Introduction A tracheostomy in the paediatric age group is a created clinical situation that demands highly specialized care. Whilst the procedure itself may be performed as a lifesaving measure, the high level of care required to maintain this artificial airway is unfortunately associated with a higher morbidity and mortality than in the adult tracheostomy patient. The successful management of these young patients with the burden of a tracheostomy airway requires the overcoming of many challenges, particularly those of a resource poor environment. No standard protocol of care for these patients exists, with care practices and care related complications varying widely between institutions and regions. Shifts in age and indication demographics have been noted internationally, with infants now comprising the largest age group, and prolonged intubation for ventilation the most common indication. Aims The aims of this study were to describe: The demographics viz. the age, indications, and outcomes for these patients - in the Johannesburg Public Hospital Sector, thus providing a basis for understanding the patient profile, and The particular clinical problems encountered in this local and regional setting. Materials and Methods A retrospective study was conducted, selecting and evaluating data over a 10 year period from 1st January 2001 to 31st December 2010. All Patients in the age group less than 18 years of age were identified. These patients had undergone the procedure of tracheostomy in any of the four Johannesburg Academic Hospitals viz. Chris Hani Baragwanath Hospital, Charlotte Maxeke Johannesburg Academic Hospital, Helen Joseph Hospital, and Rahima Moosa Mother and Child Hospital. These patients were evaluated for age and for indication profiles, and for complications associated with the technical procedure and /or of the care of this artificial airway. Various factors were identified in ascertaining the effect on the final outcome. Results of Case Identification: Complete clinical records were found for 70 patients. The ages ranged from 2 weeks (neonate) to 17 years, with a mean age of 7 years. Only 18.5 % of patients were infants (under 1 year of age), with the neonatal age group accounting for just 4% (n= 3) of cases. The largest proportion was the 5.1- 10 year age group (30% of cases). INDICATIONS: 1. The most common indication group for tracheostomy were those with a potentially life threatening upper airway obstruction. These accounted for 67% (n = 47) of the cases. 2. Only 12% (n = 9) of cases were performed for prolonged intubation for positive pressure mechanical ventilation associated with respiratory disease. 3. Central nervous system disease associated with a depressed level of consciousness accounted for 14% (n = 10) of cases. 4. Five percent (n = 4) were indicated for surgical prophylaxis associated with potential upper airway compromise. Specific indications within these groups showed that the highest numbers of tracheostomies were performed for subglottic stenosis of the laryngeal airway, accounting for 28% of cases, and severe head trauma (i.e. requiring airway protection for depressed level of conciousness), accounting for 12% of cases. Glottic stenosis consequent on repeated surgeries for excision or ablation of recurrent laryngeal papillomata accounted for 7% of cases. MORBIDITIES: A total of 65 morbidities were encountered in 41 patients. The most commonly encountered complication was tracheostomy tube / cannula obstruction with blood clots and/or thickened, desiccated pulmonary secretions - with 23 episodes accounting for 35% of complications. Nosocomial Pneumonia was the second most common complication, accounting for 33% of cases (n=22). Other complications included: Operative site bleeding, Accidental early decannulation, Local wound infection, Neck and chest wall surgical emphysema, Exuberant granulation tissue formation, and Cannula breakage with aspiration. Complication rates in the neonatal and infant subgroups were significantly higher than in other age groups (p = 0.0296), with an average complication rate of 1.53 events per patient. MORTALITY: An overall mortality rate of patients with tracheostomies was found to be 27%. The mortality rate associated directly with tracheostomy care accounted for 8.5%. Of these cases, 86% were due to cannula airways obstruction (n = 5). The mean age of the patients that died from acute cannula obstruction was 2.45 years (i.e. the toddlers). IN-HOSPITAL STAY: The duration of in-hospital stay from day of procedure to release from in-hospital based care revealed a mean of 147 days (Range 5 – 1360 days). The largest percentage of patients (44%, n = 31) were admitted for a period of less than 1 month, however, prolonged admissions were noted, with 11% of patients (n = 8) admitted for a period of more than 1 year. A significant correlation of in-hospital stay was established with age - being inversely proportional to length of stay (r = -0.29); with the infant group having the longest mean duration of in-hospital stay (259 days). The overall discharge rate was 60%. Of the discharged patients, 57% were successfully discharged with tracheostomies in place for continued care in the home environment.

