- Email: [email protected]
Tracheostomy in children
PAEDIATRIC RESPIRATORY REVIEWS (2006) 7S, S206–S209
Tracheostomy in children G. Michael Davis Division of Respiratory Medicine, Montreal Children’s Hospital, 2300 Tupper, Montreal, Quebec, Canada H2H 1P3 KEYWORDS Tracheostomy; Children; Complications; Home care therapies
Summary Indictions, timing, and interventions to the airway resulting in tracheostomy are poorly characterised. There are no promulgated standards of care for tracheostomy in childrene. This paper addresses the issues associated with decision for tracheostomy, the timing of the intervention, the care for the tracheostomy in both the acute and chronic phase and the necessities for care at home. The paper attempts to describe some of the apparent problems associated with tracheostomy and practical techniques for treatment of the inadvertent complications. ß 2006 Published by Elsevier Ltd.
Tracheostomy means, literally, ‘‘a hole (ostomy) connecting trachea to outside of body’’, The first tracheotomy was reportedly performed in Rome in the second century B.C. Antyllus in the second century A.D. further refined the technique. He suggested that the trachea be divided between the third and fourth tracheal rings using a transverse incision. Mabicot is credited with performing the first pediatric tracheotomy in 1620. In contrast to adult literature, it is an interdisciplinary area in pediatrics and pediatric otolaryngology that is changing rapidly, and is not well nor rigidly formulated. Some of the literature included premature babies and newborns or infants only. In reviewing recent (post-1990) literature, 56% of all patients were less than 6 months old, 32% were 6 months until 3 years, and 12% were between 3 and 6 years of age. Among the indications for tracheostomy, premature birth increased from 28% to 58%, congenital anomalies from 6% to 23%, acquired subglottic stenosis from 2% to 23%, and neuromuscular disease from 9% to 23% (a combination of several indications was possible). At the same time, the indication for infectious diseases declined from 50% to 3%. In the 1970s it was still recommended that a patient receive a prophylactic tracheostomy if it was foreseeable that the patient would have to be ventilated for more than 8 days. Newer studies recommend that the indication for pediatric tracheostomy also should be decided individually E-mail address: [email protected] 1526-0542/$ – see front matter ß 2006 Published by Elsevier Ltd. doi:10.1016/j.prrv.2006.04.228
according to clinical and endoscopic findings. The intubation periods in these studies ranged from 2 to 134 days (on average, 31 days) although in 1992 Puhakka quoted an average intubation period of 65 days before performing a tracheostomy. In one study the indications for tracheostomy were categorized into 3 groups: (1) unsafe or obstructed airway meadin time 59 days, (2) prolonged mechanical ventilation required (median time 4 years), and (3) tracheobronchial toilet or risk of aspiration (median time 10 years). The indications for hospital admission were categorized according to the primary system that was affected; the traumacategory encompassed patients with multiple-system injuries from motor vehicle accidents.
REASONS FOR ADMISSIONS Respiratory Anatomic upper airway obstruction Respiratory infection Respiratory arrest Trauma Closed head injuries with multiple fractures Neurologic Infection of central nervous system Hypoxic brain injury Epilepsy Cerebral hemorrhage from arteriovenous malformation
37 26 6 5 11 11 8 4 2 1 1
TRACHEOSTOMY IN CHILDREN
Cardiovascular (cyanotic heart disease) Gastrointestinal Other (malignancy, sepsis) Total
S207
4 2 3 65
REASONS FOR TRACHEOSTOMY Unsafe or obstructed airway Subglottic stenosis Subglottic hemangioma Vocal cord palsy Other (craniofacial syndromes, glossoptosis, pharyngeal hypotonia, epiglottitis) Mechanical ventilation Central nervous system abnormality Cyanotic heart disease Respiratory failure Respiratory infection Sepsis Tracheobronchial toilet or aspiration risk Trauma-related head injury Hypoxic brain injury Intracerebral hemorrhage Respiratory infection
36 13 4 4 15 15 5 4 4 I 1 14 10 2 1 1
The median PICU stay was 25 days (range 7–259 days), and a median hospital stay of 52 days (range 5–472 days). A substantial number of patients still have tracheostomy in place (64% decannulation rate). The majority were those with unstable airway/mechanical ventilation, especially where further surgical intervention was needed. The overall mortality rate was high at 18%; but was usually due to unrelated causes. The early complication most frequently mentioned in the literature is the development of interstitial air (emphysema, pneumomediastinum, pneumothorax). than 12 months is up to 43%, but is lower in infants less than 12 months, 28%, presumably because the children are less active. The complications that most often result in death are accidental decannulation and cannula obstruction. These may happen immediately after