Transcript Document

Tracheostomy Tubes:
A Primer
Tamara Simon, M.D.
Cloy Vaneman, R.T.
Special Care Clinic
July 2004
Purpose
• Used in children with:
– Upper airway obstruction
– Inability to clear secretions
– Require prolonged mechanical ventilation
Procedure
• Placed operatively
– Done by ENT or (rarely) general surgery
– Placed at the level of the second or third tracheal rings
– Couple of stay sutures are placed to hold trachea to
skin,
• Help locate trachea if tracheostomy cannula becomes
dislodged
• Are removed as stoma matures
• Generally stay in PICU until sutures are removed and Surgery
performs first tracheostomy change (POD 5)
• Placed percutaneously
Procedure (continued)
• Variety of tracheostomy tubes are available
• Differ in:
–
–
–
–
–
–
Construction material (silicone, polyvinyl chloride)
Diameter (size based on internal)
Length (2 cm beyond stoma, 1-2 cm from carina)
Curvature (distal portion concentric with trachea)
Obdurators (generally not used with well defined stoma)
Cuffs (usually cuffless in peds because the airway lumen is small
with the cricoid ring as the narrowest portion)
– Presence of internal cannula (mostly single in peds)
– Valves
– Fenestrations (difficult to place and therefore rare in peds)
Pediatric tracheostomy tubes:
cuffless with obdurators
Pediatric tracheostomy tubes:
cuffed with obdurators inserted
Pediatric tracheostomy tubes:
external and internal cannula
Pediatric tracheostomy tubes:
approximate sizes
Shiley Holinger
Portex Bivona
Berdeen ETT
Suction
Premature 00
00
3.0
2.5-3.0
---
2.5-3.0
6 Fr
Newborn
0
0
3.0
3.0-3.5
3.5
3.0-3.5
6 Fr
0-6 mo
0-1
1-2
3.5
3.5-4.0
3.5-4.0
3.5-4.0
6-8 Fr
6-12 mo
1-2
2-3
4.0
4.0-4.5
4.0-4.5
4.0-4.5
8 Fr
12-24 mo
3
3
4.5
4.5-5.0
5.0
4.5-5.0
8 Fr
3-6 yr
4
4
5.0
5.0
5.0
5.0
8-10 Fr
7-10 yr
4
5
5.0
5.0-6.0
6.0
6.0
10 Fr
10-12 yr
6
6
6.0
6.0-7.0
6.0
7.0
10 Fr
12-14 yr
6
6
7.0
7.0
7.0
7.5
10 Fr
Complications
•
•
•
•
•
Dislodgement or decannulation of tube
Obstruction of tube
Infection
Hemorrhage
Pneumothorax/ pneumomediastinum
Complication: Decannulation
• Common event
– Usually families replace themselves
– Replace the cannula with the same size and model
tracheostomy tube; refer to table for comparable brands
if not available
– Smaller size should be readily available
– Remove inner cannula
– Obdurator should be inserted into lumen of outer
cannula before insertion
– Apply water-soluble lubricant
– Extend patient neck using shoulder roll
Complication: Decannulation
–
–
–
–
Insert tube into stoma in smooth, curved motion
No resistance should be felt
Insert to length of original tube
If necessary, smaller caliber tube such as suction
catheter, nasogastric tube, or red rubber catheter can be
inserted to serve as a guide
– BMV can be done if necessary (unless there is sever
subglottic stenosis or suprastomal granuloma)
– Position confirmed by feeling respiration or bag
ventilation through tube, or CXR
– Once confirmed, secure tube using tracheostomy ties
that are tight but allow passage of one finger; inflate
cuffed tubes
Complication: Obstruction
• Many tracheostomies accumulate dried secretions
– Occurs in spite of regular maintenance and care, including
suctioning which is taught to families
– Prevention with humidifcation of air is critical
– Narrow the cannula lumen, making occlusion with mucus or other
debris easier
– Secretions can create ball-valve obstruction
• Attempt suctioning using largest diameter possible
and sterile saline to loosen secretions using clean
technique for <5 seconds
• If respiratory distress continues, replace new
cannula
• Granulomas which occlude cannula can be treated
with silver nitrate
Complication: Infection
• Peritracheal cellulitis
– Can be treated with oral antibiotics and local wound
care
– Can be complicated by mediastinitis
• Lower respiratory tract infections
– Risk factors include weak cough, decreased ciliary
action, and direct access to trachea
– Seen with change in quality, quantity, odor, and color of
secretions
– Can be complicated by pneumonia
– Consider coverage for pathogens which colonize the
tracheostomy, to include Staph aureus, Pseudomonas ,
and Candida albicans
Complication: Hemorrhage
• Common in immediate postoperative
period, usually well controlled
• Tracheoinominate artery fistula is a rare but
life-threatening complication (1-2%)
• Develops from inferiorly positioned
tracheostomy, migration of stoma inferiorly,
or high-lying inominate artery
Complication: Pneumothorax/
Pneumomediastinum
• Seen in immediate postoperative period
• Can develop if a false tract in ventilated
• Obtain CXR immediately post-operatively
Other Considerations:
Tracheostomy Placement
• Speech therapist should be consulted after
tracheostomy to facilitate speech and swallowing
• Education of family members is critical
• Skilled home nursing care is necessary for a
transitional adjustment time after tracheostomy
placement
• Financial considerations are often large
• Routine evaluation with bronchoscopy every 6-12
months to assess airway pathology, detect and
treat complications (granulomas), assess tube size
and position, and determine readiness for
decannulation
Other Considerations:
Tracheostomy Removal
• Criteria:
– need for tracheostomy tube is no longer present
– patient is able to maintain adequate airway with
tracheostomy
• One stage decannulation:
– Endoscopic evaluation of airway during spontaneous
breathing with and without tube
– Requires considerable experience
– In-house monitoring required for 24-48 hours
Late Postoperative Complications
of Pediatric Tracheostomy
•
•
•
•
•
•
•
•
Suprasternal collapse
Tracheal wall granuloma
Tracheomalacia
Tracheoesophageal fistula
Depressed scar
Larynogotracheal stenosis
Recurrent tracheitis/ bronchitis
Tracheal wall erosion
Further Questions
•
•
•
•
Questioning potential complications?
Get a chest radiograph
Consult Pulmonary Rehab
Consult pulmonologist or surgeon who
originally placed tracheostomy
References
• Teoh DL. Tricks of the Trade: Assessment
of High-Tech Gear in Special Needs
Children. Clinical Pediatric Emergency
Medicine. 3(1), March 2002.
• ATS Guidelines: Care of the child with a
chronic tracheostomy. Am J Respir Crit
Care Med 2000; 161; 297, July 1999.