Pediatric emergency medicine trisk 4644 4644
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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 4 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