the operation as well as during the entire following period. Some of the most frequent late complications are the appearance of granulations, laryngeal stenosis, and tracheal stenosis. The complication rate of our patient group was 56%, 36% being caused by granulations, which possibly do not need to be evaluated as a complication. Cannula obstruction occurs in children older than 1 year at a rate of up to 14%; in premature babies and newborns, however, it occurs at a rate of up to 72%. The much higher rate of cannula obstruction in premature babies and newborns seems to be related to the narrow inner radius of the small tracheostomy cannulas as well as to the fact that almost half of the patients suffer from a bronchopulmonary dysplasia, which goes along with the development of viscous bronchial secretion. Accidental cannula dislocation and decannulation can happen at any time and, unfortunately,
often remains unnoticed. This occurs in premature babies and newborns in up to 7% and in older children in up to 16%. MacRae found mortality rates of 24%, 15%, and 10% in the groups greater than 36, 12 to 36, and 6 to 12 months, whereas the mortality rate of children less than 6 months was 33%. All deaths in the first 3 groups were caused by the underlying illness, whereas 11% of the deaths in the group of children younger than 6 months were tracheostomy related. In the same study, almost every second child younger than 3 years had complications, the children older than 3 years, however, only had complications in 15% to 20% of cases. Tracheostomy tubes are indicated in cases of upper airway obstruction, for children who cannot protect their airway, and for patients with long-term mechanical ventilation. Children usually remain hospitalized until the first tube change, which allows some maturation of the stoma. Optimal tracheostomy care starts with the proper tube of appropriate size and shape to fit the airway without exerting pressure on the tracheal mucosa. It also must fit well enough to prevent aspiration (if that is its primary purpose) or loosely enough to allow translaryngeal air escape for vocalization and mucous clearance. It must have an adequate inside diameter to prevent airflow restriction. This should be tailored to each child’s specific circumstances. Standards of care in the hospital should include 24-hour 1:1 care from a provider trained in acute troubleshooting of tracheostomy complications. Complications include accidental decannulation, creating of a false passage, obstruction, infection, hemorrhage, pneumothorax, pneumomediastinum, peritracheal cellulitis, and lower airway infection. Although accidental decannulation and obstruction are the most common overall complications, they are rarely encountered in the inpatient setting. Because of their acuity, they are rapidly addressed by bedside caregivers and rarely impact the hospitalist directly. Peritracheal infection usually can be treated with oral antibiotics and local wound care, but it can lead to mediastinitis if not addressed. Lower respiratory tract infections are common. Children with tracheostomies are colonized with multiple pathogens, including Staphylococcus aureus, Pseudomonas aeruginosa, and Candida albicans. Empiric antibiotic therapy should reflect this. A rare(1%–2%), life-threatening complication is erosion into the innominate artery,
LIST OF POST-OPERATIVE COMPLICATIONS OF PEDIATRIC TRACHEOSTOMY Suprastomal collapse Tracheal wall granuloma Tracheoesophageal fistula Depressed scar Laryngotracheal stenosis Tracheal wall erosion
Catastrophic hemorrhage Tracheomalacia Tube obstruction or displacement Decannulation failure Recurrent tracheitis/bronchitis Death
S208
SUGGESTED CARE OF TRACHEOTOMISED PATIENT The question is, what guidelines exist to define the manner in which a prudent physician would care for a child with a tracheostomy so that such complications might be minimized? A standard management scheme would include the following: postoperative x-ray films to check tube placement; admission to the surgical intensive care unit, with an average stay of 3 days and an average hospital stay of 7 days (if tracheostomy is the only indication for hospitalization); changing of the first tube by the doctor personally an average of 6 days after initial tube placement; subsequent tube placements every 3 weeks; a follow-up office visit (barring complications) an average of 4 weeks after discharge, followed by subsequent visits every 3 months; and family instruction on tracheostomy care given by both doctors and nurses in verbal and written form covering a broad range of topics. There have been no standards published for their care and disappointingly little research.In most cases the selected tracheostomy tube should extend at least 2 cm beyond the stoma, and no closer than 1–2 cm to the carina. The diameter of the tracheostomy tube should be selected to avoid damage to the tracheal wall, to minimize work of breathing, and, when possible, to promote translaryngeal