Managing Respiratory Distress and complications post insertion of a Tracheostomy Dr P Chetcuti...
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Transcript of Managing Respiratory Distress and complications post insertion of a Tracheostomy Dr P Chetcuti...
Managing Respiratory Managing Respiratory Distress and complications Distress and complications
post insertion of a post insertion of a TracheostomyTracheostomy
Dr P ChetcutiDr P Chetcuti
Consultant Paediatrician and Consultant Paediatrician and NeonatologistNeonatologist
IndicationsIndications
Historically-Upper airways obstruction Historically-Upper airways obstruction associated with infections was the most associated with infections was the most common indication—Diptheria ,polio and common indication—Diptheria ,polio and HIB vaccinesHIB vaccines
Now most common indication is fixed Now most common indication is fixed upper airways obstruction and the upper airways obstruction and the requirement for prolonged ventilation requirement for prolonged ventilation secondary to neuromuscular and secondary to neuromuscular and respiratory problemsrespiratory problems
Changes in last 20 yrsChanges in last 20 yrs
Prematurity increased from 28% to 58%Prematurity increased from 28% to 58%Congenital anomalies increased from 6% Congenital anomalies increased from 6%
to 23%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% Infectious diseases decreased from 50%
to 3%to 3%
Indications for tracheostomyIndications for tracheostomy
Unsafe or obstructed airwayUnsafe or obstructed airwayProlonged mechanical ventilation requiredProlonged mechanical ventilation requiredTracheobronchial toiletTracheobronchial toilet
Alternatives to TracheostomyAlternatives to Tracheostomy
Non invasive ventilation-not a 24hr Non invasive ventilation-not a 24hr solution,not beneficial if fixed severe solution,not beneficial if fixed severe obstructionobstruction
Nasopharyngeal airwayNasopharyngeal airwayPalliative carePalliative care
IndicationsIndications Upper airways obstructionUpper airways obstruction Subglottic stenosisSubglottic stenosis TracheomalaciaTracheomalacia Tracheal stenosisTracheal stenosis Craniofacial syndrome - Pierre-Craniofacial syndrome - Pierre-
Robin,Charge,Treacher Collins Syndrome,Beckwith Robin,Charge,Treacher Collins Syndrome,Beckwith WiedemannWiedemann
Craniofacial and laryngeal tumours-cystic Craniofacial and laryngeal tumours-cystic hygromas,haemangiomahygromas,haemangioma
Bilateral vocal cord palsyBilateral vocal cord palsy Obstructive sleep apnoeaObstructive sleep apnoea Laryngeal trauma-burns,fractureLaryngeal trauma-burns,fracture
IndicationsIndications
Long term ventilation,pulmonary toilet-Long term ventilation,pulmonary toilet-Bronchopulmonary Bronchopulmonary Dysplasia,scoliosis,diaphragmatic paralysisDysplasia,scoliosis,diaphragmatic paralysis
Congenital heart disease in association with Congenital heart disease in association with tracheobronchomalacia,diaphragmatic paralysis tracheobronchomalacia,diaphragmatic paralysis and cardiac failureand cardiac failure
Neurological/neuromuscular disease- Neurological/neuromuscular disease- Duchennee muscular dystrophy,spinal muscular Duchennee muscular dystrophy,spinal muscular atrophy,congenital central hypoventilation atrophy,congenital central hypoventilation syndrome,cerebral palsy,traumatic brain and syndrome,cerebral palsy,traumatic brain and spine injury,spina bifidaspine injury,spina bifida
PrematurityPrematurity
Increasing no of Tracheostomies in Increasing no of Tracheostomies in smaller sicker infants-2kgsmaller sicker infants-2kg
Subglottic stenosis,long term ventilation Subglottic stenosis,long term ventilation for bronchopulmonary dysplasiafor bronchopulmonary dysplasia
Mortality from tracheostomy related Mortality from tracheostomy related complications high in this group 5-10%complications high in this group 5-10%
More prone to infectionsMore prone to infections
The loss of Auto PeepThe loss of Auto Peep
Lose the resistance of nose and larynxLose the resistance of nose and larynxCan effect optimal lung ventilation-Can effect optimal lung ventilation-
perfusion relationshipperfusion relationshipMakes it more difficult to breathMakes it more difficult to breathMay need supplemental oxygenMay need supplemental oxygen
Age at tracheostomyAge 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%
Tube sizeTube size
Too small –difficult to breath hypoventilation may Too small –difficult to breath hypoventilation may occur especially during sleepoccur especially during sleep
Too large a tube can damage airway mucosa- Too large a tube can damage airway mucosa- ulceration and fibrous stenosisulceration and fibrous stenosis
Cuffed tubes not used in young childrenCuffed tubes not used in young children The smaller the tube the more likely the The smaller the tube the more likely the
possibility of speechpossibility of speech Tubes must be changed with growth-approx Tubes must be changed with growth-approx
