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Special
Considerations
for the
Child With a
Tracheostomy
Linda Sue Van Roeyen
8
Advances in technology have brought about new developments in noninvasive
ventilatory support, and increasing numbers of premature infants and children
with tracheostomies require home care. Additionally, home ventilation with a
tracheostomy is becoming an increasingly available alternative to prolonged
intubation and hospitalization.
Changing trends in pediatric care have become apparent over the past
30 years. The numbers of tracheotomies for upper airway obstruction have decreased while the need for prolonged mechanical ventilation has increased.
More tracheotomies are performed during the first year of life than any other
pediatric age group (Wooten et al., 2006). Feudtner and others (2005) found that
20% of children discharged from children’s hospitals were dependent on a medical device. Lewis, Carron, Perkins, Sie, and Feudtner (2003) found significant regional variation in the discharge disposition of children with tracheostomies. A
notable finding was that children from the northeastern or Midwestern United
States were more likely to be discharged to long-term health facilities, with the
exception of children admitted to children’s hospitals or teaching institutions,
where they were less likely to be discharged to long-term care facilities.
243
244
Tracheostomies
Indications for Tracheostomy in Children
The decision to provide a tracheostomy for a child is made on an individual
basis and is based on family dynamics, individual patient factors, and the initial
process that led to prolonged intubation. The patient’s underlying disease process dictates whether the child is a candidate for a tracheostomy and/or longterm ventilation. Ventilator-dependent children must repeatedly demonstrate
their inability to maintain independent oxygenation and ventilation prior to the
initiation of a tracheostomy.
Indications for tracheostomy in children fall into several categories: pulmonary and airway disorders, neuromuscular conditions (including diaphragm
and chest wall), central nervous system disorders, and acquired conditions such
as trauma and smoke inhalation. See Table 8.1 for a list of indications for tracheostomy in children.
Patient prognosis depends on the underlying medical condition. In many
neonatal units, the complications of long-term intubation have become one of
the most important indicators for tracheostomy. Parilla, Scarano, Guidi, Galli,
and Paludetti (2007) reviewed current trends in pediatric tracheostomies. In a
study of 38 patients given tracheostomies for respiratory failure and upper airway obstruction, the complication rate of long-term intubation in children less
than 1 year of age was 42.1% compared to 26.3% for those over 1 year of age. The
change in indication also showed a decrease in the average age of children who
required tracheostomies.
Patients with chronic lung and diaphragm problems can become candidates
for weaning from ventilator support. As diaphragm strength increases and new
lung tissue continues to develop until approximately age 2, children are more
likely to tolerate decreasing ventilator support. Growth and development issues
are carefully monitored from infancy to early childhood to ensure calories are
used for normal growth and development. Children with neuromuscular disease require supportive care over a lifetime, while those with central nervous
system conditions may only need ventilator support during sleep.
Outcome of Children With Tracheostomies
There are few studies related to the outcome of children with tracheostomies.
One retrospective survey examined home mechanical ventilation in 20 Italian
children (Otonello et al., 2007). Their diagnoses included myopathic disorder,
congenital central hypoventilation syndrome, chest wall disorder, cystic fibrosis,
pulmonary hypertension, and diaphragmatic paralysis. The goals for optimal
ventilation included maintaining normal oxygenation and ventilation, minimizing work of breathing, and supporting normal growth and development. Unfortunately, the children with tracheostomies had frequent elective hospital
admissions, an increased number of emergency admissions, longer inpatient
stays, and many readmissions within a short time from discharge.
A recent retrospective study at Baylor College of Medicine reviewed
70 children and adolescents who underwent tracheostomy placement over a
24-month period. Median hospital stay was 46 days. Within a 6-month period,
63% of children were readmitted, and there was a mortality rate of 13%. None
Chapter 8 Special Considerations for the Child With a Tracheostomy
Indications for Tracheostomy in a Child
8.1
General Condition Indication
Pulmonary disorders Chronic lung disease ■
Bronchopulmonary dysplasia ■
Meconium aspiration ■
Congestive heart failure ■
Respiratory distress syndrome ■
Chronic aspiration ■
Airway disease ■
Stenosis ■
Malacia ■
Congenital malformation of the chest wall ■
or diaphragm
Diaphragmatic hernia
■
Omphalocele ■
Phrenic nerve injury ■
Neuromuscular disorders Spinal muscular atrophy ■
Degeneration of the anterior horn cells ■
Muscular atrophy ■
Fatty infiltration of muscle ■
Spinal cord injury ■
245
Central nervous system disorders Central hypoventilation ■
Central sleep apnea ■
Acquired conditions Trauma ■
Smoke inhalation ■
Foreign body aspiration ■
Other Infection ■
Neoplasms ■
Respiratory papillomatosis ■
Respiratory hemangiomas ■
Obstructive sleep apnea ■
Aspiration due to neurologic lesions ■
Pulmonary toilet for chronic aspiration ■
Tracheoesophageal fistula ■
Cleft larynx ■
of the deaths, however, were related to the tracheostomy (Graf, Montagnino,
Hueckel, & McPherson, 2008a).
