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To view the Course Outline and take the test online, click here.
For a printer-friendly version of the exam you can print out, complete and mail in to ADVANCE, click here.
Learning Scope #377
1 contact hour
Expires Jan. 30, 2014
You can earn 1 contact hour of continuing education credit in three ways: 1) Grade and certificate are available immediately after taking the online test. 2) Send the answer sheet (or a photocopy) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the answer sheet to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.
Merion Publications Inc. is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 221-3-O-09), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Merion Publications Inc. is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).
The goal of this continuing education offering is to provide current information to nurses on tracheostomy and care for technologically dependent children. After reading this article, you will be able to:
1. Discuss the etiology and common pediatric diagnoses requiring a tracheotomy and ventilator assistance for airway support.
2. Discuss maintenance of the tracheostomy site and care for the ventilated pediatric patient.
3. Describe the common conditions for mechanical long-term ventilation and modes of ventilation.
4. Discuss the importance of quality care and a good team of home health professionals in the client's home.
- The author has completed a disclosure form and reports no relationships relevant to the content of this article.
Over the past decade, the survival rate of seriously ill children has increased, as has the number of technologically dependent children being sent home from hospitals. By becoming familiar with your pediatric patient's needs, equipment, and emergency plan, you will create a safer and more relaxed environment for the family as well as lower the rate of hospitalizations and adverse events.
In the past, more tracheostomies were performed routinely for shorter duration, mostly due to airway infection. Changes in tracheostomy indications and the introduction of less invasive treatment methods have resulted in fewer surgeries; however, nurses still must be prepared.
The typical child who requires a tracheostomy today has a congenital syndrome resulting in multisystem complications. Other indications include: neurological defects, upper airway obstructions, bilateral vocal cord paralysis, trauma and long-term mechanical ventilation while intubated.1
Trach Care
A tracheostomy is a surgical opening (stoma) created into the trachea in an effort to bypass an upper airway obstruction, provide lung expansion with restrictive disorders or neuromuscular disorders, or to keep the airway clear of secretions. Examples of obstructive disorders include congenital anomalies such as tracheomalacia (floppy airway) and subglottic stenosis (hardening of tissue below the glottis).
Restrictive conditions result in a decreased expansion of the lungs from loss of elasticity due to chronic conditions such as bronchopulmonary dysplasia. Other neuromuscular and central nervous system disorders such as muscular dystrophy, spinal muscular atrophies or traumatic injury can prevent patients from being able to breathe on their own or to manage secretions, thus requiring long-term ventilation and airway clearance.2
A tracheostomy tube is placed in the stoma. The tube's size depends on the size of the patient's cricoid ring. Tubes may have an inner cannula or cuff on the outside to help hold it into place. The care and maintenance of a child's tracheostomy site varies only slightly according to the tube type and the physician's preference.
In general, stoma care is performed daily by cleansing the site with a sterile cotton swab and normal saline solution or soap and water. Cleansers or other types of treatments are ordered when infection or complication occurs. The stoma may be covered with a fenestrated 2-by-2 or 4-by-4 to keep the site dry from oral and airway secretions.
If the tracheostomy has an inner cannula, the inner cannula is removed at least daily and either disposed of or cleansed with a cleaning solution as ordered and dried thoroughly prior to reinserting. The whole tube itself is changed according to physician orders and varies from weekly to bimonthly and/or PRN in the pediatric population.
All routine trachesotomy tube changes require two caregivers. Best practice now says to use the "time-out" method prior to the procedure to ensure the right size and type of trachesotomy tube as families often still have on hand smaller sizes from when their child was younger.3
If the tracheostomy tube has a cuff in place, the pressure should be checked daily with a monometer or simply with a syringe by aspirating the amount of air required for inflation the cuff. This varies according to the age and size of the patient's airway and tracheostomy tube. Once the air is aspirated from the cuff, it should be replaced as ordered.
Most often, trach ties are made of a soft material with Velcro on one side, premeasured and cut to fit the patient's neck circumference. Trach ties should be tight enough to secure the tube and loose enough to prevent airway constriction. In general, pediatric patients should be tight enough to ensure one finger breadth wide, while the adult should be as tight as at least two finger breadths.2
Suctioning Guidelines
The frequency of suctioning the tracheostomy tube depends on the amount of secretions present. This can vary with each child and increase during times of infection or response to environmental conditions.
Using saline is no longer used in my organization's practice for lavage on a regular basis when suctioning due to the threat of micro-aspirations. It is safer to give a normal saline solution nebulizer treatment in an attempt to loosen a mucous plug.
