Pediatric Otorhinolaryngology: Diagnosis and Treatment, 1st Ed.

11

Tracheostomy in Children

Roy Rajan and Emily F. Boss

Tracheotomy is defined as the creation of an opening in the neck into the trachea, bypassing the larynx for air circulation. The term derives from the Greek word tome meaning “a cutting.” Tracheostomy refers to the semi-permanent or permanent physical opening between the trachea and the skin. The two terms are often used interchangeably, and likely the semantic difference is negligible. Whereas tracheotomy defines the physical operation itself, tracheostomy is typically used to describe the general procedure and circumstance and will be used as such throughout this chapter.

Nicholas Habicot is credited for performing the first successful pediatric tracheotomy in the 16th century on a child who had tracheal compression secondary to swallowed coins lodged in the cervical esophagus.1 While tracheostomy was performed most often in the remote past to relieve upper airway obstruction in children who had acute infection, prolonged mechanical ventilation is now the most common indication.2 Subglottic stenosis and bilateral vocal cord paralysis are other common indications for tracheostomy. Modern advances in neonatal and pediatric care including vaccination, use of soft polyvinyl chloride endotracheal tubes, and improved education in airway management have contributed to an increase in survival of premature infants without a need for tracheostomy. Today, the decision to perform tracheostomy in a child is generally dictated by the anticipation of long-term cardiopulmonary compromise due to chronic ventilatory or cardiac insufficiency, or by the presence of a fixed upper airway obstruction that is unlikely to resolve for a significant period of time or is not amenable to early surgical treatment.

The mortality related to pediatric tracheostomy is estimated to be as high as 3.6% of the cases, and overall morbidity from this procedure ranges from 22 to 77%.3 While the morbidity associated with tracheostomy has generally decreased, tracheostomy is associated with higher mortality in children than in adults.4 This disparity is partly due to anatomical differences, as children have shorter necks, higher extension of pleura, more pliable tracheal cartilage, as well as decreased pulmonary reserve.

In addition to complications specifically related to the operative procedure, children with tracheostomy can experience tube dislodgement, tracheal stenosis, mucous plugging of the tracheostomy tube, dysphagia, and speech dysfunction. Children, compared with adults, are less often able to signal for help in the event of tube obstruction. These factors, as well as the special care considerations for children with long-term tracheostomy, focus the need for multidisciplinary involvement in the decision to perform tracheostomy in a child. Preoperative counseling and postoperative education and care for the child and family are an essential part of this process.

Indications

Prolonged mechanical ventilation due to respiratory disease or neuromuscular compromise in the neonate is currently the most common indication for pediatric tracheostomy. Anatomic or functional upper airway obstruction is also a common indication for tracheostomy in children. Finally, children with chronic neurological impairment may require tracheostomy to assist with ventilation, decrease risk of chronic aspiration, and facilitate pulmonary toilet.5

Tracheostomy is often recommended for children, most commonly neonates, who require prolonged ventilation due to chronic lung disease (bronchopulmonary dysplasia) or conditions associated with congenital or acquired neurologic, pulmonary, or cardiovascular anomalies. In adults, tracheostomy is typically performed within two weeks of intubation to avoid more permanent laryngeal trauma. In contrast, many infants tolerate intubation for weeks to months without adverse laryngeal effects, and therefore the term “prolonged intubation” is not well-defined in the pediatric population. In recent decades, advances in endotracheal tube materials and attention to correct sizing of endotracheal tubes for the pediatric airway, have allowed extubation of many infants without airway sequelae. In general, tracheostomy is considered when weaning from mechanical ventilation is unlikely and attempts at extubation have failed.

