Tracheostomy- when?

BittyBabyGrower, MSN, RN · May 25, 2004

We have had kids intubated for nearly a year before they will trach them...it is so cruel. The other issue is getting the trach tube the right size and length...ENT will cut/file the first one for length and then we have to custom order them..very expensive! And the no neck thing is so true....most of them are so hunched up and tight and just love that head to the right that after they are trached it is a nightmare to keep their neck from breaking down.

We rarely have a trach anymore...up to about 7 or 8 years ago we would have one or two at any given time

We don't use nasal tubes anymore...we had several bad experiences with them and ENT hates them.

fergus51 · May 25, 2004

Oh, I agree, but it's just what we always do. Are you in the US or not?
I just can't picture HOW in the world you can get even a 2.5 ETT in a 500 gram baby's nose, I just can't. I've seen 2.0 ETTs and I wouldn't even put one of those down a
No, I'm in Canada, but will be going to the US soon. I didn't even consider that oral ETTs would be the norm. With all those secretions, I imagine you have to retape them constantly. We have no real problems with nasal ETTs. As long as they are properly sized, you won't get any deformation of the nares and it makes the switch to oral feeds MUCH nicer. The kids we do have orally intubated for any real length of time seem to develop hard core oral aversions which really slows down their transition from level 2 to home. The really small ones (500g) are orally intubated, like you mentionned. But even then, once they are big enough and need a new tube we usually switch to a nasal one.

nurseiam · May 25, 2004

In our unit they seem to think of a trach as a failure. When the time a baby has failed a few times his nech is not usually fat......but then we start all the doses of steroids and the multiple attempts after that........

It seems our's seem to be trached @ 6-9 months, which corrected would be 3-6 months. I had a 23 weeker that was 8 months when we sent her to the childrens hospital they trached her two days later. When they went to wean her off the vent she said the first day. She only needed the O2 flow! I guess you just never know!

prmenrs, RN · May 25, 2004

The last kid I saw that was trached was ~ 6 years ago, she CAME to us from another state trached, and w/a g-tube. They didn't think she was going to live and wanted her to be closer to home (family lived here) when she died. She actually had some BAD tracheal malachia, as well as some distal airway problems--she could turn PURPLE in a matter of seconds. Scariest baby I've ever taken care of. It took 11 months for us to get her in any shape to go home, and then it was w/24 hr nursing care.

FAST FORWARD: she's in school, some hearing and vision deficits, has learned to sign, she speaks Portuguese!, has a little brother, (terrific family, which always makes a huge difference), I think she's still getting some services like speech, ?spec ed, but overall is a great save.

As she got better, we had her on as normal a schedule as possible, including naptimes. When she woke up from a nap, if she didn't see her nurse, she would disconnect her vent carefully so that it would alarm and someone would come over. Then she'd hand you the tubing w/a big grin on her face! Loved that baby!! can you tell?

Gompers, BSN, RN · May 26, 2004

No, I'm in Canada, but will be going to the US soon. I didn't even consider that oral ETTs would be the norm. With all those secretions, I imagine you have to retape them constantly. We have no real problems with nasal ETTs. As long as they are properly sized, you won't get any deformation of the nares and it makes the switch to oral feeds MUCH nicer. The kids we do have orally intubated for any real length of time seem to develop hard core oral aversions which really slows down their transition from level 2 to home. The really small ones (500g) are orally intubated, like you mentionned. But even then, once they are big enough and need a new tube we usually switch to a nasal one.

Yeah, I think oral is the norm here - but I could be wrong. Anyone?

That makes a lot of sense, oral ETT in micropreemies but switching as soon as they're a little bigger. I wish we could at least do nasal in the larger kids - especially the big PPHN ones who are on pavulon and have copious oral secretions. We're always having trouble with their tubes staying perfectly in place, and these are the ones who REALLY need a stable tube. Also on the older chronics who are always trying to extubate themselves - it's pretty easy to succeed when the oral tube tape is all gooky from their drool...

fergus51 · May 26, 2004

It's interesting. I have only worked in Canada in the NICU, so I am interested in seeing the differences when I go to the US.

AllyZ · Jun 11, 2004

We have a baby in our unit who was born with TEF, and was just trached last week. This poor baby has coded about 10 times, has had chest tubes, the whole nine yards. She is now doing wonderful. She is also 6 months old, still in our NICU!!

Ally

kids · Jun 12, 2004

Wow, they do things VERY different in my area (Portland, OR/metro).

I think the philosophy here is to get them out of the hospital as soon as they can even if it means a trach.

Once the kiddo is stable to the point that the the only thing that seems to be holding them back is and airway or gas exchange problem they trach (and vent if needed) them and ship them to out to the general Peds floor. There they wait for the (selected) HH agency to come up with the staffing (usually have to hire nurses) to take them home.

At home the kids get 12-14 hours of skilled nursing per day to support the family. The around $20K per month it costs for in-home care is actually cheaper than the $700/ day on a Peds unit or $1200-$1500/day in the NICU or PICU.

Plus in-home care has (what I feel is) a better long term outcome due to 1:1 care, fewer infections and almost continuous PT/OT/ST (as appropriate).