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Pediatric Tracheotomy

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Pediatric Tracheotomy

 return to:Pediatric Airway; Tracheostomy and Upper Airway Management Symposium July 30 2016 IAO and SOHN Iowa City Iowa

see also: Tracheotomy, Tracheostomy & Modifications

and: Tracheotomy - Tracheostomy

  1. GENERAL CONSIDERATIONS
    1. The indications to perform a tracheotomy procedure in the pediatric population has shifted slightly in recent decades to include a younger patient population, with more of a focus on airway obstruction.
      1. Indications:
        1. General guidelines group the indications for tracheotomy into several groupings (in order of significance) including:
          1. Airway obstruction with root causes such as:
            1. Craniofacial abnormalities
            2. Subglottic stenosis.
          2. Prolonged intubation
          3. Neurological impairment
          4. Trauma
          5. Vocal cord paralysis
        2. The average age for performing the tracheotomy in a recent review was found to be at 3.5 yrs of age.
          1. The average age of the pediatric patient requiring tracheotomy in a recent study with upper airway obstruction 4.5 months of age, while those patients with prolonged intubation were averaged at 16 months.
      2. Complications:
        1. Early complications:
          1. include proper tracheotomy tube sizing, positioning problems, and accidental early decannulation
        2. Late complications
          1. Major and minor bleeding from erosion, formation of granulation tissue, suprastomal collapse.
          2. A large review of the literature including 1130 patients demonstrated 21 patients with resultant tracheal stenosis.
        3. Complication rates seem to range from 5% to 40%, and the mortality rate is approximately 2-3.8% for this procedure.
        4. 92% of pediatric patients requiring a tracheotomy were eventually decannulated.
  2. PREOPERATIVE PREPARATIONS
    1. Review of the patient
      1. Physical examination of the patient is a necessary part of the pre-operative planning phase. 
        1. Special considerations need to be made in patients with obstructive problems.
        2. Head and body positioning should be considered in patient populations with large compressive masses.
      2. A mental note should be made of the patients particular neck anatomy with attention to accessibility of the anatomical landmarks
      3. Special considerations should be made for patients that are at risk for C-spine injuries
        1. Trauma patients, and Down Syndrome patients who are at high risk for injury should be appropriately evaluated pre-operatively, and sandbagged with the head in neutral position if necessary.
    2. Choosing your tracheotomy tube:
      1. Keep in mind that patients with Down syndrome have much smaller airways.
    3. Consent
      1. Informed consent should be obtained
        1. Complications listed above should be discussed, in addition to the more common risks including bleeding, infection, injury to surrounding structures and scar formation.
        2. The possibility of forming a tracheocutaneous fistula follow decannulation should also be mentioned.
  3. Other Considerations:
    1. Anatomy
      1. The Larynx has a higher level of suspension in the pediatric population.  As such, it is possible for the hyoid bone to partially limit the surgeon to full palpation of the thyroid cartilage.  For these reasons, the cricoid cartilage is the major palpable landmark superiorly.  As the cartilage is softer, and more flexible, the trachea is also more mobile as well.  This is an important consideration as well, as the surgeon needs to maintain midline.
  4. NURSING CONSIDERATIONS
    1. Room Setup
      1. See Basic Soft Tissue Room Setup
        1. Use ENT Supply Pack instead of the Basic soft tissue pack
    2. Instrumentation and Equipment
      1. Standard
        1. Tracheotomy Tray
        2. Bipolar Forceps Trays
      2. Special
        1. Syringe, Luer tip, 10/12 cc, disposable
    3. Medications (specific to nursing)
      1. 0.5% lidocaine with 1:100,000 epinephrine
      2. 4% lidocaine, plain
    4. Prep and Drape
      1. Standard prep, 10% povidone iodine
      2. Drape
        1. Towels to square off incision site on neck, from chin to chest, from shoulder to shoulder.
        2. Drape off mouth, consider anesthesia access to the endotracheal tube.
        3. Split sheet
    5. Drains and Dressings
      1. Pediatric drain sponge present.
    6. Special Considerations
      1. Have a variety of types and sizes of trachs available.
      2. If using a cuffed trach, inflate cuff on trach tube to test and place in cup of water. If bubbles are seen, the tube is faulty.