Upper airway obstruction is a broad indication for tracheostomy in children. Airway obstruction from diphtheria and epiglottitis, historically common indications for tracheostomy, have disappeared due to widespread vaccination against diphtheria and Haemophilus influenzae type B. Causes of upper airway obstruction in children that may require tracheotomy include subglottic stenosis, bilateral vocal cord paralysis, congenital airway malformations, and neoplasms. Children with craniofacial syndromes may require tracheostomy for relief of airway obstruction due to micrognathia, glossoptosis, macroglossia, or oropharyngeal/nasopharyngeal crowding, or to facilitate airway management at the time of reconstructive surgery. Children with upper airway neoplasms such as subglottic hemangiomas or recurrent respiratory papillomatosis (RRP) occasionally require tracheostomy for severe obstruction not amenable to other treatments. In cases of RRP, tracheostomy is avoided if at all possible because of concern about distal dissemination of papillomas to the tracheobronchial tree or pulmonary parenchyma, but this procedure may be unavoidable with extensive or refractory disease causing life-threatening airway obstruction.6

Finally, children with neurological impairment may benefit from tracheostomy to relieve dynamic upper airway obstruction from pharyngeal hypotonia, assist with ventilation, help manage chronic aspiration, and most significantly, to facilitate pulmonary toilet. Children with neurological impairment have often experienced multiple hospital admissions for recurrent pneumonia, and most are fed via gastrostomy to reduce the risk of aspiration. These children tend to have a lower probability of decannulation and have a higher mortality following hospital discharge.7 Neurological conditions in children requiring tracheostomy include cerebral palsy, encephalopathy, muscular dystrophy, and traumatic brain injury.

Operative Considerations

Tube Selection

The proper choice of a tracheostomy tube is dictated both by the indication for the procedure and by the age and weight of the child. Tubes are made of metal, polyvinyl chloride, or silicone, the latter two being more popular in recent years due to increased pliability and less adherence by secretions (Fig. 11.1). Metal tracheostomy tubes can facilitate endoscopic laser airway surgery, but long-term use in children is rarely seen. Both diameter and length should be considered when choosing a tracheostomy tube. If the diameter is too large, the tracheal mucosa can be damaged due to pressure, with development of granulation, scarring, and even tracheal stenosis. If the diameter is too small, ventilation may be inadequate because of leak around the tracheostomy tube, and mucous plugging may also occur if a tube is too small for clearance of secretions with cough and suctioning.

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Figure 11.1 Standard pediatric tracheostomy tubes. Left, a Shiley 3.5 pediatric cuffless tube (inner diameter 3.5 mm, length 40 mm). Right, a Bivona 3.5 neonatal cuffed tube (inner diameter 3.5 mm, length 34 mm).

Reprinted with permission from: Elsevier. Boss EF. Pediatric tracheostomy. Operative Techniques in Otolaryngology – Head and Neck Surgery 2009;20(4):212–217.

Tube length is also an important consideration. Ideally the tip of the tracheostomy tube should rest 8 to 20 mm above the carina. Pediatric tracheostomy tubes are available in neonatal or pediatric sizes which differ in length by 8 to 10 mm. In children with airway pathology such as tracheomalacia, tracheal stenosis, or obesity, tracheostomy tubes with customized lengths may be necessary to safely bypass obstructing lesions.

Pediatric tracheostomy tubes are available with and without cuffs. Ventilators may be adjusted to minimize hypoventilation and excessive air leak around a cuffless tube. Cuffed tracheostomy tubes are sometimes useful to provide ventilation when increased inspiratory pressures are required, but these tubes may be associated with a higher risk of tracheal stenosis or pressure ulceration if the cuff pressure is not closely monitored.8 Cuffed tubes may also be more difficult to change in young children, although tubes with low-profile “tight-to-shaft” cuffs have improved this problem.

In general, the tracheostomy tube with the smallest lumen that will maintain adequate ventilation without excessive plugging is selected. Tube size is typically determined based on the weight and age of the child, but may also be determined by an age-based formula (Table 11.1).9 As children grow, the size of the tube should be appropriately adjusted to allow adequate respiration and minimize mucous plugging.

Standard Operative Technique

In most cases, tracheostomy is performed under controlled circumstances with the child intubated under general anesthesia. Urgent tracheotomy in a young child without a secured airway is fraught with disaster. An appropriately sized tracheostomy tube is selected, as well as a smaller tracheostomy tube and uncuffed endotracheal tube, for use in the event of difficult insertion.

