Tracheostomy Care Best Practice 2008 Scotland

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Best Practice Statement ~ September 2008
Caring for the child/young person

with a tracheostomy
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NHS Quality Improvement Scotland is committed to equality and diversity. We have assessed this
Best Practice Statement for likely impact on the six equality groups defined by age, disability,
gender, race, religion/belief and sexual orientation. For a summary of the equality and diversity
impact assessment, please see our website (www.nhshealthquality.org). The full report in
electronic or paper form is available on request from the NHS QIS Equality and Diversity Officer.
© NHS Quality Improvement Scotland 2008
ISBN 1-84404-522-6
First published September 2008
You can copy or reproduce the information in this document for use within NHSScotland and for
educational purposes. You must not make a profit using information in this document.
Commercial organisations must get our written permission before reproducing this document.
www.nhshealthquality.org
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Contents
Introduction 2
Key stages in the development of best practice statements 3
Best practice statement: caring for the child/young person with a
tracheostomy 4
Section 1: Education and training 5
Section 2: Communication 8
Section 3: Swallowing and nutrition 10
Section 4: Stoma care 12
Section 5: Tracheostomy tube management 14
Section 6: Suctioning 20
Section 7: Humidification 22
Section 8: Therapeutic Play Interventions 25
Appendix 1: Number of tracheostomies in children/young people

in Scotland 27
Appendix 2: Contraindications for speaking valve use 28
Appendix 3: Factors which may affect communication 29
Appendix 4: Factors which may affect swallowing 30
Appendix 5: Tracheostomy tube table 31
Appendix 6: Sizing chart for paediatric airways 32
Appendix 7: Decannulation 33
Appendix 8: Discharge checklist 35
Appendix 9: Minimal occlusion technique 37
Appendix 10: Tracheostomy suction procedure in paediatrics 39
Appendix 11: Illustrations 41
Appendix 12: Audit tool 44
Glossary 50
References 54
Who was involved in developing and reviewing the statement? 63
Caring for the child/young person with a tracheostomy
Introduction
NHS QIS’ vision is of an NHS that achieves excellence in the care of every
patient every time. It leads the use of knowledge to promote improvement
in the quality of healthcare for the people of Scotland and performs three
key functions:
• providing advice and guidance on effective clinical practice, including

setting standards
• driving and supporting implementation of improvements in quality, and
• assessing the performance of the NHS, reporting and publishing the
findings.
In addition, NHS QIS also has central responsibility for patient safety and
clinical governance across NHSScotland.
A series of best practice statements has been produced within the Practice
Development Unit of NHS QIS, designed to offer guidance on best and
achievable practice in a specific area of care. These statements reflect the
current emphasis on delivering care that is patient-centred, cost-effective
and fair. They reflect the commitment of NHS QIS to sharing local
excellence at a national level.
Best practice statements are produced by a systematic process, outlined

overleaf, and underpinned by a number of key principles.
• They are intended to guide practice and promote a consistent, cohesive

and achievable approach to care. Their aims are realistic but
challenging.
• They are primarily intended for use by registered nurses, midwives,
allied health professionals, and the staff who support them.
• They are developed where variation in practice exists and seek to
establish an agreed approach for practitioners.
• Responsibility for implementation of these statements rests at local
level.
Best practice statements are reviewed, and, if necessary, updated after 3
years in order to ensure the statements continue to reflect current thinking
with regard to best practice.
2
Key stages in the development of best practice statements
Topic selection and Scoping Process
Review literature on topic. Establish working group. Establish reference group to

Source grey literature. advise on consultation
Ascertain current policy and legislation. drafts.
Seek information from manufacturers,
voluntary groups and other relevant
sources.
Determine focus and content

of statement.
Review evidence for
relevance to practice.
Determine how patients’
views will be incorporated.
Review and update process.

Identify new research/findings
affecting topic. Draft document sent to reference group.
Consider challenges of using Wide consultation process.
statement in practice.
Review and revise

statement in light of
consultation comments.
Feedback on impact
of statement is
sought/ impact
evaluation.
Publish and disseminate
statement.
3
Best Practice Statement: Caring for the child/young person

with a tracheostomy
In 2003, NHS QIS published the best practice statement caring for the
patient with a tracheostomy1, which was relevant to adults and
children/young people with a tracheostomy. NHS QIS has a commitment to
review and, if necessary, update best practice statements every 3 years,
therefore, an updated best practice statement of the same name was
published in 20072. However, during the review process the working group
agreed that separate guidance for tracheostomy care was required for both
adult and children/young people as the two varied greatly. Therefore the
2007 best practice statement focused on adult services only and a working
group was convened to develop a separate best practice statement for
healthcare professionals caring for a child/young person with a
tracheostomy. As with the original, this statement does not refer to care of
children/young people with a laryngectomy.
The reasons that children/young people may require a tracheostomy can

be put into three broad categories: airway obstruction, unsafe
airway/airway compromise and need for long-term ventilation. More
specifically this can be due to trauma, burns, birth defects, inability to
breath without a ventilator, neurological problems, neuromuscular
problems, problems with the lungs (broncho/trachea malacia,
bronchopulmonary dysplasia), or spinal injury.
The care of a child/young person with a tracheostomy is a highly skilled

process requiring the knowledge and expertise of a multidisciplinary team
including dietitians, physiotherapists, play specialists, specialist nurses,
speech and language therapists and trained carers. The membership of the
working group convened to develop the statement reflects this.
The working group recognises that the best practice statement focuses on
the physical care of the child/young person with a tracheostomy and that
psychological support for the child/young person and their parents/carers
may also be required.
A section has been included in this statement to highlight the importance

of play interventions, and although it is included in this best practice
statement for tracheostomy care, the group feels that it could be adapted
for other specialties. An audit tool has also been developed to support
healthcare professionals and organisations that would like to audit current
local practice and is included as an appendix and available on the NHS QIS
website to download (www.nhshealthquality.org).
4
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Section 1: Education and training
Key points:
1 There are a number of children/young people with a tracheostomy both in hospital and in the community. NHS boards have a responsibility
towards these children/young people and their families/carers and also for preparing healthcare professionals to care for them.
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2 A family-centred approach, good communication skills and technical competence are required to care for, assure and assist children/young
people and their families/carers in adapting to, and managing, a tracheostomy.
3 Children/young people and their families/carers require education and support in adapting to, and living with, a tracheostomy
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Statement Reasons for statement How to demonstrate statement is being achieved
Healthcare professionals caring for a child/young person Healthcare professionals need to be equipped with the There are local training and education opportunities for
with a tracheostomy have access to: appropriate knowledge and skills to meet the unique needs healthcare professionals to meet local need.
• education and training to meet local need, and of these children/young people and their families/carers
There are local protocols or guidelines to support healthcare
• standardised local protocols or guidelines developed by competently and effectively.
professionals caring for the child/young person with a
local specialists and the multidisciplinary team with input
tracheostomy.
from children/young people and their families/carers.
Healthcare professionals who come into contact with a It is a professional responsibility to be able to address There is documented evidence of education provided to
child/young person with a tracheostomy (no matter how children/young people’s needs competently. develop and update knowledge of healthcare professionals
infrequently) understand: working with children/young people with a tracheostomy.
• the particular indications for tracheostomy
• risks associated with a tracheostomy
• potential complications with a tracheostomy
• the types of tubes and equipment involved in each case,
and
• the importance of standard infection control precautions
(SICPs).
Healthcare professionals and parents/carers who are in It is the professional responsibility of healthcare professionals Audit of resuscitation training specific to children/young
contact with a child/young person with a tracheostomy to ensure they and parents/carers are prepared and people with a tracheostomy which is tailored to local need.
have access to, and receive, training on routine and competent to deal with emergency situations. There is documented evidence that resuscitation training
emergency airway management for children/young people specific to children/young people with a tracheostomy is
with a tracheostomy. provided to families/carers.
Staff personal development plans identify resuscitation
training requirements for relevant professionals.
Key staff identified locally as competent are readily available
to attend to emergencies.
5
6

Healthcare professionals know when to seek, and have Professional expertise/judgement/knowledge is required to There is evidence of clear lines of communication and
access to, professional advice and assistance from relevant identify the point at which it is appropriate to seek specialist agreed arrangements between the different healthcare
specialists on: advice, for example from physiotherapists, dietitians, and professionals who may be required to provide care for the
4/9/08
• complex nutrition speech and language therapists based on the individual child/young person with a tracheostomy.
• chest physiotherapy child/young person’s needs.
• infection prevention and control
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• speech, language and communication
• resuscitation
• specialist equipment requirements
• child development
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• airway/respiratory nursing, and
• play.
Healthcare professionals maintain competency in caring for It is a professional commitment to maintain competency.3,4 There is evidence of attendance at competency-based
a child/young person with a tracheostomy. training and education provision for relevant healthcare
professionals.
Personal development plans reflect the level of competency
achieved or required.
Prior (where possible) to a tracheostomy being performed, In addition to care, healthcare professionals are instrumental Records of information given to children/young people and
education and reassurance of the child/young person and in inspiring confidence and offering support to families/carers at particular stages of the patient journey are
their parents/carer starts and continues through the patient children/young people with a tracheostomy and their audited to demonstrate that appropriate information is
journey. families/carers. conveyed effectively.
The education of children/young people and their Families/carers of a child/young person with a tracheostomy The families/carers of children/young people with a
families/carers, to know how to access ready advice and who receive adequate education and support, as well as tracheostomy in the community have contact details of the
support, is necessary if children/young people with a equipment, supplies, follow up, etc can be safely cared for local and/or specialist team.
tracheostomy are to live successfully in the community. out of hospital to live in the community.5-7
The education of families/carers and education staff and Children/young people with a tracheostomy have the right There is evidence of attendance at local training and
access to ready advice and support is necessary if to access full-time education. education for healthcare professionals to meet local need.
children/young people with a tracheostomy are to safely
Records of information given to children/young people,
achieve full-time education in school.8
families/carers and education staff at particular stages of the
patient journey are audited to demonstrate that appropriate
information is conveyed effectively.
An additional support plan should be developed for nursery It is important to ensure that everyone coming into contact Additional support plans are audited to ensure that
and school pupils to identify the level of support that is with the child/young person with a tracheostomy is aware appropriate support for the child/young person is provided.
required in those environments. This will include emergency of their needs.
4/9/08
guidelines.
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Key challenges:
1 Development of local policies/guidelines relating to tracheostomy education and training.
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2 Sharing education and training information with the acute and community multidisciplinary team.
3 Identification of the education and training needs of a diverse group of healthcare professionals, children/young people, families/carers and
others in hospital and the community and addressing these needs within resource constraints.
4 Raising awareness of the specific resuscitation requirements of children/young people with a tracheostomy.
5 Closer liaison/working between health and education and social work (if appropriate).
7
8

