Why tracheostomy in infants

An ideal protocol should present an efficient utilization of resources while not sacrificing patient safety. Publications on pediatric decannulation over the last 20 y are listed in Table 4. A clinical consensus statement on pediatric tracheostomy management that commented on decannulation was published by Mitchell et al 86 under the guidance of the American Academy of Otolaryngology and Head and Neck Surgery.

The recommendations were constructed from expert opinions and state that specific criteria should be met before attempting decannulation in children, provided there is resolution or improvement of the original indication for tracheostomy. First, no ventilatory support should be required for a period of 3 months before decannulation, which could vary from 2 to 4 months, depending on the time of the year.

Second, there should be no aspiration events, such that a tracheostomy would still be needed for suctioning to maintain pulmonary toilet. A flexible laryngoscopy should be performed to document a patent airway with at least one mobile vocal cord. Removal of any obstructing suprastomal granulation should be performed at the time of bronchoscopy before a decannulation attempt. A daytime tracheostomy tube capping trial is recommended for those children of at least 2 y of age leading up to decannulation.

If the child tolerates capping, options before decannulation to assess for readiness may include a capped sleep study, a capped exercise test, or a nighttime capping trial while hospitalized and being observed. In younger or smaller children, the small size of the trachea in relation to the tracheostomy tube may preclude capping, and the decannulation protocol should be tailored to the individual patient.

These recommendations serve as a guideline based on the existing evidence, and it was stated in the report that there remains room for further discussion and research on the subject. Decannulation readiness is approached in several ways and is tailored to the individual patient.

The timing and process of decannulation are dependent on several factors. Clinical readiness for decannulation involves cessation of the need for mechanical ventilation for at least 3—6 months and resolution of the original indication for tracheostomy. A supplemental oxygen requirement should not preclude a decannulation trial as long as the child can tolerate oxygen administration via nasal cannula. Comorbidities affecting the need for tracheostomy, including cardiac, pulmonary, or neurologic conditions, should have improved or resolved.

A likelihood of needing elective surgery in the future eg, spinal surgery, oromaxillofacial surgery that may affect the airway caliber in a child would support the maintenance of the tracheostomy. Certain assessments of airway form and function are important in all patients before decannulation. Whereas microlaryngoscopy and bronchoscopy evaluate airway patency at all levels, polysomnography PSG assesses sleep-related upper-airway physiology.

The ideal decannulation protocol should contain some of the following: tracheostomy size reduction and clinical observation; complete airway evaluation flexible laryngoscopy and direct laryngoscopy bronchoscopy ; capping trial at home during the day; capped PSG; and admission for decannulation and post-decannulation observation for 24—48 h; noninvasive ventilation NIV.

The child's tracheostomy tube is initially downsized to the smallest tolerated uncuffed tube according to the patient's age and size. In infants, this tube is a size 3. Although a size 2.

The importance of a formal airway evaluation, direct laryngobronchoscopy, before decannulation under general anesthesia is not disputed. A flexible laryngoscopy should be initially performed with the child awake to assess vocal cord movement and supraglottic collapse. A direct laryngobronchoscopy evaluates airway patency at all levels and is necessary for not only diagnostic evaluation but also therapeutic treatment of the airway.

Spontaneous ventilation during this procedure with the tracheostomy removed from the airway is paramount to assess any dynamic collapse or obstruction, especially suprastomal collapse and tracheomalacia. Suprastomal granulation tissue, if obstructive, should be removed. A favorable direct laryngobronchoscopy has been reported as an excellent predictor of successful decannulation. Wirtz et al 90 published a study of 35 subjects ages 1—17 y , wherein they recommended direct laryngobronchoscopy with intraoperative decannulation, in the absence of tube downsizing, a capping trial, or PSG.

If the airway was deemed adequate at the time of direct laryngobronchoscopy, the tracheostomy tube was removed, and the child was monitored overnight and discharged the following day if no complications arose. Average in-patient stay for those decannulated was 1.

Of the remaining 3 subjects, one was taken back to the operating room for further excision of a suprastomal granuloma, one was kept for further monitoring due to suprastomal collapse, and one was kept in-patient for non-airway-related issues.

