Pediatric Tracheostomy Tubes Research Articles

Utility of chest x-ray for tracheostomy tube placement in pediatric patients.

To evaluate the utility of ordering chest x-rays after pediatric tracheostomy tube placement in identifying acute, post-operative complications and how it impacts clinical decision-making. In this retrospective cohort study, we identified tracheostomies performed in 139 pediatric patients through CPT codes over a 5-year period from 2013 to 2018. Manual chart review was performed for demographic and clinical characteristics, pre-procedure and post-procedure chest x-ray interpretations, and the presence of complications. Each complication was reviewed to see if action was taken due to post-procedure chest x-ray findings. Multivariable logistic regression was performed to determine associations with changes in pre-procedure versus post-procedure chest x-rays. In a cohort of 139 pediatric patients with pre-procedure and post-procedure chest x-rays, 40 (28.8%) of patients had new significant post-procedure chest x-ray findings compared to pre-procedure chest x-ray findings. Of these 40 instances of changes in pre-procedure versus post-procedure chest x-ray findings, only eight resulted in action being taken due to the observed findings. Among these eight instances of action being taken, only one instance involved in invasive action being taken with a bronchoscopy. With multivariable regression analysis, patient age, race, gender, and the presences of genetic syndromes, were not found to be significant risk factors in predicting changes in pre-procedure versus post-procedure chest x-ray. In our study, post-procedure chest x-ray after tracheostomy tube placement did not significantly impact clinical decision making. It may be worth reconsidering the value in routine chest x-rays after tracheostomy tube placement in pediatric patients.

Chronic tracheostomy care of ventilator-dependent and -independent children: Clinical practice patterns of pediatric respirologists in a publicly funded (Canadian) healthcare system.

To describe the current clinical practice patterns of Canadian pediatric respirologists at pediatric tertiary care institutions regarding chronic tracheostomy tube care and management of home invasive ventilation. A pediatric respirologist/pediatrician with expertise in tracheostomy tube care and home ventilation was identified at each Canadian pediatric tertiary care center to complete a 59-item survey of multiple choice and short answer questions. Domains assessed included tracheostomy tube care, caregiver competency and home monitoring, speaking valves, medical management of tracheostomy complications, decannulation, and long-term follow-up. The response rate was 100% (17/17) with all Canadian tertiary care pediatric centers represented and heterogeneity of practice was observed in all domains assessed. For example, though most centers employ Bivona™ (17/17) and Shiley™ (15/17) tracheostomy tubes, variability was observed around tube change, re-use, and cleaning practices. Most centers require two trained caregivers (14/17) and recommend 24/7 eyes on care and oxygen saturation monitoring. Discharge with an emergency tracheostomy kit was universal (17/17). Considerable heterogeneity was observed in the timing and use of speaking valves and speech-language assessment. Inhaled anti-pseudomonal antibiotics are employed by most centers (16/17) though the indication, agent, and protocol varied by center. Though decannulation practices varied considerably, the requirement of upper airway patency was universally required to proceed with decannulation (17/17) independent of ongoing ventilatory support requirements. Considerable variability in pediatric tracheostomy tube care practice exists across Canada. These results will serve as a starting point to standardize and evaluate tracheostomy tube care nationally.

Pediatric tracheostomy tube decannulation with or without polysomnography: A PRO-CON debate.

Determining the timing for decannulation in children with a tracheostomy is a complex process, as the appropriate timing varies based on the initial indication for the tracheostomy tube as well as individual patient characteristics. The original condition for which a tracheostomy was created may improve over time with decannulation being a very important long-term goal for many families and multidisciplinary teams. However, decannulation is an inherently risky procedure associated with morbidity and mortality. Therefore, careful planning is required to ensure the safety of the procedure. Although routine airway endoscopy is an important component of decannulation protocols, guidelines are less prescriptive regarding the definition of a complete endoscopic airway evaluation and the routine use of polysomnography. This review will summarize the important PRO and CON arguments of integrating polysomnography into pediatric decannulation protocols.

Multi-Institutional Regional Otolaryngology Bootcamp.

