Tia Dickson, RN, BSN

Primary Children's Hospital

Pediatric tracheostomies (trachs); does this topic sound familiar? Maybe that's because we touched on it in our 2022 October issue when we talked about medically complex kids. Why revisit it?

1. Primary Children's Hospital is sending home more children with trachs and vents than ever before.
2. We are seeing several general mistakes being made by EMS when transporting kids with trachs.
3. We had a fantastic lecture on the topic in our last PETOS.

Pediatric trachs and vents for EMS

David A. Clegg MBA, RRT, RRT-NPS, PCH Respiratory Services Manager

Excerpts from March 13 PETOS

Children with trachs have a slighly different airway but they can do just about anything other children can do.

Why do we trach kids?

• Airway abnormalities: severe sleep apnea, anatomical, acute issues such as traumatic brain injury (TBI) or burns, tracheomalacia, stenosis
• Ventilation issues: genetic concerns or head injuries which affect respiratory drive

Find out which type of support your patient requires. It will help guide your care.

Type of support

• Trach assisted: They have a patent upper airway but need a trach to improve ventilation
• Trach dependent: They do not have a functioning upper airway and depend on the trach to breathe
• Ventilator assisted: They need the ventilator sometimes
• Ventilator dependent: They need the ventilator all the time

All trach tubes, regardless of manufacturer, have a universal 15 mm hub that fits all resuscitation equipment including suction catheters, ventilators, and BVMs.

PCH uses Shiley (PVC) and Bivona (silicone) trachs. All families are sent home with a spare trach and parents are instructed to keep it with the child at ALL times.

Cuffed vs. non-cuffed

Different from endotracheal tubes, uncuffed trach tubes are often preferred. They are best for stable patients because an air leak around the tube allows the child to speak. A cuffed tube will be used if the patient needs higher ventilation pressures.

Be familar with the different components of trach in case you need to change one out.

Trach stomas

Trach stomas (the hole in the neck) do not close quickly. The older, mature, or surgically matured stomas are stable and you will have time to change out tubes if that emergent situation arises. If you notice granulation tissue around the hole only change out if you have to, these can be challenging to recannulate.

Ballard suction catheters

A protected suction tube (catheter) inside a sterile plastic sleeve. This is called a closed suction system or Ballard suction. Children should always have them in their emergency bag. If these are not available, you can use a standard suction catheter.

Speaking valves

They contain a one-way flap that allows air flow over the vocal cords for speaking. These must be removed before attempting suctioning or resuscitation. They do not attach to a BVM and may impede airflow when delivering oxygen.

What you need to know about equipment

• Trach size: if it's occluded and a spare is not available, place a similarly sized ET tube in the stoma. The size and length is found on the flange of the tube.
• Is it cuffed or uncuffed?
• Is it neo, peds, or adult? This determines different lengths.

In the management of medical equipment the DOPE mnemonic is standard and trachs are no exception.

Dislodged/displaced

• Does the tube look well positioned? Is the cannula in the stoma? Remove the dressing if you can't see it.
• Do you have end tidal CO2 (ETCO2)?
• Can you feel subcutaneous air in the neck around the tube?
• Is your ventilator alarming high or low pressure?

Actions/interventions

• If dislodged, replace the tube.
• If it looks wrong, replace the tube with the spare.
• If a spare is not available, you may replace with the existing tube and the hospital may treat with antibiotics to prevent infection.

Obstructed

• The tube can become plugged with mucus, tissue, or dirt/debris.

Actions/interventions

• Try to pass a suction catheter. Parents will usually have a suction catheter and know how deep to go.
• If it passes, suction on the way out.
• If it won't pass, change out the tube with the spare.
• No spare? Remove the obstructed tube and place the same sized ET tube in the stoma
• Suction tip: You will often hear secretions with trach patients. We only suction when we hear them AND they show other signs of decompensation such as increased work of breathing, increased oxygen needs, or distress. Ask parents how deep they suction. If patients aren't available, go shallow and stop when the patient coughs or gags.

Pneumothorax

• Sudden decompensation but other DOPE elements check out
  
• Assess for equal breath sounds and chest rise
• Look for distended jugular veins

Actions/interventions

• Determine patient stability. In high risk situations, needle decompress the chest.

Equipment

• The first priority is to take care of the patient. A second person can check the equipment.

Actions/interventions

• If the equipment is malfunctioning, disconnect it from the patient and manually ventilate.

Trach management and even changing a trach tube is within the EMT, AEMT, and paramedic scope of practice. In these patients, a patent tracheostomy tube is an essential part of their patent airway and there may not be time to call in a paramedic. If the airway is compromised, you must act.

If the trach tube is patent and the patient needs bagging, bag the trach. Bagging the mouth/nose is not usually sufficient.

• Select the correct sized bag-valve-mask (BVM) and set oxygen flow at 6-10L.