airflow. Curvature should be such that the distal portion of the in situ tracheostomy tube should be concentric and colinear with the trachea. Assessment of appropriate curvature requires neck/chest radiographs or flexible bronchoscopy. All tracheostomy tubes should have a 15-mm ‘‘universal’’ adapter to allow bag ventilation in an emergency; metal tracheostomy tubes are commonly made without this capacity. Metal tubes are used in special circumstances such as with stents after laryngeal reconstruction. Most metal tubes have an inner cannula but, in small children this can lead to excessively high airway resistance. Tubes with an inner cannula may be useful in some patients with thick copious secretions, which rapidly build up on the walls of the tube. Cleaning the inner cannula avoids frequent tracheostomy changes. In patients for whom a standard polyvinyl chloride tube does not provide an optimal ‘‘fit,’’ a silicone tube will conform to the airway shape and may be a better option. Uncuffed tracheostomy tubes are preferred over cuffed tracheostomy tubes in most circumstances. Cuffed tracheostomy tubes may be used in patients requiring ventilation with high pressures, patients requiring only nocturnal ventilation and patients with chronic translaryngeal aspiration. The exact role for cuffed tracheostomy tubes in children is not defined. There is no consensus regarding the frequency of tracheostomy tube changes. The most common frequency of tracheostomy tube changes is weekly, according to those polled. The most important aspect of choosing a tracheost-
G. M. DAVIS
omy tie is not the material from which the tie is manufactured but how well the tie is secured. At least three materials are used for tracheostomy ties: twill tape, specially manufactured Velcro ties, and stainless steel beaded metal chain. There is no consensus regarding the routine frequency of tracheostomy tie changes. ‘‘Clean technique’’ is defined as the use of a clean catheter and nonsterile, disposable gloves or freshly washed, clean hands for the procedure. Care is taken not to allow the portion of the catheter that will be inserted in the tracheostomy tubeto contact any unclean surface. Clean technique of suctioning is recommended for home care. After suctioning is complete, the catheter is flushed with tap water until secretions are cleared from the lumen; the outside of the catheter is then wiped with alcohol and allowed to air dry. Individual catheters can be used as long as the catheter remains intact and allows inspection of removed secretions. d. There are a number of methods available for more thorough cleaning including commercial products, alcohol, and a vinegar and-water soak. Suctioning should be done on the basis of clinical assessment. In children with no evidence of secretions, a minimum of suctioning, at morning and bedtime, to check for patency of the tube is recommended. The routine instillation of normal saline is not recommended. The best monitoring for the child with a chronic tracheostomy is the vigilant, well-trained, and properly equipped caregiver. Children with chronic tracheostomies who are at high risk for airway complications should especially be considered for monitoring. Factors to consider when assessing risk include age, size of the tracheostomy, degree of airway obstruction, behavior of the child, the underlying airway pathology, the presence of other medical conditions, and the social environment. None of the commercially available monitoring devices are ideal. Cardiorespiratory monitors and oximeters provide only indirect evidence of airway compromise and sometimes delayed warnings. End tidal PCO2 monitoring are prone to occlusion. For some high-risk tracheostomy patients who have a history of airway instability, 24-h home nursing may be necessary. Children with chronic tracheotomies should undergo routine evaluation including rigid or flexible bronchoscopy every 6 to 12 mo to assess the underlying airway pathology, detect and treat complications, assess tube size and position, and determine the readiness for decannulation. Patients with rapidly changing medical conditions or patients with rapid growth (such as patients in the first year of life) may require more frequent endoscopic evaluation. There are few published data on surveillance bronchoscopies. An emergency/travel kit is available with the following supplies: manual resuscitation bag of appropriate size, suction source, suction catheter, DeLee suction traps, one tracheostomy tube of current size with ties in place, one tracheostomy tube that is one size smaller with ties in place, extra ties, shoulder roll, 15-mm adapter for children with metal tracheostomy tubes, suction catheter that can
TRACHEOSTOMY IN CHILDREN
be used if necessary to guide new tube through stoma into tract, scissors, emergency phone numbers, brief description of medical history, description of airway status (i.e., does anatomy preclude oral or nasal intubation and/or ventilation through upper airway?).
