Pediatric Tracheostomy Home Care Guide

Pediatric Trach
T
home care guide
2
Pages
About This Book .......................................................................... 4
General Information ..................................................................... 5

Why I need my trach…
Emergency Equipment ................................................................ 6

Always be prepared
Types of Trachs............................................................................ 7
Passy-Muir Speaking Valve ......................................................... 9
Air Humidity .................................................................................. 9

Adding moisture to trach
HME (heat and moisture exchanger)
Room Humidifiers
Changing Trach Tube ................................................................ 12
Changing Trach Ties .................................................................. 14
Care of the Stoma Site ............................................................... 15
Potential Problems ..................................................................... 16

Stoma irritation, rash
Childhood illness, infection
REVISION DATE: May 2010

 Cook Children’s
3
Pages
Emergencies ............................................................................ 18
Obstruction
Decannulation, bronchospasm
Choking when eating
Suctioning ............................................................................... 22
Colors of mucous, when to suction
Suction equipment, pre-measuring
How to suction
General .................................................................................... 25
Clothing, weather
At home…
Sleeping, bathing, playing
Communication
Baby sitters
Cleaning Solutions .................................................................. 29

Vinegar, hydrogen peroxide, normal saline, sterile water
Care of the Trach Tube…………………………………………...31
What is Nebulizer Therapy ...................................................... 32

Setting up equipment
Taking a nebulizer treatment
Care of nebulizer kit
Frequently Asked Questions .................................................. 34
Additional Resources .................................................................. 35

4
This is a book about caring for your child’s tracheostomy. Learning tracheostomy care
at first may seem scary. This is normal. However, with a little practice, tracheostomy
care can become routine and easy to do.
Everyone caring for your child must learn trach care skills. Your family members and
friends are the best baby sitters so please encourage them to join us during some of
these lessons.
Please ask us questions

Everyone needs help understanding health information. You are not alone if you find
things confusing at times. Asking questions helps. This book gives information for
helping you understand what you need to do and why it is important for you to do this.

5
Tracheostomy care
General information
The trachea is your windpipe. A tracheostomy is a surgical hole into the windpipe. A
small curved tube called a “tracheostomy tube” goes into this hole. The trach tube helps
you breathe easier.
• The word Tracheostomy is often

shortened to “trach or trachea” and
Tracheostomy Tube to “trach tube”.
• Trach tubes may be temporary and

stay in for months or years. Some
people need a trach tube all their life.
• There are many different types of trach

tubes. Most trach tubes are made with
a special plastic material.
• The opening into the trachea is called

the “stoma”.
• The air you breathe goes in and out of

the trach tube instead of your nose
and mouth.
• Over time some children will be able to

direct some air around the trach tube
and out through the nose and mouth.
Why I need my trach tube:

______________________________________________
______________________________________________
______________________________________________
______________________________________________

6
Emergency equipment you must always have with you:

1. Extra trach tube … same size with
obturator placed inside.
2. Another extra trach tube … one size
smaller with obturator placed inside.
3. Clean trach ties.
4. Scissors.
5. Water soluble jelly or lubricant.
(No petroleum products like Vaseline)
6. Suction equipment with correct size

catheters.
7. Ambu bag and mask.
8. Oxygen (if needed).
Always be prepared
Trach tube parts

Obturator helps guide trach tube into trachea. Used when inserting trach tube.
Obturator
There are four types of trach tubes:
• Single cannula
• Double cannula Wings or flanges
• Cuffed tube
• Fenestrated trach
Trach sizes are: neonatal (NEO), pediatric (PED) or adult.

