1. Pediatric Tracheotomy: An Update Shraddha Mukerji, MD University of Texas Medical Branch Department of Otolaryngology Didactics September 24, 2009

2. Overview  History  Changing Indications  Surgical Considerations  Complications  Long term effects of trach in children  Decannulation

3. History of tracheotomy Period of legend 1500BC-1500AD Homer, Galen Period of fear 460BC-1500AD Hippocrates Period of drama 1500-1900First modern tracheotomy, Pediatric tracheotomy for foreign body, tracheotomy for diphtheria Period of rationalization 1900- Jackson: better instruments, post-operative care, safer anesthetics

4. Pioneers Antonio M. Brasavola First successful tracheotomy Chevalier Jackson Good postoperative care Pierre Bretonneau Tracheotomy for diphtheria

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

6. 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

7. Why have they changed?  Endotracheal intubation  Timing between ET and tracheotomy has changed Endotracheal tubes

8. Most common indications  Prematurity, chronic ventilatory support  Craniofacial anomalies: Pierre Robin, CHARGE  Congenital anomalies: Subglottic stenosis  Tracheotomy 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..

9. Tracheotomy tubes Shiley tracheostomy tubes Bivona tracheostomy tubes Metal tracheostomy tubes

10. Pre-op Parental counseling  Multidisciplinary meeting  Reassurance about voice issues, swallowing and feeding  Educational material/videos/meeting other parents of children with tracheotomy  How soon can we go home?

11. Surgical steps  Patient position  Landmarks: hyoid and cricoid, thyroid obscured

12. Anatomical differences between pediatric and adult larynx

13. Surgical steps contd…  Incision  Removal of subcutaneous fat  Exposure of the thyroid isthmus

14. Surgical steps contd… Always divide the thyroid isthmus Always divide the thyroid isthmus Palpate cricoid and identify tracheal rings, usually skin hook is used to hitch up the cricoid Palpate cricoid and identify tracheal rings, usually skin hook is used to hitch up the cricoid Stay Sutures Stay Sutures

15. Incisions on the trachea

16. Surgical steps contd…  Vertical incision on the trachea  Tracheotomy tube sutured to skin  Stay sutures long and labeled left and right

17. Post-op care  Chest Xray  ICU stay till first trach change, then intermediate level  Sedated and paralyzed for 48 hours  Suture tray at bedside  Tracheotomy tube ≤  Endotracheal tube ≤  Trach change on day 5 (2 persons)

18. Complications  Children: Adults---2,3:1 -Premature>>Term  Complications are reduced if operation is carried out by trained physicians in a tertiary care setting  Mortality related directly to tracheotomy varies between 0-6% Pereira et al. Complications of neonatal tracheostomy: a 5 year review. Otolaryngol Head Neck Surg.2004;131:810-13

19. Complications cont’d… Early (5-49%)  Bleeding  Pneumomediastinum  Subcut emphysema  Accidental decannulation  Wound breakdown Late (24-100%)  Granuloma formation  Tracheomalacia  Tracheal stenosis  Tracheoesophageal fistula

20. Pneumomediastinum/Pneumothorax  One of the commonest early Cx  28% of premature babies affected  Damage to pleura,forceful coughing

21. Subcutaneous emphysema  Increase ventilatory pressures  Overzealous ventilation

22. Wound breakdown  Common in ‘chunky’ babies with a short neck  Avoid drag of ventilator tubing on trach tube  Wound care

23. Suprastomal granuloma  Etiology: infection, friction, stasis of secretions  Incidence: 80%  Indications for removal - Decannulation, large obstructing granulomas

24. Suprastomal/Tracheal granuloma

25. Complications cont’d…  Tracheitis  Usually colonization, viral infection  Determine: change in color of secretions, O2 saturations, vent settings  Tracheoscopy to differentiate colonization from true bacterial tracheitis  Gram stain and parenteral antimicrobials  Pneumonia

26. Accidental decannulation  Commonest cause of tracheotomy related death  Premature babies: 7% and older children 16%  Vigilant post-operative monitoring

27. Long Term Effects of Tracheotomy in Children  Study by Freeland et al – Delayed physical development and increase likelihood of complications if tracheostomy > 1 week  Hill and Singer – delayed speech acquisition and 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

28. Care of the tracheotomy  Humidification  Suctioning: aseptic technique and prevent trauma to the trachea  Communication: speaking valve  Change of cannula, daily tie changes

29. Passy Muir valve  Principle ‘No leak’, closed respiratory system with one way valve  Various types available for different tracheostomy tubes  Benefits: Speech, better cough, aids swallow, expedites decannulation

30. Decannulation  Indication for decannulation  Clinical: resolution of the primary disease, no active infection, tolerance of speaking valve  Endoscopic: a clear tracheobronchial tree  Functional: Adequate pulmonary reserve

31. Process of decannulation  Timing of decannulation-Spring,Summer vs Fall/Winter  Role of capped sleep study  Observation for 24 hours after decannulation in a monitored settting

32. Decannulation contd…  Rate of decannulation:34%-75%  Children with craniofacial anomalies have the highest decannulation rate  Neurologically impaired children and children with prolonged ventilation-lower decannulation rate  Children decannulated < 2years have a lower incidence of TCF Carron et al. Pediatric Tracheostomies: Changing Indications and Outcomes. Laryngoscope 2000;110 (7):1099-1104

33. Algorithm for decannulation Indications are met Pulmonary evaluation Capped sleep study Admission x 2 nights 1 st night: Capped trach tube 2 nd night: Decannulation and observation Discharge and FU in one week

34. Summary  Endotracheal intubation has virtually replaced tracheotomy for inflammatory lesions of the pediatric larynx  Commonest indications include chronic ventilatory dependency, craniofacial and congenital anomalies of the larynx  Removal of subcutaneous fat, vertical tracheal incision and stay sutures

35. Summary contd…  Common complications include bleeding, wound infection, pneumomediastinum and granuloma formation  Accidental decannulation remains the most important cause of tracheotomy related death  Rates of decannulation are the highest in children with craniofacial anomalies

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