All 3 subjects were discharged between post-decannulation days 3 and 5. However, 2 of these subjects ultimately failed decannulation long-term. One subject had severe obstructive sleep apnea following the tracheocutaneous fistula closure 49 d after decannulation, and ultimately the tracheostomy was replaced. The second subject also had the tracheostomy replaced 30 d after decannulation and underwent laryngotracheal reconstruction soon thereafter.

Despite the 2 failures, the authors concluded that their protocol offered a conservative approach to resource utilization and that the operative endoscopic examination of the spontaneously breathing patient is a superior evaluation for decannulation.

The use of capping and downsizing is a common part of many decannulation protocols, although its implementation is not universal. Studies supporting capping report that the reduction and occlusion of tube diameter not only predict decannulation success but also acclimate the child to the changing airway physiology that accompanies tracheostomy tube removal ie, increased dead space and use of the mouth and nose.

Kubba et al 94 stated that the ability to tolerate a blocked tube during the decannulation process is itself a test of the child's reserve, such that, if they can tolerate the additional obstruction caused by the presence of the tube, they will be more likely to manage without problems on exercise or when they next suffer an upper-respiratory tract infection.

However, a blocked size 3. The decreases in the cross-sectional area of the airway in these young children may be to such a degree that those who do not tolerate capping may in fact still tolerate decannulation. Wirtz et al 90 reported that routine daytime capping is not performed in their decannulation process, because it does not offer an accurate physiologic representation of the decannulated child due to the obstruction of the capped tube.

Tunkel et al 91 also commented on how a malacic airway may also be stented by a capped tube. The role of capped PSG in the decannulation process has recently gained wider acceptance, although its routine use is debatable. The current literature is composed of retrospective reviews and case series, and there are discrepancies regarding what is termed a favorable PSG when determining candidates for tracheostomy tube removal.

Many of those with mild and even moderate obstructive sleep apnea can be decannulated successfully. Tracheostomy in children is being performed nowadays for children with fixed laryngotracheal lesions static upper-airway anatomy and also those with dynamic airway disorders, including obstructive sleep apnea, tracheomalacia, pharyngeal hypotonia, and associated neuromuscular disorders.

Dynamic factors that influence upper-airway patency are usually more apparent during sleep, when muscular tone is decreased. PSG is thus an ideal modality to evaluate for readiness for decannulation; however, evaluation by PSG can be expensive, and pediatric PSGs are not widely available. Nonetheless, it must also be interpreted in light of possible savings achieved by decreasing the number of in-patient ICU days required after decannulation with the use of a favorable PSG.

An unfavorable PSG may prevent the morbidity and expense of an unsuccessful decannulation attempt. Parameters such as apnea-hypopnea index AHI , obstructive index, and maximal end-tidal CO 2 are valuable in predicting successful tracheostomy decannulation.

Tunkel et al 91 addressed the utility of PSG and showed that PSG provides objective data measuring upper-airway patency during a time when pharyngeal muscle tone is maximally decreased and airway obstruction is at greatest risk. In more recent years, Robison et al 87 further supported the usefulness of PSG to determine the appropriateness of decannulation.

Of the 28 subjects in their study, 20 The average AHI with a capped tracheostomy for those successfully decannulated was 2. Those who were not decannulated had multiple medical comorbidities, multilevel airway obstruction, need for additional surgery, or chronic need for pulmonary toilet. They concluded that PSG may be a useful adjunctive study in the process of determining a patient's readiness for decannulation.

Cristea et al 92 reported a series of subjects who were decannulated after a favorable direct laryngobronchoscopy and then had a PSG in the sleep laboratory. Successful tube not replaced within 6 months decannulation was achieved in subjects This study argued against performing a capped PSG due to concerns that the physiologic effects of an indwelling plugged tracheostomy tube must be considered. Infants may not tolerate even the smallest occluded capped tracheostomy tube if it creates substantial airway obstruction.

An unfavorable study with a capped tube may prevent a successful decannulation in such a case. The pressure dynamics of the airway change following decannulation.

The sudden imposition of upper-airway resistance from the nose, tongue, and pharynx can result in significant changes in lower-airway collapsibility.

While awake, airway patency is improved. These changes become more pronounced during sleep and, in the case of an abnormal upper airway, can result in varying degrees of obstruction. Thus, the literature supports that a favorable PSG with tracheostomy capping is complementary to endoscopic assessment in patients with complex airway problems.

