Tracheostomy- when?

  1. When do your cronic preemies get trached?

    I have never seen a baby with a trach, our docs dont like them.
    Now we have had one kid vented for almost 4 months. We have to retape the tube almost every day and the poor kid does not like that at all, and neither do I. What are your thoghts and opinions on this?

    Thanks
    iceNICUnurse
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  2. 19 Comments

  3. by   EmeraldNYL
    I work in an adult ICU and we usually trach patients after they have been intubated for about 2 weeks. 4 months??? That is gross, I can't imagine all of the nasty germs that are growing in that ET tube after that amount of time. Is there a reason your docs don't like to trach babies, are they more difficult to trach then adults?
  4. by   prmenrs
    They are more difficult to trach than adults--they don't have hardly any neck! Also, once trached, you really are stuck w/it for ~ 3-5 years till they can be safely "de-trached". So, of course, that affects may areas of development, not just speech and language.

    I do think 4 months is a bit long, however, considering barotrauma, feeding issues, all sorts of things. Not knowing more about the case, and why the kid was needed prolonged intubation, I can't venture a guess as to what the story is.

    Perhaps they don't like the pediatric ENT or don't think s/he's skilled enough? We had one kid we were considering for a trach, the attending did a bronch w/his brand new fiberoptic baby scope, found where and what the problem was, the ENT fixed it, and we didn't have to trach him. Ask them about bronching the baby, see what they say. Emphasize it's just for your own education....they sound like a touchy group.
  5. by   Gompers
    Yeah, the biggest problem we see is no neck on these kids, especially if they have BPD and recieved any steroids - those double chins they get just cover up any neck that they might have had! On our unit they don't trach babies until they are at 40+ weeks gestation, in hopes that once they reach term they might finally be able to extubate. So yeah, a 24-weeker might be intubated for 4 months by this time. But like prmenrs said, traching a baby is usually a 2-5 year committment. So until they get that baby to term, and until that baby has overcome all his/her non-respiratory issues - they try to hold off on the trach. If at that point they extubate and the baby still fails, then they talk about a trach. We do flexible bronchs at the bedside and "hard" bronchs in the OR before anything is decided, to rule out an anatomical problem causing the trouble.

    It does suck though - of course most of these kids self-extubate at least once a week, so we're always putting down new tubes. I'm sure they get enough trachael trauma that they're going to need a trach by then anyways!!! Ugh!!!
    Last edit by Gompers on May 24, '04
  6. by   iceNICUnurse
    Thanks for the replies.

    Maby I shuld tell you a little bit more about the case.
    It is an ex 24 weeker just about 40 weeks now with severe BPD and constantly on steroids. So yes dobble chin for sure
    We dont see that the baby can be extubated any time soon.
    We dont have a pedi ENT so I dont have a clue who would do the tracheostomy if it had to be done.
    We are just thinking that if he had a trach then it would be easier to move him around, let him sit and so on, he is getting a little bored.

    And by the way he has only extubated himself once in these 4 monts, so I think we can be pretty happy about the way we fasten the tube and take care of our little one
  7. by   Gompers
    Quote from iceNICUnurse
    And by the way he has only extubated himself once in these 4 monts, so I think we can be pretty happy about the way we fasten the tube and take care of our little one
    What kind of tape do you guys use?!?! I want it!!! Our bigger babies are always gooking the tube out with their saliva. Or do you do nasal intubations rather than oral? Sometimes we electively remove the tube, to replace it with a larger one as the baby grows, or if the baby has a respiratory infection with thick secretions that eventually plug up the tube, even with frequent suctioning.
  8. by   iceNICUnurse
    Quote from Gompers
    What kind of tape do you guys use?!?! I want it!!! Our bigger babies are always gooking the tube out with their saliva. Or do you do nasal intubations rather than oral?
    We almost only do nasal intubation, I hate oral tubes. We use brown tape, it is called Hansaplast. We are looking for something better for the skin but we have not found anything that we like. This little one has had no problems with the skin in his face from the tape.

    We had one tube in this baby constantly for 2 months before we took it out to put in a bigger one. The girls didnt belive how good the tube looked when it was finally taken out.
  9. by   Gompers
    Only once in a great while have I seen a baby with a nasal ETT. I think oral intubation is the norm in the USA, though. The few nasal tubes I have worked with stayed so well, though, and I'll bet it cuts down on oral aversion as well. I wonder why we don't do it more here??? Do you have a problem with enlarged nares though? It's a struggle sometimes to get a 5fr NG tube down a 500 gram baby's nose - what size ETT do you use on tiny kids?

    I love finding out what other countries are doing, it's fascinating!
  10. by   EmeraldNYL
    Thanks for the info. prmenrs. I guess I didn't think about how traching a baby would affect its speech and development-- I'm pretty clueless when it comes to kids!
  11. by   fergus51
    I'm really surprised you guys don't see nasal ETTs often. It is the norm here. We use either 2.5s or 3.0s and I prefer them to oral tubes anyday!!! Oral tubes are just so developmentally unfriendly.
  12. by   Gompers
    Quote from fergus51
    I'm really surprised you guys don't see nasal ETTs often. It is the norm here. We use either 2.5s or 3.0s and I prefer them to oral tubes anyday!!! Oral tubes are just so developmentally unfriendly.
    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 <1000 gram baby's nose. I just can't picture it.
  13. by   prmenrs
    I've worked w/nasal tubes in the distant past, but they have complications like nasal erosion and can deform the nares. I really think the newer trend of non-invasive ventilation is MUCH better (nasal CPAP and SIMV), altho that's hard on the schnoz as well. At least it's better for the lungs re: barotrauma and O2 toxicity. If they have to be tubed, I prefer the oral tubes.

    You're welcome Emerald--it was a logical question.
  14. by   BittyBabyGrower
    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.

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