Atlas of Procedures in Neonatology, 4th Edition

Respiratory Care



Hosai Hesham

Gregory J. Milmoe

  1. Indications
  2. Prolonged need for ventilator support —most common
  3. Acquired subglottic stenosis after prolonged intubation
  4. Craniofacial abnormalities with severe airway obstruction, e.g., Pierre-Robin sequence, Pfeiffer syndrome, Treacher Collins syndrome
  5. Congenital bilateral vocal cord paralysis
  6. Laryngeal web, subglottic hemangioma
  7. Congenital tracheal stenosis, severe tracheomalacia
  8. Congenital neuromuscular disease with insufficient respiratory effort
  9. Neurologic disease with aspiration risk, central apnea, or intractable seizures
  10. Contraindications
  11. Unstable physiology —wait until stabilized
  12. Sepsis
  13. Pneumonia not yet controlled
  14. Pulmonary instability requiring high inspiratory pressures (PIP >35–40) or need for high-frequency ventilation
  15. Cardiovascular instability, e.g., shunting, arrhythmia, or hypotension
  16. Evolving renal or neurologic injuries
  17. Distal obstruction not relieved by tracheostomy
  18. Congenital stenosis at the carina
  19. External compression from mediastinal mass
  20. Congenital anomalies that make the trachea relatively inaccessible
  21. Massive cervical hemangioma —bleeding issues
  22. Massive cervical lymphangioma —severe distortion of neck anatomy
  23. Massive goiter —might be manageable medically
  24. Chest syndromes with severe kyphoscoliosis or tracheal distortion
  25. Precautions
  26. Patient should be stable (see Contraindications); anticipate need for increased pulmonary support temporarily to counter atelectasis and reactive secretions from surgical stimulation.
  27. Tracheotomy tubes allow for air leak through stoma and through larynx. In contrast, an endotracheal tube fits more snugly at the cricoid, creating a more closed system for ventilation.
  28. Neonates are less able to tolerate bacteremia, so use perioperative antibiotic to cover skin flora.
  29. If the patient is not currently intubated, have endoscopy equipment available and discuss intubation options with the anesthesiologist.
  30. The infant larynx differs from that of the adult and older child (Fig. 35.1).
  31. More pliable and mobile
  32. Relatively higher in neck
  33. Thymus and innominate artery can override trachea in surgical field
  34. This procedure should be done only in a facility where there is appropriate support for postoperative management.
  35. Equipment
  36. Prep tray with brushes, towels, and betadine
  37. Tracheotomy tray
  38. Scalpel with no. 15 blade
  39. Hemostats
  40. Small scissors (iris, tenotomy, small Mayo)
  41. Retractors —Senn or Ragnel
  42. Suction —no. 7 Frazier
  43. Forceps —Adson
  44. Sutures: 3-0 and 4-0 nonabsorbable on small, curved needles
  45. Neonatal tracheotomy tubes
  46. Have several calibers available
  47. Standard tubes are noncuffed, but in special circumstances a cuff may be needed.
  48. Technique
  49. Check instruments, sutures. and available tracheotomy tubes.


  1. On patient arrival in operating room, apply monitors, check intravenous line, and confirm satisfactory ventilation through endotracheal tube.
  2. Anesthesia team proceeds with inhalation agents, oxygen supplementation, and intravenous agents as needed for satisfactory level of general anesthesia.
  3. Position patient with neck extended using shoulder roll.
  4. Remove nasogastric tube to avoid confusion when palpating trachea. Do not place esophageal stethescope either.
  5. Inject skin incision and the deeper tissues with local anesthetic (0.5 to 1.0 mL of ½% lidocaine with 1:200,000 epinephrine).
  6. Prep the surgical site from above the chin to below the clavicles. Give IV antibiotic to cover skin flora.
  7. Drape the patient with surgical towels, allowing the anesthesiologist access to the endotracheal tube and the securing tape.
  8. Identify the following landmarks: suprasternal notch, chin, midline, trachea, and cricoid. In small neonates, the cricoid may be difficult to palpate.
  9. The skin incision is made roughly midway between the sternal notch and the cricoid, either vertically or horizontally. Both tend to heal as a circular stoma, but the horizontal has a slightly better cosmetic effect, while the vertical allows more exposure in the midline.
  10. Excess subcutaneous fat can be excised with cautery.
  11. Identify the strap muscles and repeatedly palpate the trachea to confirm the midline. Split the raphe to separate the muscles.
  12. Grab the fascia of the strap muscles with hemostats to retract them outward and laterally, thereby exposing the thyroid gland, cricoid, and trachea.
  13. Senn retractors can then be placed on either side of the trachea for better view.
  14. The thyroid gland can usually be displaced by blunt dissection to expose the tracheal rings. If not, then the isthmus is divided and suture ligated.
  15. Place vertical stay sutures in paramedian position at the level where tracheal entry is planned—usually the third and fourth ring (Fig. 35.2).
  16. Incise trachea vertically for 2 or 3 rings, depending on the size needed for the tube employed.
  17. The anesthesiologist can then loosen the tape and withdraw the endotracheal tube until the tip is just visible (Fig. 35.3).
  18. The appropriate tracheostomy tube is then placed with the flange parallel to the trachea so that the tube more easily enters the trachea and passes posteriorly before rotating the flange 90 degrees back to its routine orientation.
  19. The anesthesiologist confirms placement by checking end-tidal carbon dioxide and oxygen saturation, as well as auscultation of both sides.

