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.
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:
As such, there is no absolute contra-indication for tracheostomy. Some relative contraindication is as follows:
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
Equipment required for positioning
Equipment required for monitoring and confirmation of tube placement
Emergency airway equipment
Equipment for the procedure
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.
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.
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.
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