THE CRITICALLY ILL CHILD: MANAGEMENT OF TRACHEOSTOMY

Abstract

The indications for and methods of performing a tracheostomy in children are many and varied. There is still controversy as to the size, types, and placement of the tube; the type of incision; the relative indications for tracheostomy in infants and older children; the use of prolonged endotracheal intubation in preference to tracheostomy; and even the type of instruments used to perform the tracheostomy. However, problems discussed here are mainly the proper care of the child with a tracheostomy tube, including those associated with its removal. Whatever the disease state from which the child suffers, certain basic principles must be kept in mind during all tracheostomy care. These relate to: (1) inspired gas mixtures, (2) humidification in inspired gas, (3) suctioning of secretions, (4) positive pressure breathing, (5) chest physiotherapy, (6) weaning of a patient from tracheostomy, (7) home care of tracheostomy by parent, and (8) complications of tracheostomy. Let us now examine these factors in detail. INSPIRED GAS MIXTURES Gas mixtures most commonly administered via tracheostomy are of oxygen and air, in percentage that will maintain arterial oxygen tension (PaO2) at near normal. Sometimes this will require 100% oxygen or sometimes 100% air, which is, of course, 20% oxygen. Whatever the mixture, the PaO2 should never exceed 250 mm Hg; ideally, it should never approach this figure. Immediately following tracheostomy, arterial blood gases should be measured with the patient breathing room air, providing that his clinical condition will tolerate this minimal oxygen percentage. If by clinical judgment additional oxygen is required, the inspired percentage should be carefully measured at the time blood is drawn for gas determination.