Pediatric trachostomy

Paediatrics
Tracheotomy

1. SCOTT BROWN’S LEARNING 2020 CHAPTER-35 PEDIATRIC TRACHEOSTOMY VOL-2 PAGES-395-412

2. PAEDIATRIC TRACHEOSTOMY PRESENTOR- DR.AMUTHAN.K.R MS PG MODERATOR- PROF.DR.ARUL SUNDARESH KUMAR ., MS(ENT)

3. INTRODUCTION AND HISTORICAL PERSPECTIVE Oldest documented surgical procedure . In 19th century Trousseau used the technique to relieve airway obstruction in diphtheria . the late 1970s many tracheostomies in children were performed to relieve airway obstruction in acute airway infections such as epiglottitis and acute laryngotracheobronchitis ( ALTB, or croup ).

4. INDICATIONS OF PEDIATRIC TRACHEOSTOMY to relieve upper airway obstruction to prevent complications of prolonged intubation to reduce anatomical dead space to allow suction toilet of the trachea.

5. the late 1990s, tracheostomy was considered the mainstay of management for obstructing subglottic haemangioma . Tracheostomy can be avoided using drug treatment or surgical excision The introduction of the cricoid split and single-stage laryngotracheal reconstruction has reduced the need for tracheostomy for extubation failure due to subglottic oedema or stenosis.

6. prolonged intubation tracheostomy should normally be considered in older children after 2–3 weeks of endotracheal intubation The long-term complications of prolonged endotracheal intubation are ulceration at the level of the glottis and, particularly in children, the subglottis , can lead to cicatrization and stenosis of the airway

7. Long-term and home ventilation Indications for long-term ventilation include: • congenital central hypoventilation syndrome • spinal injury • congenital myopathy • airway malacia • chronic lung disease.

8. Tracheal toilet Few children need tracheostomy for toilet of the airway Children with intractable aspiration may need regular suction but the presence of a tracheostomy can predispose to aspiration in itself and increase the risk of respiratory tract infection

9. TECHNIQUES OF TRACHEOSTOMY Positioning Under general anaesthesia the infant is positioned supine on the operating table with Neck extension extension of the neck in infants increases the risk of injury to the great vessels in the root of the anterior neck Overextension - risk exposing intrathoracic trachea

10. Skin incision In adult horizontal skin incision is used , situated halfway between the cricoid and sternal notch. Traditionally, a vertical incision has been avoided for fear of a poor cosmetic outcome after decannulation a vertical skin incision has become more popular with specialized paediatric otolaryngologists keep dissection in the midline, reducing a tendency to stray away from the trachea in a difficult dissection, and allows easier placement of maturation sutures.

11. Removal of subcutaneous fat and maturation sutures suturing the edge of the skin incision to the edge of the tracheal incision (maturation sutures)using absorbable sutures ( 4/0 Vicryl Rapide ). Stay sutures are placed in the wall of the trachea on either side of the vertical incision. These are generally a removable suture (e.g.  4/0 PROLENE ) and are left in situ until the first tube change

12. Dissection Dissection using monopolar or bipolar diathermy is advisable in small children to minimize blood loss and should be restricted to the midline to avoid risk to other structures in the neck

13. Tracheal incision A vertical incision is made in the midline, usually in tracheal rings 3–4 . It is vital that the cricoid cartilage is identified before the incision is made too high an incision in the trachea predisposes to subglottic stenosis. excision of an anterior tracheal window, a superiorly or inferiorly based tracheal flap is raised a cruciate incision in the trachea , the tracheal edges being closely apposed to the skin edges. advantage is increased stability of the initial tracheostomy tract and therefore greater safety in the event of accidental decannulation tracheal flaps may lead to an increased risk of long-term stenosis and the majority of authors currently favour a simple vertical incision.

