Tracheostomy

Completed tracheotomy: 1 – Vocal folds 2 – Thyroid cartilage 3 – Cricoid cartilage 4 – Tracheal rings 5 – Balloon cuff https://en.wikipedia.org/wiki/Tracheotomy

Indications for Non-Emergent Tracheostomy

• Non-emergent tracheostomy is indicated for kids who need prolonged mechanical ventilation.
• The most common indication currently is due to prolonged ventilation requirements secondary to chronic respiratory insufficiency. Causes of chronic respiratory insufficiency in children include chronic obstructive bronchopathies, upper airway abnormalities, or neuromuscular disease.
• Another major indication for tracheostomy is the presence of a fixed upper airway obstruction that is likely to be present for an extended period of time.
• Fixed upper airway obstructions may be due to:
  • Sleep apnea
  • Head/neck tumor
  • Airway anomalies
  • Airway hypersecretion
  • Recurrent aspiration

Background Epidemiology

In one set of studies, subglottic stenosis was the indication for 31.4% of pediatric tracheostomies, with bilateral vocal cord paralysis and congenital airway malformations each accounting for another 22.2%, and tumors accounting for 11% of indications for pediatric tracheostomy

In the past decade, respiratory papillomatosis, caustic alkali ingestion, and craniofacial syndromes have increased the frequency of pediatric tracheostomy

There are a few basics about tracheostomy in kids that are beneficial to know when interacting with such children in a clinical setting:

An outer cannula (top item) with inflatable cuff (top right), an inner cannula (center item) and an obturator (bottom item) https://en.wikipedia.org/wiki/Tracheotomy

The Basics

Most tracheostomy tubes include an obturator to ensure that the tube enters the trachea and doesn’t falsely track through tissue

 The neck plate is what the tracheostomy ties rest on; tracheostomy ties help to secure the tracheostomy to the patient’s neck region and guard against slippage or accidental removal

The connector connects to the ventilation tube, which is hooked up to the ventilation machine that determines the ventilation settings

The cannula enters the stoma site and is guided into the trachea via obturator guidance

The foam cuff can be inflated once the trach tube is inside to secure the trach tube in place and prevent slippage

Some trach tubes have an inner and outer cannula, but other trach tubes do come with a single cannula

Peri-procedural Considerations

Performing a tracheostomy in pediatric patients may be more difficult than in adult patients due to a difference in pediatric anatomy when compared to adult anatomy. Some special pediatric considerations are listed below:

• The cricoid cartilage can be injured if it is not accurately identified prior to incision
• The neck is shorter, thus there is less working space
• The apex of the pleura extends into the neck and is more vulnerable to trauma
• The trachea is more pliable and harder to palpate
• The trachea can be easily retracted so must be differentiated from carotid vessels

Periprocedural Care

A vital component of preparing for tracheostomy is the selection of the appropriate tube for your patient

Most importantly, the selected tube should not be small enough to where a large insufflation leak can cause hypoventilation

Most pediatric tracheostomy tubes are cuffless. But cuffed adult tracheostomy tubes are sometimes used in large children and in adolescents

Key considerations are tube diameter and length

• Making sure the diameter is not too wide: to prevent injury to tracheal mucosa by cutting off the blood supply. Such a tube would eventually cause ulceration and  fibrous stenosis of the trachea
• Overinflation of a cuffed tracheostomy tube for a prolonged period can have the same effect
• Making sure the tube is long enough: to allow adequate air entry, easy suctioning, and clearance of secretions

Complications of Tracheostomy

While adults require only one size of tracheostomy tube for life, pediatric patients require progressively larger tracheostomy tubes as they grow

• There should be a plan to increase the size of the tracheostomy tube at least every 2 years to prevent nocturnal desaturation

If a tracheostomy tube is too short, accidental decannulation or formation of a false passage may occur

If a tracheostomy tube is too long, the end of the tube may abrade the carina or rest inside of the right mainstem bronchus, thus occluding the left mainstem bronchus

Early Procedural Complications

Pneumomediastinum is a potential early peri-procedural complication. Also, surgeons must stay in the midline of the neck to prevent pneumothorax since lungs extend into the root of the neck in pediatric patients.

Acute hemorrhage, usually of the thyroid isthmus. The isthmus should be carefully examined in a case of acute bleeding and treated with electrocautery as needed.

Intermediate Complications

Local infection at the stoma site can cause excessive formation of granulation tissue, which would make trach-changes more difficult

Late Complications

Accidental decannulation is a risk as a child develops the strength and dexterity to remove the trach-tube.

• Decannulation is the removal of the tracheostomy tube. The most    common reason for failed decannulation is peristomal pathology such  as granulations, suprastomal collapse, stomal tracheomalacia, or stenosis

Partial obstruction or blockage of the cannula is also a risk

Contraindications to Tracheostomy

Surgical repair of a type IV laryngotracheoesophageal cleft is a contraindication to tracheostomy because the tracheostomy may erode the posterior suture line and result in faulty repair

References

1. Hadfield PJ, Lloyd-Faulconbridge RV, Almeyda J, Albert DM, Bailey CM. The changing indications for paediatric tracheostomy. Int J Pediatr Otorhinolaryngol. 2003 Jan. 67(1):7-10. 
2. Kilic D, Findikcioglu A, Akin S, Korun O, Aribogan A, Hatiboglu A. When is surgical tracheostomy indicated? Surgical "U-shaped" versus percutaneous tracheostomy. Ann Thorac Cardiovasc Surg. 2011 Feb. 17(1):29-32
3. Rogers JH. Tracheostomy and decannulation. Adams DA, Cinnamond MJ (eds). Scott-Brown’s Otolaryngology. Oxford: Butterworth-Heinemann; 1997. 6/26/1-6/26/16.
4. de Trey L, Niedermann E, Ghelfi D, Gerber A, Gysin C. Pediatric tracheotomy: a 30-year experience. J Pediatr Surg. 2013 Jul. 48(7):1470-5. [Medline].
5. Primuharsa Putra SH, Wong CY, Hazim MY, Megat Shiraz MA, Goh BS. Paediatric tracheostomy in Hospital University Kebangsaan Malaysia - a changing trend. Med J Malaysia. 2006 Jun. 61(2):209-13.[Medline].
6. Trachsel D, Hammer J. Indications for tracheostomy in children. Paediatr Respir Rev. Sep 2006. 7(3):162-8.[Medline].
7. McMurray JS, Prescott CAJ. Tracheotomy in the pediatric patient. Cotton RT (ed). Practical Pediatric Otolaryngology. Philadelphia: Lippincott-Raven Publishers; 1999. 575-594.