Respiratory Dysfunction
Recommendations for the treatment of children with TBI include transitioning from endotracheal intubation to tracheostomy for ventilatory support around the time the patient is 7 to 10 days post-injury.
The tracheostomy allows for pulmonary support, easier secretion clearance, and better long-term airway management. The tracheostomy is not without complications, though, including, the potential for vocal cord paralysis, tracheal stenosis, subglottic and glottic stenosis, and tracheomalacia (172). The ultimate goal is to move toward decanulation once controlled ventilation is no longer needed and when the patient is able to manage his own secretions. Another reason to move toward decanulation is to avoid the increased nursing and respiratory care requirements when the tracheostomy tube is in place. These increased needs can complicate discharge, as some long-term care facilities are unwilling to provide care for patients with tracheostomies and family members may be anxious and apprehensive about caring for a child who has one (173). The stepwise fashion moving toward decanulation has been described by Klingbeil (174). The process begins with downsizing the tracheostomy tube sequentially until, ultimately, an uncuffed small tube is tolerated. Then capping of the tracheostomy tube is recommended as the clinician evaluates the patient's tolerance. If the patient is able to maintain oxygen saturations with a comfortable breathing effort and demonstrate effective cough with good management of secretions, the tube is removed and an occlusive dressing is placed to allow the site to heal. If the patient is demonstrating difficulty during the process of decanulation with worsening respiratory function or distress, it is recommended that the patient undergo direct laryngoscopy prior to decanulation in order to evaluate for concerns such as tracheal granuloma.
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