every 2 yrs in children under 5every 2 yrs in children under 5
Tube lengthTube length
Too short- will fall outToo short- will fall outToo long- damage carina or go down r Too long- damage carina or go down r
main bronchusmain bronchusAt least 2cm from stoma and no closer At least 2cm from stoma and no closer
than 1 to 2 cm from carinathan 1 to 2 cm from carina
Tube careTube care
Tube changeTube changeFixationFixationManagement of secretionsManagement of secretionsHumidification of inspired airHumidification of inspired airManagement of stoma-clean,protect and Management of stoma-clean,protect and
dressdress
Securing the TubeSecuring the Tube
How well the tube is secured is more How well the tube is secured is more important than the material- twill important than the material- twill tape,velcro and stainless steel beaded tape,velcro and stainless steel beaded metal chainsmetal chains
Standard ManagementStandard Management
Post op CXRPost op CXR3 days intensive care3 days intensive care11stst tube change by doctor who created tube change by doctor who created
tracheostomytracheostomyTube change weeklyTube change weekly
suctioningsuctioning
As frequently as requiredAs frequently as required Instillation of boluses of saline ?Instillation of boluses of saline ?Minimum morning after waking and pre Minimum morning after waking and pre
bedtimebedtime
Passive HumidifiersPassive Humidifiers
Nose,pharynx,larynx and trachea acts as a Nose,pharynx,larynx and trachea acts as a filter,heater and humidifier of inspired airfilter,heater and humidifier of inspired air
Not available with TracheostomyNot available with Tracheostomy May damage the airway structurally and May damage the airway structurally and
functionallyfunctionally Ok if ventilatedOk if ventilated nebulised salinenebulised saline Artificial ‘noses’Artificial ‘noses’ humidifiers humidifiers
monitoringmonitoring
Vigilant,well trained and properly equipped Vigilant,well trained and properly equipped care givercare giver
Risk-age,size of tracheostomy,degree of Risk-age,size of tracheostomy,degree of airway obstruction,behaviour of airway obstruction,behaviour of child,underlying pathology,the presence of child,underlying pathology,the presence of other underlying medical conditions and other underlying medical conditions and the social environmentthe social environment
No monitoring devices are idealNo monitoring devices are ideal
Monitoring in hospitalMonitoring in hospital
Cardiorespiratory monitoringCardiorespiratory monitoringOximetry Oximetry
Early complicationsEarly complications Pneumomediastinum and pneumothoraxPneumomediastinum and pneumothorax HaemorhageHaemorhage Accidental decannulation-reduced with stay Accidental decannulation-reduced with stay
sutures-small curved artery clamp should be sutures-small curved artery clamp should be available at bedside plus 2 spare tracheostomy available at bedside plus 2 spare tracheostomy tubes(one smaller)tubes(one smaller)
Tube blockage-frequent suctioning required to Tube blockage-frequent suctioning required to preventprevent
Subcutaneous emphysema-avoided by using Subcutaneous emphysema-avoided by using appropriate sized tube and not making wound appropriate sized tube and not making wound too tighttoo tight
IntermediateIntermediate
Local infection-can produce excessive Local infection-can produce excessive granulation tissue-can make it difficult to granulation tissue-can make it difficult to reinsert tubereinsert tube
Late complicationsLate complications
Difficult decannulationDifficult decannulationPsychological dependancePsychological dependanceTracheal granulomas-due to trauma at Tracheal granulomas-due to trauma at
distal end or excessive suctioning +/- distal end or excessive suctioning +/- infectioninfection
Accidental decannulation-mortality 2%Accidental decannulation-mortality 2%Suprastomal collapse and tracheal Suprastomal collapse and tracheal
stenosisstenosis
Late complicationsLate complications
Persistent tracheocutaneous fistula-19-Persistent tracheocutaneous fistula-19-42%42%
Effect on speech and language-age at Effect on speech and language-age at time and length of timetime and length of time
Erosion into the innominate arteryErosion into the innominate arteryTracheo-oesophageal fistulaTracheo-oesophageal fistula
Failure of decannulationFailure of decannulation
Peristomal pathology-Peristomal pathology-granulations,suprastomal collapse,stomal granulations,suprastomal collapse,stomal tracheomalacia,stenosistracheomalacia,stenosis
Granulations-surgical removal,laser,?Granulations-surgical removal,laser,?potassium titanyl phosphatepotassium titanyl phosphate
Underlying pathology not adequately Underlying pathology not adequately resolvedresolved
Rigid or flexible bronchoscopy every 6 to Rigid or flexible bronchoscopy every 6 to 12 months12 months
Causes of death associated with Causes of death associated with tracheostomytracheostomy
Accidental decannulationAccidental decannulationTube obstruction-increasing likely in small Tube obstruction-increasing likely in small
