1. Tracheostomy Tubes: A Primer
Tamara Simon, M.D.
Cloy Vaneman, R.T.
Special Care Clinic
July 2004

2. Purpose Used in children with: Upper airway obstruction
Inability to clear secretions
Require prolonged mechanical ventilation

3. 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

4. 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)

5. Pediatric tracheostomy tubes: cuffless with obdurators

6. Pediatric tracheostomy tubes: cuffed with obdurators inserted

7. Pediatric tracheostomy tubes: external and internal cannula

8. Pediatric tracheostomy tubes: approximate sizes
Shiley
Holinger
Portex
Bivona
Berdeen
ETT
Suction
Premature 00
3.0
---
6 Fr
Newborn
3.5
0-6 mo
0-1
1-2
6-8 Fr
6-12 mo
2-3
4.0
8 Fr
12-24 mo 3
4.5
5.0
3-6 yr 4
8-10 Fr
7-10 yr 5
6.0
10 Fr
10-12 yr 6
7.0
12-14 yr
7.5

9. Complications Dislodgement or decannulation of tube
Obstruction of tube
Infection
Hemorrhage
Pneumothorax/ pneumomediastinum

10. 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

11. 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

12. 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

13. 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

14. 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

15. Complication: Pneumothorax/ Pneumomediastinum
Seen in immediate postoperative period
Can develop if a false tract in ventilated
Obtain CXR immediately post-operatively

16. 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

17. 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 hours

18. Late Postoperative Complications of Pediatric Tracheostomy
Suprasternal collapse
Tracheal wall granuloma
Tracheomalacia
Tracheoesophageal fistula
Depressed scar
Larynogotracheal stenosis
Recurrent tracheitis/ bronchitis
Tracheal wall erosion

19. Further Questions Questioning potential complications?
Get a chest radiograph
Consult Pulmonary Rehab
Consult pulmonologist or surgeon who originally placed tracheostomy

20. 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.