Pediatric emergency medicine trisk 4643 4643
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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.