Section 2: Communication
Key points:
1 The impact of the loss of normal voice following tracheostomy should not be under-estimated and whenever possible children/young people and
their families/carers should be prepared for this.
4/9/08
2 The speech and language therapist has a key role in the care of children/young people with a tracheostomy.9
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Healthcare professionals need to be knowledgeable about Children/young people with a tracheostomy may have There is documented evidence of in-service education to
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communication problems associated with children/young communication problems that affect their ability to interact develop and update knowledge of healthcare professionals
people with a tracheostomy. and be involved in their own care. working with children/young people with a tracheostomy,
including communication.
Involvement of children/young people/carers is vital in
supporting the child/young person.
The child/young person’s key worker involves the speech Speech and language therapists have clinical expertise in There is documented referral to the speech and language
and language therapist. Ideally assessment starts pre- assessment and management of communication difficulties. therapist.
operatively for elective tracheostomies.
The speech and language therapist will assess the Timely assessment allows for early intervention planning to There is documented evidence of specific records provided
communication skills of the child/young person, dependent facilitate the best means of communication and to reduce by the speech and language therapist following assessment
on the age and ability of the child/young person. the risk of possible future difficulties including the to allow the child/young person to develop the best way to
acquisition and development of speech, language and communicate to meet their needs.
communication skills.
The speech and language therapist implements and Children/young people with a tracheostomy may have The speech and language therapist uses ongoing
evaluates the communication record specific to a complex communication needs which require a assessment to update communication programmes in the
child/young person’s needs and reviews it at regular combination of approaches to minimise problems. This may child/young person’s record.
intervals or when health needs change. include appropriate alternative or augmentative
communication systems.10
Equipment and training should be available for hospital and
home to assist with communication if age and ability
appropriate, eg baby intercoms, sign language.
The acute speech and language therapist is responsible for To ensure continuity of communication support by giving Referral is documented in the child/young person’s record.
referring the child/young person to the community speech timeous referral to allow local services to plan ahead.
and language therapy service.
4/9/08
If clinically indicated11 (see Appendix 2), speaking Speaking valves/tracheostomy valves can be extremely A formal assessment is carried out by a speech and
valves/tracheostomy valves should be considered for effective with children/young people to improve voicing language therapist along with the child/young persons
11,12
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children/young people, and even young babies. and in babies by encouraging vocalisation at the pre-speech clinical nurse specialist and the results documented in the
development stage.11 child/young person’s record.
The decision to consider a speaking valve should be a
multidisciplinary one, as not all children/young people will The use of a one way-speaking valve allows air to be inhaled There is a documented protocol within the multidisciplinary
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tolerate its use.11,13 via the valve but exhaled up over the larynx allowing for team on the use of speaking valves/tracheostomy valves. An
voice to be produced. The presence of air leak around and individualised advice sheet is given to each child/young
above the tracheostomy tube is necessary for this to person, parent/carer and is included in the child/young
happen. persons record.
Speaking valves should not be used with a cuffed
tracheostomy tube or whilst asleep.
Key challenges:
1 Development of guidelines and protocols relating to communication of children/young people with a tracheostomy, to encompass the specific needs
of children/young people.
2 Sharing of information with the acute and community multidisciplinary team about the child/young person’s communication.
3 Provision of in-service education with the support of local speech and language therapists to develop knowledge of tracheostomy communication
issues.
4 A multidisciplinary approach with the involvement of families and carers and secondary and tertiary centres is required to manage
communication issues for children/young people with a tracheostomy.
5 Additional resources are required to provide any communication aids that may be needed, to provide support in the community/home and at
nursery/school and to provide continuing education to all involved in the care of children/young people with a tracheostomy.
6 Assessment by appropriately skilled healthcare professionals needs to be ongoing as children/young people’s needs change with development.
7 Ensuring that access to specialist advice and support is available particularly for those children/young people with complex communication needs.
8 Effective discharge planning is needed to facilitate a smooth transition into the community.
9
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Section 3: Swallowing and nutrition
Key points:
1 The presence of a tracheostomy tube may impair swallowing with increased risk of aspiration.
2 An impaired swallow may compromise the child/young person’s nutritional status. Healthcare professionals have an important role in the
4/9/08
provision of good nutritional care for children/young people with tracheostomies.
3 Swallowing difficulties may be due to many factors (Appendix 4).
4 Children/young people with a tracheostomy may experience loss of appetite due to the altered airway, which causes reduction in the ability to
01:09
smell and taste.
5 The speech and language therapist should implement an oro-motor programme for the child/young person who is non-orally fed in order to
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normalise sensation and maintain and promote skills.10 A child/young person who is non-orally fed can become orally hypersensitive resulting
in possible future behavioural feeding difficulties.14
Healthcare professionals and parents/carers, working Multidisciplinary management offers an efficient and There is documented evidence of the in-service education,
together to provide a multidisciplinary team approach, are co-ordinated way of dealing with any nutritional or including nutrition issues, provided to develop and update
knowledgeable about nutritional and swallowing problems swallowing difficulty. the knowledge of healthcare professionals and
associated with children/young people with a tracheostomy. parents/carers working with children/young people with a
tracheostomy.
Speech and language therapists undertake an initial If difficulty with swallowing is identified, early potential Where an impaired swallow is identified, additional
assessment of swallowing function, including first gathering problems can be minimised. appropriate investigations may be undertaken following
relevant information from the multidisciplinary team, and Royal College of Speech and Language Therapists (RCSLT)
Speech and language therapists are knowledgeable in the
recognise when to involve the dietitian. clinical guidelines.10
assessment of the swallow. It is essential to carry out the
The assessment should be carried out along with the assessment along with the nurse who is knowledgeable in The referral and outcome of the speech and language
child/young person’s nurse. suctioning and emergency procedures. therapy assessment is recorded in the child/young person’s
record.
Dietitians undertake the nutritional assessment of the Children/young people have particular needs that require The referral and outcome of the nutritional assessment is
child/young person with identified impaired swallow. expert intervention to maintain nutritional status. recorded in the child/young person’s record.
Children/young people’s needs will change as they develop.
Following assessments, healthcare professionals plan, A clear prescription of nutritional requirements specific to The individualised nutritional plan is documented in the
implement and evaluate a nutritional record specific to the each individual child/young person is required to ensure child/young person’s record.
child/young person’s needs and provide ongoing reviews. that adequate nutrition is received safely.
For nasogastric and gastrostomy feeding, best practice
guidelines should be followed.14
Oral hygiene should be maintained through regular oral Good oral health will assist effective nutrition.15,16 Evidence of good oral health is documented in the
care. child/young person’s record.
Oral bacteria and poor oral hygiene seem to influence the
incidence of pulmonary infections.17
4/9/08
Children who receive reduced or no oral feeds require
moisture to prevent their mouth becoming dry.14
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If the child/young person has a cuffed tube, swallowing Indications for cuffed tubes are limited in paediatrics and There is documented evidence of a protocol for the
should be assessed with the cuff deflated and only following may be used to manage severe aspiration of secretions or multidisciplinary team to follow in making any decision to
medical clearance to do so.18 significant difficulties with ventilation.20 assess the swallow if a cuffed tube is present which should
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be recorded in the child/young person’s record.
Assessment should be done along with multidisciplinary There may be dysphagia present secondary to the primary
team members able to deflate/inflate tube, suction, modify medical diagnosis.21 There is a detailed protocol for cuff deflation to follow when
ventilation settings, etc.19 assessing the swallow as well as a record of the routine
If the medical condition requires a cuffed tube because of
swallow assessment recorded in the child/young person’s
the danger of severe aspiration then oral feeding should not
record.
be considered.22
Key challenges:
1 Development of guidelines and protocols relating to nutrition of children/young people with a tracheostomy, and multidisciplinary referrals.
2 Sharing swallowing and nutrition information with the acute and community multidisciplinary team.
3 Provision of in-service education and written information (with the support of the speech and language therapy and dietetics departments) to
develop knowledge of tracheostomy nutrition issues for all healthcare professionals and parents/carers.
4 Development of readily accessible swallowing assessment services, including access to videofluoroscopy.
5 Development of guidelines and information to support transition from hospital to community care.
11
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Section 4: Stoma care
Key points:
1 Children/young people with a tracheostomy are at increased risk of infection and granulation tissue formation of the stoma site.
2 Effective nursing management of the stoma will aid the prevention of peristomal infection and irritation.
4/9/08
3 A well-formed tracheal tract will be evident about 5 days post operatively; sutures can usually be removed 5–10 days after the procedure.23,24
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All healthcare professionals involved in tracheostomy To increase clinical skill and knowledge of stoma Documented programmes relevant to clinical need and to
management are provided with education on stoma management. individual requirements are available.
management.
Healthcare professionals are able to demonstrate clean
stoma care.
All children/young people with a tracheostomy stoma Tracheostomy stomas are a potential avenue for respiratory Incidence of peristomal infection in children/young people
should have frequency of stoma care individually assessed tract infection. with a tracheostomy is kept to a minimum.
with care undertaken at least daily25 using clean technique.
Clean technique is advocated as the skin is contaminated
with organisms.26
All children/young people should have an evaluation of To allow ongoing assessment of the stoma. There is documented evidence of stomal condition in the
stomal condition documented in their record and an child/young person’s record and local policies/guidelines are
To assist sharing clinical findings.
appropriate plan of care initiated. available.
The stoma should be cleaned as per local policy. A non-irritant solution is used to clean the skin and tracheal Evidence that healthcare professionals are aware of when to
mucosa. apply barrier film and methods to encourage wound
A barrier film should be applied to the surrounding skin if
healing.
clinically indicated. To protect the skin from tracheal secretions and
encouragement of wound healing.
Cotton wool must not be used to cleanse around the stoma.
Risk of inhalation from fibres.
Use of dressings around the healthy stoma site is Tracheostomy tubes have soft flanges (except silver tubes) Documented evidence that healthcare professionals are
unnecessary, unless clinically indicated, in which case there that do not require a dressing between the tube and the knowledgeable in the types of dressings available and able
are specifically designed tracheostomy dressings available. skin. Dressings provide an ideal environment for bacterial to identify the most appropriate one based on clinical
colonisation. need.
Devices securing the tracheostomy tube should be checked To reduce the incidence of accidental tube dislodgement. Evidence of securing device being checked is documented
regularly for security. in the child/young person’s record.
Parents/carers and children/young people (age appropriate) Parents/carers/children/young people are aware of Local policies and guidelines are available on how to teach
are taught to manage stoma care prior to discharge. importance of keeping stoma clean. parents/carers/children/young people (age appropriate) to
manage stoma care.
Confidence in parents/carers and independence in
4/9/08
children/young people with a tracheostomy. There is documented evidence that the
parent/carer/child/young person has been taught to care for
their stoma.
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Observe tracheostomy site for signs of over granulation. Minimise risk of external obstruction of the stoma. Education of healthcare professionals and parents/carers to
Treat over granulation appropriately. recognise granulation.
Reduce risk of local bleeding and infection.
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• antibiotic ointment/antifungal/steroidal cream
Local guidelines.
• silver nitrate stick, and Optimise potential decannulation.
• laser. Document of affected area, treatment and result.
Healthcare professionals and parents/carers understand the Hand hygiene is considered to be the single most important Local infection control policies and guidelines are available
potential sources of micro-organisms and the need for good practice in reducing the transmission of infectious agents.27 to teach parents/carers/children/young people (age
hand hygiene before and after touching the site. appropriate) the potential sources of infection.
Evidence of infection control training packages/materials.
Key challenges:
1 Development of local policies/guidelines relating to tracheostomy stoma care.
2 Sharing stoma care information with the acute and community multi-disciplinary team.
3 Provision of educational resources to develop new skills and teach/supervise less experienced staff/carers.
4 Development of evidence to support current practice.
13
14

