- Email: [email protected]
Pediatric tracheostomy
Operative Techniques in Otolaryngology (2009) 20, 212-217
Pediatric tracheostomy Emily F. Boss, MD From the Division of Pediatric Otolaryngology, Department of Otolaryngology—Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland. KEYWORDS: Tracheotomy; Tracheostomy
Tracheotomy is most commonly performed in children who are less than 1 year of age. The most common indication is for prolonged ventilatory support secondary to lung disease of prematurity. Tracheotomy is also performed for children with anatomic upper airway obstruction or children with neurodevelopmental delay who require pulmonary toilet. Surgical approaches to tracheotomy are designed to minimize trauma, establish a mature tracheocutaneous fistula, and avoid devastating postoperative complications, such as accidental decannulation. This article details a straightforward stepwise surgical approach to tracheotomy in children. © 2009 Elsevier Inc. All rights reserved.
Tracheotomy is a surgical procedure that has been performed in children since the 17th century. Historically, the most common indication for a tracheostomy was the acute relief of airway obstruction caused by respiratory infections, such as diphtheria, epiglottitis, or croup. In modern times, however, this paradigm has shifted because of a marked improvement in neonatal intensive care and survival of premature infants. Tracheostomy is now most commonly performed for children who require prolonged ventilatory support or who fail extubation secondary to congenital or acquired laryngeal or tracheal abnormalities.1,2 More tracheostomies are performed in children within the first year of life than in any other pediatric age group. Still, the incidence of tracheostomy among infants admitted to a neonatal intensive care unit (ICU) is 0.5%-3% and is declining.3,4 The terms tracheotomy and tracheostomy can be easily confused and are often used interchangeably. Tracheotomy refers to the surgical procedure itself (“to cut the trachea”). Tracheostomy refers to the hole or fistula that is created (“to furnish the trachea with an opening”).
The author has not received financial support or funding from any source in creation of this manuscript. Address reprint requests and correspondence: Emily F. Boss, MD, Division of Pediatric Otolaryngology, Department of Otolaryngology— Head and Neck Surgery, The Johns Hopkins Outpatient Center, 601 N. Caroline Street, 6th Floor, Baltimore, MD 21287. E-mail address: [email protected]. 1043-1810/$ -see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.otot.2009.10.004
Indications There are 3 major indications for tracheostomy in children: prolonged ventilatory support, upper airway obstruction, and pulmonary toilet. The most common indication for tracheostomy in children is prolonged ventilatory support. With the advent of improved neonatal care in recent decades, premature infants can be delivered at younger ages and sustained for longer periods in the setting of chronic lung disease of prematurity (bronchopulmonary dysplasia). Because of the development of softer polyvinyl chloride endotracheal tubes, infants may be intubated for weeks to months with less risk of airway trauma secondary to prolonged intubation. Tracheostomy is indicated when safe extubation is not possible because of chronic lung disease or systemic comorbidities. Upper airway obstruction is another common indication for tracheostomy in children. Although many etiologies exist for debilitating upper airway obstruction in children, some principle anatomic diagnoses include subglottic stenosis, tracheomalacia, or bilateral vocal fold paralysis. Some children with craniofacial syndromes may require tracheostomy secondary to severe micrognathia, glossoptosis, macroglossia, or generalized oropharyngeal crowding. Neoplastic conditions are rare causes of upper airway obstruction, but they may include respiratory papillomatosis and subglottic hemangiomas.
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Pediatric Tracheostomy
Table 1
213
Common age-appropriate tube types and sizes Shiley®
Bivona®
Age
Suggested ID for age
ID
Premature ⬍1 kg
2.5
2.5 (neo)
3.0
3.0 (neo)
Neo to 6 mo
3.0-3.5
6 mo-1 yr
3.5-4.0
1-2 yr ⬎3 yr
4.0-4.5 (Age in yr ⫹ 16)/4
3.5 (neo) 3.5 (peds) 4.0 (neo) 4.0 (peds) 4.5 5.0 5.5 4 adult 6 adult
1 kg-2.5 kg
Length
ID
30 39 32 40 34 41 42 44 46
2.5 2.5 3.0 3.0 3.5 3.5 4.0 4.0 4.5 5.0 5.5
Length (neo) (peds) (neo) (peds) (neo) (peds) (neo) (peds)
30 38 32 39 34 40 36 41 42 44 46
ID, inner diameter in millimetres; Length, length of tube shaft in millimetres. Shiley® (Shiley Laboratories, Irvine, CA) tracheostomy tubes come as cuffless, cuffed, or fenestrated. A pediatric long Shiley tube as well as an adjustable length Shiley tube are also available measuring up to 80 mm in length. Bivona® (Bivona Corporation, Gary, IN) tracheostomy tubes come cuffless or cuffed (TTS, tight to shaft).
A minority of patients who are neurologically impaired require tracheostomy to assist with ventilation, to prevent chronic aspiration, and to facilitate pulmonary toilet. These children are generally older at the time of tracheostomy, often having experienced multiple hospital admissions for upper respiratory infections and pneumonia. Nearly all of these children are fed through a gastrostomy tube for improved relief of aspiration.
