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  • • Routine replacement (usually once a week).

    • Emergent replacement (occlusion with secretions, mucous plug, foreign body, or accidental dislodgment).

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Absolute

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  • • Insufficient training in procedure. (Children with tracheostomies should never be left in the care of someone who is not trained in replacement of a tracheostomy.)

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  • • Suction catheters.

    • Sterile gloves.

    • Suction machine.

    • Saline bullets.

    • 5-mL syringe to deflate balloon, if applicable.

    • Tracheostomy ties.

    • Scissors.

    • New tracheostomy tube of appropriate size (1 of same size and 1 size smaller).

    • Lubrication (water soluble).

    • Oxygen with tubing.

    • Resuscitation bag.

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  • • Inability to establish a new airway.

    • Perforation of airway.

    • Bleeding.

    • Infection.

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  • • If replacement is emergent and no new tracheostomy tubes of appropriate size are available, an endotracheal tube of the same size can be used as a temporary airway.

    • Once the endotracheal tube is inserted, the old tracheostomy tube can be cleaned and replaced.

    • Size of tracheostomy tube is embossed on wings of tracheostomy tube.

    • Suctioning of the tracheostomy is only to clear the tube itself.

    • The suction catheter should not extend beyond the end of the tracheostomy tube. (Aggressive deep suctioning can lead to granulation tissue in the airway.)

    • If unable to insert same size tracheostomy tube, use 1 size smaller.

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  • • Explain the procedure in a developmentally appropriate manner before and during the procedure to help the patient remain calm; many patients are familiar and comfortable with the routine replacement of their tracheostomy tubes.

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  • • A shoulder roll helps extend the neck for improved visualization.

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  • • If nonemergent replacement, prepare all equipment prior to beginning procedure.

    • • Place tracheostomy ties on new tracheostomy.

      • Lubricate new tracheostomy.

      • Prepare suctioning equipment.

      • Prepare resuscitation bag.

    • Suction tracheostomy tube.

    • • Give several positive pressure breaths with resuscitation bag (use 100% oxygen, if available).

      • With sterile gloves on, insert appropriate suction catheter (without suction applied) into tracheostomy tube. (Do not insert past end of tracheostomy tube.)

      • Once at desired depth, occlude suction port to begin suction.

      • Remove suction catheter while applying suction and twist catheter in fingers to allow sweep of sides of tracheostomy tube.

      • Give several positive pressure breaths with resuscitation bag (use 100% oxygen, if available).

      • Repeat as needed to clear tracheostomy tube.

      • A few drops of saline may need to be instilled before positive pressure breaths to loosen secretions and facilitate removal.

    • If tracheostomy tube has balloon, attach syringe to bulb and withdraw air.

    • Remove tracheostomy ties while holding current tracheostomy tube in place.

    • Remove tracheostomy tube.

    • Immediately replace new tracheostomy tube into existing tract.

    • Insert straight and then curve gently posteriorly and distally (Figure 17–1). Do not force.

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  • • Hold tracheostomy tube in place with fingers.

    • Remove stylet.

    • Provide positive ...

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