Parental report of pediatric tracheostomy care

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Parental Report of Pediatric Tracheostomy Care Susanna C. Bahng, BS, Sonja VanHala, MD, Virginia S. Nelson, MD, Edward A. Hurvitz, MD, Dietrich W. Roloff, MD, Elizabeth A. Grady, RRT, Cathy C. Lewis, MSN, R N ABSTRACT. Bahng SC, VanHala S, Nelson VS, Hurvitz EA, Roloff DW, Grady EA, Lewis CC. Parental report of pediatric tracheostomy care. Arch Phys Med Rehabil 1998;79: 1367-1369. Objective: There are little data on the actual care given pediatric tracheostomy patients in their homes. Information on the use of supplies and on techniques and frequency of care is valuable for a better understanding of the needs of this population. Design: Questionnaires were distributed by mail or at clinic visits from May 1995 to June 1996 to a convenience sample of tracheotomized patients at the University of Michigan Pediatric Physical Medicine and Rehabilitation clinic. Setting: Tertiary care clinic. Results: Clean technique for suctioning was reported by 96.7% of subjects and the rest reported sterile technique. Fifty percent of subjects reported reusing suction catheters. Cleaning solutions used to clean suction catheters for reuse varied. Tracheostomy tube reuse was reported by 55% of subjects. Sixty percent of those who reused tracheostomy tubes had had pneumonia within the previous year, whereas only 25% of those who never reused the tracheostomy tube had pneumonia in the same time period. Conclusions: Suctioning frequency, suction catheter, and tracheostomy tube reuse and cleaning methods are variables that warrant further investigation of safety and efficacy.

© 1998 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation ANY PEDIATRIC PATIENTS require a long-term tracheostomy for airway access, mechanical ventilation or both. 1 Home care is a reasonable goal for most children with a tracheostomy. Studies have shown that home tracheostomy care, in conjunction with proper parental training, equipment, follow-up visits, and home nursing care, can be as safe as hospital care and, in most cases, more beneficial to the child's growth and development. 1-3Home care for respiratory technology-assisted patients has also been shown to be more cost effective than institutional care. 4 Although home tracheostomy care has been evaluated for safety and cost effectiveness, and the literature describes and evaluates the proper training and preparation of parents, 5 an extensive search of the literature

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found no studies describing the actual methods and supplies used in the home. Such information would contribute to a better understanding of the needs of this population, providing recommendations in the training of home caregivers and helping to increase cost effectiveness. We asked parents of pediatric patients with tracheostomies to report use of supplies, techniques, and frequency of tracheostomy care in the home, and the incidence of pneumonia within the past year.

METHODS Questionnaires were distributed by mail or at clinic visits from May 1995 to June 1996 to a convenience sample of children with tracheostomies followed at the University of Michigan Pediatric Physical Medicine and Rehabilitation Clinic. Of 90 questionnaires distributed, 60 were returned--an overall return rate of 67%. Patients ranged in age from 9 months to 28 years, with a median age of 7.5 years; 35% of the sample was male. Length of time for which the patient had a tracheostomy ranged from 1 to 15 years, with a median of 4 years ( [ = 4.8yrs). Diagnoses of the patients were: neuromuscular problems, 63 %; lung disease, 18 %; congenital central hypoventilation syndrome and VACTERL syndrome, 12%; and airway problems, 7%. Lung disease category is comprised of patients with congenital diaphragmatic hernia, bronchopulmonary dysplasia, lymphangiectasia, or multiple congenital anomalies. In the neuromuscular category were patients with spinal cord injury, neuromuscular disease, cerebral palsy, dwarfism, myelodysplasia, brain tumor, stroke, traumatic brain injury, and neurofibromatosis. Eighty percent (48 of 60) of the patients used a ventilator. This study sample is reflective of patients followed in our clinic. Data collected in this study depended on parental report since no verification of the responses through charts or suppliers was made. The questionnaire respondent is referred to as a "subject," whereas the recipient of care is referred to as "patient." (The home caregiver and questionnaire respondent was usually a parent, but in a few cases a patient who was old enough to complete a questionnaire was also the respondent.) Frequency calculation and univariate analysis was performed using Epi Info 6.04. a Multiple regression analysis using STATA 4.0 b was performed to identify which variables played a role in recurrent infections. RESULTS

General descriptive data.