Cannula

7
Types of trach tubes
Single Cannula Neonatal or Pediatric Trach Tube

Single cannula trach tube is one tube. Most children
have single cannula trach tubes.
Double cannula trach tube

• Double cannula trach tube has two tubes. Teenagers and
adults often have double cannula trach tubes.
Inner Cannula
• Outer cannula is held in place with trach ties. It stays
in the trachea.
• Inner cannula can be taken out and changed.
Outer Cannula
• When changing a double cannula trach tube, remove

both tubes together, insert clean trach tube with
obturator in place, remove obturator, insert inner Shiley® double cannula trach tube
cannula & lock into place.
Cuffed trach tube

Some trach tubes have a cuff. The cuff is a balloon filled with air or fluid. It is
sometimes used for ventilator-dependent children (and adults).
An inflation line is used to fill the cuff. A syringe connects to the top of the inflation line.
Inflation Line
Shiley® cuffed single cannula trach

8
Fenestrated trach tube

Cuff
Fenestrations are openings or little holes in the tube.
• Trach tubes with openings lets you breathe some air
Fenestrations
through your mouth and nose and allows you to speak. or “openings”
Note: At this time we do not use fenestrated trach tubes at Cook Children’s.
What type of trach tube do I have? ________________________________________
Trach ties
A trach tube is held in place with soft material called a “trach tie”.
• The trach tie goes around the neck and ties to the
“wings” or flanges of the trach tube.
• Tie 3 times tight (1 ½ knots) when securing the tie.
• Ties should be tight enough so you can only slide
one finger snuggly under the ties. Check ties with child sitting up, if possible.

9
Passy-Muir speaking valves

Air flows past the vocal cords to make voice sounds.
Children with trachs cannot make sound when they cry or

talk because the trach tube is placed below the vocal
cords, preventing air from flowing through the vocal cords.
A speaking valve attaches to the outside of the trach tube.
The speaking valve sends air from the lungs up through the
vocal cords. When air goes through the vocal cords, sound
and words can be heard. There are also speaking valves
available for ventilator-dependent children.
Passy-Muir speaking valves

PPPPpp
Air humidity (moisture)

Humidity is the amount of moisture or wetness in the air. We need to breathe in
moisture to keep the lung’s cleaning system working. This helps our lungs stay free
from infection.
The lining of our nose and throat moistens, cleans, and warms the air each time we take
a breath.
Air going directly into a trach does not get moistened, cleansed, or warmed. Dry air can
make lung mucous thick and sticky. It can even cause lungs to make more mucous.
Gum-like mucous plugs can form that are hard to cough up.

10
Humidity in the lungs can be raised or lowered by:
• Amount of fluids you drink.

• Home heating systems.
• Weather changes.
Moisture for trach tube

There are several ways to add moisture to the trach.
• Fluid intake: It is important to drink a lot of fluids. Drinking fluids helps keep us
hydrated, which in turn keeps mucous thin.
• Trach mask: Moisture can be added to the trach using a trach mask connected to
a humidification system. Humidity can be either a warm or cool mist. Cool mist is
usually used in the home. You may need moisture all the time or only during sleep.
Your doctor will decide the best way to provide moisture to your trach.

11
HME (heat and moisture exchanger): This is a special adaptor attached directly to the
trach. It is also called an artificial nose or trach vent. The HME fits on the end of the
trach tube. When you breathe, a filter inside the HME cleans the air and collects
moisture and warmth from your breath. The moisture stays in the filter and humidifies
the air you breathe in. The HME helps moisten, clean, and warm the air.
Room/home humidifiers: Room humidifiers are not usually recommended. It is best to

check with your doctor before using one.
Why do I need moisture? _______________________________________

____________________________________________________
____________________________________________________
What am I going to use? ________________________________________

____________________________________________________________
___________________________________________________________

12
Changing trach tube

Change trach tube once a week or sooner, if needed.
• Wash your hands.

• If possible, have someone help you (everyone must wash their hands).
• Prepare clean trach with ties.
• Place obturator in clean trach tube.
• Lubricate end of tube with water-soluble jelly.
• Place a small roll under shoulders of small children.
• Suction, if necessary.
• Give extra oxygen before trach change, if necessary.
• While trach tube is held in place, cut one side of tie, gently remove trach tube
and old trach tie.
• Point curve of clean trach tube down. Slowly insert trach tube into stoma.
Remove obturator
Trach in… Obturator out…

