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 Placed percutaneously 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 3.0 2.5-3.0 --- 6 Fr Newborn 3.0-3.5 3.5 0-6 mo 0-1 1-2 3.5-4.0 6-8 Fr 6-12 mo 2-3 4.0 4.0-4.5 8 Fr 12-24 mo 3 4.5 4.5-5.0 5.0 3-6 yr 4 8-10 Fr 7-10 yr 5 5.0-6.0 6.0 10 Fr 10-12 yr 6 6.0-7.0 7.0 12-14 yr 7.5

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.