FIG. 35.1. Sagittal section. Larynx lies more cephalad than in adult. Note the proximity of the thyroid isthmus to the tracheal rings. (Drawing contributed by John Bosma, M.D.)


FIG. 35.2. Placement of stay sutures through the tracheal wall.



  1. The tracheostomy tube is then secured with twill tape tied around the neck firmly. Once tied, only one finger should fit between the tape and the neck when the baby's neck is in neutral position.
  2. The stay sutures are then secured to the chest with tape labeled as to correct side (Fig. 35.4).
  3. Transport the patient back to intensive care with a backup endotracheal tube and laryngoscope.
  4. Obtain chest radiograph on arrival in unit to check tube position and lung status.

FIG. 35.3. Artistic conception of view through tracheal incision with the tip of the endotracheal tube visible. Stay sutures hold cartilages open.

  1. Postoperative Management
  2. Provide intensive nursing (see Precautions).
  3. Keep spare tracheostomy tubes at bedside (same size and one smaller).
  4. Replace nasogastric tube for nutrition and to avoid aerophagia.
  5. Suction secretions as needed to avoid plugging. For first 24 hours, be liberal with saline irrigation.
  6. Make sure ventilator tubing is not pulling on tracheostomy tube.
  7. Be aggressive with wound care so that stoma heals quickly and thereby limits granulation. Clean once a shift with half-strength peroxide and cotton swabs, then apply antibiotic ointment.
  8. First tracheostomy change is done by surgical team in 4 to 7 days. Thereafter weekly changes are sufficient.

FIG. 35.4. Fixation of stay sutures. As soon as the position of the tracheostomy tube is confirmed and stomal ventilation is started, the tube may be fixed. Equal tension is kept on the stay sutures during taping. Right suture is marked to avoid confusion in future placement.

  1. Early Complications (0 to 7 days)
  2. Bleeding: thyroid, venous, arterial
  3. Accidental decannulation or displacement in neck —stay sutures are the child's lifeline back to the trachea to allow replacement of the tube.
  4. Plugging of tube with secretions (Fig. 35.5)
  5. Avoid by increasng humidity, saline irrigation, and suctioning.
  6. Infection of wound or pneumonia—avoid by local care, and by taking care of secretions.
  7. Air leaks
  8. Pneumothorax —may need chest tube
  9. Pneumomediastinum —serial films
  10. Subcutaneous emphysema —usually limited (avoid occlusive dressing)
  11. Tracheoesophageal fistula —iatrogenic
  12. Late Complications (after 1 week)
  13. Obstruction and decannulation remain ongoing risks that require vigilant care.
  14. Stomal infection and granulation —avoided by careful wound care
  15. Proximal tracheal granuloma —commonly occurs at the point where the tube rubs against the superior aspect of the tracheal opening, creating an obstruction between the vocal cords and the tube that can impede routine tracheostomy tube changes. This requires operative removal.
  16. Distal tracheal granulation —from overly aggressive suctioning or tube angulation causing rubbing of the tip against the tracheal wall. Hallmark sign is bloody secretions.




FIG. 35.5. Total obstructions of tracheostomy tubes. A: Mucus plug incompletely suctioned. B: Dry mucus plug pushed deeper by a suction catheter.

  1. Stenosis—preventing decannulation later on
  2. Part of original pathology requiring tracheostomy
  3. Ongoing obliteration from active inflammatory factors
  4. Consequence of procedure itself from stomal collapse or distal cicatrix
  5. Tracheocutaneous fistula after tube removal—normal physiologic sequela, but needs secondary procedure for closure


  1. Sisk EA, Kim TB, Schumacher R, et al. Tracheotomy in very low birth weight neonates: indications and outcomes. Laryngoscope.2006;116:928–933.
  2. Wooten CT, French LC, Thomas RG, et al. Tracheotomy in the first year of life: outcomes in term infants, the Vanderbilt experience.Otolaryngol Head Neck Surg.2004;134:365–369.
  3. Kremer B, Botos-Kremer AI, Eckel HE, et al. Indications, complications and surgical techniques for pediatric tracheostomies—an update. J Pediatr Surg.2002;37:1556–1562.
  4. Crysdale WS, Feldman RI, Naito K.Tracheostomies: a 10 year experience in 319 children. Ann Oto Laryngol. 1988;97:439–443.