13
• Make sure trach tube is in correctly (listen for child breathing through trach tube).
• Reconnect oxygen source, if needed.
• Hold trach tube in place until it is secured by tying ties 3 times tight (1 ½ knots).
• Check tightness of trach tie.
• Place split gauze, if needed.
If stoma tightens while inserting trach tube:
On rare occasions, some trach stomas tighten up or go into spasm during a trach
change. If this happens, go very slowly while inserting the clean trach tube.
Try the following steps:
• Remove obturator when clean trach tube is partly in the stoma.
• Replace obturator and continue to push trach tube into the stoma.
• You may have to do this more than once.
If this does not work, try to put next smaller size trach tube in.
If unsuccessful, and child is in respiratory distress or not breathing, start rescue

breathing with Ambu bag and mask over child’s nose and mouth while covering
the stoma.
Call 911
Continue to try to insert smaller size trach tube until help arrives.
These instructions are only general guidelines. Your doctor may give you
special instructions. If you have any questions or concerns, please call your doctor.

14
Changing trach ties:
Change trach ties once a day, usually after bath. This is important for preventing
irritation or rash around neck.
• Prepare fresh trach ties.
• Place a small roll under shoulders of small children.
• If possible, have someone help by holding trach

tube in place.
• Cut or untie and remove old ties. Check neck

area for rash or irritation. Clean or treat area
as needed.
• Hold trach tube in place until ties are placed on

trach and knotted.
• Secure trach with new ties. Tie ties 3 times tight (1 ½ knots) on each side.
• Check tightness of trach tie. One adult finger should fit snuggly between neck
and trach tie.
Always have emergency trach equipment within quick reach when changing
trach, trach ties, or doing stoma care.

15
Care of the stoma site:
Check and clean stoma site two times each day. This can be part of getting dressed,
going to bed, or the bathing routine. You may need to clean the skin more often if it
becomes moist, red, or infected.

• Gather supplies:
1. Clean cotton-tip applicators or clean washcloth.

2. Cleaning solution.
3. Split gauze (if needed).
• Your doctor will decide what cleaning solution to use.

(Refer to “cleaning solutions” for additional information)
• Position child by placing a small roll under shoulders.
• Remove split gauze (if present).
• Check site for redness, swelling, tenderness, bleeding, or increased drainage,

notice if there is an odor.
• Wet Q-tip with cleaning solution.
• Clean site starting at center and moving away from stoma. (see red arrow)
• Throw away dirty Q-tip. Use as many Q-tips as needed for cleaning.
• Replace new split gauze (if needed).

16
Potential problems
1. STOMA or trach tube irritation / bleeding
Always check for bleeding around stoma site and from inside trach tube. A small
amount of bleeding (pink or red streaked mucous) sometimes happens after
suctioning. Other causes include:
Causes of bleeding:
• Irritation to skin around stoma

• Low humidity to airway
• Coughing
• Too frequent, deep, or vigorous suctioning
• Suction pressure too high
• Infection
• Trauma from changing trach
• Object in airway
Call 911 immediately if you see a large amount of bleeding or if bleeding does
not stop in a few minutes.
2. Rashes
Rash around trach site may be caused by:
• Leaving a moist trach tie or wet split pad on too long

• Secretions
• Skin oozing
• Infection
Keep the site clean and dry. Daily trach tie and split pad changes often prevents or
clears up the rash.
Call your doctor if rash does not go away.

17
3. Childhood illness
Your child is just like other children and can catch colds, flu or other illnesses. Make
sure your child gets immunizations and has regular check-ups.
When your child is sick you may find:
• Fever – temperature above __________ (this may be different for each doctor)
• More mucous
• Coughing up thicker than normal yellow or green mucous
• Coughing up blood in the mucous
• Change in the smell of the mucous from bad to “foul”
• Smell is stronger and more easily noticeable
If you notice any signs of illness or infection, call your doctor.
4. Infection
REMEMBER: Good hand-washing and clean technique lowers chance of infection.
Signs of infection at stoma site:

• Red, swollen or puffy looking
• Tender to the touch
• More drainage or oozing
• Possibly a bad smell or odor
• Feverish or warm
Signs of respiratory infection:

• Increased mucous
• Thicker than normal mucous
• Increased coughing
• Mucous color changes (yellow or green)
• Odor
• Irritability
Call your doctor if you see these signs.
5. Swelling
Notify your doctor of any swelling around the stoma that does not go away.

