Managing Respiratory Distress and complications post insertion of a Tracheostomy

1. Managing Respiratory Distress and complications post insertion of a Tracheostomy Dr P Chetcuti Consultant Paediatrician and Neonatologist

2. Indications • Historically-Upper airways obstruction associated with infections was the most common indication—Diptheria ,polio and HIB vaccines • Now most common indication is fixed upper airways obstruction and the requirement for prolonged ventilation secondary to neuromuscular and respiratory problems

3. Changes in last 20 yrs • Prematurity increased from 28% to 58% • Congenital anomalies increased from 6% to 23% • Acquired subglottic stenosis from 2% to 23 % • Neuromuscular disease from 9% to 23% • Infectious diseases decreased from 50% to 3%

4. Indications for tracheostomy • Unsafe or obstructed airway • Prolonged mechanical ventilation required • Tracheobronchial toilet

5. Alternatives to Tracheostomy • Non invasive ventilation-not a 24hr solution,not beneficial if fixed severe obstruction • Nasopharyngeal airway • Palliative care

6. Indications • Upper airways obstruction Subglottic stenosis Tracheomalacia Tracheal stenosis Craniofacial syndrome - Pierre-Robin,Charge,Treacher Collins Syndrome,Beckwith Wiedemann Craniofacial and laryngeal tumours-cystic hygromas,haemangioma Bilateral vocal cord palsy Obstructive sleep apnoea Laryngeal trauma-burns,fracture

7. Indications • Long term ventilation,pulmonary toilet-Bronchopulmonary Dysplasia,scoliosis,diaphragmatic paralysis • Congenital heart disease in association with tracheobronchomalacia,diaphragmatic paralysis and cardiac failure • Neurological/neuromuscular disease- Duchennee muscular dystrophy,spinal muscular atrophy,congenital central hypoventilation syndrome,cerebral palsy,traumatic brain and spine injury,spina bifida

8. Prematurity • Increasing no of Tracheostomies in smaller sicker infants-2kg • Subglottic stenosis,long term ventilation for bronchopulmonary dysplasia • Mortality from tracheostomy related complications high in this group 5-10% • More prone to infections

9. The loss of Auto Peep • Lose the resistance of nose and larynx • Can effect optimal lung ventilation-perfusion relationship • Makes it more difficult to breath • May need supplemental oxygen

10. Age at tracheostomy • < 6 months – 56% • 6 months to 3 yrs- 32% • 3 yrs to 6 yrs – 12%

11. Tube size • Too small –difficult to breath hypoventilation may occur especially during sleep • Too large a tube can damage airway mucosa- ulceration and fibrous stenosis • Cuffed tubes not used in young children • The smaller the tube the more likely the possibility of speech • Tubes must be changed with growth-approx every 2 yrs in children under 5

12. Tube length • Too short- will fall out • Too long- damage carina or go down r main bronchus • At least 2cm from stoma and no closer than 1 to 2 cm from carina

13. Tube care • Tube change • Fixation • Management of secretions • Humidification of inspired air • Management of stoma-clean,protect and dress

14. Securing the Tube • How well the tube is secured is more important than the material- twill tape,velcro and stainless steel beaded metal chains

15. Standard Management • Post op CXR • 3 days intensive care • 1st tube change by doctor who created tracheostomy • Tube change weekly

16. suctioning • As frequently as required • Instillation of boluses of saline ? • Minimum morning after waking and pre bedtime

17. Passive Humidifiers • Nose,pharynx,larynx and trachea acts as a filter,heater and humidifier of inspired air • Not available with Tracheostomy • May damage the airway structurally and functionally • Ok if ventilated • nebulised saline • Artificial ‘noses’ • humidifiers

18. monitoring • Vigilant,well trained and properly equipped care giver • Risk-age,size of tracheostomy,degree of airway obstruction,behaviour of child,underlying pathology,the presence of other underlying medical conditions and the social environment • No monitoring devices are ideal