Background: Although a tracheostomy is a common procedure for patients who require prolonged mechanical ventilation, little evidence exists as to the best practices for performing tracheostomy care to maintain the airway and promote skin integrity. Therefore, variability is likely, which may negatively impact patient outcomes. This study described tracheostomy care practices of registered nurses (RNs) and respiratory therapists (RTs) who regularly perform tracheostomy care in critical care settings. Methodology: The descriptive study was conducted following informed consent. RNs (n=15) and RTs (n=5) were asked to perform tracheostomy care on a simulated mannequin patient. An array of supplies (both required and not necessary) was available to perform tracheostomy care. The procedure was video-recorded and the researchers also used an observation checklist. Equipment used and steps performed were compared to hospital policy and the American Association of Critical-Care Nurses (AACN) Procedure Manual. Data were analyzed with descriptive statistics. Results: The majority (80%) of participants were female and held a baccalaureate degree; median experience was 5 years. Equipment selection varied widely; supplies used by 50% or more of participants included non-sterile gloves, hydrogen peroxide, cotton swabs, disposable cannula, foam ties, and gauze dressings. The order of steps was variable with unique differences noted among all participants. The most common sequence was hand hygiene, clean flange, clean stoma, change inner cannula, change ties, and apply dressing. No one performed in the order recommended in the AACN Procedure Manual. Wide variability in practices emphasizes the need for establishing an evidence-based approach for performing tracheostomy care. Discussion: Research supported the belief that variation to technique and supplies does exist when performing tracheostomy care. Tracheostomy varied from provider to provider within one hospital unit, demonstrating the need for further research and protocols for tracheostomy care. Education on existing protocols and evidence-based practice should be conducted to ensure that providers are following unit protocols.

The thesis is focused on nursing care of patient with tracheostomy cannula from the perspective of nurses at the Department of the intensive care or Intensive Care Units. It consists of theoretical and empirical part. Essential terminology, anatomy and physiology of the airways, historical aspects of surgical procedures and types of tracheostomy tubes are described in the theoretical part. Moreover, there are discussed modern surgical techniques, indication and possible complication. The next theoretical chapter is focused on the nursing care. The last chapter deals with the different alternatives of communication of the patient with tracheostomy tubes. The research part uses questionnaires as a quantitative research method. The aim of the thesis is to investigate the theoretical knowledge of the nurses in their care of the patient with tracheotomy tubes and knowledge how to communicate with this patient. The statistically significant results are also listed and discussed. The last part concludes with the recommendations of the best practice in the care of the patient with the tracheostomy tubes. keywords tracheostomy, airway, tracheostomy tube, nursing care

Introduction The Breatheasy© Tracheostomy Program based at the Red Cross War Memorial Children's Hospital, Cape Town, manages children mostly from poor socio-economic backgrounds. In our resource-limited setting, it is unclear how these families cope with the demands of a tracheostomised child. We aim to assess the quality of life (QOL) of tracheostomised children and their families as the first study of its kind in a low-resource setting. Methods A descriptive, observational study was done to assess the QOL of tracheostomised children managed by the Breatheasy© Program over 10 months. Children with tracheostomies for longer than 6 months, complex syndromic children, and home ventilated children were included. The validated Paediatric Tracheotomy Health Status Instrument (PTHSI) was utilised, where a higher score, implied a better outcome. Results A total of 68 families were recruited. In 57 (85.1%) of the carers, the highest level of education achieved was primary or high school. Twenty-seven (42%) families reported having an annual household income of less than $675 US Dollars (ZAR10,000). Sixteen (24%) resided within informal housing. The mean scores for the 4 PTHSI domains were: physical symptoms 24.8/35 (70.9%), frequency/financial impact of medical visits 14.2/15 (94.7%), QOL of child 8.8/15 (58.7%), QOL of carer 62.3/85 (73.3%); the overall score was 110.2/150 (73.5%). There was no significant correlation between total PTHSI and annual household income, carer's educational status or type of housing. Children with a concomitant major medical condition had a significantly poorer total PTHSI scores (p-value 0.024). Conclusion Tracheostomy care compounds challenging socio-economic circumstances. In our experience, with adequate training, home-care nursing is not necessary. Despite difficult living conditions, the Breatheasy© Program empowers children and their families to live independently of the hospital system and appear to be thriving. The decision to perform a paediatric tracheostomy should not be influenced by the carer's education level, socioeconomic status, or on the basis of formal or informal housing. Children with major medical comorbidities represent a group that requires more support.

