Pediatric Tracheotomy: An Update

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

4. Pioneers

5. Indications

6. Changing Indications How have they changed? Why have they changed?

7. How have they changed?

8. Why have they changed? Endotracheal intubation Timing between ET and tracheotomy has changed

9. Most common indications Prematurity, chronic ventilatory support Craniofacial anomalies: Pierre Robin, CHARGE Congenital anomalies: Subglottic stenosis Tracheotomy for tracheobronchial hygiene

10. Tracheotomy tubes

11. 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?

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

13. Anatomical differences between pediatric and adult larynx

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

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

16. Incisions on the trachea

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

18. 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)

19. 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%

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

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

24. Subcutaneous emphysema Increase ventilatory pressures Overzealous ventilation

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

26. Suprastomal granuloma Etiology: infection, friction, stasis of secretions Incidence: <10%to>80% Indications for removal - Decannulation, large obstructing granulomas

27. Suprastomal/Tracheal granuloma

28. 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

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

30. 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

31. Care of the tracheotomy

32. 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

33. 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

34. 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

35. 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

36. Algorithm for decannulation

37. 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

38. 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