Tracheostomy--Introduction

Report
Pediatric Tracheostomy
M. Lauren Lalakea MD
Chief, Otolaryngology/HNS,
Valley Medical Center, San Jose, CA
Clinical Associate Professor, Stanford
Tracheotomy--Introduction

Initially procedure of last resort to relieve airway
obstruction, eg diphtheria, epiglottitis


High expectation for short duration, w decannulation
Indications expanded to include access for
pulmonary toilet and assisted ventilation (polio)
nathanclarkecommunication.wikispaces.com
Uofmchildrenshospital.org
Tracheostomy--Introduction


Current trends:
 ↓trachs for acute airway obstruction
 ↑trachs for prolonged ventilation (>50%)
 ↓decannulation rate: 28—51%
 ↑trach duration: 2 yrs for those decannulated
 Avg. age: 2—3 yr, >50% younger than 1 yr
Indications



Airway obstruction
Assisted ventilation
Pulmonary toilet
Indications

Airway obstruction

Congenital:





Craniofacial anomalies
Bilateral vocal cord paralysis
Tracheomalacia
Laryngeal anomaly
Neoplasm
Craniofacial Anomaly: Pierre Robin
micrognathia, glossoptosis, cleft palate
php.med.unsw.edu.au
Bilateral Vocal Cord Paralysis
High-pitched stridor, CNS etiology
www.drninashapiro.com
Tracheomalacia
Inspiratory and expiratory stridor
2011.prepsa.courses.aap.org
Laryngeal Anomaly: Glottic Web
wiki.uiowa.edu
Neoplasm: Lymphangioma
openi.nlm.nih.gov
Indications

Airway Obstruction

Acquired:

Subglottic stenosis







Cricoid is a complete ring
ETT -->mucosal ischemia, necrosis
Perichondritis, cartilage injury
Progressive stridor, failed extubation
Trach if med and surgical management fail
Recurrent respiratory papillomatosis
Trauma
emedicine.medscape.com
Indications

Assisted ventilation




Congenital central hypoventilation
Chronic lung dz, eg BPD
Neuromuscular disease
Pulmonary toilet


Neurologically impaired children
Recurrent respiratory infections, aspiration
Timing of Tracheotomy
Controversial in pedi pts


Prolonged intubation → risk of airway injury
Incidence of subglottic stenosis low in neonates
despite lengthy intubation



Older children and adults:


Meticulous NICU care
Pliable larynx and trachea
Consider trach after 2-3 wks of intubation
Consider likelihood that underlying process will
reverse/improve
Pre-Trach Evaluation

Airway obstruction



Flexible laryngoscopy—dynamic evaluation
Rigid laryngoscopy and bronchoscopy with
spontaneous ventilation
Any treatable conditions?
Pre-Trach Evaluation

Dynamic evaluation--laryngomalacia
primehealthchannel.com
Pre-Trach Evaluation

Assisted Vent + Neurologic Dz



Discussion with 1° team, Pulmonary, family
Goals of care
All



Wt> 1500 gm, FiO2 <60%
Hct, coags
Informed Consent
Tracheotomy Technique

General Anesthesia, with ETT



Positioning with neck
extended
Palpation of landmarks,
incision marked


Vs. LMA or bronchoscope
Pedi larynx is high, cricoid
easiest to palpate
Horizontal or vertical incision
below cricoid
Tracheotomy Technique



Midline dissected, thyroid isthmus divided
Stay sutures placed thru rings
Trachea opened vertically
Tracheotomy Technique


ETT is withdrawn slightly
Appropriate trach tube placed
 Position and adequate
ventilation confirmed
 Tube size adjusted prn
 Excessive leak
 Excessive length
Tracheotomy Technique


Tube secured with sutures
Stay sutures labeled


Facilitate tube replacement in
case of accidental
decannulation
Twill tape used around
neck to secure trach

Snugly tied to prevent
dislodgement
Tracheostomy Variations



Vertical skin incision
Stoma ‘matured’ by
suturing skin in 4
quadrants to edges
of tracheal incision
Allows easier tube
replacement if
dislodged
Post-Operative Care
Transport directly to ICU
 CXR to confirm tube position, r/o PTX
 Sedation to minimize risk of accidental
decannulation while stoma immature
 Routine suctioning, humidified air
 “Do not change trach ties”
 Obturator, extra trach tubes at bedside


Same size, and one size smaller
Post-Operative Care

First trach change



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

At 5-7 days post-op
2 ENT MDs
Neck extended, fresh tube placed
Stay sutures removed, ties changed
Confirms that stoma is sufficiently mature to
allow future changes by non-surgical personnel
Sedation weaned, transfer out of ICU as
appropriate
Post-Operative Care

‘Hands-on’ caregiver training begins






Infants and young children vulnerable to trach
catastrophe
Pedi trach tubes are single canula--require
meticulous care
General trach care, suctioning technique
Trach tube changes—q 1-2 wk
CPR training
Discharge planning
Complications
Complication rates vary, up to 40—50%
 Early:


Accidental decannulation



False passage, loss of airway
Potential for significant morbidity/mortality
↓Risk with:
 Adequate sedation/ immobilization
 Appropriately sized and secured tube
 Close monitoring and nursing care
 Stay sutures +/- ‘mature’ stoma to facilitate tube
replacement
sciencedirect.com
Complications: Early

Tube obstruction/ mucus plugging

Potential for significant morbidity/ mortality in kids
 Small diameter single canula, vulnerable age group




↓Risk with:
 Humidified air
 Frequent suctioning
 Appropriate monitoring
Pneumothorax/ pneumomediastinum 0.6 – 6%
Hemorrhage
Local infection, skin breakdown
Complications--Late

Tracheal granuloma—39%



Stomal, suprastomal, distal
↓Risk with meticulous trach care, proper
suctioning technique
Surveillance bronchoscopy, excision to
maintain patency
tracheostomy.com
Utmb.edu
Complications: Late
Tube obstruction/ mucus plugging – 13%
 Accidental decannulation—12%




Caregiver training is critical
Adequate monitoring and home support
Local infection – 9%
Complications: Late

Speech delay



Smaller trach size allows for better airflow and
voicing
Passey-Muir valve appropriate for some
Early Start and Speech Tx
Complications: Late
Suprastomal collapse/ malacia – 8%
 Tracheal or subglottic stenosis
 Arterial erosion/ tracheal-innominate
fistula



“Sentinel Bleed”
TE fistula--acquired
readcube.com
Complications

Tracheocutaneous fistula: 11-42%

Persistent fistula after successful decannulation



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↑Risk if trach duration > 1 yr
90% of ‘Starplasty’ trachs have TC fistula
May require surgical repair
Death

Trach-related = 0 – 3%


Accidental decannulation / mucus plugging most
common
Overall = 8.5 – 19%
Trach Tubes: Which are Best?



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Cuffed vs. uncuffed
Neonatal vs. pediatric
Bivona vs. Shiley
Single cannula vs. with inner
cannula
Metal vs. plastic
Appropriate length and
diameter?
Fenestrated
Cuffed Shiley Trach with
Inner Cannula
Jackson Trach tube
Trach Tubes: Which are Best?

Fenestrated tube



Allows passage of air
up thru vocal cords to
facilitate speech
May ↑ aspiration risk
More prone to
granulation tissue
formation
tracheostomy.com
Trach Tubes: Which are Best?

Ideal trach tube:




Soft enough to conform w/o pressure, injury,
discomfort
Rigid enough to avoid collapse
Material causes minimal tissue reaction
Has inner cannula that can be removed and
cleaned



Not available for plastic pediatric trachs
Has stylet or obturator to facilitate insertion
Bivona and Shiley meet most criteria
Trach Tube Size Guidelines
Length

Neonatal vs. Pedi


Too short



↑chance of accidental decannulation
Too long


Neonatal equivalent diameter vs. Pedi, but 5-8 mm
shorter in length
May abrade carina or rest in right mainstem
Longer tubes desirable if tracheal stenosis or
malacia
Length confirmed by CXR or flex. endoscopy
Trach Tube Size Guidelines
Diameter
 Too large



Too small




Mucosal injury, stenosis
Inability to voice
Excessive leak in ventilated pts
Inadequate air exchange
Difficult to suction adequately
Pedi trach tubes sized based on inner
diameter, correspond to endotracheal tube
sizes
Trach Tube Size Guidelines
Child’s Age
Inner Diameter (mm)
Premie, <1000 gm
2.5 neo
Premie, 1000-- 2500 gm
3.0 neo
Neonate – 6 mo
3.0 – 3.5, neo
6 mo -- 1 yr
3.5 – 4.0
1 – 2 yr
4.0 – 5.0
> 2 yrs
Age/4 + 4
Shiley Pediatric Trach Tubes
Options: Neo, Pedi, Pedi-Long (PDL),
Pedi c Cuff (PDC), Pedi-Long c Cuff (PLC)
Bivona Trachs

Similar sizing


Neo and Pedi
Cuffed Tubes: TTS
(tight to shaft)

Excellent option for pts
who need cuff
Reorder Code
Size
ID (mm)
OD (mm)
Length (mm)
67P025
2.5mm
2.5mm
4.0mm
38.0mm
67P030
3.0mm
3.0mm
4.7mm
39.0mm
67P035
3.5mm
3.5mm
5.3mm
40.0mm
67P040
4.0mm
4.0mm
6.0mm
41.0mm
67P045
4.5mm
4.5mm
6.7mm
42.0mm
67P050
5.0mm
5.0mm
7.3mm
44.0mm
67P055
5.5mm
5.5mm
8.0mm
46.0mm
Bivona FlexTend Trach Tubes
Flexible extended length connection ‘built-in’ to trach
Decannulation

Suitability:




Off ventilator, minimal suctioning requirement,
no obstructive pathology
Tolerates capping/occlusion
Recent bronchoscopy is clear
Procedure:



Admission to ICU, monitoring
Downsizing vs removal, occlusive dressing
Observation 24-72 hrs

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