Section 5: Tracheostomy tube management
Key points ~ General tube management
1 There is a variety of tracheostomy tubes available. Tracheostomy tubes are made from either polyvinyl chloride (PVC), silicone or silver. All fit
into the following categories: neonatal; paediatric and adult sizes; cuffed/uncuffed; fenestrated/unfenestrated; double/single cannula;
minitracheostomy; and those with an adjustable flange. Each tube type requires specific management.*
4/9/08
2 Some styles of adult tracheostomy tubes have inner cannulae (see Appendix 11).
3 Effective tube management combined with suction and humidification can reduce the incidence of complications in the child/young person
01:09
with a tracheostomy and is integral to the reduction of clinical risk.
4 Parents/carers and the child/young person (age/ability appropriate) should be confident and competent in tube management prior to discharge
Page 14
from hospital.
Individual assessment of the most appropriate tube should Consideration needs to be given to: There are local policies and guidelines on appropriate tube
be made by the multidisciplinary team. • the clinical need/reason for tracheostomy selection available.
• the amount of secretions
Training and education on tube selection is provided and
• whether radiotherapy is required, and
recorded.
• whether magnetic resonance imaging (MRI) is required
(see Appendix 5)
It is essential practice for the child/young person to have To facilitate a child/young person’s airway in the event of an There are local policies and guidelines on emergency airway
another tube, of the same size and type as well as a tube obstructed or accidentally decannulated tube. management.
one size smaller available at all times.
Documentation of tubes available recorded in the
child/young person’s records.
Ongoing education on emergency airway management is
provided and documented.
If the child/young person is using a single cannula tube it To minimise the risk of airway obstruction and infection. Local policies/guidelines are available on tracheostomy tube
should be changed at least once a week. This should be replacement in line with manufacturer’s guidelines and a
assessed on an individual basis as children/young people written record of serial numbers and dates replaced. This
may require more or less frequent changes.28 should be documented in child/young person’s record.
Ongoing education on tracheostomy tube replacement is
provided to healthcare professionals and documented.
* Tracheostomy tubes are commonly referred to by the name of the manufacturer, eg Shiley, Portex or Kapitex.
Illustrations of available tubes are provided in Appendix 11.
Routine tracheostomy tube changes should not occur The tracheostomy tube change procedure may cause Documented evidence of education of healthcare
immediately before or after eating. coughing/gag reflex/vomiting. professionals and parents/carers in safe routine
tracheostomy tube management.
4/9/08
The first tube change is a high risk procedure and should The time delay allows a tract to become established within There are local guidelines and policies on management of
be undertaken under medical direction. This takes place 5–7 the trachea, therefore, minimising the risk of stomal closure the tube including information on the frequency of tube
01:09
days after the surgical procedure.23 on tube removal. changing.
A note should be made of the technique used to form the Stitches and type of suturing will affect care. Documented evidence of stitching and type of suturing in
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tracheostomy, size and style of tube and, in particular, the child/young person’s record.
whether the trachea is stitched up to the skin.
All children/young people with a tracheostomy have tubes Tubes in situ are a potential reservoir for pathogenic Local policies/guidelines are available on how tracheostomy
cleaned or replaced as appropriate following manufacturer’s bacteria. tubes are cleaned. These are in line with manufacturer’s
guidelines and in line with infection control policies. guidelines, local infection control and decontamination
policies.
Local policies/guidelines are available on tracheostomy tube
replacement in line with manufacturer’s guidelines and a
written record of serial numbers and dates replaced.
Brushes are not used on plastic tubes unless specifically Brushes may cause damage to the lining of the tube. Documented the child/young person’s record.
recommended by the manufacturer.
15
16

In addition to standard resuscitation equipment, all To ensure appropriate equipment is available in an Children/young people with a tracheostomy have their own
children/young people with a tracheostomy require the emergency. emergency equipment with them at all times.
following equipment (which is checked at least daily) to be
Local policy/guidelines are available on equipment which is
4/9/08
readily accessible for emergency procedures:
to be readily accessible in an emergency.
• a tracheostomy tube the same size as the child/young
person has in situ Accessibility of equipment required in an emergency is
• a tracheostomy tube a size smaller than that in situ documented in the child/young person’s record.
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• if a cuffed tube in situ - a cuffed tracheostomy tube and Use of a larger syringe as part of the resuscitation
an uncuffed tracheostomy tube the same size as in situ equipment may pose a risk of over inflation of a cuffed
plus a 10ml syringe tracheostomy tube and subsequent damage to the trachea.
Page 16
• securing devises
• stitch cutters (prior to first tube change)
• scissors
• manual resuscitation bag
• appropriately sized face mask (to fit manual resuscitation
bag) if clinically indicated
• air-tight waterproof tape (to occlude tracheostomy stoma
if unable to insert tube and need to perform basic life
support via face mask)
• suction machine
• appropriately sized suction catheters
• gloves
• tracheal dilators prior to first tube change in an ITU
setting, and
• alcohol based hand rub.
All children/young people for whom decannulation is To facilitate safe and effective decannulation. There are local policies and guidelines on the decannulation
considered should be individually assessed by the procedure.
multidisciplinary team.
Close monitoring and observation of the child/young To allow early detection of any difficulties throughout the There are local policies and guidelines on the decannulation
person’s airway and respiratory status occurs throughout the process. procedure available.
decannulation process.
The decannulation procedure is documented in the
child/young person’s record.
All children/young people must have their emergency To ensure that emergency equipment is available to manage There are local policies and guidelines on the decannulation
equipment with them at all times during the decannulation any airway and respiratory difficulties. procedure available.
process.
The decannulation procedure is documented in the
Key points ~ Cuffed tracheostomy tubes
1 Cuffed tubes are useful for reducing aspiration and minimising air leakage during ventilation.
2 Cuffed tubes come in a variety of styles – air cuff, water cuff, foam cuff. Each cuff type requires specific management.
3 Appropriate management of a cuffed tube can prevent damage to the tracheal mucosa.
4 Tracheostomy tubes have a low-pressure cuff that removes the need to deflate the cuff on a regular basis.
4/9/08
5 In some styles of cuffed tubes a manometer should be used to measure cuff pressure, by staff competent in manometer use.
01:10
Page 17
Most tracheostomy tubes with a cuff have high volume, low The pressure of the cuff is dissipated over a wider surface Local protocols or guidelines on recording of cuff pressure
pressure cuffs. The cuff should be inflated to the minimal area. are available.
desired occlusion volume.
To prevent trauma to the mucosal wall.29 Competency of staff to undertake the technique of minimal
occlusion volume (MOV) (see Appendix 9).
Cuffed tracheostomy tubes that have air cuffs should have Cuff pressure above 30cmH2O may cause damage to the Local protocols or guidelines on recording of cuff pressure
cuff pressure checked at least once daily maintaining tracheal mucosa. If the pressure is below 15cmH2O, are available.
pressure between 15–25cmH2O using a manometer.30 aspiration may occur.
Competency of healthcare professionals to undertake the
role is assessed.
Pressure is documented within the child/young person’s
record.
17
18