INSTRUCTIONS TO PARENTS Discuss and implement safety measures. Parents should be instructed to avoid all dust, smoke, lint, pet hair, powder, sprays, small toys, and objects. The child should not be in contact with fuzzy toys, clothes, or bedding. Contact sports and water sports are not permitted. The child may be bathed in 1–2 in. of water with a trained caretaker in attendance. Showers may be permissible in older children. Be aware of and participate in goals and plan for feeding program, occupational therapy, physical therapy, and speech therapy. Be aware of and participate in the plan for return to school/classroom and any out-of-home arrangements, i.e., daycare. Children who are at most risk for a serious episode of tracheostomy obstruction are younger patients who do not yet attend school. However, in older, school-aged children who have a critical airway in which the risk of obstruction is high, a trained caregiver should be in attendance throughout transport to and from school and while in attendance at school. Be aware of monitoring needs, if prescribed. Be able to operate the monitor correctly and act on the information Be aware of projected decannulation plan Discuss the plans for follow-up care
SPEAKING VALVES A tracheostomy speaking valve offers another option for voice production with a tracheostomy tube. A speaking valve is a one-way, removable valve that is attached to the open end of the tracheostomy tube. Speaking valves that are used with children include: the Passy-Muir Speaking Valve (Passy-Muir, Inc., Irvine, CA), the Shiley Phonate Speaking Valve (Nellcor Puritan Bennett, Inc., Pleasanton, CA) and the Montgomery Tracheostomy Speaking Valve (Boston Medical Products, Westborough, MA). Although the Montgomery speaking valves and the Shiley Phonate valves are open-position valves, Passy-Muir
S209
valves use a closed-position design. Open versus closed refers to the resting position of the valve. As implied, openposition valves are maintained in an open position, and the valve closes during expiration. Passy-Muir’s biased closed design remains closed at rest. The Passy-Muir valves open with inspiration and close before the end of the inspiratory cycle and the beginning of the expiratory cycle. Regardless of design, all one-way speaking valves allow air to flow freely from the tracheostomy into the lungs. The valves are closed on exhalation, directing the expired air into the upper airway and across the larynx and out the mouth or nose. Children of all ages, including infants, may be candidates for use of a speaking valve. There are some contraindications for use of a speaking valve, and these include:
presence of severe tracheal or laryngeal obstruction a laryngectomy use of an inflated cuffed tracheostomy tube presence of excessive secretions that cannot be managed adequately gross aspiration bilateral adductor vocal cord paralysis serious illness an unconscious state
FURTHER READING 1. ATS statement. Care of the Child with a Chronic Tracheostomy. Am J Respir Crit Care Med 2000; 161: 297–308. 2. Gluth MB, Maska S, Nelson J, Otto RA. Postoperative management of pediatric tracheostomy: Results of a nationwide survey. Otolaryngol Head Neck Surg 2000; 122: 701–705. 3. Kremer B, Botos-Kremer AI, Eckel HE, Schlondorff G. Indications, Complications, and Surgical Techniques for Pediatric Tracheostomies–—An Update. J Pediatr Surg 2002; 37: 1556–1562. 4. Tantinikorn W, Alper CM, Bluestone CD, Casselbrant ML. Outcome in pediatric tracheotomy. Am J Otolaryngol 2000; 24: 131–137. 5. Carron JD, Derkay CS, Strope GL, Nosonchuk JE, Darrow DH. Pediatric tracheotomies: changing indications and outcomes. Laryngoscope 2000; 110: 1099–1104. 6. Glce Z, Celayir S, Teland GT, Murat NS, Erdojan E, Yeker D. Tracheostomy in childhood: 20 years experience from a pediatric surgery clinic. Pediatr Int 2002; 44: 306–309. 7. Leung, R Berkowitz, RG. Decannulation and Outcome Following Pediatric tracheostomy. Annal Otol Rhinol Laryngol 2005; 114: 743– 748 [PMID 16285263]. 8. Woodnorth GH. Assessing and Managing Medically Fragile Children: racheostomy and Ventilatory Support. Language speech and hearing services in schools 2004; 35: 63–74. 9. Srivastava R, Stone BL, Murphy NA. Hospitalist Care of the Medically Complex Child. Pediatr Clin N Am 2005; 52: 1165–1187. 10. Hadfield PJ, Lloyd-Faulconbridge RV, Almeyda J, Albert DM, Bailey CM. The changing indications for paediatric tracheostomy. Int J of Pediat Torhinolaryngol 2003; 67: 7–10.