infants—narrrow airay,narrow infants—narrrow airay,narrow tubes,copious viscid tubes,copious viscid secretions(bronchopulmonary dysplasia)secretions(bronchopulmonary dysplasia)
11% mortality under 6 months of age(0.5 11% mortality under 6 months of age(0.5 to 3%)to 3%)
Tube BlockageTube Blockage
Obstructive breathingObstructive breathingCant clear secretions on suctioningCant clear secretions on suctioningUrgent tube change requiredUrgent tube change required
Signs of Chest InfectionSigns of Chest Infection
Thick discoloured secretionsThick discoloured secretions+/- Unwell off feeds drowsy+/- Unwell off feeds drowsy+/- pyrexia+/- pyrexia+/- Tachypnoeic/chest wall recession+/- Tachypnoeic/chest wall recession+/- CXR changes+/- CXR changesSecretions for virusesSecretions for viruses
bacteriabacteria
Tracheostomies-infectionTracheostomies-infection
Increased risk of lower respiratory Increased risk of lower respiratory infectionsinfections
Treat with oral or gastric antibioticsTreat with oral or gastric antibiotics Infections around tracheostomy-good Infections around tracheostomy-good
wound care +/- antibiotics—may leed onto wound care +/- antibiotics—may leed onto mediastinitis if not treated optimallymediastinitis if not treated optimally
Colonisation common-Colonisation common-pseudomonas,MRSA and staphyloccus pseudomonas,MRSA and staphyloccus aureus,candidaaureus,candida
Other respiratory managementOther 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
Speaking valvesSpeaking valves
Various different typesVarious different typesAttaches to the open end of tracheostomyAttaches to the open end of tracheostomyValves close on expiration directing air into Valves close on expiration directing air into
the upper airway and across the larynxthe upper airway and across the larynxMay be used in infantsMay be used in infantsMake it more difficult to breathMake it more difficult to breath
Speaking valves-contraindicationsSpeaking valves-contraindications
Presence of severe obstructionPresence of severe obstructionA laryngectomyA laryngectomyWith cuffed tubesWith cuffed tubes In the presence of excessive secretionsIn the presence of excessive secretionsWith gross aspirationWith gross aspirationWith bilateral adductor cord palsyWith bilateral adductor cord palsy
Challenge of giving oxygenChallenge of giving oxygen
Side tubingSide tubingMasksMasksCpapCpapDo not rely on oxygen sats as an indicatorDo not rely on oxygen sats as an indicator
of a blocked tubeof a blocked tube
Oral FeedingOral Feeding
May deteriorate temporarily or May deteriorate temporarily or permanently after tracheostomypermanently after tracheostomy
Depends on pre tracheostomy feedingDepends on pre tracheostomy feedingDifficult in prems and ex premsDifficult in prems and ex premsNasogastric feeds and Gastrostomies Nasogastric feeds and Gastrostomies
sometimes requiredsometimes requiredMilk in tracheal secretions is not goodMilk in tracheal secretions is not good
Speech developmentSpeech development
Other factors-prolonged Other factors-prolonged hospitalisation,neurological hospitalisation,neurological problems,chronic middle ear problems, problems,chronic middle ear problems, lack of normal feeding experiences, lack of lack of normal feeding experiences, lack of muscle strengthmuscle strength
Do better if decannulated earlyDo better if decannulated earlySpeech therapySpeech therapySpeaking valvesSpeaking valvesSign languageSign language
Home careHome care Tube –change,fixation,suctioning-shallow and deepTube –change,fixation,suctioning-shallow and deep Saline instillationSaline instillation Suction equipmentSuction equipment Clean techniqueClean technique HumidificationHumidification Application of drugsApplication of drugs Stoma careStoma care Monitoring-continuous presence of a competent carerMonitoring-continuous presence of a competent carer monitoring device ?monitoring device ? FeedingFeeding BathingBathing Clothing-not fluffy,dressing and undressing must not be over the Clothing-not fluffy,dressing and undressing must not be over the
headhead
Home careHome care
Adaptations –electrical sockets,storage Adaptations –electrical sockets,storage space,space,space,space,
TransportationTransportationSafety-smoke,pets,household spraysSafety-smoke,pets,household spraysExtra supportExtra supportTime in hospital day and night prior to Time in hospital day and night prior to
discharge is requireddischarge is requiredLots of support requiredLots of support required
Organisation of servicesOrganisation of services
Dedicated Nurse specialistsDedicated Nurse specialistsSpecialist multidisciplinary clinicsSpecialist multidisciplinary clinicsChildren should not be transferred to Children should not be transferred to
hospitals if nurses not adequately trained hospitals if nurses not adequately trained in smaller hospitalsin smaller hospitals
Resources ‘Stretched’in larger hospitals Resources ‘Stretched’in larger hospitals