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Infants and young children with tracheostomies need better respiratory monitors. Mucus in the tracheostomy tube presents a serious choking hazard.  Current devices indirectly detect respiration, often yielding false or delayed alarms.  A compact ultrasonic time-of-flight (TOF) airflow sensor capable of attaching directly to the tracheostomy tube has been developed to address this need.  The ultrasonic flow sensing principle, also known as transit time ultrasound, is a robust method that correlates the timing of acoustic signals to velocity measurement.  The compact prototype developed here can non-invasively measure all airflow into and out of a patient, so that breath interruption can easily be detected. This paper concerns technical design of the sensor, including the transducers, analog/digital electronics, and embedded systems hardware/software integration.   Inside the sensor's flow chamber, two piezoelectric transducers sequentially transmit and receive ping-like acoustic pulses propagating upstream and downstream of flow.  A microcontroller orchestrates measurement cycles, which consist of the transmission, reception, and signal processing of each acoustic pulse.  The velocity and direction of airflow influence transit time of the acoustic signals.  Combining TOF measurements with the known geometry of the flow chamber, average air velocity and volumetric flow rate can be calculated.  These principles have all been demonstrated successfully by the prototype sensor developed in this research. / Master of Science

Medical-surgical nurses at the project site demonstrated a knowledge deficit regarding the care of adult patients with a tracheostomy. Such knowledge deficits could expose patients to higher risks for infection, bedsores, prolonged hospital stays, increased costs, increased caregiver burden, and death. The purpose of this project was to develop an educational program to improve nurses'€™ knowledge and confidence in the provision of evidence-based tracheostomy care to answer the question if the content of an evidence-based educational program developed to improve nurses'€™ knowledge and confidence in managing adult patients with tracheostomy on a medical-surgical floor would meet the expectations of a panel of content experts. Bandura'€™s self-efficacy and social learning theories provided theoretical guidance for the project. Five local nurse practitioners served as content experts and made recommendations about how the program could be improved, as well as suggestions relating to the wording of and the time allowed for the simulation aspect of the program. Content experts used a 5-point Likert-scale survey to evaluate the education at the completion of the program. Results showed that all reviewers strongly agreed that the content of the program was relevant, was based on the best available evidence, and was well organized and easy to follow. This project may promote positive change on the medical-surgical floor by improving providers'€™ knowledge, skills, and confidence in the provision of care based on the best available evidence, which may lead to improvements in the quality of care provided to tracheostomized patients.

