Home care of the pediatric patient with a tracheotomy

The efficacy of tracheostomy tube changes by speech-language pathologists: A retrospective review

Background/Aims:

The number of tracheostomised patients in the acute care setting are increasing, resulting in an equal need of providers who can safely change tracheostomy tubes without complications. The objective of this retrospective study was to ascertain if trained speech-language pathologists were able to safely and efficiently perform tracheostomy tube changes in the acute care setting with minimal adverse events.

Methods:

Our retrospective case series spans from June 2010 to March 2015 and was completed at an academic hospital with a level 1 trauma designation. A total of 107 consecutive referrals undergoing a tracheostomy tube change, with a speech-language pathologist, were identified. Success was defined as the placement of the tracheostomy tube into the tracheal lumen with confirmation of placement. Only complications occurring at the time of the tracheostomy tube change were considered and were defined as an airway loss event: oxygen desaturation <85%; uncontrollable bleeding >5mL; and the inability to perform the attempted tracheostomy tube change for any other reason.

Results:

All of the tracheostomy tubes changes were performed at the bedside at a mean of 13 days post tracheotomy (range 3–28). A total of 106 (99%) of 107 tracheostomy tubes changes were successfully completed without complications; 83 (79%) of the tracheostomy tubes changes performed were the initial tracheostomy tubes change completed post tracheotomy. The remaining 23 (21%) were a combination of either the second or third change. One, (less than 1%), of the procedures was attempted and discontinued before the removal of the tracheostomy tubes, and referred back to the surgical services and was successfully managed with no untoward effects to the patient.

Conclusions:

This is the first study to audit the outcome of speech-language pathologists' ability to successfully change a tracheostomy tube. The findings suggest that specially trained speech-language pathologists, acting as part of a multi-disciplinary care team, have the potential to safely change tracheostomy tubes in an acute care setting with the availability of immediate physician and respiratory therapy support. Additional clinical benefits of the speech-language pathologist changing tracheostomy tubes may include earlier facilitation of communication, decannulation and initiation of nutrition/hydration.

Postoperative management of pediatric tracheostomy: Results of a nationwide survey

OBJECTIVE: A survey was undertaken to document the postoperative care of pediatric tracheostomies by otolaryngologists.

STUDY DESIGN: This study represents the results of a national survey of 564 otolaryngologists covering a broad scope of postoperative pediatric tracheostomy issues considered for patients younger than 2 years and patients older than 5 years.

RESULTS: Of the surveys sent, 134 responses were received, portraying a certain standard management scheme that seems to be used by most respondents.

CONCLUSIONS: Very little difference was seen in respondents' management of patients younger than 2 years of age as compared with those who are older than 5 years. Furthermore, agreement between actual practice and published recommendations seems to vary with some management issues. The results of this study provide a means by which otolaryngologists may familiarize themselves with national trends in the postoperative management of pediatric tracheostomies.

Noninvasive positive-pressure ventilation avoids recannulation and facilitates early weaning from tracheotomy in children

OBJECTIVE

To show that noninvasive positive-pressure ventilation by means of a nasal mask may avoid recannulation after decannulation and facilitate early decannulation.

DESIGN

Retrospective cohort study.

SETTING

Ear-nose-and-throat and pulmonary department of a pediatric university hospital.

PATIENTS

The data from 15 patients (age = 2-12 yrs) who needed a tracheotomy for upper airway obstruction (n = 13), congenital diaphragmatic hypoplasia (n = 1), or lung disease (n = 1) were analyzed. Four patients received also nocturnal invasive ventilatory support for associated lung disease (n = 3) or congenital diaphragmatic hypoplasia (n = 1). Decannulation was proposed in all patients because endoscopic evaluation showed sufficient upper airway patency and normal nocturnal gas exchange with a small size closed tracheal tube, but obstructive airway symptoms occurred either immediately or with delay after decannulation without noninvasive positive-pressure ventilation.

INTERVENTIONS

In nine patients, noninvasive positive-pressure ventilation was started after recurrence of obstructive symptoms after a delay of 1 to 48 mos after a successful immediate decannulation. Noninvasive positive-pressure ventilation was anticipated in six patients who failed repeated decannulation trials because of poor clinical tolerance of tracheal tube removal or tube closure during sleep.

