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Transcript Tracheostomies

Managing Respiratory
Distress and complications
post insertion of a
Dr P Chetcuti
Consultant Paediatrician and
Historically-Upper airways obstruction
associated with infections was the most
common indication—Diptheria ,polio and
HIB vaccines
 Now most common indication is fixed
upper airways obstruction and the
requirement for prolonged ventilation
secondary to neuromuscular and
respiratory problems
Changes in last 20 yrs
Prematurity increased from 28% to 58%
 Congenital anomalies increased from 6%
to 23%
 Acquired subglottic stenosis from 2% to
23 %
 Neuromuscular disease from 9% to 23%
 Infectious diseases decreased from 50%
to 3%
Indications for tracheostomy
Unsafe or obstructed airway
 Prolonged mechanical ventilation required
 Tracheobronchial toilet
Alternatives to Tracheostomy
Non invasive ventilation-not a 24hr
solution,not beneficial if fixed severe
 Nasopharyngeal airway
 Palliative care
Upper airways obstruction
Subglottic stenosis
Tracheal stenosis
Craniofacial syndrome - PierreRobin,Charge,Treacher Collins Syndrome,Beckwith
Craniofacial and laryngeal tumours-cystic
Bilateral vocal cord palsy
Obstructive sleep apnoea
Laryngeal trauma-burns,fracture
Long term ventilation,pulmonary toiletBronchopulmonary
Dysplasia,scoliosis,diaphragmatic paralysis
Congenital heart disease in association with
tracheobronchomalacia,diaphragmatic paralysis
and cardiac failure
Neurological/neuromuscular diseaseDuchennee muscular dystrophy,spinal muscular
atrophy,congenital central hypoventilation
syndrome,cerebral palsy,traumatic brain and
spine injury,spina bifida
Increasing no of Tracheostomies in
smaller sicker infants-2kg
 Subglottic stenosis,long term ventilation
for bronchopulmonary dysplasia
 Mortality from tracheostomy related
complications high in this group 5-10%
 More prone to infections
The loss of Auto Peep
Lose the resistance of nose and larynx
 Can effect optimal lung ventilationperfusion relationship
 Makes it more difficult to breath
 May need supplemental oxygen
Age at tracheostomy
< 6 months – 56%
 6 months to 3 yrs- 32%
 3 yrs to 6 yrs – 12%
Tube size
Too small –difficult to breath hypoventilation may
occur especially during sleep
Too large a tube can damage airway mucosaulceration and fibrous stenosis
Cuffed tubes not used in young children
The smaller the tube the more likely the
possibility of speech
Tubes must be changed with growth-approx
every 2 yrs in children under 5
Tube length
Too short- will fall out
 Too long- damage carina or go down r
main bronchus
 At least 2cm from stoma and no closer
than 1 to 2 cm from carina
Tube care
Tube change
 Fixation
 Management of secretions
 Humidification of inspired air
 Management of stoma-clean,protect and
Securing the Tube
How well the tube is secured is more
important than the material- twill
tape,velcro and stainless steel beaded
metal chains
Standard Management
Post op CXR
 3 days intensive care
 1st tube change by doctor who created
 Tube change weekly
As frequently as required
 Instillation of boluses of saline ?
 Minimum morning after waking and pre
Passive Humidifiers
Nose,pharynx,larynx and trachea acts as a
filter,heater and humidifier of inspired air
Not available with Tracheostomy
May damage the airway structurally and
Ok if ventilated
nebulised saline
Artificial ‘noses’
Vigilant,well trained and properly equipped
care giver
 Risk-age,size of tracheostomy,degree of
airway obstruction,behaviour of
child,underlying pathology,the presence of
other underlying medical conditions and
the social environment
 No monitoring devices are ideal
Monitoring in hospital
Cardiorespiratory monitoring
 Oximetry
Early complications
Pneumomediastinum and pneumothorax
Accidental decannulation-reduced with stay
sutures-small curved artery clamp should be
available at bedside plus 2 spare tracheostomy
tubes(one smaller)
Tube blockage-frequent suctioning required to
Subcutaneous emphysema-avoided by using
appropriate sized tube and not making wound
too tight
Local infection-can produce excessive
granulation tissue-can make it difficult to
reinsert tube
Late complications
Difficult decannulation
 Psychological dependance
 Tracheal granulomas-due to trauma at
distal end or excessive suctioning +/infection
 Accidental decannulation-mortality 2%
 Suprastomal collapse and tracheal
Late complications
Persistent tracheocutaneous fistula-1942%
 Effect on speech and language-age at
time and length of time
 Erosion into the innominate artery
 Tracheo-oesophageal fistula
Failure of decannulation
Peristomal pathologygranulations,suprastomal collapse,stomal
 Granulations-surgical
removal,laser,?potassium titanyl
 Underlying pathology not adequately
Rigid or flexible bronchoscopy every 6 to
12 months
Causes of death associated with
Accidental decannulation
 Tube obstruction-increasing likely in small
infants—narrrow airay,narrow
tubes,copious viscid
secretions(bronchopulmonary dysplasia)
 11% mortality under 6 months of age(0.5
to 3%)
Tube Blockage
Obstructive breathing
 Cant clear secretions on suctioning
 Urgent tube change required
Signs of Chest Infection
Thick discoloured secretions
 +/- Unwell off feeds drowsy
 +/- pyrexia
 +/- Tachypnoeic/chest wall recession
 +/- CXR changes
 Secretions for viruses
Increased risk of lower respiratory
 Treat with oral or gastric antibiotics
 Infections around tracheostomy-good
wound care +/- antibiotics—may leed onto
mediastinitis if not treated optimally
 Colonisation commonpseudomonas,MRSA and staphyloccus
Other respiratory management
? Salbutamol spacer/nebuliser
 ? Ipratropium spacer/nebuliser
 ? Steroids—spacer/nebulise/oral
 IV antibioics
 ? Montelukast
 ? nebulised hypertonic saline
 ? Dnase
 ? Nebulised antibiotics
Speaking valves
Various different types
 Attaches to the open end of tracheostomy
 Valves close on expiration directing air into
the upper airway and across the larynx
 May be used in infants
 Make it more difficult to breath
Speaking valves-contraindications
Presence of severe obstruction
 A laryngectomy
 With cuffed tubes
 In the presence of excessive secretions
 With gross aspiration
 With bilateral adductor cord palsy
Challenge of giving oxygen
Side tubing
 Masks
 Cpap
 Do not rely on oxygen sats as an indicator
of a blocked tube
Oral Feeding
May deteriorate temporarily or
permanently after tracheostomy
 Depends on pre tracheostomy feeding
 Difficult in prems and ex prems
 Nasogastric feeds and Gastrostomies
sometimes required
 Milk in tracheal secretions is not good
Speech development
Other factors-prolonged
problems,chronic middle ear problems,
lack of normal feeding experiences, lack of
muscle strength
 Do better if decannulated early
 Speech therapy
 Speaking valves
 Sign language
Home care
Tube –change,fixation,suctioning-shallow and deep
Saline instillation
Suction equipment
Clean technique
Application of drugs
Stoma care
Monitoring-continuous presence of a competent carer
monitoring device ?
Clothing-not fluffy,dressing and undressing must not be over the
Home care
Adaptations –electrical sockets,storage
 Transportation
 Safety-smoke,pets,household sprays
 Extra support
 Time in hospital day and night prior to
discharge is required
 Lots of support required
Organisation of services
Dedicated Nurse specialists
 Specialist multidisciplinary clinics
 Children should not be transferred to
hospitals if nurses not adequately trained
in smaller hospitals
 Resources ‘Stretched’in larger hospitals