Summary
Pediatric tracheostomy persists as a necessary armament of the airway surgeon despite evolving indications over the past several decades. The primary indications for tracheostomy include airway obstruction, pulmonary toilet, and prolonged need for assisted ventilation. Knowledge of relevant variants between pediatric and adult laryngotracheal anatomy is essential. Multiple techniques for tracheostomy exist, each aimed toward minimization of complication. In patients with anticipated long-term need for tracheostomy or low likelihood of decannulation, a formalized stoma or starplasty tracheostomy should be considered. Early complications of tracheostomy include tube obstruction, air leak, hemorrhage, accidental decannulation, and infection. Late complications include granulomata, tube obstruction, accidental decannulation, tracheal erosion, and airway stenosis or collapse. Tracheostomy-related mortality in pediatric patients occurs at a reported rate of approximately 3%, most commonly from accidental decannulation. The risk of complication from accidental decannulation can be minimized by formalization of the tracheostoma. Successful home care of a child with a tracheostomy depends on careful education of the caregivers prior to discharge on tracheostomy management. In addition, the availability of necessary medical supplies and skilled caregivers is essential. Following tracheostomy, continued airway surveillance in a multi-disciplinary setting facilitates optimal care with regard to daily management, long-term strategic planning for decannulation, and the patient’s global health needs. Ten to 30% of patients in whom decannulation is achieved will have persistence of a tracheocutaneous fistula which may require surgical repair.
42 Pediatric Tracheostomy
42.1 Introduction
When considering pediatric tracheostomy, one must mind the mantra that children are not just small adults. Children undergoing tracheostomy have a higher rate of morbidity than their adult counterparts, and differences in anatomy, pathophysiology, and perioperative management complicate surgical decision-making. Effective interdisciplinary and parental communications are essential to patient well-being. In a field with ever-improving medicine, evolving indications, and growing patients, a thoughtful and individualized approach to airway management is essential.
42.2 Indications
The primary indications for pediatric tracheostomy are airway obstruction, pulmonary toilet, and prolonged need for assisted ventilation. The etiology of airway obstruction can be congenital, acquired, or infectious in nature. With the widespread implementation of vaccination for Haemophilus infuenzae and Corynebacterium diphtheriae and greater facility with endotracheal intubation, there has been a significant decrease in the number of tracheostomies performed for upper airway infections including epiglottitis, laryngotracheobronchitis, and diphtheria over the last 50 years. 1 – 3
Alternatively, increased survival of neonates and children with complex medical needs has led to a commiserate uptrend in the need for tracheostomy in the setting of chronic medical conditions and long-term ventilatory requirement. 1 – 3 Children with neurologic or neuromuscular disorders suffering from hypotonia or inability to manage secretions may require long-term tracheostomy for pulmonary toilet if not obstruction. Similarly, cardiopulmonary disorders including bronchopulmonary dysplasia, respiratory distress syndrome (RDS), and cardiomyopathy may necessitate prolonged ventilator support for which tracheostomy would be indicated.
Currently, established guidelines do not exist regarding the timing of tracheostomy in the intubated pediatric patient. While the pliability of the pediatric airway accommodates longer intubation than an adult, close attention to endotracheal tube selection, cuff pressure, and positioning is required to prevent complications including laryngeal edema, granulation, mucosal ischemia, ulceration, and airway stenosis. The authors recommend evaluation for tracheostomy candidacy following 2 weeks of intubation or more than two unsuccessful attempts at extubation; however, more prolonged intubation, particularly in the neonatal population, may be necessary.
42.3 Surgical Technique
42.3.1 Anatomy
The cartilages of the pediatric laryngotracheal complex are smaller and more pliable than those of their adult counterparts. Their compressibility makes palpation more difficult and increases risk of injury to adjacent structures in comparison to adults. Furthermore, the pediatric larynx is positioned more superiorly in the neck and is often shielded by the hyoid cartilage. The cricoid cartilage is the most prominent structure on palpation and the narrowest point of the airway lumen. It should be noted that due to the small caliber of the pediatric airway, mucosal edema alone can cause significant obstruction; trauma to the airway mucosa should be minimized during all airway procedures.
42.3.2 Traditional Tracheostomy
The patient is positioned on the bed with a roll beneath the shoulders to facilitate extension of the neck, thus bringing the laryngotracheal complex more anterosuperior. In patients with cervical spinal instability or immobility, use of a neutral position may be necessary. A vertical or horizontal incision is marked between the sternal notch and the cricoid cartilage and infiltrated with 1:100,000 epinephrine (▶ Fig. 42.1).