MEASUREMENTS AND MAIN RESULTS

After noninvasive positive-pressure ventilation acclimatization, decannulation was performed with success in all patients. Noninvasive positive-pressure ventilation was associated with an improvement in nocturnal gas exchange and marked clinical improvement in their obstructive sleep apnea symptoms. None of the 15 patients needed tracheal recannulation. Noninvasive positive-pressure ventilation could be withdrawn in six patients after 2 yrs to 8.5 yrs. The other nine patients still receive noninvasive positive-pressure ventilation after 1 yr to 6 yrs.

CONCLUSIONS

In selected patients with upper airway obstruction or lung disease, noninvasive positive-pressure ventilation may represent a valuable tool to treat the recurrence of obstructive symptoms after decannulation and may facilitate early weaning from tracheotomy in children who failed repeated decannulation trials.

Development of otorhinological care of the child

During the last third of the 20th century, pediatric otolaryngology became a defined specialty in many nations, resulting in focused training, fellowships, societies, journals, textbooks, etc. This development occurred as a result of an interaction between the changing sociological and economic status of the child and medical advances. In this paper the history of the status of children is investigated during the Reformation/Counter-Reformation, Enlightenment and Romantic periods, and during the recent era of Entitlement, and an analysis is made of the relationships between otolaryngological care of children during these periods, including a consideration of selected medical advances made during the 17th to 21st centuries, and the evolving status of children. Advances in education of the deaf, understanding the role of the adenoid and care of the airway were applied to the child patient not directly, as it may sometimes seem to physicians caring for a patient in a hands-on fashion, but rather via the bridge of the social and economic context of the time. This interactive process created a special body of knowledge that is now applied in a society that places a high value on the child. In the second half of the 20th century, i.e. during the period of Entitlement, the otolaryngological needs of the child became a demand, based in part upon a need for care of airway pathology in the premature infant, which fostered the establishment of pediatric otolaryngology as a specialty.

Postoperative management of pediatric tracheostomy: results of a nationwide survey

OBJECTIVE

A survey was undertaken to document the postoperative care of pediatric tracheostomies by otolaryngologists.

STUDY DESIGN

This study represents the results of a national survey of 564 otolaryngologists covering a broad scope of postoperative pediatric tracheostomy issues considered for patients younger than 2 years and patients older than 5 years.

RESULTS

Of the surveys sent, 134 responses were received, portraying a certain standard management scheme that seems to be used by most respondents.

CONCLUSIONS

Very little difference was seen in respondents' management of patients younger than 2 years of age as compared with those who are older than 5 years. Furthermore, agreement between actual practice and published recommendations seems to vary with some management issues. The results of this study provide a means by which otolaryngologists may familiarize themselves with national trends in the postoperative management of pediatric tracheostomies.

Laryngotracheal Reconstruction without Stenting

Many surgical procedures, including laryngotracheal expansion with or without grafting, have been suggested for repairing laryngotracheal stenosis in children, and although a variety of stents have been described, the practice of prolonged stenting continues to diminish. We describe 21 pediatric patients with moderate-to-severe subglottic or tracheal stenosis who had laryngotracheal reconstructions with anterior rib cartilage grafts without stenting or intubation. The patients were between 6 months and 7 years of age at the time of surgery. All patients were extubated in the operating room after the procedure was terminated. One patient required reintubation in the intensive care unit for 48 hours after surgery, and another patient required a tracheotomy. Wound infection occurred in one patient. Most patients were discharged to their homes 3 to 5 days after surgery. We report the indications, technique, results, and complications of laryngotracheal reconstruction using a rib graft without stenting.

Pediatric tracheotomy discharge teaching: a comprehensive checklist format

Discharge planning for a child undergoing a tracheotomy is a complex process. In 1989, a multidisciplinary team at Children's Hospital of Michigan developed specific discharge criteria in a checklist format to address all facets of home care for these patients. We present and discuss the checklist. A survey of user satisfaction with the checklist demonstrated that 80% of parents and care-givers felt well-prepared by this format at the time their child was discharged from the hospital with a new tracheotomy. We conclude that the protocol allows for comprehensive and efficient discharge teaching of parents and care-givers for children with new tracheotomies.

