2024-03-20 10 Panel 7 Tracheostomy Management Capping Valves Decannulation Protocols and More

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Panel 7: Tracheostomy Management: Capping, Valves, Decannulation Protocols, and More Moderator: Cinthia Perez (ENT), Sara Zak (Pulm), Arwen Jackson (SLP), Rodrigo Morales (RT), Lucrecia Wamba (RT)

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>> [Spanish] I’m from Buenos Aires, Argentina. I work in two hospitals, a public hospital and a private hospital. And I want to tell you very briefly what we do at the Garrojan Hospital with patients that do not have medical coverage or healthcare providers to teach parents how to manage tracheostomies, what to do with tracheostomies at home. We have this wonderful panel, Arvin Jackson from the Children’s Hospital of Colorado, Rodrigo Morales, speech therapist from the University of Chile, the Institute for Disabled, and neemologist Sara Sack from the Cincinnati Children’s Hospital. They will speak about what to do and how to start with capping valve de-canulation protocols. This is the Garrojan Hospital. It is a hospital in Buenos Aires, Argentina. It was founded in 1987. In all of these years, it has gained a lot of experience in management and treatment of airway conditions. These are our statistics. Since 2019, so far, the number of tracheostomies, fortunately enough, has dropped from 84 to 38 last year. And this is something we see because of the improvement in non-invasive ventilation and the advent of acute airway lesions, endoscopically or open. We all agree that we do this surgical technique. We leave the state’s teachers for 14 days to weeks, approximately. The decision in the trachea is a vertical incision. And we do the maturation of the stoma. We also do a reference to the left and right states future. And we would like to speak a little bit about this. We never have an American public, so sometimes you do not have the problems we do, so we would love to know what to do in these patients. This is a consensus published in 2016 by several airway groups, which, as you can see, these are speech therapists, TMTs, etc. And they coincided in three main things that appeared there. That is basically that the first trach change will be done in the seventh post-op day in the ICU, and with one of our nurses and the surgeon that did the tracheostomy. Then trach tube changes will take place every seven days and ten days. And the last point is that both the caregiver and the parents need to know why the trachostomy of that child. So what are we going to do when we have a trachostomized patient? What we do know is that the success of the transition from hospital to home depends fundamentally from the caregivers and parents know how to manage the trachostomy tube. Any complication here could even lead to death. It’s life-threatening. So we need a very comprehensive education, a very clear education for parents and caregivers, and the education has to be planned meticulously. This is why we have different methods to teach to the parents or the caregivers how to change the cannulas or the tubes. So we have diagrams, simulator, dolls with trachostomy, audios, videos. This is a checklist that our nurses use in the service where they will check which are the things that they see for each cannula change. But basically they see the complications in the short and mid-term. So when we start with the PICU stage, as we said before, we know that the first trach change will be done at the seven-day post-op. While the patient is in intensive care, parents and caregivers will be taught how they have to do the aspiration technique. In the pre-surgical visit, they will receive this handbook that includes everything related with the trachostomy, which are the inputs you need and all that. And we give it to them before doing the trachostomy for parents to have more support regarding what they will have to go through afterwards. Parents will always need to know which was the indication that led to the trachostomy, and also they will have to do the RCP resuscitation course. When the patient goes to the general care room, when he doesn’t need intensive care anymore, there are two stages. One stage will be done in the service and another one in the ward. The stay in respiratory endoscopy will be in the hands of our nurses who have specialized in the management of trachostomy tubes. And this will be done once a day with kids that have trachostomies without balloon, and every three days with balloon not to harm so much the trachostoma. They will be taught how to change the cannula, how to clean the stoma, and what medical supplies they need. The final step is the placement of the endotracheal tube, and this is indicated for the emergency cases. We stress that two caregivers need to be trained, father, mother, or father, and any other relative. And as we said, in parallel in the room, pediatricians and physical therapists will continue to teach and insist in the aspiration technique. They will emphasize symbiology and any sign of respiratory obstruction so that they know when they have to come to the emergency ward. All right. So when can we say that the patient beyond his clinical conditions can be discharged with a trachostomy tube home? When can he go home? When this training program is completed, when they have the CPR courses complete, and when they have all the medical knowledge they need to have. So we’ve done the trachostomy. The patient went home, and now let’s go on to those that will teach us when to remove the trachostomy. [Spanish] According to national demographics, the