Surgical aspects of tracheostomy in children

PAEDIATRIC RESPIRATORY REVIEWS (2006) 7, 169–174
MINI-SYMPOSIUM: TRACHEOSTOMY IN CHILDREN
Surgical aspects of tracheostomy in children
Lesley-Ann Cochrane* and C. Martin Bailey
Department of Paediatric Otolaryngology, Great Ormond Street Hospital for Children, Great Ormond Street,
London WC1N 3JH, UK
KEYWORDS
paediatric;
tracheostomy;
tracheostomy tube;
surgery;
complications;
decannulation;
upper airway obstruction
Summary Tracheostomy involves the surgical formation of a stoma between
the trachea and the skin. It is classically thought of as a treatment to alleviate airway
obstruction; however, its clinical applications are varied and include long-term ventilatory
support, being an aid in pulmonary toilet and use as a covering procedure during
airway surgery. In this article, we review the surgical aspects of tracheostomy, including
preoperative considerations, tracheostomy tube choice, operative technique and
postoperative complications. Postoperative care of the child with a tracheostomy will
also be discussed.
ß 2006 Elsevier Ltd. All rights reserved.
INTRODUCTION
For example, some patients with subglottic stenosis are
candidates for a single-stage laryngotracheal reconstruction
procedure, which definitively corrects the stenosis without
the need for a tracheostomy. Prior to contemplating any
surgical procedure, all patients should have their medical
management maximised; in particular, gastro-oesophageal
reflux disease should be treated aggressively with antireflux medication. Oedema or swelling of the airway
may respond to a short course of corticosteroids.
The term ‘tracheostomy’ is derived from the Greek stomoun, meaning to create an opening.1 Tracheostomies
have been performed from ancient times for a wide variety
of clinical conditions. Historically, the most common indication was for the alleviation of upper airway obstruction
secondary to infections such as diphtheria or epiglottitis.2–4
With the advent of modern medicine, we have seen a shift
in its clinical application, but it continues to be a relatively
common procedure in the paediatric tertiary care setting.
ANAESTHESIA
INDICATIONS
Tracheostomies are performed for a variety of reasons. The
most common indication for tracheostomy placement is for
long-term ventilatory support.2 4 Other indications include
alleviation of airway obstruction, as an aid in pulmonary
toilet and as a covering procedure during airway or head
and neck surgery.1–4 Developments in airway surgery over
the last 20 years have provided an alternative to tracheostomy for some causes of upper airway obstruction (Table 1).
* Corresponding author. Tel.: +44 207 813 8220;
Fax: +44 207 829 8644.
E-mail addresses: cochrl@gosh.nhs.uk (L.-A. Cochrane),
bailem@gosh.nhs.uk (C.M. Bailey).
1526-0542/$ – see front matter ß 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.prrv.2006.06.005
Paediatric tracheostomy is generally performed under general anaesthesia in the controlled environment of the
operating theatre. Patients are usually endotracheally intubated for the procedure, but if necessary a rigid ventilating
bronchoscope may be used to maintain the airway instead.
Alternatively, a laryngeal mask airway or facemask may be
used in children when intubation is not possible. In very rare
cases, it may be necessary to perform the procedure using
local anaesthesia only. Percutaneous dilatational tracheostomy is not suitable for the paediatric population: the
landmarks needed to perform the procedure are often
difficult to palpate in children as the trachea is soft and
flexible, and furthermore the airway is small and often very
precarious.5
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Table 1
L. A. COCHRANE AND C. M. BAILEY
Techniques to avoid tracheostomy
Type of lesion
Technique
Subglottic stenosis
Single-stage laryngotracheal
reconstruction
Single-stage open excision
Aryepiglottoplasty
Cricoid split
Subglottic haemangioma
Laryngomalacia
Failed neonatal extubation
should be corrected for size in children with small stature).1
Patients should be fitted with a tube that is appropriate for
their age based on the width and length of the trachea. A
sizing chart is shown as Table 2.6 Children under the age of
1 year should generally be fitted with a neonatal length
tube; older children should be fitted with a paediatric
length. For detailed information on tracheostomy tube
selection, see another article of this mini-symposium.
