1. Medical Equipment Problems: Tracheostomies and Gastrostomies Nightfloat Curriculum 2010-2011 Lucile Packard Children’s Hospital Residency Program

2. Teaching Goals Review the critical components of tracheostomy and gastrostomy tubes Begin initial management of tracheostomy emergencies Troubleshoot problems with gastrostomy tubes

3. Obturator and Uncuffed Trach

4. Cuffed Tracheostomy Tube

5. Bleeding in a Patient with a Tracheostomy: Differential Diagnosis CausesTreatment/Prevention Bleeding from stoma Trauma at stoma site Granuloma at stoma site Infection at stoma site Apply pressure, avoid trauma Triamcinolone, silver nitrate Antibiotics Internal bleeding Trauma from suctioning Tracheal wall granuloma Tracheal wall erosion Tracheal erosion into an artery Pulmonary hemorrhage Measure suction catheter; ensure it does not extend beyond length of trach tube; suction for 10 sec or less at a time. ENT eval, possible excision ENT eval Emergent ENT eval Respiratory/ventilator support

6. Desaturation in a Patient with Tracheostomy: Differential Diagnosis CausesTreatment Obstruction Mucous plugging Tube improperly placed against tracheal wall Suction; replace trach if needed Reposition trach DecannulationReplace trach PneumothoraxNeedle decompression

7. Gastrostomy Tube

8. Gastrostomy Problems: Tube blockage Usually clog as a result of medications Treat with: – Water – Carbonated beverage – Pancreatic enzymes – Replace tube (last resort) – Change to liquid medications, if possible

9. Tube Displacement Stoma can close within hours if not held open Management: Keep site open!!! – Use a foley catheter – After new tube is placed, ensure that it is in the stomach before using – A false passage may be formed between the abdominal wall and stomach, leading to peritonitis. This is especially important in new gastrostomy tubes less than 4 weeks old.

10. Drainage around Gastrostomy Tube A small amount of drainage is acceptable. Keep area dry using nonadherent gauze or foam; do not use occlusive dressings Ensure no cracks in tubing Ensure no excessive traction on tube which can stretch the stoma If drainage persists, may need to upsize tube In severe cases, may require surgical repair

11. Redness Around Gastrostomy Site CausesTreatment Granulation tissueTriamcinolone cream > silver nitrate > surgical excision Prevention: avoid traction and avoid occlusive dressings Infection Yeast infection Cellulitis/necrotizing fasciitis Topical vs. systemic antifungals Systemic antibiotics Irritation from gastric fluid leakage Barrier creams; gastric acid suppression Tape sensitivityAvoidance of tape

12. Gastrostomy Problems: Vomiting Causes – GERD (may worsen after gastrostomy placement) – Balloon obstructing gastric outlet – Other medical causes Treat underlying cause

13. Case # 1 8-year-old girl with tracheostomy suddenly desaturates and becomes cyanotic. The first thing you should do is: a)Begin chest compressions b)Administer 100% oxygen by tracheostomy c)Perform needle decompression d)Check for tracheostomy tube patency

14. Case # 1 8-year-old girl with tracheostomy suddenly desaturates and becomes cyanotic. The first thing you should do is: a)Begin chest compressions b)Administer 100% oxygen by tracheostomy c)Perform needle decompression d)Check for tracheostomy tube patency

15. Case #2 18-month-old boy post-op day 7 after a G- tube and Nissen fundoplication pulls his tube out. All of the following should be performed EXCEPT: a)Call surgery b)Place a deflated foley in the stoma c)Place an NG tube and start pedialyte to maintain hydration d)Check new tube placement using a dye study

16. Case #2 18-month-old boy post-op day 7 after a G- tube and Nissen fundoplication pulls his tube out. All of the following should be performed EXCEPT: a)Call surgery b)Place a deflated foley in the stoma c)Place an NG tube and start pedialyte to maintain hydration d)Check new tube placement using a dye study