Mini-symposium: Tracheostomy in childrenTracheostomy care in the hospital
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
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The selection of an appropriate tracheostomy tube will minimise the incidence of complications.
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In paediatric patients, indications for cuffed tracheostomy tubes are limited.
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Preservation of heat and humidity may be achieved by passive humidifiers (‘artificial noses’).
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The combination of a fenestrated tube with a speaking valve permits the acquisition of normal phonation and allows for effective coughing.
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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.
References (65)
- et al.
Ultrasound imaging in the preoperative estimation of the size of tracheostomy tube required in specialised operations in children
Br J Oral Maxillofac Surg
(2003) - et al.
A twenty year (1971–1990) review of tracheostomies in a major paediatric hospital
Int J Pediatr Otorhinolaryngol
(1996) - et al.
Indications, complications, and surgical techniques for pediatric tracheostomies–an update
J Pediatr Surg
(2002) - et al.
The role of postoperative chest radiography in pediatric tracheotomy
Int J Pediatr Otorhinolaryngol
(2001) - et al.
The use of cuffed versus uncuffed endotracheal tubes in pediatric intensive care
J Pediatr
(2004) - et al.
Pressures required to move gas through the native airway in the presence of a fenestrated vs a nonfenestrated tracheostomy tube
Chest
(1996) - et al.
Granuloma associated with fenestrated tracheostomy tubes
Am J Surg
(1985) - et al.
A new tracheostomy filter
Lancet
(1997) - et al.
Passy-Muir valve in children with tracheotomy
Int J Pediatr Otorhinolaryngol
(1999) - et al.
Special critical care considerations in tracheostomy management
Clin Chest Med
(1991)