Our first trach change

Everyone at CHLA holds Jiffy the trach nurse in the upmost esteem, part fear, part great admiration. Yet she's the one noone really wants to meet. She's counselled so many through the horrifying news that their child will need a trach and gently guided them through the fine details of trach suctioning, trach CPR and trach changes. Warning: if she sees you coming in as an outpatient without your suction machine, she'll report you to social services. Thanks for stressing the importance!

After his first trach change in the operating room on Thursday during which they saw a little reduction of swelling, though still a significant upper airway obstruction from granulomas (callouses) and swelling, we did our first trach change yesterday (what a huge day yesterday was!). Reu's trach will be changed every week with 2x 3.5 Neonatal Shileys being used on rotation. During the ENT (Ear, Nose & Throat) examination, they also think they may have seen auditory nerves and cochlears which is too much to contemplate right now, but they confirm the missing olfactory (smell) nerves. Seriously pushing for the new ABR hearing test before discharge as we've been unable to have this test whilst he's been intubated.

Despite the ideal being a weekly change with the two of us present, we will each need to learn how to do an emergency trach change in the event that Reu pulls out his tube or it falls out when we are alone. A frightening prospect, but ensuring his trach collar is sufficiently tight (1 finger should fit behind the collar) should minimise the risks.

Step 1: Getting all the supplies in place: new trach, saline, sterilised suction cathetar (8Fr) and gloves, KY jelly to lubricate the trach, sterile wipes, gauze, air bag, soapy water, obturator (plastic guide for the trach which is removed as soon as the trach is in place). At home, we'd also use a swaddling blanket to keep his rascalling hands at bay

Step 2: Sitting Reu up to remove the trach collar which will be a daily exercise to minimise the growth of granulomas and inflammation under the collar

Step 3: Jason goes first (of course) and is feeling rather nervous. His role is to remove and replace the trach. My role is to watch Reuben for distress and to clean under the trach. One of us has to hold the trach throughout the whole process. We will switch roles later so for education purposes, Reu has to go through the ordeal twice today.

Step 4: Cleaning around the trach site, removing secretions and checking for unusual discharge or smell

Step 5: Jiffy shows how to insert the new trach with a finger on each side of the trach. Meanwhile, Reu's managing to breath through the stoma (hole) in his throat although we need to minimise the amount of time the trach is out


Step 6: Inserting the new trach using KY jelly and the opturator
Step 7: Deep suctioning with saline to remove any bloody and mucus secretions

Vanessa, new mum to Milo and colleague of Jason, moments before she was thrust into recording every gory detail of the first trach change. Thanks for your 2nd visit this week and for taking all the photos which will be a handy step by step account for us!

Anne, Reuben's primary nurse in the NICU (May-July) on one of her many visits to the PICU admiring the trach change handy work. Reu's on his tummy for the first time in months and is clearly exhausted from the trach change and tummy time