Key points ~ Inner cannula management
1 Inner cannulae reduce the lumen of the outer tracheostomy tube increasing respiratory effort.
2 Inner cannulae are designed to allow easy removal for cleaning without having to remove the outer tube.
3 Provision of training to recognise a displaced tube.
4/9/08
01:10
All children/young people with a tracheostomy tube with an To minimise the risk of obstruction. Documentation identifies the:
inner cannula require individual assessment of the frequency • type of tube in situ
Page 18
of inner cannula care. • amount of secretions the child/young person produces,
and
• frequency of cleaning.
Local policies/guidelines are available on how tracheostomy
inner cannulas are cleaned. These are in line with
manufacturer’s guidelines, local infection control and
decontamination policies.
Key points ~ Fenestrated tubes
1 Fenestrated tubes are rarely used in children and young people.
2 Fenestrated tubes may be cuffed or uncuffed.
3 Fenestrated tubes are used to encourage weaning from the tracheostomy and also for voicing.
4 Fenestrated tubes are supplied with two inner cannulae; one is fenestrated and one is not.
4/9/08
01:10
All children/young people with a fenestrated tracheostomy It is possible to insert the suction catheter through the Documented evidence that healthcare professionals have
Page 19
tube have the fenestrated inner cannula removed prior to fenestration causing damage to the tracheal wall. received training in the use of fenestrated tracheostomy
tracheal suction and replaced with an unfenestrated inner tubes.
cannula.
Local policies/procedures on the management of
fenestrated tubes are available.
Management of fenestrated tubes is documented in the
All children/young people with a fenestrated tube require an To allow ventilation with emergency equipment as air will Information is recorded in the child/young person’s record.
unfenestrated tube to be readily accessible for use in an exit via the fenestration.
emergency.
Key challenges:
1 Development of local policies/guidelines relating to all aspects of tracheostomy tube care.
2 Sharing tracheostomy tube management information with the acute and community multidisciplinary team.
3 Provision of educational resources to develop new skills and teach/supervise less experienced healthcare professionals.
4 Development of evidence to support current practice.
5 Assessing the competence of healthcare professionals to undertake all aspects of tracheostomy tube management.
6 Ensuring parents/carers and children/young people (if age appropriate) are educated in all aspects of tube management and are confident
and competent in managing the tube prior to the child/young person’s discharge from hospital.
19
20

Section 6: Suctioning
Key points:
1 The frequency of tracheal suctioning should be assessed for each child/young person on an individual basis and should only be carried out
when the child/young person is unable to clear their own airway effectively.
4/9/08
2 Suctioning should maximise removal of secretions with minimal tissue damage and hypoxia.
3 Standard infection control precautions should be applied, including good hand hygiene and use of personal protective equipment.
4 Suction equipment should be easily accessible and must be checked daily.
01:10
5 Children/young people who have difficulty clearing secretions may require referral to a respiratory physiotherapist.
6 Individual assessment of the child/young person will determine what equipment is required at home.
Page 20
Where possible, the lowest effective pressure should be used There is a requirement to set suction levels which are safe There is evidence that suctioning training specific to
when suctioning, using equipment with an adjustable and and effective.35 children and young people with a tracheostomy is provided
measurable dial. The recommended pressures are: to families/carers and healthcare professionals.
Pressures in excess of 26.7kPa (200mmHg) can result in
• 60–80mmHg (8–10kPa) for neonates,31,32
greater mucosal trauma. 36,37
• 80–100mmHg (10–13kPa) for children,33 and
• 80–120mmHg (10–16kPa) for adolescents34 There is a risk of atelactasis if suction pressure is too high.38,39
Low pressures are less effective and prolong suction time.40
Suctioning should last no longer than 5 seconds at a time.5 Prolonged suctioning results in hypoxia. Local policies provide guidance on appropriate suctioning
technique.
Appropriately sized, single-use multi-eyed or closed system, Tracheal suctioning can cause tracheal mucosal damage.
multi-use catheters should be used. Multi-eyed catheters cause least trauma.39 Documented record of catheter use within the child/young
person’s record.
Suction catheter diameter must not exceed half the internal To enable gas flow between suction catheter and airway
diameter of the child/young person’s tracheostomy tube wall thus preventing atelectesis.42 Appropriate suction catheter size should be documented in
size.38, 41 the child/young person’s record.
Suctioning should be carried out using the ‘pre-measured Animal model studies45 and post mortem studies46 clearly Documented record within the child/young person’s record
technique’.44, 33 The suction catheter should not be inserted demonstrate epithelial damage where deep suction is that pre-measured technique is used.
more than half a centimetre beyond the end of the routinely performed.47
tracheostomy tube.28 (See Appendix 10).
The need for hyperoxygenation prior to procedure should To minimise risk of hypoxia associated with suctioning for Documented within the child/young person’s record.
be assessed on an individual basis in line with identified children/young people.
Hospital/community policy in place.
hospital/community policy
If a fenestrated tube is in situ, a plain inner tube should be It is possible to insert the suction catheter through the Documented within the child/young person’s record.
inserted prior to suctioning. fenestration causing damage to the tracheal wall.
4/9/08
Healthcare professionals are aware of the psychological Suction can be a traumatic experience for the child/young Information is available in a variety of accessible formats to
effect of suctioning on children/young people. person and their parents/carers. promote child/young person/parent/carer understanding
01:10
and reduce anxiety.
Local infection control policy must be adhered to There is a risk of contamination of equipment, cross A local infection control policy addresses issues and
Page 21
throughout the tracheal suctioning process including the infection to the child/young person and exposure of precautions required in relation to tracheal suctioning and
use of personal protective equipment (PPE) and performing healthcare professionals to tracheal secretions. disposal of equipment.
hand hygiene. There must be use of intact sterile equipment
Instillation of sodium chloride can have an adverse effect on Documented within the child/young person’s record.
and safe disposal of waste.
oxygen saturations.49
Isotonic sodium chloride solution should not be instilled
routinely.48
Key challenges:
1 Development of local policies/guidelines for children/young people relating to suctioning of a tracheostomy.
2 Sharing suctioning information with the acute and community multi-disciplinary team.
3 Ensuring appropriate equipment is readily available, including correct catheter size and type.
4 Providing regular in-service training/communication for healthcare professionals working with children/young people with a tracheostomy.
5 Providing support and teaching of suctioning technique for children/young people and families/carers and ensuring that the family/carers
understand the procedure.
21
22

Section 7: Humidification
Key points:
1 The normal humidification and filtration system is bypassed in children/young people with a tracheostomy. Breathing unhumidified air can
thicken secretions and increase the risk of mucous plugging. Humidification must be artificially supplemented to minimise this risk of thickened
secretions and mucous plugging.50
4/9/08
2 The need for humidification in children/young people with a tracheostomy is ongoing. A range of products are available for providing
humidification in the child/young person’s home environment. The choice of artificial humidification system is dependent on the child/young
01:10
person’s age and condition (see Appendix 11). An ideal device for every child/young person is not available28 and it may be necessary to use
a combination of humidification systems.
Page 22
3 Maintenance of safety is a key consideration in children/young people with a tracheostomy when using any humidification product.
Healthcare professionals undertake assessment of The normal humidification and filtration system is bypassed There is documented evidence of humidification assessment
humidification needs in children/young people with a in children/young people with a tracheostomy. in the child/young person’s records.
tracheostomy.
Children/young people with a tracheostomy require It is desirable to heat and humidify inspired gas to match There is a system to monitor inspired gas temperatures.
humidification to maintain mucocillary clearance and to the normal physiological conditions at the level of the
reduce the risk of pulmonary infection.51 carina.9
Heat and moisture exchanger (HME) filters heat air to the Humidification is necessary to prevent:
child/young persons body temperature.28 • obstruction/occlusion of tracheostomy tube
• atelectasis
• pulmonary infection
• poor ventilation/perfusion coupling, and
• tracheitis.51,52
Healthcare professionals are aware of the benefits associated HME filters are efficient when used with children/young Documented evidence of training and education
with the various humidification devices available for people with ‘normal’ amounts of thin secretions. HME filters programmes to inform healthcare professionals of the types
children/young people with a tracheostomy. are simple to use and are cost effective.28 of humidification systems available and the safe use of
systems which are employed locally.
HME filters should be changed every 24 hours, or more
often as indicated.6
Heated systems are very efficient and temperature can be
controlled at recommended humidity levels. Delivery of
inspired air at 37ºC and 100% relative humidity maintains
the body’s normal defence mechanisms.51,53
Nebulisers are safe and efficient. 28
Healthcare professionals are aware of particular problems Excessive artificial humidification of inspired gases may Appropriate sized HME documented in the child/young
associated with artificial humidification in children/young produce as much harm as under humidification.5 person’s record.
people with a tracheostomy.
HME filters (artificial noses) increase the dead space,
4/9/08
resistance and the weight on the tracheostomy tube. The
HME filter may become blocked.6
Heated systems are prone to rain out (condensation in the
01:10
tubing) when water vapour cools and collects in the tubing.28
Distilled water and saline reservoirs in humidification
Page 23
systems have been shown to be a source of infection.54
Nebulisers may be too cool28 and they require a gas flow
generator and tubing making them inconvenient for active
children/young people.6,20
Humidification systems are managed in accordance with the Humidification systems vary and healthcare professionals Local guidelines and protocols are in place.
manufacturer’s instructions, local guidelines or protocols must be aware of differences in equipment.
and infection control policy.
23
24

