Hey everybody, it's Trish from STARS. Thanks so much for joining us. What we bring to you today is a condensed version of our hour long training that we provide on pediatric emergency tracheostomy care. Our intent with this presentation was to offer that condensed version that really solely focuses on that high acuity event of recognition and treatment of the pediatric patient who's in respiratory distress or worse, peri-arrest or in cardiac arrest from a trach decannulation or plugging. So let's go ahead and get started. So usually when I start out my slides, I always include a why slide. Why are we here? Why are we reviewing what we are reviewing? And what's the importance? Well, that's really easy with this one. It's these kids right here, not just these kids, but all of the kids that we have enrolled in our program. They're all incredibly special to their families and to us as well here at Cardinal Glennon. We just want to do everything we can at all costs to prevent any negative outcomes, especially like the ones that we have seen and experienced in the past. I don't ever want to be morbid or too graphic, but failure to recognize and manage a tracheostomy emergency can and will result in neurological devastation and death. And unfortunately, when we've seen these occurrences, it's been very apparent that these children have suffered during the event. It's a terrible thing to have to think about or review. And we really, to repeat myself, we really want to prevent any incidents occurring at all costs. So let's start at the very beginning. What is a trach? Well, it's actually very simple. All you are dealing with is a single flexible tube that's inserted into a surgically created stoma. This is their airway. So please can compare and consider this patient to your patient who's endotracheally intubated. That tube is their airway and you have to protect it and prove patency at all times. So our kids have trachs for usually one or two reasons. Either they need that to facilitate their time on a ventilator or they need that tracheostomy tube to bypass an airway malformation or what we sometimes call an anatomical airway obstruction. So basically they aren't able to effectively breathe past that stoma. There's something going on with their upper airway and glottic area that's preventing them to breathe naturally on their own. So please, please keep in mind something that we like to enforce and really drive home is that stoma that has been created at the hospital is completely healed when these kids come home. They've had trach changes. That tracheostomy tube is not meant to stay in place for long periods of time. It is made to be changed out by lay caregivers who've been trained in this. And they change them weekly or bi-weekly. I sometimes hear confusion when I'm out and about about are they sutured in? Absolutely not. Kids do not go home with any sort of sutures in their stoma or anything that sutures the trach actually to their body. That's not the case. So in a nutshell, what you're dealing with is a clear stoma with an open tract that has been created so that this tube, which is their airway, can easily be replaced on a routine basis and then when needed as well. So for this slide, what I wanted to offer was just a visual of what the trache tube looks like on a cross section inside the trachea. Here, we're going to discuss two types of trachs. However, there are many types that are out there. But for this presentation in particular, I just wanted to highlight the differences between cuffed and uncuffed. So if you have an uncuffed trach, which you'll know by the presence or absence of a pilot balloon. Let's see if I can use this for some assistance here. So for an uncuffed trach, what you see here is the ability of some air to bypass the trach tube and go through the upper airways. So the child can actually usually somewhat, you know, breathe pretty well around it if they have a typical airway. So if they have some type of airway malformation that blocks everything right here, then that's not an option anyway. But keep that in mind that, you know, when you have an uncuffed trach, you also don't have to worry about deflating before you would remove it. Over here, we have a trach with a cuff. And again, you'll know you have a cuffed trach because you're going to have a pilot balloon sticking out of the flange here that you fill the cuff up with. And they're filled with sterile water, by the way. And there's, I often get asked, well, how much is it written on the flange? It's not. Every kid who does have cuff inflation typically has different amounts. You definitely don't want to over inflate. That's almost more dangerous than under inflating. Actually, it is more dangerous than under inflating, but you should have an inflation amount written on your STARS form. You know, anywhere from 0.5 to 2.5 mils, typically for the kids that we see. But remember, when your cuff is inflated, which you see right here, you've now eliminated any air passing if they did have that ability in the first place. So if you plug up this trach tube and you have a cuff inflated, that's complete asphyxiation and imminent death. So that makes it all the more important to act quickly when we're dealing with these. Also, when you have a cuffed tube, that will require you to deflate before you would do an emergency trach change, which we're gonna talk about later. And talking about amounts, we're gonna mention it during the video, but something to keep in mind is to just keep, if you can remember, keep the sterile water that you pulled out prior to the trach change, and then you can refill it with that same amount if you think about it and you have it ready. I also wanted to offer a visual of two different types of airway malformations or what you may see written as an anatomical airway obstruction. There's many different types of those as well, but you can just see two different common reasons why children