1995 OPEN FORUM Abstracts
IMPROVED VERSATILITY USING NEW CUFFED TRACHEOSTOMY TUBES IN CHILDREN ON HOME MECHANICAL VENTILATION
Richard Francis R.R.T., Michelle Howenstine M.D., David Geller M.D., Kathy Renn R.N. Division of Pediatric Pulmonology, Department of Respiratory Care, All Children's Hospital, St. Petersburg, Fl.
PROBLEM: The problem with most pediatric ventilator dependent patients with uncuffed trach tubes is that during sleep, airway tone decreases. This allows the leak around the trach tube to increase, leading to lower alveolar volumes. Standard cuffed trach tubes create problems: #1. The need for a larger stoma for insertion. #2. The cuff, when deflated takes up a large amount of space in the trachea not allowing the patient to phonate properly. #3. Improper cuff management may lead to tracheal necrosis. We used the Bivona tight to the shaft tube (TTS) to eliminate these potential problems.
METHOD: Of 32 Home ventilator patients at All Children's Hospital, 6 were having difficulty with leaks at night. Patients complained of desaturations, low pressure alarms, decreased chest rise, low energy levels, and daytime fatigue. Ventilator rates, tidal volumes, and continuous flow rates were bled into the circuit to try to correct these problems.
In these patients we used the Bivona TTS tube and inflated the cuff with saline, to minimal leak volume at night. This allowed us to volume ventilate these patients with appropriate alveolar volumes.
The patients were followed every 3 months, and bronchoscopies were performed every 6 months to evaluate for tracheal necrosis, or tracheal dilatation.
Results: Of the 6 patients that had problems with ventilation at night, all were successfully ventilated with the Bivona TTS trach tube. The results demonstrated improved energy levels during the day and elimination of all other problems the patients had previously experienced. Follow up bronchoscopies every 6 months reveal no tracheal dilatation or necrosis. The cuffs on all the patients were deflated during the day to enhance phonation.
EXPERIENCE: In our 27 months of pediatric experience with the Bivona TTS tube all patients were volume ventilated at night with the cuff inflated to minimal leak volume. The patients were managed with the cuff fully deflated, during the day to allow phonation. This tube proved useful in patients where phonation is very important and uncuffed tube management becomes a problem. Other types of cuffed trach tubes when deflated, decrease the volume allowed to leak into the upper resp tract and limit phonation.
Conclusions: We feel the use of the Bivona TTS tube can be a valuable alternative to problems with pediatric home ventilation. Especially with increased nocturnal leaks. This tube enables you to maintain the smallest stoma size, and have a decreased incidence of stoma breakdown. Long term follow up will continue as our patient population expands.