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

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Presentation on theme: "Managing Respiratory Distress and complications post insertion of a Tracheostomy Dr P Chetcuti Consultant Paediatrician and Neonatologist."— Presentation transcript:

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 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 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% Prematurity increased from 28% to 58% Congenital anomalies increased from 6% to 23% Congenital anomalies increased from 6% 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% to 3% Infectious diseases decreased from 50% to 3%

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

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

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

7 Indications Long term ventilation,pulmonary toilet- Bronchopulmonary Dysplasia,scoliosis,diaphragmatic paralysis Long term ventilation,pulmonary toilet- Bronchopulmonary Dysplasia,scoliosis,diaphragmatic paralysis Congenital heart disease in association with tracheobronchomalacia,diaphragmatic paralysis and cardiac failure 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 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 Increasing no of Tracheostomies in smaller sicker infants-2kg Subglottic stenosis,long term ventilation for bronchopulmonary dysplasia Subglottic stenosis,long term ventilation for bronchopulmonary dysplasia Mortality from tracheostomy related complications high in this group 5-10% Mortality from tracheostomy related complications high in this group 5-10% More prone to infections More prone to infections

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

10 Age 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%

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

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

13 Tube care Tube change Tube change Fixation Fixation Management of secretions Management of secretions Humidification of inspired air Humidification of inspired air Management of stoma-clean,protect and dress 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 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 Post op CXR 3 days intensive care 3 days intensive care 1 st tube change by doctor who created tracheostomy 1 st tube change by doctor who created tracheostomy Tube change weekly Tube change weekly

16 suctioning As frequently as required As frequently as required Instillation of boluses of saline ? Instillation of boluses of saline ? Minimum morning after waking and pre bedtime 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 Nose,pharynx,larynx and trachea acts as a filter,heater and humidifier of inspired air Not available with Tracheostomy Not available with Tracheostomy May damage the airway structurally and functionally May damage the airway structurally and functionally Ok if ventilated Ok if ventilated nebulised saline nebulised saline Artificial ‘noses’ Artificial ‘noses’ humidifiers humidifiers

18 monitoring Vigilant,well trained and properly equipped care giver 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 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 No monitoring devices are ideal

19 Monitoring in hospital Cardiorespiratory monitoring Cardiorespiratory monitoring Oximetry Oximetry

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

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

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

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

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

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

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

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

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

30 Other 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

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

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

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

34 Oral Feeding May deteriorate temporarily or permanently after tracheostomy May deteriorate temporarily or permanently after tracheostomy Depends on pre tracheostomy feeding Depends on pre tracheostomy feeding Difficult in prems and ex prems Difficult in prems and ex prems Nasogastric feeds and Gastrostomies sometimes required Nasogastric feeds and Gastrostomies sometimes required Milk in tracheal secretions is not good 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 Other factors-prolonged hospitalisation,neurological problems,chronic middle ear problems, lack of normal feeding experiences, lack of muscle strength Do better if decannulated early Do better if decannulated early Speech therapy Speech therapy Speaking valves Speaking valves Sign language Sign language

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

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

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


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