M Lauren Lalakea MD Chief OtolaryngologyHNS Valley Medical Center San Jose CA Clinical Associate Professor Stanford TracheotomyIntroduction Initially procedure of last resort to relieve airway obstruction eg diphtheria epiglottitis ID: 253527
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Pediatric Tracheostomy
M. Lauren Lalakea MDChief, Otolaryngology/HNS, Valley Medical Center, San Jose, CAClinical Associate Professor, StanfordSlide2
Tracheotomy--Introduction
Initially procedure of last resort to relieve airway obstruction, eg diphtheria, epiglottitisHigh expectation for short duration, w decannulationIndications expanded to include access for pulmonary toilet and assisted ventilation (polio)
nathanclarkecommunication.wikispaces.com
Uofmchildrenshospital.orgSlide3
Tracheostomy--Introduction
Current trends:↓trachs for acute airway obstruction↑trachs for prolonged ventilation (>50%)↓
decannulation rate: 28—51%
↑
trach duration: 2 yrs for those decannulated
Avg. age: 2—3 yr, >50% younger than 1 yr
Indications
Airway obstruction
Assisted ventilation
Pulmonary toiletSlide4
Indications
Airway obstructionCongenital:Craniofacial anomaliesBilateral vocal cord paralysisTracheomalaciaLaryngeal anomalyNeoplasmSlide5
Craniofacial Anomaly: Pierre Robinmicrognathia, glossoptosis, cleft palate
php.med.unsw.edu.auSlide6
Bilateral Vocal Cord ParalysisHigh-pitched stridor, CNS etiology
www.drninashapiro.comSlide7
TracheomalaciaInspiratory and expiratory stridor
2011.prepsa.courses.aap.orgSlide8
Laryngeal Anomaly: Glottic Web
wiki.uiowa.eduSlide9
Neoplasm: Lymphangioma
openi.nlm.nih.govSlide10
Indications
Airway ObstructionAcquired:Subglottic stenosisCricoid is a complete ringETT -->mucosal ischemia, necrosisPerichondritis, cartilage injuryProgressive stridor, failed extubationTrach if med and surgical management failRecurrent respiratory papillomatosis
Trauma
emedicine.medscape.comSlide11
Indications
Assisted ventilationCongenital central hypoventilationChronic lung dz, eg BPDNeuromuscular diseasePulmonary toiletNeurologically impaired childrenRecurrent respiratory infections, aspirationSlide12
Timing of Tracheotomy
Controversial in pedi ptsProlonged intubation → risk of airway injuryIncidence of subglottic stenosis low in neonates despite lengthy intubationMeticulous NICU care
Pliable larynx and trachea
Older children and adults:
Consider trach after 2-3 wks of intubation
Consider likelihood that underlying process will reverse/improve Slide13
Pre-Trach Evaluation
Airway obstructionFlexible laryngoscopy—dynamic evaluationRigid laryngoscopy and bronchoscopy with spontaneous ventilationAny treatable conditions?Slide14
Pre-Trach Evaluation
Dynamic evaluation--laryngomalaciaprimehealthchannel.comSlide15
Pre-Trach Evaluation
Assisted Vent + Neurologic DzDiscussion with 1° team, Pulmonary, familyGoals of careAllWt> 1500 gm, FiO2 <60%Hct, coagsInformed ConsentSlide16
Tracheotomy Technique
General Anesthesia, with ETTVs. LMA or bronchoscopePositioning with neck extendedPalpation of landmarks, incision markedPedi larynx is high, cricoid easiest to palpateHorizontal or vertical incision below cricoidSlide17
Tracheotomy Technique
Midline dissected, thyroid isthmus dividedStay sutures placed thru ringsTrachea opened verticallySlide18
Tracheotomy Technique
ETT is withdrawn slightlyAppropriate trach tube placedPosition and adequate ventilation confirmedTube size adjusted prn Excessive leakExcessive lengthSlide19
Tracheotomy Technique
Tube secured with sutures Stay sutures labeled Facilitate tube replacement in case of accidental decannulationTwill tape used around neck to secure trachSnugly tied to prevent dislodgement Slide20
Tracheos
tomy VariationsVertical skin incisionStoma ‘matured’ by suturing skin in 4 quadrants to edges of tracheal incisionAllows easier tube replacement if dislodgedSlide21
Post-Operative Care
Transport directly to ICUCXR to confirm tube position, r/o PTXSedation to minimize risk of accidental decannulation while stoma immatureRoutine suctioning, humidified air“Do not change trach ties”Obturator, extra trach tubes at bedsideSame size, and one size smallerSlide22
Post-Operative Care
First trach changeAt 5-7 days post-op2 ENT MDsNeck extended, fresh tube placedStay sutures removed, ties changedConfirms that stoma is sufficiently mature to allow future changes by non-surgical personnelSedation weaned, transfer out of ICU as appropriateSlide23
Post-Operative Care