Although there are many variations in operative technique, most surgeons approach the procedure in a fairly standard manner.10 The child is positioned with neck extended and the head stabilized. Nasogastric tubes are removed, as the presence of a stiff esophageal tube may complicate palpation of the trachea in small neonates. Local anesthetic is often infiltrated for hemostasis and anesthesia, along a planned horizontal skin incision approximately one-third distance between the cricoid cartilage and the sternal notch. Orientation of the incision varies by surgeon preference; while the more commonly used horizontal skin incision leaves a more cosmetically sensitive scar, a vertical skin incision allows for ease of retraction of soft tissue during the procedure.10 Subcutaneous fat is removed or reflected and the cervical fascia is identified. The strap muscles are separated in the midline along the midline raphe to the thyroid isthmus, which may need to be divided or reflected inferiorly. Care should be taken to avoid aggressive dissection inferiorly or laterally to preserve the integrity of the pleura and prevent vascular injury.

Table 11.1 Tracheostomy Tube Sizing in Children

Tube size (inner diameter) based on child age and weighta

Infants <1 kg

2.5 mm

Infants 1–2.5 kg

3 mm

Term infants (0–6 mo)

3–3.5 mm

Term infants 6–12 mo

3.5–4 mm

Infants 1–2 y

4–4.5 mm

Children > 2 y

(Age in years + 16)/4

Formulaic prediction of tube size in childrenb

Inner diameter (mm)

Outer diameter (mm)

Age (y)/3 + 3.5

Age (y)/3 + 5.5

aAdapted from: Wetmore RF. Tracheotomy. In: Bluestone CD, Stool SE, Alper CM, et al., eds. Pediatric Otolaryngology. Philadelphia: Saunders; 2003:1583–1598.

bAdapted from: Behl S, Watt J. W. Prediction of tracheostomy tube size for pediatric long-term ventilation: an audit of children with spinal cord injury. Br J Anaesth 2005;94(1):88–91.

mo, month(s); y, year(s).

Once the laryngotracheal cartilage is clearly exposed, vertically oriented “stay” sutures are placed on both sides of the midline of tracheal rings 2 to 4 (Fig. 11.2). These sutures can help provide traction during the procedure and help identify the tracheotomy lumen should there be accidental decannulation. The lateral retractors can then often be removed, and the trachea is incised vertically at rings 2 to 4 to enter the airway. A vertical incision has been shown in some studies to have less risk of suprastomal collapse or stenosis than other tracheal incisions.11 If electrocautery is used during the procedure, the inspired oxygen concentration in the anesthesia circuit should be reduced to avoid airway fire.12 With the tracheal lumen well exposed by gentle retraction on the stay sutures, the endotracheal tube is withdrawn under direct view until it lies just proximal to the tracheal incision, and the tracheostomy tube is gently inserted with an obturator. Following connection of the circuit, forceful ventilation is avoided until proper tracheostomy position is confirmed by presence of breath sounds, chest inflation, and end-tidal CO2 on monitors. The tube is usually secured with circumferential cloth neck ties placed and tied with the neck is flexed. Skin sutures, or a combination of sutures and trach ties, are less commonly used.10 Stay sutures are clearly labeled “right” and “left” and secured to the chest. Flexible tracheobronchoscopy may be performed to confirm appropriate positioning of the tracheostomy tube proximal to the carina.

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Figure 11.2 Stay sutures (3–0) are placed lateral to the planned incision site through the second and third tracheal cartilages in preparation for vertical tracheotomy incision.

The stay sutures are left in place until the first tracheostomy tube change, usually at 5 to 7 days after the procedure. The sutures can help provide traction and identify the tracheotomy should there be a decannulation. A chest radiograph may be obtained to check the tube position and identify pneumothorax, but the need for routine postoperative chest films has recently been questioned for asymptomatic patients.13

Alternative Techniques

Because of the complexity of the pediatric anatomy and the potentially severe complications of tube dislodgement in children, several variations in tracheotomy technique have been described. To avoid inadvertent dissection lateral to the trachea and neurovascular injury, Pereira and Weinstock propose bronchoscopy-assisted neonatal tracheostomy.14 This technique involves rigid bronchoscopy to define the trachea with placement of an angiocatheter in the midline of the trachea just inferior to the first tracheal ring. A guidewire is passed through it and grasped from within the bronchoscope. The wire is then used to elevate the surgically exposed trachea and guide operative dissection.

