Received 11.18.05 Revisions Received 1.26.06 Accepted 2.2.06 Validating New Reagents: Roadmaps Through the WildernessRoberta A. Martindale, BSc (MLS), MT(ASCP),1 George S. Cembrowski MD, PhD,1,2 Lucille J. Journault,1,2 Jennifer L. Crawford,BSc (MLS),1,2 Chi Tran,1,2 Tammy L. Hofer, BSc (MLS), MBA,1,2 Bev J. Rintoul, BSc (MLS)1,2 Jean S. Der,1,2 Cathy W. Revers, BSc (MLS),1,2 Cheryl A. Vesso,1,2 Carol E. Shalapay,1,2 Connie I. Prosser, PhD, FCACB,1,2 Donald F. LeGatt, PhD, FCACB1,2( 1Department of Laboratory Medicine and Pathology, University of Alberta Hospitals, 2Capital Health Authority, Edmonton, Canada)
Doi:10.1016/j.prrv.2006.06.003PAEDIATRIC RESPIRATORY REVIEWS (2006) 7, 185–190 MINI-SYMPOSIUM: TRACHEOSTOMY IN CHILDREN Tracheostomy care in the home Be´atrice Oberwaldnerand Ernst Eber Respiratory and Allergic Disease Division, Paediatric Department, Medical University of Graz,Auenbruggerplatz 30, A-8036 Graz, Austria Summary There are hardly any controlled studies in paediatric tracheostomy care; instead, most established standards, procedures and details have been elaborated at the domiciliary care; bedside by trial and error. Once the appropriate tube is chosen, tube care consists of tube endotracheal suctioning; change, fixation, management of secretions, humidification of inspired air and application of medications. The stoma requires cleaning, protection and dressing. Child care may be teaching programme for structured into monitoring, feeding, bathing and clothing. Preparing the home and family environment are important prerequisites for discharge from the hospital. Last but not least, the family of the child or other caregivers must undergo a structured and detailedtraining programme to become competent in long-term home care.
ß 2006 Elsevier Ltd. All rights reserved.
Most tracheostomies performed for the former indica- tion can be removed once the underlying pathology has Since tracheostomies in children are almost exclusively been corrected surgically or has ameliorated with growth used as a long-term artificial airway, long-term caregiving and development of the airway; tracheostomies for venti- concepts have had to be developed. Children with a latory support can also be removed once ventilation can be chronic tracheostomy face the potential hazards of airway applied non-invasively. Long-term management differs compromise, and optimal care aims at reducing this risk.
between these two groups in terms of decannulation Most caregiving strategies, standards, procedures and protocols and control investigations; however, tube selec- details have been developed by trial and error at the tion (discussed elsewhere), tube care, stoma care and the bedside; even nowadays, recommendations for optimal education and training of caregivers are essentially the care stem rather from the consensus of experts rather than from controlled In many ways, long-term management depends on the indication for tracheostomy. In a chronically obstructed upper airway, tracheostomy is used for bypassing the stenosis; in the presence of tracheomalacia, a tracheostomytube may also be used to stent the airway. Where there is a The frequency of tube change depends on the material of chronic need for invasive ventilatory support as well as for the tube and the presence of infection and/or secretions.
management of secretions, tracheostomy is used for The polyvinyl chloride material, most widely used for directly accessing the airway.
paediatric tracheostomy tubes, allows the tubes to stayin place for several weeks, although inspissated secretionsoccasionally call for more frequent changes. If tubes are * Corresponding author. Tel.: +43 316 385 84597; reusable, it is essential to inspect the tube for possible Fax: +43 316 385 3276.
damage and for reduced flexibility with time and repeated (B. Oberwaldner).
1526-0542/$ – see front matter ß 2006 Elsevier Ltd. All rights reserved.
