Pediatric Tracheostomy

M. Lauren Lalakea MDChief, 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 cuffReorder 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