Tracheostomy in Infants and Children

Tracheostomy in Infants and Children

Tracheostomy in infants and children is a life-saving procedure but carries significant risks due to the delicate anatomy of paediatric airways. The procedure is often performed to manage airway obstruction, prolonged ventilation, or congenital anomalies. Adherence to meticulous surgical techniques, proper tube selection, and vigilant postoperative care are crucial to minimizing complications and ensuring optimal outcomes. Understanding the potential risks and their management is essential for healthcare providers involved in pediatric airway care.

 

Indications of Tracheostomy in Infants and Children

Key Considerations for Pediatric Tracheostomy

1. Anatomical Challenges:
   • The trachea in infants and children is soft, compressible, and smaller in diameter, increasing the risk of injury to surrounding structures such as the recurrent laryngeal nerve, carotid artery, or oesophagus.
   • Preoperative Preparation: Insertion of an endotracheal tube or bronchoscope before tracheostomy aids in identifying the trachea and ensuring accurate placement. General anesthesia is preferred for safety and precision.
2. Positioning:
   • The child is placed supine with the neck extended using a sandbag under the shoulders and a head ring for stability. Excessive neck extension should be avoided to prevent injury to pleura, brachiocephalic vein, innominate vessels and thymus or placement of the tracheostomy too low near the suprasternal notch (low tracheostomy).
3. Surgical Technique:
   • A horizontal incisionis made one fingerbreadth above the suprasternal notch.
   • The superficial fat and strap muscles are dissected to expose the trachea. If the thyroid gland obstructs access, it may be retracted superiorly or divided with electrocautery.
   • Before incising trachea, silk sutures are placed in the trachea, on either side of midline.
   • Tracheal Incision: A vertical midline incision is made between the second and fourth tracheal rings, avoiding excision of circular piece of tracheal wall to prevent long-term stenosis.
   • Tracheal lumen is small, do not insert knife too deep; it will injure posterior tracheal wall or even oesophagus causing tracheo-oesophageal fistula.
4. Tracheostomy Tube Insertion:
   • The endotracheal tube is withdrawn, and a pre-selected tracheostomy tube is inserted. A silastic or portex tube is better as compared to metallic tubes which causes more trauma. Care must be taken to avoid infolding of the anterior tracheal wall.
   • Tube Selection: The tube must have an appropriate diameter, length, and curvature to avoid impingement on the carina, bronchus, or tracheal walls.
   • Stay Sutures: Placed on either side of the tracheal incision are now secured to the chest (marked ‘do not remove’) for easy reinsertion in case of accidental decannulation.
5. Imaging:
   • Imaging: A postoperative neck and chest X-ray confirms proper tube placement.

Complications of Pediatric Tracheostomy

1. Early Complications (Immediate to 1 Week):
   • Obstruction: Often caused by mucus or crusts in the tube lumen. It is prevented by adequate humidification, suctioning, and hydration.
   • Accidental Decannulation: A serious complication in the first few days due to the lack of a well-formed fistula tract. Stay sutures facilitate safe reinsertion.
   • Air Leak: Surgical emphysema or pneumomediastinum may occur due to air leakage into soft tissues. Low tracheostomy increases the risk of pneumothorax.
   • Apnoea: Sudden reduction in dead space can cause apnoea in children with chronic airway obstruction. Sedation should be avoided.
   • False Passage: Improper tube reinsertion can create a false passage, leading to obstruction or pneumothorax.
   • Haemorrhage: Early bleeding may arise from wound edges or unnoticed vessels.
2. Late Complications (After 1 Week):
   • Obstruction: Granulomas or mucous plugs can obstruct the tracheal lumen or tube. Granulations may require surgical removal.
   • Haemorrhage: Rare but catastrophic bleeding may occur due to erosion of the anterior tracheal wall into the innominate artery.
   • Chest Infections: Increased risk of infections in children with tracheostomies, requiring prompt treatment.

Post-operative care of tracheostomy in Infants and Children

Children with a tracheostomy require close monitoring in a pediatric intensive care unit (PICU) or high dependency unit (HDU) during the initial days. Early complications are life-threatening and necessitate vigilant care. Infants are particularly vulnerable due to their immature immune systems and smaller tracheal diameters, requiring frequent suctioning to clear secretions.