The child/young person and parents/carers should be fully Provision of appropriate information may improve Documented discussion with the parents/carers.
aware of the need for and appropriate use of humidification parent/carer/child/young person compliance and, therefore,
Information provided to parents/carers in the local parental
equipment. minimise long-term problems.
information and treatment pack on tracheostomy care and
4/9/08
management.
01:10
Key challenges:
1 Development of local policies/guidelines relating to humidification of a tracheostomy for children/young people.
Page 24
2 Sharing humidification information with the acute and community multidisciplinary team.
3 Provision of training and education to develop the knowledge of parents/carers whose child/young person requires artificial humidification.
4 Provision of training and education to develop knowledge of healthcare professionals caring for children/young people who require artificial
humidification.
5 Development and implementation of evidence-based protocols and procedures for all healthcare professionals and parents/carers.
6 Local provision and access to a range of humidification systems and equipment.
Section 8: Therapeutic play interventions
Key points:
1 Play is an essential part of a child/young person’s normal healthy development which enables children/young people to learn, communicate
and develop.
4/9/08
2 Play programmes assist in the achievements of developmental goals for children/young people. When development is impaired or delayed,
a referral should be made to a physiotherapist skilled in neuro-developmental therapy.
3 Play services in hospital help families/carers adjust to potentially stressful situations and events and understand illness and treatments.
01:10
Page 25
All children/young people staying in hospital should have Play is essential to the overall healthy development of Audit of play services.56, 57
access to a qualified play specialist.55 children/young people. Medical conditions must not limit
the child/young person’s social and emotional
development.
Healthcare professionals have knowledge of childhood In order to support the parents/carers’ a good There is documented evidence of local training and
development and should recognise the importance of safe understanding of child development is essential. education organised by the play specialist.
play techniques for a child/young person with a
Play/toys of other children/young people can be a risk for There is documented referral to the play specialist.
tracheostomy and refer to the play specialist.
children/young people with tracheostomy, eg sand play.
Risk assessments are carried out and documented.
Play specialists should meet the developmental, medical and Play can be an important factor in reducing any harmful This is documented in child/young person’s
emotional needs of individual children/young people and effect of stress and hospitalisation. It is through play that record/developmental assessment.
families/carers as part of the multidisciplinary team liaising children/young people can be empowered to communicate
Local guidelines for professional practice based on the
with all disciplines to meet the overall needs of the and have an outlet for behaviours.
National Association of Hospital Play Staff Guidelines for
child/young person. Structured play and developmental
Play specialists have specific training in providing play for Professional Practice.58
play programmes are planned, developed and evaluated by
children/young people and families/carers in the hospital
a qualified play specialist. Personal development plan (PDP) for play specialist and
and community setting.
team.
Education/information packs should incorporate advice on Not all materials/activities are suitable for children/young Documented evidence of local guidance.
appropriate and safe play for children/young people with people with a tracheostomy.59
Record of information given to
tracheostomy.
parents/carers/school/nursery on the discharge checklist.
These packs will be distributed to the child/young person’s
Local parent/carers information and teaching pack on
nursery/school. Play specialists will liaise with community
tracheostomy care and management is given to
teams.
parents/carers nurseries and schools.
25
26

All children/young people should be offered psychological Research demonstrates that psychological preparation has Documented evidence in the child/young person’s record
preparation/post procedural play programmes. been found to be effective in reducing distress and that psychological preparation has been offered.
enhancing coping.57,60
Documented evidence of local guidance.
4/9/08
Post procedural play sessions can help families understand
Risk assessments are carried out and documented.
the treatment/condition.61
01:10
All children/young people should be offered distraction Distraction is an effective coping strategy.62 Documentation of use of distraction therapies, observation
therapy for any treatment or procedure undertaken, eg tube and families feedback.
The play specialist is a facilitator who works in partnership
changes, suction.
with parents and other staff.63
Page 26
Parents/carers should be taught distraction techniques.
Key challenges:
1 Development of local policies/guidelines relating to therapeutic play interventions for children/young people with a tracheostomy.
2 Sharing therapeutic play intervention information with the acute and community multidisciplinary team.
3 Development of a national parent/carers information and treatment pack on tracheostomy care and management for children/young people.
Appendix 1: Total number of tracheostomies in

children/young people in Scotland
Total Number of tracheostomies (excluding laryngectomies) in

children/young people.
Years ending 31 December 1997–2006
Year of Total Rate per
main Age number of 100,000
operation group tracheostomies population Population
0–12 13 1.58 822,181

1997
13–17 10 3.14 318,166
0–12 21 2.58 813,307

1998
13–17 6 1.89 317,491
0–12 24 2.99 802,755

1999
13–17 7 2.21 316,627
0–12 21 2.66 789,128

2000
13–17 19 5.96 318,872
0–12 18 2.32 774,409

2001
13–17 5 1.55 323,196
0–12 35 4.60 761,434

2002
13–17 4 1.23 324,364
0–12 16 2.13 750,795

2003
13–17 9 2.79 322,877
0–12 23 3.10 742,572

2004
13–17 6 1.85 324,074
0–12 24 3.27 734,015

2005
13–17 8 2.46 325,012
0–12 18 2.47 727,633

2006
13–17 5 1.55 322,557
Source: Information Services Division (ISD), SMR01 data

Based on all operations during the patients’ stay.
ICD10 codes - E42 (excluding E425, E426 and E427).
Population figures taken from the Scottish GRO mid-year population estimates.
27
Appendix 2: Contraindications for speaking valve use11

• Severe stenosis
• Severe tracheomalacia
• Excessive granulation tissue
• Tracheal oedema
• Bilateral vocal cord palsy (adducted)
• Medical instability
• Severely reduced lung capacity
• Copious thick secretions
• Cuffed tracheal tube
• Laryngeal papillomatosis (aggressive)
28
Appendix 3: Factors which may affect communication

• The position of the tracheostomy tube changes the diversion of the
airflow with the majority of the outgoing breath passing out through
the tracheostomy tube as opposed to the normal flow up and over the
vocal cords and out of the mouth, resulting in the decreased ability to
vocalise.
• The time from birth to five years is a critical period for acquiring
speech, language and communication skills and the impact of not being
able to vocalise can affect the development of these skills.5
• Children/young people who had a tracheostomy as babies and

decannulated between the age of one and four can have significant
delay of expressive language use. In addition the longer the period of
the tracheostomy, the more likely there will be impairment of speech
sound production.64
• Babies use both vocalisation, crying and non-verbal communication
such as facial expression and eye contact to communicate. Decreased
ability to vocalise can have an impact on the child/young
person/parent/carer interactions at this early stage as well as possible
future impact on communication development and social interaction.5
• There may be other medical, neurological, sensory disorders or
structural abnormalities involved which can have a direct affect on the
ability to communicate.10
• Good air leak around the tracheostomy tube and evidence of being able
to make voice can allow for the use of a speech valve by creating an oral
air stream and allow voicing on the outgoing breath. Using a speech
valve can create a louder voice as well as impacting on speech and
language development in the younger child.65
• Some children/young people will have had normal speech and language
use prior to the tracheostomy and their communication needs will be
different. Frustration at not being able to communicate needs, feelings
and opinions is an added factor. Speech and language therapy input as
early as possible will allow for decisions to be made for developing an
appropriate communication system for the child/young person to allow
them a means of expression even if it is only required for a short time.64
This may involve alternative communication systems using low or high
tech aids.66
29
Appendix 4: Factors which may affect swallowing