Larger studies are needed, however, to validate specific PSG parameter thresholds in all pediatric patients undergoing decannulation.

Also, sleep centers with pediatric expertise unfortunately are not available everywhere, and in those that are, there are considerable wait times.

NIV can be delivered via nasal prongs or face mask at night following decannulation. Use of NIV is more frequently used in this manner in Europe. Fauroux et al 98 reported on 15 children age 2—12 y in whom decannulation was proposed because endoscopic evaluation showed sufficient upper-airway patency and normal nocturnal gas exchange with a small-size closed tracheal tube, but obstructive airway symptoms occurred either immediately or with a delay after decannulation without noninvasive ventilation.

After NIV acclimatization, decannulation was performed with success in all patients. NIV was associated with an improvement in nocturnal gas exchange and marked clinical improvement in their obstructive sleep apnea symptoms. None of the 15 subjects needed tracheostomy recannulation.

NIV was withdrawn in 6 subjects after 2—8. Thus, in selected patients with obstructive sleep apnea or lung disease, NIV may represent a valuable tool to treat the recurrence of obstructive symptoms after decannulation and may facilitate early weaning from tracheostomy in children who have failed repeated decannulation trials. Children have a substantial risk of significant morbidity and mortality following tracheostomy. Guidance to help physicians inform and advise families facing decisions regarding tracheostomy in children with chronic health conditions has been difficult to develop, in part because these children have a heterogeneous array of underlying diagnoses.

It is predicted that tracheostomy is a procedure that will be performed with increasing frequency in the future as pediatric ICU care continues to improve and children with complex medical conditions survive longer.

Despite this, there has not been a parallel standardization in the quality of care these patients receive. Safe and effective care for a new tracheostomy requires intensive monitoring and care from a variety of providers, including multiple medical specialties, nursing, and ancillary services.

For example, communication with and education of the emergency medical staff in the management of tracheostomy emergencies should be mandatory in a community where a child with a tracheostomy resides. This could be provided by the hospital-based tracheostomy teams caring for the child on discharge. Substantial concerns have been raised regarding suboptimal standards in tracheostomy care, and this is a growing concern in view of the increasing demands for intensive care services.

Tracheostomy outcome metrics that exist for adult patients, including time to decannulation and time to wearing a speaking valve, are difficult to adapt to the pediatric population. Also, many of the reported tracheostomy-related events are in fact preventable events and should be amenable to prospective system improvement strategies.

In adults, much is known about the life experience associated with tracheostomy, the potential for adverse outcomes, and associated health-care costs. There is less in the pediatric literature and also a clear lack of standardization of protocols and policies. In , Das et al published the results of surveys of members of the American Academy of Otolaryngology-Head and Neck Surgery, addressing those that had experienced at least one patient with a catastrophic event related to a tracheostomy.

There were respondents who described recent catastrophic events related to tracheostomies. Twenty-nine patients were specified to be children, in whom the most commonly reported events were tracheostomy tube occlusion, 12 decannulation leading to loss of airway, 10 and tracheoinnominate artery fistula. Ten of the 28 events occurred at home. Although a survey methodology was used in this study and there is a high possibility of both response bias and recall bias, it is very possible that the number of events was underestimated because there are a number of pediatric patients who may die from tracheostomy-related complications at home or are lost to follow up.

A companion paper by the same group also reported significant variability in ongoing surveillance and care of tracheostomy patients. As evidenced in other studies, 2 — 5 the children in the cohort were very medically complex. Two-year rates of in-hospital mortality and tracheostomy complication excluding the admission when the tracheostomy was placed were 8. Of the children who had a tracheostomy complication An analysis of the American College of Surgeons National Surgical Quality Improvement Program Pediatric performed by Mahida et al 28 demonstrated that the highest contribution to composite morbidity in otolaryngology is seen in children younger than 2 y undergoing tracheostomy.

The National Surgical Quality Improvement Program Pediatric reports predefined d postoperative outcomes for surgical cases from participating institutions for quality improvement. The study attempted to determine predictive factors for complications following tracheostomy placement in patients younger than 2 y that, if targeted for reduction in quality initiatives, might result in improved surgical outcomes.