In order to increase junior resident physician proficiency and improve patient safety, simulation-based procedural training courses, or bootcamps, have been become an emerging educational tool. To compare pre- and post-course confidence levels and to assess station efficacy after completion of our single day bootcamp. We developed the University of California (UC) Davis otolaryngology bootcamp, a single day course including six cadaveric task trainer stations and four simulations. The six task trainer stations included (1) Epistaxis, (2) Cricothyrotomy/tracheostomy, (3) Peritonsillar abscess/auricular hematoma, (4) Nasal bone reduction/zygoma reduction/lateral canthotomy/canalicular trauma and probing, (5) Local nerve blocks, and (6) Soft tissue reconstruction. The simulations comprised of airway fire during tracheostomy, pediatric respiratory code during airway evaluation, dislodged pediatric tracheostomy tube in the ICU, and angioedema in the emergency department with inability to intubate or ventilate. Junior residents from multiple locoregional institutions were recruited to participate. Pre- and post-course Likert surveys assessing participant confidence and station efficacy were collected and analyzed. There was a statistically significant increase in resident confidence levels for all task trainer stations. All stations had a station efficacy Likert score average of 4 "very effective" or 5 "most effective." A multi-institutional, locoregional, simulation-based bootcamp can be a valuable adjunct to junior resident training. It can promote camaraderie, pool limited resources, and may be cost-effective.

Feasibility of shotgun metagenomics to assess microbial ecology of pediatric tracheostomy tubes.

Biofilm formation on medical devices such as tracheostomy tubes (TTs) is a serious problem. The clinical impact of biofilms on the airway is still unclear. Biofilms may play a role in granulation tissue development, recurrent airway infections, and failure of laryngotracheal reconstructions. The microbial ecology on TTs has yet to be elucidated. The purpose of this study was to determine the feasibility of shotgun metagenomics to assess the biodistribution of microorganisms on TTs. Four TTs were collected from pediatric patients (1.4-10.2 years) with (n = 2) and without (n = 2) granulation tissue formation. Duration of TT placement prior to retrieval from patients ranged from 5 to 365 days. DNA extraction was performed using the MO BIO UltraClean Microbial Isolation (Mo Bio Laboratories, Carlsbad, CA). Library generation using Nextera XT adapters (Illumina Inc., San Diego, CA) and metagenomic shotgun sequencing was performed using the Illumina NextSeq500 (Illumina Inc, San Diego, CA). Salinibacter ruber, a species not found in mammalian microbiome communities, was used as a DNA standard and represented 0.7% to 5.7% of the microbiome, ensuring good quality and abundance of sample DNA. Metagenomic shotgun sequencing was successful for all patients. In TTs associated with granuloma, Fusobacterium nucleatum, Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pneumoniae were predominant, most of which are considered pathogens. From TTs without granulomas, Neisseria mucosa, Neisseria sicca, Acinetobacter baumannii, and Haemophilus parainfluenzae were identified, primarily consistent with respiratory microbiome. This study reveals that metagenomic shotgun sequencing of biofilms formed on pediatric TTs is feasible with an apparent difference in microbiome for patients with granulation tissue. Further studies are necessary to elucidate the pathogenesis of microbial ecology and its role in airway disease in patients with TTs. 2c Laryngoscope, 129:317-323, 2019.

Tracheostomy care: Clinical practice patterns of pediatric otolaryngologists-head and neck surgeons in a publicly funded (Canadian) health care system

ObjectivesTo investigate variability in pediatric tracheostomy tube care practice patterns and access to resources across Canada. MethodsCanadian pediatric otolaryngologists-head & neck surgeons reported their own practice patterns for children with chronic tracheostomy tubes using a web-based, 29-item multiple choice and short answer questionnaire. Domains investigated included tracheostomy team membership, inpatient care practices, caregiver education, homecare resources, speech and communication, and completeness of emergency tracheostomy kits. ResultsThe response rate was 86.4% (38/44). Most respondents care for children with tracheostomy tubes as part of an inter-professional team (25/36; 69.4%) and arrange routine follow-up with a speech and language pathologist (22/36; 61.1%). However, the majority (23/34; 67.6%) of respondents do not formally reassess caregiver competencies (i.e. cardiopulmonary resuscitation, emergency tracheostomy care). Notably, respondents were also unsure 36.1% (13/36) of how frequently Shiley tracheostomy tubes should be washed and reused with the majority (15/36; 41.7%) reporting never. Most (15/36; 41.7%) respondents were also unsure of reuse recommendations for Bivona tracheostomy tubes. One third (12/36; 33.3%) of respondents were unsure about government-funded homecare services being provided in their community to children with tracheostomy tubes. ConclusionThere is much variability in pediatric tracheostomy tube care practice patterns across Canada. Results suggest that an evidence-based Canadian clinical practice guideline may help to streamline care provided to Canadian children with tracheostomy tubes.

