Orientation Program on the Care of Children Tracheostomized in the Home Environment

Objective: The aim of the study was to make a literature review on counseling and family education about the care with tracheostomy and develop a guidance booklet for parents about the cautions in handling tracheostomy tubes at home. Methods: This research is based on literature review from 1992 to 2012, realized from October of 2011 to August 2012, through the following databases: medline, lilacs, scielo and sibinet USP, with the elaboration of a guidance booklet for parents, about home care of tracheostomized children. Results: We elaborated a guidance booklet for parents, about the care of tracheostomized children and all were described according to literature review. Conclusion: According to the literature review family education in the care of tracheostomized children is essential so that caregivers have full autonomy to safely and effectively conduct the necessary techniques in their homes.


Introduction
The survival rate of newborns hospitalized in Neonatal Intensive Care Units has increased in recent years, due to professional training and advancement of mechanical ventilatory support [1] [2] and tracheostomy (TQT) is a feature that is often performed with an increase of its indication in children that are under one year old [3] [4].
According to Edwards [12], children routinely remain with the TQT at home, being critical to have an adequate support and diligent planning for caregivers guided by health professionals.
The scientific literature shows several complications associated with the prolonged use of TQT, but no study reports the guidance and care in the household, in a practical way, for parents, showing the need of home assistance for caregivers of tracheostomized children.
The aim of this study was to present a literature review about family education and guidance for the care of tracheostomy, and elaborate a booklet of guidance to parents about cautions in handling tracheostomy at home.

Method
Research based on bibliographic review, conducted from October 2011 to August 2012.
The search for scientific articles was performed through medline, lilacs, scielo and sibinet USP database, with the descriptors: tracheostomy, child, newborn, child care, home care services; in Portuguese and English.Original articles and reviews about tracheostomy published between 1992 and 2012 were selected, being excluded articles with children over one year of age.
Later was elaborated a guidance booklet for parents, about the care of tracheostomized children (Figure 1).

Results
Orientations to parents about care with the child's tracheostomy were described, according to literature review, in Figure 1.

Discussion
According to published studies, family orientation about the process of care with the child's tracheostomy has been beneficial for caregivers who adapt to this new routine performing specific procedures, and for the child who can be cared for effectively in the home environment [3] [9] [17] [18].
In a study about the training with guidelines program, the authors concluded that home care can be as safe as hospital care [17], but the guidelines passed on to caregivers, do not cover only first world countries, according to a study made in South Africa, children can be safely cared for even in an environment with limited resources, but with the applicability of a program about education and appropriate orientation [18].
The consensus elaborated by Sherman et al., shows us that by the time the child goes home from the hospital it is necessary for parents or caregivers to undergo a specific home training given by health professionals [19].Supported by Fiske which indicates how one of the main goals of a home-based program, the family's adaptation and interaction with the child [3].
Physiotherapy may help in the guidelines, clarifying doubts and helping the person responsible for the child to safely and effectively perform techniques at home [3] [11].Recent studies demonstrate the importance of the multidisciplinary team, in discussing why the tracheostomy was performed in the child [11], didactically teach the anatomy of the airways and the respiration's physiology, so that the caregiver understands the changes that have occurred and the child's needs from this moment on [11] [20].
The upper airway of the individual heats, filters and humidifies the inspired air [3].However, in tracheostomized children, the airway is ignored by the presence of the cannula and the air is not filtered and humidified, compromising the mucociliary activity.Consequently there is an increase in the production and thickening of the secretion [16] which may obstruct the TQT cannula [14]- [16].Studies report that the use of the humidifier heats and humidifies the inspired air, keeping the mucus fluidized and reducing the risk of tube obstruction [11].
The aspiration of the TQT tube helps reducing the obstruction.The technique must be performed with caution and only when necessary, it is important not to exceed 15 seconds because it can cause hypoxemia [11].Fraga [4], relate in their research that the aspiration of the TQT tube is primordial, because the tracheostomized child reduces the cough reflex, accumulating secretion in the tube.The caregivers should be alert to signs that the child may present, including cyanosis, restlessness, tachypnea, increase of the respiratory work, audible breathing, desaturation and coughing.Such signs may indicate obstruction of the tube which is the main complication related to the TQT, which may lead the child to an emergency if the problem is not avoided [11].
The caregivers' daily practices with hygiene such as to wash hands and use disposable gloves, to frequently change the suction tubes and sanitize all equipments [3] [19] are fundamental in the home environment, because the respiratory system of the tracheostomized child is more prone to infections and performing aseptic techniques decreases the possibility of contamination [4].
The stoma should also be sanitized and frequently observed.Any change such as redness, fetid odor, rashes and signs of infection must be reported to the doctor [11].These changes can be prevented with some care such as cleaning the air twice daily or whenever needed, with water and mild soap, using gauze and always keeping the spot dry [3], cares that reduce the chance of developing a stoma granuloma or subcutaneous emphysema in the child [13]- [16].
The material that fixes the tracheostomy must also receive care, it should therefore be changed whenever dirty or moist and tied a finger away from the neck [13] [19].Materials for fixing the TQT tube on the child were settled by a consensus of the Pediatric Assembly of the American Thoracic Society, twill tape or velcro may be used.However the care must be the same to prevent moisture and consequently irritability in the child's skin [19].Moreover, caution with the exposure of equipments used or the child itself to cigarette smoke, dust, animal hair and sprays, are also needed in home practice [3] [17].
The baby's garments also deserve attention because turtlenecks may obstruct the air inlet, and clothing should be carefully dressed to prevent accidental decannulation [3] [17].The bath should be monitored at all times, water should not exceed the level of the abdomen and toys in the tub should be avoided because according to the study of Oberwaldner and Eber, children run the risk of bronchoaspirating them during immersion in water [17].

Conclusion
According to the literature review family education in the care of tracheostomized children is essential so that caregivers have full autonomy to safely and effectively conduct the necessary techniques in their homes.