Top 10 Things Pediatricians Should Know About Tracheostomies

Top 10 Things Pediatricians Should Know About Tracheostomies Cecilia Lang, APNP Cindy Griffith, RN © Children’s Specialty Group. All rights reserved....
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Top 10 Things Pediatricians Should Know About Tracheostomies

Cecilia Lang, APNP Cindy Griffith, RN © Children’s Specialty Group. All rights reserved.

Disclosures I have no relevant financial relationships to disclose.

© Children’s Specialty Group. All rights reserved.

Objectives • Understand common reasons children receive tracheostomies • Identify different types of tracheostomy tubes used in Pediatrics. • Review basic care and supplies needed when caring for a tracheostomy tube. • Identify common problems seen in tracheostomy patients and suggested treatment. • Demonstrate hands on review of tracheostomy suctioning, trach tube change and obtaining tracheal aspirates.

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Reasons for Tracheostomy • Upper Airway Obstruction • Laryngotracheal Problem

• Need for Mechanical Ventilation

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Indications for Tracheostomy: Obstructive/Laryngotracheal – Upper airway obstruction – – – – –

Choanal atresia Glossoptosis Micrognathia Laryngomalacia Vocal cord paralysis

– Subglottic stenosis – Large airway malacia – Tracheomalacia – Bronchomalacia

– Large airway compression – Vascular anomalies – Congenital heart disease

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Indications for Tracheostomy: Mechanical Ventilation • Airway/Pulmonary Disorders

• Large airway malacia or compression • Chronic lung disease • Pulmonary hypertension

• Neuromuscular Disorders • • • •

Duchenne’s muscular dystrophy Spinal muscular atrophy Myopathies Mitochondrial disorders

• Neurologic Disorders

• Brainstem abnormalities

» Arnold-Chiari malformations » Brainstem tumors

• Control of breathing disorders

» Congenital central hypoventilation syndrome

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Standard Trach Tubes Shiley Structure

More rigid

Sizes

Bivona More flexible

Neonatal and Pediatric and Adult

Sizes – Neonatal/Pediatric

3.5 to 6.5 mm ID

2.5 to 5.5 mm ID

Sizes - Adult

5.0 to 8.0 mm ID

5.0 to 8.0 mm ID

Uncuffed/Cuffed

Both

Both – Cuff is TTS

Special features Special features

Can add Flextend Safe to use in MRI scanner

Shiley Bivona

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Wire-reinforced which causes distortion for MRIs

Basic Tracheostomy Care • Stoma Care and Tie Changes – Stoma dressings usually off by discharge – Use tap water with liquid soap • Sterile tip applicators around stoma

– Stoma care once a day and PRN – Tie changes: Emphasize 2-PERSON for safety

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Basic Tracheostomy Care Suctioning HOME

HOSPITAL

• Clean gloves (boxed gloves)

• Sterile Gloves

• Re-use catheters up to 8 hours

• Single use catheter dispose after use

• Rinse catheter at end of suctioning with ½ strength hydrogen peroxide; rinse with sterile water

• Rinse catheter with sterile water

• Store in clean container

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Basic Tracheostomy Care Suctioning • Suction to pre-measured length • Suction as needed • Suction less than 5 seconds and allow child to return to baseline • Apply suction on insertion/withdrawal • Give breaths with manual resuscitation device between suctioning passes • Clean technique at home: may reuse catheter

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Basic Tracheostomy Suctioning Oxygenation/hyperventilation • Apply suction for less than 5 seconds • Allow child to rest for 10 seconds after each suctioning pass • Use manual resuscitation device to give breaths after the each suctioning pass © Children’s Specialty Group. All rights reserved.

Saline Use During Suctioning • Routine use of normal saline in NOT recommended

• Used to stimulate a cough – Use 1-3 cc

• Maintain adequate humidification

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Routine Trach Tube Changes • Routine changes weekly; 2 person procedure • Re-clean tracheostomy tubes according to instructions • Emergency equipment (Go-Bag) with child at all times

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Be prepared: GO BAG Emergency equipment with child at all times Suction machine Suction catheters Resuscitator bag with appropriate size mask Same and smaller size tracheostomy tubes Trach ties Normal Saline Lubricant Scissors Tape Roll or blanket for under head of smaller infants © Children’s Specialty Group. All rights reserved.

Replacing the Trach Tube 1. Reposition and try again, pulling down on the stoma to open 2. Try the smaller size trach 3. If still unable to replace: assess child If breathing: Monitor and call for help If not breathing: Tape stoma and provide bag mask breathing or mouth-to-stoma © Children’s Specialty Group. All rights reserved.

CPR and Trach Emergencies • Most Common Emergencies – Occluded/partially occluded trach – Accidental Decannulation – Inability to replace the trach

• Suction, Bag, Change the Trach • When in Doubt, Change the Trach Out

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Common Pediatrician Calls • “My child has thick yellow secretions” – Viral vs. Bacterial? • Are other household contacts ill, fever curve, do secretions have odor, are the secretions thicker and have parents increased in suctioning frequency, what is oxygen requirement or saturations • Viruses can change your normal flora and colonized bacteria can progress to bacterial tracheitis

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Common Pediatrician Calls – Deciding to treat: look at results from last trach culture • Amoxicillin alone may not treat • Bactrim will cover MSSA and MRSA • H/o pseudomonas: inhaled Tobra

– Bethkis – Kitabis pak – Pari neb kit needed for some patients (trach only)

• Family history of what worked last time and repeat • In doubt, call Pulmonary and we can help guide tx

– Never wrong to obtain trach aspirate to help guide therapy, can change therapy based on results if needed – If Bactrim allergy: consider alternatives based on previous sensitivities and call Pulmonary for recommendations – 10 days coverage for both inhaled and oral

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Blood tinged secretions • Quantity of secretions and how often seen? – If frank blood and large amounts, refer to local ER

• How often is child on heated humidity? – May need to increase in winter months

• Does child have cold symptoms? – Can be signs of tracheitis

• How often and how deep are caregivers suctioning? © Children’s Specialty Group. All rights reserved.

Skin Concerns related to Trach • Redness around neck or stoma – Rarely yeast – Most common: moisture-associated dermatitis – Treatments: • keep area as dry as possible • If using stoma dressing, change often or leave off • Use barrier creams around neck and stoma such as Sensicare or other diaper creams

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Skin Concerns Related to Trach A mature stoma has surrounding skin that is flesh colored and sometimes mildly erythematous

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Skin Concerns related to Trach • A tracheostomy granuloma can occur as a result of surgery, infection or irritation. • The granuloma is usually red in color and bleeds easily. It does not contain nerves, so it is not painful. • A granuloma can grow in size and occlude the stoma when the trach tube is removed for changing • If granuloma present, notify the ENT so early treatment can occur. • Treatment can include: application of silver nitrate and/or use of steroid cream or steroid drops to stoma

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Granulation Tissue

Small granuloma noted at 6 o’clock (inferior aspect of stoma)

Moderate granuloma noted extending between 3 and 7 o’clock (inferior aspect of the stoma)

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Hands on Demonstration • Trach Changes • Suctioning Trach • Trach Aspirates/Cultures

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Contact Information Cecilia Lang (414) 266-2484 Physician Consultation and Referral: (800) 266-0366

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