Changes in pediatric tracheostomy tubes exposed to home dishwashing

ObjectiveDetermine the effects of household dishwashing on Tracheostomy Tube safety. IntroductionTracheostomy tubes accumulate biofilms, which may limit their lifespan. Frequent cleaning of the tubes is a method for biofilm prevention. Cleaning practices vary widely. Some families prefer dishwashing of tubes, but its effects are currently unknown. We hypothesize that dishwashing has no significant effect on the physical properties of tracheostomy tubes and can be recommended as a safe way to clean tracheostomy tubes. MethodsTwenty 4.0 Shiley™ pediatric tracheostomy tubes were randomly assigned into dishwashed (DW) and non-dishwashed (NDW) groups, 10/group. DW tubes were subjected to 12 wash cycles. Each tube's hardness along with the surface spectra were analyzed to assess for chemical composition changes. Three cannula samples from each group were also randomly assessed with scanning-electron microscopy and scored by blinded examiners to assess for changes in surface heterogeneity. ResultsHardness testing revealed a statistically significant difference (p = 0.0009) between the NDW and the DW group indicating increased fragility in the dishwashed tubes. Spectral analysis revealed loss of plasticizers, indicating decreased flexibility. Blinded electron microscopy scoring revealed increased surface heterogeneity in the DW group (p = 0.00007). ConclusionA significant decrease in tube hardness and increased surface heterogeneity were found with dishwashing. The spectral analysis demonstrated increasing fragility. We believe these effects could potentially lead to decreased mechanical safety. With increased surface heterogeneity there is a greater potential for biofilm formation. At this time, dishwashing cannot be recommended as a tracheostomy tube cleaning method.

Neonatal Tracheostomy

ABSTRACT Tracheostomy is an established and widely practiced surgical technique. Neonates and young children represent a special population with unique tracheostomy-related concerns. A tracheostomy may be of substantial benefit to the child but is associated with significant morbidity and potential mortality risk. We describe surgical techniques, review pediatric tracheostomy tubes, and discuss relevant care issues. How to cite this article Stephenson KA, Wyatt ME. Neonatal Tracheostomy. Int J Head Neck Surg 2016;7(2):136-142.

Effect of repeated tracheostomy tube reprocessing on biofilm formation.

Objectives/HypothesisTo determine the effect of repeated reprocessing of pediatric tracheostomy tubes (TTs) on biofilm formation.Study DesignIn vitro microbiological study.MethodsPediatric, uncuffed, polyvinyl chloride (PVC) TTs from two different manufacturers (Tracoe Mini and Shiley) were reprocessed mechanically with household detergent and soaked in sodium hypochlorite (bleach). Two TTs of each brand were reprocessed 0 (control), 10, or 20 times. Twenty 2‐mm coupons were then obtained from each TT, immersed in human mucus, and cultured with either Staphylococcus aureus or Pseudomonas aeruginosa. Biofilm formation was evaluated with bacterial counts.ResultsBacterial counts of S. aureus for both brands were significantly higher on the TTs that were reprocessed 20 times compared to those that were not reprocessed (Tracoe: P = .040, Shiley: P < .0001) or those that were reprocessed 10 times (Tracoe: P = .022, Shiley: P = .0002). There was no difference between controls and TTs reprocessed 10 times (Tracoe: P = .76, Shiley: P = .24). P. aeuruginosa counts were not significantly different among the varying numbers of reprocessing cycles for either Tracoe or Shiley TTs (P = .08 and P = .97, respectively).ConclusionsRepeated reprocessing of PVC TTs with detergent and bleach paradoxically promotes S. aureus biofilm development, possibly due to degradation of the tube surface that facilitates bacterial attachment. Further investigation is needed to determine the optimal technique and limits of reprocessing TTs in clinical practice.Level of EvidenceNA Laryngoscope, 126:996–999, 2016

Care of pediatric tracheostomy in the immediate postoperative period and timing of first tube change

ObjectiveTo analyze the safety of a standardized pediatric tracheostomy care protocol in the immediate postoperative period and its impact on tracheostomy related complications. Study designRetrospective case series. SubjectsPediatric patients undergoing tracheotomy from February 2010–February 2014. MethodsIn 2012, a standardized protocol was established regarding postoperative pediatric tracheostomy care. This protocol included securing newly placed tracheostomy tubes using a foam strap with hook and loop fastener rather than twill ties, placing a fresh drain sponge around the tracheostomy tube daily, and performing the first tracheostomy tube change on postoperative day 3 or 4. Outcome measures included rate of skin breakdown and presence of a mature stoma allowing for a safe first tracheostomy tube change. Two types of tracheotomy were performed based on patient age: standard pediatric tracheotomy and adult-style tracheotomy with a Bjork flap. Patients were analyzed separately based on age and the type of tracheotomy performed. ResultsThirty-seven patients in the pre-protocol group and 35 in the post-protocol group were analyzed. The rate of skin breakdown was significantly lower in the post-protocol group (standard: p=0.0048; Bjork flap: p=0.0003). In the post-protocol group, all tube changes were safely accomplished on postoperative day three or four, and the stomas were deemed to be adequately matured to do so in all cases. ConclusionA standardized postoperative pediatric tracheostomy care protocol resulted in decreased rates of skin breakdown and demonstrated that pediatric tracheostomy tubes can be safely changed as early as 3 days postoperatively.

