pediatric tracheotomies: an update · chest xray icu stay till ... etiology: infection, friction,...
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Pediatric Tracheotomy:
An Update
Shraddha Mukerji, MD
The University of Texas Medical Branch
Department of Otolaryngology
Grand Rounds Presentation
September 24, 2009
Overview
History
Changing Indications
Surgical Considerations
Complications
Long term effects of trach in children
Decannulation
History of tracheotomy
Period of legend 1500BC-1500AD Homer, Galen
Period of fear 460BC-1500AD Hippocrates
Period of drama 1500-1900 First modern tracheotomy,
Pediatric tracheotomy for
foreign body, tracheotomy for
diphtheria
Period of rationalization 1900- Jackson: better instruments,
post-operative care, safer
anesthetics
Pioneers
Antonio M. Brasavola
First successful tracheotomy
Chevalier Jackson
Good postoperative care
Pierre Bretonneau
Tracheotomy for diphtheria
Indications
Fraga JC, et al Pediatric tracheostomy. J Pediatr (Rio J). 2009 Mar-Apr;85(2):97-103. Epub 2009 Mar 12.
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
Why have they changed?
Endotracheal
intubation
Timing between ET
and tracheotomy has
changed
Endotracheal tubes
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.
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?
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
Incisions on the trachea
Surgical steps contd…
Vertical incision on the trachea
Tracheotomy tube sutured to skin
Stay sutures long and labeled left and right
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)
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
Kremer B, Botos-Kremer AI, Eckel HE, Schlöndorff G Indications,
complications, and surgical techniques for pediatric tracheostomies--an
update. J Pediatr Surg. 2002 Nov;37(11):1556-62
Kremer B, Botos-Kremer AI, Eckel HE, Schlöndorff G Indications,
complications, and surgical techniques for pediatric tracheostomies--an
update. J Pediatr Surg. 2002 Nov;37(11):1556-62
Complications cont’d…
Early (5-49%)
Bleeding
Pneumomediastinum
Subcut emphysema
Accidental decannulation
Wound breakdown
Late (24-100%)
Granuloma formation
Tracheomalacia
Tracheal stenosis
Tracheoesophageal
fistula
Pneumomediastinum/Pneumothorax
One of the commonest
early Cx
28% of premature
babies affected
Damage to
pleura,forceful
coughing
Wound breakdown
Common in ‘chunky’
babies with a short neck
Avoid drag of ventilator
tubing on trach tube
Wound care
Suprastomal granuloma
Etiology: infection,
friction, stasis of
secretions
Incidence:
<10%to>80%
Indications for removal
- Decannulation, large
obstructing granulomas
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
Accidental decannulation
Commonest cause of tracheotomy related
death
Premature babies: 7% and older children 16%
Vigilant post-operative monitoring
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
Care of the tracheotomy
Humidification
Suctioning: aseptic technique
and prevent trauma to the trachea
Communication: speaking
valve
Change of cannula, daily tie
changes
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
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
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
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
Algorithm for decannulation
Indications are met
Pulmonary evaluation
Capped sleep study
Admission x 2 nights
1st night: Capped trach tube
2nd night: Decannulation and observation
Discharge and FU in one week
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
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