Technique Pediatric and adult tracheostomy differ in many ways, as tracheostomy in children is associated with significantly greater morbidity and mortality. The pediatric airway is small, soft, and pliable, and overzealous retraction intraoperatively may lead to disorientation, lateral dissection, and accidental injury to the lung or a major vessel. The pediatric larynx is located higher in the neck than the adult larynx, and therefore careful extension and exposure are critical aspects of a successful procedure. Neonates may have very poor pulmonary reserve or severe systemic comorbidities, and any temporary loss of airway patency both intraoperatively or postoperatively could lead to severe complications including death. Given these factors, numerous precautions are taken to prevent complications associated with pediatric tracheostomy. Preoperative evaluation of the patient is necessary for planning and patient safety. The neck is inspected for landmarks, excessive fat, central lines, or scars from former vascular access or surgery. If the patient is intubated, the size and position of the endotracheal tube and presence of air leak around the tube are noted. An appropriately sized tracheostomy tube is selected and made available in the operating room. Tubes 1 size smaller and larger than the
selected tracheostomy tube should also be available. Standard tracheostomy tube diameters and lengths for age are depicted in Table 1. Principles to consider when selecting a tracheostomy tube include the inner and outer diameter (tubes are typically sized according to the inner diameter), tube length (neonatal, pediatric, pediatric long, or adjustable), and presence or absence of a cuff (Figure 1). In general, the tube with the smallest lumen that will maintain adequate ventilation is indicated to minimize mucosal trauma. The distal tip of the tracheostomy tube should lie 7-20 mm proximal to the carina. Pediatric tracheostomy is performed under general anesthesia with the airway secured by an endotracheal tube. Some surgeons prefer to first perform rigid bronchoscopy, leaving the rigid bronchoscope to ventilate the patient and
Figure 1 Standard tracheostomy tubes. Left, a Shiley® 3.5 pediatric cuffless tube (inner diameter 3.5 mm, length 40 mm). Right, a Bivona® 3.5 neonatal cuffed tube (inner diameter 3.5 mm, length 34 mm). (Color version of figure is available online.)
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serve as a firm airway stent over which to perform tracheotomy. The patient is generally placed on a shoulder roll for ideal exposure of the laryngeal and tracheal cartilages. Frequently skin and pannus are retracted from the surgical site with tape to facilitate exposure and easy access to the airway. Time spent gaining proper positioning and exposure before draping is valuable and can mitigate difficulty later in the procedure. The patient is prepared and draped so the face and mouth are exposed and easily accessible should the orotracheal airway need to be reestablished. The neck is carefully palpated, and the thyroid cartilage, cricoid cartilage, and sternal notch are marked (Figure 2). Occasionally, the hyoid bone may obscure the thyroid cartilage. The incision site is planned approximately one-third to one-half distance between the cricoid cartilage and the sternal notch, and a weight-appropriate dosage of topical lidocaine with epinephrine is injected. A horizontal skin incision is made and extended through the subcutaneous tissue. Subcutaneous fat is grasped and removed with electrocautery. “Defatting” is performed to improve exposure and to help the tracheocutaneous stoma mature more quickly (Figure 3). Using opposing traction, the fascia overlying the strap musculature is elevated with forceps and divided with scissors (Figure 4). Next the scissors or a hemostat are used to bluntly dissect the strap musculature along the avascular midline raphe in the vertical plane. As the midline plane is created, the strap muscles are elevated and gently retracted laterally. Care should be taken not to aggressively retract the musculature, as sometimes the trachea is also mistakenly pulled laterally with the retractors. The trachea is palpated repeatedly throughout this dissection to confirm that the dissection is indeed in the appropriate midline trajectory. Extensive dissection lateral to the trachea may lead to disorientation and resultant vascular injury or pneumothorax. Frequently the thyroid isthmus is encountered overlying the trachea deep to the strap musculature. If encountered, the isthmus may be carefully undermined and retracted
Figure 2 The patient is placed on a shoulder roll, and the thyroid cartilage, cricoid cartilage, planned horizontal incision site, and sternal notch are clearly marked.
Figure 3 A horizontal incision has been made one-third to one-half distance from the cricoid to the sternal notch, and now the subcutaneous fat is removed with electrocautery. The fat is grasped with a forcep and elevated to facilitate removal. To expose the fat, the skin incision is retracted with digital manipulation or skin hooks.
superiorly until the trachea is well visualized. Alternatively, the thyroid isthmus may be elevated and divided with cautery. I typically identify the cricoid cartilage, elevate the isthmus from the pretracheal fascia with a right-angled hemostat, and divide the isthmus with cautery over the hemostat. Caution is used when dividing the isthmus to avoid accidental airway entry or fire. At this point, the trachea is well visualized with the strap musculature and thyroid isthmus retracted laterally on either side. A peanut may help to bluntly sweep away any remaining soft tissue or fascia that is obscuring the airway. A cricoid hook may be placed to improve positioning of the
Figure 4 After the subcutaneous fat is removed, fascia overlying the strap muscles is grasped using opposing traction and sharply divided with a scissors. The scissors are then used to bluntly dissect the avascular midline muscular raphe, and the musculature is retracted laterally. The trachea is palpated throughout this step to confirm midline dissection.