most common age at — ages at which tracheostomies are placed in children include the years critical to the acquisition of development of language, speech, and oral feeding skills. And while I think that — I have to think about the development of the child, I have to think about the one-way valve and how can we utilize a one-way valve for speaking and swallowing, I can’t do that without thinking about the patient and the family. And we just heard from the previous panel the impact that a trach can have on a family, and this is our chronic ventilation roadmap that we provide all families for children with trachs who are also on a vent. And this is just the steps that they have to go through before they go home. And the one-way valve is one little piece of it, but I like to, you know, kind of pull back and think about where is — where’s the family, where is the patient in their process, and how do I incorporate the one-way valve to support quality of life and to support the child. So at Children’s Hospital, we call it a one-way valve. A lot of people think about it as a speaking valve, but it does so much more. So years ago, we changed our terminology and we refer to it as a one-way valve because it can help with taste and smell. For some children, it can help with airway protection when they’re swallowing, it can help with their communication, restoring physiologic PEEP, secretion management, behavioral compliance because they’re communicating — the child’s communicating better, can help with more functional phonatory patterns, and it’s relatively low cost for really significant benefit. So in our outpatient setting, we actually have three multidisciplinary clinics where we care for children with trachs. Our vent clinic, our trach clinic, which is a like sub-clinic of the aerodigestive clinic, and one-way valve clinic. And what I wanted to show is that the respiratory therapist in our center, we call our respiratory therapist who have expertise in trachs respiratory care, chronic care specialists, and the speech pathologists are in vent clinic, they’re in trach clinic, and in one-way valve clinic. And the one-way valve clinic is an offshoot of vent clinic and trach clinic, and it’s a place where we provide developmentally supportive assessments for one-way valves and caps. Years ago we would go into the clinic with the medical examination table and, you know, all these different providers coming and going and trying to figure out if a patient is safe to go home with a one-way valve and trying to provide education to families, and we decided that was not adequate. For some families and patients, we need a full hour to developmentally support them to see if really they are ready for this and to educate our families. Sorry. That transition. So it’s really a multidisciplinary approach team — team approach, which we talked about today with the child and family at center. So our process, we think about inclusion and exclusion criteria, we request an order from pulmonary or ENT, we do an initial assessment, and that is with a respiratory therapist and a speech pathologist. We establish a wear plan with specific education and parameters for wearing the valve. We provide education, we collaborate with the medical team, school, and community therapists, and then ongoing assessment and management is really directed by the speech pathologist. Some indications for one-way valve use is alert — you know, is the child alert? Are they trying to make attempts to communicate? Are they on their baseline oxygen requirements? Are they stable? If they’re on a vent, is their PEEP less than 10 centimeters H2O or less? And if they have a cuff, is the cuff deflated or can we use an uncuffed trach? And then we have a patient who is in the hospital with a valve that is not able to communicate with the patient. So we have a patient who is on a vent with a cuff that is not able to communicate with the patient. And then we have a patient who is on a vent with a cuff that is not able to communicate with the patient. So in the assessment, as a speech pathologist, I’m looking at cognition, I’m looking at the child’s communicative attempts, their feeding and swallowing, their vocalizations, their vocal quality, tolerance of occlusion trials, and their secretion management. And then we have a patient who is on a vent with a cuff that is not able to communicate with the patient. And then we have a patient who is on a vent with a cuff that is not able to communicate with the patient. And then we have a patient who is on a vent with a cuff that is not able to communicate with the patient. And then we have a patient who is on a vent with a cuff that is not able to communicate with the patient. And then we have a patient who is on a vent with a cuff that is not able to communicate with the patient. And then we have a patient who is on a vent with a cuff that is not able to communicate with the patient. And then we have a patient who is on a vent with a cuff that is not able to communicate with the patient. And then we have a patient who is on a vent with a cuff that is not able to communicate with the patient. And then we have a patient who is on a vent with a cuff that is not able to communicate with the patient. [ Applause ] [ Speaking in Spanish ] >> To take part in this activity, we are making history in this first international meeting. I’m going to tell you about the decannulation protocols and some keys to effective management of tracheostomy in pediatrics. All right. The goals for this very brief presentation is to share a global point of view about the management of