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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4773_Библиотеки_им_академика_М_И_Перельмана.pdf
If you are by yourself, do not leave the patient at this stage. Open and
check the child's airway by placing supine on a flat firm surface. It may be
helpful to put a folded towel under the shoulders, only if this is
immediately available. Do not waste time by collecting towels. Gently tilt
the tip of the chin upward, taking care not to press on the soft tissue
underneath.
Any humidification devices, HME filters or speaking valves should be
removed in an emergency as they may have become blocked with blood or
secretions. Inspect tube for obvious problems or signs of blockage: crusts,
kinks or dislodgement.
Older children may have tracheostomy tubes in situ, which are large
enough to accommodate a removable inner cannula. Inner tubes used with
tracheostomies can significantly reduce the risk of tube occlusion,
provided they are cared for and used appropriately. If a tracheostomy tube
becomes blocked, simply removing the inner tube may resolve the
obstruction. However, it must be remembered that inner tubes vary
significantly in their design, with some requiring replacing after cleaning,
to allow connection to breathing circuits. It is essential to know what
equipment is used in your clinical areas, as unfamiliarity with equipment
may lead to morbidity and mortality. If an inner tube is present, this
should be removed at this stage (Figure 9.21).
Figure 9.21 Removing the inner tube (if present) may alleviate an
obstruction.
Reproduced with permission of GOSH.
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Assessing tracheostomy patency
The next step is to suction the tracheostomy tube. Suctioning will clear
any obstruction in the majority of cases. However, if any resistance is felt
or the suction catheter is unable to pass down the tube, then the tube may
be partially displaced or completely blocked. The tracheostomy tube
should be changed immediately. If the stoma is less than 1 week old, then
the risks of inserting a new tube into a false passage in the soft tissues of
the neck are increased, along with trauma and bleeding. Misplacement of
a tube into a false passage does not secure the airway (Figure 9.23).
Figure 9.22 Suctioning the tracheostomy tube.
Reproduced with permission of GOSH.
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Figure 9.23 Tube insertion into a false passage in the soft tissues of the
neck.
Reproduced with permission of HEE eLfH.
When changing a tube, the same size tube should be inserted. If you are
unable to insert the same size tube, try to insert the one that is a size
smaller. If the stoma closes on removal of the tube and the new tube
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cannot be replaced, attempt to pass a smaller tube. If this is unsuccessful,
thread a suction catheter through the tracheostomy tube and insert the tip
into the stoma. Then attempt to guide the tracheostomy tube along the
catheter and through the stoma. The Seldinger technique should be
practiced as a first-line attempt at reinserting a tracheostomy tube.
Tracheal dilators should only be used by practitioners experienced in their
use. If tube reinsertion is unsuccessful, ventilation can be attempted either
via the catheter or by conventional rescue breaths (e.g. mouth-to-mouth or
bag and mask over the mouth and nose). Supplemental oxygen should be
applied as soon as it is available.
It is important not to attempt high-pressure ventilation via a tracheostomy
tube that appears blocked or displaced (suction catheter won't pass, absent
capnography trace). If the tube has become displaced into the soft tissues
of the neck, rapid surgical emphysema can develop and even a small
amount of gas in the tissues can make managing a paediatric stoma or
airway difficult or impossible.
All options may not be suitable for all infants or children, especially those
with abnormal upper airway anatomy. The exact requirements and
sequence of events will be discussed and agreed when the patient first
presents. Airway alert or tracheostomy bedhead signs can be extremely
useful in these circumstances to inform emergency responders of
underlying disease or anatomy.
If the patient has a patent upper airway, breathing around the
tracheostomy tube may be possible, even if it is blocked or displaced. If
there is any evidence of breathing via the upper airways, then oxygen
should be applied via a conventional facemask (Figure 9.24).
Figure 9.24 Airflow may be possible around the tube.
Reproduced with permission of HEE eLfH.
224
Primary emergency oxygenation
Following airway opening manoeuvres (native upper airway and
attempting to suction or change the tracheostomy tube), the next step is to
reassess whether the interventions have improved the situation. This
assessment is primarily a clinical one, but is supported by appropriate
monitoring, such as pulse oximetry and capnography.
Look, listen and feel for any breathing at both the upper airway (nose and
mouth) and the tracheostomy tube, or open stoma if a new tube could not
be re-inserted. At the same time look at the child's chest to observe any
breathing movement. Take up to a maximum of 10 s to do this.