Tracheostomy in children G. Michael Davis Division of Respiratory Medicine, Montreal Children’s Hospital, 2300 Tupper, Montreal, Quebec, Canada H2H 1P3 KEYWORDS Tracheostomy; Children; Complications; Home care therapies
Summary Indictions, timing, and interventions to the airway resulting in tracheostomy are poorly characterised. There are no promulgated standards of care for tracheostomy in childrene. This paper addresses the issues associated with decision for tracheostomy, the timing of the intervention, the care for the tracheostomy in both the acute and chronic phase and the necessities for care at home. The paper attempts to describe some of the apparent problems associated with tracheostomy and practical techniques for treatment of the inadvertent complications. ß 2006 Published by Elsevier Ltd.
Tracheostomy means, literally, ‘‘a hole (ostomy) connecting trachea to outside of body’’, The first tracheotomy was reportedly performed in Rome in the second century B.C. Antyllus in the second century A.D. further refined the technique. He suggested that the trachea be divided between the third and fourth tracheal rings using a transverse incision. Mabicot is credited with performing the first pediatric tracheotomy in 1620. In contrast to adult literature, it is an interdisciplinary area in pediatrics and pediatric otolaryngology that is changing rapidly, and is not well nor rigidly formulated. Some of the literature included premature babies and newborns or infants only. In reviewing recent (post-1990) literature, 56% of all patients were less than 6 months old, 32% were 6 months until 3 years, and 12% were between 3 and 6 years of age. Among the indications for tracheostomy, premature birth increased from 28% to 58%, congenital anomalies from 6% to 23%, acquired subglottic stenosis from 2% to 23%, and neuromuscular disease from 9% to 23% (a combination of several indications was possible). At the same time, the indication for infectious diseases declined from 50% to 3%. In the 1970s it was still recommended that a patient receive a prophylactic tracheostomy if it was foreseeable that the patient would have to be ventilated for more than 8 days. Newer studies recommend that the indication for pediatric tracheostomy also should be decided individually E-mail address: [email protected] 1526-0542/$ – see front matter ß 2006 Published by Elsevier Ltd. doi:10.1016/j.prrv.2006.04.228
according to clinical and endoscopic findings. The intubation periods in these studies ranged from 2 to 134 days (on average, 31 days) although in 1992 Puhakka quoted an average intubation period of 65 days before performing a tracheostomy. In one study the indications for tracheostomy were categorized into 3 groups: (1) unsafe or obstructed airway meadin time 59 days, (2) prolonged mechanical ventilation required (median time 4 years), and (3) tracheobronchial toilet or risk of aspiration (median time 10 years). The indications for hospital admission were categorized according to the primary system that was affected; the traumacategory encompassed patients with multiple-system injuries from motor vehicle accidents.
REASONS FOR ADMISSIONS Respiratory Anatomic upper airway obstruction Respiratory infection Respiratory arrest Trauma Closed head injuries with multiple fractures Neurologic Infection of central nervous system Hypoxic brain injury Epilepsy Cerebral hemorrhage from arteriovenous malformation
37 26 6 5 11 11 8 4 2 1 1
TRACHEOSTOMY IN CHILDREN
Cardiovascular (cyanotic heart disease) Gastrointestinal Other (malignancy, sepsis) Total
S207
4 2 3 65
REASONS FOR TRACHEOSTOMY Unsafe or obstructed airway Subglottic stenosis Subglottic hemangioma Vocal cord palsy Other (craniofacial syndromes, glossoptosis, pharyngeal hypotonia, epiglottitis) Mechanical ventilation Central nervous system abnormality Cyanotic heart disease Respiratory failure Respiratory infection Sepsis Tracheobronchial toilet or aspiration risk Trauma-related head injury Hypoxic brain injury Intracerebral hemorrhage Respiratory infection
36 13 4 4 15 15 5 4 4 I 1 14 10 2 1 1
The median PICU stay was 25 days (range 7–259 days), and a median hospital stay of 52 days (range 5–472 days). A substantial number of patients still have tracheostomy in place (64% decannulation rate). The majority were those with unstable airway/mechanical ventilation, especially where further surgical intervention was needed. The overall mortality rate was high at 18%; but was usually due to unrelated causes. The early complication most frequently mentioned in the literature is the development of interstitial air (emphysema, pneumomediastinum, pneumothorax). than 12 months is up to 43%, but is lower in infants less than 12 months, 28%, presumably because the children are less active. The complications that most often result in death are accidental decannulation and cannula obstruction. These may happen immediately after the operation as well as during the entire following period. Some