children with tracheostomy. And rather than showing how to solve the cases, I’d like to spark discussion, open space for discussion, based on a very brief description of two clinical cases. Let’s move on. Well, welcome to the TRAC multiverse. Why do I use this image? Because in the world of tracheostomy and the families of patients with tracheostomy, in their history there will be lots of heroes and also some villains. What we have in common, all of the users and all of the patients, is this very small plastic tube. But the rest will be a universe of possibilities that could become difficulties at the same time. As a meeting point, we have tracheostomy. From the standpoint of patients, we will find many, many phenotypes, different comorbidities, and of course the difference of working in pediatrics that we can have congenital problems with a user that is just being born or an acquired problem. So we are going to be working at different stages of development. And as this was presented, this is a critical period of acquiring skills that are important for speech therapists, which have to do with eating, speaking, and communicating. There will be a lot of variability in the clinical setting where we’re going to be with the patient. It could be the pediatric intensive care unit, neonatal intensive care unit. The patient could be hospitalized, could be an outpatient that comes from home, or a patient under home care, which in Chile and some countries of Latin America can be private. We have professionals and equipment and devices, or a public system. We know that access to care and variety and devices is less. From the standpoint of the team of professionals, when there is a team, we have to see who the members are, procedures to assess rehabilitation, and also surgeries that can be performed. And the universal multiverse of family has different configurations, different times in the previous panel of quality of life. They said that we have to take into account the standpoint of patients, their families. When you have father and mother, they live the process in a very different way. So they make different decisions. So we are facing a complex equation. Two cases. Case number one, a boy that today is one year old. His initials are EZB, 37 weeks gestationally. He was born on March last year, congenital diaphragmatic here, neosectically treated, intubated at birth. He’s got two failed extubations. And before the third attempt, a fibro-broncoscopy was performed. And they saw a laryngotracheal bronchomalacia that was severe. On May 10th, tracheostomy was done. He was put a cannula 4.0 in the ear. And because of feeding difficulties, a gastrostomy was placed at the same stage, at the same period when the tracheostomy was put. So he’s got the whole combo, tracheostomy and gastrostomy. In November last year, he was admitted for rehabilitation. We have a protocol which is still under development. But we agreed on some important things you have to do, when to do them, and the results that will guide us. One of the elements — literature is quite controversial — is the importance of the modified Evans test. In Latin America, especially in Chile, there are colleagues that make the decision of opening oral feeding by doing just a negative staining test. And we know that this test has a lot of false negatives. So it is very important what we discussed this morning about tests and assessment that have to be objective via fluoroscopy, via video fluoroscopy and PHIS. Ventilator parameters, 12.7, frequency of 20. They were done together with the respiratory physical therapy. They measured transtrical pressures so as to start using the phonation valve, or the one-way valve. Video fluoroscopy was conducted on December 13th last year. We saw that the user with the valve installed could swallow in a safe manner. So we moved forward with oral feeding while he was using the phonation valve. This is his father. Parents do not like to feed the babies, so as soon as they appear, we have them doing it, just like any member of the family, considering that education is quite important. In the respiratory aspect, he moved forward in CPAP windows. The specter was sent by his mother yesterday. We had a stop of oral feeding, secondarily to respiratory problem due to a virus, rhinovirus. He started to vomit a lot and reject eating. And he is being studied to see if there is gastroparesis. So we will see what happens as soon as he sees the gastroenterologist, and we will provide the proper medical management. Today, he tolerates ventilator disconnections two times a day for 20 minutes. The idea is to ask questions that could be useful in general, in pediatrics. Our philosophy is that as soon as we can, we work together with physical therapists. We do joint sessions with occupational therapists to work towards a common goal. Questions for debate. From what age or weight can we use the phonation valve? We have found physicians that say you have to wait for two years to use the phonation valve, or you have to wait that he or she weighs a certain number of kilos. But as we know, since six months old, human babies start to — not to speak, but to say something. Can we start oral intake with a negative modified blue dye test? Another question that sparks debate is do we face decanulation in parallel or subsequently to the G-tube removal? This is another issue for discussion. In this case, four-year-old boy, pre-term, 36 weeks of session, he was born 18 January 2020. He’s got a congenital esophageal stenosis with esophageal perforation. He was hospitalized for six months, 11 esophageal