B. OBERWALDNER AND E. EBER In the case of a very tight stoma, the tissue layers between skin and trachea tend to close or narrow the In children with a tracheostomy, airway patency is main- stoma channel by shifting differently; therefore, changing tained by suctioning of the tube.
the tube may be difficult. It can be accomplished bythreading the new tube over a guiding structure such asan appropriately sized suction tube. A smaller tube and Frequency (timing) of suctioning ambubag should be within easy reach in case of insertion Suctioning is best performed on an as-needed basis, the frequency depending on the child's ability to generate aneffective cough and on viscosity and amount of secretions.
Consequently, caregivers must be trained to assess com-petently the need for removal of secretions, and suction Various materials, such as Velcro ties, twill tapes, elastic equipment must be with the child at all times. Suctioning on straps with hooks and stainless steel chains, are available to a routine basis is restricted to children with hardly any secure the tube in place. In children, especially in those with secretions and should then be performed at least in the tracheostomies for bypassing an obstructed upper airway, morning and evening in order to ensure continued patency preventing accidental decannulation is vital. Hence a twill of the tube.
tape, securely tied with triple square knots to both sides ofthe neck flange, is the most reliable option. As these tapestend to shrink with moisture and might then cause skin Depth of suctioning irritation or even compromise of the venous return, thread-ing the tape through a silicone tube is recommended. This Shallow suctioning. A pre-measured length of the catheter is protects the skin and allows for easy cleaning underneath.
inserted to a depth where the side-holes reach the tip of When a fresh tape is needed, a recommended procedure, the tube. This technique avoids mucosal damage and which is safe even in a young active baby, is to tie the new irritation; however, it also carries some risk of encrusted over the old one and cut the latter only once the tube has secretions and consecutive tube obstruction in case the been secured by the new tape. Velcro tapes are reserved catheter does not fully reach the end of the tube. Exact for children in whom accidental decannulation would not measurement of tube length and catheter insertion depth cause serious adverse events. Elastic straps with hooks as are prerequisites for correct suction technique.
well as chains should not be used in children.
Deep suctioning. This means inserting the catheter until Tapes should be tight enough to prevent accidental resistance is met and applying suction only on withdrawal.
decannulation yet loose enough to allow for a change in Because of the risk of epithelial damage, this technique neck size during laughing, crying and feeding. The correct should never be used as a routine; however, in selected tension is given when one finger can be slipped without situations, it can be necessary for clearance of secretions force beneath the tape at the back of the flexed neck located beyond the tube.
All adjuncts fitted onto the tracheostomy tube, such as Suction equipment breathing circuits, heat and moisture exchangers, as well asspeaking valves, should be secured in a way that avoids Suction pump. Depending on his or her mobility, the child tension on the tube ).
has to be equipped with two or three different suctionpumps. A stationary suction pump must have a manometerfor setting the suction pressure and should be capable ofgenerating the preset vacuum rapidly. It should be equippedwith an easily removable bottle that is big enough forholding a day's suction volume.
An additional portable suction pump must be able to run on batteries for a considerable time span, should belight-weight and ought to be equipped with a valvemechanism to prevent spill-over of secretions into themotor during transportation. Finally, a hand or foot pumpis necessary to allow for suctioning independent ofelectricity.
Suction catheters. Catheters, marked longitudinally for easy control of insertion depth, are preferred. They musthave an ideal combination of flexibility and stability to Tube fixation. Checking for the correct tension of the facilitate a quick and easy pass. A rounded end-hole and several side-holes close to the end of the catheter clear
TRACHEOSTOMY CARE IN THE HOME Saline instillation When no secretions are present in the tube, a sterile 0.9%sodium chloride solution can be instilled in order to elicit acough, which transports secretions from the peripheralairways towards the tube. When secretions are presentin the tube, there is no need for saline instillation. In fact,saline instillation could then have the negative effect ofwashing secretions down into the lung periphery, therebyincreasing resistance and decreasing oxygen saturation. Ifsaline is used, it should never be bagged down the tubebecause of the risk of carrying infectious material into theperipheral airways.