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Pediatric Tracheostomy
trachea. The anesthesiologist should be alerted that the airway is being manipulated and will soon be entered. “Stay” sutures are placed through the cartilaginous rings on either side of the planned vertical incision in the trachea. Nonabsorbable sutures such as 3-0 polypropylene are preferred. The sutures should be positioned securely through the tracheal cartilage when not breaching the tracheal mucosa. Stay sutures serve to assist both in elevation of the trachea intraoperatively and also in facile exposure of the tracheotomy incision if a tube needs to be replaced due to an accidental decannulation in the immediate postoperative period. A vertical incision is now made through the second and third cartilaginous rings until the tracheal lumen is visualized. The stay sutures are retracted laterally to better expose the incision (Figure 5). A hemostat may be spread in the tracheal incision to provide improved visualization of the lumen and endotracheal tube. The endotracheal tube is retracted slowly until the tip lies proximal to the superior side of the tracheal incision, but it is not withdrawn from the larynx. The tracheostomy tube is inserted using an obturator for guidance. The ventilator circuit is connected to the tracheostomy tube, and a small breath is administered. Aggressive positive pressure ventilation is avoided until tube positioning within the lumen is confirmed to avoid subcutaneous air dissection. When end tidal CO2 is detected, the cricoid hook and skin retractors are removed. The tracheostomy tube is secured with ties that fit snugly around the neck, permitting 1 finger width under the tie, with the neck in neutral to flexed position. Although surgeon preference varies, the tracheostomy is generally not sutured to the skin so that any dislodgement of the tube would be more quickly recognized and managed. A flexible bronchoscope is passed through the lumen of the tracheostomy tube and used to visualize the trachea to the level of the carina and mainstem bronchi to assess proper positioning and length of the tube. The stay sutures are carefully marked to indicate right and left sides, and they are affixed to the chest with adhesive (Figure 6). A chest x-ray is obtained immediately after surgery to evaluate for pneumothorax and tube position. Postoperatively, the patient is managed in an ICU until the first tracheostomy tube change. The ICU nurses and physicians are educated regarding the function of the stay sutures in the event of tube dislodgement. The patient is examined daily for any skin breakdown from the ties, displacement of the stay sutures, or purulent respiratory secretions. The first tracheostomy tube change is performed between postoperative day 5 and 7, after there has been an adequate time for the tracheocutaneous fistula to mature.
Complications Complications of tracheostomy are common and may occur up to 70% of the time.6 Tracheostomy-related mortality occurs in as many as 4% of patients and is most often secondary to mucous plugging or accidental decannulation.
215
Figure 5 The thyroid isthmus has been divided, and the visualization of the tracheal cartilages is improved with a cricoid hook. Polypropylene stay sutures (3-0) are now placed 3-5 mm lateral to the planned incision site through the second and third tracheal cartilages. The vertical midline dashed line indicates the planned tracheal incision site (A). The vertical tracheal incision is exposed by stay suture and cricoid hook refraction (B).
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Figure 6 After incision of the trachea and confirmed insertion of the tracheostomy tube, the tracheostomy tube is secured snugly with ties, and the stay sutures are clearly marked right and left and affixed to the chest for easy identification and use in the event of an accidental decannulation. (Reprinted with permission.5)
Complications may occur during the operation, in the immediate postoperative period, and weeks, months, or years after tracheotomy in the delayed postoperative period. Intraoperative hemorrhage can be prevented with careful tissue dissection and midline orientation. Stomal granulation tissue can develop postoperatively from tube movement and irritation in the tracheocutaneous fistula. Excessive granulation tissue may make tube changes difficult and bloody. Stomal granulation may be observed, cauterized at the bedside, or excised, as they frequently recur. Tracheal suprastomal granulation or stenosis may occur postoperatively due to tube irritation of the tracheal mucosa. Tracheal stenosis may develop if the tube is placed too close to the cricoid cartilage, or if the tip or cuff causes pressure necrosis on the tracheal mucosa and cartilage. These changes often require surgical removal or reconstruction, particularly if decannulation is anticipated. Perhaps the most common complication of tracheostomy is persistence of the tracheocutaneous fistula after decannulation, occurring up to 40% of the time. Frequently the fistula will persistently drain, irritate the skin, and hinder sound and speech projection. As previously stated, the most severe complications of tracheostomy are accidental decannulation and tracheostomy tube plugging. Accidental decannulation can occur any time after the procedure and may be due to a small tube size, short tube length, or excessive patient motion in the setting of an immature tract. Mucous plugging may be prevented with humidification, careful suctioning of the tube, and routine tracheostomy tube changes.
