Continuing Education Activity
Tracheostomy has been increasingly performed in children with complex medical conditions for the management of upper airway obstruction, prolonged ventilation, abnormal ventilatory drive, and irreversible neuromuscular conditions. This activity reviews the indication of pediatric tracheostomy, tracheostomy procedure techniques, and their complications in the pediatric population and highlights the role of the interprofessional team in taking care of children with a tracheostomy.
- Describe the indications for tracheostomy in children including the differences in anatomy and physiology between pediatric and adult airway.
- Summarize the equipment required in the operation theater, patient preparation, and technique for doing the pediatric tracheostomy.
- Outline the early as well as late complications associated with a pediatric tracheostomy.
- Review how well-coordinated interprofessional tracheostomy care can significantly reduce adverse events and improve the outcome in patients with tracheostomy.
Surgical access to the trachea has been in practice since ancient times, but the modern era of tracheostomy started with Armand Trousseau, who used it to treat children suffering from diphtheria associated dyspnea in the mid-1800s. The procedure, as we know today, was standardized by Chevalier Jackson in the early 20th century. Tracheostomy is considered a life-saving procedure, but older evidence demonstrates a higher risk in children as compared to adults. The last few decades have seen a dramatic change in indications for tracheostomy in pediatric patients due to better survival of premature infants and those suffering from severe congenital anomalies.
Previously, the most common indication for tracheostomy was upper airway obstruction due to infectious diseases, but now, most of the pediatric tracheostomies are being done for prolonged ventilation, laryngotracheal stenosis, trauma, neurological disorders and airway obstruction due to craniofacial abnormalities. Many clinicians still consider pediatric tracheostomy to be a high-risk procedure, but recent evidence suggests that the inherent risk associated with it is not as high as previously perceived.
Anatomy and Physiology
It is very crucial to understand the difference between pediatric and adult airway anatomy and physiology before planning for the tracheostomy.
The first anatomical difference is that the head of the pediatric patient, which is relatively larger than the body size with prominent occipital protuberance. The larger occiput, along with short neck, makes positioning during tracheostomy relatively difficult in pediatric patients. The tongue in infants and children is larger, while the mandible is smaller in size. Cross-sectional studies of the airway reveal that adult airway is more elliptical than that of the child. The larynx lies at a higher level in children. The location of cricoid cartilage varies with age such that it is located at the C4 vertebral level at the time of birth and C6 in adults.
The vocal cords do not lie at right angles to the trachea; instead, they are inclined at anterior-inferior to the posterior-superior direction. The epiglottis in pediatric patients is more U shaped and may lie across the laryngeal inlet. The airway is narrowest at the level of the cricoid cartilage for children, while for adults, it is at the level of the vocal cords. The cartilaginous part of the pediatric airway is soft and compliant as compared to adults. As a result, they are more susceptible to obstruction with negative pressure ventilation, especially when there is preexisting partial airway obstruction. The mucous membrane covering the supraglottic and subglottic parts of the airway are lax in infants and are more prone to edema when injured or inflamed.
The common indications for tracheostomy in children are as follows:
- Airway obstruction:
- Syndromes with airway anomalies e.g., Treacher Collins syndrome, Nager syndrome, Robin sequence, Beckwith-Wiedemann syndrome
- Congenital anatomical abnormalities such as bilateral vocal cord paralysis, laryngomalacia, subglottic web
- Infectious disease compromising the airway e.g., epiglottis and laryngotracheobronchitis
- Benign pediatric airway tumors e.g., recurrent respiratory papillomatosis
- Extrinsic neck tumors causing airway compression e.g., cystic hygroma
- Unprotected airway, to prevent aspiration, e.g., laryngeal cleft, bulbar palsy
- To assist weaning off from ventilator
- To prevent laryngotracheal stenosis in long-term intubation
- Pulmonary toilet
- As access for ventilation in cases with difficult intubation such as retropharyngeal abscess, post-tonsillectomy bleed, obstructive sleep apnea, foreign body in the trachea, facial burn, etc.