A traqueostomia percutânea é um procedimento realizado rotineiramente na Unidade de Terapia Intensiva (UTI), guiada por broncoscopia. Recentemente, a ultrassonografia tem surgido como uma ferramenta potencialmente útil para assistir à traqueostomia percutânea e reduzir as complicações relacionadas ao procedimento. Um ensaio clínico randomizado, aberto, paralelo, de não inferioridade, foi conduzido comparando a traqueostomia percutânea guiada por ultrassonografia com a traqueostomia percutânea guiada por broncoscopia, em pacientes sob ventilação mecânica na UTI. O desfecho primário, a falência do procedimento, foi definido como um desfecho composto, incluindo (1) a conversão para traqueostomia cirúrgica, (2) o uso associado e não planejado da broncoscopia ou da ultrassonografia, ou (3) a ocorrência de uma complicação maior. Um total de 4.965 pacientes foram avaliados quanto a elegibilidade. Desses, 171 pacientes foram elegíveis e 118 foram submetidos ao procedimento, com 60 pacientes randomizados para o grupo ultrassonografia e 58 pacientes randomizados para o grupo broncoscopia. A falência do procedimento ocorreu em um (1,7%) paciente no grupo ultrassonografia e um (1,7%) paciente no grupo broncoscopia, sem diferença no risco absoluto entre os grupos (intervalo de confiança de 90%, -5,57 a 5,85), na análise \"conforme tratados\", não incluindo a margem de não inferioridade pré-especificada de 6%. Nenhum outro paciente apresentou uma complicação maior em ambos os grupos. As complicações menores relacionadas ao procedimento ocorreram em 20 (33,3%) pacientes no grupo ultrassonografia e em 12 (20,7%) pacientes no grupo broncoscopia, (P = 0,122). A duração do procedimento foi de 11 [7-19] vs. 13 [8-20] minutos (P = 0,468), respectivamente, e os desfechos clínicos também não foram diferentes entre os grupos. Em conclusão, a traqueostomia percutânea guiada por ultrassonografia é eficiente, segura e associada com taxas de complicações semelhantes à traqueostomia percutânea guiada por broncoscopia, em pacientes sob ventilação mecânica na UTI / Percutaneous Dilational Tracheostomy (PDT) is routinely performed in the intensive care unit (ICU) with bronchoscopy guidance. Recently, ultrasound has emerged as a potentially useful tool in order to assist PDT and reduce procedure-related complications. An open-label, parallel, non-inferiority, randomized controlled trial was conducted comparing the ultrasound-guided PDT with the bronchoscopy-guided PDT in mechanically ventilated critically ill patients. The primary outcome was procedure failure, defined as a composite end-point of conversion to a surgical tracheostomy; unplanned associated use of bronchoscopy or ultrasound during PDT; or the occurrence of a major complication. A total of 4,965 patients were assessed for eligibility. Of these, 171 patients were eligible and 118 underwent the procedure, with 60 patients randomly assigned to the ultrasound group and 58 patients to the bronchoscopy group. Procedure failure occurred in one (1.7%) patient in the ultrasound group and one (1.7%) patient in the bronchoscopy group, with no absolute risk difference between the groups (90% confidence interval, -5.57 to 5.85), in the \'as treated\' analysis, not including the pre-specified margin of 6% for noninferiority. No other patient had any major complication in both of the groups. Procedure-related minor complications occurred in 20 (33.3%) patients in the ultrasound group and in 12 (20.7%) patients in the bronchoscopy group, (P=0.122). The median procedure length was 11 [7-19] vs. 13 [8-20] minutes (P=0.468), respectively, and the clinical outcomes were also not different between the groups. In conclusion, ultrasound-guided PDT is effective, safe and associated with similar complication rates and clinical outcomes compared with bronchoscopy-guided tracheostomy in mechanically ventilated critically ill patients

Background: Evidence on aerosol delivery via tracheostomy is lacking. The purpose of this study was to evaluate the effect of aerosol device and administration technique on drug delivery in a simulated spontaneously breathing pediatric model with tracheostomy. Methods: Delivery efficiencies during spontaneous breathing with assisted and unassisted administration techniques were compared using the jet nebulizer (JN- MicroMist), vibrating mesh nebulizer (VMN- Aeroneb Solo) and pressurized metered-dose inhaler (pMDI- ProAirHFA). The direct administration of aerosols in spontaneously breathing patients (unassisted technique) was compared to administration of aerosol therapy via a manual resuscitation bag (assisted technique) attached to the aerosol delivery device and synchronized with inspiration. An in-vitro lung model consisted of an uncuffed tracheostomy tube (4.5 mmID) was attached to a collecting filter (Respirgard) which was connected to a dual-chamber test lung (TTL) and a ventilator (Hamilton). The breathing parameters of a 2 years-old child were set at an RR of 25 breaths/min, a Vt of 150 mL, a Ti of 0.8 sec and PIF of 20 L/min. Albuterol sulfate was administered with each nebulizer (2.5 mg/3 ml) and pMDI with spacer (4 puffs, 108 µg/puff). Each aerosol device was tested five times with both administration techniques (n=5). Drug collected on the filter was eluted with 0.1 N HCl and analyzed via spectrophotometry. Results: The amount of aerosol deposited in the filter was quantified and expressed as inhaled mass and inhaled mass percent. The pMDI with spacer had the highest inhaled mass percent, while the VMN had the highest inhaled mass. The results of this study also found that JN had the least efficient aerosol device used in this study. The trend of higher deposition with unassisted versus assisted administration of aerosol was not significant (p>0.05). Conclusions: Drug deposited distal to the tracheostomy tube with JN was lesser than either VMN or pMDI. Delivery efficiency was similar with unassisted and assisted aerosol administration technique in this in vitro pediatric model.