Discussion A recent survey of pediatric otolaryngologists evaluated the variability of techniques used in pediatric tracheostomy and identified that most pediatric otolaryngologists perform the
steps listed above when performing the procedure, particularly making a horizontal skin incision, defatting the subcutaneous tissue, dividing the thyroid isthmus with electocautery, placing stay sutures, entering the trachea with a vertical incision, and securing the tracheostomy tube with ties.7 Because of the complexity of the pediatric airway and the potential severity of complications of tracheostomy in children, numerous surgical techniques have been proposed throughout recent decades that warrant mention. To avoid inadvertent dissection lateral to the trachea in the difficult neonatal airway, Pereira8 proposed bronchoscopy assisted neonatal tracheostomy. This technique involves direct visualization of the trachea and ventilation with rigid bronchoscopy. After skin incision, an angiocath is placed in the tracheal midline inferior to the first tracheal ring, and a guidewire is passed through it and grasped from within the bronchoscope. The wire is then used to elevate the pliable trachea so that dissection may be facilitated without repeated palpation of the trachea. Some surgeons prefer to make a vertical skin incision as opposed to horizontal skin incision because of the ease of exposure during surgery and access to the trachea should the tube become dislodged, however a horizontal incision may tend to leave a more cosmetically acceptable scar after decannulation.9 Numerous techniques of tracheal entry and stomal sutures have been proposed to limit postoperative accidental decannulation, tracheal stenosis, or anterior tracheal wall collapse. Although most pediatric otolaryngologists make a vertical incision in the trachea,7 many prefer to make a horizontal incision in the trachea with an inferior flap sutured to the skin as initially described by Bjork.10,11 Koltai12 proposed a starplasty procedure to reduce the risk of pneumothorax and to facilitate replacement of the tracheostomy tube if it should accidentally become dislodged. This procedure creates a cruciate incision in the skin and trachea, and affixes the tracheostomy flaps to the skin flaps with sutures to create a more formal stoma. Another method of creating a more permanent stoma is with placement of maturation sutures from the anterior wall of the trachea to the inferior and superior skin flaps.13 These procedures are generally associated with a higher rate of tracheocutaneous fistula postoperatively.14-16
Conclusion Whichever surgical technique is instituted, there are several key factors to consider for successful pediatric tracheotomy. The tracheostomy tube size and type should be chosen before starting the procedure, and additional sizes should be available in the operating room. The neck is extended so the trachea is adequately exposed. Careful vertical dissection in the midline of the neck with continuous palpation of the trachea will help to avoid lateral retraction of the trachea and resultant injuries. Placement of stay sutures before making a tracheal incision helps both to elevate and expose the trachea intraoperatively and to assist with replacement of the tube in the event of accidental decannulation. Commu-
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Pediatric Tracheostomy
nication with the anesthesiologist throughout the procedure is essential, as is education to the ICU staff regarding use of stay sutures for emergency recannulation.
References 1. Cochrane LA, Bailey CM: Surgical aspects of tracheostomy in children. Paediatr Respir Rev 7:169-174, 2006 2. Hadfield PJ, Lloyd-Faulconbridge RV, Almeyda J, et al: The changing indications for paediatric tracheostomy. Int J Pediatr Otorhinolaryngol 67:7-10, 2003 3. Pereira KD, MacGregor AR, McDuffie CM, et al: Tracheostomy in preterm infants: Current trends. Arch Otolaryngol Head Neck Surg 129:1268-1271, 2003 4. Sidman JD, Jaguan A, Couser RJ: Tracheotomy and decannulation rates in a level 3 neonatal intensive care unit: A 12-year study. Laryngoscope 116:136-139, 2006 5. Bluestone CD, Rosenfeld RM: Tracheotomy, in Bluestone CD, Rosenfeld RM (eds): Surgical Atlas of pediatric Otolaryngology. Hamilton, Ontario, Canada, BC Decker Inc, 2002, pp 587-596 6. Carr MM, Poje CP, Kingston L, et al: Complications in pediatric tracheostomies. Laryngoscope 1117:1925-1928, 2001
217 7. Ruggiero FP, Carr MM: Infant tracheotomy: Results of a survey regarding technique. Arch Otolaryngol Head Neck Surg 134:263-267, 2008 8. Pereira KD, Weinstock YE: Bronchoscopy assisted neonatal tracheostomy (BANT): A new technique. Int J Pediatr Otorhinolaryngol 71: 211-215, 2007 9. Hotaling AJ, Robbins WK, Madgy DN, et al: Pediatric tracheotomy: A review of technique. Am J Otolaryngol 13:115-119, 1992 10. Gilmore BB Jr, Mickelson SA: Pediatric tracheotomy. Controversies in management. Otolaryngol Clin North Am 19:141-151, 1986 11. Waki EY, Madgy DN, Zablocki H, et al: An analysis of the inferior based tracheal flap for pediatric tracheotomy. Int J Pediatr Otorhinolaryngol 27:47-54, 1993 12. Koltai PJ: Starplasty: A new technique of pediatric tracheotomy. Arch Otolaryngol Head Neck Surg 124:1105-1111, 1998 13. Craig MF, Bajaj Y, Hartley BE: Maturation sutures for the paediatric tracheostomy—An extra safety measure. J Laryngol Otol 119:985987, 2005 14. Kremer B, Botos-Kremer AI, Eckel HE, et al: Indications, complications, and surgical techniques for pediatric tracheostomies—An update. J Pediatr Surg 37:1556-1562, 2002 15. Sautter NB, Krakovitz PR, Solares CA, et al: Closure of persistent tracheocutaneous fistula following “starplasty” tracheostomy in children. Int J Pediatr Otorhinolaryngol 70:99-105, 2006 16. Solares CA, Krakovitz P, Hirose K, et al: Starplasty: Revisiting a pediatric tracheostomy technique. Otolaryngol Head Neck Surg 131: 717-722, 2004
Pediatric tracheostomy Emily F. Boss, MD From the Division of Pediatric Otolaryngology, Department of Otolaryngology—Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland. KEYWORDS: Tracheotomy; Tracheostomy
Tracheotomy is most commonly performed in children who are less than 1 year of age. The most common indication is for prolonged ventilatory support secondary to lung disease of prematurity. Tracheotomy is also performed for children with anatomic upper airway obstruction or children with neurodevelopmental delay who require pulmonary toilet. Surgical approaches to tracheotomy are designed to minimize trauma, establish a mature tracheocutaneous fistula, and avoid devastating postoperative complications, such as accidental decannulation. This article details a straightforward stepwise surgical approach to tracheotomy in children. © 2009 Elsevier Inc. All rights reserved.