would have to have that upper airway bypassed by having the trach tube in place. You may see children who have airway malformations more often than not have an uncuffed trach, because especially if they don't have any reason to be on a vent. Children that have vent requirements are more likely to have that cuffed trach because really there's really no other reason to have it inflated other to ensure positive pressure ventilation. If they're not being bagged and not on a vent, really that trach balloon, that cuff shouldn't be inflated at all. It's best that it's not. So gonna move on now to our next. Number one rule for EMS. The trach is the problem until proven otherwise. Going to repeat that. The trach is the problem until proven otherwise. We don't care if you arrive on scene and that child is seizing, unresponsive, bleeding and cardiac arrest, doesn't matter. You cannot move on from A. You have got to establish that you have a patent airway. We've seen this skipped in cardiac arrest before. So make sure that even though anxiety might be way up here and everybody's working off of adrenaline, that we say timeout, pause, do we have an airway before you go on continuing your compressions. Make sure that you have an established airway. So what our two priorities are within that first priority is is it clear and is it in the stoma? So here's an example on that bottom picture of a trach plug. This was an actual trach plug from the field. EMS did a trach change and they were so proud of themselves that they took a picture of it to show me just how plugged that trach was. I was like, wow, guys, thank God you did that because this kid also had an inflated trach cough. So obviously that was a complete asphyxial type situation they had going on there. Plugs occur from mucus, excess secretions, blood, vomit, you name it, they can create plugs. So here's your, you need to make sure that you have a nice clear patent tube. Your second priority or assess at the same time, basically, they don't really go in order. They're both as important as the next. Then make sure that that tube has not slipped out of the stoma. This is actually more common than one would think. This can occur with really active children who are moving around quite a bit, even when you have your ties in place and you don't suspect it. You've got to check and make sure that that tube is in the stoma. Not only might it happen with an active child, but in a child that's being manipulated and moved from place to place by caregivers or during CPR. So consider the pressure of those compressions, you know, potentially causing that tube to expel from the stoma. So you need to actually visualize, just like we say, when you're intubating, you visualize the tube past the cords. You want to visualize the tube inside the stoma. So where we've seen this missed is when that tube is buried underneath, hidden rather, underneath drain sponges, neck rolls, clothing, et cetera. And someone's over here bagging, you know, doing compressions and no one's actually discovered the fact that they're not ventilating at all. So we need to make sure that those are things we do not miss and that they are absolute number one priority before we move on. So step-by-step, when you get on scene, assess under that drain sponge, neck rolls, clothing, make sure that that trach is actually in the stoma and then suction secretions, assess patency and document. Please, please, please, we're asking you to document clearly that you have breath sounds, breath sounds were auscultated easily, that you've got positive pulse oximetry findings that are improving hopefully with treatment and absolutely we want that end title recorded. That's your proof that you're in place just like with your ET tubes. We no longer transport patients who are intubated or intubate in the field without confirming with wave form capnography. Please consider the same for our kids. Now there's one little caveat I want to add here. If you have an infant with say a size 4-0 trach or smaller, then we just want to spot check that end title. You can spot check when you get on scene, mid transport if you're coming any kind of distance and then before you exit the ambulance as well to come in, please, please document that you had positive CO2 return. With the larger kids, you can actually go ahead and just maintain continuous monitoring which is preferred for us. And again, document that you visualized it in the stoma just like you would document, you visualize the tube past the cords. And also work of breathing and then include any bag to trach assistance that may be needed. So if the kid's really struggling to breathe, is unresponsive or is really fighting that vent, please don't hesitate to go ahead and just assist breathing with bag to trach just like you see here in this picture. Now, if you cannot prove patency, if you do not have positive end title, if it's coming back at zero or undetected, that's a clear sign that you don't have a patent trach. If the child doesn't improve with suctioning and administering oxygen and assisting ventilations, providing treatments, et cetera, and especially if they start to decline, you have got to do an emergency trach change and it has to be done without hesitation. Our hope is always that we have that caregiver on scene to do it or who has already done it, but we must be prepared to take over and swap that trach out if we need to. It's literally a matter of life and death. So most of you, I'm sure, are pretty comfortable with suctioning, but for those of you who might not be or wanted to review it briefly, I just threw this up here. So just remember not too deep. Sometimes when we're taught to suction in the adult world, or if we've been taught to suction trachs a long time ago, the common practice was to induce a cough by dropping that suction catheter low enough to actually tap the carina and induce a big forceful cough, which in theory would help clear