Several variations of tracheal incision and stomal creation have also been proposed to limit postoperative accidental decannulation, tracheal stenosis, or anterior tracheal wall collapse. As opposed to a vertical tracheal incision with stay sutures, some surgeons make a horizontal incision in the trachea with creation of an inferior cartilage flap sutured to the skin as initially described by Bjork15 (Fig. 11.3). An “H”-type, or double Bjork flap, may further minimize risk of accidental decannulation, but is associated with greater incidence of suprastomal collapse.16 Tracheotomy techniques with extensive tracheal flaps may be unwise in infants and neonates, in whom tracheal diameters are small. Koltai proposed a “starplasty,” which is created with a cruciate incision in the skin and trachea. The tracheostomy cartilage flaps are then affixed to the skin flaps with sutures to create a formal stoma (Fig. 11.4).17 Another method of fashioning a more permanent stoma is the use of maturation sutures from the anterior wall of the trachea to the surrounding skin flaps.18 These stoma maturation procedures may increase the incidence of persistent tracheocutaneous fistula after decannulation.2

Percutaneous tracheotomy has become common in the adult population. It is a procedure which can be performed quickly in the intensive care unit setting without the need for operation room personnel or associated costs. The rate of infection with percutaneous tracheotomy is also significantly less than with open techniques in adults.19 The technique has been described in some older children with comparable complication rates to open procedures. Candidates for this procedure must be carefully selected as anatomical obscuration of landmarks such as from morbid obesity or goiter may be contraindications. Experience with the technique is also key to avoiding complications. The technique uses a Seldinger technique to dilate a tracheal opening over a guidewire with visualization from a bronchoscope at the end of an endotracheal tube in the subglottis. Application of percutaneous tracheotomy in children is still novice, and as such it is not recommended in neonates and very young children.

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Figure 11.3 Bjork flap tracheostoma modification.

Reprinted with permission from: Elsevier. Scurry Jr WC, McGinn JD. Operative tracheotomy. Operative Techniques in Otolaryngology – Head and Neck Surgery 2007;18(2):85–89.

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Figure 11.4 Starplasty tracheostoma modification. (A) Corner of trachea is sutured to diagonal skin. (B) Skin is sutured to trachea circumferentially. (C) Final configuration.

Reprinted with permission from: Elsevier. Solares CA, Krakovitz P, Hirose K, Koltai PJ. Starplasty: revisiting a tracheostomy technique. Otolaryngology – Head and Neck Surgery 2004;131(5):717–722.

Complications

Complications of tracheostomy in children, both early and delayed, are outlined in Table 11.2. More common complications are discussed below.

Tracheostomy may result in hemorrhage during or after surgery. The rate of postoperative bleeding is approximately 5 to 7%.2 The thyroid isthmus is a common site for intraoperative bleeding and is usually controlled with electrocautery or suture ligation. Early postoperative hemorrhage may arise from raw mucosal surfaces either from suctioning the trachea or from dissected soft tissues in the neck. This bleeding is usually limited and resolves without aggressive management, but control with hemostatic agents or temporary packing around the tracheostomy tube may be necessary.

Table 11.2 Early and Delayed Complications of Tracheotomy

Early

Delayed

• Hemorrhage

• Accidental decannulation

• Mucous plugging

• Subcutaneous emphysema

• Pneumothorax/pneumomediastinum

• Recurrent laryngeal nerve injury

• Esophageal injury

• Tracheitis/stomal infections

• Airway fires

• Hemorrhage, tracheo-innominate fistula

• Accidental decannulation

• Mucous plugging

• Tracheoesophageal fistula

• Tracheitis/stomal infections

• Granulation tissue/granuloma

• Subglottic/tracheal stenosis

• Tracheomalacia

With long-term tracheotomy, the tip of the tube may erode through the tracheal wall and create a communication between the trachea and innominate artery. This rare phenomenon of tracheo-innominate fistula can produce a massive hemorrhage and is usually fatal. A small sentinel bleed may be the first sign of this phenomenon in up to one-third of patients, but a massive hemorrhage is more common.20Suspicion of tracheo-innominate fistula in a patient with unusual tracheal bleeding may warrant further investigation, including bronchoscopy, computed tomographic angiography, or formal arteriography.