Tracheotomy is a surgical procedure that has been performed in children since the 17th century. Historically, the most common indication for a tracheostomy was the acute relief of airway obstruction caused by respiratory infections, such as diphtheria, epiglottitis, or croup. In modern times, however, this paradigm has shifted because of a marked improvement in neonatal intensive care and survival of premature infants. Tracheostomy is now most commonly performed for children who require prolonged ventilatory support or who fail extubation secondary to congenital or acquired laryngeal or tracheal abnormalities.1,2 More tracheostomies are performed in children within the first year of life than in any other pediatric age group. Still, the incidence of tracheostomy among infants admitted to a neonatal intensive care unit (ICU) is 0.5%-3% and is declining.3,4 The terms tracheotomy and tracheostomy can be easily confused and are often used interchangeably. Tracheotomy refers to the surgical procedure itself (“to cut the trachea”). Tracheostomy refers to the hole or fistula that is created (“to furnish the trachea with an opening”).
The author has not received financial support or funding from any source in creation of this manuscript. Address reprint requests and correspondence: Emily F. Boss, MD, Division of Pediatric Otolaryngology, Department of Otolaryngology— Head and Neck Surgery, The Johns Hopkins Outpatient Center, 601 N. Caroline Street, 6th Floor, Baltimore, MD 21287. E-mail address: [email protected]. 1043-1810/$ -see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.otot.2009.10.004
Indications There are 3 major indications for tracheostomy in children: prolonged ventilatory support, upper airway obstruction, and pulmonary toilet. The most common indication for tracheostomy in children is prolonged ventilatory support. With the advent of improved neonatal care in recent decades, premature infants can be delivered at younger ages and sustained for longer periods in the setting of chronic lung disease of prematurity (bronchopulmonary dysplasia). Because of the development of softer polyvinyl chloride endotracheal tubes, infants may be intubated for weeks to months with less risk of airway trauma secondary to prolonged intubation. Tracheostomy is indicated when safe extubation is not possible because of chronic lung disease or systemic comorbidities. Upper airway obstruction is another common indication for tracheostomy in children. Although many etiologies exist for debilitating upper airway obstruction in children, some principle anatomic diagnoses include subglottic stenosis, tracheomalacia, or bilateral vocal fold paralysis. Some children with craniofacial syndromes may require tracheostomy secondary to severe micrognathia, glossoptosis, macroglossia, or generalized oropharyngeal crowding. Neoplastic conditions are rare causes of upper airway obstruction, but they may include respiratory papillomatosis and subglottic hemangiomas.
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Pediatric Tracheostomy
Table 1
213
Common age-appropriate tube types and sizes Shiley®
Bivona®
Age
Suggested ID for age
ID
Premature ⬍1 kg
2.5
2.5 (neo)
3.0
3.0 (neo)
Neo to 6 mo
3.0-3.5
6 mo-1 yr
3.5-4.0
1-2 yr ⬎3 yr
4.0-4.5 (Age in yr ⫹ 16)/4
3.5 (neo) 3.5 (peds) 4.0 (neo) 4.0 (peds) 4.5 5.0 5.5 4 adult 6 adult
1 kg-2.5 kg
Length
ID
30 39 32 40 34 41 42 44 46
2.5 2.5 3.0 3.0 3.5 3.5 4.0 4.0 4.5 5.0 5.5
Length (neo) (peds) (neo) (peds) (neo) (peds) (neo) (peds)
30 38 32 39 34 40 36 41 42 44 46
ID, inner diameter in millimetres; Length, length of tube shaft in millimetres. Shiley® (Shiley Laboratories, Irvine, CA) tracheostomy tubes come as cuffless, cuffed, or fenestrated. A pediatric long Shiley tube as well as an adjustable length Shiley tube are also available measuring up to 80 mm in length. Bivona® (Bivona Corporation, Gary, IN) tracheostomy tubes come cuffless or cuffed (TTS, tight to shaft).
A minority of patients who are neurologically impaired require tracheostomy to assist with ventilation, to prevent chronic aspiration, and to facilitate pulmonary toilet. These children are generally older at the time of tracheostomy, often having experienced multiple hospital admissions for upper respiratory infections and pneumonia. Nearly all of these children are fed through a gastrostomy tube for improved relief of aspiration.
