Scenario Practice - Trach - Wisc-Online OER

Your child wakes up in the morning, crying. You can hear their oximeter and ventilator alarming. You go to check on them, and they are inconsolable. You feel that they are very warm and their face is red from crying. What is your first action?

You assess your child, you notice that they are breathing faster than normal. The monitor is showing the SPO2 at 90%. When checking the ventilator you notice the circuit disconnect alarm, and low Vte and low MV are both alarming. What do you want to do next?

The circuit is clear of rainout, the exhalation port is clear, all connections are tight, and the circuit is free of kinks. When you look at the stoma site you can see that the trach is in. The monitor has a good reading. When you lift your child's shirt you see that they have abdominal breathing and intercostal indrawing. What next?

You are unable to pass the suction catheter, the SPO2 is now reading 80% and your child's lips appear bluish. What do you think is the problem?

You've recognized that the trach tube is blocked, what should you do now? You are home alone.

You remembered the obturator and the shoulder roll, and you were able to successfully change the trach, secure it, and get your child back on the ventilator. What should you assess your child for now?

You have just arrived home and your child is asleep in the car seat. You decide to move them to their crib. You really have to use the bathroom, so you're rushing and didn't ensure that the ventilator circuit was free with enough slack before transferring. While lowering them down the circuit pulls tight. The vent alarms, what do you do?

The ventilator is continuing to alarm, it's reading circuit disconnect, low Vte and low MV. The oximeter is now reading low with an SpO2 of 90%. You look at your child and their chest rise isn't great. What do you suspect?

When you assess the stoma site you realize you were correct, the trach tube has come out. By this point your partner has come to the bedroom to see what all the commotion is. You ask them to get a new trach ready. What are you doing while the new trach is being prepared?

Had your partner not come to help out, what's another option to get the trach tube back in?

It's time for a routine trach change. Your child does have a bit of a runny nose and a mild cough, but no fever, with white secretions that are a bit thicker than normal. Everything is ready for the trach change and you proceed as normal. When trying to insert the new trach tube you feel resistance. Should you continue to try and push?

You notice a large thick glob of secretions covering the opening of the stoma. Your partner uses a clean gauze to remove the secretions away from the site and you attempt to insert the trach for a second time. You feel the same resistance. Spo2 has dropped to 88% and your child is looking panicked. What now? Has your child's status changed?

Your partner is getting out the smaller sized trach. SpO2 is now 82%, you child is starting to look off colour with bluish lips, and still has a panicked look on their face. Is it appropriate for you to insert the smaller sized trach without lubricant and having the trach ties attached?

The smaller trach is inserted easily. You are able to secure the ties and connect your child back to their ventilator. You can see them start to relax, and their colour and SpO2 is improving. What should your next steps be?

Could your child have difficulty breathing now that they have a smaller sized trach tube in place?

What other difficulties might you see with the smaller sized trach?

What would you have done if the smaller trach could not be inserted?

If you are unable to get the smaller trach inserted and your child begins to have trouble breathing, what should you do?

How can you give rescue breaths if your child no longer has a stable airway?

Your child wakes up crying, you notice their voice sounds louder than normal. You can hear the oximeter alarming. When you enter the room you notice your child is breathing faster than normal and having trouble catching their breath. Their lips appear blue. Is your child showing you signs of difficulty breathing?

After assessing your child and recognizing they are showing signs of difficulty breathing what should you do next?

You attempt to suction your child's trach and notice that it is out. Your child's SpO2 is 91% and their heart rate is increased. Do you have time to prepare a new trach or should you re-insert the old one?

You've gotten the trach back in, but as you’re about to connect to the ventilator your child begins to cough and secretions can be seen coming from the hub of the trach. SpO2 since inserting the trach hasn't improved yet, still 91%, but heart rate has come down and your child appears less panicked. What should you do?

You decide to open suction before connecting. You are able to clear the trach with one pass of the suction catheter, you see the SpO2 improve to 94%. Should you suction again?

Your child has been needing more suctioning, up from every 2 hours while awake to every 30 minutes. The secretions are thicker than usual and are slightly yellow in colour. Your child has a prescription to use O2 up to 3LPM to keep SpO2 greater than 92%. Normal SpO2 for your child is 96%, Currently SpO2 is 93% on 1LPM. What can you do?

You decide to suction, you make one pass and now your child has began to cough and SpO2 is now 88%. You notice that your child has started nasal flaring. What do you do now?

You suction a second time, you're still getting a large amount of very thick yellow secretions. You have no difficulty in passing the suction catheter. Your child's SpO2 improves from 88 to 91%. You verify the oxygen tank is 3/4 full and O2 is flowing from the tank to the ventilator. What should you do?

You've decided to try increasing the oxygen being delivered to the ventilator. What should you increase to from 1LPM (with a prescription that allows up to 3LPM to maintain SpO2 greater than 92%)?

With the increase in amount and thickness in secretions and the need for increased oxygen to maintain target SpO2, what else are you worried about?

You've recognized that your child's trach tube might have a partial blockage. What do you do next?

Scenario Practice - Trach

Troubleshooting scenarios for trach related problems

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