TRACHEOSTOMY TUBE SELECTION
OPERATIVE TECHNIQUE
There are many different manufacturers, models and sizes
of tracheostomy tube, each with their own advantages and
disadvantages.6 Of primary importance when selecting an
appropriate tracheostomy tube is the child’s age (which
Tracheostomy is performed with the patient lying supine on
the operating table. Adequate exposure of the larynx and
upper trachea is essential and is best obtained with the neck
in a hyperextended position. This can be achieved by placing
Table 2
A guide to the size of paediatric tracheostomy tubes, bronchoscopes and endotracheal tubes
Reproduced with Permisson from Wyatt et al.6
SURGICAL ASPECTS OF TRACHEOSTOMY IN CHILDREN
a sandbag or jelly roll under the patient’s shoulders. If the
surgical site is obscured by the soft tissues of the submental
area, they can be retracted superiorly with the use of a
chinstrap tape, which is secured to the operating room table.
The patient’s head is then stabilised by the use of a head ring.
The neck is palpated to identify the hyoid bone, thyroid
notch and cricoid cartilage. These laryngeal landmarks are
marked on the skin as a guide. In neonates, the larynx is high
in the neck, and the cricoid cartilage is not easily palpable.
The hyoid bone often overrides the upper edge of the
thyroid cartilage, making the notch difficult to identify.7 The
skin midway between the cricoid and the suprasternal
notch is marked and infiltrated with local anaesthetic
(1% lignocaine with 1:200 000 adrenaline). A skin incision
approximately 2 cm in length is made through the infiltrated area, cutting through fat and platysma.
Either a horizontal or a vertical skin incision may be
used.8 In infants and small children, a vertical skin incision
has traditionally been used. In this age group, the pleural
apices may extend superiorly into the neck: a vertical skin
incision minimises the need for dissection lateral to the
trachea, and thereby reduces the risk of pneumothorax. In
older, larger children, this risk is greatly reduced, and a
horizontal skin incision is often employed as it is likely to
result in a superior cosmetic result. After making the skin
incision, a plug of subcutaneous fat is removed with the aid
of bipolar diathermy forceps. This step greatly aids in the
exposure of deeper tissues and makes it much easier to
replace a blocked or displaced tracheostomy tube in the
immediate postoperative period.7
The incision is then deepened until the strap muscles are
reached. The trachea should be reidentified frequently by
palpation in order to avoid inadvertent injury to surrounding
structures. The strap muscles are divided in the midline by
blunt scissor dissection, allowing them to be separated and
retracted laterally, revealing the underlying thyroid isthmus
and trachea. The cricoid cartilage lies just superior to the
isthmus of the thyroid gland. The cricoid is usually easily
visible in older children, but in neonates it is often easier to
identify by palpation, feeling for its prominence with fine
curved artery forceps. The thyroid isthmus should be separated from the underlying trachea by blunt dissection using
fine curved artery forceps and is subsequently divided with
bipolar diathermy. In older children with a bulky, vascular
isthmus, it may be preferable to divide the isthmus between
artery forceps and secure the ends by suture transfixion and
ligation. The underlying cricoid cartilage and trachea should
then be visible. It is important to identify the cricoid cartilage
to prevent inadvertent cannulation at the wrong level.
Opening the trachea and tracheostomy tube
insertion
In children, a vertical incision is generally made in the trachea
through the third, fourth and fifth tracheal rings.7 A more
superiorly placed incision (i.e. through the second and third
171
tracheal rings) should be avoided in small children if possible,
because if the first tracheal ring becomes eroded by pressure
from the tracheostomy tube, the cricoid cartilage may then
be damaged. Prolene stay sutures are placed on either side of
the planned tracheal incision. These are placed to aid in
opening the tracheal incision at the time of tracheostomy and
are left in place until the first tracheostomy tube change.
These sutures facilitate distraction of the tracheal opening in
the event that a tube change is required in the early postoperative period before a tract has formed.
Once the tracheal incision has been made, the anaesthetist withdraws the endotracheal tube (in the intubated
patient) until the tip is just superior to the tracheostome.
