Professional Documents
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Introduction
A tracheostomy is a surgical opening into the trachea below the larynx through which an indwelling tube is placed
to overcome upper airway obstruction, facilitate mechanical ventilatory support and/or the removal of tracheo-
bronchial secretions.
Definition of terms
The aim of the guideline is to outline the principles of management for patients with a new or existing tracheostomy
for clinicians at the Royal Childrens Hospital.
Tracheostomy kit
A blocked or partially blocked tracheostomy tube causes severe breathing difficulties. The key concept of
tracheostomy management is to ensure patency of the airway. A tracheostomy kit is to accompany the patient
at all times and be checked each shift by the nurse caring for the patient.
Tracheostomy kit
x1tracheostomy tube of the same size insitu (with introducer if available)
x1tracheostomy tube one size smaller (with introducer if applicable)
Spare inner tubes for double lumen trache tubes
Spare ties (cotton and velcro)
Scissors (or chain cutters as applicable)
Resuscitation bag and mask (appropriate size for patient)
One way valve (community use only)
Wall or portable suction
Appropriate size suction catheters
0.9% sodium chloride ampoule and 1 ml syringe
x1 HME or tracheostomy bib
Fenestrated gauze dressing
Cotton wool sticks
Water based lubricant for tube changes
Mucous trap-for emergency suction
Tape (ie sleek)
NB: NeopuffTM is the resuscitation device used at the bedside in Neonatal Unit at RCH.
Special considerations
All children 6 years and under are to have cotton ties only to secure tracheostomy tubes.
Children 6 years and over who are considered at risk of undoing velcro ties should have cotton ties.
For patients with a newly established tracheostomy it is recommended that tracheal dilators are available at
the patients bedside until after the first successful tube change.
Emergency management
The majority of children with a tracheostomy are dependent on the tube as their primary airway. Cardiorespiratory
arrest most commonly results from tracheostomy obstructions or accidental dislodgement of the tracheostomy tube
from the airway. Obstruction may be due to thick secretions, mucous plug, blood clot, foreign body, or kinking or
dislodgement of the tube.
Early warning signs of obstruction include tachypnoea, increased work of breathing, abnormal breath sounds,
tachycardia and a decrease in SpO2 levels . Cyanosis, bradycardia and apnoea are late signs - do not wait for
these to develop before intervening.
The resuscitation flowchart for a tracheostomy patient follows APLS principles.
It is recommended that a copy of this flow chart is readily available e.g. placed in a prominent
position at the bedside or in the patients bed chart folder.
Download the flowchart (PDF 21 KB)
Complications
After a tracheostomy is inserted, the patient is managed in either the Paediatric Intensive Care (PICU - Rosella) or
Neonatal Unit (NNU - Butterfly) in the initial post-operative period.
Patients return from theatre with stay sutures in situ, which should be taped to the chest and labeled left and
right. The stay sutures should remain in situ and securely attached to the chest wall, , until the first
successful tube change. The stay sutures facilitate the opening of the stoma during reinsertion of the
tracheostomy tube.
The ENT team, in consultation with the parent medical team, will perform the first tube change, including the
removal of the stay sutures. This is usually done 5-7 days after insertion of the tracheostomy tube.
Most children will undergo their first tracheostomy tube change while in the intensive care environment.
However, on occasions, following consultation between members of the PICU, ENT team and the parent
unit, children may be transferred to a ward from PICU prior to their first tracheostomy tube change if they
meet the following criteria:
Have a non critical airway i.e. these children are able to breathe and maintain their airway in the
event of accidental decannulation.
Are not dependent on positive pressure ventilation/CPAP via the tracheostomy.
It is imperative that the first tracheostomy tie change is dealt with in the same manner as the first
tracheostomy tube change with both nursing and medical staff present who are competent in
tracheostomy management. The tracheostomy kit should be present at the bedside.
The tracheal stoma in the immediate post operative period requires regular assessment and management
including once daily dressing change following cleaning of the stoma area with 0.9% normal saline, or more
frequently if required.
The comfort of patients is imperative throughout the post-operative period. Pain should be managed
effectively as per RCH procedural pain management policy.
Each child requires a Tracheostomy Tube Management Form to be completed and placed at the bedside.