18
Emergencies
1. Obstruction
A mucous plug or a small object (toy, food, etc.) can block or obstruct the trach
tube.
Mucous plugs develop because:
• low humidity or moisture (dry air)
• suctioning that does not clear trach tube
• trach tube not changed as scheduled
• inner cannula not changed (if child has one)
• respiratory infection (increased mucous production)
Signs of Blocked Trach Tube:
• child unusually anxious and has frightened look
• child restless or irritable
• decreased air moving in or out of trach tube
• unusual high pitched noise (whistling) during breathing
• blue or pale skin or lip color
• breathing hard
• gasping
• very noisy breathing
• breathing faster than normal
• nostrils opening wide with each breath (nasal flaring)

19
Retractions: unusual chest movement with skin sucking in with each breath.
• neck
• skin between the ribs
• skin under the breastbone
Trouble
Breathing?
Suction
No change or
Improved? getting
worse?
Suction Slightly Change trach

again, if & suction
needed
improved?
Suction No change
Continuing
to improve? Call 911
Start Rescue
Only suction if
Breathing until
needed help arrives
1. DECANNULATED TRACH TUBE (Pulled Out)
Sometimes the trach tube is accidentally pulled out. Children connected to a

ventilator or oxygen may reach for a toy and turn too far. Other causes include
falling, catching trach on something, or your child or another child pulling on
trach.

20
Signs of decannulated trach tube
• Sudden crying that you usually cannot hear

• Sudden loud coughing or choking
• Skin or lip color changes to blue or pale
• Difficult and hard breathing
• Heaving chest
• May pass out
What to do:
• Remain calm.
• Look to see if trach is out of stoma.
• Replace trach tube immediately with same trach or a clean one (if readily
available).
• Watch to make sure child is free of distress.
2. Bronchospasms
Strong muscles surround the airway. A bronchospasm occurs when airway

muscles suddenly tighten up. This makes the airway small and may lead to
symptoms such as wheezing, coughing and shortness of breath.
Bronchospasms (narrow airways) can be caused by:
• Reactive (sensitive) airways

• Temper tantrums
• Irritation to the child’s lungs such as smoke, strong smells,
fumes, or dust.
airway
Normal airway Bronchospasm

21
Signs of bronchospasms
• Little or no air moving in or out of trach tube

• Immediate blue or pale skin or lip color
• Difficulty or hard breathing
• May pass out
What to do:
Some air movement No air moving in or out of trach tube No improvement
Give breathing treatment Start rescue breathing with Ambu bag Do immediate trach
with bronchodilator medicine change
If unable to insert trach tube, go slowly as discussed in “Changing the Trach Tube”.
If still unable to insert trach tube, try smaller size trach tube. (If smaller trach is
inserted, remember to change back to correct size trach later.) Notify your
healthcare provider if unable to change back to correct size trach.
• If unable to insert smaller size trach tube, place face mask, attached to Ambu
bag, over nose and mouth with a good seal, bag child while covering stoma.
Look for child’s chest to rise with each breath. If no Ambu bag is available, begin
mouth to mouth breathing.
• Call 911 and continue rescue breathing.
Choking when eating or drinking
Sometimes a child with a trach chokes or gags when eating or drinking.
What to do:
• Sit up when eating or drinking.
• Eat and drink slowly.
• Offer smaller bites of food.
• Lean head forward to open food pipe (esophagus).
• Burp infants often during feeding.
• If vomiting occurs, turn child to side and suction trach, mouth, and nose.