The tracheostomy tube can then be inserted into the
trachea with the aid of its introducer. Once in place, the
anaesthetic circuit can be transferred from the endotracheal tube to the tracheostomy tube. In general, it is not
necessary to close the skin incision unless it is large. A gap
around the tube is essential to allow air escape and prevent
postoperative subcutaneous emphysema. A non-adherent
dressing is applied to the wound with a keyhole to accommodate the tracheostomy tube. The tracheostomy tube is
then secured in place with tapes. These should be tied fairly
tightly with the shoulder roll removed and the patient’s
neck in a flexed position.
At the end of the procedure, the surgeon should
auscultate the chest to ensure that there is equal air entry
bilaterally: asymmetrical air entry may indicate that the
tracheostomy tube is too long and has intubated the right
main bronchus, or more rarely that the patient has developed a pneumothorax.
ALTERNATIVE SURGICAL
TECHNIQUES
The placement of maturation sutures between skin and
trachea is an optional addition to the standard tracheostomy
technique that is becoming more popular. With this technique, size 4.0 absorbable sutures are placed between the
superior and inferior aspects of the tracheostomy incision
and the skin edges, creating a mature stomal tract.9 Maturation sutures provide an additional safety measure as they
allow for easier replacement of a displaced tracheostomy
tube in the immediate postoperative period. However, this
technique may result in an increased incidence of persistent
tracheocutaneous fistula following decannulation.
The starplasty procedure is an alternative technique for
paediatric tracheostomy described by Koltai, which is based
on the geometry of a three-dimensional Z-plasty.10 Cruciform incisions are made in both the skin and the trachea. The
resultant triangular flaps are circumferentially interdigitated
using size 5.0 absorbable sutures to form a stoma. The
tracheostomy site is isolated from the fascial layers that
communicate with the pleura, thereby reducing the risk of
pneumothorax.10 As with maturation sutures, this technique
produces a mature stoma, which makes tube replacement
172
easier. The major disadvantage of this technique is the
universal persistence of a tracheocutaneous fistula following
decannulation.10
We have described here variations on a standard
tracheostomy technique for use in infants and children
up to approximately 12 years of age. After the age of
12, the trachea approaches adult size, and conventional
adult tracheostomy techniques can be used.
COMPLICATIONS
Intraoperative complications
Bleeding
Significant blood loss during tracheostomy is rare. Injury to
an abnormally high innominate artery or other anomalous
vessel can occasionally occur. This can generally be avoided
by careful, controlled dissection of the structures lower in
the neck.
Pneumomediastinum and pneumothorax
The pleural apex rises higher in children than in adults and
may extend up into the lower neck. Damage to the cervical
pleura may result in pneumothorax or pneumomediastinum. This risk can be minimised by avoiding any dissection
lateral to the trachea. Pneumomediastinum and small
pneumothoraces are likely to resorb and can be observed,
whereas larger pneumothoraces require the insertion of a
chest drain.1
Anatomic injury
Injury to the oesophagus, cricoid and recurrent laryngeal
nerves should not occur in elective tracheostomy.7 Inadvertent damage to the oesophagus can occur if it is
mistaken for the trachea. Naso/orogastric tubes should
be removed prior to surgery to avoid confusion.
L. A. COCHRANE AND C. M. BAILEY
antibiotic. Children with long-standing tracheostomies
often become colonised with Pseudomonas aeruginosa
and/or Staphylococcus aureus.1 Colonisation does not
require treatment unless there are signs of acute infection.
Subcutaneous emphysema
When air leaking around the tracheal incision becomes
trapped in the subcutaneous tissues, surgical emphysema
ensues. It results from closing the wound too tightly around
the tracheostomy tube. If it occurs, the wound should be
opened fully.
Displacement and blocking of the tracheostomy tube
These complications can be avoided by good tracheostomy
tube care. New tracheostomies should receive continuous
humidification until the first tracheostomy tube change to
prevent blockage of the tracheostomy tube. All carers should
be trained in how to manage an accidental decannulation or
tube blockage, including emergency tracheostomy tube
changes as well as cardiopulmonary resuscitation.11
Mortality
Tracheostomy-related mortality ranges from 0.5 to 3% in
different series.1,12–14 The main causes of death are accidental decannulation and blockage of the tracheostomy
tube.