If the child is breathing adequately, give oxygen and keep the airway open
by regular suction and wait for the clinical emergency team.
If the child is not breathing (or only making agonal gasps), then
emergency oxygenation is required. The priority is to oxygenate the child,
not necessarily to reinsert a new tracheostomy tube or oral/nasal
endotracheal tube, although these more invasive methods may be required
if simpler measures are unsuccessful.
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If the tracheostomy tube is patent, commence artificial respiration with a
bag-valve system directly connected to the tracheostomy tube and
administer five breaths. This is best achieved with a 15 mm swivel
connector attached to a self-inflating bag (e.g. Ambu bag) or paediatric
anaesthetic breathing circuit (Figure 9.25 shows a Mapleson F circuit).
Remember to attach oxygen and capnography as soon as they are
available. Oxygen should be set at a minimum of 10 l/min for a paediatric
system (usually weight under 20 kg) and 15 l/min for the adult system
(appropriate for weights over 20 kg). Ensure that the breaths are effective
by observing chest movement and an appropriate waveform on the
capnography display.
Figure 9.25 A Mapleson F circuit, commonly known as Jackson-Rees'
modification of the Ayre's T-piece.
Standard oral airway manoeuvres include the use of oral or nasal adjuncts
(Guedel airways, nasopharyngeal airways) or supraglottic airway devices
such as the LMA (Figure 9.26). If the tracheostomy stoma is open
(without a tube) and the patient is being ventilated via the upper airways,
the stoma may need to be covered to allow effective delivery of the gas to
the lungs.
Figure 9.26 Laryngeal mask airways.
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Ventilation can also be achieved by delivering oxygen via the open stoma.
Suitable techniques include a small, paediatric facemask (Figure 9.27), or
an LMA applied to the skin.
Figure 9.27 Selection of facemasks.
Secondary emergency oxygenation
If the less invasive methods of oxygenation fail, then insertion of an
airway device is required. This can either be via the upper airways (oral or
nasal intubation) or via the tracheostomy stoma. The choice of route
depends on several factors.
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• The age of the tracheostomy stoma. A stoma that is less than 1
week old will be more difficult to cannulate with increased risks of
misplacement. The stoma may also close on removal of a tube.
• The presence of stay sutures. These may assist reinsertion of a tube
into the stoma, making this the easier airway to manage.
• If the patient has a known difficult (or sometimes impossible) to
manage upper airway. The stoma becomes the easier airway in this
circumstance. It may still be possible to oxygenate to some degree
via the upper airway.
• The expertise and experience of the attending emergency team. If
your expertise is managing upper airways (usually anaesthetic
backgrounds), then don't change what you do normally in an
emergency. Likewise if you are more comfortable manipulating
tracheostomy tubes and managing stomas (usually head and neck
surgical backgrounds).
• The equipment that is immediately available. All difficult airway
equipment including a range of laryngoscopes, bougies, introducers
and a suitable fibreoptic endoscope should be available for
tracheostomy emergencies. Emergency anaesthetic and
resuscitation drugs may also be rapidly required.
• The location. Sometimes it is better to wait until the patient is in a
safe location for airway management before attempting invasive
airway manoeuvres. The risks of transferring a patient will need to
be balanced by the attending clinical teams. If a patient's
oxygenation can be adequately maintained, it is often safer to
assemble the personnel, equipment and any required drugs in a
critical care or theatre area to optimise the chances of successful
difficult airway management.
Discharge from hospital with
a paediatric tracheostomy
Consideration of discharge planning should start as soon as the decision to
perform a tracheostomy is taken. Consideration needs to be given to who
will provide care, where and how the child with a tracheostomy will be
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managed following discharge. This can be straightforward in the case of a
well-supported child, but the complex interactions between primary and
secondary care mean that planning and communication are essential to
facilitate the smooth transfer of safe care (Figures 9.28 and 9.29).
Figure 9.28 New tracheostomy flow chart © 2009 Great Ormond Street
Hospital for Children NHS Trust, London, UK.
Reproduced with permission of GOSH.
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Figure 9.29 Tracheostomy equipment checklist © 2009 Great Ormond
Street Hospital for Children NHS Trust, London, UK.
Reproduced with permission of GOSH.
230