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

Tracheotomy for diphtheria

Good postoperative care

Pierre Bretonneau
Chevalier Jackson
 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?
Inflammatory
diseases of the 50% - 3%
upper airway

Prematurity, 1980 28% - 58%

prolonged
intubation

Congenital 6% - 23%
anomalies

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

Bivona
tracheostomy
tubes

Shiley 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, Schlndorff 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, Schlndorff G Indications,
complications, and surgical techniques for pediatric tracheostomies--an
update. J Pediatr Surg. 2002 Nov;37(11):1556-62
 Complications contd
Early (5-49%) Late (24-100%)
Bleeding Granuloma formation
Pneumomediastinum Tracheomalacia
Subcut emphysema Tracheal stenosis
Accidental decannulation Tracheoesophageal
Wound breakdown 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 contd
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
Timingof 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
Pulmonary evaluation

Indications are met 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