Adult literature on swallowing with a tracheostomy has suggested
associated difficulties relating to the pharyngeal stage of the swallow.21 Also
well documented, is that aspiration is the major swallowing difficulty
associated with tracheostomy in the adult population.19 There is however
little data available for the paediatric population21 but a number of factors
are suggested which may impact on swallowing.
• Swallowing difficulties may be present secondary to the primary medical

diagnosis.21
• Children/young people with isolated airway problems are not likely to
have any swallowing problems.67
• Children/young people with long-term tracheostomies may have
pharyngeal stage difficulties.62
• Restriction of upward laryngeal movement can limit laryngeal closure
necessary for complete epiglottic closure.68
• Air diversion through the tracheostomy tube may lead to laryngeal
desensitisation due to lack of airflow in the upper respiratory airway.
This may also have an effect on co-ordinated laryngeal closure.69
• In ventilated children, the co-ordination of sucking, swallowing and
breathing is altered and may lead to swallow dysfunction.69
• Cuffed tube use is limited in paediatrics but if required oral feeding
should not be considered.21
• Presence of infantile gastro oesophageal reflux commonly affects
behaviour, swallowing and food intake.70
30
Appendix 5: Tracheostomy tube table
Manufacturer and description Sizes Comments
SHILEY Neonatal Cuffless Tracheostomy Tube: sizes 3.0–4.5mm Shiley tubes can be left in situ for up to 28 days.
Paediatric Cuffless Tracheostomy Tube: sizes 3.0–5.5mm They can be reused several times, subject to the
4/9/08
Opaque, thermosensitive
polyvinyl chloride (PVC) Paediatric Cuffless Long Tracheostomy Tube: sizes 5.0–6.5mm integrity of the tube. Follow manufacturer’s advice
(latex-free) Paediatric Cuffed Tracheostomy Tube: sizes 4.0–5.5mm regarding cleaning tubes.
Paediatric Cuffed Long Tracheostomy Tube: sizes 5.0–6.5mm
01:10
TRACOE Mini Neonatal (350 series) Cuffless Tracheostomy Tube: sizes 2.5–4.0mm Tubes not reusable, but may remain in situ for up to
Radiopaque polyvinyl chloride (PVC) Paediatric (355 series) Cuffless Tracheostomy Tube: sizes 2.5–6.0mm 28 days. However, at least weekly changes are
Page 31
recommended, as the tube may become coated and
blocked with secretions.
SIMS PORTEX Bivona Neonatal Cuffless Tracheostomy Tube: sizes 2.5–4.0mm Bivona tubes can be left in situ for up to 28 days.
Opaque, silconised polyvinyl chloride Paediatric Cuffless Tracheostomy Tube: sizes 2.5–5.5mm Unlike most other plastic products, they can be reused
(PVC) (latex-free) several times, subject to the integrity of the tube.
Neonatal Aire – cuf Tracheostomy Tube: sizes 2.5–4.5mm
Follow manufacturers advice regarding cleaning tubes.
Paediatric Aire – cuf Tracheostomy Tube: sizes 2.5–5.5mm
The silicone tube is reinforced with wire –
Neonatal Tight to the Shaft (TTS)
the wire is not compatible with use during MRI
Cuffed Tracheostomy Tube: sizes 2.5–4.5mm
Paediatric Tight to the Shaft (TTS) Aire – cuff has an air-filled cuff
Cuffed Tracheostomy Tube: sizes 2.5–5.5mm TTS Cuff has a water-filled cuff
Fome-cuf has a rubber foam-filled cuff. The foam is
Neonatal Fome-cuf Tracheostomy Tube: sizes 2.5–4.5mm
self-expanding.
Paediatric Fome-cuf Tracheostomy Tube: sizes 2.5–5.5mm
Great Ormond Street Available in sizes 3.0–7.0mm Tubes not reusable. Not compatible with standard
Polyvinyl chloride (PVC) ventilator tubing and/or HMEs and/or resuscitation
equipment. Must have access to a portex
male/female adaptor of appropriate size for
emergency situations.
SILVER tracheostomy tubes Available in a range of sizes – measured in the French gauge and not Thin walled tube, allowing for inner cannula. Silver
Silver compatible to the metric measurements of plastic tubes. tubes can be left in situ for 28 days. Follow
manufacturer’s advice regarding cleaning tubes.
Not compatible with use during MRI.
All sizes stated are for the internal diameter.

For information on adult tubes, please see the caring for the patient with a tracheostomy best practice statement.2
31
Appendix 6: Sizing chart for paediatric airways71
1-6 6-18 18 mths 3-6 6-9 9-12 12-14

Preterm-1 month
months months - 3 yrs years years years years
Trachea
(Transverse 5 5-6 6-7 7-8 8-9 9-10 10-13 13
Diameter mm)
Great Ormond ID (mm) 3.0 3.5 4.0 4.5 5.0 5.5 6.0 7.0
Street OD (mm) 4.5 5.0 6.0 6.7 7.5 8.0 8.7 10.7
Shiley Size 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5
ID (mm) 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5
OD (mm) 4.5 5.2 5.9 6.5 7.1 7.7 8.3 9.0
Length (mm)
Neonatal 30 32 34 36
*Cuffed Tube Paediatric 39 40 41* 42* 44* 46*
Available Long Paediatric 50* 52* 54* 56*
Portex ID (mm) 3.0 3.5 4.0 4.5 5.0 5.0 6.0 7.0
(Blue Line) OD (mm) 4.2 4.9 5.5 6.2 6.9 6.9 8.3 9.7
Portex (555) Size 2.5 3.0 3.5 4.0 4.5 5.0 5.5
ID (mm) 2.5 3.0 3.5 4.0 4.5 5.0 5.5
OD (mm) 4.5 5.2 5.8 6.5 7.1 7.7 8.3
Length
Neonatal 30 32 34 36
PLASTIC
Paediatric 30 36 40 44 48 50 52
Bivona Size 2.5 3.0 3.5 4.0 4.5 5.0 5.5
ID (mm) 2.5 3.0 3.5 4.0 4.5 5.0 5.5
OD (mm) 4.0 4.7 5.3 6.0 6.7 7.3 8.0
All sizes avail-
able with Fome Length
Cuff, Aire Cuff & Neonatal 30 32 34 36
TTS Cuff Paediatric 38 39 40 41 42 44 46
Bivona ID (mm) 2.5 3.0 3.5 4.0 4.5 5.0 5.5
+\SHUÀH[ Usable Length
55 60 65 70 75 80 85
(mm)
Bivona Flextend ID (mm) 2.5 3.0 3.5 4.0 4.5 5.0 5.5
Shaft Length (mm) 38 39 40 41 42 44 46
Flextend Length
10 10 15 15 17.5 20 20
(mm)
TracoeMini ID (mm) 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0
OD (mm) 3.6 4.3 5.0 5.6 6.3 7.0 7.6 8.4
Length (mm)
30 32 34 36 36
Neonatal (350)
Paediatric (355) 32 36 40 44 48 50 55 62
Alder Hey FG 12-14 16 18 20 22 24
SILVER
Negus FG 16 18 20 22 24 26 28
Chevalier
FG 14 16 18 20 22 24 26 28
Jackson
6KHI¿HOG FG 12-14 16 18 20 22 24 26
ID (mm) 2.9-3.6 4.2 4.9 6.0 6.3 7.0 7.6
Cricoid (AP 9.0-
ID (mm) 3.6-4.8 4.8-5.8 5.8-6.5 6.5-7.4 7.4-8.2 8.2-9.0 10.7
Diameter) 10.7
Bronchoscope Size 2.5 3.0 3.5 4.0 4.5 5.0 6.0 6.0
(Storz) ID (mm) 3.5 4.3 5.0 6.0 6.6 7.1 7.5 7.5
OD (mm) 4.2 5.0 5.7 6.7 7.3 7.8 8.2 8.2
Endotracheal ID (mm) 2.5 3.0 3.5 4.0 4.5 5.0 6.0 7.0 8.0
Tube (Portex) OD (mm) 3.4 4.2 4.8 5.4 6.2 6.8 8.2 9.6 10.8
Updated Great Ormond Street Hospital sizing chart for paediatric airways
Tweedie DJ, Skilbeck CJ, Cochrane LA, Cooke J, Wyatt ME. Choosing a paediatric
tracheostomy tube: an update on current practice. J Laryngol Otol. 2008;122(2):161-9 , page
9 © JLO (1984) Limited, reproduced with permission.
32
Appendix 7: Decannulation
Decannulation involves removal of the tracheostomy tube allowing
‘normal’ respiration to occur. The following steps should be taken.
Pre admission
Physical and psychological assessment is essential and will involve the
following assessments:
• Swallowing and cough: this can be carried out by medical staff and or a
speech and language therapist, it may be necessary to perform a
videofluoroscopy.
• Secretions: consider how often is suction required? Are oral secretions
still evident? Do they increase during activity?
• Airway assessment: this could include an microlaryngobronchoscopy
(MLB) and can be carried out as a pre admission or on day one. This
will enable a view of the airway and if the tracheostomy has been
inserted due to a primary airway cause, this will be assessed. If the
tracheostomy has been inserted to facilitate treatment, it is still
advisable to review through an MLB, as the tracheostomy tube can
cause airway complication.
• Psychological: it is not always necessary to have a professional
psychologist available. However, discussing and listening with the
parents, and the child if appropriate, is essential.
Admission
Day one following airway assessment by ear, nose and throat (ENT)
consultant, undertake an MLB if necessary.
Downsize to size 3.mm tracheostomy tube.
Day two cover with decannulation cap if available, or occlude with

airtight tape for 12 hours, then uncover overnight.
Day three cover for 24 hours from 8am.
Day four decannulate. Occlude stoma with airtight dressing and

continue observations.
Day five child/young person is able to go off the ward.
Day six discharge, with outpatient department appointment in 6

weeks.
33
Throughout the process, the child/young person should be observed for

clinical signs of respiratory distress/fatigue. The child/young person may
experience a feeling of panic at each stage initially. It is vital to alleviate this
panic, while being vigilant for any signs of respiratory distress. The
parents/carers may experience anxiety as their child/young person will be
breathing through a smaller tube, before it is occluded and removed. This
may feel like they are losing a safe airway. Reassurance of both the
child/young person and parents/carers is essential to maximise the safety of
this procedure.
If this is unsuccessful, the child/young person’s original tube is reinserted.