(see attached form)
Routine management
Additional tests/assessments
Humidification
A tracheostomy bypasses the upper airway and therefore prevents normal humidification and filtration of inhaled
air. Therefore, unless air inhaled via the tracheostomy tube is humidified, the epithelium of the trachea and bronchi
will become dry which increases the potential for tube blockage. Tracheal humidification can be provided by a
heated humidifier or Heat and Moisture Exchanger (HME) or a Tracheostomy bib.
Heated humidification: delivers gas at body temperature saturated with water which prevents the thickening of
secretions. The temperature is set at 37C delivering a temperature ranging from 36.5C - 37.5C at the
tracheostomy site. Heated humidification for tracheostomy patients should be delivered via a humidifier as per the
Oxygen clinical guideline (nursing). Indications for the use of heated humidification include:
Heat Moisture Exchanger (HME): contains a hygroscopic paper surface that absorbs the moisture in expired air.
Upon inspiration the air passes over the hygroscopic paper surface and moistens and warms the air that passes
into the airway.
Tracheostomy bibs: are a specialized foam that traps the moisture in the expired air, upon inspiration the
foam moistens and warms the air that passes into the airway.
Suctioning
Suctioning of the tracheostomy tube is necessary to remove mucus, maintain a patent airway, and avoid
tracheostomy tube blockages. Indications for suctioning include:
The suction depth is determined by the length of the individual tracheostomy tube.
The depth of insertion of the suction catheter needs to be determined prior to suctioning to avoid airway
trauma.3
Using a spare tracheostomy tube of the same size and a measuring tape:
measure the distance from the length of the tracheostomy tube connector to the end of the
tracheostomy tube.
record the suction depth on the tape measure and the patients observations chart.
attach the tape measure to the cot/bedside/suction machine for future use.
Use pre - measured suction catheters(where available) to ensure accurate suction depth
The pressure setting for tracheal suctioning is 80-120mmHg (10-16kpa) to avoid tracheal damage. The
suction pressure setting should not exceed 120mmHg/16kpa.
It is recommended that the episode of suctioning (including passing the catheter and suctioning the
tracheostomy tube) is completed within 5-10 seconds.3
Suction catheters can be used for a 24hour period and then discarded unless indicated earlier.
Routine use of 0.9% sodium chloride is not recommended however, In situations where this may be of
benefit e.g., thick secretions and to stimulate a cough 0.2 - 0.5ml of 0.9% sodium chloride can be used.2,3
Suctioning equipment:
Suction apparatus (wall attachment or portable unit)
Suction canister
Tubing
Suction catheter
Sterile water
Suctioning checks:
Ensure tracheostomy kit is present
Appropriate size suction catheter
Depth required for tracheostomy tube suctioning3
Appropriate suction pressure.
The correct suction pressure for use on a tracheostomy tube is 80-120mmHg maximum when occluded. The
Medigas suction gauges on the ward are measured on kPa. The equivalent of 80- 120mmHg is 10-16kPa.
Suctioning: Procedure
1. Explain to the patient and their family that you are going to suction the tracheostomy tube.
2. Hand hygiene - ABHR
3. Use personal protective equipment including non sterile gloves and safety glasses.
4. Suction using a clean, non touch technique.
5. Attach suction catheter to suction tubing
6. Gently introduce the suction catheter into the tracheostomy tube to the pre-measured depth.3
7. Apply suction & gently rotate the catheter while withdrawing. Each suction should not be any longer than
5-10 seconds.3
8. Assess the patient's respiratory rate, skin colour and/or oximetry reading to ensure the patient has not been
compromised during the procedure. Repeat the suction as indicated by the patient's individual condition.
9. Rinse the suction catheter with sterile water decanted into bowl, not directly from bottle.
10. Look at the secretions in the suction tubing - they should be clear or white and move easily through the
tubing.
11. Notify the parent team if the secretions are abnormal, and consider sending a specimen for culture and
sensitivity.
Suction catheters are to be routinely replaced every 24hours or at any time if contaminated or blocked by
secretions. Suction water/and the container to be replaced every 24 hours.
Persistant blood stained secretions from the tracheostomy tube need to be investigated to determine the cause.
Tracheostomy kit
Two equal lengths of cotton ties or Velcro ties (for patients older than 6 years)
At The Royal Children's Hospital the frequency of a tracheostomy tube change is determined by the Respiratory
and ENT teams except in an emergency situation. This can vary from weekly to monthly depending on the
patient's individual needs and tracheostomy tube type. Tracoe, Portex, Shiley and Bivonna tracheostomy
tubes are used at RCH.
