Pediatric Tracheotomy:

An Update

Shraddha Mukerji, MD

The University of Texas Medical Branch

Department of Otolaryngology

Grand Rounds Presentation

September 24, 2009

Overview

History

Changing Indications

Surgical Considerations

Complications

Long term effects of trach in children

Decannulation

History of tracheotomy

Period of legend 1500BC-1500AD Homer, Galen

Period of fear 460BC-1500AD Hippocrates

Period of drama 1500-1900 First modern tracheotomy,

Pediatric tracheotomy for

foreign body, tracheotomy for

diphtheria

Period of rationalization 1900- Jackson: better instruments,

post-operative care, safer

anesthetics

Pioneers

Antonio M. Brasavola

First successful tracheotomy

Chevalier Jackson

Good postoperative care

Pierre Bretonneau

Tracheotomy for diphtheria

Indications

Fraga JC, et al Pediatric tracheostomy. J Pediatr (Rio J). 2009 Mar-Apr;85(2):97-103. Epub 2009 Mar 12.

Changing Indications

How have they changed?

Why have they changed?

How have they changed?

1980

Inflammatory

diseases of the

upper airway

50% - 3%

Prematurity,

prolonged

intubation

28% - 58%

Congenital

anomalies 6% - 23%

Arcand and Granger, J Otol 1988, Line et al Laryngoscope 1986, Fraga et al, J Pediatr

2009

Why have they changed?

Endotracheal

intubation

Timing between ET

and tracheotomy has

changed

Endotracheal tubes

Most common indications

Prematurity, chronic ventilatory support

Craniofacial anomalies: Pierre Robin, CHARGE

Congenital anomalies: Subglottic stenosis

Tracheotomy for tracheobronchial hygiene

Carron JD, et al Pediatric tracheotomies: changing indications and

outcomes. Laryngoscope. 2000 Jul;110(7):1099-10

Fraga JC, et al Pediatric tracheostomy. J Pediatr (Rio J). 2009 Mar-

Apr;85(2):97-103. Epub 2009 Mar 12.

Tracheotomy tubes

Shiley tracheostomy tubes

Bivona

tracheostomy

tubes

Metal tracheostomy tubes

Pre-op Parental counseling

Multidisciplinary meeting

Reassurance about voice issues, swallowing

and feeding

Educational material/videos/meeting other

parents of children with tracheotomy

How soon can we go home?

Surgical steps

Patient position

Landmarks: hyoid and cricoid, thyroid

obscured

Anatomical differences between

pediatric and adult larynx

Surgical steps contd…

Incision

Removal of

subcutaneous fat

Exposure of the thyroid

isthmus

Surgical steps contd…

Always divide the thyroid isthmus

Palpate cricoid and identify tracheal rings,

usually skin hook is used to hitch up the

cricoid

Stay Sutures

Incisions on the trachea

Surgical steps contd…

Vertical incision on the trachea

Tracheotomy tube sutured to skin

Stay sutures long and labeled left and right

Post-op care

Chest Xray

ICU stay till first trach change, then intermediate level

Sedated and paralyzed for 48 hours

Suture tray at bedside

Tracheotomy tube ≤

Endotracheal tube ≤

Trach change on day 5 (2 persons)

Complications

Children: Adults---2,3:1

-Premature>>Term

Complications are reduced if operation is carried out by trained physicians in a tertiary care setting

Mortality related directly to tracheotomy varies between 0-6%

Pereira et al. Complications of neonatal tracheostomy: a 5 year review.

