Managing Respiratory Managing Respiratory Distress and complications Distress and complications

post insertion of a post insertion of a TracheostomyTracheostomy

Dr P ChetcutiDr P Chetcuti

Consultant Paediatrician and Consultant Paediatrician and NeonatologistNeonatologist

IndicationsIndications

Historically-Upper airways obstruction Historically-Upper airways obstruction associated with infections was the most associated with infections was the most common indication—Diptheria ,polio and common indication—Diptheria ,polio and HIB vaccinesHIB vaccines

Now most common indication is fixed Now most common indication is fixed upper airways obstruction and the upper airways obstruction and the requirement for prolonged ventilation requirement for prolonged ventilation secondary to neuromuscular and secondary to neuromuscular and respiratory problemsrespiratory problems

Changes in last 20 yrsChanges in last 20 yrs

Prematurity increased from 28% to 58%Prematurity increased from 28% to 58%Congenital anomalies increased from 6% Congenital anomalies increased from 6%

to 23%to 23%Acquired subglottic stenosis from 2% to Acquired subglottic stenosis from 2% to

23 %23 %Neuromuscular disease from 9% to 23%Neuromuscular disease from 9% to 23% Infectious diseases decreased from 50% Infectious diseases decreased from 50%

to 3%to 3%

Indications for tracheostomyIndications for tracheostomy

Unsafe or obstructed airwayUnsafe or obstructed airwayProlonged mechanical ventilation requiredProlonged mechanical ventilation requiredTracheobronchial toiletTracheobronchial toilet

Alternatives to TracheostomyAlternatives to Tracheostomy

Non invasive ventilation-not a 24hr Non invasive ventilation-not a 24hr solution,not beneficial if fixed severe solution,not beneficial if fixed severe obstructionobstruction

Nasopharyngeal airwayNasopharyngeal airwayPalliative carePalliative care

IndicationsIndications Upper airways obstructionUpper airways obstruction Subglottic stenosisSubglottic stenosis TracheomalaciaTracheomalacia Tracheal stenosisTracheal stenosis Craniofacial syndrome - Pierre-Craniofacial syndrome - Pierre-

Robin,Charge,Treacher Collins Syndrome,Beckwith Robin,Charge,Treacher Collins Syndrome,Beckwith WiedemannWiedemann

Craniofacial and laryngeal tumours-cystic Craniofacial and laryngeal tumours-cystic hygromas,haemangiomahygromas,haemangioma

Bilateral vocal cord palsyBilateral vocal cord palsy Obstructive sleep apnoeaObstructive sleep apnoea Laryngeal trauma-burns,fractureLaryngeal trauma-burns,fracture

IndicationsIndications

Long term ventilation,pulmonary toilet-Long term ventilation,pulmonary toilet-Bronchopulmonary Bronchopulmonary Dysplasia,scoliosis,diaphragmatic paralysisDysplasia,scoliosis,diaphragmatic paralysis

Congenital heart disease in association with Congenital heart disease in association with tracheobronchomalacia,diaphragmatic paralysis tracheobronchomalacia,diaphragmatic paralysis and cardiac failureand cardiac failure

Neurological/neuromuscular disease- Neurological/neuromuscular disease- Duchennee muscular dystrophy,spinal muscular Duchennee muscular dystrophy,spinal muscular atrophy,congenital central hypoventilation atrophy,congenital central hypoventilation syndrome,cerebral palsy,traumatic brain and syndrome,cerebral palsy,traumatic brain and spine injury,spina bifidaspine injury,spina bifida

PrematurityPrematurity

Increasing no of Tracheostomies in Increasing no of Tracheostomies in smaller sicker infants-2kgsmaller sicker infants-2kg

Subglottic stenosis,long term ventilation Subglottic stenosis,long term ventilation for bronchopulmonary dysplasiafor bronchopulmonary dysplasia

Mortality from tracheostomy related Mortality from tracheostomy related complications high in this group 5-10%complications high in this group 5-10%

More prone to infectionsMore prone to infections

The loss of Auto PeepThe loss of Auto Peep

Lose the resistance of nose and larynxLose the resistance of nose and larynxCan effect optimal lung ventilation-Can effect optimal lung ventilation-

perfusion relationshipperfusion relationshipMakes it more difficult to breathMakes it more difficult to breathMay need supplemental oxygenMay need supplemental oxygen

Age at tracheostomyAge at tracheostomy

< 6 months – 56%< 6 months – 56%6 months to 3 yrs- 32%6 months to 3 yrs- 32%3 yrs to 6 yrs – 12%3 yrs to 6 yrs – 12%

Tube sizeTube size

Too small –difficult to breath hypoventilation may Too small –difficult to breath hypoventilation may occur especially during sleepoccur especially during sleep

Too large a tube can damage airway mucosa- Too large a tube can damage airway mucosa- ulceration and fibrous stenosisulceration and fibrous stenosis