It is imperative that the first tracheostomy tube change is performed with both nursing and medical staff
who are competent in tracheostomy management present and the tracheostomy kit is available at the
bedside.
A minimum of two people who are competent in tracheostomy care are required for all tracheostomy tube
changes (except in an emergency if a second person is not readily available eg. Transporting the child).
The tube change should occur before a meal or at least one-hour after to minimise the risk of aspiration.
Utilise personal protective equipment including non sterile gloves and safety glasses.
The tube change is a clean, non touch technique.
1. Hand hygiene ABHR & use personal protective equipment including non sterile gloves and safety glasses.
2. Prepare the new tracheostomy tube by removing it from the packaging/container, check the expiry dates
and inspect for any signs of damage to the tube and then thread the ties into the flange and tie.
3. If using velcro ties- insert the ties on one side of the flange only
4. Clearly explain the procedure to the patient and their family/carer.
5. Consider distraction techniques and or procedural sedation.
6. Swaddle the patient if age appropriate by wrapping the arms and containing them in the sheet.
7. Place the rolled towel under the patient's shoulders to extend their neck (unless contraindicated). The older
child may find it more comfortable to sit upright with their head tilted back.
8. Position the child so that you have good visibility and access to the stoma. If necessary extend the neck
further and open the stoma wider by using your thumb and forefinger.
9. Suction the existing tracheostomy tube immediately before removing the existing tube and inserting the new
one.
10. Person 1 holds the existing tube with their hand, person 2 cuts and removes the cotton ties from around
the child's neck. If using Velcro ties - undo and remove from the flange.
11. Person 1 removes the existing tube. Person 2 immediately inserts the new tube into the stoma and
removes the introducer (if applicable).
12. Person 2 holds the tube in place while Person 1 ties and secures the tracheostomy ties.
13. Check the tension of the ties to allow - one finger to fit snugly between the skin and the ties, adjust if
necessary. If using cotton ties, finish by making a reef double knot and cut off any excess fabric leaving
approximately3cm.
14. Observe the child immediately after the tube change to:
15. ensure they are breathing normally with no signs of respiratory distress.
16. Check that air is moving in and out of the tube by:
17. listening for sounds of air coming out of the tube
18. looking at the rise and fall of the chest
19. feeling with your hand for a flow of air
20. Check the old tube for blockages and or wear and tear.
21. Discard single use tubes or wash and dry reusable tubes tubes according to the manufacturers
recommendations.
A rare complication is for the tube to slip into a false passage instead of the airway. If there are any signs of
breathing difficulties/respiratory distress remove the tube and reinsert (a new tube) via the stoma into the
airway.
Unless instructed otherwise, all single use tracheostomy tubes should be used once only and discarded
after every tube change, do not clean or re-use single use tubes.
Difficulties in re-inserting the tracheostomy tube can occur at any time. These occur usually as a result of
one of the following:
False tract
Patient agitation or distress
Closure of the stoma
Spasm of the trachea
Stoma is blocked by scar tissue (granuloma)
Skin flaps
Structural airway abnormalities eg: Tracheo/bronchomalaca.
At times the difficulty is for no obvious reason and cannot be explained
Stoma care
Care of the stoma is commenced in the immediate post-operative period, and is ongoing.
Daily cleaning of the stoma is recommended using 0.9% sterile saline solution. After cleaning, ensure the
skin is clean and dry to avoid breakdown.
The care of the stoma includes routine observation of the site and accurate documentation of the findings
including:
Redness
Swelling
Evidence of granulation tissue
Exudate
Increased discomfort during care
Stomal odour.
Refer to stomal therapy/respiratory CNC for advice on the frequency and type of dressing required.
Consider a dietician referral to assess optimal nutritional intake including oral versus tube feeding (PEG, PEJ or
NG), continuous versus intermittent feeding.
Oral care
Patients with a tracheostomy have altered upper airway function and may have increased oral care requirements.
Mouth care should assessed by the nurse caring for the patient and documented in the patient care record
Communication
Children communicate in many different ways, such as using gestures, facial expressions and body postures, as
well as vocalising. The tracheostomy may impact on the child's ability to produce a normal voice.
For patients with a new tracheostomy, refer to a speech pathologist for assessment and provision of
communication aids such as:
Pen and paper
Alphabet board
Picture communication device
Teaching manual for Auslan signing
Electronic devices
Assessment for suitablility of speaking valve attachement
For children with established tracheostomy tubes it is essential that the methods used for communication
are identified via discussion with the patient (age appropriate), and the parent/carers. These methods
should be documented in the medical record and verbally handed over to staff to ensure adequate
communication and appropriate understanding of the patient and their needs.