• Remove your BVM bag mask. The adapter is universal and should fit snuggly onto the trach hub. Be sure to remove any speaking valves.
• For children, give 1 breath every 3 seconds (20-30 breaths per minute). Watch for chest rise with each breath (bag as you would an ET tube).
  
• If bagging the trach with a good seal does not produce chest rise, you may try to bag the mouth/nose but you must occlude the trach while doing so.

Yes but . . .

• Ventilator pieces or speaking valves must be removed and the NRB should be secured directly around the trach opening or to the patient's trach mask.
• If the NRB is in place over a trach, oxygen must be flowing. If it is not, the patient will rebreathe their own CO2.

Do you have a question for our EMSC medical director, Sarah Becker, MD, PCH, ER attending physician about this newsletter topic or anything related to pediatrics? Email tdickson@utah.gov.

Every April is World Autism Month! Light It Up Blue as Autism Speaks kicks it off beginning with World Autism Awareness Day on April 2.

A White House Proclaimation on World Autism Awareness Month

If you'd like agency training on Autism contact our Utah EMSC FAN Representative Jeff Wilson. Jeffwilson122615@gmail.com

Many thanks for your help. We met our 100% goal for responses on the EMSC EMS survey. Thank you for helping us identify pediatric gaps. We will share our state survey results with you soon.

Utah EMSC is participating in the upcoming zero fatalities conference which has an exclusive EMS track. We have scholarships available for attendance. Join us and contact our program manager jaredwright@utah.gov if you'd like to go on our dime.

Please see this month’s highlighted resources on Home Ventilators and Tracheostomy

The Medical Home Portal is a resource developed by our state partners for parents and providers of children and youth with special health care needs (CYSHCN). Why should our PECCs use them? For example, a child with a rare syndrome moves into your community and parents ask you for resources. Your agency is frequently called to the home of a child with an unfamiliar diagnosis. You want to educate your staff. Hospitals are discharging a child to a rural community and the portal can guide follow up care.

• The Portal’s Diagnosis Modules provide information, tools, and resources to guide clinicians in caring for children with chronic and complex conditions. Each module includes sections on:
• Description, treatment and management, resources for families, clinical assessment, resources for clinicians, services for patients and families

The modules are written for primary care clinicians, but offer valuable information for other professionals and caregivers, including families.

What is a medical home?

A medical home is not a house, office, or hospital, but rather an approach to providing comprehensive primary care. In a medical home, a primary care clinician and her/his team work as a team with the family/patient to make sure the medical and non-medical needs of the child/youth are met. The clinical team can help the family/patient find and arrange specialty care, school services, out-of-home care, family support, and other public and private services which are vital to the total health and well-being of the child and family.

The American Academy of Pediatrics (AAP) describes the ideal medical home as one that provides:

• Accessible
• Continuous
• Comprehensive
• Family-centered
• Coordinated
• Compassionate
• Culturally effective care

Though many uses of the medical home model focus on children and youth with special health care needs (CYSHCN), "every child deserves a Medical Home." AAP Policy Statements ([American: 2004], [Rushton: 2005], [Cooley: 2004], [Council: 2005]) recognize the role of pediatricians and other primary care clinicians in providing comprehensive care for children with chronic and complex conditions and define the medical home concept.

The Portal Periodical, is a free digital newsletter with relevant news and information. Check out previous issues online and subscribe.

Emergency information forms for CYSHCN:

https://downloads.aap.org/AAP/PDF/EIF%20(Blank%20Form).pdf

Backpack cards: https://www.cdc.gov/cpr/readywrigley/documents/backpack_emergency_card.pdf

The Utah Women and Newborns Quality Collaborative Out-of-hospital Birth committee has a document which describes best practices around transfers from out-of-hospital birth venues to hospitals. Our current guide covers best practices for midwives, doulas, receiving hospitals, and hospital systems. We have long wanted to include EMS in the document, but we have never had a group of people from the EMS community who could contribute and let us know if the practices we might suggest would work for EMS. Meetings are once a month, usually on a Tuesday at 3 pm. We really value the EMS perspective and would love to have someone who could bring it to our work!

If interested email tdickson@utah.gov

Pediatric education for the prehospital provider

Register online at www.peppsite.com. Look up classes in Utah and find the 1 that works for you. Once you find the class, go to jblearning.com, and look up pepp als in the search tool. Purchase the number ($21.95). Return to peppsite.org to register for the class and follow the prompts.

If you have any questions, please email Erik Andersen at erikandersen@utah.gov or text/call 435-597-7098. Continue to watch the website for additional classes.

The Emergency Medical Services for Children (EMSC) Program aims to ensure emergency medical care for the ill and injured child or adolescent is well integrated into an emergency medical service system. We work to ensure the system is backed by optimal resources and that the entire spectrum of emergency services (prevention, acute care, and rehabilitation) is provided to children and adolescents, regardless of where they live, attend school, or travel.

Email: tdickson@utah.gov
Website: https://bemsp.utah.gov/
Phone: 801-707-3763
Facebook: facebook.com/Chirp-UtahDepartmentofHealth