Pediatric Tracheotomy: Pediatric Tracheotomy: An UpdateAn Update

Shraddha Mukerji, MDShraddha Mukerji, MDUniversity of Texas Medical BranchUniversity of Texas Medical Branch

Department of OtolaryngologyDepartment of OtolaryngologyDidactics Didactics

September 24, 2009September 24, 2009

OverviewOverview

HistoryHistory Changing IndicationsChanging Indications Surgical ConsiderationsSurgical Considerations ComplicationsComplications Long term effects of trach in children Long term effects of trach in children DecannulationDecannulation

History of tracheotomyHistory of tracheotomy

Period of legend 1500BC-1500AD Homer, Galen

Period of fear 460BC-1500AD Hippocrates

Period of drama 1500-1900 First modern tracheotomy, Pediatric tracheotomy for foreign body, tracheotomy for diphtheria

Period of rationalization 1900- Jackson: better instruments, post-operative care, safer anesthetics

PioneersPioneers

Antonio M. Brasavola

First successful tracheotomy

Chevalier Jackson

Good postoperative care

Pierre Bretonneau

Tracheotomy for diphtheria

Indications Indications

Fraga JC, et al Pediatric tracheostomy. J Pediatr (Rio J). 2009 Mar-Apr;85(2):97-103. Epub 2009 Mar 12.

How have they changed?How have they changed?

1980

Inflammatory diseases of the upper airway

50% - 3%

Prematurity, prolonged intubation

28% - 58%

Congenital anomalies

6% - 23%

Arcand and Granger, J Otol 1988, Line et al Laryngoscope 1986, Fraga et al, J Pediatr 2009

Why have they changed?Why have they changed?

Endotracheal Endotracheal intubationintubation

Timing between ET Timing between ET and tracheotomy has and tracheotomy has changedchanged

Endotracheal tubes

Most common indicationsMost common indications Prematurity, chronic ventilatory supportPrematurity, chronic ventilatory support

Craniofacial anomalies: Pierre Robin, Craniofacial anomalies: Pierre Robin, CHARGECHARGE

Congenital anomalies: Subglottic stenosisCongenital anomalies: Subglottic stenosis

Tracheotomy for tracheobronchial hygieneTracheotomy for tracheobronchial hygiene

Carron JD, et al Pediatric tracheotomies: changing indications and outcomes. Laryngoscope. 2000 Jul;110(7):1099-10

Fraga JC, et al Pediatric tracheostomy. J Pediatr (Rio J). 2009 Mar-

Apr;85(2):97-103. Epub 2009 Mar 12.

Tracheotomy tubesTracheotomy tubes

Shiley tracheostomy tubes

Bivona tracheostomy tubes

Metal tracheostomy tubes

Pre-op Parental counselingPre-op Parental counseling

Multidisciplinary meetingMultidisciplinary meeting Reassurance about voice issues, swallowing Reassurance about voice issues, swallowing

and feedingand feeding Educational material/videos/meeting other Educational material/videos/meeting other

parents of children with tracheotomyparents of children with tracheotomy How soon can we go home?How soon can we go home?

Surgical stepsSurgical steps

Patient positionPatient position

Landmarks: hyoid and cricoid, thyroid Landmarks: hyoid and cricoid, thyroid obscuredobscured

Anatomical differences between Anatomical differences between pediatric and adult larynxpediatric and adult larynx

Surgical steps contd…Surgical steps contd…

IncisionIncision

Removal of Removal of subcutaneous fatsubcutaneous fat

Exposure of the thyroid Exposure of the thyroid isthmusisthmus

Surgical steps contd…Surgical steps contd…

Always divide the thyroid isthmusAlways divide the thyroid isthmus Palpate cricoid and identify tracheal rings, Palpate cricoid and identify tracheal rings,

usually skin hook is used to hitch up the usually skin hook is used to hitch up the cricoidcricoid

Stay SuturesStay Sutures

Incisions on the tracheaIncisions on the trachea

Surgical steps contd…Surgical steps contd…

Vertical incision on the tracheaVertical incision on the trachea Tracheotomy tube sutured to skinTracheotomy tube sutured to skin Stay sutures long and labeled left and rightStay sutures long and labeled left and right

Post-op carePost-op care

Chest XrayChest Xray ICU stay till first trach change, then ICU stay till first trach change, then

intermediate levelintermediate level Sedated and paralyzed for 48 hoursSedated and paralyzed for 48 hours Suture tray at bedsideSuture tray at bedside Tracheotomy tube Tracheotomy tube ≤≤ Endotracheal tube ≤Endotracheal tube ≤ Trach change on day 5 (2 persons)Trach change on day 5 (2 persons)

ComplicationsComplications

Children: Adults---2,3:1Children: Adults---2,3:1-Premature>>Term-Premature>>Term

Complications are reduced if operation is Complications are reduced if operation is carried out by trained physicians in a tertiary carried out by trained physicians in a tertiary care settingcare setting

Mortality related directly to tracheotomy Mortality related directly to tracheotomy varies between 0-6%varies between 0-6%

Pereira et al. Complications of neonatal tracheostomy: a 5 year review. Otolaryngol Head Neck Surg.2004;131:810-13

Complications cont’d…Complications cont’d…

Early (5-49%)Early (5-49%) BleedingBleeding PneumomediastinumPneumomediastinum Subcut emphysemaSubcut emphysema Accidental decannulationAccidental decannulation Wound breakdownWound breakdown