POSTOPERATIVE CARE
In the immediate postoperative period, a chest radiograph
should be performed to ensure that there is no pneumothorax and to check that the tube length is correct, with
the tip above the carina.15 The patient must be monitored
closely and cared for by appropriately trained nursing staff.
Patients should have the following items set up at the
bedside:11
Postoperative complications
Bleeding
Early postoperative bleeding can occur if adequate haemostasis has not been achieved intraoperatively or if there is an
unsuspected bleeding diathesis or coagulopathy. Over time,
the tracheostomy tube can cause local irritation and inflammation, resulting in a delayed haemorrhage. This risk can be
minimised with proper care and adequate humidification. Illfitting metal tracheostomy tubes can cause local erosion of
the tracheostome or of the anterior tracheal wall: if left
untreated, this can extend to the overlying innominate artery,
resulting in a potentially fatal haemorrhage.
Infection
Local wound infection can occur as in any surgical procedure and is usually easily treated with a short course of oral
1. Emergency kit:
a. A spare tracheostomy tube of the same size and
brand as that currently in use.
b. A tracheostomy tube one size smaller than that
currently in use.
c. Round-ended scissors.
d. Tracheostomy tube tapes.
e. Water-based lubricant.
f. A length of suction catheter that can be used to
railroad in a new tracheostomy tube if required.
2. Suction apparatus and sterile suction catheters with
distal and lateral holes at the tip.
3. Humidification.
Adequate humidification is essential. During the initial
postoperative period, humidified air should be delivered
continuously to reduce the tenacity of the secretions and
SURGICAL ASPECTS OF TRACHEOSTOMY IN CHILDREN
maintain tube patency.11 The tracheostomy tube must be
kept clear of secretions by frequent suctioning. Suctioning
can be facilitated by the instillation of 0.5 ml sterile normal
saline into the tube first. A sterile catheter is then inserted
into the tracheal lumen gently, and suction is applied only as
the catheter is withdrawn. Tracheostomy tubes are generally
changed for the first time after 7 days. The timing of
subsequent tube changes is variable, depending upon the
type of tracheostomy tube used. Some patients may require
more frequent tube changes due to thick secretions, infection or patient preference. Following the first tracheostomy
tube change, continuous humidification can be discontinued
and a heat and moisture exchanger or ‘Swedish nose’ fitted.
DECANNULATION
Once the underlying indication for the tracheostomy has
resolved or has been corrected, decannulation can be
considered. Prior to decannulation, a laryngoscopy and
bronchoscopy should be performed to evaluate the airway
for granulation tissue, suprastomal collapse or any other
problem that might preclude successful decannulation.
Once any granuloma or suprastomal collapse has been
adequately treated, the patient can be decannulated on the
ward.16,17 During ward decannulation, the patient’s tracheostomy tube is gradually down-sized and then blocked
off prior to removal. A full decannulation protocol is
detailed in Table 3.16,17 Should the child experience respiratory distress at any time, the protocol should be aborted
and the tracheostomy re-established. Following a successful
decannulation, the stoma is left to heal by secondary
intention. Approximately 40% of stomas fail to close
completely on their own, leaving a persistent tracheocutaneous fistula.1,12,13,18 If this persists for 6 months or more,
it can be closed surgically.
Surgical closure of persistent
tracheocutaneous fistula
Persistent tracheocutaneous fistulas are closed surgically
under general anaesthesia. An elliptical skin incision is made
around the fistula. Dissection is then carried through the
surrounding scar tissue to isolate the tract from the adjacent
Table 3
Decannulation protocol
Day 1
Down-size to a size 3 tracheostomy tube
Day 2
Block the tracheostomy tube for 12 h
If successful, continue overnight for a further 12 h
If unsuccessful, unblock overnight and repeat
the next day
Day 3
Decannulate and observe on the ward
Day 4
Observe off the ward
Day 5
Discharge
173
healthy tissue down to the level of the trachea. After the tract
has been completely isolated from surrounding tissues, it is
resected from the trachea and the edges are approximated
with reabsorbable sutures.18 The strap muscles are also
mobilised from the surrounding scar tissue and then reapproximated in the midline over the tracheal closure. The skin
and subcutaneous tissues are neatly sutured together. A
small Penrose drain can be used to avoid any subcutaneous
emphysema, although this is not always necessary. A period
of intubation is not required postoperatively.