As such, there is no absolute contra-indication for tracheostomy. Some relative contraindication is as follows:
- Local infection
- Distorted or difficult anatomy
- Difficult surgical approach
Instruments and equipment for tracheostomy may be divided into various categories for ease of memory. These are:
For the safety of patient and healthcare worker
- Informed written parental consent
- Mask, gown, gloves, goggles or protective eye shield
Equipment required for positioning
- Sandbag of appropriate size
- Head ring
Equipment required for monitoring and confirmation of tube placement
- Pulse oximeter
- Fibreoptic bronchoscope
Emergency airway equipment
- A crash cart containing various airway equipment
- Resuscitation equipment
Equipment for the procedure
- 5 and 10 ml syringes
- Functioning suction apparatus and catheter of different sizes
- Kidney tray, sponge holder and dressing gauge
- 2 B.P handle with 11/15 blade
- 2 Langenbach retractor of small size
- Small and medium artery forceps
- Cricoid hook
- Tracheal forceps and tracheal dilators
- Different size tracheostomy tube
- Sutures, needle holder and tracheostomy tapes
Personnel required for tracheostomy include anesthetists, surgeons, OT assistants, and nursing staff.
It is essential to ensure that all equipment is available in the operation theatre (OT) and fully functional, as well as informed written parental consent is taken before the procedure. After receiving the patient in the OT, all the standard ASA monitors are attached. The method of induction of anesthesia can be inhalational or intravenous, depending upon anesthetist preference. Orotracheal intubation is done for airway management during tracheostomy. The positioning of the patient is the most important aspect of preparation. The OT table should be adjusted according to the height of the operating surgeon. The patient is positioned supine with sandbag placed between shoulder blades and neck is extended over roll or pillow so that trachea comes close to the skin.
The first step of pediatric tracheostomy is identifying the cricoid cartilage and sternal notch; then, a midline horizontal incision is made between the two landmarks. The incision is deepened up to the strap muscles after dissecting the subcutaneous fat. The strap muscles are displaced laterally, and bipolar cautery is used for hemostasis. Sometimes, isthmus of thyroid obscure the view of the trachea; hence, it can be clamped and divided. The anterior surface of the trachea is identified and exposed over 2 to 4 rings. The two vertically placed stay sutures are taken on either side of the midline, and a vertical midline incision is made on the anterior wall of the trachea between 2 and 4 tracheal rings.
The anesthetist is asked to withdraw the endotracheal tube just below the level of vocal cords. Now, the tracheostomy tube of appropriate size is placed inside the tracheal lumen and connected to the ventilatory circuit for confirming its position. The endotracheal tube is kept at its place till the proper position of the tracheostomy tube is not confirmed. The distal tip of the tracheostomy tube is kept approximately 2 or 3 rings above the carina, which can be confirmed with the help of a flexible fibreoptic bronchoscope. The tracheostomy tube is secured around the neck with the help of tracheostomy ties and stay sutures are labeled as right or left depending upon their position on trachea around the incision and are taped on the anterior chest wall. These stay sutures help to rapidly identify newly created stoma in case of accidental decannulation.
Complications associated with adult tracheostomy are well reported in the literature, which is around 15 percent. However, data regarding complications associated with a pediatric tracheostomy is lacking in the literature. 15 to 19 % of children suffer from tracheostomy related complications. They can range from mild complications requiring no intervention to life-threatening complications. Data from various studies have shown increased complication and mortality in an emergency situation, sick patients, and children. The most common causes of death in children due to tracheostomy are tube obstruction, tube misplacement, and accidental decannulation.
- Air Leak: 3 to 9 % of tracheostomies in pediatric patients is associated with subcutaneous emphysema, pneumothorax, or pneumomediastinum. As a result, a chest radiograph is routinely advised whenever the patient returns to the ward/ICU to check the position of the tube and condition of the chest.
- Hemorrhage: Perioperative bleeding can be stopped by judicious use of cautery and paying fine attention to hemostasis. Most of the bleeding is in the form of capillary ooze from the thyroid gland or inferior thyroid vein, but sometimes significant hemorrhage can occur from aberrant vessels or vascular anomalies. Children with coagulation abnormalities or thrombocytopenia should undergo complete evaluation before undergoing tracheostomy.
- Injury to Surrounding Structures: cricoid cartilage and the tracheal ring should be identified before making an incision, as accidental incision on cricoid cartilage may result in subglottic stenosis. Injury to recurrent laryngeal nerves and esophagus has also been reported during pediatric tracheostomies, which can be prevented with the careful surgical technique.
- Pulmonary Edema: sudden relief of upper airway obstruction due to tracheostomy may result in re-expansion pulmonary edema in pediatric patients.
