Emergency use of a customized tracheostomy tube for pediatric patients

Authors


  • The authors have no funding, financial relationships, or conflicts of interest to disclose.

Abstract

This article describes how to make a customized tracheostomy tube in an emergency setting for a pediatric patient. This is particularly critical when a commercial customized tracheostomy tube cannot be readily obtained.

INTRODUCTION

A 2-year-old female with Crouzon syndrome underwent successful repair of moderate subglottic stenosis. Her neonatal history included severe upper airway obstruction requiring tracheotomy. She remained tracheotomy-dependent with a 3.5 mm pediatric Bivona (Smiths Medical, Ashford, UK) tracheostomy tube secondary to her distal tracheomalacia.

The child's immediate postoperative course was complicated by positional respiratory difficulty while on the ventilator, which was intermittent. She was evaluated with flexible tracheoscopy. This confirmed that the tracheostomy tube was too short. The distal tip of the tracheostomy tube became obstructed from collapsing trachea secondary to severe tracheomalacia. She needed a longer tracheostomy tube that permitted the distal tip to be located just above the carina. Also, despite the large array of tracheostomy tubes at our institution, there was no available tube in the hospital that would fit her unique anatomy. Her recent rib graft precluded intubation from above.

To remedy her ventilator airway requirements, she needed a customized tracheostomy tube that had to be ordered from the manufacturer. A temporary solution was fashioned from modifying a 3.5 mm endotracheal tube as a bridging measure to stabilize her on the ventilator. This temporary, hospital-made, customized tracheostomy tube assisted in ventilating the patient by bypassing the obstruction while an appropriate commercial custom-made tracheostomy tube could be obtained. Although this clinical pearl has been reported by Martin and Shapiro in The Laryngoscope nearly 30 years ago, our case illustrates the wisdom of this life-saving and older technique.

METHOD

The following simple steps can be used to make a customized tracheostomy tube from an endotracheal tube (ET). First, the flexible laryngoscope is inserted into the cervical stoma, and the insertion distance is measured, thereby determining the length to where the tip of the tube should rest. Second, the connector hub is removed from the ET, and the ET tube is split down the middle with a 15 blade to the appropriate length as determined by the flexible scope. Third, the connector hub is moistened with alcohol and tightly twisted into the proximal end of the ET tube (Fig. 1). The outer diameter of the ET tube should match the diameter of the tracheostomy tube. Fourth, the endotracheal tube stylet can be used as an obturator. Fifth, small keyhole incisions are made on the outer flanges through which the trach ties are placed. Last, a spare customized tracheostomy tube should be kept by patient's bedside as well.

Figure 1.

Customized tracheostomy tube, readily made in minutes.

DISCUSSION

This customized tube can be quickly made in a few minutes with readily available supplies when an appropriate-length traditional tracheostomy tube is unobtainable. This can occur for a patient with unique anatomy, such as an obese neck, distal tracheal granulation tissue, or severe tracheomalacia.1 This life-saving fabricated tube is also practical in less industrialized nations without access to a large supply and variation of tracheostomy tubes.

This particular technique was first described in the literature in 1981 and has been reported for obese necks, but little mention is made of its use in pediatric otolaryngology.1–3 We feel that it is important for all otolaryngologists as well as those in pediatrics to be aware of this quick technique in an emergency situation. Currently, many children with unique anatomical constraints have customized manufactured tracheostomy tubes, which are constructed according to a patient's particular specification and then shipped to the patient. These tubes are able to bypass granulomas, stent open malacic segements, and thread through stenotic segments, but that does not prevent a situation in which a tracheostomy tube needs to be man made.

In our patient, despite access to a vast tracheostomy tube supply and overnight express mail system, an appropriate-length tracheostomy tube could not be found on the premises but was readily constructed in minutes at the patient's bedside.

CONCLUSION

This technique is an easy and inexpensive solution to a potentially fatal problem. As such, it is important that this lost art is not forgotten among the younger generation of otolaryngologists who grow accustomed to having all tube shapes and sizes possible on hand.

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