8. Respiratory tract infections and ventilator associated pneumonia
Respiratory tract infections (RTIs), including tracheobronchitis and pneumonia, are prevalent among children with tracheostomy tubes and often lead to frequent hospital admissions. In a study conducted in Taiwan, 139 children who received HIMV support for more than 3 months were followed and found that the most common reason (47.7%) for re-admissions after discharge was infections, the most common infection type was respiratory tract infection. They thought that the reason for this was the negative psychosocial effects of caregiver family members, limited home care resources and financial burden 14. Borges et al. observed hospital readmissions and found that the most common cause was respiratory infection, which was the most common prolonging and aggravating factor for hospitalizations15. Kun et al. found that pneumonia and tracheitis were the most common causes of hospital readmissions in the year following the initiation of HIMV 4.
Ventilator-associated pneumonia (VAP) is a serious complication with high morbidity and mortality in intensive care units. In studies conducted on patients dependent to HIMV, the incidence of VAP was found to be lower than in intensive care, but the risk increases as the duration of ventilator support is prolonged. Although VAP performed in a home environment rarely causes death, it often requires hospitalization. Treatment of bacterial tracheobronchitis or pneumonia should be based on the clinical picture and recent cultures and sensitivities. Additionally, vaccinations should be up-to-date for children receiving chronic ventilator support. High-risk children are recommended the flu vaccine, and antiviral drugs may be considered for flu treatment or prophylaxis. Palivizumab is recommended for reducing serious respiratory infections caused by respiratory syncytial virus in high-risk infants. To prevent respiratory viral infections, families should be trained to reduce exposure through handwashing and to limit time in high-risk environments 16.
Appropriate aspiration techniques should be used to prevent respiratory tract infections. There are two techniques for absorbing secretions from the airway. ”Sterile technique” involves using a sterile catheter and sterile gloves for each aspiration procedure, ensuring that the catheter placed in the tracheostomy cannula does not encounter any contaminated area. This method is traditionally used in hospitals, with the ”modified clean technique” (using non-sterile gloves and sterile catheters) being used in recent years. In contrast, the ”clean technique” for aspiration in the home environment is more common and useful. In clean technique, all caregivers should wash their hands before and after each aspiration procedure to avoid contamination. Alcohol or disinfectant solution is an acceptable tool when water and soap are not available. After aspiration is complete, the main catheter should be flushed with clean water until secretions are cleared 10. Exposure to tobacco smoke also causes RTIs through a variety of mechanisms and avoidance of tobacco smoke exposure is recommended 17.
Also, there is a high aspiration rate in early readmission and recurrent pneumonia. Improper care by nurses, such as inadequate feeding methods for example feeding in the supine position, may contribute to a higher aspiration rate. In addition, nasogastric tube feeding is thought to cause aspiration pneumonia because it facilitates bacterial colonization and reflux in the upper gastrointestinal tract. In one study, the prevalence of nasogastric tube feeding was found to be higher in the early readmission group compared with oral and gastrostomy feeding tubes, suggesting that this may increase the incidence of aspiration. Prior to discharge, caregivers should be provided with appropriate training, knowledge of aspiration techniques to prevent contamination of the aspiration catheter and to prevent food aspiration. Also, training in feeding methods such as proper head height and proper feed rate control is recommended. Providing adequate training may help reduce the risk of aspiration and related complications in long-term ventilator dependent patients 18.
In addition, local wound infection is usually a self-limiting but possible event. This is often associated with inadequate secretion management leading to premature failure of maturation sutures. If these sutures become infected and fail too soon, it can result in direct access from the wound site to the cervical neck and chest. Rapid detection allows for home wound care, preventing more serious complications.