14. Securing tracheostomy tubes Until the tracheostome has epithelialized and matured , the risks associated with accidental decannulation are more significant. tapes supplied with the tube. The tapes are tied in a secure knot, sufficiently tight to allow one finger to be inserted between the tapes and the neck skin Suturing the flange of the tracheostomy tube to the skin should be avoided in children ; infant skin is flexible and thin and does not provide a strong enough anchor point for fixing the tube

15. TRACHEOSTOMY CARE Adequate tracheostomy care is critical in the first 2–3 postoperative days . It is during the formation of the tract of the stoma Suction Humidification Skin care Change of tracheostomy tub

16. Suction Immediately after tracheostomy, the change from air that is warmed and humidified by the upper airway to dry, cold air leads to a rapid increase in airway secretions. This gradually reduces after a few weeks Humidification of inspired air and regular suctioning will reduce this tendency Suctioning is required as often as is necessary to keep the tube and airway clear. Overzealous suctioning may lead to mucosal trauma in the distal trachea if the catheter is inserted into the tracheal lumen itself and eventually granulation may form at the tip of the tracheostomy tube, irrigation of the tracheostomy tube with sterile saline to loosen secretions prior to suctioning is often advocated but there is little evidence to support this practice and it may increase contamination of the lower airway

17. Humidification Initially, humidification should be given via nebulizers and a tracheostomy mask . A few weeks after tracheostomy, more mobile devices can replace permanent humidification. Longer-term humidification may be achieved by using a heat and moisture exchanger ( HME or ‘Swedish nose ’) attachment contains a filter which becomes saturated by the moisture in exhaled air; this in turn humidifies the inhaled air. The tracheal bib works in a similar way. Both devices have the advantage of acting as filters for inspired air

18. Skin care The wound heals by secondary intention and eventually the tract becomes lined with squamous epithelium and organized scar tissue. Securing the wound edge skin to the trachea with maturation sutures hastens the development of an epithelialized tract. At this stage the tracheostome is considered mature. If the skincare in the first few days is not meticulous, skin and wound breakdown will occur. Usually a dry gauze or foam ( lyofoam ) dressing used

19. Change of tracheostomy tube The first change of tube is generally undertaken at around the seventh post-operative day . This allows some time for maturation of the stoma but is short enough to reduce the risk of tube obstruction from dried and thickened secretions. no standard proscribed interval at which tubes should be changed; this varies between children and also in the same child given variation in season and in the health of the lower airway Bivona ® and Shiley ® tubes are changed after a maximum of 28 days although most tubes are changed more frequently than this on clinical grounds.)

20. TRACHEOSTOMY TUBES Diameter Modern tracheostomy tubes are sized in relation to the diameter of the lumen in millimetres and the length of the tube from the skin flange to the tip of the tube A child with a long-standing tracheostomy should undergo regular age-appropriate ‘upsizing’ a smaller-sized tube will allow air to flow up thought the glottis and aid in normal speech production. Too large a tube will predispose to suprastomal collapse and may increase the risk of granulations and stenosis.

21. Tube length When inserted correctly, the end of the tracheostomy tube should sit comfortably proximal to the carina . Too long a tube will abut the carina and lead to ventilation problems, mucosal injury and potentially subsequent scarring . Too short a tube increases the risk of accidental decannulation . Ideally, the tube should be at least 2 cm, inside the stoma and 1–2 cm clear of the carina. Tube tip position can be assessed on chest X-ray , at regular rigid bronchoscopy or by passing a flexible endoscope down the lumen of the tube to inspect the carina.

22. Material Soft or siliconized PVC is now the most widely used material in paediatric tracheostomy tubes and materials may be hydrophobic to reduce the deposition of secretions. The relative flexibility of newer tubes reduces the risk of mucosal trauma during neck movements and the soft flange is less likely to lead to skin injury around the tracheostome .

23. Fenestration Fenestrated tubes allow air to pass upwards through the glottis in expiration to improve phonation . These are less practical in smaller children as the fenestration tends to become a focus for granulation and mucosal trauma on suctioning. Adequate passage of air upwards into the larynx is usually achieved by selecting a smaller tube diameter and allowing air leakage around the tube on expiration

24. Cuff There are two specific indications for cuffed tubes in children first, where there is a significant risk of aspiration (although a cuff will not completely protect against this) and, second, where there is a decrease in lung compliance with intercurrent infection in a ventilated child and ventilation pressures need to be raised temporarily The presence of a cuff increases the risk of mucosal ischaemia and subsequent tracheal stenosis , particularly if high cuff pressures are employed. Traditionally , cuffed tubes are rarely indicated in paediatrics

