Pediatric emergency medicine trisk 4642 4642

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.