Bag ventilation/reinstitution of functional residualcapacity after suctioning In spontaneously breathing children who need lengthysuctioning, restoration of lung volume is essential to preventatelectasis and reduce dyspnoea after suctioning. An ade-quately sized bag, equipped with a positive end-expiratorypressure (PEEP) valve (with an individually set PEEP level), isconnected to the tracheostomy tube, and, in coordinationwith the child's respiration, several slow inspirations areapplied.
Set-up for mechanical ventilation. Observe the extra Suction procedure fixation of the tubing and the padding of the chin by the stomadressing.
Tube length and depth of insertion to the tip of the tube arenoted before suctioning. When secretions are present inthe tube (suctioning on demand), the catheter is inserted to secretions from the tip and the inside of the tube. The top the premeasured depth with already applied negative end of the catheter should carry a hole that can be opened pressure in order to prevent pushing secretions further or occluded by the operator's thumb for interrupting or down the airway. Using a catheter with an outer diameter recommencing suction as needed.
of approximately 75% of the tube's lumen provides for arapid removal of secretions. For routine suction, a smaller catheter (outer diameter approximately 50% of the lumen)is inserted without negative pressure in order to prevent Depending on the length and internal diameter of the loss of lung volume during a more lengthy search for catheter, the suction pressure at the end of the catheter is variable. Suction pressures should be set between 80 and On withdrawal, the catheter is twisted between the 150 mm Hg; gauging the pressures is essential.
fingers for clearing secretions from as much of the innerwall of the tube as possible. After the tube has been cleared Clean versus sterile technique of secretions, bag ventilation is used to restore lung volume.
In the home, a clean technique (freshly washed hands and a sterile, non-reusable catheter) will most likely suffice. In thehospital, as well as out of the home, when hand-washing is Since the upper airway is bypassed by the tracheostomy, not possible, a sterile technique (sterile glove and catheter) the inspired air will be neither sufficiently warmed nor should be used.
humidified, thereby compromising ciliary action and inspis-sating secretions. Occasionally, it might therefore be neces-sary to actively humidify the tracheostomy. For this Duration of suction purpose, pressurised air is directed through a heated water A rapid technique reduces the risk of development of bath into tubing connected to a tracheostomy collar. Ideally, atelectasis. With adequate suction pressure and a firm inspired air should contain approximately 36–40 mg of catheter with longitudinal marks, effective suctioning can water per litre of air at 32 8C. Such conditions can only be performed in a few seconds.
be achieved with cumbersome technical equipment; con- B. OBERWALDNER AND E. EBER sequently, such a maximally effective humidification is only can be removed with a cotton wool swab and normal practicable in a sedentary child or during sleep. Otherwise, saline. Around the stoma, the skin should be kept dry and the tracheostomy should be equipped with a passive liquid creams avoided. In case of fungal infections or humidifier (‘artificial nose') that traps exhaled vapour and inflammation, adequate ointments can be used cautiously temperature and redelivers some of this during inspiration.
for a short period of time.
Weight, resistance, dead space and hygroscopic capacity are important characteristics of these humidifiers. For children, wearing a speaking valve for longer periods ofthe day, humidifiers will not work because exhalation does A partially slit dressing, with a key hole for accommodating not use the same route as inhalation. If dryness of secretions the tube and made of non-fluffy and water-permeable is evident, a speaking valve equipped with a filter inside the material, helps to keep the skin around the stoma dry. In valve can ameliorate the problem.
case of a short distance between the chin of a baby and thecannula, these dressings also serve as padding when used Application of drugs with the closed side under the chin In case ofdischarge from the stoma, the dressing can provide some Various drugs can be administered via a tracheostomy for a protection for clothes when it is slipped under the neck local or systemic therapeutic effect.
plate from below.
Sometimes granulation tissue around the stoma inter- feres with the snug fit of the tube; this problem can betackled with silver nitrate dressings or silver nitrate sticks.