Of the children younger than 2 y who underwent elective tracheostomy from to among 61 participating institutions, The most common complications were pneumonia 7. Due to their medical complexity, children with tracheostomy are usually cared for by an array of medical providers and care teams, including otorhinolaryngologists, pulmonologists, cardiologists, neurologists, primary care physicians, nurses, respiratory therapists, and equipment specialists.

Unfortunately, the majority of these patients experience extremely disorganized, fragmented care and poor communication between providers, which continue to be obstacles to optimal patient outcomes. It has been demonstrated that care can be dramatically improved and tracheostomy-related adverse events can be radically reduced through implementation of tracheostomy care teams.

Over the last decade, a few adult institutions have shown that with truly integrated multidisciplinary tracheostomy care, it is possible to radically reduce adverse events and significantly improve care for patients with tracheostomy.

Significantly, annual cost savings were also 8 times greater than the cost of program provision. In , Hettige et al reported a multidisciplinary care model consisting of a tracheostomy bundle with 3 components: a checklist, a dedicated tracheostomy multidisciplinary team, and an educational program. Welton et al, subsequently reported that following implementation of the interprofessional tracheostomy team, there was no improvement in decannulation times or time from weaning to speech-language pathology referral.

However, a significant improvement was noted in the average time to first tracheostomy tube change from They concluded that a multidisciplinary tracheostomy team can improve the quality of tracheostomy care through earlier tracheostomy tube changes and swallowing assessment referrals. The authors commented that the lack of improved weaning to decannulation time was potentially due to poor adherence with established protocols as well as a change in mechanical ventilation practices. Most of these reports are with respect to adult tracheostomy care, and unfortunately there has not been as much reported progress in the pediatric tracheostomy literature.

Abode et al demonstrated that a multidisciplinary approach can yield measurable improvements in important outcomes. Their study had 3 primary aims: 1 optimize stay for children with newly placed tracheostomies, 2 improve communication among providers and caregivers, and 3 avoid tracheostomy complications. They instituted and tracked initiatives — , including an enhanced tracheostomy education program and weekly clinical care conferences, and also developed and implemented institutional consensus of care for aspects of care currently lacking published evidence-based or expert guidelines.

The authors recommended that institutions with multidisciplinary pediatric airway programs should adapt structure, processes, and goals to individual institutional strengths, barriers, and resources.

The United Kingdom National Tracheostomy Safety Project primarily aimed to improve management of tracheostomy critical incidents through the development of emergency algorithms that describe a universal approach to management of adult and pediatric tracheostomy emergencies. In , the International Pediatric Otolaryngology Group published consensus recommendations for perioperative tracheostomy care in pediatric patients, aimed at improving patient-centered care in this patient population.

Although there are no studies validating the outcome of these recommendations to date, they are an important step in proposing standardization of pediatric tracheostomy care. Although a small number of hospitals have demonstrated that it is possible to reduce adverse events substantially, in some cases by 5-fold or more, the system-wide changes that led to these improvements are not easy to implement and have not been rapidly adopted by other hospitals.

The slow diffusion of medical and health-care innovation is widely recognized ; one approach to overcome this delay is a quality improvement collaborative. This is accomplished in part by utilizing a prospective multi-institutional database to gather data on patients undergoing tracheostomy. Specifically, the Global Tracheostomy Collaborative promotes a number of key drivers that are known to be associated with improvement that include: 1 truly multidisciplinary effectively coordinated multidisciplinary care teams, 2 institutionwide protocols, 3 broad staff education, 4 patient and family involvement, and 5 data analysis.

The Global Tracheostomy Collaborative aims to improve outcomes in tracheostomy care. One of its key drivers in achieving that goal is the development of best practices and standardization of care. Prospectively collecting outcome data on a large scale via an international, multi-institutional HIPAA-compliant database will eventually allow for benchmarks to be set and for novel targets for quality improvement initiatives to be identified.

The database contains branching logic to collect data specific to both adult and pediatric patients with tracheostomy. Variables collected include demographics, clinical characteristics, indication for tracheostomy, stay in ICU, duration of mechanical ventilation, time to decannulation, and adverse events.

The purpose of the database is to allow hospitals to track their own progress and ultimately to allow hospitals to benchmark themselves against their peers anonymously. Tracheostomy is being increasingly performed in pediatric patients. The indications for tracheostomy and the characteristics of children with tracheostomy have changed significantly over the last 50 years, reflecting the changes that have occurred in the management of critically ill children.