of the most frequent late complications are the appearance of granulations, laryngeal stenosis, and tracheal stenosis. The complication rate of our patient group was 56%, 36% being caused by granulations, which possibly do not need to be evaluated as a complication. Cannula obstruction occurs in children older than 1 year at a rate of up to 14%; in premature babies and newborns, however, it occurs at a rate of up to 72%. The much higher rate of cannula obstruction in premature babies and newborns seems to be related to the narrow inner radius of the small tracheostomy cannulas as well as to the fact that almost half of the patients suffer from a bronchopulmonary dysplasia, which goes along with the development of viscous bronchial secretion. Accidental cannula dislocation and decannulation can happen at any time and, unfortunately,
often remains unnoticed. This occurs in premature babies and newborns in up to 7% and in older children in up to 16%. MacRae found mortality rates of 24%, 15%, and 10% in the groups greater than 36, 12 to 36, and 6 to 12 months, whereas the mortality rate of children less than 6 months was 33%. All deaths in the first 3 groups were caused by the underlying illness, whereas 11% of the deaths in the group of children younger than 6 months were tracheostomy related. In the same study, almost every second child younger than 3 years had complications, the children older than 3 years, however, only had complications in 15% to 20% of cases. Tracheostomy tubes are indicated in cases of upper airway obstruction, for children who cannot protect their airway, and for patients with long-term mechanical ventilation. Children usually remain hospitalized until the first tube change, which allows some maturation of the stoma. Optimal tracheostomy care starts with the proper tube of appropriate size and shape to fit the airway without exerting pressure on the tracheal mucosa. It also must fit well enough to prevent aspiration (if that is its primary purpose) or loosely enough to allow translaryngeal air escape for vocalization and mucous clearance. It must have an adequate inside diameter to prevent airflow restriction. This should be tailored to each child’s specific circumstances. Standards of care in the hospital should include 24-hour 1:1 care from a provider trained in acute troubleshooting of tracheostomy complications. Complications include accidental decannulation, creating of a false passage, obstruction, infection, hemorrhage, pneumothorax, pneumomediastinum, peritracheal cellulitis, and lower airway infection. Although accidental decannulation and obstruction are the most common overall complications, they are rarely encountered in the inpatient setting. Because of their acuity, they are rapidly addressed by bedside caregivers and rarely impact the hospitalist directly. Peritracheal infection usually can be treated with oral antibiotics and local wound care, but it can lead to mediastinitis if not addressed. Lower respiratory tract infections are common. Children with tracheostomies are colonized with multiple pathogens, including Staphylococcus aureus, Pseudomonas aeruginosa, and Candida albicans. Empiric antibiotic therapy should reflect this. A rare(1%–2%), life-threatening complication is erosion into the innominate artery,
LIST OF POST-OPERATIVE COMPLICATIONS OF PEDIATRIC TRACHEOSTOMY Suprastomal collapse Tracheal wall granuloma Tracheoesophageal fistula Depressed scar Laryngotracheal stenosis Tracheal wall erosion
Catastrophic hemorrhage Tracheomalacia Tube obstruction or displacement Decannulation failure Recurrent tracheitis/bronchitis Death
S208
SUGGESTED CARE OF TRACHEOTOMISED PATIENT The question is, what guidelines exist to define the manner in which a prudent physician would care for a child with a tracheostomy so that such complications might be minimized? A standard management scheme would include the following: postoperative x-ray films to check tube placement; admission to the surgical intensive care unit, with an average stay of 3 days and an average hospital stay of 7 days (if tracheostomy is the only indication for hospitalization); changing of the first tube by the doctor personally an average of 6 days after initial tube placement; subsequent tube placements every 3 weeks; a follow-up office visit (barring complications) an average of 4 weeks after discharge, followed by subsequent visits every 3 months; and family instruction on tracheostomy care given by both doctors and nurses in verbal and written form covering a broad range of topics. There have been no standards published for their care and disappointingly little research.In most cases the selected tracheostomy tube should extend at least 2 cm beyond the stoma, and no closer than 1–2 cm to the carina. The diameter of the tracheostomy tube should be selected to avoid damage to the tracheal wall, to minimize work of breathing, and, when possible, to promote translaryngeal airflow. Curvature should be such