TRACHEOSTOMY TUBE REPLACEMENT Purpose: Emergency tracheostomy tube replacement occurs when the tube becomes blocked, dislodged or has been unintentionally removed. Additional Authority: Nevada Revised Statute, Nevada Nurse Practice Act, School Nurse Advisory Opinion, CCSD Regulation 5150 Health and Welfare: Students Scope: School Nurses, Specialized Procedure Nurses, contracted licensed staff (RN, LPN), and qualified, trained unlicensed assistive personnel (UAP) Responsible Party: Health Services Director Distribution: Health Services Coordinators, School Nurses, Specialized Procedure Nurses, First Aid Safety Assistants, Health Services Department Secretarial Staff and other UAP trained to the procedure POLICY 1.0 Policy Statement 1.1 Licensed Health Care Provider orders are required for tracheostomy tube replacement to be performed in the school setting and must be renewed annually. 1.1.1 See - Licensed Health Care Provider s Specialized Orders for Health Services at School: Tracheostomy /Ventilator (HS). 1.2 A tracheostomy tube replacement may only be delegated to unlicensed assistive personnel (UAP) in accordance with the NSBN School Nurse Advisory Opinion.
1.2.1 Qualified, trained unlicensed personnel may only replace a tracheostomy tube in an emergency. 1.3 Healthcare personnel and designees responsible for the tracheostomy tube replacement procedure should have demonstrated and documented knowledge and skills through monthly verification of training 1.4 Routine tracheostomy tube changes are performed at home. 1.4.1 It is recommended that the nurse who is providing direct care observe or perform one routine tracheostomy tube replacement procedure in a controlled setting such as at home during a home visit. 1.5 Activate EMS (9-1-1 dispatch) and provide CPR as necessary when an emergency tracheostomy tube replacement is needed so response time is not delayed. 1.5.1 Special Consideration: John F. Miller Special School 1.5.1.1 Student is stable and in no distress: initiate trach tube replacement, then activate EMS if needed 1.5.1.2 Student is unstable and in distress: Activate EMS immediately 1.5.2 If student is independent with emergency replacement, EMS may be activated at the discretion of the nurse providing direct care. 2.0 General Guidelines for Tracheostomy Tube Replacement 2.1 Indications for tracheostomy tube replacement include the following:
2.1.1 Signs of respiratory distress, such as difficulty breathing, agitation, paleness, excessive coughing, cyanosis, hypoxia, nasal flaring or retractions, or if suctioning is unsuccessful. 2.1.2 Plugged tracheostomy tube or accidental dislodgement of the tube. 2.1.3 Suction catheter will not pass or there is an obstructed airway. 3.0 Procedural Steps ESSENTIAL STEPS KEYPOINTS-PRECAUTIONS 1. Review current LHCP orders An order from a LHCP is required prior to the beginning of each school year or upon enrollment during the midyear, and must be reviewed prior to the student attending school. A new order is also required whenever student status changes. 2. Wash hands. Use Universal Precautions 3. Assemble equipment: Prescribed type and size of tracheotomy tube for student and one size smaller Tracheostomy ties Obturator, if applicable Blunt scissors BVM Oxygen, if ordered Suction machine and catheters/supplies Syringe to deflate cuff for cuffed tube Sterile water-soluble lubricant or sterile saline Blanket roll, if desired Gloves 4. Explain procedure to student at level of understanding. 5. Position student with head and neck in neutral or hyperextended A cuffed tracheostomy tube must be deflated before removal. Never use petroleum jelly or any oilbased lubricant. A blanket roll may be used to hyperextend the neck, if not contraindicated. Consideration is given to how the student is most comfortable and how it is usually performed at home. The tracheostomy tube may be changed with student in a sitting or