19. Monitoring in hospital • Cardiorespiratory monitoring • Oximetry

20. Early complications • Pneumomediastinum and pneumothorax • Haemorhage • Accidental decannulation-reduced with stay sutures-small curved artery clamp should be available at bedside plus 2 spare tracheostomy tubes(one smaller) • Tube blockage-frequent suctioning required to prevent • Subcutaneous emphysema-avoided by using appropriate sized tube and not making wound too tight

21. Intermediate • Local infection-can produce excessive granulation tissue-can make it difficult to reinsert tube

22. Late complications • Difficult decannulation • Psychological dependance • Tracheal granulomas-due to trauma at distal end or excessive suctioning +/- infection • Accidental decannulation-mortality 2% • Suprastomal collapse and tracheal stenosis

23. Late complications • Persistent tracheocutaneous fistula-19-42% • Effect on speech and language-age at time and length of time • Erosion into the innominate artery • Tracheo-oesophageal fistula

24. Failure of decannulation • Peristomal pathology-granulations,suprastomal collapse,stomal tracheomalacia,stenosis • Granulations-surgical removal,laser,?potassium titanyl phosphate • Underlying pathology not adequately resolved

25. Rigid or flexible bronchoscopy every 6 to 12 months

26. Causes of death associated with tracheostomy • Accidental decannulation • Tube obstruction-increasing likely in small infants—narrrow airay,narrow tubes,copious viscid secretions(bronchopulmonary dysplasia) • 11% mortality under 6 months of age(0.5 to 3%)

27. Tube Blockage • Obstructive breathing • Cant clear secretions on suctioning • Urgent tube change required

28. Signs of Chest Infection • Thick discoloured secretions • +/- Unwell off feeds drowsy • +/- pyrexia • +/- Tachypnoeic/chest wall recession • +/- CXR changes • Secretions for viruses bacteria

29. Tracheostomies-infection • Increased risk of lower respiratory infections • Treat with oral or gastric antibiotics • Infections around tracheostomy-good wound care +/- antibiotics—may leed onto mediastinitis if not treated optimally • Colonisation common-pseudomonas,MRSA and staphyloccus aureus,candida

30. Other respiratory management • ? Salbutamol spacer/nebuliser • ? Ipratropium spacer/nebuliser • ? Steroids—spacer/nebulise/oral • IV antibioics • ? Montelukast • ? nebulised hypertonic saline • ? Dnase • ? Nebulised antibiotics

31. Speaking valves • Various different types • Attaches to the open end of tracheostomy • Valves close on expiration directing air into the upper airway and across the larynx • May be used in infants • Make it more difficult to breath

32. Speaking valves-contraindications • Presence of severe obstruction • A laryngectomy • With cuffed tubes • In the presence of excessive secretions • With gross aspiration • With bilateral adductor cord palsy

33. Challenge of giving oxygen • Side tubing • Masks • Cpap • Do not rely on oxygen sats as an indicator of a blocked tube

34. Oral Feeding • May deteriorate temporarily or permanently after tracheostomy • Depends on pre tracheostomy feeding • Difficult in prems and ex prems • Nasogastric feeds and Gastrostomies sometimes required • Milk in tracheal secretions is not good

35. Speech development • Other factors-prolonged hospitalisation,neurological problems,chronic middle ear problems, lack of normal feeding experiences, lack of muscle strength • Do better if decannulated early • Speech therapy • Speaking valves • Sign language

36. Home care • Tube –change,fixation,suctioning-shallow and deep • Saline instillation • Suction equipment • Clean technique • Humidification • Application of drugs • Stoma care • Monitoring-continuous presence of a competent carer monitoring device ? • Feeding • Bathing • Clothing-not fluffy,dressing and undressing must not be over the head

37. Home care • Adaptations –electrical sockets,storage space,space, • Transportation • Safety-smoke,pets,household sprays • Extra support • Time in hospital day and night prior to discharge is required • Lots of support required

38. Organisation of services • Dedicated Nurse specialists • Specialist multidisciplinary clinics • Children should not be transferred to hospitals if nurses not adequately trained in smaller hospitals • Resources ‘Stretched’in larger hospitals