that the distal portion of the in situ tracheostomy tube should be concentric and colinear with the trachea. Assessment of appropriate curvature requires neck/chest radiographs or flexible bronchoscopy. All tracheostomy tubes should have a 15-mm ‘‘universal’’ adapter to allow bag ventilation in an emergency; metal tracheostomy tubes are commonly made without this capacity. Metal tubes are used in special circumstances such as with stents after laryngeal reconstruction. Most metal tubes have an inner cannula but, in small children this can lead to excessively high airway resistance. Tubes with an inner cannula may be useful in some patients with thick copious secretions, which rapidly build up on the walls of the tube. Cleaning the inner cannula avoids frequent tracheostomy changes. In patients for whom a standard polyvinyl chloride tube does not provide an optimal ‘‘fit,’’ a silicone tube will conform to the airway shape and may be a better option. Uncuffed tracheostomy tubes are preferred over cuffed tracheostomy tubes in most circumstances. Cuffed tracheostomy tubes may be used in patients requiring ventilation with high pressures, patients requiring only nocturnal ventilation and patients with chronic translaryngeal aspiration. The exact role for cuffed tracheostomy tubes in children is not defined. There is no consensus regarding the frequency of tracheostomy tube changes. The most common frequency of tracheostomy tube changes is weekly, according to those polled. The most important aspect of choosing a tracheost-
G. M. DAVIS
omy tie is not the material from which the tie is manufactured but how well the tie is secured. At least three materials are used for tracheostomy ties: twill tape, specially manufactured Velcro ties, and stainless steel beaded metal chain. There is no consensus regarding the routine frequency of tracheostomy tie changes. ‘‘Clean technique’’ is defined as the use of a clean catheter and nonsterile, disposable gloves or freshly washed, clean hands for the procedure. Care is taken not to allow the portion of the catheter that will be inserted in the tracheostomy tubeto contact any unclean surface. Clean technique of suctioning is recommended for home care. After suctioning is complete, the catheter is flushed with tap water until secretions are cleared from the lumen; the outside of the catheter is then wiped with alcohol and allowed to air dry. Individual catheters can be used as long as the catheter remains intact and allows inspection of removed secretions. d. There are a number of methods available for more thorough cleaning including commercial products, alcohol, and a vinegar and-water soak. Suctioning should be done on the basis of clinical assessment. In children with no evidence of secretions, a minimum of suctioning, at morning and bedtime, to check for patency of the tube is recommended. The routine instillation of normal saline is not recommended. The best monitoring for the child with a chronic tracheostomy is the vigilant, well-trained, and properly equipped caregiver. Children with chronic tracheostomies who are at high risk for airway complications should especially be considered for monitoring. Factors to consider when assessing risk include age, size of the tracheostomy, degree of airway obstruction, behavior of the child, the underlying airway pathology, the presence of other medical conditions, and the social environment. None of the commercially available monitoring devices are ideal. Cardiorespiratory monitors and oximeters provide only indirect evidence of airway compromise and sometimes delayed warnings. End tidal PCO2 monitoring are prone to occlusion. For some high-risk tracheostomy patients who have a history of airway instability, 24-h home nursing may be necessary. Children with chronic tracheotomies should undergo routine evaluation including rigid or flexible bronchoscopy every 6 to 12 mo to assess the underlying airway pathology, detect and treat complications, assess tube size and position, and determine the readiness for decannulation. Patients with rapidly changing medical conditions or patients with rapid growth (such as patients in the first year of life) may require more frequent endoscopic evaluation. There are few published data on surveillance bronchoscopies. An emergency/travel kit is available with the following supplies: manual resuscitation bag of appropriate size, suction source, suction catheter, DeLee suction traps, one tracheostomy tube of current size with ties in place, one tracheostomy tube that is one size smaller with ties in place, extra ties, shoulder roll, 15-mm adapter for children with metal tracheostomy tubes, suction catheter that can
TRACHEOSTOMY IN CHILDREN
be used if necessary to guide new tube through stoma into tract, scissors, emergency phone numbers, brief description of medical history, description of airway status (i.e., does anatomy preclude oral or nasal intubation and/or ventilation through upper airway?).