dilatations. In February 2020, when he was two months old, a gastrostomy was placed. Between six months of age and one year, he was able to be fed orally, and the team was thinking of removing the G-tube when, in December, he’s got to do an emergency tracheostomy due to severe laryngitis, which was very, very difficult to intubate. He was left with a cannula without CAF 4.5. This patient has been intubated 16 times, the longest, for two weeks when he was one year old. Nasophabro-monoscopy was conducted in November 2022 that showed a left vocal cord paralysis. No anti-reflux surgery was done. And because of motility difficulties and frequent vomiting and aspiration of that vomiting, they decided to do an E-C-F-A application in November 2022. And in April 2023, a team from Bronco ENT and GI decided to perform reconstructive airway surgery. Unfortunately, because of multiple respiratory difficulties, that surgery has been postponed. In a flexible nasopharoscopy, we saw that the larynx was flooded with saliva. So then we were not sure how this patient was swallowing. They consulted in the speech therapy unit. We did a stain test that was negative. And we proposed to do a video fluoroscopy. We explained and we anticipated because this patient in whom we detected aversion to feeding, we prepared the patient. He was taken two to three times to the room where video fluoroscopies are done. And he’s got functional airway protection mechanisms. The gastroenterologist believes that surgery should be performed after reviewing the functionality of the Nissan fund application. See how he avoids eating. This is a bit of yogurt. In the second session, he was eating yogurt, drinking water after having a feeding only through gastrostomy. I’m finishing just two questions for discussion. What are, in this case, the requirements for taking this patient to the ER and do reconstructive airway surgery? Is it possible to work on oral feeding in a patient with aversion, who is averse to eating, and that because of his laryngeal condition cannot tolerate a phonation valve? Preparation of the family and his family, the cannulation and follow-up are common elements in all of the protocols. Protocols should be adapted to existing local resources, teams of people and material resources and equipment. In developing countries, there is a lack of our digestive teams. We need to have assessment and treatment procedures that are cost effective, and we have to expand our approach to include quality of life measurement parameters. Successful experiences in relation to the teams have to do with good communication, coordination, collaboration, and education to families. Thank you very much. [ Applause ] [ Foreign Language Spoken ] >> All right, I’ll try to make this quick because I know coffee is the next thing, and I don’t want to be the person that stands between you guys and coffee. So I’m one of the pulmonologists in Cincinnati. I’m going to walk through some cases that highlight some difficulties that we’ve had achieving decannulation for some of our patients and what you might be able to do to work through this. So our first case is an 18-month-old little girl. She had her trach placed shortly after she was born for bilateral vocal cord paralysis. She had been doing well. Her cord function just never returned and so needed airway reconstruction in order to provide an adequate airway to breathe without her trach. So we did her initial combined evaluation and really was significant for both upper and lower airway inflammation, and she wasn’t quite ready for reconstructive surgery. Her bronchobial lavage demonstrated a neutrophilic inflammation but did not grow anything on her cultures. Her EGD was reassuring. She had no microscopic or visual evidence of reflux or inflammation. She had known silent aspiration that we were managing with thickened liquids and was overall seeming to do fairly well with that with no staining of secretions from her trach tube in any way. And I don’t know how to get the video to play, but this video is demonstrating inflammation in the lower airways going through the trach tube. You see just pretty edematous, boggy mucosa loss of crispness of the carina. You see some furrowing in the bronchial mucosa throughout the lower airways but did not have a significant secretion burden in her lungs. And so based on this and her neutrophilic inflammation, we ended up starting her on azithromycin and inhaled steroids. We know that this can be helpful for patients with neutrophilic inflammation in their lower airways and she had pretty significant improvement with that. We then got her to her double stage LTP to address her glottic obstruction and her airway was appropriately sized for her age at this point, but she still wasn’t able to move forward with either a speaking valve or capping. And so we repeated her dynamic evaluation that demonstrated that she had a pretty significant suprastomal tracheal collapse and so ultimately underwent a single stage LTP. Initially she did really well but then had worsening Schreider, increased worker breathing, retractions, just looked very uncomfortable, especially while she was asleep. And if you play this video here, she has pretty significant laryngomalacia that was not identified prior to decannulation due to the degree of collapse that she had. We weren’t able to just get that great dynamic upper airway evaluation at that point. And so you see those retinoids are collapsing over her glottis and she’s audibly stridulous during this evaluation as well. So she underwent a supraglottoplasty and is doing better. The second