Prolonged invasive ventilation is now the primary indication for tracheostomy in children, but the definition of time when the tracheostomy should be placed remains highly variable, between 14 and 90 d in some studies, and most consider that timing should be made on an individual patient basis.

The open surgical technique continues to remain the optimal technique for tracheostomy in children. The role of percutaneous tracheostomy in children is not yet clearly defined, but it may be feasible in older children.

The optimal pediatric decannulation protocol supports tube downsizing and daytime capping, in addition to a favorable capped PSG and endoscopic airway assessment direct laryngobronchoscopy as a strong predictor of successful decannulation.

As a result of the increased use of capped PSGs, the length of ICU admission following decannulation can be decreased in those children receiving favorable capped sleep studies.

However, larger studies are needed to validate specific favorable PSG parameter thresholds in pediatric patients undergoing decannulation. Tracheostomy care in children is a complex, truly multidisciplinary process. It is widely recognized that patients with tracheostomy are at high risk for potentially preventable adverse events that can lead to significant morbidity and even mortality, and there is a recognized need for improvement of care.

Future directions include multi-institutional analyses of care coordination and transitions for pediatric tracheostomy patients as well as testing the effectiveness of interventions such as multidisciplinary tracheostomy care teams, standardized tracheostomy protocols and policies, broad staff education, and family involvement.

These factors will be key to improving the quality of care for these patients. In response to globally identified recurrent themes that have led to measurable harm and a clear need to accelerate the spread of improvements in tracheostomy care, an international, multidisciplinary quality improvement collaborative aimed at improving outcomes for both adult and pediatric patients with tracheostomy has been established.

Thank you for your presentation. I have a couple of comments, and there's a common theme to both. First is: Do you really practice an interdisciplinary discussion before a trach is placed? My experience has been that the process of tracheostomy lasts 7 d for the intensivist as long as they stay in the ICU , a few hours for the surgeon during the placement and the follow-up, and for up to 18 y or more for us pediatric pulmonologists when there is chronic ventilatory dependence or chronic lung disease present.

Many times we are not invited to the pre-tracheostomy discussion; we are called after the fact. Sometimes the same thing happens with the decannulation process because you alluded to a group that has upper-airway obstruction and doesn't have chronic lung disease.

That probably doesn't require much conversation. Sometimes I see disconnect between the surgeon and the pulmonologist as to why the patient should still have a tracheostomy.

I would like to hear your thoughts. I agree, a lot of the multidisciplinary teamwork we've focused on has all been after the tracheostomy is placed, around care at home and in the community. I think there are a lot of issues with regards to the actual decision-making process of whether a tracheostomy is indicated or not. I really think that is an area that needs to be improved. Plus, we have no consensus, for example, if you focus on the premature population, as to the timing of when the tracheostomy should be placed.

One of the reasons why we do not want to place the tracheostomy too early is the known associated mortality of children with a tracheostomy and also the care of a child in the community with a tracheostomy, which can be highly variable. Some children are intubated for up to 8 or 12 weeks before we are consulted for tracheostomy placement.

I think recurrent attempts of extubation are made, to try to avoid a tracheostomy. After 3 or 4 failed extubations, it becomes clear that a tracheostomy should be considered. However, there is no consensus as to the length of time a child should be intubated.

I think a lot of it depends on the associated comorbidities that the child has, and taking into account children with neuromuscular disorders, it often becomes an ethical situation as well: Is placing a tracheostomy in this child the right thing to do?

Getting back to the preterm population, there are some data from large databases that suggest tracheostomy is associated with worse outcome. But that may be because the trach is a marker for severe disease as opposed to the cause. Those are children who have chronic lung disease who require long-term mechanical ventilation. The flip side of that is that development may be hampered by not performing a tracheostomy a little earlier because the infant needs to be restrained so that he or she doesn't pull out an ETT.

The infants are confined to bed, they can't work as well with rehabilitation specialists, and so I think that there is a need for a more thoughtful approach to identify which infants you would anticipate are going to need long-term ventilation and perhaps go to earlier tracheostomy to enhance development while they're still in the NICU. Just to add on, it seems like with us getting better at NIV, I do think those multidisciplinary discussions are happening in that patient population.