‘Hands-on’ caregiver training beginsInfants and young children vulnerable to trach catastrophePedi trach tubes are single canula--require meticulous careGeneral trach care, suctioning techniqueTrach tube changes—q 1-2 wkCPR trainingDischarge planningSlide24
Complications
Complication rates vary, up to 40—50%Early:Accidental decannulationFalse passage, loss of airwayPotential for significant morbidity/mortality↓Risk with:
Adequate sedation/ immobilization
Appropriately sized and secured tube
Close monitoring and nursing care
Stay sutures +/- ‘mature’ stoma to facilitate tube replacement
sciencedirect.comSlide25
Complications: Early
Tube obstruction/ mucus pluggingPotential for significant morbidity/ mortality in kidsSmall diameter single canula, vulnerable age group↓Risk with:Humidified air
Frequent suctioning
Appropriate monitoring
Pneumothorax/ pneumomediastinum 0.6 – 6%
Hemorrhage
Local infection, skin breakdownSlide26
Complications--Late
Tracheal granuloma—39%Stomal, suprastomal, distal↓Risk with meticulous trach care, proper suctioning techniqueSurveillance bronchoscopy, excision to maintain patency
Utmb.edu
tracheostomy.comSlide27
Complications: Late
Tube obstruction/ mucus plugging – 13%Accidental decannulation—12%Caregiver training is criticalAdequate monitoring and home supportLocal infection – 9%Slide28
Complications: Late
Speech delaySmaller trach size allows for better airflow and voicingPassey-Muir valve appropriate for someEarly Start and Speech TxSlide29
Complications: Late
Suprastomal collapse/ malacia – 8%Tracheal or subglottic stenosisArterial erosion/ tracheal-innominate fistula“Sentinel Bleed”TE fistula--acquired
readcube.comSlide30
Complications
Tracheocutaneous fistula: 11-42%Persistent fistula after successful decannulation↑Risk if trach duration > 1 yr90% of ‘Starplasty’ trachs have TC fistulaMay require surgical repair
Death
Trach-related = 0 – 3%
Accidental decannulation / mucus plugging most common
Overall = 8.5 – 19%Slide31
Trach Tubes: Which are Best?
Cuffed vs. uncuffedNeonatal vs. pediatricBivona vs. ShileySingle cannula vs. with inner cannulaMetal vs. plasticAppropriate length and diameter?Fenestrated
Jackson Trach tube
Cuffed Shiley Trach with Inner CannulaSlide32
Trach Tubes: Which are Best?
Fenestrated tubeAllows passage of air up thru vocal cords to facilitate speechMay ↑ aspiration riskMore prone to granulation tissue formation
tracheostomy.comSlide33
Trach Tubes: Which are Best?
Ideal trach tube:Soft enough to conform w/o pressure, injury, discomfortRigid enough to avoid collapseMaterial causes minimal tissue reactionHas inner cannula that can be removed and cleanedNot available for plastic pediatric trachsHas stylet or obturator to facilitate insertionBivona and Shiley meet most criteriaSlide34
Trach Tube Size Guidelines
LengthNeonatal vs. PediNeonatal equivalent diameter vs. Pedi, but 5-8 mm shorter in lengthToo short↑chance of accidental decannulation
Too long
May abrade carina or rest in right mainstem
Longer tubes desirable if tracheal stenosis or malacia
Length confirmed by CXR or flex. endoscopySlide35
Trach Tube Size Guidelines
DiameterToo largeMucosal injury, stenosisInability to voiceToo smallExcessive leak in ventilated ptsInadequate air exchange
Difficult to suction adequately
Pedi trach tubes sized based on inner diameter, correspond to endotracheal tube sizesSlide36
Trach Tube Size Guidelines
Premie, <1000 gm
2.5 neo
Premie, 1000-- 2500 gm
3.0 neo
Neonate – 6 mo
3.0 – 3.5, neo
6 mo -- 1 yr
3.5 – 4.0
1 – 2 yr
4.0 – 5.0
> 2 yrs
Age/4 + 4
Child’s Age Inner Diameter (mm)Slide37
Shiley Pediatric Trach Tubes
Options: Neo, Pedi, Pedi-Long (PDL), Pedi c Cuff (PDC), Pedi-Long c Cuff (PLC)Slide38
Bivona Trachs
Similar sizingNeo and PediCuffed Tubes: TTS (tight to shaft)Excellent option for pts who need cuff
Reorder Code
Size
ID (mm)
OD (mm)
Length (mm)
67P025
2.5mm
2.5mm
4.0mm
38.0mm
67P030
3.0mm
3.0mm
4.7mm
39.0mm
67P035
3.5mm
3.5mm
5.3mm
40.0mm
67P040
4.0mm
4.0mm
6.0mm
41.0mm
67P045
4.5mm
4.5mm
6.7mm
42.0mm
67P050
5.0mm
5.0mm
7.3mm
44.0mm
67P055
5.5mm
5.5mm
8.0mm
46.0mm Slide39
Bivona FlexTend Trach Tubes
Flexible extended length connection ‘built-in’ to trachSlide40
Decannulation
Suitability:Off ventilator, minimal suctioning requirement, no obstructive pathologyTolerates capping/occlusionRecent bronchoscopy is clearProcedure:Admission to ICU, monitoringDownsizing vs removal, occlusive dressingObservation 24-72 hrs