Otolaryngol Head Neck Surg.2004;131:810-13

Kremer B, Botos-Kremer AI, Eckel HE, Schlöndorff G Indications,

complications, and surgical techniques for pediatric tracheostomies--an

update. J Pediatr Surg. 2002 Nov;37(11):1556-62

Kremer B, Botos-Kremer AI, Eckel HE, Schlöndorff G Indications,

complications, and surgical techniques for pediatric tracheostomies--an

update. J Pediatr Surg. 2002 Nov;37(11):1556-62

Complications cont’d…

Early (5-49%)

Bleeding

Pneumomediastinum

Subcut emphysema

Accidental decannulation

Wound breakdown

Late (24-100%)

Granuloma formation

Tracheomalacia

Tracheal stenosis

Tracheoesophageal

fistula

Pneumomediastinum/Pneumothorax

One of the commonest

early Cx

28% of premature

babies affected

Damage to

pleura,forceful

coughing

Subcutaneous emphysema

Increase ventilatory

pressures

Overzealous ventilation

Wound breakdown

Common in ‘chunky’

babies with a short neck

Avoid drag of ventilator

tubing on trach tube

Wound care

Suprastomal granuloma

Etiology: infection,

friction, stasis of

secretions

Incidence:

<10%to>80%

Indications for removal

- Decannulation, large

obstructing granulomas

Suprastomal/Tracheal granuloma

Complications cont’d…

Tracheitis

Usually colonization, viral infection

Determine: change in color of secretions, O2 saturations, vent settings

Tracheoscopy to differentiate colonization from true bacterial tracheitis

Gram stain and parenteral antimicrobials

Pneumonia

Accidental decannulation

Commonest cause of tracheotomy related

death

Premature babies: 7% and older children 16%

Vigilant post-operative monitoring

Long Term Effects of Tracheotomy

in Children

Study by Freeland et al – Delayed physical

development and increase likelihood of

complications if tracheostomy > 1 week

Hill and Singer – delayed speech acquisition

and delayed communication

Freeland AP Developmental influences of infant tracheostomy. J Laryngol Otol. 1974

Oct;88(10):927-36

Hill BP, Singer LT Speech and language development after infant tracheostomy. J Speech

Hear Disord. 1990 Feb;55(1):15-20

Care of the tracheotomy

Humidification

Suctioning: aseptic technique

and prevent trauma to the trachea

Communication: speaking

valve

Change of cannula, daily tie

changes

Passy Muir valve

Principle ‘No leak’, closed

respiratory system with one

way valve

Various types available for

different tracheostomy tubes

Benefits: Speech, better

cough, aids swallow,

expedites decannulation

Decannulation

Indication for decannulation

Clinical: resolution of the primary disease, no

active infection, tolerance of speaking valve

Endoscopic: a clear tracheobronchial tree

Functional: Adequate pulmonary reserve

Process of decannulation

Timing of decannulation-Spring,Summer vs

Fall/Winter

Role of capped sleep study

Observation for 24 hours after decannulation

in a monitored settting

Decannulation contd…

Rate of decannulation:34%-75%

Children with craniofacial anomalies have the highest decannulation rate

Neurologically impaired children and children with prolonged ventilation-lower decannulation rate

Children decannulated < 2years have a lower incidence of TCF

Carron et al. Pediatric Tracheostomies: Changing Indications and

Outcomes. Laryngoscope 2000;110 (7):1099-1104

Algorithm for decannulation

Indications are met

Pulmonary evaluation

Capped sleep study

Admission x 2 nights

1st night: Capped trach tube

2nd night: Decannulation and observation

Discharge and FU in one week

Summary

Endotracheal intubation has virtually replaced tracheotomy for inflammatory lesions of the pediatric larynx

Commonest indications include chronic ventilatory dependency, craniofacial and congenital anomalies of the larynx

Removal of subcutaneous fat, vertical tracheal incision and stay sutures

Summary contd…

Common complications include bleeding, wound

infection, pneumomediastinum and granuloma

formation

Accidental decannulation remains the most important

cause of tracheotomy related death

Rates of decannulation are the highest in children

with craniofacial anomalies

Christmas in the bronchoscopic clinic ward.

Children with tracheostomies usually lived in the hospital.

Photo from The Life of Chevalier Jackson, An Autobiography