Speaking valves are a small plastic device with a silicone one-way valve, they sit on the end of the
tracheostomy tube. The one-way valve opens on inspiration allowing air to enter the tracheostomy tube and
closes on exhalation directing air up through the trachea, larynx and nose and mouth as in normal breathing
and normal speech. Not all children will be able to produce a voice when the speaking valve is first used.
Speaking valves:
Various types of speaking valves are available. The most commonly used at the Royal Children's are Passy-Muir
one-way valves.
The child's tolerance to the speaking valve will depend on their airway around and above the tracheostomy tube.
To exhale sufficiently the child must have enough airway patency around the tracheostomy tube, up through the
larynx and out of the nose and mouth. If exhalation is not adequate with the speaking valve in place the child may
become distressed and air trapping/breath stacking or barotrauma to the lungs may occur.
Remove the valve if any signs or symptoms of distress or changes in respiratory effort.
As it can be more difficult for the child to exhale with the valve in place, the child may initially fail a trial of
PMV due to anxiety, discomfort.
Children may need to slowly build up longer periods of valve use and PMV placement will be repeated on
subsequent days.
Many children however, have difficulty adjusting to changes to their airways. Children may initially
experience increased coughing due to restoration of a closed respiratory system, which re-establishes
subglottic pressure and normalizes exhaled airflow in the oral/nasal chambers.
In infants and young children consider using an device to secure the PMV to the child's ties - to prevent
accidental loss of the PMV.
Some speaking valves are suitable for use in combination with oxygen therapy and during ventilation.
If you determine there is no airway patency then the degree of stenosis is a contraindication to speaking
valve use.
If the child has prolonged excessive coughing and obvious discomfit with increased respiratory effort and
air trapping - remove the valve immediately and reassess for adequate airway patency before a repeat trial.
If airway patency adequate then aim to reassess the child at regular intervals to place the PMV gradually
increasing the time and frequency of use.
PMV may be contraindicated depending on type of cuffed tube e.g. foam cuff
If the child has severe airway obstruction the speaking valve should not be used.
In cuffed tracheostomy tubes - ensure cuff is completely deflated.
The young child should always be supervised when wearing the speaking valve.
The speaking valve should not be worn when the child is sleeping.
Speaking valves do not humidify the air - therefore may be unsuitable for children with copious thick
secretions.
If the speaking valve is not functioning properly (i.e. sticking, noisy or vibrates) or the child shows signs of
respiratory distress/discomfort, then remove the valve immediately and replace.
Do not use in combination with HME (heat moisture exchanger)
Remove valve before aerosol/nebulizer medication is administered
The speaking valve should be cleaned daily by washing the valve in warm mild soapy water, then rinsed
thoroughly and allowed to air dry completely before reuse.
Once dry and when not in use, it should be stored in the appropriate storage container.
Ensure the valve is clean and not damaged in any way before each use.
Replace the valve immediately if any signs of wear/tear or damage are noted.
All children with a tracheostomy tube in situ require a referral to Family Choice Program to identify if support
is required either for the patient or their family. The referral should be made as soon as possible following
tracheostomy tube insertion to allow adequate time for planning home support services.
The referring team is responsible for ensuring appropriate equipment is organised in collaboration with the
Equipment Distribution Centre. This should occur in consultation with the nursing staff, respiratory nurse
consultants and the parent medical team.
Ensure all members of the medical, nursing and allied health teams are aware of the planned discharge.
Prior to discharge an intervention chart is required to be completed to provide detailed information about
the interventions required for the patient over a past 24-48 hour period including:
Frequency of care the patient required including the amount of suctioning the child has required.
Level of dependency the patient has on their tracheostomy.
Assessment will be made in accordance to the above information as to the child's eligibility for assistance
required at home and for discharge.
Education for primary care givers regarding tracheostomy care commences soon after insertion of the tube
and is usually initiated by the respiratory CNC in collaboration with the parent unit nursing staff.
Principles of the care for children with a tracheostomy in the community who are managed by FCP are
based on the recommendations of this clinical practice guideline. However individualised care plans are
developed specifically to their care needs. These are located in the home care manuals in FCP department.
