Tracheostomy Care and Complications
Renée B. Stromsness, MD, FAAP, and Manisha Newaskar, MBBS
Introduction
•The most common indications for tracheostomy are anatomic upper- airway obstruction and chronic respiratory failure caused by pulmonary or neuromuscular conditions (see Box 112-1).
•Forty percent to 70% of pediatric tracheostomies are performed in children <1 year of age.
•Optimal care requires an interdisciplinary team, which may include the primary care physician, otolaryngologist or surgeon, pulmonologist, speech therapist, home nursing staff, and family members well trained in tracheostomy care.
Box 112-1. Indications for Tracheostomy in Children
Upper-Airway Obstruction
•Foreign body
•Laryngeal or pharyngeal cysts or neoplasms
•Craniofacial disorders, such as macroglossia or micrognathia
•Epiglottitis
•Severe laryngotracheomalacia
•Bilateral true vocal cord paralysis
•Subglottic stenosis
•Facial or laryngeal trauma
•Laryngeal edema after burns
Prolonged Ventilatory Support
•Chronic respiratory failure
•Neuromuscular diseases
•Bronchopulmonary dysplasia
•Guillain-Barré syndrome
•Coma with respiratory dysfunction
•Neonatal, pediatric, and adult tube sizes vary by length and radius or curvature (Figure 112-1). Tubes can be customized.
•Tubes can be made of silicone, polyvinyl chloride, and, uncommonly, metal.
•Silicone tracheostomy tubes are safe for magnetic resonance imaging, but they may cause signal scatter.
•Uncuffed tubes are generally preferred for children to allow for vocalization by air leak around the tube.
•Cuffed tubes are used for patients who require mechanical ventilation with high pressures or who are at risk for aspiration.
—Cuff pressures are kept below 20 cm H2O to prevent necrosis injury to the airway epithelium.
—Air cuffs are inflated with air; water cuffs are inflated with sterile water (not saline).
•Fenestrated tubes are used for adults to promote translaryngeal airflow but are not commonly used for children because of a higher propensity to form granulomas.
Figure 112-1. Cuffed and uncuffed tracheostomy tubes.
Altered Physiology After Tracheostomy
•Airway clearance is impaired, leading to increased risk of infection.
—Scar tissue disrupts the normal ciliary function of the anterior trachea at the tracheostomy site.
—Cough clearance is less effective because the compressive phase of glottic closure before forced expiration is bypassed with the tracheostomy in place.
•The sense of smell is impaired because of decreased airflow through the nose.
•Speech is impaired because of decreased airflow past the vocal cords.
—To achieve speech without augmentative communication devices, the tube must not exceed two-thirds of the tracheal lumen.
—A speaking valve can be used to augment speech, depending on the severity of upper-airway obstruction.
•Humidification of inspired air is bypassed.
—This can lead to desiccation of secretions, damage to mucous glands, mucous plugging, and impaired ciliary function unless external humidification is provided.
—External humidification with cool mist or heat and moisture exchangers is needed.
•Swallow function is impaired, leading to a risk of dysphagia.
—The tube limits superior excursion of the larynx with deglutition.
—The tube may inhibit the normal laryngeal reflex that prevents aspiration.
—The tube may contribute to mass effect on the esophagus posteriorly.
Management
Home Care
Caregiver Education
•Education of the child’s caregivers is an important step in the successful transition from hospital to home that should be individualized to the child and family.
•Some institutions require training of ≥2 adult caregivers who will provide constant care to the child. If appropriate, older siblings could be included in this process.
•Hands-on caregiver teaching should start at the bedside as soon as the tracheostomy is placed.
•Education should include
—Technical skills, such as tracheostomy tube and tie changes, appropriate suctioning techniques, stoma care, and cardiopulmonary resuscitation training
—Decision-making skills, such as recognizing signs and symptoms of respiratory problems and troubleshooting
• Caregivers should demonstrate proficiency before the patient is discharged from the hospital.
Home Supervision and Monitoring
•Constant supervision by an adult trained in tracheostomy care is required. If at any time after hospital discharge a trained adult caregiver is not available, the child should be readmitted until a trained caregiver is available.
•Skilled home nursing care is often prescribed, both during the transitional adjustment time after hospital discharge and when trained family members cannot be available.
•For high-risk tracheostomy-dependent patients (eg, with a critically narrow airway), 24-hour nursing support may be necessary.
•A pulse oximeter should be considered for children at high risk for complications.
•Apnea monitors do not indicate airway obstruction and may not be appropriate for monitoring patients with tracheostomies.
Tracheostomy Supplies for Home
•Essential supplies must be available in the home and are usually supplied via prescription from a durable medical equipment company before hospital discharge (Box 112-2).
•Home care equipment should be tested in the hospital before discharge.
Box 112-2. Tracheostomy Home Care Supplies
•Extra trach tube, same size
•Extra trach tube, 0.5 or 1 size smaller
•Suction machine and tubing
•Suction catheters and olive tip
•Resuscitation bag with trach adapter and face mask
•Scissors
•External humidification (nebulizer, compressor, or heat and moisture exchanger)
•Trach ties
•Clean jar of water
•Normal saline for suctioning
•Cotton swabs and gauze
•Oxygen with tubing (if ordered)
•Breathing monitor, such as a pulse oximeter (if ordered)
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