

If there are bloody streaks in the mucus, try using saline drops with suctioning. More time on the mist machine may also help decrease blood in the mucus. If the blood in the mucus does not get better within 24-48 hours, notify your doctor. If you see bright red blood your child needs to be seen right away by your doctor.

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