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.