1. Pediatric Tracheostomy
M. Lauren Lalakea MD
Chief, Otolaryngology/HNS,
Valley Medical Center, San Jose, CA
Clinical Associate Professor, Stanford

2. Tracheotomy--Introduction
Initially procedure of last resort to relieve airway obstruction, eg diphtheria, epiglottitis
High expectation for short duration, w decannulation
Indications expanded to include access for pulmonary toilet and assisted ventilation (polio)
nathanclarkecommunication.wikispaces.com
Uofmchildrenshospital.org

3. Tracheostomy--Introduction
Current trends:
↓trachs for acute airway obstruction
↑trachs for prolonged ventilation (>50%)
↓decannulation rate: 28—51%
↑trach duration: 2 yrs for those decannulated
Avg. age: 2—3 yr, >50% younger than 1 yr
Indications
Airway obstruction
Assisted ventilation
Pulmonary toilet

4. Indications Airway obstruction Congenital: Craniofacial anomalies
Bilateral vocal cord paralysis
Tracheomalacia
Laryngeal anomaly
Neoplasm

5. Craniofacial Anomaly: Pierre Robin micrognathia, glossoptosis, cleft palate
php.med.unsw.edu.au

6. Bilateral Vocal Cord Paralysis High-pitched stridor, CNS etiology

7. Tracheomalacia Inspiratory and expiratory stridor
2011.prepsa.courses.aap.org

8. Laryngeal Anomaly: Glottic Web
wiki.uiowa.edu

9. Neoplasm: Lymphangioma
openi.nlm.nih.gov

10. Indications Airway Obstruction Acquired: Subglottic stenosis
Cricoid is a complete ring
ETT -->mucosal ischemia, necrosis
Perichondritis, cartilage injury
Progressive stridor, failed extubation
Trach if med and surgical management fail
Recurrent respiratory papillomatosis
Trauma
emedicine.medscape.com

11. Indications Assisted ventilation Pulmonary toilet
Congenital central hypoventilation
Chronic lung dz, eg BPD
Neuromuscular disease
Pulmonary toilet
Neurologically impaired children
Recurrent respiratory infections, aspiration

12. Timing of Tracheotomy Controversial in pedi pts
Prolonged intubation → risk of airway injury
Incidence of subglottic stenosis low in neonates despite lengthy intubation
Meticulous NICU care
Pliable larynx and trachea
Older children and adults:
Consider trach after 2-3 wks of intubation
Consider likelihood that underlying process will reverse/improve

13. Pre-Trach Evaluation Airway obstruction
Flexible laryngoscopy—dynamic evaluation
Rigid laryngoscopy and bronchoscopy with spontaneous ventilation
Any treatable conditions?

14. Pre-Trach Evaluation Dynamic evaluation--laryngomalacia
primehealthchannel.com

15. Pre-Trach Evaluation Assisted Vent + Neurologic Dz All
Discussion with 1° team, Pulmonary, family
Goals of care
All
Wt> 1500 gm, FiO2 <60%
Hct, coags
Informed Consent

16. Tracheotomy Technique
General Anesthesia, with ETT
Vs. LMA or bronchoscope
Positioning with neck extended
Palpation of landmarks, incision marked
Pedi larynx is high, cricoid easiest to palpate
Horizontal or vertical incision below cricoid

17. Tracheotomy Technique
Midline dissected, thyroid isthmus divided
Stay sutures placed thru rings
Trachea opened vertically

18. Tracheotomy Technique
ETT is withdrawn slightly
Appropriate trach tube placed
Position and adequate ventilation confirmed
Tube size adjusted prn
Excessive leak
Excessive length

19. Tracheotomy Technique
Tube secured with sutures
Stay sutures labeled
Facilitate tube replacement in case of accidental decannulation
Twill tape used around neck to secure trach
Snugly tied to prevent dislodgement

20. Tracheostomy Variations
Vertical skin incision
Stoma ‘matured’ by suturing skin in 4 quadrants to edges of tracheal incision
Allows easier tube replacement if dislodged

21. Post-Operative Care Transport directly to ICU
CXR to confirm tube position, r/o PTX
Sedation to minimize risk of accidental decannulation while stoma immature
Routine suctioning, humidified air
“Do not change trach ties”
Obturator, extra trach tubes at bedside
Same size, and one size smaller

22. Post-Operative Care First trach change
At 5-7 days post-op
2 ENT MDs
Neck extended, fresh tube placed
Stay sutures removed, ties changed
Confirms that stoma is sufficiently mature to allow future changes by non-surgical personnel
Sedation weaned, transfer out of ICU as appropriate

23. Post-Operative Care ‘Hands-on’ caregiver training begins
Infants and young children vulnerable to trach catastrophe
Pedi trach tubes are single canula--require meticulous care
General trach care, suctioning technique
Trach tube changes—q 1-2 wk
CPR training
Discharge planning

