Tracheostomies

Tracheotomy vs Trachesotomy Tracheotomy: temporary surgical creation of an airway Tracheostomy: more permanent surgical creation of an airway.

Airways Nasopharynx – warms, filters, and moisturizes Oropharynx Trachea – passageway, smooth muscle, cricoid cartilage Bronchi – right, left, carina (neuronal tissue) Bronchioles Terminal bronchioles Alveoli – gas exchange

Physiology of Respiration Ventilation Movement of air between the alveoli and atmosphere Diffusion Movement of CO2 and O2 between alveoli and capillaries Transport Movement of O2 from the alveoli to the cells Movement of CO2 from the cells to the alveoli

Reasons for Tracheostomy Tumors Laryngectomy Infection Vocal Cord Paralysis (VCP) Laryngeal injury or spasms Congenital abnormalities of the airway Large tongue or small jaw that blocks airway Severe neck or mouth injuries Airway burns from inhalation of corrosive material, smoke or steam Obstructive sleep apnea Foreign body obstruction

History

1544

1666

Incidence/Prevalence Within the 1st year of life, we can expect 3,000 babies to undergo a tracheostomy 85% of children requiring tracheostomies are < 1 year old

Side effects Loss of natural humidification and warming Lung infection Coughing Aspiration of food particles Phonation is affected

Equipment

Tracheostomy & Ventilator-Dependent Patients Tracheostomy tubes come in many varieties, including cuffed, uncuffed and fenestrated. A cuff is a soft balloon around the distal (far) end of the tube that can be inflated to allow for mechanical ventilation in patients with respiratory failure.

Tracheostomy & Ventilator-Dependent Students When the cuff is inflated, a seal is created in the trachea which permits air to flow in and out of the lungs through the tracheal tube, but not out of the upper airway and mouth. Over inflation of the cuff can cause unequal pressure against the tracheal and esophageal walls and result in tissue damage.

Tracheostomy & Ventilator-Dependent Students Because air cannot be routed out through the upper airway and vocal folds when the cuff is inflated, or if the cuff is too tight, the cuff must be deflated in order to achieve vocalization. The cuff also limits the elevation of the larynx during swallowing, so it should also be deflated during eating.

Tracheostomy & Ventilator-Dependent Students Cuffed tracheostomy tubes are used infrequently in children because of the risk of damage to the developing trachea. Thus they are only used when adequate ventilation cannot be achieved without a cuffed trach tube.

Tracheostomy & Ventilator-Dependent Students A special type of foam cuff (Bivona Medical Technology, Inc.) is made to reinflate on its own. Children wearing a foam cuff are not candidates for a one-way speaking valve or for occlusion of the cannula for speaking.

Bivona Fome-Cuff Tracheostomy Tube

Tracheostomy & Ventilator-Dependent Students A fenestrated tracheostomy tube is designed to allow airflow to be shunted through the upper airway via a single port on the convex surface of the cannula when the external opening is blocked.

Tracheostomy & Ventilator-Dependent Students Air flows through the port and passes into the upper airway for speech production during exhalation. Fenestrated tubes are not recommended for small children, as aspiration of secretions can occur.

Metal tube with inner cannula and obturator

Single Cannular Shiley Pediatric Tracheostomy Tube

Tracheal buttons

Montgomery T-Tube

Antique tubes

Precautions

Use extreme caution with baths Use extreme caution with baths. Use shallow water and prevent water from splashing into the trach. A trach mask, mist collar or moisture exchanger can be worn during baths for added protection. Never leave a child alone in the bathtub! For hair washing, lay the child back while supporting the head and neck. Pour water toward the back of the head, keeping the trach area dry. Have a dry towel handy for drips. No Swimming No Showering When holding a child with a trach, be sure the chin is up and that the tube opening is unobstructed. Check with the doctor before applying any salves or ointments near the trach. Avoid powder, talc, chlorine bleach, ammonia, aerosol sprays or perfumes near a child with a trach. Prevent foreign objects from entering the trach tube, such as water, sand, dust, small toy pieces, etc.