A German retrospective study of 85 children in a pediatric ICU reviewed
the experience of tracheostomies over an 8-year period. Indications for tracheostomy included upper airway obstruction, craniofacial syndromes, longterm mechanical ventilation, neurological deficits, trauma and sequelae, and
246
Tracheostomies
bilateral vocal cord paralysis. Successful decannulation occurred in 50.6% of
patients, with a mean cannulation time of 21.6 months (Zenk et al., 2009).
Procedural Steps in the Care of the Child With a Tracheostomy
Tube Selection
Performing a tracheostomy in children can be more difficult than in adults. (See
chapter 2 for discussion of a pediatric tracheotomy.) The trachea is more pliable,
making it difficult to palpate, and the operative area is smaller, requiring an otolaryngologist skilled with pediatric patients. There are many types of neonatal
and pediatric tracheostomy tubes available (Figure 8.1, Figure 8.2, Table 4.3). Like
adult tubes, materials include polyvinyl chloride, polyurethane, silicone, and metal.
Cuffed tubes are rarely used with neonatal and pediatric patients but can improve
the delivery of tidal volume when the patient is ventilator dependent. When a
tube with extended length is required, a pediatric tube should still be chosen over
an adult tube because they are significantly shorter. Inner cannulas are never
used because of the very narrow inner diameter of neonatal and pediatric tubes.
8.1
Shiley pediatric tracheostomy.
Chapter 8 Special Considerations for the Child With a Tracheostomy
8.2
Bivona pediatric
tracheostomy.
The type of tracheostomy tube is also selected based on the shape and
length of the airway to prevent pressure on any portion of the neck or trachea.
The flexibility of the tube is also taken into consideration. For example, tubes
made of silicone are generally more flexible than those made from polyvinyl
chloride (PVC) or plastic. Tubes made from PVC may become stiffened after 3
to 4 months of use and cleaning, while tubes made from silicone remain flexible. Metal tubes, which can be reused indefinitely, are generally not used in
pediatrics due to their inflexibility (ATS, 2000).
The clinician must also evaluate the need for a cuffed versus an uncuffed
tube. If the patient is mechanically ventilated, a cuffed tube may be preferable
to decrease the possibility of a leak during ventilation and the risk of aspiration. The cuff provides the ability to adjust the fit of the tube within the airway
(ATS, 2000). Considerations for tube selection should exclude the presence of
tracheomalacia. If tracheomalacia is present, the tube should be long enough to
ventilate past that area. Occasionally, children have areas of granulation tissue
within their airway, which must also be considered in determining the length of
the tube. Finally, it is important to select a tube that does not cause pressure or
erosion on sensitive areas within the trachea.
The difference between the internal and external diameter may not be significant until the child begins to speak. At that time, the child may not be able
to get enough air around the tube to enable vocalization. If this is the case, the
tracheostomy tube should be downsized until a leak occurs. If the patient is mechanically ventilated, monitoring the return of tidal volume is helpful to ensure
the leak is not too large.
The neck flanges of the tracheostomy tube are shaped like wings, remain
on the outside of the neck, and are used to attach tracheostomy ties to secure
the tube around the neck. A v-neck flange is often preferable with children’s
neck anatomy to allow for better placement against the neck (Figure 8.3). A
soft Velcro tracheostomy holder is used predominantly in pediatrics. Other tracheostomy holders include a chain tracheostomy holder, utilized frequently in
preteens, or the Snappy tracheostomy holder, which uses an elastic material
that snaps onto the flanges. The Velcro tracheostomy holder is secured behind
247
248
Tracheostomies
8.3
Tracheostomy
in situ.
the patient’s neck and at the flanges. If the patient is mechanically ventilated,
the ventilator tubing is secured with cotton twill tracheostomy ties to the swivel
adapter.