24. Complications Complication rates vary, up to 40—50% Early:
Accidental decannulation
False passage, loss of airway
Potential for significant morbidity/mortality
↓Risk with:
Adequate sedation/ immobilization
Appropriately sized and secured tube
Close monitoring and nursing care
Stay sutures +/- ‘mature’ stoma to facilitate tube replacement
sciencedirect.com

25. Complications: Early Tube obstruction/ mucus plugging
Potential for significant morbidity/ mortality in kids
Small diameter single canula, vulnerable age group
↓Risk with:
Humidified air
Frequent suctioning
Appropriate monitoring
Pneumothorax/ pneumomediastinum 0.6 – 6%
Hemorrhage
Local infection, skin breakdown

26. Complications--Late Tracheal granuloma—39% Stomal, suprastomal, distal
↓Risk with meticulous trach care, proper suctioning technique
Surveillance bronchoscopy, excision to maintain patency
tracheostomy.com
Utmb.edu

27. Complications: Late Tube obstruction/ mucus plugging – 13%
Accidental decannulation—12%
Caregiver training is critical
Adequate monitoring and home support
Local infection – 9%

28. Complications: Late Speech delay
Smaller trach size allows for better airflow and voicing
Passey-Muir valve appropriate for some
Early Start and Speech Tx

29. Complications: Late Suprastomal collapse/ malacia – 8%
Tracheal or subglottic stenosis
Arterial erosion/ tracheal-innominate fistula
“Sentinel Bleed”
TE fistula--acquired
readcube.com

30. Complications Tracheocutaneous fistula: 11-42% Death
Persistent fistula after successful decannulation
↑Risk if trach duration > 1 yr
90% of ‘Starplasty’ trachs have TC fistula
May require surgical repair
Death
Trach-related = 0 – 3%
Accidental decannulation / mucus plugging most common
Overall = 8.5 – 19%

31. Trach Tubes: Which are Best?
Cuffed vs. uncuffed
Neonatal vs. pediatric
Bivona vs. Shiley
Single cannula vs. with inner cannula
Metal vs. plastic
Appropriate length and diameter?
Fenestrated
Jackson Trach tube
Cuffed Shiley Trach with Inner Cannula

32. Trach Tubes: Which are Best?
Fenestrated tube
Allows passage of air up thru vocal cords to facilitate speech
May ↑ aspiration risk
More prone to granulation tissue formation
tracheostomy.com

33. Trach Tubes: Which are Best?
Ideal trach tube:
Soft enough to conform w/o pressure, injury, discomfort
Rigid enough to avoid collapse
Material causes minimal tissue reaction
Has inner cannula that can be removed and cleaned
Not available for plastic pediatric trachs
Has stylet or obturator to facilitate insertion
Bivona and Shiley meet most criteria

34. Trach Tube Size Guidelines
Length
Neonatal vs. Pedi
Neonatal equivalent diameter vs. Pedi, but 5-8 mm shorter in length
Too short
↑chance of accidental decannulation
Too long
May abrade carina or rest in right mainstem
Longer tubes desirable if tracheal stenosis or malacia
Length confirmed by CXR or flex. endoscopy

35. Trach Tube Size Guidelines
Diameter
Too large
Mucosal injury, stenosis
Inability to voice
Too small
Excessive leak in ventilated pts
Inadequate air exchange
Difficult to suction adequately
Pedi trach tubes sized based on inner diameter, correspond to endotracheal tube sizes

36. Trach Tube Size Guidelines
Child’s Age Inner Diameter (mm)
Premie, <1000 gm
2.5 neo
Premie, gm
3.0 neo
Neonate – 6 mo
3.0 – 3.5, neo
6 mo -- 1 yr
3.5 – 4.0
1 – 2 yr
4.0 – 5.0
> 2 yrs
Age/4 + 4

37. Shiley Pediatric Trach Tubes
Options: Neo, Pedi, Pedi-Long (PDL),
Pedi c Cuff (PDC), Pedi-Long c Cuff (PLC)

38. Bivona Trachs Similar sizing Cuffed Tubes: TTS (tight to shaft)
Neo and Pedi
Cuffed Tubes: TTS (tight to shaft)
Excellent option for pts who need cuff
Reorder Code
Size
ID (mm)
OD (mm)
Length (mm)
67P025 
2.5mm 
4.0mm 
38.0mm 
67P030 
3.0mm 
4.7mm 
39.0mm 
67P035 
3.5mm 
5.3mm 
40.0mm 
67P040 
6.0mm 
41.0mm 
67P045 
4.5mm 
6.7mm 
42.0mm 
67P050 
5.0mm 
7.3mm 
44.0mm 
67P055 
5.5mm 
8.0mm 
46.0mm 

39. Bivona FlexTend Trach Tubes
Flexible extended length connection ‘built-in’ to trach

40. Decannulation Suitability: Procedure:
Off ventilator, minimal suctioning requirement, no obstructive pathology
Tolerates capping/occlusion
Recent bronchoscopy is clear
Procedure:
Admission to ICU, monitoring
Downsizing vs removal, occlusive dressing
Observation hrs