The child/young person’s condition will be reassessed, with the possibility
of returning to the decannulation process at a later date.
Following a successful decannulation, it may take a number of weeks for

the stoma to close. Sometimes a surgical closure is necessary after 6
months.
It is necessary to inform the disability living allowance (DLA) office of the

successful decannulation.
Observations
The child/young person will be continually observed for:
• breathing pattern
• respiratory distress
• restlessness
• agitation
• colour
• oxygen saturations, and
• vital signs.
If there any concerns, medical staff must be informed immediately.
34
Appendix 8: Discharge checklist

Name_________________ DOB_________________ Date_____________
Action Achieved/signature Date

Ear, nose, throat (ENT)/respiratory consultant to make clinical decision that the
child/young person requires long-term tracheostomy airway
Specialist nurse to discuss and answer questions with child/young person

(age/ability appropriate) and parents/carers regarding the management of
tracheostomy, and training schedule post tracheostomy surgery. Written
information given
Referral to speech and language therapy service
Referral to play specialist
Specialist nurse/named nurse to liaise with discharge planning service
Referral to the relevant community children’s nursing (CCN) service if available
Inform relevant children’s nursing service regarding equipment required for

discharge
Equipment delivered direct to the ward for parental/carer training
All supplies and sundries required for tracheostomy management to be

documented and listed with order codes to be faxed to relevant community
children’s nursing service
Parents/carers and child/young person (where appropriate) to be given training -

practical demonstration and supervised practice regarding tracheostomy
management and troubleshooting – see individual child/young person’s
tracheostomy information.
• Why the individual child/young person has a tracheostomy airway?
• What size/type of tracheostomy tube is in situ?
• Tracheal suction technique
• What is pre-measured tracheal suction depth?
• Set-up of portable suction equipment
• Portable suction negative pressure setting?
• Tracheal stoma care
• Tracheostomy tube change technique
• Troubleshooting
- Recognition and management of airway obstruction/respiratory distress
- Emergency airway management and use of Ambu Bag
- Stoma over-grannulation management
- Equipment breakdown
- Accessing replacement equipment/supplies
- Management of respiratory infections
• Basic life support and tracheostomy resuscitation training
• Written information regarding child/young persons tracheostomy management
and completed parent/carer tracheostomy teaching guideline
• Relevant contact telephone numbers
• Written information regarding readmission criteria
• Information on how to dispose of clinical waste
35
Action Achieved/signature Date

Outreach training by specialist nurse regarding tracheostomy management/basic
life support and tracheostomy resuscitation training for child/young persons local
hospital (nursing and medical staff), community team – GP, CCN, health visitor,
community paediatric physiotherapist, respite/hospice services and education
(nursery/school) to be arranged, as required
Tracheostomy sundries/supplies for discharge

• Portable suction unit
• Appropriate sized resuscitation bag
• Apnoea monitor (for child <1 year) and sensors
• Tracheostomy tube - same size
• Tracheostomy tube - smaller size
• Tracheostomy securing devices (ie collars/tape, relevant size)
• Suction catheters (relevant size)
• Suction tubing
• Non-sterile gloves
• HME filters
• Airtight waterproof tape
Parent/identified carer(s) to be competent in all aspects of tracheostomy

management, essential tracheostomy supplies, basic life support and emergency
airway management and use of Ambu Bag prior to discharge
Document names and relationship to child/young person of all people
tracheostomy trained/competent, with completed parent/carer tracheostomy
teaching guidelines
Follow-up with respiratory service and/or ENT service – outpatient clinic

appointment to be arranged, prior to discharge. Parent/carer to be informed
Inform local hospital, Children’s Community Nurse, GP regarding discharge date.

Discharge letter and relevant written tracheostomy information to be sent timeously
Telephone follow-up by specialist nurse within week of discharge – date arranged

with parent/carer
36
Appendix 9: Minimal occlusion technique72,73

Cuff inflation
It is very important that care is taken not to over inflate the cuff on a
tracheostomy tube. The tracheostomy cuff has several important functions
(to prevent aspiration of upper airway secretions and/or prevent loss of
airway pressure in the ventilated child/young person), however, it can also
cause damage to the tracheal mucosa. An over inflated cuff can reduce
perfusion to the tracheal mucosa, which may lead to ulceration, dilation
and stenosis of the trachea.
Most cuffed tracheostomy tubes have a high volume, low pressure cuff –
thereby, reducing the risk of trauma due to pressure. This style of cuff
allows the pressure of the cuff to be diffused over a wider surface area.
However, this does not eliminate the risks entirely. Therefore, the cuff
should be inflated to the minimal desired occlusion volume to prevent
trauma to the mucosal wall.
37
Minimal occlusion volume (MOV) technique

This technique requires two people.
• When the cuff is inflated with volume (air or water depending on style
of tracheostomy cuff), it is gradually inserted in 0.2–0.5mls increments
with a 5ml syringe into the tracheostomy tube cuff (for paediatric cuffed
tubes – adult cuff volumes will require a 10ml syringe).
• A stethoscope is positioned just below the thyroid cartilage, enabling air
leaks to be heard.
Oral
pharynx
Epiglotis
Larynx
Thyroid Vocal cords
cartilage
Cricothyroid Trachea
membrane
Cricold
cartilage Oesophagus
Stethoscope
• One person inserts the volume, while the second person listens for
absence of an air leak as the volume is inserted.
• When no air leak is heard, the cuff is inflated to the minimal occlusion
volume and, no further increments of volume are required.
• It is important that the volume inserted is documented in the
child/young person’s record for reference.
• For greater accuracy, the first person withdraws 0.5–1.0ml of air until an
air leak is heard by the second person.
• The first person re-inflates the cuff until no air leak is heard by the
second person, thereby confirming the amount of volume required to
achieve a minimal occlusion volume.
DO NOT EXCEED THE MANUFACTURER’S RECOMMENDED CUFF

VOLUME.
38
Appendix 10: Tracheostomy suction procedure in paediatrics34
Action Rationale
Preoxygenate child/young person for one • To minimise hypoxia
minute prior to procedure and continue until
child/young person is clinically stable if:
• child/young person is at risk of
desaturation
• child/young person routinely requires
>40% oxygen
• child/young person has experienced
detrimental effect of suctioning on a
previous occasion74
Universal precautions must be used. • To minimise risk of infection

• Clinical hand wash must be performed • To minimise risk of contamination
• Non-sterile gloves must be worn
• Non-touch techniques should be adopted
Suction catheter should be attached to the • To minimise risk of contamination

suction tubing without touching the end of
the suction catheter
Suction catheter should be inserted using • As a point of reference for healthcare

pre-measured technique professionals
Tube length should be pre-determined by
inserting a suction catheter into a
tracheostomy the same size as the
child/young person’s. This measurement
should be recorded in the child/young
persons record75
Deep suctioning is not recommended. • Animal model studies45 and post mortem
However, it may be necessary in particular studies46 clearly demonstrate epithelial
circumstances, eg during broncho-alveolar damage where deep suction is routinely
lavage, or for airway clearance in acutely ill performed
child/young person with lung consolidation • Deep suction should never be used
and/or collapse routinely, however in selected situations it
can be necessary for clearance of
secretions located beyond the tube20
Suction should be applied to the • There is increased risk of hypoxia and

recommended pressure (see Section 6) atelectasis in children/young people and
infants due to smaller residual lung
Negative pressure should be applied for the
volume76
recommended duration
Healthcare professionals must use their • Children/young people with impaired
clinical judgement to assess if a child/young respiratory or cardiac function may be at
person can only tolerate shorter duration of increased risk of hypoxia77
suction based on clinical symptoms
Suction catheter should be withdrawn as
negative pressure is applied
Assess child/young person’s condition after To determine whether child/young person
first suction attempt requires further suctioning
39
Action Rationale
If further suction is required, a new suction • To minimise infection
catheter should be used as suction catheters • To comply with licensing laws
are licensed for single use only
If secretions are thick and offensive, a sample • To establish if the child/young person has
specimen should be collected and sent for an infection or requires additional
screening treatment
If the child/young person has thick or dry • Dehydration affects secretion viscosity
secretions the healthcare professional must: • Nebulised solutions decrease secretion
• assess the child/young persons hydration viscosity79
status, and
• provide additional methods of airway
humidification, eg a humidified air system
• Research concludes that saline instillation
or saline nebulisers78
can have detrimental effects for the
Routine instillation of saline is not advised child/young person
During the entire suction procedure, the • To ensure patient safety

child/young person must be continually • To note deterioration in the child/young
monitored/observed for changes in person’s condition
respiratory rate, oxygenation, colour, heart • So that appropriate action can be taken if
rate, respiratory effort necessary
• To influence future suction practices
Any changes during the suction procedure
should be documented in the child/young
persons record
Table adapted from Ireton J. 2007. Tracheostomy Suction: a protocol for practice.
Paediatric Nursing, 19(10), 14-1834 with permission from RCN Publishing.
40
Appendix 11: Illustrations
1. Humid-vent 2. Trach phone 3. Swedish Nose
4. Thermovent 5. Portex Thermovent HME 6. Tyco healthcare tracheolife
7. Catheter with side holes 8. Velcro tracheostomy collar 9. Humidification Bib
41
10. Heated humidifier and 11. Ultrasonic Nebuliser 12. Great Ormond Street tubes,
water chamber flat and extended versions
13. Cuffed tracheostomy tube 14. Portex blue line uncuffed 15. Single cannulated tube
tracheostomy tube
16. Uncuffed fenestrated tube 17. Speaking valve 18. Passy Muir speaking valve
42
19. Passy Muir speaking valve with 20. Smiths medical biovona 21. Smiths medical biovona
oxygen connector fome-cuf paediatric/neonatal uncuffed paediatric/neonatal
tracheostomy tube tracheostomy tube
22. Smiths medical biovona aire- 23. Shiley paediatric uncuffed 24. Pharma neo port
cuf paediatric/neonatal tracheostomy tube
tracheostomy tube
25. Pharma neo basic
43
Appendix 12: Audit tool