      3. Moisten tube with saline before giving to surgeon to insert.
      4. Be sure obturator is taped to patient's chest or shoulder before patient leaves the room.
      5. Will suture tracheotomy tube to keep in place using 2-0 silk sutures. A trach tie will also be used to reinforce the positioning.  A drain sponge will also be placed.
      6.  
  5. ANESTHESIA CONSIDERATIONS 
    1. The pediatric patient has a markedly decreased oxygen reserve when compared to the adult patient population.  This should be kept in mind while securing the airway, and underlines the necessity to be prepared for any airway situation.  Several strategies may be helpful in considering securing the airway in the pediatric population.
      1. Mask ventilation is among the most basic, and safe ways to provide ventilatory support to the pediatric patient.  Make note at the beginning of the case if the patient is an "easy mask", or if there are difficulties in masking the patient.
      2. A Miller or MAC blade may be used to view the airway for intubation of the patient with an ET tube under direct visualization.  It is important to make an assessment of the airway at this initial point of airway observation.
    2. If this cannot be achieved, several other considerations can be deployed.
      1. An LMA is a safe way to intubate the pediatric population.  A decreased rate of laryngospasm has been shown through the use of an LMA in these patients.
        1. An intubating LMA can be used as a quick way to secure an airway in an unstable situation.  A 2.0 intubating LMA can be placed, and a 4.0 ET tube can be threaded through this secured LMA and subsequently placed into the airway.  Placement of this tube should be performed over a flexible fiberoptic scope.  A stylet is then placed on the end of the ET tube to hold it in place while the intubating LMA is withdrawn.
      2. An ET tube may be placed on the end of a rigid scope.  Entering the airway through the "gutter", the child can then be intubated through direct visualization.
  6. OPERATIVE PROCEDURE
    1. Table will be positioned with head toward the anesthesiologist.  This is important as they will be manipulating the position of the ET tube in a later portion of the case.
    2. Ensure patient is properly positioned.  Place a shoulder roll and a doughnut to secure the head midline to ensure adequate exposure of the neck with extension.
      1. If patient has Down Syndrome, it is important to perform flexion/extension films prior to the case.
      2. If other C-spine injuries are present, take the necessary precautions.
    3. Landmarks should be palpated and marked: thyroid notch, cricoid, and suprasternal notch.
      1. A vertical incision is used in pediatrics that is performed approximately 1 cm above the sternal notch.
    4. The planned incision site should be marked and injected with approximately 0.5 cc of 0.5% lidocaine with 1:100,000 epinephrine.
    5. The patient is prepped and draped in a sterile manner.
    6. A vertical incision is then made approximately 1 cm above the sternal notch that extends approximately 1.5 cm in length. (May do horizontal incision depending on age)
    7. Dissection is carried down in midline through subcutaneous tissues utilizing fine tipped hemostats.  Retraction can be performed at this time using either Army-Navy, or Sen retractors, depending on the size of the patient.
    8. Anterior jugular veins can be retracted laterally or ligated, if necessary.
    9. The strap muscles are then identified and divided by a combination of electrocautery and blunt dissection through the median raphe.  They are also retracted laterally to continue with the procedure.
    10. The thyroid isthmus is then encountered. This should be dissected free from the underlying trachea and surrounding soft tissue.
      1. The thyroid isthmus is retracted superiorly if possible.
      2. The isthmus is alternatively clamped using two small hemostats and then subsequently divided.  Electrocautery to perform an isthmusectomy and the edges are tied off with either a running "baseball" suture or a figure of eight stitch using a 3-0 silk.
    11. Once the anterior tracheal wall is identified, the overlying soft tissue can be cleaned off the surface with Kitners.
    12. If the ET tube is cuffed, it is advanced by our Anesthesia colleagues at this time to ensure to protect the cuff.  Two 3-0 prolene stay sutures are then placed laterally in a vertical fashion, and are subsequently labelled right and left accordingly.
      1. Great care is taken at this point in placing these sutures as young children have friable tracheal cartilage.
      2. Sutures are usually placed between tracheal rings 2 and 4.
      3. Sutures should be in a submucosal plane - do not enter into airway with the suture.
