Mini-symposium: Tracheostomy in children
Tracheostomy care in the hospital

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Summary

Long-term tracheostomy in infants and children is associated with significant morbidity. The majority of paediatric patients experience tracheostomy-related complications during cannulation and/or after decannulation. A large proportion of these complications are, however, preventable or may be minimised by good tracheostomy care and clinical evaluation of the patients at regular intervals, tailored to the needs of the individual child. By and large, infants and children benefit from a specialist tracheostomy service. In this article, we review different aspects of hospital-based care, covering a wide range of topics including the selection of tracheostomy tubes and adjuncts, clinical evaluation, speech/communication, and late complications and their prevention.

Introduction

In the tertiary care setting, children with a long-term tracheostomy constitute an important and challenging group needing a specialist tracheostomy service. Many recommendations for the standards of care for these patients are still by consensus, based on experience rather than scientific data.1 The indication for a tracheostomy, and thus the underlying problem, the presence of other medical conditions, the patient's anatomy, respiratory mechanics and needs for speech, ventilation and airway clearance all determine aspects of hospital-based care, the duration of cannulation, the occurrence of complications and the probability of successful decannulation. Consequently, the care of the child with a long-term tracheostomy has to be individualised. This will only be possible in a specialised tertiary care unit where all the necessary diagnostic techniques and experienced staff are available.

Section snippets

Tracheostomy tube (and adjuncts) selection

Tracheostomy tube selection is usually the joint responsibility of the physician who takes care of the patient and the surgeon performing the tracheotomy; in some specialised units, respiratory physiotherapists are also involved. The most important factor for determining an appropriate tracheostomy tube is the age of the patient, and for quick orientation published paediatric tracheostomy sizing charts may be used (see Table 2 in the article by Cochrane and Bailey on surgical aspects of

Speech

Clinical experience and research have shown that the presence of a tracheostomy may adversely influence speech acquisition in infants and children.31, 32, 33, 34, 35 Other factors that can affect language development in tracheostomised children include repeated and/or extended periods of hospitalisation, neurological problems, chronic middle ear problems, lack of normal feeding experiences, and inadequate muscle strength due to chronic lung disease, neuromuscular disorders or spinal cord

Clinical evaluation

Most physicians follow up stable patients with tracheostomies every 1–3 months.18, 42

After the immediate postoperative period, we do not perform chest or neck radiographs or other imaging studies on a routine basis but as required when complications develop.18

Microbiological studies are occasionally performed to allow targetted antibacterial treatment.18, 43 Recently, a significant neutrophilic inflammatory reaction in the lower respiratory tract was shown in asymptomatic children with a

Late complications

Late complications occur more frequently than early ones and have been reported in up to 60% of children with a tracheostomy.1, 7, 8, 9, 10, 11, 12, 13 The overall mortality rate in tracheostomised children, which is mainly associated with the underlying medical condition, is up to 40%. Mortality directly associated with the tracheostomy appears to be much lower, in the range of 0.5–3%.9, 10, 11, 12, 13 The most common tracheostomy-related causes of death are accidental decannulation and

Practice points

  • The selection of an appropriate tracheostomy tube will minimise the incidence of complications.

  • In paediatric patients, indications for cuffed tracheostomy tubes are limited.

  • Preservation of heat and humidity may be achieved by passive humidifiers (‘artificial noses’).

  • The combination of a fenestrated tube with a speaking valve permits the acquisition of normal phonation and allows for effective coughing.

  • With careful selection of candidates for the use of a speaking valve, the majority tolerate

Acknowledgement

The authors would like to thank Professor Maximilian Zach, Graz, Austria, for reviewing this manuscript and for his valuable comments.

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