General Care of the Tracheostomy
During the first postoperative week, the stomal area should be cleansed with
a solution of hydrogen peroxide and sterile water. Using a sterile gauze pad,
a 1:1 concentration of hydrogen peroxide and sterile water should be used to
cleanse the stoma, wiping in a semicircular motion around the top half of the
stoma and repeating with another pad along the inferior portion of the stoma.
After the first postoperative week, individual soap cleansing pads (e.g., Castille
soap) or plain soap and water may be used to clean around the tracheostomy
tube. The dressing should be changed at least three times per day, and skin care
of the stoma should be performed daily. Gauze dressings should not be cut to fit
around the tube, as loose fibers can work their way into the tracheostomy.
Precautions While Bathing
A child with a tracheostomy should never be submerged in water without covering the tube, either with an artificial nose or the ventilator tubing. When bathing
Chapter 8 Special Considerations for the Child With a Tracheostomy
a toddler with a tracheostomy, the water level should not be higher than the
child’s waist. This prevents water from entering the tracheostomy, with subsequent risk for aspiration pneumonia.
Changing the Tracheostomy Tube
After the initial tracheotomy, a tube change should be avoided for at least 5–7 days
to allow the tract time to become well established (Wilson, 2005). The first tube
change should be done by the surgeon to allow for evaluation of the stoma and
confirmation it has healed enough for other professionals and family members
to safely change the tube. The tracheostomy tube of a child should be changed
weekly and at a time when the child is awake and least irritable. This will improve cooperation for a successful outcome.
The tracheostomy tube should be changed by two people whenever possible. The goal is to change the tracheostomy in a calm manner, without fear on
the part of the child or caregiver. Depending on the age of the child, it is best
if a pattern is established. Small children should be instructed to keep their
hands at their sides each time the procedure is begun. The two-person method
is used so that one person does the work of the tracheostomy tube change while
the other person provides a distraction. In this way, the tube change can be
done without traumatizing the child or increasing the anxiety of the child or
caregiver.
Prior to the tube change, it is wise to organize the necessary equipment and
plan to ventilate the child if required. This involves inserting the obturator into
the new tube, lubricating the tip, and attaching the Velcro ties, which should be
cut to fit the child’s neck. The caregiver should inflate the cuff and inspect it
prior to insertion. An infant or small child should have his or her tracheostomy
tube changed while lying down in bed, while an older child may sit in a chair or
stand. If the supine position is used, a rolled blanket should be placed under the
patient’s neck so his or her chin is pointing to the ceiling and his or her head is
tilted back to a neutral position. The child’s head should not be tilted too far back
because this will make it more difficult to insert the tube. To prevent the child
from coughing out the tube, one person should secure the neck flange while the
other is undoing the ties. The tracheostomy tube should be removed and a new
one reinserted with the curve of the tube pointing downward into the trachea.
Contrary to the adult insertion procedure, in children it is not necessary to make
a significant caudal turn when inserting the tracheostomy tube. This is because
the anatomy of the child is much smaller; therefore, the angle of the caudal turn
does not need to be accentuated. After insertion, the obturator should be removed while holding the tracheostomy tube in place. The tracheostomy holder
should be secured, allowing for only one finger width under it. The tube should
not be released until the ties are secure. If the tracheostomy leans to the left or
right, the ties may be too tight (Downs, Beland, Reamer, & Hird, 2008).
249
Suctioning
Suctioning of the tracheostomy occurs only when needed. The risks associated
with suctioning include trauma, atelectasis, hypoxemia, laryngospasm, bronchospasm, infection, and increased mucus production (Ireton, 2007). Suctioning
250
Tracheostomies
should occur after waking, before meals, before leaving home, before bedtime,
and as needed during the day or night. Children, especially those with neurological impairment, require frequent assessments for suctioning. Suctioning is an opportune time to evaluate secretions for color, odor, and consistency.
When possible, encourage coughing to enhance airway clearance with suctioning. Surveillance cultures should be obtained weekly on all hospitalized patients with tracheostomies. Many patients are colonized with specific types of
organisms, and this information is helpful to identify organisms that respond
to treatment.
Suctioning pressures recommended for children are detailed as follows.
Adolescents require pressures of 80–120 mm Hg (10–16 kPa), children require
80–100 mm Hg (10–13 kPa), and neonates, 60–80 mm Hg (8–10 kPa). Threeholed suction catheters are recommended, and they should be no larger than
half the internal diameter of the child’s tracheostomy (Ireton, 2007). To determine the length of the suction catheter, the tracheostomy tube should be measured and 1.5 cm added for suctioning purposes. Measurement is especially
important with customized tubes. It is helpful to leave a catheter at the bedside
as an example of how deep the suction catheter should be when entering the
tracheostomy tube. In neonates, the length of the suction catheter introduction
may be shorter due to their smaller anatomy.