secretions and result in a more positive outcome and efficacy with suctioning. But that's just, it's not good practice. It can cause damage to the carina, even in adults. We have better ways of inducing coughs now than doing that. And with pediatrics, we've got a very sensitive area we can cause bleeding, and which can increase their chances of plugging. And you can also cause a vasovagal response and induce some bradycardia, which we definitely don't want when we're already dealing with a little one who's having respiratory distress. So there's actually a depth written on those STARS forms. And if it's not on the STARS form, it might be on a trach card that is with them with their trach bag. But just keep in mind, if you don't have a number, don't let that prevent you from suctioning, but you're only suctioning to the end of the trach tube itself, no deeper than that. So if they have the inline suction that you see on top, which is enclosed, it's color-coded for pediatrics. I've actually had someone ask if that matched Braslow. It doesn't, I just wanted to mention that in case there was any confusion with anybody else. But on the STARS plan, it will tell you to suction to, let's say red or green, and that will be your guide to, for depth when you're suctioning. For the bottom suction, the free French catheter suction catheter, you know, just there's numbers on there and centimeters, and that depth should be written as well. So that will guide you to how deep you want to suction with that. Also, if you, for some reason, don't have the supplies with you that you're supposed to have for the child to measure the size of French catheter that you will need to pass, you can just double that trach size. So if you, for example, have a size 4-0 trach, a size 8-0 or smaller will fit within the cannula to suction. So swirl that suction catheter on the way out. That will help you get even more secretion. So twirl on the way out, try to suction for no longer than five seconds and give them a rest between. Even if you're continuously pulling out, you know, whatever, you know, secretions, emesis, blood, whatever you're suctioning out, you know, give them a rest between, let them oxygenate. That's really stressful to constantly, you know, be having that suction catheter passed. So if you're getting thick, chunky secretions that are sticking within the catheter, don't hesitate to use sterile saline to loosen the secretions. If you have the child's equipment with you, you most likely have also those pink saline bullets. So they have, they contain three cc's of sterile saline. If you don't have them, absolutely pull some sterile saline off your truck. Just please make sure that you don't go, you don't exceed the three cc's when you're introducing it into the trach. So this is our tracheostomy algorithm that's included in our emergency department slash ED guide that we have on an app here at Glennon. If you don't have access to that, let me know, and I'll make sure that you get a link to it so you can download it on your phone. Or if you just want a copy of this algorithm, you know, copy it off this presentation, or if my face is blocking it, I'd be more than happy to send that to you as well. It's just kind of step-by-step on how to deal with a trach tube, but it's really honestly not something you want to read in the moment. So please study it prior to. We're gonna show a video here that demonstrates an emergency trach change, and it goes really smoothly. But before you watch that, I just wanted to review a little bit of troubleshooting. One of the most common issues that can occur that would throw you off would be that difficult recannulation. If you decide that, yeah, you have a plug, you know, you really need to change that out, or the kid's already decannulated and you can't recannulate. It's very difficult, because we've seen those calls go out as well. Always the option to try more lubrication, go with a smaller size trach tube. They should have that smaller size emergency tube, remember. If you're in the home, they'll have it there, or if you're already in route, it should be in the trach bag that you remembered to bring with you, right? Also, this issue can occur if you have a kid with a trach plug, they're out in the public or you're out and about, don't have that trach bag for some reason, you don't have a replacement trach, like that would ever happen in EMS, right? So if you don't have a replacement, honestly, it's safest if you can clear out that trach that you removed, squirt it out with saline, clean it out. If you can get that replaced without having the operator, because if you don't have a spare trach, you most likely don't have an operator, that could be difficult if this trach tube is very flexible and that stoma is at all narrow or difficult to recannulate in the first place. So if you can though, if you can get it back in, that's advantageous because you can secure it properly. And that trach was measured specifically for that child. So it's not going to touch the trachea, cause irritation, be too deep, et cetera. So it's best if you can reuse it, we're really not worried about the cleanliness of it. I mean, keep it clean, we're not worried about anything being sterile at this point. If all else fails, you can't recannulate. You can't even recannulate with that smaller size trach and you really need to get something in that stoma. An ET tube is an alternative. It's not the best, but it's an airway and if you bring that kid in pink and oxygenated, kudos to you. Little trick, if you look at the circles there on the screen, on the phalange, that is the size that correlates with your ET tube sizes. So if that's a 3-0, that's the same size and diameter as your 3-0 ET tube. So if you're having that challenging stoma giving you trouble recannulating, you can theoretically drop down a size or two sizes just to get it cannulated. So for example, you have a child with a size 5-0 