You’ve got this! Tracheostomies in children – what to do and teaching caregivers to do it too!�

Robin Kingston, CRNP

Objectives

• Identify the indications for tracheostomies in children.
• Differentiate the various types of tracheostomy tubes
• List complications of tracheostomies
• Describe current care of tracheostomies in children

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Disclosures

• None

Tracheostomy

• Definition
• The anastomosis of the trachea to the skin
• The surgical procedure by which a cannula is introduced into the trachea in order to establish direct communication with the external environment
• Can be done as emergent or elective procedure
• Temporary vs. permanent

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Indications

• Upper airway obstruction
• Subglottic stenosis
• Congenital/acquired
• Tracheomalacia/tracheobronchomalacia
• Congenital/acquired
• Bilateral vocal cord paralysis
• Facial trauma
• Foreign body

Indications

• Upper airway obstruction
• Craniofacial syndromes
• Pierre-Robin sequence, Treacher-Collins syndrome
• Tumors
• Larynx, trachea, pharynx and tongue, hemangioma
• Sleep disorders
• Collapse of pharyngeal musculature, enlarged adenoids

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Indications

• Need for long-term mechanical ventilation
• Pulmonary disease
• Neurologic and neuromuscular disease
• Brain tumors
• Diaphragm paresis
• Prolonged intubation

Complications

• Children suffer 2-3 times more tracheostomy morbidity and mortality than adults
• Early complications
• Bleeding
• Pneumothorax
• Pneumomediastinum
• Tracheoesophageal fistula
• Accidental decannulation
• Obstructed tube
• Infection of surgical sites
• Tracheal laceration
• False track

Complications

• Late complications
• Tracheitis
• Granulation tissue formation
• Obstruction (mucous plugging)
• Accidental decannulation
• Tracheoesophageal fistula
• Bleeding

Trachestomy tubes

• A tracheostomy (trach) tube is a curved tube that is inserted into a tracheostoma.
• Several brands
• Similar parts

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Single cannula Shiley Pediatric Tracheostomy tube

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Obturator to left

Parts of a tracheostomy tube

Bivona Flex tend silicone uncuffed tube

Bivona tight to shaft cuffs

• TTS™ (tight-to-shaft) tubes have the profile of an uncuffed tube with the insurance of a cuff, if and when needed.

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Bivona Air Cuff Tubes

• Aire-Cuf® neonatal and pediatric tracheostomy tubes provide a traditional cuff management option.
• Aire-Cuf® tubes provide better control when high PEEP or high PEAK pressures are needed�

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Bivona Fome Cuff Tubes

• Fome-Cuf® tubes can breathe with the patient to provide a safe, effective, and low pressure seal throughout the ventilatory cycle

Adjustable Length Tubes

• Adjustable neck flange tracheostoAdjustable neck flange tracheostomy tubes are intended for temporary use until the proper length fixed neck flange tube can be obtained.
• Adjustable neck flange Hyperflex™ tracheostomy tubes can be adjusted for both horizontal and vertical shaft drop to accommodate unusual anatomy or pathology

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Tracoe Pediatric Tracheostomy Tube

Tracoe Twist

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So how do you take care of a tracheostomy and teach parents too?

There is not a lot of evidenced based research for caring for children with chronic tracheostomy tubes

OFFICIAL STATEMENT:�CARE OF THE CHILD WITH A CHRONIC TRACHEOSTOMY�

The American Thoracic Society�1999

Which trach tube?

• Must fit airway and needs of patient

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• Appropriate shape and length to be secure and to fit without out undue pressure on the neck or trachea

Which trach tube?

• Should extend at least 2cm beyond stoma and not be closer than 1-2cm to carina
• Diameter should be chosen to avoid damage to trachea wall, minimize work of breathing, and when possible, promote translaryngeal airflow
• Curve should be such that the distal portion of the tube should concentric and colinear with the trachea

Which trach tube?

• Flexibility of the tube needs to be considered
• Metal tubes may be used in special circumstances (stent after reconstruction)
• Tubes with inner cannula may help when very thick secretions
• Silicone will conform to the airway shape (quite flexible)

Which trach tube?