In other words, we've sent them home receiving NIV, and they continued to fail or have issues, and then the pulmonologist is involved and the hospitalist or the intensivist is often involved because they keep getting readmitted. Prior to us doing so much NIV, I don't think that discussion was happening. To Ariel's [Berlinski] point, it was sort of one person made the decision that this patient needed a trach, and it wasn't widely discussed.

But it seemed to fall out of favor, and I'm not sure why it did, because you could get some pretty small sizes of those. I'm curious as to what your thoughts are on that. We've looked into the Olympic buttons recently for certain patients. They don't come small enough for kids under the age of 2 that you're trying to decannulate; they just don't make them. I think our main fear is that they're going to go into the airway as a foreign body. I would generally not recommend them in small children, which unfortunately are the population we are concerned about the capped tracheostomy taking up some much space in the airway.

It doesn't look like by the data that we actually decannulate anybody before 2 anyway, so it might actually work out.

Karen, that was a great presentation, thank you. I want to go back to the theme of Ariel's first question and your comment about the timing of tracheostomy. You showed some nice data on the costs and complications of tracheostomy. But, when we think about trachs, including the comments that have already been made, these patients are often in the ICU for a long time and are often extubated 3 or 4 times before everyone accepts the fact that the patient needs a trach.

So the data presented do not take into account the costs of waiting to trach and also the potential morbidity of waiting.

I do not have the answers, but what we need to get to is a determination of the right timing for tracheostomy. I throw this issue to you, as well as to our pulmonology friends. Howard [Panitch] and Dennis [Stokes], what do you think? Do we wait too long? Should we be proceeding with trachs earlier for those patients who clearly need it? I think in a lot of situations, we do wait too long. I think in some situations, a lot of that is due to social issues around caring for the child.

In a lot of cases, the family isn't ready to have a child with a trach. That often prolongs it. So, if you put a trach in this child—I know they're taking up a bed—where are they going to go? Perhaps the child is in foster care or the child can't go home, so we have to know that the child can be taken care of with the trach in. I do agree; I think in a lot of cases, we are waiting far too long. I agree that sometimes the families are not ready, but it often comes back to us.

Maybe we don't raise this option early enough in an admission, as is more often done in the adult world. Again, I do not know the answer but am simply raising this issue to provoke thought and discussion on this important topic. I think in a lot of cases, the introduction of a trach, just the conversation with the parents should start earlier.

Just to plant the seed. Also, this is a side comment, but we started introducing trach teaching to families now even a week or two before the trach is actually placed, and it's been shown that the sooner you start doing that, the sooner you get the child with a new trach out of the hospital. How do you handle that group; upper-airway and chronic lung disease I think are pretty straightforward, but with that group, it's hard. I agree those children have such a high risk of recurrent hospitalizations.

I know that in our institution how they usually end up getting a trach is on one of those admissions, and they can't be extubated. Then they finally need a trach, but I think that whole topic should be broached a lot sooner, probably in the out-patient setting. For the families, it changes the care of the patient entirely; they're going to need nursing care at home to take care of this child, but perhaps that's better than ending up in the ICU 4 or 5 times a year on a ventilator because of recurring pneumonias.

The other thing is I want to congratulate you on this collaborative, I think that approach, most of us who work in cystic fibrosis are really familiar with the value of this kind of feedback about how your center compares to others.

Is that an organization that any hospital can join? It's something we would be interested in. The Global Tracheostomy Collaborative is open to any institution to join, and we encourage institutions to join.

Over the last year or so, we've done a lot of work that hopefully in time and as our database matures, it will be a very rich source of data. I think there are 2 pieces to this conversation. The one group of patients for whom trach actually may be a tool to get them out of the ICU, and it seems to me that we're not framing that well with our patients. We're framing it that tracheostomy may appear to be a long-term intervention as opposed to a tool, and I think that messaging needs to be something we develop as a care team.

The second aspect is the decision-making for the patient for whom it's clear the trach is going to be a long-term intervention. Pulling together the care teams, including palliative care, to make that decision is a critical part of what needs to happen. I think it's only happening more consistently in the recent past.