case is a little boy with trisomy 21. He came to us when he was four. He had his trach placed when he was an infant for subglottic stenosis and dependence on mechanical ventilation. He had been off the vent for a period of time and family really wanted to get his trach out. He was able to wear a speaking valve for typically only a few minutes at a time before getting distressed and parents reported that if his trach came out, he became distressed very quickly and did not do well with that. He had a known history of aspiration, was G-tube dependent, had been increasing his oral intake, but was still having lots of emesis, gagging, and retching with feeds. We did his evaluation and he had pure limb bronchitis throughout his lower airways, which is what the first two images are showing, and multi-level upper airway obstruction, or suprastomal obstruction. That’s a grade three subglottic stenosis and he had glossoptosis and suprastomal collapse as well. So after lots of discussion, we repeated his feeding evaluation, which demonstrated ongoing aspiration and so ultimately decreased what he was taking by mouth with significant improvement in his lower airways. He then had his double stage with a adequate subglottic airway at this point and is still MPO due to ongoing aspiration. We’ve tried to cap him multiple times and he does great while he’s awake during the day while he’s upright, but as soon as he falls asleep, he has increased stridor, work of breathing, and so we proceeded with a capped sleep study for him, which demonstrated pretty moderate to severe obstructive sleep apnea. This is a drug-induced sleep endoscopy that he had that is demonstrating that he has ongoing glossoptosis. He has complete– in the video, will show complete obstruction of the upper airway due to the tongue base. We attempted non-invasive positive pressure for him. Unfortunately, given his Down syndrome and some behavioral issues, he does not tolerate anything on his face, and so that has not been successful for him at this point. We’re currently giving him some time and talking about potential other interventions to address his glossoptosis, but you can see really complete collapse of the upper airway for a pretty extensive length. And you’ll see in this video here, you don’t see much of the larynx of the glottis at all because of the tongue base. And then our last case that I wanted to go through is a boy with chaos syndrome who was trach at birth. He came to us when he was 11 after several failed airway reconstruction procedures. He re-stenosed each time. We did his initial evaluation that had, again, diffuse bronchitis, lots of secretions in the lower airways, and a pretty significant erosive esophagitis in the second picture there. His culture was positive for– I think it was more excellus, so we treated that. And his biopsies were positive for reflux. He did not have any eosinophilic inflammation on his esophageal biopsies. Given his history of repeated airway surgeries without significant success, the secretions in his lower airway, we also repeated his feeding evaluation, which was reassuring, and got a chest CT to make sure there were no other pulmonary findings that would be potentially contributing to that. He had no evidence of bronchiectasis or other chronic infection in his lungs. And so we aggressively treated his reflux. And he improved significantly. He had his double stage. But every time we tried to pull back on his reflux treatment, he would get worse again. So he remains on PPI therapy while working towards decannulation. So what can you do? Just key points to take home. Making sure that you are addressing any other concerns that are happening in the airway. Is there ongoing inflammation that is preventing you from moving forward with airway surgery? Is this infection? Is it aspiration? Is there GI pathology that’s contributing that needs to be addressed? Is there other airway obstruction that needs to be dealt with? We know that just relieving– we see one level of obstruction. But sometimes as we relieve that, the change in airflow creates another level that we didn’t necessarily know about ahead of time. And so making sure we’re understanding, is this dynamic, is this static obstruction, when is it occurring, and what do we need to do about it? What additional workup do we need? Do we need to repeat a feeding evaluation? Do we need additional imaging to make sure we’re not missing something? And then if all of that is reassuring, what can you treat them with? So inhaled or intranasal corticosteroids can help address inflammation, azithromycin, especially for neutrophilic inflammation in the lower airways. Do we need to be aggressive with GI therapy? I know we don’t always love using PPI’s and other things. But if we need to, we need to. And then making sure that we are managing them from a feeding and protecting their lungs from aspiration. Non-invasive positive pressure can be helpful in some kids. Some kids don’t tolerate it. And it can be really challenging to decannulate to non-invasive positive pressure, because the trach in the airway can cause some obstruction from that standpoint. And then do they just need time? Do you just need to give them time and growth and let them kind of settle down and revisit this in six months or a year? So lots of things that you can do. If you get stuck, don’t worry. Call your friends. This is Mike Rutter, taped to a pole in medical school. He eventually got there. And so you can too. [APPLAUSE] [SPEAKING SPANISH] –we have not made, so maybe we can hear them there. Thank you very much. [APPLAUSE] (audience