Technique Pediatric and adult tracheostomy differ in many ways, as tracheostomy in children is associated with significantly greater morbidity and mortality. The pediatric airway is small, soft, and pliable, and overzealous retraction intraoperatively may lead to disorientation, lateral dissection, and accidental injury to the lung or a major vessel. The pediatric larynx is located higher in the neck than the adult larynx, and therefore careful extension and exposure are critical aspects of a successful procedure. Neonates may have very poor pulmonary reserve or severe systemic comorbidities, and any temporary loss of airway patency both intraoperatively or postoperatively could lead to severe complications including death. Given these factors, numerous precautions are taken to prevent complications associated with pediatric tracheostomy. Preoperative evaluation of the patient is necessary for planning and patient safety. The neck is inspected for landmarks, excessive fat, central lines, or scars from former vascular access or surgery. If the patient is intubated, the size and position of the endotracheal tube and presence of air leak around the tube are noted. An appropriately sized tracheostomy tube is selected and made available in the operating room. Tubes 1 size smaller and larger than the
selected tracheostomy tube should also be available. Standard tracheostomy tube diameters and lengths for age are depicted in Table 1. Principles to consider when selecting a tracheostomy tube include the inner and outer diameter (tubes are typically sized according to the inner diameter), tube length (neonatal, pediatric, pediatric long, or adjustable), and presence or absence of a cuff (Figure 1). In general, the tube with the smallest lumen that will maintain adequate ventilation is indicated to minimize mucosal trauma. The distal tip of the tracheostomy tube should lie 7-20 mm proximal to the carina. Pediatric tracheostomy is performed under general anesthesia with the airway secured by an endotracheal tube. Some surgeons prefer to first perform rigid bronchoscopy, leaving the rigid bronchoscope to ventilate the patient and
Figure 1 Standard tracheostomy tubes. Left, a Shiley® 3.5 pediatric cuffless tube (inner diameter 3.5 mm, length 40 mm). Right, a Bivona® 3.5 neonatal cuffed tube (inner diameter 3.5 mm, length 34 mm). (Color version of figure is available online.)
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serve as a firm airway stent over which to perform tracheotomy. The patient is generally placed on a shoulder roll for ideal exposure of the laryngeal and tracheal cartilages. Frequently skin and pannus are retracted from the surgical site with tape to facilitate exposure and easy access to the airway. Time spent gaining proper positioning and exposure before draping is valuable and can mitigate difficulty later in the procedure. The patient is prepared and draped so the face and mouth are exposed and easily accessible should the orotracheal airway need to be reestablished. The neck is carefully palpated, and the thyroid cartilage, cricoid cartilage, and sternal notch are marked (Figure 2). Occasionally, the hyoid bone may obscure the thyroid cartilage. The incision site is planned approximately one-third to one-half distance between the cricoid cartilage and the sternal notch, and a weight-appropriate dosage of topical lidocaine with epinephrine is injected. A horizontal skin incision is made and extended through the subcutaneous tissue. Subcutaneous fat is grasped and removed with electrocautery. “Defatting” is performed to improve exposure and to help the tracheocutaneous stoma mature more quickly (Figure 3). Using opposing traction, the fascia overlying the strap musculature is elevated with forceps and divided with scissors (Figure 4). Next the scissors or a hemostat are used to bluntly dissect the strap musculature along the avascular midline raphe in the vertical plane. As the midline plane is created, the strap muscles are elevated and gently retracted laterally. Care should be taken not to aggressively retract the musculature, as sometimes the trachea is also mistakenly pulled laterally with the retractors. The trachea is palpated repeatedly throughout this dissection to confirm that the dissection is indeed in the appropriate midline trajectory. Extensive dissection lateral to the trachea may lead to disorientation and resultant vascular injury or pneumothorax. Frequently the thyroid isthmus is encountered overlying the trachea deep to the strap musculature. If encountered, the isthmus may be carefully undermined and retracted
Figure 2 The patient is placed on a shoulder roll, and the thyroid cartilage, cricoid cartilage, planned horizontal incision site, and sternal notch are clearly marked.
Figure 3 A horizontal incision has been made one-third to one-half distance from the cricoid to the sternal notch, and now the subcutaneous fat is removed with electrocautery. The fat is grasped with a forcep and elevated to facilitate removal. To expose the fat, the skin incision is retracted with digital manipulation or skin hooks.
superiorly until the trachea is well visualized. Alternatively, the thyroid isthmus may be elevated and divided with cautery. I typically identify the cricoid cartilage, elevate the isthmus from the pretracheal fascia with a right-angled hemostat, and divide the isthmus with cautery over the hemostat. Caution is used when dividing the isthmus to avoid accidental airway entry or fire. At this point, the trachea is well visualized with the strap musculature and thyroid isthmus retracted laterally on either side. A peanut may help to bluntly sweep away any remaining soft tissue or fascia that is obscuring the airway. A cricoid hook may be placed to improve positioning of the
Figure 4 After the subcutaneous fat is removed, fascia overlying the strap muscles is grasped using opposing traction and sharply divided with a scissors. The scissors are then used to bluntly dissect the avascular midline muscular raphe, and the musculature is retracted laterally. The trachea is palpated throughout this step to confirm midline dissection.
