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Tracheostomy in children

Background

Advances in medical care have led to a growing population of children assisted by respiratory technology, who require a substantial amount of attention from their providers and parents. The following information has been assembled to assist health care providers in understanding the background, care issues, and complications associated with tracheostomy tubes.

Descriptive terms

Tracheotomy - a surgical incision between the 2nd and 3rd tracheal rings, designed to provide an airway that bypasses the epiglottis.
Tracheostomy - the stoma or opening that results from the tracheotomy.
Decannulation - the process of removing or weaning the patient from tracheostomy dependence. Without the presence of the tracheostomy tube, the stoma will spontaneously close within hours or days.
Parts of a Tracheostomy Tube (commonly abbreviated to "trach" or "trach tube")
  • Inner cannula - the "sleeve" inside of the tracheostomy tube that can be removed for cleaning.
  • Neck plate (flange) - site for ties; prevents movement and skin-breakdown secondary to pressure points.
  • Obturator - a guide for positioning the actual trach tuve.
  • Cuff - inflates with air inside the trachea to seal the tracheal airway, preventing aspiration and potential air leak around the cannula. Cuffed trach tubes are used primarily for patients who require mechanical ventilation with high pressures to minimize risk of aspiration and aid management of airway pressures. [Sherman: 2000] For patients requiring only nocturnal ventilation, the cuff can be deflated during the day. Uncuffed trach tubes are preferred over cuffed tubes in most cases.
  • valve - a one-way valve placed over the external opening of the trach that allows air to pass through the trach only during inhalation. During exhalation the valve closes and air is forced around the trach tube (if a cuff is not present) into the oropharynx to permit phonation and speech. The Passy-Muir is a popular choice for a speaking valve. See
www.passy-muir.com

Types of Tracheostomy Tubes
Composition - The tube material is chosen on desired flexibility. Metal tubes (e.g., Jackson ) are rigid. Silicone tubes (see Bivona) are very flexible. Polyvinyl chloride, or PVC (e.g., Shiley ) tubes may be flexible or rigid.

Types of cannulas
Double-cannula tube - Contains a removable, inner cannula. Double-cannula tubes are used mostly for children with thick, copious secretions. [Sherman: 2000] Cleaning the inner cannula avoids frequent tracheostomy tube (outer cannula) changes. Can be cuffed or un-cuffed depending on the indication.
Single-cannula tube - Used mostly for infants and small children. Single-tubes are typically plastic and uncuffed.
Fenestrated tube - Contains an opening on the superior portion of the cannula, where air can travel from the vocal cords, into the cannula, and up through the fenestration to the oropharynx. This allows the patient to vocalize but requires manual obstruction of the tube, unlike when using a speaking valve.

Humidification

Bypassing the upper airway can lead to a humidity deficit of inspired air. This lack of humidity can lead to pathologic airway changes including loss of ciliary action, thickening of mucous secretions, and cellular desquamation. [Van: 1986]Passive humidifier use in adults with tracheostomy correlates with improved secretion viscosity, lung function, and sputum production. [Vitacca: 1994] The American Thoracic Society recommends the humidification of inspired air through a tracheostomy with the following regulations.
  • The air temperature should be 32-34 deg C
  • The relative humidity should be 100%
  • The absolute humidity should be 33 to 37 mg of H2O / L.
[Sherman: 2000]

