Tracheostomy

Nilesh R. Vasan and K. J. Lee

• Pediatric tracheotomies pose special considerations because of differences in anatomy and physiology. Subsequently, the evaluation, surgical technique, and postoperative management for pediatric patients are different compared with adults, and these points will be highlighted. A cricothyroidotomy is to be avoided in infants due to poor landmarks and a higher risk of subglottic stenosis.
  
• The procedure can be performed under general or local anesthesia. Performing this operation under general anesthesia in an operating room, with the airway secured via orotracheal intubation, is the most common and safest technique.
  
• Patients with impending airway compromise require the procedure performed under local anesthesia. In these patients, a general anesthetic would lead to collapse of the upper aerodigestive tract musculature, which the patient is actively using to maintain the airway.
  
• The following should be available: a good headlight and an open tracheostomy instrument tray that includes tracheal dilators, suction, retractors, and a cricoid hook. In pediatric patients, a wide selection of tracheostomy tubes and pediatric bronchoscopes should also be available. The airway can be secured with a ventilating bronchoscope, and a tracheostomy in children can be performed with the bronchoscope in place.