Tracheostomy Tubes: A Primer

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 • 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

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 24-48 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.