INSTRUCTIONS TO PARENTS Discuss and implement safety measures. Parents should be instructed to avoid all dust, smoke, lint, pet hair, powder, sprays, small toys, and objects. The child should not be in contact with fuzzy toys, clothes, or bedding. Contact sports and water sports are not permitted. The child may be bathed in 1–2 in. of water with a trained caretaker in attendance. Showers may be permissible in older children. Be aware of and participate in goals and plan for feeding program, occupational therapy, physical therapy, and speech therapy. Be aware of and participate in the plan for return to school/classroom and any out-of-home arrangements, i.e., daycare. Children who are at most risk for a serious episode of tracheostomy obstruction are younger patients who do not yet attend school. However, in older, school-aged children who have a critical airway in which the risk of obstruction is high, a trained caregiver should be in attendance throughout transport to and from school and while in attendance at school. Be aware of monitoring needs, if prescribed. Be able to operate the monitor correctly and act on the information Be aware of projected decannulation plan Discuss the plans for follow-up care
SPEAKING VALVES A tracheostomy speaking valve offers another option for voice production with a tracheostomy tube. A speaking valve is a one-way, removable valve that is attached to the open end of the tracheostomy tube. Speaking valves that are used with children include: the Passy-Muir Speaking Valve (Passy-Muir, Inc., Irvine, CA), the Shiley Phonate Speaking Valve (Nellcor Puritan Bennett, Inc., Pleasanton, CA) and the Montgomery Tracheostomy Speaking Valve (Boston Medical Products, Westborough, MA). Although the Montgomery speaking valves and the Shiley Phonate valves are open-position valves, Passy-Muir
S209
valves use a closed-position design. Open versus closed refers to the resting position of the valve. As implied, openposition valves are maintained in an open position, and the valve closes during expiration. Passy-Muir’s biased closed design remains closed at rest. The Passy-Muir valves open with inspiration and close before the end of the inspiratory cycle and the beginning of the expiratory cycle. Regardless of design, all one-way speaking valves allow air to flow freely from the tracheostomy into the lungs. The valves are closed on exhalation, directing the expired air into the upper airway and across the larynx and out the mouth or nose. Children of all ages, including infants, may be candidates for use of a speaking valve. There are some contraindications for use of a speaking valve, and these include:
presence of severe tracheal or laryngeal obstruction a laryngectomy use of an inflated cuffed tracheostomy tube presence of excessive secretions that cannot be managed adequately gross aspiration bilateral adductor vocal cord paralysis serious illness an unconscious state
FURTHER READING 1. ATS statement. Care of the Child with a Chronic Tracheostomy. Am J Respir Crit Care Med 2000; 161: 297–308. 2. Gluth MB, Maska S, Nelson J, Otto RA. Postoperative management of pediatric tracheostomy: Results of a nationwide survey. Otolaryngol Head Neck Surg 2000; 122: 701–705. 3. Kremer B, Botos-Kremer AI, Eckel HE, Schlondorff G. Indications, Complications, and Surgical Techniques for Pediatric Tracheostomies–—An Update. J Pediatr Surg 2002; 37: 1556–1562. 4. Tantinikorn W, Alper CM, Bluestone CD, Casselbrant ML. Outcome in pediatric tracheotomy. Am J Otolaryngol 2000; 24: 131–137. 5. Carron JD, Derkay CS, Strope GL, Nosonchuk JE, Darrow DH. Pediatric tracheotomies: changing indications and outcomes. Laryngoscope 2000; 110: 1099–1104. 6. Glce Z, Celayir S, Teland GT, Murat NS, Erdojan E, Yeker D. Tracheostomy in childhood: 20 years experience from a pediatric surgery clinic. Pediatr Int 2002; 44: 306–309. 7. Leung, R Berkowitz, RG. Decannulation and Outcome Following Pediatric tracheostomy. Annal Otol Rhinol Laryngol 2005; 114: 743– 748 [PMID 16285263]. 8. Woodnorth GH. Assessing and Managing Medically Fragile Children: racheostomy and Ventilatory Support. Language speech and hearing services in schools 2004; 35: 63–74. 9. Srivastava R, Stone BL, Murphy NA. Hospitalist Care of the Medically Complex Child. Pediatr Clin N Am 2005; 52: 1165–1187. 10. Hadfield PJ, Lloyd-Faulconbridge RV, Almeyda J, Albert DM, Bailey CM. The changing indications for paediatric tracheostomy. Int J of Pediat Torhinolaryngol 2003; 67: 7–10.