Patient Presentation
A 4-year-old male came to clinic with increased respiratory secretions for the past 24 hours. He had a tracheostomy and the secretions were increased in amount and were thicker and yellowish in color instead of white. He had problems sleeping the night before because of coughing, which had continued into the daytime. He did not have problems breathing after suctioning but needed it at least hourly and often more. He also had copious clear rhinorrhea. He was uncommunicative, but his mother didn’t believe he was having any pain. He was afebrile, and was urinating and stooling as usual.
The past medical history was positive for a currently unidentified neurological condition where he had hypotonia, decreased strength and cognitive deficits. He had a tracheostomy and a gastrostomy tube placed around 1 year of life after multiple episodes of hospitalization for respiratory infections and failure to thrive. During that hospitalization, he needed chronic ventilatory support. Since that time he had been hospitalized 2-3 times/year for respiratory infections and pulmonary toilet. He had a decannulation attempt the previous year that failed because of general intolerance. The family history was positive for an adoptive brother who had congenital heart disease.
The pertinent physical exam showed a thin male with a respiratory rate of 42/minute, heart rate of 98 beats/min, with a normal blood pressure and temperature. His saturation was 90%. Weight had increased ~250 grams from an office visit 5 weeks ago. HEENT showed copious clear rhinorrhea, clear throat, and dull tympanic membranes bilaterally without fluid. His trach cannula was in place and the stoma was clear without erythema or granulation tissue. Lungs were quite coarse with fluid that moved with coughing. He had no specific wheezing or decreased breath sounds. His abdomen was soft and non-tender with a gastrostomy tube in place. The stoma site showed normal skin tissue. Neurologically, he was uncommunicative but would follow the examiner with his eyes. He had hypotonia and decreased strength. After he was suctioned, his saturation increased to 94%.
The work-up included a chest radiograph that was normal for the patient and without specific focal consolidation. A tracheostomy culture and gram-stain was sent. Some gram-positive cocci in pairs were seen along with increased polymorphonuclear cells.
The diagnosis of an upper respiratory tract infection with increased secretions was made. The mother was concerned about being able to care for the child because her husband was out of town and her backup nursing staff was not available. “I’m not sure that I can really take care of him, along with his brother by myself. I don’t want him to be hospitalized, but he needs to be watched all the time,” she said. The pediatrician called his pulmonologist who agreed with the mother. “He gets sick pretty quickly and he probably would be okay if there was nursing care, but I don’t feel comfortable with her being alone. She’s very good and if she is worried, then I know I should be worried too,” the pulmonologist said. Over the night, the patient’s clinical course worsened slightly and he need very frequent suctioning and 2 liters of oxygen/minute by trach cuff. He still remained afebrile. Over the next 2 days, he was slowly weaned off the oxygen and the secretions decreased in amount. He was discharged home.
Discussion
In the past, indications for tracheostomy were often because of infection, but today are more often due to need for chronic airway support and/or ventilation. Many more children and infants are having tracheostomies placed. Decannulation rates for these children are low due to concomitant complex chronic disease such as neurological, pulmonary and congenital heart diseases. Co-morbidies are common with 3-4 being average, and frequently also including chronic technology such as gastrostomy tubes or ventriculoperitoneal shunts. Approximately 8% of children do not survive the hospitalization where the tracheostomy is placed. It is believe this is not specifically due to the tracheostomy, but is secondary to underlying medical conditions. About 15-20% of children with tracheostomies have a tracheostomy-related complication and many have frequent hospitalizations. Frequent hospitalizations are often due to respiratory issues (50.8% with pneumonia accounting for 15.4%) and neurological and otolarygological problems accounting for 8.4% each in a 2015 study.
Decannulation is highly individual and many children will need the tracheostomy for their lifetimes. In general before a decannulation attempt, there should be no ventilatory support needed for at least 3-6 months, no aspiration events, no need for supplemental oxygen, no need for elective surgery in the near future necessitating intubation, and co-morbidies that have resolved or are improved. Patients who are being considered for decannulation often will have a trial of capping the trach during the day and night, and/or have the tracheostomy tube downsized. All have some type of formal airway assessment usually by laryngoscopy to evaluate the overall airway and to detect potential problems such as granulation tissue in the airway. A favorable direct airway evaluation is a good predictor of decannulation success.
Learning Point
Potential complications of tracheostomy include:
- Early complications
- Air leak
- Pneumothorax
- Pneumomediastinum
- Subcutaneous emyphasema
- Airway obstruction
- Decannulation, accidental
- Mucous plugging
- Hemorrhage
- Aberrant vessels
- Innominate artery
- Thyroid gland
- Pulmonary edema
- Respiratory arrest
- Surrounding tissue injury
- Cricoid cartilage
- Esophagus
- Recurrent laryngeal nerve
- Tube placement injuries
- Main bronchus cannulation
- Tracheal tear/fistula
- Air leak
- Delayed complications
- Airway obstruction
- Decannulation, accidental
- Mucous plugging
- Hemorrhage
- Stomal
- Tracheal mucosa
- Tracheo innominate fistula
- Swallowing or speech problems
- Stomal problems
- Granulation tissue
- Tracheocutaneous fistula
- Tracheal lesions
- Granuloma, suprastomal or distal
- Suprastomal collapse
- Subglottic stenosis
- Tracheoesophageal fistula
- Airway obstruction
Modified from Watters, 2017.
Questions for Further Discussion
1. What is the general formula for sizing an endotracheal tube or tracheostomy tube?
2. What are the treatments for stomal granulation tissue?
3. What special problems may infants or young children have with development because of a tracheostomy?
Related Cases
- Disease: Tracheostomy | Tracheal Disorders
- Symptom/Presentation: Respiratory Distress | Rhinitis
- Specialty: Allergy / Pulmonary Diseases | Critical Care
- Age: Preschooler
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Tracheal Disorders
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Yaneza MM, James HL, Davies P, Harrison S, McAlorum L, Clement WA, Kubba H. Changing indications for paediatric tracheostomy and the role of a multidisciplinary tracheostomy clinic. J Laryngol Otol. 2015 Sep;129(9):882-6.
Zhu H, Das P, Roberson DW, Jang J, Skinner ML, Paine M, Yuan J, Berry J. Hospitalizations in children with preexisting tracheostomy: a national perspective. Laryngoscope. 2015 Feb;125(2):462-8.
Watters K, O’Neill M, Zhu H, Graham RJ, Hall M, Berry J. Two-year mortality, complications, and healthcare use in children with medicaid following tracheostomy. Laryngoscope. 2016 Nov;126(11):2611-2617.
Watters KF. Tracheostomy in Infants and Children. Respir Care. 2017 Jun;62(6):799-825.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa
Pediatric Education 