From the Departmentof PhysicalMedicineand Rehabilitation(Ms. Bahng,Drs. VanHala,Nelson,Hurvitz),the Departmentof PediatricsandCommunicableDiseases (Dr. Roloff),C.S. Mott Children'sHospitalRespiratoryCare (Ms. Grady),and the Department of Pediatric/PerinatalNursing, C.S. Mott Children's Hospital (Ms. Lewis),Universityof MichiganMedicalCenter,AnnArbor,MI. Submittedfor publicationFebruary26, 1998.AcceptedMarch26, 1998. Supportedby NIHgrant5T32HDO7422-05. No commercialpartyhavinga directfinancialinterestin the resultsof the research supporting this article has or will confer a benefitupon the authors or upon any organizationwithwhichthe authorsare associated. Reprintrequeststo VirginiaS. Nelson,MD, Departmentof PhysicalMedicineand Rehabilitation,C.S. Mott Children'sHospital,Room F-7822, 1500 East Medical CenterDrive.AnnArbor,M148109-0230. © 1998by the AmericanCongressof RehabilitationMedicineand the American Academyof PhysicalMedicineandRehabilitation 0003-9993/98/7911-479453.00/0

Of patients who used a ventilator, 10 used a bilevel positive airway pressure machine and 38 used a volume ventilator. Hours of ventilator use ranged from 1 to 24 hours, with 16 patients using the ventilator 24 hours a day. Forty-five percent (27 of 60) of the patients were reported to have had pneumonia within the past year, with 12 subjects reporting one episode, 7 subjects reporting two episodes, 3 subjects reporting three episodes, and 2 subjects reporting four episodes. Three subjects did not indicate the number of pneumonias. Inner cannulas were used by 26 of 60 (26.7%) patients. Thirteen (21.7%) used a cuffed tracheostomy tube; 12 of the 13 used an air cuff and one subject used a foam cuff. Suctioning. Suctioning was performed once every hour by 13.6% (8), once every 1 to 4 hours by 40.7% (24), once every 4 Arch Phys Med Rehabi! Vol 79, November 1998

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to 8 hours by 20.4% (12), and less frequently than once every 8 hours by 25.4% (15). Use of clean technique when suctioning was reported by 58 (96.7%), and only 2 (3.3%) reported using sterile technique. Clean gloves were used by 43 (71.7%) of the subjects, sterile gloves were used by 10 (16.7%), and 7 (11.7%) reported using no gloves. No association was found between glove usage and reported pneumonia. Fifty percent of the subjects reported reusing suction catheters and the others reported using sterile catheters. Of those who reported reusing suction catheters (30), 80% (24) cleaned their catheters with vinegar, 17% (5) used water, and 13% (1) used another solution. No statistically significant association was found between the use of sterile or reused suction catheters and reported pneumonia within the past year. Number of catheters used per month is shown in table 1. The median number of catheters used per month was 60; the mean was 108. Tracheostomy care. Brand A (Shiley c) tracheostomy tubes were used by 28 (46.7%) patients, brand B (Bivona d) by 19 (31.7%), and brand C (Portex e) by 13 (21.7%). Fifty-five percent (33 of 60) reported reusing the tracheostomy tube and the rest reported never reusing the tracheostomy tube. Reuse of the tracheostomy tube was correlated with a higher incidence of pneumonia. Approximately 60% (20 of 33) of those who reused the tracheostomy tube reported pneumonia within the past year, whereas only 25% (7 of 27) of those who never reused reported pneumonia. Age, type of tracheostomy tube, diagnosis, and frequency of tube change were tested along with tube reuse using logistic regression. Among these variables, reuse of the tracheostomy tube was the only predictor of pneumonia. The odds ratio for tube reuse with pneumonia as an outcome was 5.6 (confidence interval 1.2 to 26; p = .03). The R 2 value was. 12. Frequency of tracheostomy tube change is presented in table 2. Frequency of tube change correlated with the patient's age, with older patients tending to change less frequently. Seventytwo percent (31 out of 43) of patients younger than 13 years reported changing the tube weekly to twice monthly, whereas 24% (4 out of 17) of older patients reported changing at this frequency. Seventy percent (12 out of 17) of older patients and only 23% (10 of 43) of younger patients changed the tube monthly or less frequently than every month. Those who changed the tube more frequently were more likely to reuse the tracheostomy tube. Sixty-six percent of those who changed weekly to twice monthly reused, whereas only 9% of those who changed monthly to less than every month reused their tubes. Reuse of the tracheostomy tube correlated with a higher incidence of pneumonia, whereas the frequency of tube change and age did not. Of those who reused their tracheostomy tubes (33 subjects), 40.6% (13) used hydrogen peroxide to disinfect the tube, 21.9% (7) used soap and water, 12.5% (4) used vinegar, and 25% (8) used a combination of solutions (hydrogen peroxide, vinegar, Table 1: Suction Catheters Used Per Month Catheters (no.)

Patients (no.)

2-10 11-25 30-35 40-50 60 90-100 105-155 168-200 200-299 300 plus

4 4 15 3 4 6 5 4 3 5

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Table 2: Frequency of Tracheostomy Tube Changes Frequency

Patients (no.)

2/day 1/day 1/week 2/month 1/month