- Respiratory Arrest: rapid washout of retained carbon dioxide and loss of ventilatory drive may result in respiratory arrest during tracheostomy.
- Injury due to Tracheostomy Tube Placement: Complications like the creation of false passage may occur if the tracheostomy tube is pushed forcefully or the incision on the trachea is too small as compared to the tracheostomy tube. It may also lead to laceration of the posterior wall of the trachea, and sometimes larger size tubes may result in cannulation of the mainstem bronchus.
- Accidental Decannulation: this complication can happen in the immediate postoperative period. It can be prevented by proper patient positioning, correct selection of size, and placement of a tracheostomy tube.
- Mucus Plugging: it may obstruct the tracheostomy tube resulting in respiratory distress. Such complications can be prevented by proper stoma care, humidification, and regular tube changes.
- Granulation Tissue: friction due to movement of the tracheostomy tube and chronic inflammation may lead to the development of peristomal granulation tissue. This complication can be prevented by local wound care and regular tracheostomy tube change and dressing.
- Scar: formation of scar tissue around the stoma may lead to difficulty in changing the tube, and sometimes, stoma needs surgical revision and excision of scar tissue.
- Tracheocutaneous Fistula: it is formed when there is an apposition of skin to the mucous membrane of the trachea. It is common in chronically tracheostomy-dependent children.
- Suprastomal Granuloma: it is one of the commonest complications of longstanding tracheostomy, which is diagnosed by fibreoptic bronchoscopy.
- Suprastomal Collapse: longstanding pressure on the first and second tracheal rings can lead to the development of chondritis, weakening of tracheal ring, which ultimately results in tracheomalacia in the suprastomal region.
- Subglottic Stenosis: high placement of a tracheostomy tube in the airway may result in subglottic stenosis. Other factors that contribute to such side effects are prolonged endotracheal intubation and chronic inflammation. It can be prevented by careful tube placement and stoma care.
- Tracheoesophageal Fistula: Erosion of the posterior wall of the trachea and anterior wall of the esophagus from the distal end of the tracheostomy tube may lead to the development of a tracheoesophageal fistula. It is one of the delayed complications of tracheostomy in children.
- Swallowing Problem: it may occur due to anchoring of trachea to the strap muscles. Sometimes cuff of the tracheostomy tube may result in increased pressure in the esophagus and hypopharynx, causing dysphagia. But tracheostomy should not be considered as a contraindication to oral feeding.
Tracheostomy is one of the most important surgical procedures performed on children. Tracheostomy has become a viable alternative for a clinical condition requiring prolonged mechanical ventilation with the benefit of reducing airway resistance, reducing the need for deep sedation, improving patient comfort, and allowing for proper care of airway. Anesthesiologists, pediatricians, and otolaryngologists need to understand the indications, contraindications, and side effects associated with the procedure. Anesthesiologists need to understand the pathophysiology of the disease and surgeon to understand the neck anatomy so that procedure could be done uneventfully with lesser postoperative complications.
Enhancing Healthcare Team Outcomes
Tracheostomy in children is associated with significant morbidity and mortality. It is believed that the majority of deaths after tracheostomy are not due to tracheostomy but are due to the patient's underlying chronic condition. Complications associated with tracheostomies are well documented, with approximately 20% of patients suffering from some form of tracheostomy-associated complication. Children with tracheostomy are one of the most complicated patients, and they need coordination of pulmonologists, pediatricians, anesthetists, otorhinolaryngologists, cardiologists, respiratory therapists, primary care physicians, nurses, neurologists and equipment specialists for proper care and a better outcome. But the majority of these patients suffer from disorganized care and poor communication between different specialties resulting in poor patient outcomes.
Various studies have demonstrated that tracheostomy related adverse events can be significantly reduced by the implementation of tracheostomy care teams. Data from the previous decade on adult tracheostomy has shown that well-coordinated interprofessional tracheostomy care can significantly reduce adverse events and improve the outcome in patients with tracheostomy.
The International Pediatric Otolaryngology Group, in the year 2016, published recommendations for taking care of pediatric patients with tracheostomy during the perioperative period. The recommendation was targeted to pediatric patients with recent tracheostomies and included preoperative, intraoperative, post-operative care, sedation, and enteral feeding algorithms as well as bedside information sheets. Although no studies have been conducted for validating such recommendations, they are an important step in standardizing pediatric tracheostomy care.