Tracheostomy tubes

Children with special health care needs will require additional considerations during mass casualty or disaster care. These considerations include decontamination procedures following radiation or chemical exposure for children using wheelchairs, ventilators, or oxygen and decontamination procedures for children with gastrostomy tubes, tracheostomy tubes, indwelling bladder catheters, and indwelling central venous catheters. Replacement supplies would be needed once the cutaneous decontamination is completed. Such supplies may not be readily available, so provisions must be made to secure these items or to have comparable clean or sterile supplies on hand. 

Different auxiliary methods of administration can be used in conjunction with nebulizers to deliver aerosol to the patient [144]. A mouthpiece may be inserted in the mouth or a face mask may be attached tightly to the face. A large-bore inlet adapter attaches tubing from the nebulizer outlet to the mouthpiece or mask. It is possible to compensate for exhaled aerosol without increasing resistance to prevent condensation. A face tent fits more loosely around the patient s mouth, allowing speech. The latter arrangement is frequently used with ultrasonic nebulizers. A tracheostomy mask may be fitted to the patient s tracheostomy tube directly and requires a T-shaped adapter. Environmental chambers are used to enhance therapy and include incubators, pediatric croup tents, and hoods. 

A low-flow cascade impactor can be inserted into the ventilator circuit between the distal tip of the endotracheal (or tracheostomy) tube and the inhaled mass filter. Impaction experiments have repeatedly shown that the aerosols leaving the tube and entering the patient are similar to those produced by small-particle nebulizers such as the AeroTech n. Often the MMADs are about 1.0 pm (27). 

Fig. 2.24a,b. Two impacted coins, a The AP view of the airway is confusing. The metallic density resembles part ofthe tracheostomy tube, b The lateral radiograph reveals two coins in the esophagus... 

Sun M, Ernst A, Boiselle PM (2007) MDCT of the central airways comparison with bronchoscopy in the evaluation of complications of endotracheal and tracheostomy tubes. J Thorac Imaging 22 136-142... 

Rumbak MJ, Graves AE, Scott MP, et al. Tracheostomy tube occlusion protocol predicts significant tracheal obstruction to air flow in patients requiring prolonged mechanical ventilation. Crit Care Med 1997 25(3) 413 17. 

Bach JR, Sapmito LR. Criteria for extubation and tracheostomy tube removal for patients with ventilatory failure a different rqrproach to weaning. Chest 1996 110 1566-1571. 

Patients receiving IPPV represent a small fraction of the patients receiving domiciliary ventilation. In a recent European survey, they comprised 13% of those ventilated at home, representing 24%, 8%, and 5%, respectively, of patients with neuromuscular disease (NMD), parenchymal disease, and RTD, respectively (9). Selection and management of tracheostomy tubes for IPPV must maximize the patients ability to speak and swallow (7). 

The choice of size, shape, and composition of the tube should be individualized. Tracheostomy tubes and cannulae for home use are made of plastic or silicon. Silicone tubes are more flexible than PVC tubes and may offer a better fit. To allow for connection to the ventilator, the tube must extend at least 2 to 3 cm beyond the stoma, but should be situated no closer than 2 cm from the carina. The tube curvature should be such that the tube is in the center of the tracheal lumen rather than impinging on the tracheal wall—to avoid damage to the tracheal wall and to avoid problems with ventilation, comfort, and speech. 

Lloyd-Owen SJ, Donaldson GC, Ambrosino N, et al. Patterns of home mechanictil ventilation use in Europe results from the Eurovent survey. Eur Respir J 2005 25 1025-1031. Yaremchuk K. Regular tracheostomy tube changes to prevent formation of granulation tissue. 

Nomori H, Ishihara T. Pressure-controlled ventilation via a mini-tracheostomy tube for patients with neuromuscular disease. Neurology 2000 55 698-702. 

Scalise P, Prunk SR, Healy D, et al. The Incidence of tracheoarterial fistula in patients with chronic tracheostomy tubes A retrospective study of 544 patients in a long-term care facility. Chest 2005 128 3906-3909. 