• Cuffed tubes – with ventilation, to minimize risk of aspiration
• Cannot talk if cuff inflated
• Uncuffed preferred over cuffed in most instances
• Cuffs can be high volume/low pressure or low volume/high pressure

Which Trach tube?

• Fenestrated or No?
• Not generally recommended in Peds
• Strong feeling from experts is that fenestrated tubes promote growth of granulation tissue at the area of the fenestrations. (no real evidenced to back this up)

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Which Trach Tube?

• Custom vs. Standard (off the shelf product)
• Off the shelf products work for majority of patients
• Custom are used for various reasons
• Tracheomalacia
• Trach tube too short – accidental decannulations
• Airway anomaly

Frequency of trach tube change

• In Pediatrics
• Weekly tube changes is what is most commonly recommended
• No real consensus regarding this issue
• If secretions are thick and families are having to change earlier than 7 days some will just go every 5 days in order not to have an emergency trach change
• Older kids with adult size tubes – every 2-4 weeks

Suctioning

• Clean vs. Sterile Technique
• In the hospital we use sterile technique
• At home, caregivers will use a clean technique
• All caregivers should wash hands
• Clean disposable gloves should be worn by any caregiver who is not a family member

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Suctioning

• Reuse suction catheters?
• YES!!!
• Limited number of supplies in the home
• How do you reuse?
• After suctioning, rinse the catheter with distilled water
• The outside of the catheter can be wiped with alcohol
• Place the catheter back in it’s plastic sheath

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Suctioning

• Resterilization of suction catheters
• Wash and flush used catheters with hot, soapy water
• Disinfect catheters by soaking in a vinegar-and-water solution or a commercial disinfectant
• Rinse catheters inside and out with clean water
• Air dry

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Suctioning

• The cleanliness of the outside of the catheter is more important than the cleanliness of the internal surface of the catheter.

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Suctioning Depth

• Premeasured Technique
• The catheter is inserted into the tube with the most distal side holes just exiting the tip of the tracheostomy tube
• This technique is recommended for all routine suctioning
• Prevents injury to the airway

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Twirl or Swirl?

• Suctioning technique should also include twirling or rotating the catheter between the fingers and thumb, not stirring the catheter with the entire hand.
• This reduces friction, so that the catheter is more easily inserted, and moves the side holes of the catheter in a helix, thereby suctioning all areas of the tube wall.

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How often should you suction?

• Suctioning as needed is most frequently recommended.
• Will vary on the basis of individual characteristics including age, muscular and neurologic status, activity level, ability to generate an effective cough, viscosity and quantity of mucus, and maturity of the stoma

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How often should you suction?

• Should be done on the basis of clinical assessment
• In children with no evidence of secretions, a minimum of suctioning in the morning and at bedtime to check tube patency is recommended

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Do you need to do bag ventilation when you suction?

• Really depends on the patient
• End tidal CO2 measurement and oxygen saturations can guide decision making
• If bag ventilation is needed, make a pass with a suction catheter prior to bagging the patient

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Why suction before bagging?

• To deliver a manual breath when secretions are bubbling in the tube only serves to force these secretions into the more distal parts of the airway

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Should normal saline be used with suctioning?

• Has been considered useful to help stimulate a cough, loosen or thin secretions, lubricate the catheter, or serve as a vehicle for mucus to be removed from the airway

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Should normal saline be used with suctioning?

• There actually is research on this!!!
• Studies do not demonstrate the efficacy of normal saline in thinning mucus
• Also can be associated with undesirable outcomes such as decrease in oxygen saturations and contamination of the lower airways with unsterile saline
• Consensus is that the routine instillation of normal saline is not recommended

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What size suction catheter?

• Largest catheter that will fit into the tube is what is recommended
• A large-bore tube will remove secretions more efficiently that a smaller size tube

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Suction Pressure

• Pressures of 80-100 mm Hg are typically used for pediatric patients
• More important is the ability of the machine to generate adequate vacuum to efficiently suction the mucus in a few seconds
• Suction should be applied both while inserting and removing the catheter and should be adequate to efficiently remove secretions with a rapid pass of the catheter (IF USING PREMEASURED TECHNIQUE)

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Duration of suction

• The literature typically recommends limiting deep suctioning to 15 seconds or less.
• A premeasured technique should take 5 seconds or less (again with suction on the way in as well as on the way out).

