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

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Presentation on theme: "Pediatric Tracheostomy M. Lauren Lalakea MD Chief, Otolaryngology/HNS, Valley Medical Center, San Jose, CA Clinical Associate Professor, Stanford."— Presentation transcript:

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)

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

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

7 Tracheomalacia Inspiratory and expiratory stridor

8 Laryngeal Anomaly: Glottic Web

9 Neoplasm: Lymphangioma

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

11 Indications  Assisted ventilation 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

15 Pre-Trach Evaluation  Assisted Vent + Neurologic Dz 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

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

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

30 Complications  Tracheocutaneous fistula: 11-42% 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

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 Premie, <1000 gm2.5 neo Premie, gm3.0 neo Neonate – 6 mo3.0 – 3.5, neo 6 mo -- 1 yr3.5 – – 2 yr4.0 – 5.0 > 2 yrsAge/4 + 4 Child’s AgeInner Diameter (mm)

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 Neo and Pedi  Cuffed Tubes: TTS (tight to shaft) Excellent option for pts who need cuff Reorder CodeSizeID (mm)OD (mm)Length (mm) 67P mm 4.0mm 38.0mm 67P mm 4.7mm 39.0mm 67P mm 5.3mm 40.0mm 67P mm 6.0mm 41.0mm 67P mm 6.7mm 42.0mm 67P mm 7.3mm 44.0mm 67P mm 8.0mm 46.0mm

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

40 Decannulation  Suitability: 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

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