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trachea. The anesthesiologist should be alerted that the airway is being manipulated and will soon be entered. “Stay” sutures are placed through the cartilaginous rings on either side of the planned vertical incision in the trachea. Nonabsorbable sutures such as 3-0 polypropylene are preferred. The sutures should be positioned securely through the tracheal cartilage when not breaching the tracheal mucosa. Stay sutures serve to assist both in elevation of the trachea intraoperatively and also in facile exposure of the tracheotomy incision if a tube needs to be replaced due to an accidental decannulation in the immediate postoperative period. A vertical incision is now made through the second and third cartilaginous rings until the tracheal lumen is visualized. The stay sutures are retracted laterally to better expose the incision (Figure 5). A hemostat may be spread in the tracheal incision to provide improved visualization of the lumen and endotracheal tube. The endotracheal tube is retracted slowly until the tip lies proximal to the superior side of the tracheal incision, but it is not withdrawn from the larynx. The tracheostomy tube is inserted using an obturator for guidance. The ventilator circuit is connected to the tracheostomy tube, and a small breath is administered. Aggressive positive pressure ventilation is avoided until tube positioning within the lumen is confirmed to avoid subcutaneous air dissection. When end tidal CO2 is detected, the cricoid hook and skin retractors are removed. The tracheostomy tube is secured with ties that fit snugly around the neck, permitting 1 finger width under the tie, with the neck in neutral to flexed position. Although surgeon preference varies, the tracheostomy is generally not sutured to the skin so that any dislodgement of the tube would be more quickly recognized and managed. A flexible bronchoscope is passed through the lumen of the tracheostomy tube and used to visualize the trachea to the level of the carina and mainstem bronchi to assess proper positioning and length of the tube. The stay sutures are carefully marked to indicate right and left sides, and they are affixed to the chest with adhesive (Figure 6). A chest x-ray is obtained immediately after surgery to evaluate for pneumothorax and tube position. Postoperatively, the patient is managed in an ICU until the first tracheostomy tube change. The ICU nurses and physicians are educated regarding the function of the stay sutures in the event of tube dislodgement. The patient is examined daily for any skin breakdown from the ties, displacement of the stay sutures, or purulent respiratory secretions. The first tracheostomy tube change is performed between postoperative day 5 and 7, after there has been an adequate time for the tracheocutaneous fistula to mature.
Complications Complications of tracheostomy are common and may occur up to 70% of the time.6 Tracheostomy-related mortality occurs in as many as 4% of patients and is most often secondary to mucous plugging or accidental decannulation.
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Figure 5 The thyroid isthmus has been divided, and the visualization of the tracheal cartilages is improved with a cricoid hook. Polypropylene stay sutures (3-0) are now placed 3-5 mm lateral to the planned incision site through the second and third tracheal cartilages. The vertical midline dashed line indicates the planned tracheal incision site (A). The vertical tracheal incision is exposed by stay suture and cricoid hook refraction (B).
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Figure 6 After incision of the trachea and confirmed insertion of the tracheostomy tube, the tracheostomy tube is secured snugly with ties, and the stay sutures are clearly marked right and left and affixed to the chest for easy identification and use in the event of an accidental decannulation. (Reprinted with permission.5)
Complications may occur during the operation, in the immediate postoperative period, and weeks, months, or years after tracheotomy in the delayed postoperative period. Intraoperative hemorrhage can be prevented with careful tissue dissection and midline orientation. Stomal granulation tissue can develop postoperatively from tube movement and irritation in the tracheocutaneous fistula. Excessive granulation tissue may make tube changes difficult and bloody. Stomal granulation may be observed, cauterized at the bedside, or excised, as they frequently recur. Tracheal suprastomal granulation or stenosis may occur postoperatively due to tube irritation of the tracheal mucosa. Tracheal stenosis may develop if the tube is placed too close to the cricoid cartilage, or if the tip or cuff causes pressure necrosis on the tracheal mucosa and cartilage. These changes often require surgical removal or reconstruction, particularly if decannulation is anticipated. Perhaps the most common complication of tracheostomy is persistence of the tracheocutaneous fistula after decannulation, occurring up to 40% of the time. Frequently the fistula will persistently drain, irritate the skin, and hinder sound and speech projection. As previously stated, the most severe complications of tracheostomy are accidental decannulation and tracheostomy tube plugging. Accidental decannulation can occur any time after the procedure and may be due to a small tube size, short tube length, or excessive patient motion in the setting of an immature tract. Mucous plugging may be prevented with humidification, careful suctioning of the tube, and routine tracheostomy tube changes.
