Pediatric Tracheostomy - An Overview

Introduction:

“Tracheostomy” or “pediatric tracheostomy” is a surgical procedure performed during emergency conditions in the management of breathing difficulties such as airway obstruction or irreversible neuromuscular conditions. This procedure was performed as early as the mid-1800s, only for the purpose of relieving upper airway obstruction. Later this procedure gained its standardization by Mr.Chevalier Jackson in the early 20th century. Today, tracheostomy is considered a “life-saving procedure” that has dramatically increased and is also done on premature babies with congenital anomalies. However, clinicians are still considering pediatric tracheostomy as a high-risk procedure, but the risks are not reported as before.

What Is Tracheostomy?

During tracheostomy, an opening or incision is made, and a tracheostomy tube is inserted through the neck, which opens into the trachea or windpipe. This allows air in and out for the child to breathe. It is performed only in cases of emergencies in an operating room under anesthesia to relieve pain. Depending on the patient’s condition, it may be permanent or temporary. The tracheostomy tube is available in different sizes and types for people of all age groups. The type of the tube is usually decided by the surgeon depending on the associated condition.

What Are the Indications for Tracheostomy?

We know that pediatric tracheostomy is performed when the child is unable to breathe for various reasons at any stage of life. Here are a few conditions that may require tracheostomy in your child. They are:

1. Lung Conditions: Chronic lung disease and subglottic stenosis.

2. Airway Obstruction: This may be due to:

• Trauma and swelling.

• Infectious diseases like epiglottitis and laryngotracheobronchitis.

• Tumors of the neck cause neck compressions, such as cystic hygroma and recurrent respiratory papillomatosis.

• Foreign body in the trachea.

• Obstructive sleep apnea (airway gets blocked when the baby is asleep).

• Facial burns.

3. Neuro-logical Impairments: They cause upper airway obstructions such as cerebral palsy and congenital central hypoventilation.

4. Congenital Birth Defects: They cause inadequate airflow to the lungs in the case of bilateral vocal cords paralysis, subglottic web, and laryngomalacia.

5. Craniofacial Syndromes:

• Treacher Collins syndrome.

• Crouzon syndrome.

• Pierre Robin sequence.

• Nager syndrome.

• Beckwith-wiedmann syndrome.

In some cases where prolonged ventilation was indicated, as in cases of retropharyngeal abscess, post-tonsillectomy bleed, and tracheostomy is used for assisting the weaning off from the ventilator.

How Is The Tracheostomy Tube Designed?

A small trach (tube) is attached to the tracheostomy tube. This keeps the opening (stoma) patent. The trach has a main shaft called the outer cannula, and a neck plate called a flange. This flange rests over the neck portion where the opening of the tube is present. These tubes are available in different sizes, and materials, semi-rigid, rigid, or plastic material. The tubes and inner cannula can also be disposed of or reused. The tracheostomy tube is of two types, cuffed and uncuffed.

• The cuffed tubes are indicated in patients with swallowing difficulties along with mechanical ventilation.

• The non-cuffed tubes are used for creating airways when the ventilator is not used.

What Are the Complications of a Tracheostomy?

• Air Leak: It is common in pediatric patients; three to nine percent is associated with pneumothorax, subcutaneous emphysema, and pneumomediastinum. So routine chest X-rays are mandatory to check the position of the tube and the chest condition.

• Hemorrhage: Post-operative hemorrhage is the most common complication. It is due to capillary leaks from the thyroid gland, inferior thyroid artery, and surrounding blood vessels. Special investigation in children with coagulation and bleeding disorders is required before undergoing treatment.

• Injury to the Adjacent Structures: Accidental injury to the cricoid cartilage may result in subglottic stenosis, and damage to the recurrent laryngeal nerve is common with a pediatric tracheostomy.

• Respiratory Arrest: There is the cessation of breathing.

• Accidental Decannulation: This occurs immediately after the tracheostomy when the tube get dislodged. So frequent monitoring of the position and the placement of the tube is essential.