Decannulation
Decannulation is a planned intervention for the permanent removal of the tracheostomy tube once the
underlying indication for the tracheostomy has been resolved or corrected.
The patient is admitted to hospital for the procedure.
Bronchoscopy evaluation is usually performed prior to planned decannulation to evaluate airway stability,
assess possible granulation or suprastomal collapse, to assess whether the child can maintain their airway
and ventilation adequately without the tracheostomy tube.
Decannulation planning can also include a staged process with downsizing and capping of the
tracheostomy tube in order to assess how the child would cope with a smaller tracheostomy in the airway
and to encourage the use of the upper airway.
The tracheostomy is usually blocked off using a decannulation cap if tolerated the child is monitored
overnight (downloadable oximetry) with the tube occluded.
To ensure the patient and the caregivers are prepared for the decannulation ensure the procedure has been
explained.
Decannulation is usually performed between the hours of 9am and 6pm.
There should be a clearly documented plan for the decannulation process from the parent medical team
Decannulation should not be performed unless a member of the parent medical team is present in the
ward at the time of decannulation. Inform the ENT team of the planned decannulation prior to removal of
the tracheostomy tube.
It is recommended that the child's caregiver/s are present to alleviate the anxiety of the child.
The child should be fasted for 2 hours prior to the decannulation.
Post decannulation, the patient is ideally nursed 1:1 for 24 hours and should not leave the ward unless
supervised by nursing staff. At the end of this 24 hour period the need for nursing supervision of the patient
(away from the ward area) is assessed by the patient's parent medical team.3
Occasionally the trial of decannulation is unsuccessful requiring the need to re-insert the tracheostomy
tube. This is an emergency procedure and it can occur at any time
Decannulation: Equipment
Equipment - to stay at bedside until the child is discharged:
Tracheostomy Kit
Set of tracheostomy tubes (same size and smaller sizes than tube child has insitu down to a size 3mm -
keep a size 3mm in freezer).
Surgical scissors
Tracheostomy ties or velcro ties
Gauze dressing and an occlusive dressing - Comfeel with hypafix borders or tegaderm/opsite to
cover the tracheostomy stoma
Oxygen and suction
Cotton tipped applicators
Small towel (if applicable)
Oxygen and suction equipment
Laerdal Resuscitator kit
Decannulation: Procedure
Obtain baseline observations including heart rate, respiratory rate, haemoglobin-oxygen saturation, and
work of breathing. Ensure patient vital signs are within appropriate parameters forage
Monitor patient continuously throughout the procedure.
Clean the stoma and suction the tracheostomy tube immediately prior to decannulation.
Cut/undo tracheostomy tube ties.
Remove tracheostomy tube.
Observe for any signs of respiratory distress including:
Tachypnoea
Stridor
Retraction
Tachycardia
Colour
Decreased perfusion
Haemoglobin-oxygen desaturation or low oximetry reading.
Restlessness
cough effectiveness swallow and voice quality
activity levels
Apply occlusive dressing to stoma site post decannulation if no evidence of respiratory distress.
Patient should again be assessed for signs of respiratory distress after applying occlusive dressing to
stoma site.
Patient should be nursed 1:1 for the first 24 hours post decannulation if complications with the
decannulation are anticipated.
Following decannulation:
Monitor the patient's respiratory rate, heart rate, oxygen saturation, colour and work of breathing
continuously throughout the procedure then:
15 minutely for the first hour
Half hourly for the next 4 hours
Hourly for 24 hours
Continuous pulse oximetry (SpO2) for patients during all periods of sleep (day and night) post
decannulation for 24 hours.
Call a MET for assistance as per RCH guidelines
Discharge:
The child is usually discharged home when they're considered to have a safe airway. The average length of
stay post decannulation is 24 -48 hours but this maybe longer if required.
Ensure the caregivers are provided with adequate supplies and are aware of how to care for stoma site -
this includes daily cleaning of the site and dressing changes as required.
Advise the family/caregiver to contact the hospital and/or medical team if any episodes of:
Tachypnoea/bradypnoea
SpO2 desaturation
Increased WOB - as evidenced by: sternal/intercostal retraction, tracheal tug, nasal flaring, stridor
Restlessness/anxiety
Colour change/ Cyanosis
Unable to clear secretions - gagging
Advise the family/caregiver to contact the hospital and/or medical team if there are any signs of infection at
the stoma site including any
Redness
Odour
Swelling
Discharge
Following a successful decannulation the family are able to return all tracheostomy and suctioning
equipment but are encouraged to keep the pulse oximeter until seen at follow up outpatient appointment
Documentation
All written documentation related to the management of a patient with a tracheostomy is in accordance with
the RCH documentation policy.