25. Types of tube The commonest standard tubes used in the UK at the time of writing are the Shiley ® and Bivona ® tubes . The Bivona ® Flextend ™ tube is a silicone tracheostomy tube with a longer external component than a normal tracheostomy tube This allows a greater degree of flexibility in children who are mechanically ventilated and is particularly useful in very small infants with a limited gap between the chin and chest The main disadvantage of this tube is the increased length of tube, which increases the dead space and risk of obstruction by secretions The Bivona ® Hyperflex ™ tube has an adjustable flange which allows change of the effective length of the tracheostomy tube,This is useful in children with particular anatomical constraints

26. Speaking valves Speaking valves are one-way valves which allow inhalation though the tube but force air upwards through the glottis on exhalation, creating sufficient subglottic pressure to allow phonation allowing speech, by increasing tracheal pressure on exhalation, these may improve lung function and reduce aspiration Many children learn to occlude the end of the tube on exhalation by flexing the neck and occluding the end of the tube with the neck skin to achieve the same result to help phonation. Rusch speaking valves are open apart from in significant expiration whereas the Passy-Muir® valve is designed to be closed apart from in inspiration and encourages use of the normal airway for expiration even in quiet respiration

27. COMPLICATIONS OF TRACHEOSTOMY Tracheostomy complications are more likely in children than in adults, and more common in children under 2 years of age,particularly preterm infants. Overall complication rates are quoted between 25% and 77% The higher complication rate in smaller children is likely to reflect the relatively small diameter of the airway in small children and the ease with which the airway may be occluded

28. Accidental decannulation The risk is increased by insufficiently tight ties , too short a tracheostomy tube and excessive traction on the tube from ventilator tubing. In the first few days before the tract matures, it is likely to be harder to reintroduce the tube if decannulated . Wetmore et al report accidental decannulation in 29 of 420 (6.9%) children in the first week. tracheostomy nursing care, and surgical techniques (stay sutures, maturation sutures) may help reduce the morbidity by allowing easier and safer reinsertion of a displaced tub

29. Tube obstruction Immediately after tracheostomy the tube is most likely to become blocked with secretions. Regular suction is required. Humidification reduces the rate of secretion and helps to prevent the secretions drying in the lumen of the tube and narrowing the airway. In a mature tracheostomy, the tube is more likely to be obstructed by granulation

30. Pneumothorax, pneumomediastinum , surgical emphysema In infant the domes of the pleura extend well into the neck. Inadvertently straying from the midline during dissection increases the risk of post-operative pneumothorax Small pneumothoraces can be treated conservatively while larger ones will require chest drainage. If the tracheostomy wound is closed too tightly or tight dressings leads to air may leak into the soft tissues of the neck (surgical emphysema) or track down into the mediastinum. The wound should be reopened to allow air to track and then corrugated drain should be inserted. Pneumothorax is a rare complication in elective tracheostomy but commoner in emergency tracheostomy . chest X-ray after all paediatric tracheostomies both to check tube position and to exclude pneumothorax

31. Bleeding Bleeding in the first few days due to failure to achieve complete haemostasis during surgery. Commonly, bleeding may persist from the wound edge, anterior jugular veins or their tributaries, or the edge of the thyroid isthmus . If direct pressure is not adequate to control haemorrhage , the wound may be carefully packed with haemostatic gauze ( Surgicel or Kaltostat ®). Re-exploration is rarely required. Later, minor bleeding may arise from areas of granulation around the tube. This can normally be controlled with cautery and ongoing medical treatment such as application of steroid and antibiotic ointment .

32. Tracheo -innominate fistula Tracheo -innominate artery fistula is a rare but lethal complication . If innominate artery lies abnormally high in the neck then tracheostomy should be reconsidered orelse high tracheostomy can be planned accepting the risk of subglottic stenosis. An abnormally low tracheostomy will also increase the risk. A fistula into the artery forms as a result of erosion of the arterial wall by direct pressure from the tube. If bleeding r/o tracheal innominate artery fistula and trachea should be examined by flexible bronchoscopy on the ward or by rigid endoscopy under anaesthesia tamponade the bleeding by using a cuffed tube temporarily and then exploration

