Pediatric Considerations Flashcards
Incidence of trachs in the pediatric population
~4,861 trachs performed each year – > 1/2 of those are children between birth & 11 months
Indications for trach in pediatric population
- Providing access for prolonged ventilation
- Bypassing airway obstruction
- Subglottic stenosis
- Facilitating tracheobronchial toilet
Common diagnosis that result in peds w/trachs
- Prematurity
- Pierre Robin Syndrome, Bronchopulmonary Dysplasia (BPD), Tracheomalacia, Spinal bifida, Muscular dystrophy, Cystic fibrosis, Craniofacial abnormalities
- Accidents, abuse, trauma
Pierre Robin Syndrome
- Congenital, infant has a smaller than normal lower jaw, a tongue that falls back in the throat, and difficulty breathing
- Aspiration is a common risk w/this population
- Severe cases may require a trach
Bronchopulmonary Dysplasia (BPD)
- Chronic lung condition that affects newborn babies who were either put on a breathing machine after birth or were born very early
- risk factor: severe respiratory or lung infection
Symptoms of bronchopulmonary dysplasia
- Bluish skin color
- Chronic cough
- Rapid breathing
- Shortness of breath
Signs/tests for bronchopulmonary dysplasia
- Arterial blood gas
- Chest CT scan
- Chest x-ray
- Pulse oximetry
Bronchopulmonary dysplasia treatment (in the hospital)
- Vent required to send pressure to lungs to keep them inflated & deliver more oxygen
- Pressure & oxygen slowly reduced - weaned from vent but may need mask or nasal cannula
- Usually fed by NG tubes
- Need extra calories due to effort of breathing
- May need to limit fluids or use diuretics to keep lungs from filling w/fluid
- Medications: corticosteroids, bronchodilators, surfactants
Bronchopulmonary dysplasia treatment (at home)
- May need oxygen therapy for weeks/months after leaving hospital
- Need to receive enough calories
- May need tube feeds / special formulas
- Prevent child from getting colds / other respiratory infections (respiratory RSV virus)
Do preterm infants stop breathing because of swallowing?
NO
What is the most frequent swallow & respiration pattern with preterm infants?
Inspiration –> swallow –> expiration
Do infants with bronchopulmonary dysphasia often demonstrate sucking difficulties?
YES
What do you need to evaluate with infants with bronchopulmonary dysplasia?
- Suck –> swallow –> breath
- Sucking endurance
Literature on swallowing in infants suggest that the movement of the supra glottis structures during the act of bolus swallowing is _____ and tends to be ____________ in young children w/ long term trachs
slower; more restrictive
__% of pediatric patients with a trach had swallowing problems. (Arvedson & Brodsky – Rosingh & Peek)
48% (A & B)
*Many of these patients also had an underlying neurophysiological factor that may be affecting the swallow
91% (R & P)
Marianjoy Pediatric Study: Was there a difference between the acquired group and the congenital group?
Nope
Marianjoy Pediatric Study: Aspirators were significantly ____ than the non-aspirators
OLDER (10 y/o vs. 3 y/o)
What do you use for clinical swallow evaluations of infants?
Formula
What do you use for clinical swallow evaluations of older children?
Use age appropriate / developmentally appropriate foods
Can you use blue food coloring during CSE with infants?
NO - their digestive system probably is not able to handle blue dye foods
Can you use blue food coloring during CSE with older children?
MAYBE - blue popsicles, suckers, kool-aide, yogurt, etc.
*Many children have a sensitivity to “blue” foods - need to be careful
May be able to gather some information during the CSE that will…
Help direct your instrumental examination, determine appropriate timing for an instrumental examination with this patient, radiation exposure / FEES tolerance
The inability to palpate laryngeal movement with young child or infants with a trach during a CSE may warrant _______________.
An instrumental examination of the swallow.
Specific deficits to rule out during a VFSS include: (3)
- Slowing of laryngeal vestibule closure
- Reduced laryngeal excursion
- Airway contamination / penetration / aspiration
Airway / Secretions -all 50 patients presented with ….
Secretion management issues
__% had reduced secretion management issues at the level of the trachea.
98%
__% had problems with oral secretion management.
56%
__% showed reduced secretion management at the level of the larynx.
40%
Are excessive secretions with this patient population extremely common?
Yes
Management of secretions of ____ and ____ _____ are critical to maintaining _________________.
Upper & lower airway; pulmonary health
Are frequent infections common with the pediatric population?
YES
__% of peds with a trach were able to tolerate the one-way valve
49%
The peds that were able to tolerate the one-way valve demonstrated improvement with ________________ at the oral cavity, larynx, and/or trachea
secretion management
Airway Protective Responses: __% displayed problems with airway protection responses
90%
- Did not elicit a reflexive cough to clear
- Had a delayed cough
- Only coughed when suctioned
VFSS / FEES special considerations (3)
- Radiation exposure (timing of VFSS)
- Oral spillage of barium
- Accidental spillage from cup (trach tube hub - artificial nose / trach vent covering - trach ties becoming saturated)
If a ped w/a trach is medically stable, is it likely that they can swallow safely?
Yes!
__% of infants who require mechanical ventilation via trach tube did NOT aspirate during VFSS or FEES
93%
Medically table / good prognostic factors: (3)
- Improving physical condition
- Stable ventilator setting for 7-14 days
- Ongoing tachypnea w/respiratory rate of 40 to 50 breaths per minute
PMV may be used as young as _________.
13 DAYS old
PMV is better to be used as early as possible because:
- Communication development / speech production (cooing, crying, vocal play, more normal socialization for the infant)
- may use play/trust environment (trach dino) and distraction
Pediatrics with a trach tube has a _______ ______ of airway abnormality as compared to adults.
larger %
Most pediatric trachs are …
cuffless
Patient selection: their airways are much smaller so you need to make sure of what..?
Need to insure properly sized trach tube in place and that the patient has a patent upper airway with the use of a one-way valve
Premature infants in the NICU may be ______ with ____________.
Ventilated; high pressure
Premature infants in the NICU may have difficulty … (2)
maintaining ventilation / compensating for the leak of air out of the mouth when downsizing the trach or deflating the cuff in order to use the PMV in-line with the ventilator
Team members for pediatrics w/trachs
- Physician
- Respiratory Therapist
- SLP
- OT
- PT
- Child life specialist
- Child & Family
__% of peds with trachs were able to tolerate the PMV
83%
__% of the children who are able to tolerate the PMV were able to vocalize on the first valve trial
****
75%