Record the reason and type of the interventions performed relating to tracheostomy care and appropriate
outcomes in the progress notes. These include:
Suctioning (amount, colour and consistency of aspirates)
Tracheostomy cares including tie changes and stoma dressings
Stoma condition (ongoing documentation and any changes eg: signs of infection)
Significant changes in patient's condition
In the event of a tube change (routine or emergency), the following should be documented in the progress
notes:
The size and type of tube inserted
Lot number
Expiry date of the tracheostomy tube
Name of person who inserted the tube
Patient condition throughout the tube change
Any difficulties experienced during changing the tracheostomy tube.
Evidence table
References
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intubated mannequin". Arch Dis. Child. Fetal Neonatal Ed. (2004); 89; 490-93.
2. Raymond SJ. Normal Saline Instillation Before suctioning: Helpful or Harmful? A review of the Literature".
American Journal of Critical Care July 1995 Volume 4, No. 4 267-271.
3. Gray JE, MacIntyre NR, Kronenberger WG. The effects of bolus normal saline instillation in conjunction with
endotracheal suctioning.
4. respir. Care. 1990;35:785-790.
5. Choate, K and Snadford, M (2003) "Tracheostomy: Clinical Practoce and the formation of policy and
guidelines" Australian Nursing Journal, 10, 8 p:CU1.
6. Scoble M, Copnell, B. Taylor, A. Kinney, S and Shann, F. (2001) "Effect of reusing suction catheters on the
occurence of pneumonia in children" Heart and Lung vol 30, 3 p: 225-233.
7. Celik, S and Kanan, N (2006) " A current conflict use of Isotonic Sodium Chloride Solution on the
Endotracheal Suctioning in Critically Ill Patients" Dimensions of Critical Care Nursing vol 25/No1 pp:11-14.
8. Ridling, D. Martin, LD and Bratton, S. (2003) "Endotracheal Suctioing With or Without Instillation of Isotonic
Sodium Chloride Solution in Critically Ill Children". American Journal of Critical Care vol 12, no 3 pp:212-219.
9. Griggs, A. (1998) "Tracheostomy suctioning and humidification". Nursing Standard vol 13 (2) pp: 49-53, 55-
56.
10. Woodrow, P. (2002) "Managing patients with a tracheostomy in acute care". Nursing Standard vol 16 (44)
pp: 39-48.
11. Carr, M. Poje, C.P. Kingston, L. Kielma, D. Heard, C. (2001) "Complications in Pediatric Tracheostomies"
Laryngoscope 111: November 2001.
12. Edwards, E.A. Byrnes, C.A (1999) " Humidification Difficulties in Two Tracheostomized Children" Anaesthesia
and Intensive Care, 27, 6, pp: 656-58.
13. Wyatt, M.E. Bailey, C.M. Whiteside, R.N (1999) "Update on paediatric tracheostomy tubes" The Journal of
Laryngology and Otology , 113, 1, Health and Medical Complete pp:35-40.
14. Wetmore, R.F. Marsh, R.R. Thompson, M.E. Tom, L.W. (1999) "Pediatric Tracheostomy: A Changing
Procedure". The Annals pf Otology, Rhinology and Laryngology, 108, 7, pp:695-699.
15. Dixon, L.and Wasson, D. (1998) "Comparing Use and Cost Effectiveness of Tracheostomy Tube Securing
Devices. Medsurg Nursing, 7, 5 pp: 270-274
16. Tamburri, L.M. (2000) "Care of the Patient with a Tracheostomy". Orthopedic Nursing, 19, 2 pp:49-60.
17. Oberwaldner, B. Eber, E. (2006) "Tracheostomy care in the home". Paediatric Respiratory Reviews, 7, 185-
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18. O'Toole, EA. Wallis, C. (2004) "Sending children home on tracheostomy dependent ventilation:pitfalls and
outcomes". BMJ vol 89 (3) pp: 251-255.
The development of this clinical guideline was coordinated by Sueellen Jones, Registered Nurse, Respiratory
Medicine. Approved by the Clinical Effectiveness Committee. Authorised by Bernadette Twomey, Executive
Director Nursing Services. First published March 2008, reviewed February 2013 and most recently May 2014.