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• Suctioning on way in and out is only with regular catheter

In-line suction catheter

What type of trach tube holder?

• At least 3 materials are used for tracheostomy ties
• Twill tape
• Manufactured Velcro ties
• Stainless steel beaded metal chain

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Dale Velcro Trach Tube Holder

Stainless Steel Trach Tube Holder

Trach Tube Holder

• The most important aspect of choosing a trach tie is not the material but how well the tie is secured
• There is no consensus regarding the routine frequency of tie changes
• We recommend at least daily

Humidification

• Humidifier
• Heated or cool mist
• Preference is heated

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Humidification

• Heat Moisture Exchanger – HME
• Also called artificial nose

Speaking valves

Speaking Valves

• One way diaphragm – allows patient to inhale via trach but not exhale forcing air around trach tube and up through vocal cords and out the mouth and nose
• Must have large enough air leak around the tube to allow patient to exhale
• If have trach cuff MUST BE DEFLATED!!

Tracheal Caps

Decannulation

• To be considered, patients mush have a reliable history of tolerating routine trach changes at home without s/s of respiratory distress, thriving and gaining weight, and have no (or very little) need for supplemental O2
• Must be off mechanical ventilation entirely

Decannulation

• Every Center differs in their protocol if they even have a protocol.
• Options
• Downsize tube – start capping
• If tolerates capping – Polysomnogram (PSG)
• Sleep study looks good – bronch and decannulate

Decannulation

• Some centers don’t use sleep studies
• Riley decannulation protocol:
• Bronch (flexible or rigid)
• Sleep lab (within 30 days of bronch)
• Trach removed – stoma covered
• PSG for 4 hours – hopefully both awake and napping
• Admit to floor and then back to sleep lab same night for overnight PSG

Questions???

References

• Al-Samri, M., Mitchell, I., Drummond, D. S., & Bjornson, C. (2010). Tracheostomy in children: A population-based experience over 17 years. Pediatric Pulmonology. doi:10.1002/ppul.21206
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• Basic Pediatric Care: Best Evidence Statement. (2011, June 11). Retrieved 2016, from Cincinnati Children’s Hospital, https://www.cincinnatichildrens.org
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• Care of the child with a chronic Tracheostomy (2000). American Journal of Respiratory and Critical Care Medicine, 161(1), 297–308. doi:10.1164/ajrccm.161.1.ats1-00
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• Cristea, A. I., Jalou, H. E., Givan, D. C., Davis, S. D., Slaven, J. E., & Ackerman, V. L. (2016). Use of Polysomnography to Assess Safe Decannulation in Children. Pediatric Pulmonary, 51, 796–802.
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• Deutsch, E. S. (2010). Tracheostomy: Pediatric Considerations. Respiratory Care, 55(8), 1082–1090.
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• Fraga, J. C., de Souza, J. C. K., & Kruel, J. (2009). Pediatric Tracheostomy. Jornal de Pediatria, 85(2), 97–103.
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• Kent, C. L. (2005). Tracheostomy Decannulation. Respiratory Care, 50(4), 538–541.
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• Pandian, V., Miller, C. R., Schiavi, A. J., Yarmus, L., Contractor, A., Haut, E. R., … Bhatti, N. I. (2014). Utilization of a standardized tracheostomy capping and decannulation protocol to improve patient safety. The Laryngoscope, 124(8), 1794–1800. doi:10.1002/lary.24625
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• Tracheostomy and Decannulation. Retrieved 2016, from The Children’s Hospital of Philadephia, http://www.chop.edu/treatments/tracheostomy-and-decannulation
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• Trachsel, D., & Hammer, J. (2006). Indications for tracheostomy in children. Paediatric Respiratory Reviews, 7(3), 162–168. doi:10.1016/j.prrv.2006.06.004
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• Use of Tracheostomy with a Child. (2016, April ). Retrieved from American Thoracic Society, https://www.thoracic.org/.../tracheostomy-in-child
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