Cuffed tubes not used in young childrenCuffed tubes not used in young children The smaller the tube the more likely the The smaller the tube the more likely the

possibility of speechpossibility of speech Tubes must be changed with growth-approx Tubes must be changed with growth-approx

every 2 yrs in children under 5every 2 yrs in children under 5

Tube lengthTube length

Too short- will fall outToo short- will fall outToo long- damage carina or go down r Too long- damage carina or go down r

main bronchusmain bronchusAt least 2cm from stoma and no closer At least 2cm from stoma and no closer

than 1 to 2 cm from carinathan 1 to 2 cm from carina

Tube careTube care

Tube changeTube changeFixationFixationManagement of secretionsManagement of secretionsHumidification of inspired airHumidification of inspired airManagement of stoma-clean,protect and Management of stoma-clean,protect and

dressdress

Securing the TubeSecuring the Tube

How well the tube is secured is more How well the tube is secured is more important than the material- twill important than the material- twill tape,velcro and stainless steel beaded tape,velcro and stainless steel beaded metal chainsmetal chains

Standard ManagementStandard Management

Post op CXRPost op CXR3 days intensive care3 days intensive care11stst tube change by doctor who created tube change by doctor who created

tracheostomytracheostomyTube change weeklyTube change weekly

suctioningsuctioning

As frequently as requiredAs frequently as required Instillation of boluses of saline ?Instillation of boluses of saline ?Minimum morning after waking and pre Minimum morning after waking and pre

bedtimebedtime

Passive HumidifiersPassive Humidifiers

Nose,pharynx,larynx and trachea acts as a Nose,pharynx,larynx and trachea acts as a filter,heater and humidifier of inspired airfilter,heater and humidifier of inspired air

Not available with TracheostomyNot available with Tracheostomy May damage the airway structurally and May damage the airway structurally and

functionallyfunctionally Ok if ventilatedOk if ventilated nebulised salinenebulised saline Artificial ‘noses’Artificial ‘noses’ humidifiers humidifiers

monitoringmonitoring

Vigilant,well trained and properly equipped Vigilant,well trained and properly equipped care givercare giver

Risk-age,size of tracheostomy,degree of Risk-age,size of tracheostomy,degree of airway obstruction,behaviour of airway obstruction,behaviour of child,underlying pathology,the presence of child,underlying pathology,the presence of other underlying medical conditions and other underlying medical conditions and the social environmentthe social environment

No monitoring devices are idealNo monitoring devices are ideal

Monitoring in hospitalMonitoring in hospital

Cardiorespiratory monitoringCardiorespiratory monitoringOximetry Oximetry

Early complicationsEarly complications Pneumomediastinum and pneumothoraxPneumomediastinum and pneumothorax HaemorhageHaemorhage Accidental decannulation-reduced with stay Accidental decannulation-reduced with stay

sutures-small curved artery clamp should be sutures-small curved artery clamp should be available at bedside plus 2 spare tracheostomy available at bedside plus 2 spare tracheostomy tubes(one smaller)tubes(one smaller)

Tube blockage-frequent suctioning required to Tube blockage-frequent suctioning required to preventprevent

Subcutaneous emphysema-avoided by using Subcutaneous emphysema-avoided by using appropriate sized tube and not making wound appropriate sized tube and not making wound too tighttoo tight

IntermediateIntermediate

Local infection-can produce excessive Local infection-can produce excessive granulation tissue-can make it difficult to granulation tissue-can make it difficult to reinsert tubereinsert tube

Late complicationsLate complications

Difficult decannulationDifficult decannulationPsychological dependancePsychological dependanceTracheal granulomas-due to trauma at Tracheal granulomas-due to trauma at

distal end or excessive suctioning +/- distal end or excessive suctioning +/- infectioninfection

Accidental decannulation-mortality 2%Accidental decannulation-mortality 2%Suprastomal collapse and tracheal Suprastomal collapse and tracheal

stenosisstenosis

Late complicationsLate complications

Persistent tracheocutaneous fistula-19-Persistent tracheocutaneous fistula-19-42%42%

Effect on speech and language-age at Effect on speech and language-age at time and length of timetime and length of time

Erosion into the innominate arteryErosion into the innominate arteryTracheo-oesophageal fistulaTracheo-oesophageal fistula

Failure of decannulationFailure of decannulation

Peristomal pathology-Peristomal pathology-granulations,suprastomal collapse,stomal granulations,suprastomal collapse,stomal tracheomalacia,stenosistracheomalacia,stenosis

Granulations-surgical removal,laser,?Granulations-surgical removal,laser,?potassium titanyl phosphatepotassium titanyl phosphate

Underlying pathology not adequately Underlying pathology not adequately resolvedresolved

Rigid or flexible bronchoscopy every 6 to Rigid or flexible bronchoscopy every 6 to 12 months12 months

Causes of death associated with Causes of death associated with tracheostomytracheostomy

Accidental decannulationAccidental decannulationTube obstruction-increasing likely in small Tube obstruction-increasing likely in small

infants—narrrow airay,narrow infants—narrrow airay,narrow tubes,copious viscid tubes,copious viscid secretions(bronchopulmonary dysplasia)secretions(bronchopulmonary dysplasia)