In addition, deep suctioning can cause irritation, leading to bleeding and other complications such as scarring and infection. Therefore, the depth of suctioning depends on the length of the patient's tube and should be premeasured.
Most suction catheters have centimeter marks to use as a guide. In general, only suction as deep as the tube itself to avoid the soft tissue of the trach - unless specifically ordered by the physician for purposes of clearing a mucous plug.
When suctioning, it is important to aspirate while on the way out rather than on insertion in order to avoid irritation and hypoxia. Practice in my organization is to use a "twirling motion" with pointer finger and thumb to ensure a safe technique. Some ventilator-dependent patients may require hyper-oxygenation before and after suctioning. Monitoring the facial expressions, perfusion and work of breathing can help ensure the patient tolerates the procedure with minimal discomfort.2
Mechanical Ventilation
Many children requiring an artificial airway also depend on mechanical ventilation for survival due to their neurological, neuromuscular, pulmonary or congenital cardiovascular anomalies. Mechanical ventilators have evolved so that children no longer have to remain hospitalized to receive technological assistance. Ventilators are now smaller and more portable, with higher functions and sensitivities to help keep a patient safe and more mobile.
Pulmonologists, surgeons and ears, nose and throat specialists work together to find the right size and type of tube as well as vent settings through testing, trial and error and a variety of measurements and studies prior to sending a child home.
The child's need for assistance in breathing dictates the mode of ventilation. Mechanical ventilation can assist patients according to their needs by providing volume or pressure. Sometimes, children with neuromuscular conditions may require a negative pressure that creates a sub-atmospheric pressure around the chest wall less than inside the child's chest cavity, allowing air to move into the lungs. Technology also can detect and assist a patient to breathe by synchronizing with the natural breath or by providing each breath according to their needs.
Modes of mechanical ventilation include:
• Assist control mode delivers a preset number of breaths per minute, and when the child attempts to take a breath, the ventilator will breathe for the patient on demand.
• Synchronized intermittent mandatory ventilation (SIMV) will provide a preset number of breaths per minute, and when patients attempt to take a breath on their own, the ventilator will allow them to do so without any assistance synchronizing mechanical breaths with their spontaneous breaths.
• Continuous positive airway pressure provides a continuous pressure to keep the lungs open while they take breaths on their own. The continuous airway pressure will not allow the patient to exhale completely to a pressure of zero.
• Pressure support can be used alone or along with SIMV. When used alone, the ventilator will give a preset pressure only when the client takes a natural breath. If used in conjunction with SIMV, the ventilator will still deliver the preset number of breaths; but when they breathe spontaneously, they will have pressure to support the breath.4
Differences From Adults
Clinically, the anatomical differences in the pediatric population affect work of breathing. First, because of the higher metabolic rate of the child, alveoli oxygen consumption is greater than that of the adult. Therefore, any apnea or inadequate alveoli ventilation will cause hypoxemia to develop more rapidly.
Second, because work of breathing is directly affected by factors influencing compliance of the lung tissue and elastic recoil, a child's spontaneous breath is less efficient than that of the adult until the child's chest wall grows so that compliance can decrease while elastic recoil increases.
Third, the pediatric upper airway in shorter in length and more narrow in diameter compared to that of the adult, making any inflammation of the upper airway critical for the pediatric patient. These differences are important when assessing the technologically dependent child to develop an effective care plan.
Be Prepared
It is the responsibility of home care nurses to keep our patients safe. This is accomplished by staying up to date on the latest technological advances in medical equipment, treatments and practice.
The best way to prepare yourself or the caregiver for the inevitable is to practice real-life situations in either a lab or the patient's home. Ensuring that emergency equipment is on hand and ready for use is the key to preventing an adverse event. Routinely checking the oxygen tanks, the ventilator settings and emergency equipment will help prepare for the worst-case scenario.
Each shift, the nurse or caregiver should check that all equipment is working and charging properly. This includes the ventilator (and back-up), external batteries or power sources such as a generator, hand ventilator with mask, a telephone, emergency tracheostomy board or bag within reach and "go bag."
Patients should have a trach board or bag with them at all times which should include: a same-size (and smaller) tracheostomy tube with obturator and ties, water-soluble lubricant for insertion, suction catheters, handheld ventilator with mask, bandage scissors and syringe for inflating the cuff, if applicable.
To view the Course Outline and take the test online, click here.
For a printer-friendly version of the exam you can print out, complete and mail in to ADVANCE, click here.
References for this article can be accessed here.
Davina DiGiacomo is pediatric clinical home care manager at Bayada Nurses, Mt. Laurel, NJ, and an adjunct instructor at the University of Medicine and Dentistry of New Jersey.
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