22
Mucous & suctioning

Mucous, also called secretions or phlegm, is a gel-like substance made in the airways of
the lungs. Mucous helps catch and remove dust and other irritating particles in the
airways. The mucous moves dust up the windpipe so it can be either coughed out or
swallowed. Mucous in a trach tube can be coughed out or suctioned. It is important to
remove any mucous that can block breathing.
Different colors of mucous
Clear, white, cream This is normal.
Yellow, green or foul odor Infection. Call the doctor and suction as needed.
Bloody or blood streaked Not enough humidity or moisture, or may be

irritated from suctioning or infection.
Bubbly or watery Possibly too much mist from trach mask.
When to suction:
Suction the trach tube if:
• unusual high pitched noise (whistling sound) during breathing

• blue or pale fingernails or lips
• hard time breathing
• unusual chest movement
• gasping, grunting
• coarse, noisy or wet breathing ( gurgle or bubbly sounds)
• mucous is bubbling out of trach tube
• coughing frequently
• cannot cough out secretions
*Suction whenever necessary but at least twice a day.
• after waking up*

• before meals if needed (waiting until shortly after eating may cause vomiting)
• after naps if needed
• before bedtime*
Remember: Suctioning too much can cause more secretions.

23
Suction equipment
• suction machine
• canister for collection of secretions
• tubing (connects the machine to the catheter)
• suction catheters
• tap, distilled, or sterile water for rinsing catheter
Note: Sleeved catheters can be used up to 24 hours. If
mucous clogs up catheter & can’t be cleared, throw it away. Catheters with no
sleeve can be used up to 8 hours & stored in a plastic baggie after being rinsed.
Pre-measurement of suction catheter
You must know how far to insert catheter into trach tube before you suction. Suctioning
too deep can injure the airway.
How far the catheter is inserted is called “pre-measuring”.

1. Take same size and type catheter normally used for
suctioning.
(8 FR, 10 FR, 12 FR, etc.)
2. Use EXTRA same size trach tube for measuring.
3. Push suction catheter through extra trach tube until tip of

catheter is even with end of trach tube (see picture).
4. Read number on catheter where it enters top of trach tube.

You will insert suction catheter to this number each time you suction.
5. Write this number on a trach sign. This tells all caregivers how far to insert the
suction catheter when suctioning.
6. Measurements must be done for each different adapter used on trach tube. If your
child is sometimes on a ventilator, trach mask, O-Ring, or HME, you need different
measurements listed.

24
How to suction

• Attach suction catheter to suction tubing.
• Turn on suction machine.
• Apply suction to catheter to make sure
there is suction pressure. The staff will tell
you how much pressure is needed.
• Apply suction and insert catheter into trach tube to pre-measured depth.
• Twist (twirl) catheter between fingers and remove catheter within 5 seconds.
(Count: one-thousand-one, one-thousand-two, one-thousand-three…)
• You will be suctioning going into and coming out of the trach.
• It is normal to cough during suctioning and sometimes children need time to

catch their breath. Allow child to calm down between suction catheter passes.
Always watch your child to see if they need oxygen or bagging.
• Suction small amount of water through catheter to rinse out mucous.
• Each time you suction, look at the mucous:

What color is it?
How thick is it?
How much did you suction out?
This information is important to the doctor if your child becomes sick.
Remember: normal mucus is clear to white with no odor.

25
General care
Clothing
• Wear shirts that open at neck with zippers, Velcro, snaps or buttons. This allows
fast and easy access to the trach.
• Some children wear a size larger shirt to make dressing easier.
• Do not wear turtlenecks, crew necks, or any type of tight shirt that covers the
trach.
• Do not wear anything around your neck such as necklaces, beads, strings, fuzzy
collars, ties, or scarves. They can get into the trach and make it hard to breathe.
• Wash clothing and bedding before using. Keep everything as lint and fuzz free as
possible.
Weather
• Cover the trach if going outside in cold, windy, or dusty weather. This weather
can irritate the airway.
• Very hot weather can also be irritating.
• Loosely cover the trach tube with gauze or a lint-free kerchief. This warms the
air and keeps dust or dirt from irritating your airway.
• A trach bib or HME may be worn over the trach tube.
• A bandana or crocheted bib also works.