Development and assessment of a home care tracheotomy manual

As home care tracheotomy has become a viable option for children with long-term canulation, medical personnel are challenged to provide as safe an environment as possible out of the hospital for these children. The tools used in the training of the families and other caregivers have received little attention in the literature. This study describes the development of a home-care tracheotomy manual for parents. The use of appropriate content presented in an organized, informative and pleasing fashion at the appropriate reading level is stressed. The evaluation of the manual by parents with children who have a child with a tracheotomy is also described.

Nursing management of the child with a tracheotomy

The management of medically fragile children with tracheotomies can be challenging to the pediatrician. This management includes the well child care for these children as well as coordination of the often complex care associated with the underlying condition. Various diseases exist that cause airway obstruction, respiratory failure, or chronic aspiration, necessitating tracheotomies. Tracheotomies require astute observation and skilled care to minimize complications.

Tracheostomy in children

We reviewed the records of 108 patients who had a tracheostomy performed over a 10-year period from July 1979 to April 1989. Median age at tracheostomy was 6 months (1 week-15 years). Indications for surgery were acquired subglottic stenosis (31.4%), bilateral vocal cord paralysis (22.2%), congenital airway malformations (22.2%) and tumours (11.1%). No epiglottis and no emergency situation had to be managed by tracheostomy. Operation was uneventful in all, but 8 patients (7.4%) developed a pneumothorax in the postoperative period. Twenty-one (19.5%) had severe complications during the cannulation period (tube obstruction in 11 patients with cardiorespiratory arrest in 4; dislocation of the tube in 6 patients). Fifteen patients (13.8%) had severe complications after decannulation (2 had a cardiorespiratory arrest); all 15 had to be recannulated. At the end of the study period 85 patients (78.7%) were successfully decannulated with a median period of tracheostomy of 486 days (8 days-6.6 years). The median hospital stay was 159 days (13 days-2.7 years). All patients could be discharged. Eight patients (7.4%) died but no death was related to tracheostomy. In summary the mortality rate is lower than reported in previous reviews and tracheostomy is a safe operation even in small children but cannula-related complications may lead to life-threatening events. The management of tracheostomized small children and infants in a highly staffed and monitored intensive care unit has allowed better handling of complications and has resulted in a reduction in cannula-related deaths.

Tracheostomy: acute and long-term mortality and morbidity in very low birth weight premature infants

Thirty-six very low birth weight premature infants (VLBW-PT) born at 24 to 32 weeks gestation and with birth weights 635 to 1,360 g who had tracheostomies performed for acquired subglottic stenosis or for prolonged mechanical ventilation were followed in relation to acute and long-term mortality and morbidity. Mortality due to the tracheostomy occurred in 4 patients (11%); mortality from all other causes was 25%. Death after hospital discharge was associated with the nonuse of prescribed cardiorespiratory monitors. Complications < 1 week postsurgery occurred in 31% of infants and complications > or = 1 week postsurgery occurred in 64% of infants. Fifty percent of infants required tracheostomy for > 2 years and/or extensive reconstructive surgery of the airway. Parents should be counselled that VLBW-PT infants with a tracheostomy may require extended medical and home care. An effective home care program requires parental training in tracheostomy care, the use of ancillary equipment, and infant cardiopulmonary resuscitation.

Tracheostomy in children with emphasis on home care

Tracheostomy in children is not a benign procedure. Tracheostomy-related mortality rates among children have been previously reported to be as high as 10% to 27%. Children with tracheostomies are especially vulnerable after home discharge with mortality rates of 0.5 to 2 deaths per 100 months at home. In order to assess the impact of extensive parental education and home nursing care on tracheostomy-related mortality, we report our experience over 9 years with 44 children receiving tracheostomies. Each child was maintained at home with a tracheostomy for an average of 19 months for a total of 635 months of home tracheostomy care. Indications for tracheostomy were tracheomalacia (32%), obstructive airway lesions (23%), central nervous system lesions (16%), vocal cord paralysis (9%), Pierre Robin syndrome (9%), and a list of miscellaneous conditions (11%). Our tracheostomy care regimen begins with intensive parental training in tracheostomy management for a minimum of 10 days prior to discharge. Home nursing was arranged for 77% of these children for an average of 11 hours per day at the time of discharge. Eighty-three percent had home apnea monitors. Discharge of these children was delayed or transfer to a secondary hospital was made when parents failed to show adequate proficiency in tracheostomy management with existing home nursing. Eight percent were ventilator dependent at discharge. As of January 1, 1989, 34% of these children have been decannulated. There were six deaths, all due to underlying disease. There were no tracheostomy-related deaths in hospital or after discharge home.(ABSTRACT TRUNCATED AT 250 WORDS)