1. Maintain a patent airway through regular suctioning and humidification using heat moisture exchange (HME) devices or heated water systems to prevent thick secretions and tube occlusion.
2. Use stay sutures to facilitate tube reinsertion if accidental decannulation occurs.
3. Monitor for signs of infection, such as redness, swelling, or exudate at the stoma site.
4. For suction and cleaning, use a catheter with a diameter half the internal diameter of the tracheostomy tube. Limit suctioning to 5–10 seconds, allowing 30 seconds for recovery between attempts.
5. Clean the stoma daily with 9% saline and inspect for granulation tissue or skin breakdown.
6. Encourage ambulation and chest physiotherapy to loosen secretions and prevent infections.
7. Provide emotional and educational support to the child and family, addressing their concerns and ensuring proper home care techniques.

Decannulation

Decannulation is the process of removing a tracheostomy tube once the patient’s condition has improved. Prolonged tube use should be avoided as it can cause infections, ulcers, scarring, and airway narrowing. When removing the tracheostomy tube (decannulation) in an infant or young child, follow these guidelines:

1. Check the prerequisites for decannuation. The primary cause is resolved or improved and the upper airway is open and patent. There is good lung capacity and a strong cough reflex able to manage secretions. The patient must be stable, without fever, infection, or sepsis.
2. Perform the procedure in an operating room where a trained nurse and anaesthetist are present.
3. Keep emergency equipment ready for reintubation if needed. This includes a good headlight, a laryngoscope, properly sized endotracheal tubes, and a tracheostomy tray.
4. Monitor the child closely after decannulation for several hours. Watch for signs of breathing difficulties, fast heart rate (tachycardia), or changes in skin colour. Use a pulse oximeter to check oxygen levels, and consider blood gas tests if necessary.

If decannulation fails, look for possible causes, such as:

1. The original problem that required the tracheostomy is still present.
2. Blockage from scar tissue (granulations) around or below the stoma where the tube was placed.
3. Swelling in the trachea (tracheal oedema) or narrowing below the vocal cords (subglottic stenosis).
4. The trachea wall collapses inward at the stoma site.
5. Weakness of the trachea (tracheomalacia).
6. The child is psychologically dependent on the tracheostomy or unable to adjust to breathing through the upper airways.
7. In complex cases, an endoscopic examination of the larynx, trachea, and bronchi may be needed, preferably using magnifying telescopes or a flexible endoscope.

———— End of the chapter ————

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Reference Textbooks.

• Scott-Brown, Textbook of Otorhinolaryngology-Head and Neck Surgery.
• Cummings, Otolaryngology-Head and Neck Surgery.
• Stell and Maran’s, Textbook of Head and Neck Surgery and Oncology.
• Ballenger’s, Otorhinolaryngology Head And Neck Surgery
• Susan Standring, Gray’s Anatomy.
• Frank H. Netter, Atlas of Human Anatomy.
• B.D. Chaurasiya, Human Anatomy.
• P L Dhingra, Textbook of Diseases of Ear, Nose and Throat.
• Hazarika P, Textbook of Ear Nose Throat And Head Neck Surgery Clinical Practical.
• Mohan Bansal, Textbook of Diseases of Ear, Nose and Throat Head and Neck Surgery.
• Hans Behrbohm, Textbook of Ear, Nose, and Throat Diseases With Head and Neck Surgery.
• Logan Turner, Textbook of Diseases of The Nose, Throat and Ear Head And Neck Surgery.
• Arnold, U. Ganzer, Textbook of  Otorhinolaryngology, Head and Neck Surgery.
• Ganong’s Review of Medical Physiology.
• Guyton & Hall Textbook of Medical Physiology.

Author:

Dr. Rahul Bagla
MBBS (MAMC, Delhi) MS ENT (UCMS, Delhi)
Fellow Rhinoplasty & Facial Plastic Surgery.
Renowned Teaching Faculty
Mail: msrahulbagla@gmail.com
India

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