26
At home
• “Child Proof” your home according to your child’s age.
• Place small objects that can fit inside the trach tube out of reach.
• Shedding pets (dogs, cats, rabbits, hamsters, ferrets) and caged birds can be
a problem. Fur or feathers can get into the trach.
• Some children may also breathe easier if temperature in room is kept cool.
Remember the tracheostomy provides a direct route to the lungs. Things

floating in the air can be breathed directly into the lungs.
Things in air
Cigarette smoke irritates the lungs and can make breathing hard. Never allow smoking
in your home or vehicle. Smoking is also very dangerous around oxygen.
Powders, strong smells, and aerosols should not be used in the same room with your
child. Particles and fumes can cause a burning feeling and make breathing hard.
NO:
• Strong smelling perfume, cologne, cleaning products like bleach
• Aerosol sprays (hair spray, bug spray, air freshener spray)
• Dust, powder
• Fumes
• People who are sick

27
Sleeping/monitor
Your child must have their apnea monitor on while napping or sleeping at night. Infants
must also have monitor on if you are not in direct eye contact of them. Remember, you
cannot hear your child if something happens with the trach. The monitor is their “voice”.
Bathing
If water enters trach tube it goes right into lungs.
• Never leave your child alone in or near water.
• Do not let water enter trach, suction immediately if it does.
• Children splash. Wearing trach mask or HME over trach while bathing can
help prevent water from entering the trach.
• Keep bath water shallow to reduce splashing.
Play
• Kids of all ages need to play. Choose play activities and toys for your child’s age.
• Check toys for all small, removable parts that could go into the trach or mouth.
(Examples: Lego parts, small doll accessories, beads, marbles, clay, etc.)
• Stuffed toys must be lint and fuzz free.
• No sand box play.
• No swimming pools, sprinklers, water guns, water hose play, etc.

28
Communication
Your child must always have a way to call you.
• Although children with trachs cannot be heard

crying or talking, they soon figure out ways to
get our attention and let you know what they
need or want.
• Older children may place a finger over the

trach opening so they can talk, then take
their finger off to breathe. This often becomes
a habit but it can take a while to learn.
• Some children use their chin to cover the

trach opening. Words may not be as clear,
but it’s easier because both hands are free.
.
Different ways of calling and talking may include:
• Squeeze toys or bells

• Paper and pen
• Sign Language
• Speaking Valve
• Evaluation by a speech therapist may be helpful.
Babysitters
Your child must never be left alone with anyone who is not trach trained.
Family members and friends may be the best babysitters for your child. All babysitters
must learn how to:
1. suction
2. change the tracheostomy tube
3. provide CPR via trach tube
Babysitters should be included in the teaching while your child is in the hospital.
It is also possible for your home health nurse to assist in the training at home.

29
Cleaning solutions
Acetic acid (vinegar) solution for cleaning equipment
• Use clean container
• Mix 1 part white vinegar and 2 parts tap water

(half the amount of white vinegar than the amount of water)
Hydrogen peroxide solution for cleaning stoma site
• Use clean container

• Mix 1 part hydrogen peroxide and 1 part tap water
(same amount of hydrogen peroxide and water)
Note: Your doctor will decide on the stoma cleaning solution.
Normal saline
2 level teaspoons of non-iodized salt

4 cups of water
• Mix salt and water in kettle or pot.

• Gently boil the water for 5 minutes (start timing after water begins to boil).
• Remove kettle from stove. Let water cool.
• Pour salt water in sterile jars. Keep jars tightly closed.
• Label jars “normal saline” and date & time prepared.
• Place in refrigerator. Saline is good for 24 hours.
• Small amount of normal saline can be kept in a jar at the bedside.
• Use new jar of normal saline every 12 hours.
• You may want to cut ingredients in half if refrigerated saline is not used up in 24
hours (1 level teaspoon of non-iodized salt and 2 cups of water).

30
Sterilize water
• Put water in kettle or pot.

• Boil water for 5 minutes (start timing after water begins to boil).
• Remove kettle from stove. Let water cool.
• Put water in sterile jars. Keep jars tightly closed.
• Label jars “Sterile Water” and date & time prepared.
• Place in refrigerator. Sterile water is good for 24 hours.
• Small amount of sterile water can be kept in a jar at bedside.
• Use new jar of sterile water every 12 hours.
Sterilize jars and lids
• Put jars & lids in a large pot. Cover with water.