Avoid sandboxes and beaches Avoid chalk dust. Watch play with other children so that toys, fingers and food are not put into trach tube and that other children don‘t pull on the trach. No contact sports Avoid clothing that blocks the trach tube, such as crew necks, turtlenecks, and shirts that button in the back. No plastic bibs No necklaces No fuzzy or fur clothing or stuffed toys Avoid animals with fine hair or that shed excessively. Do not allow anyone to smoke near child. Keep the home as free from lint, dust and mold as possible. Limit the use of wood stoves and fireplaces, which dry the air. During cold weather, avoid allowing child to breathe freezing cold air directly into trach.

Use a heat moisture exchanger (HME), gauze bandage, loose cotton scarf or surgical mask to protect the tracheostomy on dusty, smoggy or windy days. No Latex balloons, these are dangerous for all children. Latex over any airway will block breathing. There must be a trained person with your child at all times. At minimum, this person must be trained in CPR and be able to suction and change a tracheostomy tube. For school-age children, there should be a trained person (preferably an RN or LPN) with the child at school and on the bus to and from school. Avoid exposure to people with colds or other contagious illnesses.

Respiratory Distress Mucus plugs are the most common cause of respiratory distress for children with tracheostomies. Symptoms of a mucus plug include resistance when trying to suction or bag and/or signs of respiratory distress

Possible Causes of Minor Bleeding Irritation to the fragile tissue around the stoma Insufficient humidity to the airway Too frequent, deep or vigorous suctioning Suction pressure that is too high (Suction machine pressure for small children 50-100mm Hg, for older children/adults 100-120mm Hg) Infection Trauma, manipulation of trach Foreign object in the airway Excessive coughing

Infection Children with tracheostomies are at high risk for respiratory infections. The trach tube bypasses the natural defenses (nasal hair and mucus membranes) of the upper airway that filter out dust and bacteria. Also, monitor for local infections at the stoma site. Hand washing before any trach care is one of the best defenses against infection.

CPR: If child is not breathing Open the airway using the chin lift, but do not hyperextend the neck. Suction the trach tube. If the trach has an inner cannula, remove the inner cannula and suction slightly past (mm) the length of the trach tube. Change the trach tube if plugged or dislodged. Give two gentle puffs of air into the trach tube using an Ambu bag (breathing bag) with trach adapter or mouth to trach technique. If air leaks from nose and mouth, hold them closed. If the tube is obstructed or lost, it may be possible to give ventilation by sealing your mouth over the stoma and blowing or place the face mask of ambu bag over the stoma (gently, just enough to cause the child’s chest to expand). If the child's airway is not obstructed, you can use mouth to mouth resuscitation by closing the stoma with your finger. Give CPR as indicated.

Ventilation

Daily Care

Stoma care Daily care to prevent infection and skin breakdown Observe for changes in appearance

Suctioning

Signs that a child needs suctioning Rattling mucus sounds from the trach Fast breathing Bubbles of mucus in trach opening Dry raspy breathing or a whistling noise from trach Older children may vocalize or signal a need to be suctioned. Signs of respiratory distress under tracheostomy complications

Suctioning

Changing a Trach tube

Tracheostomy ties

Respiratory Secretions

Postural drainage

Oxygen Management

Hypoxia Hypoxia is a state of oxygen deficiency in the body which is sufficient to cause an impairment of function. Hypoxia is caused by the reduction in partial pressure of oxygen, inadequate oxygen transport, or the inability of the tissues to use oxygen.

Cyanosis Cyanosis is a condition in which the lips, fingers, and toes appear blue. It happens in some people with congenital heart defects that cause the blood to circulate abnormally

Oxygen therapy Considered “drug therapy” Must be given in a prescribed amount

Oxygen equimpent

Delivery system Nasal cannula Oxygen mask Tracheostomy collar Face tent Oxygen tent/hood

Oxygen sources Compressed oxygen Liquid oxygen systems Oxygen concentrator Wall oxygen