Suprastomal granuloma
Suprastomal granuloma formation is common.1,12,13 Granulomas occur in the tracheal lumen at the superior margin of
the tracheostome where the mucosa is irritated and inflamed
by the tracheostomy tube. Granulomas may also arise at the
site of the tracheostomy tube tip, due to either an ill-fitting
tube or traumatic suction. Large and obstructing granulomas
should be treated prior to decannulation. This can be done
via the stoma with punch forceps under bronchoscopic
control or endoscopically using a KTP laser.19,20
Suprastomal collapse
Some degree of collapse of the anterior tracheal wall just
superior to the tracheostome is almost inevitable in longterm paediatric tracheostomies. It results from pressure on
the tracheal rings from the tracheostomy tube, with subsequent inflammation, chondritis and eventual weakening
of the cartilaginous rings. The degree of collapse is usually
mild and does not require any treatment prior to decannulation. More significant collapse requires treatment as it
may prevent successful decannulation.
Suprastomal collapse causing less than 50% occlusion of
the airway can usually be successfully treated endoscopically
using a KTP laser to vaporise the collapsing area.20 Collapse
causing more than 50% occlusion requires an open surgical
decannulation or a formal open stomal reconstruction.
Surgical decannulation
This is a single-stage procedure in which the tracheostomy
tube is removed and the stoma site is surgically closed.21 At
the beginning of the procedure, the tracheostomy tube is
replaced with an endotracheal tube. The technique involves
excising the stoma with an ellipse of skin and carefully
dissecting out the fibrous tracheostomy tract down to the
opening in the tracheal cartilage. Any intraluminal suprastomal granuloma can be excised in continuity with the tract.
The tract is then excised flush with the anterior surface of
the trachea, taking care not to remove any tracheal wall.
The collapsing portion of the tracheal wall is hitched
forward by suturing it anteriorly to the strap muscles on
either side.21 This provides constant anterior traction on
the collapsed area during healing. Postoperatively, the
patient is intubated for a period of 24–48 h. Surgical
174
decannulation is usually reserved for selected cases in which
there is moderate suprastomal collapse.
Stomal reconstruction
Patients with severe suprastomal collapse or stomal stenosis will require a formal stomal reconstruction procedure
in order to successfully achieve decannulation. Stomal
reconstruction is a single-stage procedure similar to a
laryngotracheal reconstruction. The tracheostomy fistula
is excised as in a surgical decannulation, leaving a small
defect in the trachea at the site of the former tracheostomy.
The area of collapse immediately superior to this defect is
incised to allow for the placement of a reinforcing graft. A
costal cartilage graft is then used to close the tracheostomy
defect and to expand and reinforce the area of collapse.
The graft is sutured into place with absorbable sutures. A
Penrose drain is left in the wound for 48 h to prevent
subcutaneous emphysema. Postoperatively, the patient is
left intubated for a period of 5–7 days.
PRACTICE POINTS
Indications for tracheostomy include the alleviation of upper airway obstruction, long-term ventilatory support, as an aid in pulmonary toilet and as
a covering procedure for head and neck surgery.
Children should have a postoperative chest radiograph to rule out pneumothorax and pneumomediastinum, and to check the position of the tube
tip.
Prior to decannulation, children with long-standing
tracheostomies should undergo a laryngoscopy
and bronchoscopy to evaluate for suprastomal
granuloma or collapse.
A suprastomal granuloma can be removed via the
stoma with punch forceps under bronchoscopic
control or endoscopically using a KTP laser.
Suprastomal collapse causing less than 50% occlusion of the airway can usually be successfully
treated with a KTP laser to vaporise the collapsing
area. More significant collapse requires surgical
decannulation or formal open stomal reconstruction in order to successfully achieve decannulation.
Following ward decannulation, up to 40% of children have a persistent tracheocutaneous fistula
that requires surgical closure.
L. A. COCHRANE AND C. M. BAILEY
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