Bronchodilators and anti-inflammatory drugs can be admi-nistered effectively by a metered-dose inhaler (MDI)equipped with a valved holding chamber. A special holding chamber with a non-rebreathing valve and a connector to fit onto the tube can be used in children with inspiratoryflows that are sufficient for opening the valve and emptying When the continuous presence of a competent caregiver is the chamber. In children who are unable to generate these not available, the child should always be connected to a flows, an ambubag connected to the holding chamber can monitoring device. Ideally, a monitor should provide for an facilitate drug delivery. An MDI plus holding chamber is early and reliable warning of airway compromise. Alarms better than a nebuliser for aerosol deposition distal to the need to be set individually, and caregivers should be trained tracheostomy tube.
to stay alert despite the occurrence of unavoidable falsealarms.
Antibiotics that are not available as a per os formula can be instilled for local infection control. Diluting the drug to an Even if swallowing is no problem and a baby is capable of optimal osmolality, warming it, and instilling it slowly drop holding a bottle, he or she should only do so under by drop prevents irritation and helps to avoid coughing or supervision, because accidental disconnection of the demand for suctioning. Bagging the droplets carefully down sucker may result in massive aspiration via the tracheost- towards the lower airways can be useful in tubes with a In children who are tube-fed for a certain length of time, By the drug's direct action in the lung, the effective dose oral food intake may cause some problems. In these, as well might be lower than the comparable i.v. dose.
as in children with additional neurological disorders, speechtherapists should be consulted.
Emergency intravenous drugs In emergency situations, where no intravenous access is readily available, drugs such as atropine, epinephrine and A bath with a water level not higher than the child's lidocaine show a systemic effect when administered endo- abdomen is safe for the young patient who is under constant supervision. Care must be taken to preventaspiration of splash water. Bath toys such as buckets and STOMA (SKIN) CARE water pistols should not be allowed. When washing hair, awaterproof protector (like a collar) should be used if the child cannot extend or flex the head far enough to direct The skin around the neck is cleaned with a wet but not the water away from the stoma. Showering that carefully dripping cloth. Encrusted secretions under the neck plate avoids the head and neck is safe for older children.
TRACHEOSTOMY CARE IN THE HOME cause substantial stress. Increased attention to the childand insecurity concerning disciplinary measures can cause Clothing should not consist of furry or fluffy materials. To jealousy and resentment in the rest of the family; social prevent accidental decannulation, dressing and undressing isolation as well as physical and emotional overload may must not be over the head. High necks could occlude or follow. To prevent burnout, additional caregivers have to dislodge the tube and should therefore be avoided.
be recruited and trained, and community resources utilised.
It often helps caregivers to consult with support groups and Preparing the home environment establish links with other families who have successfully The home into which a child with a tracheostomy is to be cared for a child with a tracheostomy. Provision needs to be discharged often needs adaptations that have to be planned made well in advance for accommodating the child in with the help of the health-care team well in advance.
playgroup, kindergarten and school.
When, due to the underlying pathology, voice genera- tion fails, other ways of communication, such as an elec- trolarynx, sign language or a letter board, need to be Additional electricity sockets around the bed and in the considered in order prevent isolation of child and family.
child's living area, as well as some extra space for storingdisposable utensils, are needed. Bath/shower facilities mustbe adapted to provide safety and to suit both child and caregivers. Occasionally, a clever rearrangement of rooms will substantially facilitate caregiving and monitoring. In caseof room-sharing between siblings, one must consider the A structured training protocol, tailored to the needs of the disturbance of the co-sleeper by alarms and various care individual child and equipment, has proved to be useful. The measures. Transporting the child together with all neces- achievements of the trainee caregivers are monitored step sary equipment often calls for adaptation of staircases, car by step in an appropriate log book.
seats, prams, etc.