Discussion A recent survey of pediatric otolaryngologists evaluated the variability of techniques used in pediatric tracheostomy and identified that most pediatric otolaryngologists perform the
steps listed above when performing the procedure, particularly making a horizontal skin incision, defatting the subcutaneous tissue, dividing the thyroid isthmus with electocautery, placing stay sutures, entering the trachea with a vertical incision, and securing the tracheostomy tube with ties.7 Because of the complexity of the pediatric airway and the potential severity of complications of tracheostomy in children, numerous surgical techniques have been proposed throughout recent decades that warrant mention. To avoid inadvertent dissection lateral to the trachea in the difficult neonatal airway, Pereira8 proposed bronchoscopy assisted neonatal tracheostomy. This technique involves direct visualization of the trachea and ventilation with rigid bronchoscopy. After skin incision, an angiocath is placed in the tracheal midline inferior to the first tracheal ring, and a guidewire is passed through it and grasped from within the bronchoscope. The wire is then used to elevate the pliable trachea so that dissection may be facilitated without repeated palpation of the trachea. Some surgeons prefer to make a vertical skin incision as opposed to horizontal skin incision because of the ease of exposure during surgery and access to the trachea should the tube become dislodged, however a horizontal incision may tend to leave a more cosmetically acceptable scar after decannulation.9 Numerous techniques of tracheal entry and stomal sutures have been proposed to limit postoperative accidental decannulation, tracheal stenosis, or anterior tracheal wall collapse. Although most pediatric otolaryngologists make a vertical incision in the trachea,7 many prefer to make a horizontal incision in the trachea with an inferior flap sutured to the skin as initially described by Bjork.10,11 Koltai12 proposed a starplasty procedure to reduce the risk of pneumothorax and to facilitate replacement of the tracheostomy tube if it should accidentally become dislodged. This procedure creates a cruciate incision in the skin and trachea, and affixes the tracheostomy flaps to the skin flaps with sutures to create a more formal stoma. Another method of creating a more permanent stoma is with placement of maturation sutures from the anterior wall of the trachea to the inferior and superior skin flaps.13 These procedures are generally associated with a higher rate of tracheocutaneous fistula postoperatively.14-16
Conclusion Whichever surgical technique is instituted, there are several key factors to consider for successful pediatric tracheotomy. The tracheostomy tube size and type should be chosen before starting the procedure, and additional sizes should be available in the operating room. The neck is extended so the trachea is adequately exposed. Careful vertical dissection in the midline of the neck with continuous palpation of the trachea will help to avoid lateral retraction of the trachea and resultant injuries. Placement of stay sutures before making a tracheal incision helps both to elevate and expose the trachea intraoperatively and to assist with replacement of the tube in the event of accidental decannulation. Commu-
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nication with the anesthesiologist throughout the procedure is essential, as is education to the ICU staff regarding use of stay sutures for emergency recannulation.
References 1. Cochrane LA, Bailey CM: Surgical aspects of tracheostomy in children. Paediatr Respir Rev 7:169-174, 2006 2. Hadfield PJ, Lloyd-Faulconbridge RV, Almeyda J, et al: The changing indications for paediatric tracheostomy. Int J Pediatr Otorhinolaryngol 67:7-10, 2003 3. Pereira KD, MacGregor AR, McDuffie CM, et al: Tracheostomy in preterm infants: Current trends. Arch Otolaryngol Head Neck Surg 129:1268-1271, 2003 4. Sidman JD, Jaguan A, Couser RJ: Tracheotomy and decannulation rates in a level 3 neonatal intensive care unit: A 12-year study. Laryngoscope 116:136-139, 2006 5. Bluestone CD, Rosenfeld RM: Tracheotomy, in Bluestone CD, Rosenfeld RM (eds): Surgical Atlas of pediatric Otolaryngology. Hamilton, Ontario, Canada, BC Decker Inc, 2002, pp 587-596 6. Carr MM, Poje CP, Kingston L, et al: Complications in pediatric tracheostomies. Laryngoscope 1117:1925-1928, 2001
217 7. Ruggiero FP, Carr MM: Infant tracheotomy: Results of a survey regarding technique. Arch Otolaryngol Head Neck Surg 134:263-267, 2008 8. Pereira KD, Weinstock YE: Bronchoscopy assisted neonatal tracheostomy (BANT): A new technique. Int J Pediatr Otorhinolaryngol 71: 211-215, 2007 9. Hotaling AJ, Robbins WK, Madgy DN, et al: Pediatric tracheotomy: A review of technique. Am J Otolaryngol 13:115-119, 1992 10. Gilmore BB Jr, Mickelson SA: Pediatric tracheotomy. Controversies in management. Otolaryngol Clin North Am 19:141-151, 1986 11. Waki EY, Madgy DN, Zablocki H, et al: An analysis of the inferior based tracheal flap for pediatric tracheotomy. Int J Pediatr Otorhinolaryngol 27:47-54, 1993 12. Koltai PJ: Starplasty: A new technique of pediatric tracheotomy. Arch Otolaryngol Head Neck Surg 124:1105-1111, 1998 13. Craig MF, Bajaj Y, Hartley BE: Maturation sutures for the paediatric tracheostomy—An extra safety measure. J Laryngol Otol 119:985987, 2005 14. Kremer B, Botos-Kremer AI, Eckel HE, et al: Indications, complications, and surgical techniques for pediatric tracheostomies—An update. J Pediatr Surg 37:1556-1562, 2002 15. Sautter NB, Krakovitz PR, Solares CA, et al: Closure of persistent tracheocutaneous fistula following “starplasty” tracheostomy in children. Int J Pediatr Otorhinolaryngol 70:99-105, 2006 16. Solares CA, Krakovitz P, Hirose K, et al: Starplasty: Revisiting a pediatric tracheostomy technique. Otolaryngol Head Neck Surg 131: 717-722, 2004