Teaching self-administration of suctioning to children with tracheostomies

We examined the effectiveness of using dolls to teach young children with tracheostomies to self-administer a suctioning procedure. Four children between the ages of 5 and 8 years, who had had tracheostomies for 6 months or longer, participated. After skills were taught via doll-centered simulations, in vivo skills were evaluated. All of the training and probe sessions were conducted in the participants' classrooms or homes. Results of a multiple baseline design across subjects and skill components indicated that the performance of all children improved as a function of training. Skill maintenance was demonstrated by all participants during follow-up assessments conducted 2 to 6 weeks posttraining. Results of a questionnaire completed by caregivers and interviews with the children revealed high levels of satisfaction with the training procedures and outcomes.

Physician survey on the care of children with tracheotomy

A survey was distributed to practicing pediatric otolaryngologists in the United States, Canada, and England to determine the range of care of the pediatric tracheostomy patient. The questionnaire addressed the use of monitoring devices, intensive care unit usage, timing of first tracheotomy change, as well as parent education and home care. Of the 187 questionnaires issued, 65 responses were received, representing almost 1,500 tracheotomies per year. The results show a number of centers moving toward the establishment of a tracheostomy team, including a surgeon, specialty nurse, speech therapist, and others. As of recent years, most centers reported the increased use of monitoring devices along with earlier discharges made possible by better-trained parents.

Surgical treatment for laryngeal paralysis in infants and children

Clinical and endoscopic data of 219 cases of laryngeal paralysis in newborns, infants, and children are briefly reported. The management of severe cases of persistent dyspnea then is discussed, according to the literature. Of 219 cases, 22 young patients underwent a surgical procedure because of lack of spontaneous recovery and poor tolerance of their disease after 6 to 9 months of follow-up. Arytenoidectomy technique has been used three times and arytenoidopexy 19 times, with fair to excellent results. Other possible treatments for infants are discussed. On the basis of this important series of surgical pediatric cases, the arytenoidopexy technique is advocated, besides arytenoidectomy, to avoid the risks of a long-term tracheostomy in young patients with vocal cord paralysis and severe dyspnea.

Quantitative study of the early effects of tracheotomy and endotracheal intubation on the rabbit tracheobronchial tree

Histopathologic evaluation of the tracheobronchial tree was performed in 12 rabbits to study the effects of 1 hour of tracheotomy or endotracheal intubation. In five animals who underwent oral endotracheal intubation, epithelial erosions and submucosal inflammation in the proximal (bronchial) airway covered 34.9% and 71.3% of the luminal circumference, respectively. This was highly significant (p less than .001) against two control animals, in which 4.8% erosion and 3.9% inflammation were observed. Tracheotomy in three animals caused 22.8% bronchial epithelial erosion and 46.0% inflammation, which were not significantly greater than values of 15.0% and 20.6% observed following "sham" tracheotomy. The severity of the proximal (indirect) consequences of endotracheal intubation may have been attributable to the lack of humidification, but this does not explain the lesser damage caused by tracheotomy. It is postulated that increased inspiratory flow rate and pressures occurring in endotracheally intubated animals may be contributory factors.

