1. Increased respiratory secretions and airway
obstruction
Airway obstruction is the most critical and life-threatening event that
can occur in patients with a tracheostomy tube or on home mechanical
ventilation. Immediate and effective action is crucial to clear the
airway obstruction to prevent the development of hypoxemia, which is a
condition characterized by low oxygen levels in the blood. Even a slight
contamination of small cannulas used in children can cause a significant
increase in airway resistance, as the smaller the inside diameter of the
cannula, the greater the risk of airway obstruction by secretions.
A tracheostomy tube, while necessary for respiratory support, bypasses
the natural protective mechanisms of the nose and oral cavity, such as
ciliary clearance, filtration, humidification and warming of the inhaled
air. Consequently, children with a tracheostomy may encounter an array
of respiratory challenges, including an increased likelihood of cough,
susceptibility to pulmonary infections, and dryness of pulmonary
secretions. To safeguard the airways from irritation caused by dry air,
dust, or harmful particles present in the environment, the use of
appropriate filters becomes indispensable. Equally vital is the
implementation of humidification and frequent suctioning, essential
measures aimed at reducing the risk of crust formation, mucus plugs, and
potential tube blockages. By adhering to these meticulous care
practices, we can ensure optimal airway health and enhance the overall
well-being of children reliant on tracheostomy tubes for long-term
respiratory support 6. This vulnerable population,
emergencies related to the tracheostomy cannula occur more frequently
compared to adults, with accidental removal of the cannula and
aspiration being particularly prevalent. When encountering symptoms such
as fever, increased secretions, persistent cough, dyspnea, and
exhaustive forced breathing, close monitoring is essential to identify
potential complications. In such cases, employing pulse oximetry during
spontaneous inhalation of ambient air aids in timely intervention and
ensures adequate oxygenation for these young patients7. In patients requiring HIMV with ineffective cough
and/or neuromuscular disease with poor respiratory muscle strength can
be used a mechanical insufflation–exsufflation device to help maintain
airway clearance. Despite advanced home monitoring systems, almost 20%
of the overall mortality rate are attributed to preventable deaths
related to tracheostomy accidents that like accidental decannulation and
mucous plugging of the tracheostomy tube 1. In such
situations, one of the caregivers must always be awake and promptly
remove the obstruction using an aspiration device. Ensuring the patient
receives adequate oxygenation is crucial during this critical time.
According to the latest Canadian research study at a tertiary care
center that involved pediatric respiratory specialists and pediatricians
with specialist in tracheostomy tube care and home ventilation; in
patients experiencing excessive oral secretions, medical centers accept
a range of effective strategies for management. Among the approaches;
salivary gland botox injection, nutritional assessment, gastrostomy
feeding, humidifier thorough tracheal masks, enteral glycopyrrolate
administration, salivary gland duct ligation, and scopolamine patches8.