Following skin incision, the subcutaneous tissues are divided with monopolar cautery and the anterior jugular veins are retracted laterally or ligated if needed. Dissection is carried onto the strap muscles, which are divided vertically in the midline raphe and also retracted laterally.
The cricoid cartilage and thyroid isthmus are then identified. The isthmus may be retracted superiorly in some patients, facilitating exposure of the trachea, or dissection may be carried out in the pretracheal plane to elevate the isthmus and divide it with monopolar cautery or suture ligation.
Meticulous hemostasis should be obtained prior to entering the airway, and FiO2 should be reduced to a maximum of 30% in the event electrocautery is needed after incision of the airway. Monopolar cautery is contraindicated in the event that FiO2 cannot be reduced below 30%.
Non-absorbable 3.0 stay sutures are then placed on either side of the planned midline vertical incision through two tracheal cartilages. Tracheal rings 2 and 3 or 3 and 4 may be used depending on exposure. These are labeled “left” and “right” accordingly. A vertical incision is then made in the midline anterior tracheal wall (▶ Fig. 42.2).
During incision, one should avoid rupture of the endotracheal tube balloon. Deflating the balloon prior to incision or advancement of the endotracheal tube past the fourth tracheal ring is the commonly used technique to avoid rupture. The endotracheal tube is then partially withdrawn under direct visualization via the newly created tracheotomy until it is superior to the incision. The tracheostomy tube is inserted, the ventilatory circuit is connected, and the return of end tidal CO2 is confirmed.
The endotracheal tube may then be completely withdrawn from the oral cavity.
The tracheostomy tube is secured using four-point fixation with non-absorbable sutures. The stay sutures are taped to the chest. The skin of the neck is then circumferentially dressed, the authors favor Allevyn or Duoderm, to prevent pressure injury and either a foam or a ribbon collar is placed around the neck, further securing the tracheostomy tube.
42.3.3 Bjork Flap
In older children with adequate tracheal width to accommodate an inferiorly based tracheal flap, the above technique may be modified. As an alternative to vertical tracheal incision, a horizontal incision may be made between rings 2 and 3 or 3 and 4. Using curved Mayo scissors, an inferiorly based flap is created with the cartilaginous ring below the tracheal incision. An absorbable suture is then thrown around the tracheal ring incorporated in the flap and through the inferior midline dermis and secured. This flap aims at safe replacement of a displaced cannula. 4 While commonly used in adult tracheostomy, few direct comparisons of tracheostomy techniques exist, and there is insufficient evidence to consider it standard of care in adult tracheostomy. 5
42.3.4 Starplasty Tracheostomy
Starplasty tracheostomy, originally described by Koltai, is based on the geometry of three-dimensional Z-plasty. A cruciate or x-shaped skin incision is marked halfway between the sternal notch and cricoid cartilage and infiltrated with 1% lidocaine with 1:100,000 epinephrine (▶ Fig. 42.3). Skin is incised and the resulting triangular skin flaps are undermined with scissors (▶ Fig. 42.4). The subcutaneous fat overlying the strap musculature is excised (▶ Fig. 42.5) and the strap muscles are vertically divided in the midline raphe and retracted. The thyroid isthmus, if encountered, is divided.
The pretracheal connective tissues are then dissected bluntly from the trachea and incision is made in the anterior tracheal wall vertically through four tracheal rings. A horizontal incision is then created in the middle of the vertical incision (two tracheal rings above and two below) forming a plus “+” shape (▶ Fig. 42.6). The triangular skin flaps and triangular tracheal flaps are then circumferentially interdigitated with mattressed 5.0 vicryl suture approximating first the tip of the upper tracheal flap to the trough of the upper skin flap (▶ Fig. 42.7a), followed by the trough of the adjacent tracheal flap to the tip of the adjacent skin flap (▶ Fig. 42.7b). The remaining flaps are then approximated in a similar manner until the entire stoma is formalized (▶ Fig. 42.7c).
The authors favor starplasty tracheostomy in patients with an anticipated long-term need for cannulation or low likelihood of decannulation. This technique has been shown to reduce the rate of major complications including pneumothorax and more importantly death from accidental decannulation. However, this technique results almost universally in tracheocutaneous fistula, should the patient no longer require tracheostomy. 6 – 8
In the setting of a formalized stoma, some patients may be candidates for long-term tube-free tracheostomy. This technique was developed by Eliachar for adult patients with obstructive sleep apnea. 9 There are anecdotal uses of tube-free tracheostomy in children, but it remains far from standard of care. Starplasty tracheostomy with its high rate of permanent tracheocutaneous fistula has been used by the authors for tube-free tracheostomy in selected patients.
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