• Boil water for 5 minutes (start timing after water begins to boil).
• Remove pot from stove. Let water cool.
• Remove jars & lids with tongs. Do not touch the inside of jar or lid.

31
Care of the trach tube
Cleaning
We clean both the Bivona and Shiley trach tubes and obturators with a mild soap and
water solution. Do not leave obturator inside trach tube during cleaning and disinfecting
process. Clean inside and outside of the trach tube using a trach brush or pipe cleaner.
You may need to soak the trach tube in cleaning solution for several minutes to help
remove all secretions. Rinse well with water after cleaning.
Disinfecting (Sanitizing)
Soak the Shiley trach and obturator in ½ strength hydrogen peroxide solution for 30
minutes, rinse well with sterile water, and place on clean towel to air dry.
Place Bivona trach and obturator in pan of rapidly boiling water. Cover pan and remove
from heat. Allow water to cool, at least 20 minutes. After cooling, place trach and
obturator on clean towel to air dry.
Important: Make sure the trach tube is safe to use on your child. Always check the trach tube and
obturator, during cleaning, for any nicks or cracks.

32
What is nebulizer therapy (breathing treatment)?
Nebulizer therapy sends medicine deep into the lungs. Medicine for the lungs works
best when it is breathed in as a fine mist.
Examples of common medicines used in nebulizers:
• Bronchodilators help relieve wheezing or coughing (ex: Albuterol or Xopenex).

• Anti-inflammatory medicines help prevent swelling in the airways (ex: Pulmicort).
Nebulizer equipment
The most common nebulizer system sends a stream of air through liquid medicine to
create a fine mist. The nebulizer has 2 main parts:
1. Plastic nebulizer kit with cup for liquid medicine.

2. Air compressor.
Air
compressor
Nebulizer
kit
Electric
cord
Air tubing
There are many different companies that make portable nebulizers. Always read and
follow the company’s instructions.

33
Setting up equipment
If possible, find a quiet area in your home for treatments. It’s important to take your
treatment comfortably and without interruption.
Always remember … Good Hand Washing is the way to stop the spread of germs!
Always wash your hands before touching nebulizer equipment.
• Place air compressor on clean, flat surface near electrical outlet.

• Plug in compressor.
• Connect air tubing to compressor.
• Measure prescribed amount of medicine and place in clean nebulizer cup. Top of
nebulizer cup may be removed for easier access.
• Turn compressor on and check for mist.
.
Taking a nebulizer treatment
• If possible, position child in an upright position.

• Place trach mask, with nebulizer cup attached, over trach.
• Turn on compressor and begin treatment.
• Keep nebulizer cup upright.
• Treatment usually takes 10-15 minutes, depending on amount of medicine in
nebulizer cup.
• When nebulizer cup begins to sputter, shake or tap it once or twice.
• If it continues to sputter, treatment is done.
Note: There are many different nebulizer medicines. Call your pharmacist, home health
nurse, or doctor for medicine questions or concerns.

34
Care of nebulizer kit
• Take nebulizer cup apart.

• Wash all parts (except air tubing) in warm soapy water, including mask.
• Rinse with clean water.
• Shake off excess water and allow to air dry.
• Once dry, store in a clean bag.
Clean nebulizer kit once a week, using either of these methods:
• Boil in water for 5 minutes

• Wash in dishwasher
An optional method of cleaning is to soak nebulizer in a bleach solution (1:50):

• Make a solution of 1 tablespoon of bleach and 3 cups of water. Always use a
fresh solution.
• Soak all parts of nebulizer kit and mask for 3 minutes (do not soak air tubing).
• Rinse with clean water.
• Shake off excess water and allow to air dry.
• Discard bleach and water solution.
Care of the air compressor
• Wipe off compressor with a damp cloth.

• Check filter monthly and replace when it can no longer be cleaned.
• Read and follow manufacturer's directions for care of compressor.
Troubleshooting and safety
• ALWAYS keep a spare nebulizer kit on hand.

• Before using, check nebulizer parts for cracks or possible caking of residue
inside.
• Do not block air inlet of compressor.
If treatment is longer than 10 or 15 minutes, check mist output.