Experience with the home-care of tracheotomised paediatric patients

Many infants with tracheotomies remain cannulated for prolonged periods while the underlying cause of airway obstruction is either treated or natural resolution is awaited (usually by growth). To enable these children to enjoy a relatively normal family environment despite a tracheotomy, it is desirable that they should be managed at home for at least part of the time. For the past 8 years we have routinely used soft polyvinyl chloride paediatric tracheotomy tubes (Shiley) in our patients. These tubes have proved to be relatively resistant to obstruction with secretions and are changed at 1- to 2-week intervals. They can be modified by making a series of three to four 2-mm through-and-through fenestrations around the shoulder in order to improve speech production and facilitate decannulation. Parents are tutored in tracheotomy care, which includes tube changing, humidification and suction. They are then permitted to take their child home from hospital when they are considered to be competent. Twenty-eight children (13 boys, 15 girls) with a mean age of 14.5 weeks (range 1-525 weeks) at the time of tracheotomy have been managed at home using this system. The median period of hospitalisation was 12 weeks (range 5-75 weeks), and the median duration of home management was 94 weeks (range 13-394 weeks). Sixteen patients have been successfully decannulated, 11 remain cannulated and 1 died at home from sudden infant death syndrome. Despite supportive measures, the majority of the children developed intermittent chest infections.(ABSTRACT TRUNCATED AT 250 WORDS)

Infantile subglottic hemangiomas. An update

Between 1913 and 1985, 323 cases of infantile subglottic hemangiomas have been reported in the English language literature. The purpose of this study is to review these cases, to report The Johns Hopkins Hospital experience with ten additional cases, and to compare the various methods of treatment in an attempt to identify the regimens associated with the best outcome. The majority of the patients presented before the age of 6 months with respiratory distress, most commonly inspiratory stridor. There was a 2:1 female to male preponderance. The diagnosis was established by endoscopy in the majority and confirmed by biopsy in one third, without serious bleeding complications. A plethora of treatment methods have been described, including the following: corticosteroids, tracheotomy, radiation therapy, radioactive implant therapy, surgical excision, cryotherapy, and carbon dioxide laser. These methods were reviewed and their results compared to our own. We conclude that several methods are effective, each having its advantages and disadvantages. We believe that immediate tracheotomy should be performed in cases with severe airway obstruction. Smaller lesions may be vaporized with the carbon dioxide laser without tracheotomy if postoperative care is provided in a pediatric intensive care unit. Corticosteroids may be used alone or in combination with other modalities. External radiation therapy and injection of sclerosing agents are not advised.

Obstructive airway disease in infants and children

Airway obstruction in infants and children can produce rapidly progressive life-threatening emergencies. An understanding of the common symptom complexes associated with regional obstructive abnormalities allows rapid evaluation and appropriate therapy. This article discusses the most common types of obstructive congenital and acquired airway anomalies, describes their symptomatology, and reviews the available diagnostic and treatment options.

Simplified oxygen administration in tracheostomized patients with bronchopulmonary dysplasia

The report describes a simple effective system of meeting the oxygen requirements of tracheostomized infants in the home setting. It consists of oxygen tubing which may be run under the infant's clothing and connected to the tracheostomy tube through a specially created hole. This allows a continuous administration of oxygen while minimizing the risk of accidental decannulation of disconnection by the infant grabbing the oxygen tubing. This has been used successfully in the management of infants with tracheostomies and chronic oxygen needs due to bronchopulmonary dysplasia.

Laryngeal stenosis following carbon dioxide laser in subglottic hemangioma. Report of three cases

Recent reports recommend carbon dioxide laser as the safest and the most effective treatment for subglottic hemangioma in infants. Though one report mentions the development of a small amount of subglottic scarring in an 8-month-old girl after resection of a subglottic hemangioma, there is insufficient emphasis in the literature with respect to stenosis as a complication of CO2 laser therapy. The authors present three cases of severe laryngotracheal stenosis developing in infants treated with the CO2 laser for subglottic hemangioma. The presentation of these three cases should be a warning to the otolaryngologist that the use of the CO2 laser is not without significant risk of scar tissue formation.

Clinical-pathological correlates of congenital subglottic hemangiomas

One hundred thirty-six cases of subglottic hemangioma in infants have been reported in the English -language literature; four additional cases are reported here. The clinical presentations, diagnostic work-ups, treatments, and outcomes are analyzed. Twenty-one patients died, 17 of whom underwent autopsy. The histology of the laryngeal pathology from seven of these patients was reviewed by the authors. Possible correlation between the pathological findings and the clinical presentation is made. Approaches to diagnosis and treatment are suggested based on these findings.