Please see the NHS QIS website (www.nhshealthquality.org) to download a Word version of this audit tool
to save and use electronically or print to use by hand.
Do
Action and
Section Y N not
comments
know
Section 1: Education and training
a Healthcare professionals have access to:

• Education
• Training
• Standardised local policies or guidelines
All healthcare professionals who come into contact with a

b child/young person with a tracheostomy (no matter how
infrequently) understand:
• Indications for the tracheostomy

• Risks associated with a tracheostomy
• Potential complications with a tracheostomy
• Types of tubes and equipment for each case
• Importance of standard infection control precautions
Healthcare professionals and parents/carers receive training on

c routine and emergency airway management for children/young
people with a tracheostomy
Healthcare professionals demonstrate knowledge of when to seek,

d and have access to, professional advice and assistance from
relevant specialists
Healthcare professionals have a record of maintaining competency

e
in caring for a child/young person with a tracheostomy
Education and reassurance of the child/young person and their

f parents/carers starts (where possible) prior to a tracheostomy
being performed
Education of family/carers and education staff, and access to ready
g
advice and support, is provided
An additional support plan including emergency guidelines is
h
developed for nursery/school and other agencies
44
Do
Action and
Section Y N not
comments
know
Section 2: Communication
Healthcare professionals can demonstrate they are knowledgeable

a about communication problems associated with children/young
people with a tracheostomy
The key worker involves the speech and language therapist
b
(ideally pre-operatively)
The speech and language therapist assesses the communication
c
skills of the child/young person.
The speech and language therapist implements, evaluates and
d
reviews the specific communication record
The acute speech and language therapist refers the child/young
e
person to the community speech and language therapist
Clinical indicators are reviewed to ascertain whether speaking
f
valves/tracheostomy valves should be considered
Section 3: Swallowing and nutrition
Healthcare professionals and parents/carers are knowledgeable

a about nutritional and swallowing problems associated with
children/young people with a tracheostomy
Speech and language therapists undertake the initial swallowing
b
assessment and recognise when to involve the dietitian
Dietitians undertake the nutritional assessment of the child/young
c
person with identified impaired swallowing
Following assessments, healthcare professionals plan, implement,
d
evaluate and review a specific nutritional record
e Regular oral care is provided
If the child/young person has a cuffed tube, swallowing should be
f
assessed with the cuff deflated following medical clearance to do so
45
Do
Action and
Section Y N not
comments
know
Section 4: Stoma care
All healthcare professionals involved in stoma management

a
undertake training on it
The child/young person with a tracheostomy stoma has frequency
b
of stoma care individually assessed
An evaluation of stomal condition is documented in the
c child/young person’s record and an appropriate plan of care
initiated
The stoma is cleaned as per local guidelines/policies and no

d cotton wool used around the stoma. If clinically indicated, barrier
film is applied
No dressings are used around the healthy stoma site unless
e
clinically indicated
f Devises securing the tracheostomy tube are checked for security
Parents/carers and children/young people (age appropriate) are
g
taught to manage stoma care prior to discharge
h Tracheostomy site is observed for signs of granulation
Healthcare professionals and parents/carers follow hand hygiene
i
procedures
46
Do
Action and
Section Y N not
comments
know
Section 5: Tracheostomy tube management
General tube management

The multidisciplinary team individually assesses the most
a
appropriate tube to be used
The child/young person has another tube of the same size and
b
type and one size smaller at all times
If the child/young person is using a single cannula tube, it is
c
changed at least once a week and assessed on an individual basis
Routine tube changes do not occur immediately before or after
d
eating
The first tube change takes place 5–7 days after the surgical
e
procedure and under medical direction
A note is made of the technique used to perform the
f tracheostomy, size and style of tube and whether it is stitched up
to the skin
g The tracheostomy tube is cleaned or replaced as appropriate

Brushes are not used on plastic tubes unless specifically
h
recommended by the manufacturer
In addition to standard resuscitation equipment, all
i children/young people with a tracheostomy require the
equipment listed on page 16 of the best practice statement
If decannulation is considered, the child/young person is
j
individually assessed by the multidisciplinary team
Close monitoring and observation of the child/young person’s
k airway and respiratory status occurs throughout the decannulation
process
The child/young person has their emergency equipment with
l
them at all times during the decanulation process
Cuffed tracheostomy tubes

The cuff should be inflated to the minimal desired occlusion
a
volume
Cuffed tracheostomy tubes that have air cuffs should have cuff
b pressure checked at least once daily maintaining pressure between
15–25cmH20 using a manometer
Inner cannula management

Individual assessment of the frequency of inner cannula care is
a
undertaken
47
Do
Action and
Section Y N not
comments
know
Fenestrated tubes
The fenestrated inner cannula is removed prior to tracheal suction
a
and replaced with an unfenestrated inner cannula
All children/young people with a fenestrated tube require an
b
unfenestrated tube readily accessible
Section 6: Suctioning
The lowest effective pressure is used when suctioning using

a equipment with an adjustable and measurable dial. See page 20 of
the best practice statement for recommended pressures
Suctioning lasts no longer than 5 seconds at a time and an
b
appropriate catheter is used
c Suctioning is carried out using the pre-measured technique
The need for hyperoxygenation prior to the procedure is assessed

d
on an individual basis in line with local policies
A plain inner tube is inserted prior to suctioning if a fenestrated
e
tube is in situ
Healthcare professionals are aware of the psychological effect of
f
suctioning on children/young people
The local infection control policy is adhered to throughout the
g
tracheal suctioning process
Section 7: Humidification
An assessment of humidification needs is undertaken by healthcare

a
professionals
Mucocillary clearance and reduction in the risk of pulmonary
b
infection is achieved with humidification
Healthcare professionals are aware of the benefits associated with
c
humidification device
Healthcare professionals are aware of the particular problems
d associated with artificial humidification in children/young people
with a tracheostomy
Humidification systems are managed in accordance with
e
manufacturers instructions and local policies and guidelines
The child/young person and parents/carers are aware of the need
f
for and appropriate use of humidification equipment
48
Do
Action and
Section Y N not
comments
know
Section 8: Therapeutic play interventions
The child/young person in hospital has access to a qualified play

a
specialist
Healthcare professionals have knowledge of childhood development
b
and refer to the play specialist
Play specialists are part of the multidisciplinary team caring for the
c child/young person with a tracheostomy and plan, develop and
evaluate structured play and developmental programmes
Education/information packs include advice on appropriate and safe
d
play for children/young people with a tracheostomy
Parents/carers are offered psychological preparation/post procedural
e
play programmes
Parents/carers are offered distraction therapy for any treatment
f
undertaken
49

Tracheostomy Care Best Practice 2008 Scotland

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10906 Cover.

qxp:9005 Cover 28/8/08 09:38 Page 1

Best Practice Statement ~ September 2008

Caring for the child/young person

© NHS Quality Improvement Scotland 2008

First published September 2008

Appendix 1: Number of tracheostomies in children/young people

Caring for the child/young person with a tracheostomy

• providing advice and guidance on effective clinical practice, including

Best practice statements are produced by a systematic process, outlined

• They are intended to guide practice and promote a consistent, cohesive

Key stages in the development of best practice statements

Topic selection and Scoping Process

Review literature on topic. Establish working group. Establish reference group to

Determine focus and content

Review and update process.

Review and revise

Caring for the child/young person with a tracheostomy

Best Practice Statement: Caring for the child/young person

The reasons that children/young people may require a tracheostomy can

The care of a child/young person with a tracheostomy is a highly skilled

A section has been included in this statement to highlight the importance

Caring for the child/young person with a tracheostomy

Caring for the child/young person with a tracheostomy

Caring for the child/young person with a tracheostomy

Statement Reasons for statement How to demonstrate statement is being achieved

Caring for the child/young person with a tracheostomy

Caring for the child/young person with a tracheostomy

Statement Reasons for statement How to demonstrate statement is being achieved

Caring for the child/young person with a tracheostomy

Caring for the child/young person with a tracheostomy

Caring for the child/young person with a tracheostomy

Caring for the child/young person with a tracheostomy

Statement Reasons for statement How to demonstrate statement is being achieved

Caring for the child/young person with a tracheostomy

Caring for the child/young person with a tracheostomy

Appendix 1: Total number of tracheostomies in

Total Number of tracheostomies (excluding laryngectomies) in

0–12 13 1.58 822,181

0–12 21 2.58 813,307

0–12 24 2.99 802,755

0–12 21 2.66 789,128

0–12 18 2.32 774,409

0–12 35 4.60 761,434

0–12 16 2.13 750,795

0–12 23 3.10 742,572

0–12 24 3.27 734,015

0–12 18 2.47 727,633

Source: Information Services Division (ISD), SMR01 data

Caring for the child/young person with a tracheostomy

Appendix 2: Contraindications for speaking valve use11

Appendix 3: Factors which may affect communication

• Children/young people who had a tracheostomy as babies and

Caring for the child/young person with a tracheostomy

Appendix 4: Factors which may affect swallowing

• Swallowing difficulties may be present secondary to the primary medical

Manufacturer and description Sizes Comments

All sizes stated are for the internal diameter.