Tracheostomy Care

Supplies Pediatric Trach Tubes - Online Medical Supply Store is an on-line vendor for comparison of prices and other information.
Changing Tracheostomy Tubes Recommended frequencies for tube changes range from daily to monthy. [Lichtenstein: 1986] [Fitton: 1994] There is no consensus regarding the frequency of changing by the American Thoracic Society. [Sherman: 2000] Advantages of frequent tube changes include the potential of decreasing airway infection, granulomas, and the incidence of tube blockage by trapped secretions. [Sherman: 2000] Disadvantages of frequent tube changes include patient discomfort, and the potential of stretching the stoma site when cuffed tubes are changed. [Sherman: 2000] All tubes should be inspected for cracking or splitting prior to re-insertion. Duration of use prior to splitting or cracking is dependent of tube composition. Metal tubes can be used indefinitely if no cracking is observed. Silicone tubes do not stiffen after repeated use, although cracks and tears can occasionally develop. PVC tubes stiffen over time, and may be used in a patient no longer than 3 to 4 months. [Sherman: 2000]
Tracheostomy Ties Tracheostomy ties are made from twill tape, Velcro, and stainless steel (bearded chain form). The American Thoracic Society committee on trach care has found no superiority of a particular type of tie material.Tension on the tie should be that one finger can be placed beneath the tie without difficulty.Ties should be kept clean and dry. Skin breakdown has been seen more with narrow ties than wide ties. [Sherman: 2000]
Suctioning
Cleaning the suction catheter: The American Thoracic Society recommends a four step cleaning process for suction catheters. This cleaning procedure demonstrated sterility in 98% of all suction catheter exteriors and 91% of all suction catheter interiors up to 20 days after cleaning. [American: 1993]
  • Wash and flush the catheter with hot, soapy water
  • Soak the catheter in a vinegar-and-water solution or a commercial disinfectant.
  • Allow the catheter to air dry.
  • Non-sterile, disposable gloves should be worn during suctioning.
  • Rinse the outside and inside of the catheter with clean water
  • All caregivers should wash their hands before and after suctioning.
Suctioning depth: Epithelial damage and inflammation of the trachea distal to the end of the trach tube have been demonstrated with routine deep suctioning. [Runton: 1992] [Hodge: 1991] A pre-measured technique is recommended for suctioning. Premarked catheters are strongly recommended to ensure proper depth of suctioning. [Sherman: 2000]
  • Measure the length of a trach tube cannula that is the same size as currently used in the child.
  • Correlate the length of the cannula with the side-holes on the suctioning catheter. Insert the catheter to this length.
  • Slowly remove the catheter with a twirling or rotation motion to reduce friction and increase the surface area of the cannula that is being suctioned.
Suctioning frequency: Routine suctioning frequency depends on the clinical status of the child and the amount of secretions produced. For children with little or no secretions, suctioning is still recommended at morning and bedtime to check for tube patency. [Sherman: 2000]

Complications

Up to 50% of children with tracheostomy will experience complications. Risk factors for complications include younger age (less than 3 yrs of age), prematurity, emergent vs. elective tracheotomy, and duration of cannulation (11% with tracheostomy less than 100 days, 55% for 100-500 days, and 80% for greater than 500 days). [Arcand: 1988] [Kenna: 1987] [Ward: 1995] [Wetmore: 1982] [Gianoli: 1990]

Known complications include:
  • Mucous Plugs Mucous that significantly obstructs air movement through the trach tube will result in respiratory distress. Resistance against the plug can sometimes be felt when attempting to suction. Unsuccessful removal of the plug and continued respiratory distress requires immediate medical evaluation.
  • Accidental Decannulation Parents should always have a trach tube of one-size smaller available in case a same-sized trach tube will not advance. If re-placement of a trach tube is unsuccessful, then immediate medical evaluation is necessary. In some cases, the child can breathe through the stoma until the trach tube is re-placed.
  • Blood in tracheal secretions Frank blood in the tracheal secretions could be indicative of a catastrophic hemorrhage, which requires immediate medical evaluation. Catastrophic bleeding occurs from tracheal erosion into a major artery. Bleeding from suction trauma can also occur. The amount of bleeding typically is very small (pink or red streaks in the mucous).

Resources

Information & Support

For Professionals

http://www.tracheostomy.com/
Helpful to those caring for a child with a tracheostomy, or to anyone seeking to learn more about tracheostomies.

For Parents and Patients

Aaron's Tracheostomy Page
Created by Cynthia Bissell, RN; a great reference for parents, with easy-to-understand descriptions without heavy medical terminology.

Care of the Child with a Chronic Tracheostomy
Comprehensive article on the American Thoracic Society (ATS) site; includes pictures, recommendations, and guidelines from the 1999 Consensus Panel statement on tracheostomy care for children.

Authors

Author: Lisa Samson-Fang MD, 10/2009
Content Last Updated: 5/2011

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