Indications
Tracheostomy is used to bypass an obstructed upper airway ( ▶ Fig. 23.1; ▶ Table 23.1 a). It reduces the respiratory “dead space” and permits easier instrumentation, including suctioning, of the tracheobronchial tree. It obviates the need for prolonged endotracheal (ET) intubation and facilitates respiratory ventilation ( ▶ Table 23.1 b) in ventilated patients. Home ventilation is now frequently used in children with conditions that in the past would not have been treated or would have meant long-term inpatient care ( ▶ Table 23.1 b,c) and is an increasingly common indication for tracheostomy.
Fig. 23.1 Tracheostomy in a child with a large lymphangioma of the head and neck, extending into the tongue and obstructing the airway.
| Craniofacial syndromes, e.g., Treacher Collins’ and Goldenhar’s syndromes |
Severe macroglossia | |
Subglottic stenosis | |
Large lymphangioma | |
| Head injury |
Coma | |
Severe bronchopulmonary dysplasia | |
| Tracheobronchomalacia |
Severe sleep apnea (some forms) | |
Abbreviation: PICU, pediatric intensive care unit. | |
23.3 Emergency Tracheotomy
An emergency opening into the trachea can save a child who presents with complete or near-complete upper airway obstruction. This was a frequent occurrence in the preantibiotic era when diphtheria and epiglottitis were commonplace and steroids were not widely used in the management of acute laryngotracheobronchitis (ALTB) or “croup.” Pediatricians and anesthesiologists were less skilled at managing ET intubation in the very young. A tracheotomy “in extremis” is now a very rare procedure, and a scheduled operation under optimum conditions with skilled pediatric anesthesia is much to be preferred.
A child can nearly always be managed by airway supportive measures such as “bag and mask” or by ET intubation prior to a planned tracheostomy.
In a desperate situation, you can make an opening into the trachea using a large bore needle to puncture the cricothyroid membrane (cricothyroidotomy; see ▶ Fig. 20.3).
23.4 Preoperative Planning
Traditional advice has been that tracheostomy is preferable to “prolonged” intubation, that is, use of an ET tube for more than a few weeks. With modern-day ET tubes causing much less tissue trauma and with improved neonatal care and better overall management of very sick children, particularly premature neonates, ET intubation can now be prolonged often for several weeks before a tracheostomy is needed. Tracheostomy is typically considered when it becomes clear that a child who is being managed by ET intubation is unlikely to cope without some form of airway support. Often one or more attempts will have been made at extubation.
The parents or carers of a child needing a tracheostomy, and in the case of the older child the child him/herself, will need careful and detailed preoperative counseling. 2 In addition to an explanation of the condition and its natural history, with and without a tracheostomy, they should be aware of the possible complications and of the postoperative concerns as detailed in the next section. The child will initially be unable to vocalize, including crying, a prospect parents often find very distressing. 3, 4 If home care of the child is planned, then the parents should be trained in how to change the tube, how to suction the trachea, how to ensure optimum humidification, and in basic resuscitation techniques. It can be useful to show them a variety of tracheostomy tubes, introducers and suction equipment using a teaching doll or mannequin (see below) prior to surgery.
23.5 Special Considerations in Children
The principles that govern tracheostomy apply to both adults and children, but there are some factors that make pediatric tracheostomy very different. The child has a short fat neck, and the surgical landmarks may be very close together. The trachea is much softer and less well anchored than in an adult and easily rolls away to one side when palpated. This, coupled with its small caliber and its proximity to surrounding structures such as the carotid sheath, can make the trachea difficult to identify, particularly if the surgeon is inexperienced or if there is no ET tube in place. The small caliber of the trachea means that only a small diameter tube can be used. Pediatric tubes are typically single, that is, there is no “inner” and “outer” tube as in adults as this would reduce lumen of the tube. There is rarely room to accommodate a cuff, so pediatric tracheostomy tubes are generally uncuffed except for in the older child.
Children are inclined to produce brisk inflammatory responses to foreign bodies (i.e., a tracheostomy tube). Peristomal granulations and granulation tissue at the site of the lower end of the tube where it abuts the tracheal wall are common and can give rise to bleeding and obstruction.
For this reason, fenestrated tubes are almost never used in children—the fenestra is liable to become blocked by inflammatory tissue.
Some technical issues of particular importance in children are discussed next, for example, the need to be extra cautious to avoid the possibility of tracheal stenosis by avoiding the removal of any cartilage and the need to ensure that there is a good gap between the end of the tube and the carina given the very short length of the trachea especially in the newborn.
