Acute Care of Technology-Assisted Children

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Chapter 42 Acute Care of Technology-Assisted Children

Kate M. Cronan, MD, FAAP, Joel A. Fein, MD, MPH, Jill C. Posner, MD

TRACHEOSTOMY

1 What are the most common reasons for tracheostomy tube placement in a child?

In children, tracheostomies are indicated for respiratory insufficiency due to a variety of causes, most commonly bronchopulmonary dysplasia and airway anomalies (e.g., congenital anomalies and subglottic stenosis). Also relatively common indications are neuromuscular disorders or central disorders, such as a brain tumor or Chiari malformation. A child with a tracheostomy may or may not require additional ventilatory assistance.

Hadfield PJ, Lloyd-Faulconbridge RV, Almeyda J, et al: The changing indications for paediatric tracheostomy. Int J Pediatr Otorhinolaryngol 67:7–10, 2003.

Pilmer SL: Prolonged mechanical ventilation in children. Pediatr Clin North Am 41:473–512, 1994.

Schreiner MS, Downes JJ, Kettrick RG, et al: Chronic respiratory failure in infants with prolonged ventilator dependency. JAMA 258:3398–3404, 1987.

2 How do I determine the appropriate tracheostomy tube size?

A tracheostomy tube is sized by three dimensions: its inner diameter, its outer diameter, and its length. The size of the tube can be ascertained by checking the flanges of the tube where the inner diameter, and in many cases the outer diameter, are imprinted. Many caretakers of technology-assisted children become experts in their child’s technology and are excellent resources for medical personnel. Often, children will travel with emergency boards or “go bags,” which contain all the equipment necessary to change a tracheostomy tube, including a replacement tube. If a patient presents without a tube in place and no replacement tube on hand, a reasonable estimate would be to use the formula for endotracheal tube sizing (16 + age)/4 or 4 + age/4.

KEY POINTS: THREE DIMENSIONS OF A TRACHEOSTOMY TUBE

1 ID (internal diameter)

2 OD (outer diameter)

3 What are the immediate management priorities for a child with a tracheostomy who presents in respiratory distress?

Assume this patient has an inadequate airway until proven otherwise. The tracheostomy tube may be obstructed or malpositioned. Assess airway patency and the adequacy of breathing through physical examination and the usual monitoring. Administer supplemental oxygen. Suction the tracheal tube to evaluate patency and to clear secretions as this may be help to alleviate symptoms. Do not be falsely reassured by a tube entering into the stoma because it may actually descend into the soft tissues of the neck rather than into the trachea, especially if a prior tracheostomy tube change was attempted and unknowingly resulted in a false passage. An emergent tracheostomy tube change may be indicated if respiratory distress persists or the cannula clearly is dislodged.

4 What are the most common causes of respiratory distress in a child who has a tracheostomy tube?

Mechanical failure (cannula obstruction or dislodgement), infectious causes (pneumonia, tracheitis, viral respiratory infections), asthma, or reactive airway disease.

5 What are the causes of bleeding from the tracheostomy tube?

The most common cause of bleeding from the tracheostomy tube is drying and friability of the tracheal mucosa due to inadequate humidification. Anatomically, the tracheostomy tube inserts into the airway below the vocal cords. Therefore, inspired air bypasses the natural warming and humidification processes of the upper airway. Humidification is an important component of the ventilator circuit for patients with mechanical ventilation. For those patients who breathe independently from the ventilator, a heat-moisture exchanger device is inserted at the opening of the tube. This plastic device contains a hydrophilic substance that captures the patient’s own heat and humidity on exhalation so that it can be inhaled on inspiration. Other causes of bleeding include granuloma formation, infection (i.e., tracheitis), and erosion of the tube tip into a blood vessel.

6 How should I manage bleeding from the tracheostomy tube?

First, ensure the adequacy of the airway, breathing, and circulation. Suction frequently to avoid aspiration of blood. Minor bleeding usually indicates the need to increase inspired humidification. A larger amount of blood may indicate that the tip of the tube has eroded into a blood vessel. Treat this as a surgical emergency with immediate notification of surgical, anesthesia, and operating room personnel. Obtain IV access with two large-bore catheters and initiate resuscitation with isotonic fluids or blood products. Overinflating the tracheostomy tube may tamponade the bleeding vessel, thereby providing a temporizing measure. Importantly, leave the tracheostomy tube in place, as this may be the only way to ensure an airway.

7 What can I do if I am unable to replace a dislodged tracheostomy tube?

When a tracheostomy tube becomes dislodged or decannulated, there is a tendency for the stoma to constrict, making it difficult to replace the tube. If stomal constriction prevents insertion of the replacement tube, several options are available: (1) insert a smaller tracheostomy tube; (2) insert a smaller endotracheal tube (being careful not to advance it into a mainstem bronchus), and then slowly dilate the stoma by inserting tubes of successively increasing size; (3) cover the stoma and use a bag-valve-mask device to ventilate by using traditional methods via the patient’s upper airway; and (4) insert an oral tracheal tube. Oral intubation may be exceptionally difficult, especially if the original indication for tracheostomy was to overcome an airway anomaly. Therefore, use neuromuscular blocking agents with great caution and consider anesthesiology or otolaryngology assistance early.

Posner JC, Cronan K, Badaki O, Fein JA: Emergency care of the technology-assisted child. Clin Pediatr Emerg Med 7:38–51, 2006.

Posner JC: Acute care of the child with a tracheostomy. Pediatr Emerg Care 15:49–54, 1999.

ENTERAL FEEDING

8 What are the indicators for placement of a gastrostomy tube in a child?

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