• Swallowing Problems: Sometimes, the cuff of the tracheostomy tube may create pressure on the esophagus and hypopharynx, causing difficulty in swallowing (dysphagia).

• Scar Formation: Scar tissue may be formed around the stoma, which may cause difficulty during the tube change, so surgical management or excision of the scar tissue may be required.

How Does Tracheostomy Help Your Child?

As you know that tracheostomy helps your child to ease breathing problems, you may not know how this happens.

• When a tracheostomy tube is used, your child does not make use of the nose, mouth, and larynx. Instead, it breathes through the trach tube. So only a little air passes to the nose, mouth, or larynx. The air passes to the lungs through the trach tube and does not go to the nose.

• When the trach tube is placed, your child may not be able to talk. This is because the air does not go to the larynx and vocal cords to make them vibrate and produce sound.

• Generally, the air, before going to the lungs, goes to the nose, where it is purified by the nasal cilia. In the case of tracheostomy, the air goes straight to the lungs, so the air is not purified, and it may irritate your child’s lungs. So the doctor will teach you how to protect your child from dirty air.

What Are the Anatomical Differences in Children and Adults for Tracheostomy?

• Head position - Normally, pediatric patients will have a head larger than the body size. So the large occiput and short neck cause difficulty in positioning the patient for tracheostomy.

• The tongue is larger, and the mandible is smaller.

• The adult airway is more elliptical than in children.

• The larynx is at a higher level in children.

• The cricoid cartilage varies with age. It is at the level of C4 in children and C6 in adults.

• The vocal cords are not at right angles, which creates difficulty in children.

What Are the Preoperative Measures to Be Taken?

• All the required equipment should be made ready in the operating theater.

• Proper consent in a written or printed format should be taken from the patient's parents before starting the procedure.

• Depending on the anesthetist's preference, the anesthesia can be either through inhalation or intravenous route.

• Orotracheal intubation is done to maintain the airway patent.

• The patient is positioned in the supine position.

• Sandbags are placed between the shoulder blades, and the neck is extended. This makes the trachea come closer to the skin surface.

How Is Tracheostomy Performed?

• The cricoid cartilage and the sternal notch are identified. A median horizontal incision is made using these two landmarks.

• The subcutaneous fat is dissected and deepened up to the strap muscles.

• The strap muscles are displaced laterally using a bipolar cautery to achieve hemostasis.

• Sometimes the isthmus of the thyroid may obscure the view, so the isthmus is identified and clamped for clear vision.

• The anterior surface of the trachea is identified, exposing two to four rings.

• Now the endotracheal tube is withdrawn below the level of vocal cords, and the tracheostomy tube is inserted into the tracheal lumen.

• The endotracheal tube is kept intact until the correct position of the tracheostomy tube is confirmed.

• With the help of the fiber-optic bronchoscope, the distal end of the tracheostomy tube is kept two to three rings above the carina (the point of bifurcation of the trachea).

• With the help of tracheostomy ties and stay sutures, the tracheostomy tube is secured around the neck.

• The stay sutures help in easy identification of the new stoma in case of accidental decannulation.

What Are the Post-operative Instructions?

It is always important to maintain hygienic and sterile measures after tracheostomy. Always wash your hands before doing the procedure.

• Always keep the tracheostomy site and the tube clean.

• Clean the inside of the tube and regularly suction the mucous secretions lining the tube.

• Frequently change the ties and bands around the neck.

• In case of bathing, make sure that water does not enter the tube as it enters the airway.

Conclusion:

Pediatric tracheostomy is a high-risk procedure and is performed only in unavoidable conditions to stabilize the patient. However, due to the high proficiency of the medical team and advancements in medicine, the risk has significantly got lowered. Proper care after the procedure is very crucial and important for the best outcomes. Parents of the patients are generally taught how to manage the tubes and their changing protocols. Always follow the instructions from the doctor and interprofessional team. In case you find any distress in your child, then immediately reach out to the hospital.