Care of Pediatric Tracheostomy in the Immediate Postoperative Period and Timing the First Tube Change

Objectives: 1) Analyze the impact of a new postoperative care protocol on complications, including skin breakdown. 2) Analyze the safety of performing the first tracheostomy tube change prior to postoperative day 5. Methods: Retrospective case series in an academic medical center. Patients: Pediatric patients undergoing tracheostomy from February 2010 to February 2013. Intervention: In 2012 a new protocol was instituted for pediatric tracheostomy care in the immediate postoperative period that included: 1) securing tracheostomy tubes with Velcro straps rather than twill ties, 2) placing a clean drain sponge around the tracheostomy tube daily, and 3) performing the first tracheostomy tube change on postoperative day 3 or 4. Outcome Measures: 1) Rate of complications, including skin breakdown, related to the tracheostomy tube and securing straps. 2) Presence of a mature stoma allowing for a safe first tracheostomy tube change. Results: 37 patients in the pre-protocol group and 16 in the post-protocol group were analyzed. Rate of skin breakdown related to the tracheostomy tube or securing straps was significantly higher in the pre-protocol group (32.40% vs. 0%, P = 0.01). There was a trend towards a higher overall complication rate change in the pre-protocol group, but this was not statistically different (18.90% vs. 0%, P = 0.062). In the post-protocol group, all tube changes were safely performed on postoperative day three or four. Conclusions: This new care protocol for pediatric tracheostomies resulted in decreased rates of skin breakdown. In addition, pediatric tracheostomy tubes can be safely changed as early as 3 days postoperatively.

Efficacy of disinfecting solutions in removing biofilms from polyvinyl chloride tracheostomy tubes

Bacterial biofilms are prevalent in pediatric tracheostomy tubes (TTs) and are not completely cleared by standard cleaning with gauze and household detergents. We aimed to examine the effectiveness of different disinfecting solutions to remove Staphylococcus aureus (SA) and Pseudomonas aerginosa (PA) biofilms from TTs. Prospective, controlled, in vitro microbiologic study. Uniform coupons obtained from polyvinyl chloride (PVC) pediatric TTs were briefly exposed to human plasma. The samples were incubated in growth media with either PA or SA for 7 days, and total bacterial growth was monitored by media turbidity. Five sets of 18 coupons each were exposed for 5 minutes to one of five different solutions: 2% aqueous chlorhexidine gluconate solution, 0.3% aqueous sodium hypochlorite, Polident denture cleanser, 3% hydrogen peroxide, or preservative-free phosphate-buffered saline (PBS) as a negative control. Biofilm presence was measured with bacterial counts, and surface integrity was assessed with scanning electron microscopy (SEM). All treatments significantly reduced mean SA counts (P = <.001). Sodium hypochlorite and chlorhexidine were more effective than peroxide and Polident. Chlorhexidine, sodium hypochlorite, and peroxide reduced PA counts (P = .001, .001, and .002, respectively), but Polident tabs had no significant effect. SEM revealed preserved TT surface integrity after exposure to all solutions. Disinfection with sodium hypochlorite or chlorhexidine solutions significantly reduces SA and PA biofilms on PVC TTs. Standard home care of reusable pediatric TTs may be improved by use of these readily available solutions.

Effectiveness of Pediatric Tracheostomy Tube Cleaning

To determine the effectiveness of typical reprocessing of pediatric tracheostomy tubes (TTs) with detergent-soaked gauze pads. In vitro microbiologic study. Department of Otolaryngology, University of Florida, Gainesville. Polyvinyl chloride and silicone TTs of 3 different manufacturers. Thirty TTs were cultured with Pseudomonas aeruginosa or Staphylococcus aureus and reprocessed after 4 days. Eighteen additional TTs were exposed to plasma and then cultured with P aeruginosa or S aureus for 7 days. The presence of biofilms was assessed before and after cleaning by quantitative bacterial counts and scanning electron microscopy. Bacterial counts that were obtained before cleaning of the tubes did not differ among brands. Reprocessing reduced P aeruginosa and S aureus bacterial counts in the 4-day group (P = .003 and P = .004, respectively), but clean TTs had a mean count of 10(5) colony-forming units/mL. Reprocessing did not significantly reduce S aureus or P aeruginosa bacterial counts in TTs pretreated with plasma and exposed to 7-day culture. P aeruginosa and S aureus biofilms in pediatric TTs are not eradicated by standard cleaning methods. Further research is needed to determine the clinical significance of these findings and whether strategies to prevent biofilm formation or more effective disinfection methods would result in improved clinical outcomes.