Those are my perspectives on the decision-making and ethics of tracheostomy. I also want to circle back to your decannulation discussion because there were 2 pieces of that I wanted to be clear on. First, in your video, you didn't show the trach tube coming out to assess the airway, and I wanted to make sure that is included in the airway evaluation.

Yes, the tracheostomy does of course come out of the airway on every direct laryngobronchoscopy; I just wanted to get on to the next slide. Obviously, routinely we do an initial pass to see how the trach is sitting in the airway, then the trach is removed and the airway is examined without the trach in situ.

We want to make sure there isn't superstomal collapse or malacia. It's a very important part of the upper-airway examination. The second question has to do with the utility of a sleep study. What's the false negative rate? Since you've got the tube obstructing the airway by its presence, you may increase the likelihood of getting a sleep study that forces you to defer decannulation.

When your child has recovered from surgery, the doctors review his needs again and discuss this with you. Sometimes a tracheostomy is permanent.

Many children who have a tracheostomy might need to stay on a ventilator at home. If you agree to a tracheostomy for your child, you will learn how to care for the trach, including:.

You will go to classes in the Family Resource Center. There, you will practice these skills on a doll. Plan to go to class right after the trach surgery and before the first trach change by the surgeons.

This allows you to practice at the hospital and learn what to do at home. This is set up so you are prepared to care for your child at home. Skip to Content. Urgent Care. In This Section. The more common reasons for a tracheostomy are listed below. A blockage in the upper airway: if the upper airway is blocked, air cannot get into the lungs.

The trach tube helps your child breathe. Inability to clear mucus from the lungs and airway: lungs make mucus. Mucus cleans the lungs by picking up tiny bits of dirt and dust. Cilia, which line the lungs, help the mucus carry the dirt and dust out of the lungs.

This protects the lungs from irritation and infection. Long-term help with breathing: A trach tube is put in when a child has to be on a ventilator for a long time. You will need to discuss this with your child's doctor. Avoid using powders or aerosol sprays around the tracheostomy tube, as they may cause breathing problems. When your child goes home, they will be able to carry on with most of their normal activities. Your child should be encouraged to play, but you will need to watch them at all times.

Don't have small toys or objects around a young child, as there is a risk of them breathing small items in through the tube. Careful supervision is necessary when your child is around sand. If possible, avoid sand pits and beaches.

Older children may have to avoid contact sports such as football and basketball. Your treating team will arrange regular follow-up to ensure your child's tracheostomy is safe and functioning well. You will be given an individual action plan for tracheostomy management and emergency scenarios.

A tracheostomy may be permanent, long-term or short-term, depending on the needs of your child. Your child will have regular medical appointments, and the removal of the tracheostomy tube will be planned once the medical team is confident that your child can breathe well without it. Your child will need to stay in hospital for at least one to two nights when the tube is removed. Usually a smaller size tracheostomy tube is put in, and then this is blocked overnight to see how well your child can breathe through their nose and mouth, rather than through the tracheostomy tube.

Your child will be monitored closely by the nursing staff. If your child can breathe well with the tube blocked, it is taken out the next morning. Global Tracheostomy Collaborative page. You don't need to buy special clothing for your child. Any type of clothing is fine as long as the clothing doesn't block the tracheostomy tube e. Young children should wear a filter over the tracheostomy tube, or cover it with a light scarf.

The term tracheostomy is used to describe a surgically created hole in the neck that extends to the trachea windpipe to allow for safe breathing. A tracheostomy tube is the plastic breathing tube that is placed into the hole.

Upper airway obstruction may occur due to bilateral vocal cord paralysis, tracheal or laryngeal stenosis, infection, trauma, or due to a cyst or tumor.

A tracheostomy provides an alternative pathway for air to easily bypass the upper airway and enter the lungs. Long-term mechanical ventilation may be required as a result of lower airway obstruction such as bronchomalacia or tracheomalacia or due to neurologic conditions or chronic lung or heart disease.

A tracheostomy allows for a ventilator to be used without a breathing tube that goes through the mouth or nose endotracheal tube. For long-term ventilation, a tracheostomy is considered safer and more comfortable than an endotracheal tube. For most children the tracheostomy is not permanent. The length of time it stays in place depends on the individual patient and the reason it was initially placed.

Although some tracheostomy tubes stay in place for many months or years, many are temporary and can be removed after a shorter period of time.