alignment 6. Open tracheostomy tube package 7. Put on gloves 8. If the new tube has an obturator, insert it into the sterile tracheostomy tube 9. Lubricate end of tracheostomy tube with water-soluble lubricant or sterile saline. 10. Undo ties/velcro on existing tube. Deflate cuff with syringe, if applicable. 11. Remove existing tracheostomy tube. 12. Insert new tracheostomy tube and remove obturator if present. lying position. Only touch the external adapter part of the tube, not the tube itself Hold the tracheostomy tube in place at all times to prevent accidental dislodgement. Cuffed tubes must always be deflated before removal. Only touch the external part of the tube, not the tube itself If the new tube does not have an obturator by design, insert the clean (new) tube straight down into the stoma. Hold in place until secured. If tracheostomy is designed with an inner cannula, insert the inner cannula in accordance with manufacturer s instructions 13. Attach tracheostomy ties/velcro securely to tube. 14. Listen and feel for air movement through tracheostomy tube. 15. Auscultate breath sounds anteriorly and posteriorly (licensed nurses only). 16. Secure tracheostomy ties/velcro apparatus around student s neck. 17. Give two to four breaths with BVM as needed. Observe the student for signs of distress such as cyanosis, agitation, and/or shortness of breath. Listen to breath sounds after insertion of a tracheostomy tube to determine proper placement. The ties should be loose enough to slip one finger between the ties and the neck. If oxygen is ordered, make certain tubing is attached to the BVM and oxygen is flowing (See Bag-Valve-
Mask, Use of) 18. Suction if needed. (See Suctioning, Modified Sterile Tracheal) 19. Discard used equipment in appropriate receptacle. 20. Remove gloves and wash hands. POSSIBLE COMPLICATIONS OBSERVATIONS REASONS/ACTIONS 1. Unable to insert new tube. Reposition and reattempt insertion 2. Increased secretions or thicker than usual mucus If unsuccessful, attempt to insert tube one size smaller Reassure and calm student If unable to insert tube, initiate blowby-oxygen if ordered or start BVM to stoma or mouth as appropriate. Activate Emergency Medical Services 9-1-1 and Initiate CPR as needed May require more frequent suctioning. These changes, or yellow or green mucus, may indicate infection. Thicker mucus also may be a sign of insufficient humidity. 3. Fever May be a sign of respiratory infection 4. Redness or crusting at the stoma May be due to a tracheal infection; the site should be thoroughly cleaned 5. Bleeding or pain at stoma site May be due to infection or trauma 6. Bloody secretions from tracheostomy May be due to infection or trauma from vigorous suctioning 4.0 Documentation 4.1 Document required training of unlicensed assistive personnel. 4.2 Document required training of student s who will be independent in nonemergent tracheostomy replacement care.
4.3 Document procedure in the electronic medical record (Healthmaster) and electronic billing record (EdPlan). 5.0 References, Sources, Bibliography 5.1 American Thoracic Society. (2009). Suctioning: Clean vs sterile consensus. Retrieved from: C:\Documentsand Settings\student\My Documents\Trach care\suctioning.mht. 5.2 American Thoracic Society. (2000). Care of the child with a chronic tracheostomy. American Journal of Respiratory and Critical Care Medicine, 161, 297 308. 5.3 American Thoracic Society. Oxygen Delivery Methods. Retrieved from: http://www.thoracic.org/clinical/copd-guidelines/for-healthprofessionals/exacerbation/inpatient-oxygen-therapy/oxygen-deliverymethods.php 5.4 Anderson, L., Besser, R., Bridges, C., Hajjeh, R., & Tablan, O. (2003). Guidelines for preventing health-care associated pneumonia: Recommendations of CDC and the Healthcare Infection Control Practice Advisory Committee. Retrieved from: www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm. 5.5 Children's Memorial Hospital (Chicago). (2009). A guide for tracheostomy care at home. Retrieved from: C:\Documents and Settings\student\My Documents\Trach care\ear, nose and throat (Otolaryngology)-A guide for tracheostomy care at home, Children's Memorial Hospital (Chicago, Il).mht
5.6 Escambia County Health Department-School Health Program. (2000, April). Policy for tracheostomy care and suctioning in the school health setting. School Health Special Procedures. 5.7 Hootman, J. (2004). Quality nursing interventions in the school setting: Procedures, models and guidelines (2nd ed.). Maine: National Association of School Nurses. 5.8 MD Anderson Cancer Center, University of Texas, 2004, Tracheostomy and endotracheal tube suctioning - respiratory care, UTMDACC Institutional Policy # CLN0706 5.9 St. Jude Children's Research Hospital, 2008, How to suction a trach, August 2008, www.stjude.org 5.10 Nevada State Board of Nursing 5.11 Clark County School District Regulation 5150 - Health and Welfare: Students 6.0 Authorizations Health Services Director (Print) Signature Date