23.6 Technique
The operation is almost invariably carried out under general anesthesia, often, but not always, with an ET tube in position.
Position the child with the head stabilized in a rubber head ring and use a small shoulder roll to lift the upper chest. A standard sandbag is good for older children, but in babies, a rolled up draping towel placed under the shoulders is gentler. Be careful not to overextend the head or to use too bulky a shoulder support as otherwise the thoracic vessels, particularly the brachiocephalic vein, may be pulled into the neck where they are at risk during dissection. An adhesive tape under the child’s chin and extending on either side to the head of the table helps to keep overhanging skin and soft tissue away and makes for an easier approach to the neck, particularly if the baby is a little “pudgy.”
Once the skin is prepared with a disinfectant and the child is draped, identify the landmarks: suprasternal notch, the trachea, the cricoid and thyroid cartilages, and the tracheal rings, and mark the site of incision halfway between the suprasternal notch and the cricoid.
An injection of local anesthetic and a vasoconstrictor (the author uses “Lignospan” [Septodont] cartridges, which contain lidocaine and epinephrine) helps minimize bleeding.
Make a transverse skin incision and secure hemostasis with precise bipolar diathermy, tying the anterior jugular veins if they are bulky and get in the way. A little subcutaneous fat is inclined to prolapse through the skin wound and can be removed to facilitate access to the deeper structures ( ▶ Fig. 23.2).
Incise the platysma. Separate and move the strap muscles laterally to expose the pretracheal fascia. If the thyroid isthmus is bulky and obscuring a good view of the trachea, it can be divided using monopolar diathermy but more often than not it can be left intact.
Clean away the pretracheal fascia to expose the tracheal rings, making absolutely certain that you have identified the trachea to your own satisfaction and that of your assistant. There is rarely a need for extensive opening up of tissue planes, and if you confine your dissection as close as possible to the midline, the risk of trauma to adjacent structures, and the risk of troublesome bleeding, is minimized.
If the child is intubated, you will feel the ET tube, which you can roll between finger and thumb. Count the tracheal rings up to the cricoid and prepare to incise the trachea vertically exactly in the midline between the second and fourth tracheal rings.
Now place two stay sutures in the trachea, one on each side of the midline, and secure them with a knot well away from the trachea so they are easy to remove postoperatively. Make sure they are securely anchored in the tracheal cartilage as they can easily pull out if they are tentatively placed in the fascia.
Liaise carefully with the anesthetist so that he/she knows you are about to open the airway.
Check the tracheotomy tube. Make sure it is patent and that the introducer slides easily in and out as you can very occasionally get a poorly fitting introducer or a defective tube. A little lubricant jelly on the tip of the introducer helps to get it into position.
Now ask your assistant to use the stay sutures to gently elevate the trachea and stabilize it as you incise it ( ▶ Fig. 23.3). Make your incision and extend it upward, staying well below the first tracheal ring.
Now insert and position the tracheostomy tube as the anesthetist gradually withdraws the ET tube.
The breathing circuit is now quickly attached to the tracheostomy tube and assuming the tube is correctly positioned, the anesthetist will soon detect carbon dioxide in the exhaled gases and both lungs will be easily ventilated.
Many surgeons now recommend that the cut edges of the tracheal wall be sutured to the skin edge (maturation sutures) to make for easier tube replacement and to facilitate the development of a stoma. 5
Before securing the flanges, it is the author’s practice to check the position of the lower end of the tube using a flexible endoscope, measuring first the distance from the upper opening of the tube to the carina and then withdrawing the endoscope to exactly the lower end of the tube and ensuring that this end is at least one centimeter above the carina, otherwise the tube is too long and may slip down into a bronchus, causing difficulty with ventilation of one lung in the postoperative period.
Place the free ends of the stay sutures on the child’s chest wall, taping them in place. Some units prefer to label them “right” and “left” to avoid the confusion that can arise in a fraught situation where the stay sutures need to be used to help open the stoma for rapid tube replacement.
Now position the tapes around the child’s neck so as to leave a good finger’s width between the tape and the neck ( ▶ Fig. 23.4). Some units recommend suturing the flanges to the skin for extra security.
Fig. 23.2 Removing subcutaneous fat.
Fig. 23.3 Stay sutures help to open the trachea to facilitate insertion of the tube.
Fig. 23.4 Tracheostomy tube in position with tapes secured.
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