Pediatric emergency medicine trisk 1161

FIGURE 135.2 Dual cannula tracheostomy tube.

Swivel
A swivel is often attached to the end of the tracheostomy tube. Some unique
characteristics of children make the swivel particularly useful. First, children have
a natural inclination to move and explore. The swivel device accommodates
movement in the ventilator-assisted child, so traction is not placed on the
ventilator tubing or on the tracheostomy tube. Second, the short neck and bulky
soft tissues of young children can obstruct the tracheostomy tube opening. The
swivel provides additional length, so the tube opening extends beyond the soft
tissues of the neck.
Heat–Moisture Exchanger
Air inspired directly into the trachea through a tracheostomy tube bypasses the
important warming and humidification mechanisms provided by the natural upper
airway. Therefore, a humidification system is an important component of the
equipment used in a patient with a tracheostomy. A home ventilator setup


includes a stationary humidification system that is used when the child is
connected to the circuit. Similarly, a heat–moisture exchanger is attached to the
end of the tracheostomy tube in patients who do not require the ventilator. The
device is composed of a hydrophilic material that captures the patient’s own heat
and humidity on exhalation so that it can be inspired on inhalation.

Clinical Findings/Management
The approach to the ill patient with an artificial airway is the same as that for any
patient who comes to the ED. The initial evaluation consists of an assessment of
the patient’s ABCDs (airway, breathing, circulation, and disability), with
particular attention to the airway and breathing. An emergency physician who
knows how to anticipate common problems and to recognize them early is able to
institute appropriate therapy without delay.

Obstruction and Decannulation
The most life-threatening complication in a patient with an artificial airway is
cannula obstruction or dislodgment. Younger children are more likely to
experience accidental decannulation because of the short length of the trachea and
tracheostomy tube. Some infant tubes are as short as 3 to 4 cm H2 O. In addition,
the small lumen is more easily occluded by a mucous plug or by an accumulation
of secretions. Infants with less-developed intercostal muscles and children with
neuromuscular disorders may be unable to generate an adequate cough to keep
the airway clear of debris.
The presentation is similar to that of other children with airway obstruction.
The child may appear distressed with tachypnea, cyanosis, accessory muscle use,
and/or nasal flaring. Alternatively, the child may be lethargic or obtunded as a
result of prolonged respiratory effort or an elevated carbon dioxide level.
Any child with an artificial airway and respiratory distress is assumed to have
an obstruction. The patient should be placed immediately on high-flow
humidified oxygen. The physician should determine whether the tracheostomy
tube appears to be in place, recognizing that a tube in the stoma does not
necessarily indicate a tube in the trachea. If a cannula change was attempted
before the child’s arrival in the ED, a false passage into the paratracheal soft
tissues may have occurred. Auscultation for the presence and symmetry of
bilateral breath sounds should be performed and the quality of the patient’s
respiratory effort should be assessed. Immediate suctioning is appropriate in an
attempt to assess tube patency and to clear the airway of secretions.


The physician should not hesitate to change the cannula. Suctioning alone may
not clear an obstruction caused by thick secretions. All the necessary equipment
for the change should be present, including a replacement tracheostomy tube, an
endotracheal tube one-half size smaller, and a bag–valve–mask ventilation circuit
with oxygen flow, scissors, and tracheostomy ties. The change is best

accomplished with the participation of two people: one secures the patient and
removes the old tube, whereas the other inserts the new tube. Remember to
deflate the cuff prior to removal, if one exists. Please see Chapter 130 Procedures
for details on how to change a tracheostomy tube.
Infection
Bacterial colonization of the trachea usually occurs in a child with a
tracheostomy. Common colonizing organisms include gram-positive cocci
(Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pneumoniae
, α- and β-hemolytic streptococci), gram-negative bacilli (Klebsiella,
Pseudomonas, Escherichia coli, Serratia marcescens, Haemophilus influenzae ),
and anaerobes (Peptostreptococcus, Bacteroides ). These same organisms can
become pathogenic, causing tracheitis or pneumonia.
Differentiating between bacterial colonization of the trachea and clinical
infection can be difficult. The physician should elicit a history of any changes in
the quantity, thickness, or odor of the tracheal secretions, and any systemic signs
of infection or respiratory distress. Along with physical examination, there should
be a determination of oxygenation by pulse oximetry. A Gram stain and bacterial
culture, and a rapid viral detection assay of the tracheal secretions, may be helpful
in determining the presence and cause of an infection. Leukocytosis in the
tracheal secretions and a predominant organism by Gram stain may be suggestive
of bacterial tracheitis; radiographic evidence of a new infiltrate indicates
pneumonia.
If the child appears well and follow-up can be ensured, outpatient antibiotic
therapy may be appropriate. For children with increased oxygen or ventilatory
requirements, hospitalization should be considered for intravenous (IV) antibiotic
therapy, aggressive pulmonary toilet, and close monitoring.
Erythema of the peristomal skin is usually caused by irritation and should be
managed by increasing the frequency of the tracheostomy care at home. The
additional findings of warmth, tenderness, purulent drainage, or fever may
suggest the presence of a peristomal cellulitis. Depending on its severity, this

condition should be treated with oral or IV antibiotics.


The skin of the neck under the ties securing the tracheostomy tube can also
become inflamed. Generally, this situation can be treated by increasing the
amount of padding and by keeping the area dry. An erythematous rash with
satellite lesions classic for a monilial dermatitis should be treated with topical
antifungal creams.
Asthma
The incidence of asthma is increased in children with chronic lung disease. Many
children are maintained at home on inhaled β-agonist and inhaled corticosteroid
therapy. The usual viral and environmental triggers, such as dust, pets, and
smoke, precipitate exacerbations of asthma.
The presentation is similar to that of other asthmatic patients, with varying
amounts of respiratory distress, wheezing, and hypoxemia. As previously
mentioned, the physician must consider the possibility of cannula obstruction or
dislodgment in all cases. Treatment with oxygen, bronchodilators, and steroids
should be initiated promptly. However, emergency clinicians should recognize
that children with chronic lung disease have less pulmonary reserve, and patients
with neurologic diseases may not be able to generate the necessary increase in
work of breathing to overcome the poor lung compliance associated with acute
asthma. Chest radiography and blood gas analysis should be performed as
clinically indicated. Continuous monitoring of pulse oximetry and end-tidal CO2
are helpful in tracking the illness trajectory in the ED. Increased ventilatory
support or continuous positive airway pressure may be required to overcome
fatigue and atelectasis.
Bleeding and Granuloma
The tracheal mucosa located adjacent to the stoma, the cuff, and the distal tip of
the tracheostomy tube is prone to bleeding and granuloma formation. The most
common reason for bleeding is inadequate humidification causing drying and

friability of the tracheal mucosa. Infection or granuloma formation can also result
in small amounts of bleeding. Large amounts of blood coming from the
tracheostomy tube opening can signify erosion of the tube into the
brachiocephalic artery. The incidence of tracheoarterial fistula formation is rare
(approximately 0.7%) but commonly results in death due to massive hemoptysis
and blood loss. The risk for development of this life-threatening complication is
highest during the postoperative period (i.e., within 4 weeks of tube placement).
Small amounts of bleeding from the tracheal stoma usually resolve with
increased humidification of the inspired air. The persistence of minor bleeding