Pneumomediastinum and pneumothorax are complications seen most commonly in the early postoperative period, and their incidence ranges from 4 to 43%.2 In infants, the apex of the lung can extend into the root of the neck. Mid-line dissection and attention to avoid inferior dissection may prevent violation of the pleura. A postoperative chest radiograph can be used to exclude or diagnose pneumothorax.

Mucous plugging with tube obstruction is the most common complication of tracheostomy with an incidence of 14 to 72%.2 Mucous plugging is more common in premature infants and newborns due to the smaller size of the tracheostomy tubes. This complication can be severe and may even lead to arrest and death. Saline should be gently instilled within the tracheostomy tube, and the tube should be suctioned at regular intervals according to the individual needs of the child. Medical management of increased or changed tracheal secretions may be necessary. Routine upsizing of tracheostomy tube according to age, humidification, and regularly scheduled tube changes also are key steps in preventing tube obstruction.

Accidental decannulation is a feared complication and is the second most common complication following tracheostomy. In the immediate postoperative period, accidental decannulation is particularly worrisome as the tracheotomy site and tract are not mature and established. For this reason, young children are usually observed postoperatively in the intensive care unit for 5 to 7 days until the first tracheostomy tube change. A false passage can mistakenly be created during emergent reinsertion. Proper use of the stay sutures, visualization, and an orderly approach are the best ways to prevent false entry. Care providers must not forget that endotracheal intubation from above may often be the best way of securing the airway after accidental decannulation. Early tube dislodgement should be prevented as possible by carefully securing the tracheostomy with appropriately tight ties (one fingerbreadth between the tie and neck) or sutures that are directly observed on a daily basis after surgery. Bjork flap modification, starplasty, and other stomaplasty techniques have been proposed to allow easy tube replacement should there be dislodgement. Two spare tracheostomy tubes (one of a smaller size) and a small clamp should be available at the bedside at all times. Neonatal tubes are more likely to dislodge accidentally because of the shorter tube length. Once the stoma has matured, the tube is easier to safely reinsert, though dislodged tubes should be replaced as soon as possible to prevent stomal stenosis and closure. Delayed dislodgement becomes more of a risk as the child develops the dexterity to remove the tracheostomy tube. Despite these precautions, tube dislodgement and blockage remain the most important late complications and are responsible for a mortality rate of 1 to 2%.

Children with tracheostomy are susceptible to stomal or pulmonary infections. Aseptic suctioning and site cleaning should be employed as possible to prevent infection. A Humi-Vent™ (Hudson/Teleflex, Durham, North Carolina, United States) may also help filter pathogens and prevent respiratory irritation from decreased ciliary activity and inspissated secretions.21 Topical, inhaled, and/or systemic antibiotics may be necessary depending on the symptoms and signs of infection.

Tracheal mucosal granulation or suprastomal granuloma/fibroma formation is reported in 30 to 40% of children with tracheostomy (Fig. 11.5).22 Granulation tissue refers to the pink, friable healing tissue whereas granulomas/fibromas represent the more thickened and indurated respiratory mucosa. The most common cause of granulation tissue is either trauma at the distal tip of the tracheostomy tube or excessive suctioning. Granulation can lead to bleeding or partial tube occlusion. Suprastomal granuloma, tissue on the anterior tracheal wall proximal to the stomal site, can be problematic when voice is diminished or when decannulation is being attempted. Formation is likely due to several factors, most significantly tube movement and irritation. These lesions can be removed endoscopically using microlaryngeal instruments, lasers, or microdebriders, or they can be excised through the stoma using open techniques.

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Figure 11.5 Suprastomal granuloma completely occluding suprastomal airway leading to impaired phonation and inability to decannulate.

