pediatric tracheostomy m. lauren lalakea md chief, otolaryngology/hns, valley medical center, san...
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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)
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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
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Bilateral Vocal Cord Paralysis
High-pitched stridor, CNS etiology
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TracheomalaciaInspiratory and expiratory stridor
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Laryngeal Anomaly: Glottic Web
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Neoplasm: Lymphangioma
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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
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Indications Assisted ventilation
Congenital central hypoventilation Chronic lung dz, eg BPD Neuromuscular disease
Pulmonary toilet Neurologically impaired children Recurrent respiratory infections, aspiration
Timing of TracheotomyControversial in pedi pts Prolonged intubation → risk of airway injury Incidence of subglottic stenosis low in neonates
despite lengthy intubation Meticulous NICU care Pliable larynx and trachea
Older children and adults: 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
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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
Vs. LMA or bronchoscope Positioning with neck
extended Palpation of landmarks,
incision marked 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
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
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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
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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
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Complications Tracheocutaneous fistula: 11-42%
Persistent fistula after successful decannulation ↑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? Cuffed vs. uncuffed Neonatal vs. pediatric Bivona vs. Shiley Single cannula vs. with inner
cannula Metal vs. plastic Appropriate length and
diameter? Fenestrated
Jackson Trach tube
Cuffed Shiley Trach with Inner Cannula
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
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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 GuidelinesLength Neonatal vs. Pedi
Neonatal equivalent diameter vs. Pedi, but 5-8 mm shorter in length
Too short ↑chance of accidental decannulation
Too long 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 GuidelinesDiameter Too large
Mucosal injury, stenosis Inability to voice
Too small 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
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
Child’s Age Inner Diameter (mm)
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 TubesFlexible 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