Education is started preferably before elective tracheot- omy; topics include indications for tracheostomy, the rele-vant anatomy and physiology, and differences form ‘normal' breathing. Models, drawings and videos provide support for Hazards for the child with a tracheostomy need to be understanding the often complex situation. During the identified and removed wherever possible. Exposure to postoperative period, parents are encouraged to spend feathery or furry pets, garden sprinklers, fountains, swim- as much time as possible with their child in order to gain ming pools, sand pits and powdery building or cleaning confidence in mastering the expected challenge of having a material, as well as air pollution by pollen, smoke, mist and child with a tracheostomy at home.
household sprays, must be avoided.
Feeding, bathing, lifting the child out of bed, cuddling and carrying are demonstrated and gradually taken over by theparents. Once they feel confident with handling their child, teaching progresses to stoma and tube care as well as to Well before discharge, communication with the family monitoring vital signs. Special emphasis is directed towards doctor, paediatrician, pharmacist, nurse specialist, when a correct suction technique, and mock emergency situa- applicable also speech pathologist and physiotherapist as tions as well as the appropriate resuscitation measures are well as equipment supplier should be established. A tele- discussed and practised over and over again. The equip- phone connection and power supply must be secured.
ment purchased for domiciliary care should already be usedon the ward to practice correct handling, cleaning, main-tenance and trouble-shooting.
Once all necessary knowledge and skills have been Home tracheostomy care is a considerable burden and obtained and the child is ready to go home, the caregivers challenge for any family; commitment to provide optimal are admitted together with their child onto a side ward, care in the home and a conviction that home care is the where they can practise the home situation day and night best for the child's social, communicative and motor devel- and see for themselves whether they are competent and opment helps caregivers to cope with this challenge and confident enough. An emergency package should be with strive for a family life as near to normal as possible. As a the child at all times. This must contain a spare tube of same prerequisite for tracheostomy home care, caregivers have size and one size smaller, scissors, ties, suction catheters, to acquire the necessary knowledge and become compe- normal saline, gloves and an ambubag with appropriate tent in a spectrum of practical skills.
mask, together with an information card to quickly identify Once the child is in the home, parental responsibility is brand, size and length of tube, catheter insertion depth, the massive; anxiety and preparedness for an emergency may reason for the tracheostomy, potential individual risks and
B. OBERWALDNER AND E. EBER the names and telephone numbers of physicians, therapists, 2. Carr MM, Poje CP, Kingston L, Kielma D, Heard C. Complications in nurses and service and maintenance companies.
pediatric tracheostomies. Laryngoscope 2001; 111: 1925–1928.
3. Alladi A, Rao S, Das K, Charles AR, D'Cruz AJ. Pediatric tracheostomy: a 13-year experience. Pediatr Surg Int 2004; 20: 695–698.
4. American Thoracic Society. Care of the child with a chronic tra- cheostomy. Am J Respir Crit Care Med 2000; 161: 297–308.
In summary, caring for a child with a chronic tracheostomy 5. Oberwaldner B. Tracheostoma. In: Rieger C, von der Hardt H, Sennhauser FH, Wahn U, Zach M, eds: Pa¨diatrische Pneumologie.
in the home provides a challenge that can be met con- Berlin: Springer, 2004; pp. 412–417.
fidently by a package of optimal medical management, 6. Fiske E. Effective strategies to prepare infants and families for home motivated caregivers, adequate training and education, a tracheotomy care. Adv Neonatal Care 2004; 4: 42–53.
well prepared and equipped home environment, support 7. Oberwaldner B, Zobel G, Zach M. Pa¨diatrische Tracheostomapflege.
from the extended family and community, and well-estab- Monatsschr Kinderheilkd 1992; 140: 206–215.
8. Oberwaldner B. Physiotherapie. In: Rieger C, von der Hardt H, lished communication with the health-care team. With Sennhauser FH, Wahn U, Zach M, eds: Pa¨diatrische Pneumologie.
these prerequisites, domiciliary tracheostomy care is as Berlin: Springer, 2004; pp. 379–389.
safe as, and in many other aspects superior to, long-term 9. Bailey C, Kattwinkel J, Teja K, Buckley C. Shallow versus deep endotracheal suctioning in young rabbits: pathologic effects on thetracheobronchial wall. Pediatrics 1988; 82: 746–751.