Late (24-100%)Late (24-100%) Granuloma formationGranuloma formation TracheomalaciaTracheomalacia Tracheal stenosisTracheal stenosis Tracheoesophageal Tracheoesophageal

fistulafistula

Pneumomediastinum/PneumothoraxPneumomediastinum/Pneumothorax

One of the commonest One of the commonest early Cxearly Cx

28% of premature 28% of premature babies affectedbabies affected

Damage to Damage to pleura,forceful pleura,forceful coughing coughing

Subcutaneous emphysemaSubcutaneous emphysema

Increase ventilatory Increase ventilatory pressurespressures

Overzealous ventilationOverzealous ventilation

Wound breakdownWound breakdown

Common in ‘chunky’ Common in ‘chunky’ babies with a short neckbabies with a short neck

Avoid drag of ventilator Avoid drag of ventilator tubing on trach tubetubing on trach tube

Wound careWound care

Suprastomal granulomaSuprastomal granuloma

Etiology: infection, Etiology: infection, friction, stasis of friction, stasis of secretionssecretions

Incidence: Incidence: <10%to>80%<10%to>80%

Indications for removalIndications for removal- Decannulation, large - Decannulation, large

obstructing granulomasobstructing granulomas

Suprastomal/Tracheal granulomaSuprastomal/Tracheal granuloma

Complications cont’d…Complications cont’d…

TracheitisTracheitis Usually colonization, viral infectionUsually colonization, viral infection Determine: change in color of secretions, O2 Determine: change in color of secretions, O2

saturations, vent settingssaturations, vent settings Tracheoscopy to differentiate colonization from Tracheoscopy to differentiate colonization from

true bacterial tracheitistrue bacterial tracheitis Gram stain and parenteral antimicrobialsGram stain and parenteral antimicrobials

PneumoniaPneumonia

Accidental decannulationAccidental decannulation

Commonest cause of tracheotomy related Commonest cause of tracheotomy related deathdeath

Premature babies: 7% and older children 16%Premature babies: 7% and older children 16%

Vigilant post-operative monitoringVigilant post-operative monitoring

Long Term Effects of Tracheotomy Long Term Effects of Tracheotomy in Childrenin Children

Study by Freeland et al – Delayed physical Study by Freeland et al – Delayed physical development and increase likelihood of development and increase likelihood of complications if tracheostomy > 1 weekcomplications if tracheostomy > 1 week

Hill and Singer – delayed speech acquisition Hill and Singer – delayed speech acquisition and delayed communicationand delayed communication

Freeland AP Developmental influences of infant tracheostomy. J Laryngol Otol. 1974 Oct;88(10):927-36

Hill BP, Singer LT Speech and language development after infant tracheostomy. J Speech Hear Disord. 1990 Feb;55(1):15-20

Care of the tracheotomyCare of the tracheotomy

Humidification

Suctioning: aseptic technique and prevent trauma to the trachea

Communication: speaking valve

Change of cannula, daily tie changes

Passy Muir valvePassy Muir valve

Principle ‘No leak’, closed Principle ‘No leak’, closed respiratory system with one respiratory system with one way valveway valve

Various types available for Various types available for different tracheostomy tubesdifferent tracheostomy tubes

Benefits: Speech, better Benefits: Speech, better cough, aids swallow, cough, aids swallow, expedites decannulation expedites decannulation

DecannulationDecannulation

Indication for decannulationIndication for decannulation

Clinical: resolution of the primary disease, no Clinical: resolution of the primary disease, no active infection, tolerance of speaking valveactive infection, tolerance of speaking valve

Endoscopic: a clear tracheobronchial treeEndoscopic: a clear tracheobronchial tree

Functional: Adequate pulmonary reserveFunctional: Adequate pulmonary reserve

Process of decannulationProcess of decannulation

Timing of decannulation-Spring,Summer vs Timing of decannulation-Spring,Summer vs Fall/WinterFall/Winter

Role of capped sleep studyRole of capped sleep study

Observation for 24 hours after decannulation Observation for 24 hours after decannulation in a monitored setttingin a monitored settting

Decannulation contd…Decannulation contd… Rate of decannulation:34%-75%Rate of decannulation:34%-75%

Children with craniofacial anomalies have the highest Children with craniofacial anomalies have the highest decannulation ratedecannulation rate

Neurologically impaired children and children with prolonged Neurologically impaired children and children with prolonged ventilation-lower decannulation rateventilation-lower decannulation rate

Children decannulated < 2years have a lower incidence of Children decannulated < 2years have a lower incidence of TCFTCF

Carron et al. Pediatric Tracheostomies: Changing Indications and Outcomes. Laryngoscope 2000;110 (7):1099-1104

Algorithm for decannulationAlgorithm for decannulation

Indications are met

Pulmonary evaluation

Capped sleep study

Admission x 2 nights

1st night: Capped trach tube

2nd night: Decannulation and observation

Discharge and FU in one week

SummarySummary

Endotracheal intubation has virtually replaced Endotracheal intubation has virtually replaced tracheotomy for inflammatory lesions of the pediatric tracheotomy for inflammatory lesions of the pediatric larynxlarynx

Commonest indications include chronic ventilatory Commonest indications include chronic ventilatory dependency, craniofacial and congenital anomalies of dependency, craniofacial and congenital anomalies of the larynxthe larynx

Removal of subcutaneous fat, vertical tracheal Removal of subcutaneous fat, vertical tracheal incision and stay suturesincision and stay sutures

Summary contd…Summary contd…

Common complications include bleeding, wound Common complications include bleeding, wound infection, pneumomediastinum and granuloma infection, pneumomediastinum and granuloma formationformation

Accidental decannulation remains the most important Accidental decannulation remains the most important cause of tracheotomy related deathcause of tracheotomy related death

Rates of decannulation are the highest in children Rates of decannulation are the highest in children with craniofacial anomalieswith craniofacial anomalies

Christmas in the bronchoscopic clinic ward. Children with tracheostomies usually lived in the hospital. Photo from The Life of Chevalier Jackson, An Autobiography