Suprastomal collapse and tracheal stenosis may result from local chondritis and weakening of cartilage.23 Suprastomal collapse is more common in younger children. Removal of a cartilaginous window at the time of initial tracheotomy may contribute to stomal narrowing or collapse. Fry et al demonstrated that tracheal stenosis is less common in the setting of vertical tracheotomy incision when compared with other methods.24

Persistent tracheocutaneous fistula after decannulation occurs in 19 to 65% of children.2 Stomal maturation techniques may affect the incidence of fistula following decannulation.23 Young age at tracheotomy and longer durations of tracheotomy use seem to be the most significant factors contributing to fistula. Treatment involves either excision of the epithelialized tract with closure of the defect, or excision of the tract with allowed secondary healing. The risk of subcutaneous emphysema and pneumothorax from postoperative air leak needs to be considered during surgical decision-making,

Airway fires are rare complications of tracheostomy. According to a recent survey of otolaryngologists, 18% of operating room fires were attributed to tracheostomy.12 The electrosurgical unit was attributed as the cause when supplemental oxygen was in use.

Additional Considerations

Tracheostomy affects speech and language development in those with and without neurological disorders. Factors associated with speech and language delay in neurodevelopmentally normal children include young age at time of the tracheostomy and longer duration of the tracheostomy before decannulation. Children who experience long periods of aphonia during critical periods of language development (birth to 3 years) are known to be at risk for delayed communication skills. Thus, early decannulation improves the likelihood for normal speech and language development.25 Children with tracheostomy should be encouraged to learn to temporarily and safely occlude their stomas to create sound. Early intervention with a speech and language pathologist (SLP) is important in developing the most effective way of verbal communication for the individual patient. A one-way speaking valve (Passy-Muir) is an effective tool both in facilitation of verbal communication as well as intermediary to capping. The child is assessed for alertness; cognition to follow directions; the absence of thick, copious secretions; and the ability to move air through the glottis before using the valve.26 Any use of speech valve or tube cap should be monitored by a capable adult due to the obstruction created from capping.

Additionally, the presence of a tracheostomy may produce difficulties with swallowing and feeding. Inhibition of laryngeal reflexes, pressure, or interruption of the strap musculature, reduction of laryngeal elevation, poor coordination of breathing and swallowing, and pressure in the esophagus from the tube or tube cuff may all contribute to aspiration and dysphagia in children with tracheostomy. Tracheostomy may also impede generation of adequate subglottic pressure for the child to adequately cough out secretions. Some studies have shown speaking valves can improve swallowing by increasing subglottic pressure.27 SLP evaluation can be helpful in determining appropriateness of oral feeding and necessary modifications.

Successful decannulation depends on significant improvement or resolution of the primary underlying disorder for which the tracheostomy was originally placed. Secondary anatomic abnormalities that may impede respiration such as suprastomal collapse or granuloma must also be ruled out and treated. Prescott suggested that the most common reason for failure of decannulation is peristomal pathology including tracheal granuloma, suprastomal collapse, stomal tracheomalacia, and stenosis.28 Microlaryngoscopy and bronchoscopy are routinely used to evaluate the airway for any contributing factors to decannulation failure. The frequency of these evaluations after tracheostomy placement has not reached universal consensus.5 Reconstructive procedures may be necessary to facilitate decannulation. Capped polysomnography evaluation or monitored intensive care unit stays with downsized capped tracheotomy tubes are means of evaluating readiness to decannulate.29 The creation of fenestrations in a capped tracheostomy has also been proposed to get a more accurate measure of tracheostomy-independent breathing.22 There is a 2 to 5% risk of decannulation failure when attempted, often related to dynamic airway problems.30

Summary

Tracheostomy in children is most commonly indicated for prolonged ventilation, upper airway obstruction, or pulmonary toilet in the setting of neurological disease. The technical aspects of tracheotomy in children are unique, as the airway and neck anatomy differs from adults and complications are potentially severe. The postoperative care issues are substantial. Tracheostomy impacts voice, language development, and swallowing in children. Decannulation, following assessment for peristomal sequelae and controlled capping trials, is often achieved when the indications for tracheotomy have been successfully treated or have resolved. A multidisciplinary approach to care of the child with tracheostomy may promote positive long-term functional outcomes.

References

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