    13. A number 11 blade is then used to enter the airway, creating a vertical incision through the second and third tracheal rings at midline. 
      1. Special Note: If cauterization for hemostasis is necessary, the FiO2 of the inhalational agents should be lowered by the anesthesiologist.
      2. Hemostasis is achieved with bipolar cautery.
    14. A hemostat (occasionally a tracheal spreader) is used to open the incision and prepare it for the tracheotomy tube. 
    15. The stay sutures are used to elevate the trachea, and retract them laterally to prepare for receiving the tracheotomy tube. 
    16. With the tracheal lumen exposed, the endotracheal tube was partially removed, so that the tip was just superior to the tracheotomy site.  
    17. A Pediatric cuffed Shiley tracheostomy tube can then be placed.   
    18. Placement of the tube is confirmed by evaluating ETCO2 return on the anesthesia monitor. 
    19. The tracheal hook is then carefully removed in addition to the Army/Navy or Sen retractors. 
    20. The fiberoptic scope is used to ensure appropriate positioning with the tip of the tracheostomy tube demonstrated an appropriate distance from the carina. 
    21. The tracheotomy tube is then secured in place with 2-0 silk sutures placed at each corner to the underlying skin in a simple interrupted fashion.
      1. These sutures are placed through the flanges of the tracheotomy tube to provide for additional security and decrease movement.
    22. A tracheal strap is also placed in addition to a drain sponge. 
  7. POSTOPERATIVE CARE
    1. The patient is generally monitored in a supervised setting (NICU/PICU) prior to the first tracheostomy tube change. 
    2. As a safety precaution, the patient's obturator is always placed in a plastic bag and hung at the head of bed in an obvious location. 
      1. This should be easily accessible for replacement of the tracheotomy tube if is becomes dislodged.
    3. A second back-up trach, and one that is one size smaller should always be kept at bedside as well, prior to the first tracheotomy tube change.
    4. Stay sutures are an important part of the pediatric tracheotomy.  These should be labelled left and right and be easily accessible, yet secured in such a fashion so that they will not be accidentally tugged on by either the patient, or during routine cares by the nursing staff.  These sutures are generally used at a safety precaution early on for easy replacement of the tracheotomy tube should it become dislodged. 
    5. A drain sponge may be placed around the tube to collect secretions.  This is initially changed out twice per day.
    6. Appropriate suctioning is performed, sometimes initially at Q2 hours, following instillation of saline solution for airway hygiene. 
    7. Humidified air is provided.
    8. The first tracheostomy tube change is performed at around post-operative day number 5.  Stay sutures are removed at this time.
      1. For an instructional video on changing tracheotomy tubes, please see the University of Iowa Resident Website at:
        1.  http://www.uiowaoto.com/instrumentrevindex_files/trachchange.htm
    9. It necessary that the family is comfortable with appropriate tracheostomy cares.  Proper cares should be taught as early as possible.  Any home equipment should also be planned for and provided accordingly. 
      1. (see Tracheostomy Home Care Booklet Protocol)
    10. Please see Airway Monitoring protocol
  8. SUGGESTED READING
    1. Shah RK, Patel A, Lander L, Choi SS. Management of foreign bodies obstructing the airway in children. Arch Otolaryngol Head Neck Surg. 2010 Apr;136(4):373-9
    2. Mahadevan M, Barber C, Salkeld L, Douglas G, Mills N. Pediatric tracheotomy: 17 year review. Int J Pediatr Otorhinolaryngol. 2007 Dec;71(12):1829-35. Epub 2007 Oct 22. Review.
    3. Carron JD, Derkay CS, Strope GL, Nosonchuk JE, Darrow DH.  Pediatric Tracheotomies: changing indications and outcomes.  Laryngoscope. 2000 Jul;110(7):1099-104. \
    4. Tweedie DJ, Skilbeck CJ, Cochrane LA, Cooke J, Wyatt ME.  Choosing a paediatric tracheostomy tube: an update on current practice. J Laryngol Otol. 2008 Feb;122(2):161-9. Epub 2007 Apr 10.
    5. Shott SR. Down syndrome: analysis of airway size and a guide for appropriate intubation. Laryngoscope. 2000 Apr;110(4):585-92.
    6. Carr MM, Poje CP, Kingston L, Kielma D, Heard C.  Complications in pediatric tracheostomies. Laryngoscope. 2001 Nov;111(11 Pt 1):1925-8.
    7. Graf JM, Montagnino BA, Hueckel R, McPherson ML.  Pediatric tracheostomies: a recent experience from one academic center.. Pediatr Crit Care Med. 2008 Jan;9(1):96-100.
    8.  Ireton J. Tracheostomy suction: A protocol for practice. Paediatr Nurs. 2007 Dec;19(10):14-8.

