FIGURE 135.2 Dual cannula tracheostomy tube Swivel A swivel is often attached to the end of the tracheostomy tube Some unique characteristics of children make the swivel particularly useful First, children have a natural inclination to move and explore The swivel device accommodates movement in the ventilator-assisted child, so traction is not placed on the ventilator tubing or on the tracheostomy tube Second, the short neck and bulky soft tissues of young children can obstruct the tracheostomy tube opening The swivel provides additional length, so the tube opening extends beyond the soft tissues of the neck Heat–Moisture Exchanger Air inspired directly into the trachea through a tracheostomy tube bypasses the important warming and humidification mechanisms provided by the natural upper airway Therefore, a humidification system is an important component of the equipment used in a patient with a tracheostomy A home ventilator setup includes a stationary humidification system that is used when the child is connected to the circuit Similarly, a heat–moisture exchanger is attached to the end of the tracheostomy tube in patients who not require the ventilator The device is composed of a hydrophilic material that captures the patient’s own heat and humidity on exhalation so that it can be inspired on inhalation Clinical Findings/Management The approach to the ill patient with an artificial airway is the same as that for any patient who comes to the ED The initial evaluation consists of an assessment of the patient’s ABCDs (airway, breathing, circulation, and disability), with particular attention to the airway and breathing An emergency physician who knows how to anticipate common problems and to recognize them early is able to institute appropriate therapy without delay Obstruction and Decannulation The most life-threatening complication in a patient with an artificial airway is cannula obstruction or dislodgment Younger children are more likely to experience accidental decannulation because of the short length of the trachea and tracheostomy tube Some infant tubes are as short as to cm H2 O In addition, the small lumen is more easily occluded by a mucous plug or by an accumulation of secretions Infants with less-developed intercostal muscles and children with neuromuscular disorders may be unable to generate an adequate cough to keep the airway clear of debris The presentation is similar to that of other children with airway obstruction The child may appear distressed with tachypnea, cyanosis, accessory muscle use, and/or nasal flaring Alternatively, the child may be lethargic or obtunded as a result of prolonged respiratory effort or an elevated carbon dioxide level Any child with an artificial airway and respiratory distress is assumed to have an obstruction The patient should be placed immediately on high-flow humidified oxygen The physician should determine whether the tracheostomy tube appears to be in place, recognizing that a tube in the stoma does not necessarily indicate a tube in the trachea If a cannula change was attempted before the child’s arrival in the ED, a false passage into the paratracheal soft tissues may have occurred Auscultation for the presence and symmetry of bilateral breath sounds should be performed and the quality of the patient’s respiratory effort should be assessed Immediate suctioning is appropriate in an attempt to assess tube patency and to clear the airway of secretions The physician should not hesitate to change the cannula Suctioning alone may not clear an obstruction caused by thick secretions All the necessary equipment for the change should be present, including a replacement tracheostomy tube, an endotracheal tube one-half size smaller, and a bag–valve–mask ventilation circuit with oxygen flow, scissors, and tracheostomy ties The change is best accomplished with the participation of two people: one secures the patient and removes the old tube, whereas the other inserts the new tube Remember to deflate the cuff prior to removal, if one exists Please see Chapter 130 Procedures for details on how to change a tracheostomy tube Infection Bacterial colonization of the trachea usually occurs in a child with a tracheostomy Common colonizing organisms include gram-positive cocci (Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pneumoniae , α- and β-hemolytic streptococci), gram-negative bacilli (Klebsiella, Pseudomonas, Escherichia coli, Serratia marcescens, Haemophilus influenzae ), and anaerobes (Peptostreptococcus, Bacteroides ) These same organisms can become pathogenic, causing tracheitis or pneumonia Differentiating between bacterial colonization of the trachea and clinical infection can be difficult The physician should elicit a history of any changes in the quantity, thickness, or odor of the tracheal secretions, and any systemic signs of infection or respiratory distress Along with physical examination, there should be a determination of oxygenation by pulse oximetry A Gram stain and bacterial culture, and a rapid viral detection assay of the tracheal secretions, may be helpful in determining the presence and cause of an infection Leukocytosis in the tracheal secretions and a predominant organism by Gram stain may be suggestive of bacterial tracheitis; radiographic evidence of a new infiltrate indicates pneumonia If the child appears well and follow-up can be ensured, outpatient antibiotic therapy may be appropriate For children with increased oxygen or ventilatory requirements, hospitalization should be considered for intravenous (IV) antibiotic therapy, aggressive pulmonary toilet, and close monitoring Erythema of the peristomal skin is usually caused by irritation and should be managed by increasing the frequency of the tracheostomy care at home The additional findings of warmth, tenderness, purulent drainage, or fever may suggest the presence of a peristomal cellulitis Depending on its severity, this condition should be treated with oral or IV antibiotics The skin of the neck under the ties securing the tracheostomy tube can also become inflamed Generally, this situation can be treated by increasing the amount of padding and by keeping the area dry An erythematous rash with satellite lesions classic for a monilial dermatitis should be treated with topical antifungal creams Asthma The incidence of asthma is increased in children with chronic lung disease Many children are maintained at home on inhaled β-agonist and inhaled corticosteroid therapy The usual viral and environmental triggers, such as dust, pets, and smoke, precipitate exacerbations of asthma The presentation is similar to that of other asthmatic patients, with varying amounts of respiratory distress, wheezing, and hypoxemia As previously mentioned, the physician must consider the possibility of cannula obstruction or dislodgment in all cases Treatment with oxygen, bronchodilators, and steroids should be initiated promptly However, emergency clinicians should recognize that children with chronic lung disease have less pulmonary reserve, and patients with neurologic diseases may not be able to generate the necessary increase in work of breathing to overcome the poor lung compliance associated with acute asthma Chest radiography and blood gas analysis should be performed as clinically indicated Continuous monitoring of pulse oximetry and end-tidal CO2 are helpful in tracking the illness trajectory in the ED Increased ventilatory support or continuous positive airway pressure may be required to overcome fatigue and atelectasis Bleeding and Granuloma The tracheal mucosa located adjacent to the stoma, the cuff, and the distal tip of the tracheostomy tube is prone to bleeding and granuloma formation The most common reason for bleeding is inadequate humidification causing drying and friability of the tracheal mucosa Infection or granuloma formation can also result in small amounts of bleeding Large amounts of blood coming from the tracheostomy tube opening can signify erosion of the tube into the brachiocephalic artery The incidence of tracheoarterial fistula formation is rare (approximately 0.7%) but commonly results in death due to massive hemoptysis and blood loss The risk for development of this life-threatening complication is highest during the postoperative period (i.e., within weeks of tube placement) Small amounts of bleeding from the tracheal stoma usually resolve with increased humidification of the inspired air The persistence of minor bleeding ... breathing, circulation, and disability), with particular attention to the airway and breathing An emergency physician who knows how to anticipate common problems and to recognize them early is able... cases Treatment with oxygen, bronchodilators, and steroids should be initiated promptly However, emergency clinicians should recognize that children with chronic lung disease have less pulmonary