11% mortality under 6 months of age(0.5 11% mortality under 6 months of age(0.5 to 3%)to 3%)

Tube BlockageTube Blockage

Obstructive breathingObstructive breathingCant clear secretions on suctioningCant clear secretions on suctioningUrgent tube change requiredUrgent tube change required

Signs of Chest InfectionSigns of Chest Infection

Thick discoloured secretionsThick discoloured secretions+/- Unwell off feeds drowsy+/- Unwell off feeds drowsy+/- pyrexia+/- pyrexia+/- Tachypnoeic/chest wall recession+/- Tachypnoeic/chest wall recession+/- CXR changes+/- CXR changesSecretions for virusesSecretions for viruses

bacteriabacteria

Tracheostomies-infectionTracheostomies-infection

Increased risk of lower respiratory Increased risk of lower respiratory infectionsinfections

Treat with oral or gastric antibioticsTreat with oral or gastric antibiotics Infections around tracheostomy-good Infections around tracheostomy-good

wound care +/- antibiotics—may leed onto wound care +/- antibiotics—may leed onto mediastinitis if not treated optimallymediastinitis if not treated optimally

Colonisation common-Colonisation common-pseudomonas,MRSA and staphyloccus pseudomonas,MRSA and staphyloccus aureus,candidaaureus,candida

Other respiratory managementOther respiratory management

? Salbutamol spacer/nebuliser? Salbutamol spacer/nebuliser? Ipratropium spacer/nebuliser? Ipratropium spacer/nebuliser? Steroids—spacer/nebulise/oral? Steroids—spacer/nebulise/oral IV antibioics IV antibioics ? Montelukast? Montelukast? nebulised hypertonic saline? nebulised hypertonic saline? Dnase? Dnase? Nebulised antibiotics? Nebulised antibiotics

Speaking valvesSpeaking valves

Various different typesVarious different typesAttaches to the open end of tracheostomyAttaches to the open end of tracheostomyValves close on expiration directing air into Valves close on expiration directing air into

the upper airway and across the larynxthe upper airway and across the larynxMay be used in infantsMay be used in infantsMake it more difficult to breathMake it more difficult to breath

Speaking valves-contraindicationsSpeaking valves-contraindications

Presence of severe obstructionPresence of severe obstructionA laryngectomyA laryngectomyWith cuffed tubesWith cuffed tubes In the presence of excessive secretionsIn the presence of excessive secretionsWith gross aspirationWith gross aspirationWith bilateral adductor cord palsyWith bilateral adductor cord palsy

Challenge of giving oxygenChallenge of giving oxygen

Side tubingSide tubingMasksMasksCpapCpapDo not rely on oxygen sats as an indicatorDo not rely on oxygen sats as an indicator

of a blocked tubeof a blocked tube

Oral FeedingOral Feeding

May deteriorate temporarily or May deteriorate temporarily or permanently after tracheostomypermanently after tracheostomy

Depends on pre tracheostomy feedingDepends on pre tracheostomy feedingDifficult in prems and ex premsDifficult in prems and ex premsNasogastric feeds and Gastrostomies Nasogastric feeds and Gastrostomies

sometimes requiredsometimes requiredMilk in tracheal secretions is not goodMilk in tracheal secretions is not good

Speech developmentSpeech development

Other factors-prolonged Other factors-prolonged hospitalisation,neurological hospitalisation,neurological problems,chronic middle ear problems, problems,chronic middle ear problems, lack of normal feeding experiences, lack of lack of normal feeding experiences, lack of muscle strengthmuscle strength

Do better if decannulated earlyDo better if decannulated earlySpeech therapySpeech therapySpeaking valvesSpeaking valvesSign languageSign language

Home careHome care Tube –change,fixation,suctioning-shallow and deepTube –change,fixation,suctioning-shallow and deep Saline instillationSaline instillation Suction equipmentSuction equipment Clean techniqueClean technique HumidificationHumidification Application of drugsApplication of drugs Stoma careStoma care Monitoring-continuous presence of a competent carerMonitoring-continuous presence of a competent carer monitoring device ?monitoring device ? FeedingFeeding BathingBathing Clothing-not fluffy,dressing and undressing must not be over the Clothing-not fluffy,dressing and undressing must not be over the

headhead

Home careHome care

Adaptations –electrical sockets,storage Adaptations –electrical sockets,storage space,space,space,space,

TransportationTransportationSafety-smoke,pets,household spraysSafety-smoke,pets,household spraysExtra supportExtra supportTime in hospital day and night prior to Time in hospital day and night prior to

discharge is requireddischarge is requiredLots of support requiredLots of support required

Organisation of servicesOrganisation of services

Dedicated Nurse specialistsDedicated Nurse specialistsSpecialist multidisciplinary clinicsSpecialist multidisciplinary clinicsChildren should not be transferred to Children should not be transferred to

hospitals if nurses not adequately trained hospitals if nurses not adequately trained in smaller hospitalsin smaller hospitals

Resources ‘Stretched’in larger hospitals Resources ‘Stretched’in larger hospitals