DICTATION TEMPLATE

Modified Operative Note

Informed consent for tracheotomy with microdirect laryngoscopy on their infant child was reviewed with the parents.  The patient was then transferred to the OR and placed in the supine position.  A time out was performed. The patient was mask ventilated with ease.  Landmarks were palpated and marked in the neck including the cricoid and suprasternal notch.  A vertical line was drawn at midline on overlying the trachea.  Planned incision site was then marked and injected with 0.5 cc of 0.5% lidocaine with 1:100,000 epinephrine.  A number #15 blade was used to create a vertical incision approximately 1 cm above suprasternal notch, extending 1.5 cm in length.  Dissection was carried out at midline through subcutaneous tissues with the use of hemostats.  The strap muscles were identified, and divided by blunt dissection through the median raphe and retracted laterally with sen retractors. The thyroid was then encountered and was carefully elevated from the trachea with hemostats.  It was then divided at the isthmus using electrocautery.  The anterior tracheal wall was identified, and the overlying soft tissue was cleared using Kitners.  Numbers 1-4 tracheal rings were identified, and the ET tube was advanced. Prolene sutures were placed in a vertical fashion bilaterally in the lateral portion of the trachea.  A cricoid hook was then placed beneath the cricoid cartilage to stabilize and elevate the trachea.  A number 11 blade was used to create a vertical incision through the second and third tracheal rings at midline.  A tracheal spreader was used to open the incision and prepare it for the tracheotomy tube.  Hemostasis was achieved with bipolar cautery.  The stay sutures were used to elevate the trachea, and retract it laterally to prepare for receiving the tracheotomy tube.  The endotracheal tube was partially removed, so that the tip was just superior to the tracheotomy site.  A 3.5 pediatric cuffed Shiley tracheostomy tube was then placed. Placement of the tube was confirmed with CO2 return on the anesthesia monitor.  The tracheal hook was carefully removed in addition to the sen retractors.  The fiberoptic scope was used to ensure appropriate positioning with the tip of the trachea demonstrated an appropriate distance from the carina.  The tracheotomy tube was then secured in place with 2-0 silk sutures placed at each corner to the underlying skin. A tracheal tie was also placed in addition to a drain sponge.  The procedure was complete and the patient was returned to anesthesia in good condition.

*Patient subjects used in this protocol have consented to the release and usage of these photos for the sole use of UIHC Department of Otolaryngology for educational purposes only.  Consents remain on file.