• nebulizer may be clogged
• compressor filter may be dirty which will obstruct air flow from compressor
If treatment is shorter than normal, check to see if medicine is leaking out of nebulizer.

35
Frequently asked questions

1. Are treatments better when child is crying?
Treatments are better when child is calm. However, crying may trigger coughing
which may help clear loose secretions.
2. Is it normal for children to cry, kick and scream when first beginning breathing
treatments?
Younger children may not enjoy breathing treatments and need special time and
attention during the treatment.
3. Is it unusual for a child to vomit after crying hard?

Crying children swallow air and mucous. Crying and coughing can stimulate the gag
reflex and cause some vomiting. If this happens often, call your doctor.
4. How do I know when to give treatments as needed (prn)?

Always discuss treatment plan with your doctor. Treatments are based on type of
medicine and your child’s symptoms.
5. Can someone in the house smoke during the treatments?

Do not allow anyone to smoke in your house or car at any time! Secondhand
smoke is very dangerous to everyone’s lungs.

36
Additional resources:
American Journal of Respiratory and Critical Care Medicine 2000 Vol. 161: 297-308
www.atsjournal.org
ATS Patient Education Series 2006 American Thoracic Society

www.thoracic.org
Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008

www.cdc.gov
Shiley Parent’s Guide to Pediatric Tracheostomy Home Care 2005

www.nellcor.com
Smiths Medical
www.smiths-medical.com
The Transitional Care Unit, Cook Children’s Medical Center, Fort Worth, Texas
C. Elizabeth Barriteau, BS, RRT, AE-C

Respiratory Patient/Family Education Coordinator
Cook Children’s Medical Center
Fort Worth, Texas

37
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Pediatric Trach

About This Book .......................................................................... 4

General Information ..................................................................... 5

Emergency Equipment ................................................................ 6

Passy-Muir Speaking Valve ......................................................... 9

Air Humidity .................................................................................. 9

Changing Trach Tube ................................................................ 12

Changing Trach Ties .................................................................. 14

Care of the Stoma Site ............................................................... 15

Potential Problems ..................................................................... 16

REVISION DATE: May 2010

Cleaning Solutions .................................................................. 29

Care of the Trach Tube…………………………………………...31

What is Nebulizer Therapy ...................................................... 32

Frequently Asked Questions .................................................. 34

Additional Resources .................................................................. 35

REVISION DATE: May 2010

Please ask us questions

REVISION DATE: May 2010

• The word Tracheostomy is often

• Trach tubes may be temporary and

• There are many different types of trach

• The opening into the trachea is called

• The air you breathe goes in and out of

• Over time some children will be able to

Why I need my trach tube:

REVISION DATE: May 2010

Emergency equipment you must always have with you:

6. Suction equipment with correct size

Trach tube parts

There are four types of trach tubes:

Trach sizes are: neonatal (NEO), pediatric (PED) or adult.

REVISION DATE: May 2010

Types of trach tubes

Single Cannula Neonatal or Pediatric Trach Tube

Double cannula trach tube

• When changing a double cannula trach tube, remove

Cuffed trach tube

Shiley® cuffed single cannula trach

REVISION DATE: May 2010

Fenestrated trach tube

What type of trach tube do I have? ________________________________________

REVISION DATE: May 2010

Passy-Muir speaking valves

Children with trachs cannot make sound when they cry or

Passy-Muir speaking valves

Air humidity (moisture)

REVISION DATE: May 2010

Humidity in the lungs can be raised or lowered by:

• Amount of fluids you drink.

Moisture for trach tube

REVISION DATE: May 2010

Room/home humidifiers: Room humidifiers are not usually recommended. It is best to

Why do I need moisture? _______________________________________

What am I going to use? ________________________________________

REVISION DATE: May 2010

Changing trach tube

• Wash your hands.

Trach in… Obturator out…

REVISION DATE: May 2010

• Reconnect oxygen source, if needed.

• Check tightness of trach tie.

• Place split gauze, if needed.

If stoma tightens while inserting trach tube: