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 L (length)

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?

image Inability to feed orally (due to swallowing dysfunction, esophageal injury, neuromuscular disease)

image Failure to thrive

image Risk of aspiration from oral secretions

9 What is the difference between a percutaneous endoscopic gastrostomy (PEG) tube and a surgically placed gastrostomy tube?

image A PEG procedure may be performed under sedation or general anesthesia. An endoscope is inserted into the esophagus and a light source indicates the appropriate location on the stomach wall. An incision is made on the external abdominal wall and the tube is placed via this aperture.

image A surgical or open gastrostomy tube is placed via laparotomy under general anesthesia. A purse string suture is made in the stomach to secure the tube and the stomach is then sutured to the abdominal wall.

Gauderer MW: Percutaneous endoscopic gastrostomy. A 10 year experience with 220 children. J Pediatr Surg 26:288–294, 1991.

10 What are some of the complications of gastrostomy tubes in children?

image Dislodgement

image Clogging

image Leaking

image Gastric outlet obstruction

image Bleeding

image Gastric ulceration

image Worsened gastroesophageal reflux

Kazi S, Gunasekaran TS, Berman JH, Kavin H, Kraut JR: Gastric mucosal injuries in children from inflatable low-profile gastrostomy tubes. J Pediatr Gastroenterol Nutr 24:75–79, 1997.

Koulentaki M, Reynolds N, Steinke D, et al: Eight years’ experience of gastrostomy tube management. Endoscopy 34:941–945, 2002.

11 How is dislodgement of a gastrostomy tube managed in the emergency department (ED)?

The first step is to determine the age of the stoma. If the stoma is older than 8 weeks, the ED physician or nurse should take action. If the stoma is less than 8 weeks, obtain a surgical or gastroenterology consultation.

As soon as possible, stent the stoma open with a temporizing device, such as a Foley catheter. This should be placed with lubricant; rarely, a mild sedative is required. When the stoma is located, place the appropriate-size replacement gastrostomy tube in the stoma after removing the Foley catheter. If the tube has been dislodged for an extended period of time (hours), smaller gastrostomy tubes may be initially required to dilate the stoma. Always check the balloon’s function before replacing the tube. Fill the balloon and check the tube to ensure that it is snug.

KEY POINTS: STEPS TO REPLACE A DISLODGED GASTROSTOMY TUBE

1 Determine the age of the stoma.

2 Stent the stoma open with a temporary device.

3 Check the balloon of the new gastrostomy tube.

4 Remove the temporary tube.

5 Place the new gastrostomy tube using lubricant.

6 Fill the balloon and check for adequate fit.

12 What is the danger of inserting a tube into a stoma that has recently been placed?

The stomach wall may not have adhered to the peritoneal lining and skin. The fistula tract can be disrupted and a false lumen into the peritoneum may be formed. Formula inserted through the tube can lead to chemical or bacterial peritonitis.

13 What are some of the complications of replacing a gastrostomy tube?

image Accidental insertion into the peritoneal cavity, which can occur in specific scenarios

image Lysis of adhesions of the stomach wall away from the abdominal wall, resulting in pneumoperitoneum

image If a false lumen is created, formula may be installed into the space, causing chemical peritonitis

image Inadequate advancement of the tip of the tube can result in the tube’s staying in the fistula; the fistula can thus be disrupted when the balloon is dilated, and having the tip in the fistula can result in pain

image Bleeding at the site of insertion can occur from trauma during insertion

Graneto J: Gastrostomy tube replacement. In Henretig FM, King C (eds): Textbook of Pediatric Emergency Medicine Procedures. Baltimore, Williams & Wilkins, 1997, pp 915–920.

14 Is it necessary to perform a dye study in order to verify gastrostomy tube location after replacement?

Not usually. Aspiration of stomach contents after the gastrostomy tube is replaced confirms that the tube is in the stomach. Listening over the stomach for borborygmi when 15 mL of air is inserted into the tube’s lumen is also confirmatory. If in doubt, radiographic studies may be indicated.

15 What is the best treatment for a clogged gastrostomy tube?

Warm water is the best irrigant and has been shown to be superior to vinegar, soda, and juices. Repeated gentle flushing is advised. Prevention includes regular flushing after feedings.

16 What are some complications that can occur in relation to the stoma?

image Peristomal infection

image Irritation

image Bleeding

image Stretching

image Granuloma formation

17 How is a stomal granulation treated?

Application of silver nitrate to the granuloma is most often successful.

CEREBROSPINAL FLUID SHUNTS

18 Name the most common symptoms associated with cerebrospinal fluid (CSF)shunt obstruction

Symptoms frequently include headache, vomiting, and some alteration of mental status, however subtle. Alteration in vital signs may reflect autonomic instability or brain herniation. Seizures are rarely the only manifestation of increased intracranial pressure, and more likely represent an underlying seizure disorder. When a CSF shunt is obstructed, parents often accurately state, “this is what my child looked like when she/he had the last shunt obstruction.”

Browd SR, Ragel BT, Gottfried ON, Kestle JR: Failure of cerebrospinal fluid shunts: part I: Obstruction and mechanical failure. Pediatr Neurol 34(2):83–92, 2006.

KEY POINTS: SYMPTOMS OF VENTRICULOPERITONEAL SHUNT OBSTRUCTION

1 Headache

2 Vomiting

3 Change in mental status, may be subtle

4 Alteration of vital signs

19 What is “pumping the shunt,” and what does this tell me?

Conventional wisdom, which need not always be conventional or wise, suggests that easy depression of a shunt reservoir bubble signifies that the distal end is patent, and rapid refilling of this bubble signifies that the proximal shunt is patent. In reality, the amount of useful information gleaned from this procedure is less than expected. One study found that an “abnormal finding” when pumping the shunt identified less than 40% of obstructed shunts, and that a finding of “normal function” on pumping the shunt would miss between 10% and 35% of shunt obstructions for various brands of shunts.

Piatt JH: Physical examination of patients with cerebrospinal fluid shunts: Is there useful information in pumping the shunt? Pediatrics 89, 470–473, 1992.

Woodward GA, Carey CM: Evaluation of ventricular shunt function. In King C and Henretig FM (eds), Textbook of Pediatric Emergency Procedures, 1st ed, Williams & Wilkins, Philadelphia, 1997.

20 When should shunt infection be suspected? How can I differentiate CSF shunt infection from obstruction?

Suspect shunt infection in any febrile child with a shunt. However, in one series, fever was present in fewer than half of the patients with shunt infection. Meningeal signs are also an insensitive indicator of infection. A history of surgical manipulation of the shunt in the prior 2 months should increase suspicion for infection; infections rarely occur more than 6 months after surgery. Gram-positive organisms, such as Staphylococcus epidermidis and S. aureus, acquired in the surgical suite cause most infections. Gram-negative organisms are uncommon but can originate from an abdominal source or, rarely, bacteremia.

Symptoms of CSF shunt infection overlap considerably with those of CSF shunt obstruction because the diagnoses often occur together. The higher viscosity of infected fluid may lead to a partial or complete obstruction of the small fenestrations on the shunt tubing.

Duhaime AC: Evaluation and management of shunt infections in children with hydrocephalus. Clin Ped 45(8):705–713, 2006.

Nelson JD: Cerebrospinal fluid shunt infections. Pediatr Infect Dis 3:30–32, 1984.

Odio C, McCracken GH Jr, Nelson JD: CSF shunt infections in pediatrics. A seven-year experience. Am J Dis Child 138:1103–1108, 1984.

Walters BC, Hoffman HJ, Hendrick EB, Humphreys RP: Cerebrospinal fluid shunt infection. Influences on initial management and subsequent outcome. J Neurosurg 60:1014–1021, 1984.

21 What studies are helpful in diagnosing CSF shunt infections?

Culture of an organism from the CSF is the most accurate method of diagnosing a shunt infection. Attention to the white blood cell count and Gram stain from the shunt fluid are helpful but not foolproof methods of determining if a shunt is infected. The Gram stain is positive in a little more than half of all shunt infections. CSF that is aspirated from an infected shunt usually reveals a moderate pleocytosis but can be misleadingly normal, as can the CSF glucose. Peripheral white blood cell counts and blood cultures are frequently normal in the presence of shunt infection.

Anderson EJ, Yogev R: A rational approach to the management of ventricular shunt infections. Pediatr Dis J 24(6):557–558, 2005.

22 What techniques can an emergency medicine practitioner use to treat the critically ill patient with a CSF shunt obstruction?

When a child with suspected CSF shunt obstruction is critically ill with signs of increased intracranial pressure, emergent action is required to reduce that pressure. Conventional therapies, such as hyperventilation and mannitol administration, may be used, but if possible the pressure should be relieved by accessing the shunt. If there is a distal obstruction or partial proximal obstruction, fluid can be withdrawn in a sterile fashion by using a 23-gauge butterfly needle and 20-mL syringe. This potentially lifesaving procedure is usually done by a neurosurgeon but should not be delayed if the patient’s condition is deteriorating—the procedure is well described in pediatric emergency procedure textbooks.

Duhaime AC, Wiley JF II: Ventricular shunt and burr hole puncture. In King C, Henretig FM (eds): Textbook of Pediatric Emergency Procedures, 2nd ed. Lippincott Williams & Wilkins, Philadelphia, 2006.

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