trach, consider using a 4 or even a 3.5, lube it up, measure the length of the trach against your ET tube and that way you know how deep you want to go and go ahead and attempt to insert that. Now, where your challenge is gonna be here is securing it. It's just gonna be difficult. We don't have any surefire ways to make sure that that is super secure. So assign someone, if you have extra hands, to just have their hands on that ET tube, making sure that it is in place. That is their job. This is when you definitely need to use your end-tidal on and you need to assess very carefully that this is in fact ventilating your child, pulse oximetry, waveform capnography and all the other ways you assess that your child is ventilating well. So that's one trick if you have difficulty. Now we're gonna go ahead and move on to watching a video of how everything should go in an emergency as smooth as can be. Action. So we're on scene with a baby who we just popped off the vent. She was throwing high-pressure alarms. She's desatting on us. She doesn't look so great. We've attempted suctioning. I've assessed her trach to make sure it's in place. I've assessed patency and she's becoming a little bit more difficult for me to bag again. I'm worried that she's gonna start braiding on us and I've determined that I think it's time for an emergency trach change. So guys let's get her supplies ready. Okay, I'm gonna go find and get her trach bag. We made sure that we didn't leave it. So it's at all of her supplies in here. I'm gonna find that trach the same size for you. I'm gonna go ahead and have you start bagging her over the nose and mouth. To do that I'm gonna ensure that we have this cuff deflated since we just pulled her off the vent. Hey Trisha, there's also a size smaller in here if you get needed, okay? Thank goodness. I'm gonna try to suction one more time. Oh yeah, I'm not getting, I'm not getting really anywhere with that. Let's get her in the proper position. I'm gonna go with the actual change. I'm gonna position her with a towel roll underneath. Let's get her hyperextended here so we can really expose that area. Can you go ahead and get her ties undone for me? Her ties are undone, the cuff is deflated. Okay, great. On my count, three, two, one. I got this new trach ready to go. I'm passing it. I'm gonna pull out my obturator. Can you get those ties down for me? And then I'm gonna, let's go ahead and bag her again right away from bag to trach. Okay, and I'm gonna go ahead and reinflate this with the water that came out of the old trach. Okay, how is she bagging? Much easier. Oh, good. I'm gonna take a listen here. Oh, I've got much better aeration. Good. How does she look on the monitor, guys? Yeah, she's actually picking her heart rate back up and her oxygen saturation is coming up. Oh, her color looks much better, too. Good job, everybody. So transport rules. EMS, do not leave the scene without the patient's go bag. Every patient, no matter if they come from Cardinal Glennon or St. Louis Children's or Mercy, should be home with their emergency trach bag that they usually call their go bag. So consider it the child's lifeline. You don't want to be without it. So what you have in there that will help you is an extra trach packaged and ready to go. Some of our patients are even, even have the forethought to have the trach ties already in place for you, which is very beneficial. What you will also have is a trach a half size or full size, smaller, and sometimes both. That way, if you have that difficult recannulation, you can lube that up, grab, you know, grab that smaller one, lube it up, and hopefully have more success in cannulating with something a little bit smaller. You'll have their BVM, which most likely will have a peep valve on it, already set. So for children, especially those who are on ventilators, they're gonna do better if you can match their peep if you need to bag them. You'll have surgery lube packets, those saline bullets, spare trach ties, you know, everything you need to manage that trach in an emergency should be in that bag. Also, if you're coming to the hospital, some parents are, have a misunderstanding as well, that they're gonna have their child's trach ready at the bedside when they arrive, and that's really unlikely. We'll try to have it here if we know the size the kid has coming in, but especially if they have a specialty trach that needs to be ordered, it's unlikely that it's gonna be here when they get here. So please, please, please bring that trach bag. And all trach patients, no matter adult or pediatric, always have to have working suction right with them. So at all times, these kids with trachs have to have their emergency trach supplies, working suction, ready to go for an emergency, and a caregiver who is trained and willing to act and intervene and perform an emergency trach change if need be. If you have any questions, please, please don't hesitate to reach out to us. We're pretty easygoing and easy to work with, I think. So you can reach out to us individually, together, call us if you have our number, however you'd like to reach out. We would like to help you. Our goal is to make you all more comfortable with these kids and to improve outcomes. So if there's any more information that you'd like to see on emergency trachs, if you have any questions, if something didn't seem clear, you know, that's what we're here for. So we encourage you to to get a hold of us, and we are here to help. So thank you, thank you everyone for everything that you do. Please stay healthy and safe in this scary time of pandemic, and stay safe out there in general. And thank you so much for being there to take care of our kids. We really do appreciate everything that you do for us and them. Have a great evening everybody. Bye-bye.

pediatric emergency tracheostomy care

respiratory distress

cardiac arrest

trach decannulation

trach plugging

tracheostomies

trach tubes