During suctioning, it is important to avoid contact with the carina because
of the high potential for trauma and scarring. Scarring can interfere with later
decannulation. The catheter should remain in the airway for 5–10 seconds. Some
authors (Hooper, 1996) recommend twisting the suction catheter upon withdrawal from the airway to avoid adherence to the tracheal mucosa. In a review
of tracheostomy care in children, isotonic sodium chloride should not be routinely instilled for suctioning. Routine instillation of saline may dislodge bacteria, cause infection, and be detrimental to oxygenation (ATS, 2000; Neill, 2001).
Humidification
Humidification is extremely important to maintain airway patency and prevent
the destruction of epithelium, ciliary function, and atelectasis (Wissing, 2004).
If the airway is dry, there may be increased incidence of mucus plugs. Mucus
plugs occur when secretions become thick and block the tracheostomy tube.
When the patient is ventilated, the in-line humidifier should be set at 37°C.
An artificial nose or high-humidity tracheostomy collar may be used while the
patient is awake to filter and humidify the air. Nebulized saline treatments have
been shown to thin secretions with uniform distribution and may be helpful
when secretions are too thick (Klockare et al., 2006).
Medications
Common issues related to children with tracheostomies include excessive oral
and tracheal secretions and the inability to manage them. Occasionally, it can
be helpful to use ammonium glycopyrrolate (Robinul) to dry secretions slightly.
It is important to start with a very low dose in order to prevent drying secretions too much, thereby causing a mucus plug. The dosing range for Robinul is
40 –100 mcg/kg up to four times per day. It is preferable to start with a 40-mcg/kg
dose three to four times per day and increase as needed. If copious secretions
Chapter 8 Special Considerations for the Child With a Tracheostomy
continue to be an issue, surgical removal of the salivary glands has been helpful in some cases. Laryngeal tracheal separation reconstruction is sometimes
done to alleviate excessive oral/tracheal secretions preventing aspiration. An
intraglandulary injection of Botulinum toxin-A (BTX-A) may be used to block
the release of acetylcholine from motor and autonomic nerve terminals and
decrease saliva production (Svetel et al., 2009).
251
Pulmonary Medications.
tracheostomy patients is accomplished via in-line or manual devices. Children
with tracheostomies utilize a spacer for metered dose inhalation (MDI) administration. For children on ventilator support, an in-line device is placed in the
ventilator circuit proximal to the patient’s airway. With a dual limb circuit, the
placement of the spacer should be on the inspiratory side to ensure better absorption of the medication into the airway. Aerosols can be delivered through
hand bag-in methods, which do not disturb the integrity of the circuit. If given
into the circuit, medications pass through the exhalation valve and cause the
valve to stick over time, causing nuisance alarms.
The administration of respiratory medications for
Management of the Child With a Tracheostomy in the Community
Resources for Home Care
The prevalence of children in the United States under 18 years of age with special health care needs is high—approaching 14% (U.S. Department of Health
and Human Services, Health Resources and Services Administration, 2009). In
2008, Baylor College of Medicine studied 70 children and adolescents undergoing tracheostomy over a 24-month period. Their objective was to describe
an educational program and timeline for the discharge of children with new
tracheostomies and to identify common impediments to education and the
discharge process. Multiple medical and social factors can impede the child’s
transition to the outpatient setting. These include regional variations in rates of
tracheostomy throughout the United States as well as variations in discharge disposition (home versus chronic care facilities). In addition, technology-dependent
children require frequent readmission. Implementing a structured education
and discharge program resulted in shorter hospitalization and more successful
discharge to home (Graf et al., 2008b).
The stress of having a child with a tracheostomy has not been quantified;
however, several studies have attempted to identify the challenges to parents
and families with children with tracheostomies or on ventilators. In a study
from the United Kingdom, the effects on the quality of life of both the patient
and caregiver were evaluated. Questionnaires were received from 26 caregivers who reported adverse effects on all aspects of their quality of life, including
sleep, relationships, social life, and ability to work. This study identified the need
for improved preoperative care and increased community support for families
of children with tracheostomies or on mechanical ventilation (Hopkins, Whetston, Foster, Blaney, & Morrison, 2009).
A review of children with tracheostomies and gastrostomies evaluated
pa rental stress and coping mechanisms (Montagnino & Mauricio, 2004). A