Intersession repeatability of a novel nasal lavage technique

This study describes a novel nasal lavage method using a pediatric tracheostomy tube and examines intersession repeatability for several clinically and technically relevant parameters. Fourteen healthy subjects were included in this study. Both nasal cavities were washed using a standard amount of saline solution (7 mL) via a pediatric tracheostomy tube, and the 2 samples were pooled for measurement of cytokine concentrations and cell count. Recovery volume was also recorded. For each subject, measurements were repeated on 5 consecutive days. Intersession repeatability of recovery volume, cell count, and cytokine concentrations interleukin (IL)-6 and IL-8 were expressed in terms of mean coefficient of variation, intraclass correlation coefficient, and interitem correlations. Intraclass correlation coefficients and interitem correlation coefficients indicated almost perfect agreement for cell count and IL-8 concentrations. Recovery volume and IL-6 concentrations were more variable. The mean coefficient of variation was low for cell count (2%), IL-8 concentration (3%), and recovery volume (3%), whereas the mean percentage recovery was high (87%). This newly developed nasal lavage technique is repeatable over successive sessions for cytokine concentrations and cell counts in nasal secretions of healthy subjects. This method might be valuable in the study of inflammatory conditions involving the upper respiratory tract.

Babies With Tracheostomies

Babies With Tracheostomies

Mislabeling of Pediatric Tracheostomy Tube Leads to Recall

Mislabeling of Pediatric Tracheostomy Tube Leads to Recall

Early tracheostomy tube change in children.

To review the safety of early tracheostomy tube change in children. Retrospective case series. Pediatric tertiary care hospital. Twenty-one consecutive pediatric patients undergoing routine tracheotomy. First tracheostomy tube change performed at patient's bedside at 3 (n = 15) or 4 (n = 5) days after surgery. The ability to safely change a tracheostomy tube at the patient's bedside 3 or 4 days after surgery. The first tracheostomy tube change was safely performed at 3 or 4 days after surgery in 20 patients. All changes were accomplished without complication or difficulty on the first attempt. The patients' ages ranged from 4 days to 16 years. The smallest child weighed 1.6 kg. Early tracheostomy tube change was not attempted in one obese 10-year-old girl whose pediatric tracheostomy tube became dislodged and formed a false tract 2 days after surgery. Most pediatric tracheostomy tubes can be safely changed at the patient's bedside approximately 3 days after surgery. Clinical applications of early tracheostomy tube change may include facilitating better hygiene, earlier completion of family caregiver tracheotomy education, and shorter hospital stays. It appears safe and advantageous for surgeons to consider early initial tracheostomy tube change for pediatric patients.

Percutaneous cricothyroidostomy (minitracheostomy) for bronchial toilet: Results of therapeutic and prophylactic use

In the period 1984 to 1988, 2,448 patients underwent major thoracic operations in our unit. Of these patients, 144 (5.9%) underwent percutaneous cricothyroidostomy (minitracheostomy) using a 20F pediatric silver tracheostomy tube. Minitracheostomies were performed for the treatment of sputum retention in 81 patients, prophylactically in 62 patients, and as a route for high-frequency jet ventilation in 1 patient. Minitracheostomy tubes remained in situ a median of four days. Suction function was satisfactory in 99% of patients, with only 2 patients requiring subsequent suction bronchoscopy and no occurrence of tube blockage. Ninety-four percent of minitracheostomies performed were entirely uneventful. Bleeding was the most common complication (3.5%), and no instances of subglottic stenosis have occurred. During the review period, there was a significant increase in the percentage of patients requiring major operations undergoing prophylactic, but not therapeutic, minitracheostomy ( p < 0.001). This was associated with a significant decrease in the percentage of patients requiring suction bronchoscopy ( p < 0.001). We conclude that prophylactic minitracheostomy with the 20F pediatric silver tracheostomy tube is a safe and effective procedure in the prevention of postoperative sputum retention.