10. Kerem E, Yatsiv I, Goitein KJ. Effects of endotracheal suctioning on arterial blood gases in children. Intensive Care Med 1990; 7: 227–231.
11. Raymond S. Normal saline instillation before suctioning: helpful or harmful? A review of the literature Am J Crit Care 1995; 4: 267–271.
The authors would like to thank Professor M. Zach, Graz, 12. Schwenker D, Ferrin M, Gift AG. A survey of endotracheal suctioning with instillation of normal saline. Am J Crit Care 1998; 7: 255–260.
Austria, for reviewing this manuscript and for his valuable 13. Dajlby RW, Hogg JC. Effect of breathing dry air on structure and function of airways. J Appl Physiol 1980; 61: 312–317.
14. Branson RD, Davis K Jr. Evaluation of 21 passive humidifiers according to the ISO 9360 standard: moisture output, dead space and flowresistance. Respir Care 1996; 41: 736–743.
15. Lewarski JS. Long-term care of the patient with a tracheostomy. Respir Care 2005; 50: 534–537.
Tracheostomy care can be safely performed in the 16. Piccuito CM, Hess DR. Albuterol delivery via a tracheostomy tube.
Respir Care 2005; 50: 1071–1076.
It is essential that all caregivers are appropriately 17. Mirza S, Hopkinson L, Malik TH, Willatt DJ. The use of inhalers in patients with tracheal stomas or tracheostomy tubes. J Laryngol Otol trained in all aspects of tracheostomy care and the 1999; 113: 762–764.
management of relevant emergency situations.
18. Fitton C, Myer CM III. Home care of the child with a tracheostomy. In: All necessary equipment for routine and emer- Myer CM, III, Cotton RT, Shott SR, eds: The Pediatric Airway–an gency care, together with a competent caregiver, Interdisciplinary Approach. Philadelphia: JB Lippincott, 1995; pp. 171– must be with the child at all times.
19. Bryant K, Davis C, Lagrone C. Streamline discharge planning for The home environment should be adequately the child with a new tracheotomy. J Pediatr Nurs 1997; 12: 191–192.
adapted and equipped ahead of time once the 20. Buzz-Kelly L, Gordin P. Teaching CPR to parents of children with decision to carry out future domiciliary care is tracheostomies. MCN Am J Matern Child Nurs 1993; 18: 158–163.
21. Carnevale FA, Alexander E, Davis M, Rennick J, Troini R. Daily Family burnout can be prevented by the recruit- living with distress and enrichment: the moral experience offamilies with ventilator assisted children at home. Pediatrics 2006; ment and training of additional caregivers and the 117: 48–60.
utilisation of community resources.
22. Messineo A, Giusti F, Narne S, Mognato G, Antoniello L, Guglielmi M.
The safety of home tracheostomy care for children. J Pediatr Surg 1995;30: 1246–1248.
23. Fitton C. Nursing management of a child with a tracheostomy. Pediatr Clin North Am 1994; 3: 513–523.
1. Shinkwin CA, Gibbin KP. Tracheostomy in children. J R Soc Med 1996; 24. Barnes LP. Tracheostomy care: preparing parents for discharge. MCN 89: 188–192.
Am J Matern Child Nurs 1992; 17: 293.
Contents lists available at Complementary Therapies in Clinical Practice Pilates for low back pain: A systematic review Paul Posadzki ,, Pawel Lizis , Magdalena Hagner-Derengowska a Complementary Medicine, Peninsula Medical School, 25 Victoria Park Road, Exeter, Devon EX2 4NT, UKb Institute of Physiotherapy, Saint Cross Physiotherapy College, Kielce, Polandc Rehabilitation Clinic, Department of Health Sciences, Collegium Medicum, Nicolas Copernicus University, Bydgoszcz, Poland