Tracheostomy tubes are associated with long-term complications, particularly related to cuff inflation (4). As this population has already failed endotracheal weaning, they must be approached in a systematic way to optimize the likelihood of success. Ceriana et al. have suggested a decision tree to help with this process (5). 

Figure 3 (A) An LVR using a resuscitation bag in spinal cord injury around tracheostomy tube. (B) Ventilation trial with volume ventilation around a corked tracheostomy tube. Abbreviation LVR, lung volume recruitment.

Epstein SK. Anatomy and physiology of tracheostomy. Respir Care 2005 50(4) 476-482. Hussey JD, Bishop MJ. Pressures required to move gas through the native airway in the presence of a fenestrated vs a nonfenestrated tracheostomy tube. Chest 1996 110(2) 494—497. 

Sancho J, Servera E, Vergara P, et al. Mechanical insufflation-exsufflation vs. tracheal suctioning via tracheostomy tubes for patients with amyotrophic lateral sclerosis a pilot study. Am J Phys Med Rehabil 2003 82 750-753. 

Careful patient selection prevents unsafe levels of alveolar hypoventilation with subsequent hypoxemia and hypercapnea, especially if the tidal volume leakage is >20%. Any compensatory increase in respiratory rate and shortened expiratory time, attributable to the air leakage, may aggravate dynamic hyperinflation, especially among patients with airflow obstruction (15). Ventilator-supported speech has been reported in patients with neuromuscular diseases (NMD) and intact bulbar function (16-19). The physiologic characteristics that enable this population to tolerate ventilator-supported speech include little or no decrease in chest wall or lung compliance and the absence of airflow obstmction. Therefore, patients with NMD may be ventilated with a deflated or cuffless tracheostomy tube accepting the modest compromise in alveolar ventilation (16,20-22). Patient populations, such as those with chronic obstructive pulmonary disease may be able to tolerate cuff deflation for short periods provided there is adequate supervision. 

The third condition is the creation of an effective and adjustable air leak channel during tracheostomy cuff deflation. An effective channel has a lower impedance compared to the tracheostomy tube and exhalation HMB, in order to allow airflow to reach the vocal cords. If the impedance is too high, exhaled volume is diverted to the tracheostomy tube... 

Relationship between tracheal diameter and tracheostomy tube sizing in order to allow... 

The channel s impedance is mainly affected by the tracheal diameter in relation to the outer diameter of the tracheostomy tube and the added resistance of the volume of the deflated floppy cuff (Fig. 5). 

Siddharth P, Mazzarella L. Granuloma associated with fenestrated tracheostomy tubes. Am J Surg 1985 150(2) 279-280. 

He was also taught GPB increasing his endurance to eight hours, to maintain an alternate method of ventilation and to augment tidal volumes, for secretion clearance, while his tracheostomy tube was corked. With this enhanced ventilatory independence, he returned to live in the community, first to a transitional living center and subsequently to an attendant care facility. 

Except after a meal, an abdominal thrust is applied in conjunction with the insufflation-exsufflation mechanically assisted coughing (MAC) (66). MI-E can be provided via an oronasal mask (Eig. 11), a simple mouthpiece, or via a translaryngeal or tracheostomy tube. When delivered via the latter, the cuff, when present, should be inflated (73). 

During a follow-up study she was noted to have an elevated PCO2 associated with leakage around her tracheostomy tube. This was addressed by increasing her cuff inflation pressure by adding 1 cc of water (Fig. 12). This cuff inflation resulted in improved ventilation, as shown (Fig. 13) by increased respiratory excursions and increased exhaled volumes. 

In this case, patient refusal to tolerate NIPPY eventually resulted in invasive ventilation. Serial follow-up studies confirmed clinical stability and a leak around her tracheostomy tube were addressed by increasing her cuff volume. 

Figure 15 Recording channels for Sa02 and PCO2 from an overnight polysomnogram. Note The ventilatory mode has been changed to assist control and the tracheostomy tube from a fenestrated uncuffed tube to a tight to the shaft tube. There is improved synchrony between the patient and the ventilator, resulting in improved gas exchange.

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