33. Granulation the persistent presence of bacterial flora in the tract act as an ongoing stimulus for the formation of granulation tissue. peristomal granulation suprastomal granulation more common with more rigid tube designs, particularly the silver45 and PVC designs . Peristomal granulations can generally be controlled with topical steroid/antibiotic preparations. When more severe, they may be removed with bipolar diathermy prior to planned decannulation , all granulation should be removed to maximize airway patency. After decannulation and stomal closure, granulation generally resolves spontaneously

34. REMOVAL OF SUPRASTOMAL GRANULATION microdebrider using a Skimmer® or Tru -Cut® blade or by KTP or CO2 laser . Large granulation may be removed using a small sphenoid punch or a sinus surgery backbiting forceps

35. Suprastomal collapse the anterior tracheal wall immediately superior to the stoma itself softens and prolapses into the lumen of the subglottic trachea excision and transfixion of the tracheostomy tract followed by endotracheal intubation for 2–3 days to support the trachea as the stoma heals ablation of the collapsed segment with KTP laser , supporting the collapsed segment with a cartilage graft in more severe collapse

36. Speech development If decannulation occurs in the first 12–18 months, before the time at which normal speech patterns begin to develop, the long-term outcome is favourable longer-term tracheostomy may lead to longer-term impairment of speech function .

37. Effects on caregivers and family mental health status social-economic status are adversely affected in caregivers of children with tracheostomy.

38. TRACHEOSTOMY SAFETY INITIATIVES 1. An emergency minimum set of equipment should accompany a tracheostomy patient at all times, including spare tubes, suction catheters and dressings 2. Bedhead documentation should be displayed at all times 3. Emergency treatment algorithms

39. DISCHARGE AND HOME CARE the caregivers must be educated to care for the day-to-day eventualities of tracheostomy, including tube changing , the recognition and initial treatment of complications and basic life-support training Activities like swimming, water-based sports and contact sports are avoided

40. Physical requirements

41. DECANNULATION Decision to decannulate endoscopic assessment of the airway prior to definitive decannulation . Suprastomal collapse and granulation lead to a considerable reduction in the lumen of the subglottic airway in children In airway compromising surgeries like(e.g. mandibular advancement or cleft palate repair), decannulation should be deferred until these treatments are complete.

42. Decannulation technique The dead space is doubled and airway resistance is trebled. With a longstanding tracheostomy, the child may have no memory of mouth and nose breathing and the new sensation may be distressing- decannulation panic STAGED DECANNULATION ‘downsizing’ and reversible capping

43. IMMEDIATE DECANNULATION some children will not be able to tolerate the degree of tracheal obstruction, for them remove the whole tube and occlude the stoma with a dressing. These procedure done in a controlled setting- intensive care units. In cases of difficult intubation like Treacher Collins syndrome immediate decanulation is not safe decannulation should be delayed until the child is large enough to tolerate staged decannulation with capping off.

44. Persistent tracheocutaneous fistula A fistula may persist between the trachea and skin . This may be small and only lead to problems with discharge of tracheal secretions . A larger fistula may continue to function as an alternative airway . The incidence of tracheocutaneous fistula (TCF) is 19% to 42% in various series.

45. Closure of TCF upper airway be reassessed prior to TCF closure to exclude persistent obstruction and tracheal granulation . Surgically removing the skin lining the tract , or cauterizing the tract using diathermy , coblation or chemicals such as trichloroacetic acid may lead to scarring and satisfactory closure, known as secondary closure or closure by secondary intention. More commonly, the tract of the stoma is dissected down to the level of the trachea and closed with transfixion sutures. This is referred to as primary closure.

46. Revision of the tracheostomy scar Revision of the tracheostomy scar usually involves a fusiform horizontal incision to excise the scarred skin of the tracheostome with wide undermining of surrounding skin to assist in primary closure

47. TAKE HOME POINTS Tracheostomies in children are performed in the main to relieve upper airway obstruction . • To allow prolonged ventilation in children with complex medical problems. • Tracheostomy in children is now an uncommon operation. • Vertical skin incisions and maturations sutures are now considered standard practice.

48. • Tracheostomy complications are more likely in children than in adults . Preterm infants are at particular risk. • Specific medical and nursing skills are essential in postoperative care . • Suprastomal granulations are almost universal in children. • Getting home with a tracheostomy is a complex and timeconsuming process. Not all families will have sufficient support or resources at home to care for a child with a tracheostomy

49. THANK U