1 / 40

Pediatric Tracheostomy

Pediatric Tracheostomy. M. Lauren Lalakea MD Chief, Otolaryngology/HNS, Valley Medical Center, San Jose, CA Clinical Associate Professor, Stanford. Tracheotomy--Introduction. Initially procedure of last resort to relieve airway obstruction, eg diphtheria, epiglottitis

telyn
Download Presentation

Pediatric Tracheostomy

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

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) nathanclarkecommunication.wikispaces.com Uofmchildrenshospital.org

  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 Robinmicrognathia, glossoptosis, cleft palate php.med.unsw.edu.au

  6. Bilateral Vocal Cord ParalysisHigh-pitched stridor, CNS etiology www.drninashapiro.com

  7. TracheomalaciaInspiratory and expiratory stridor 2011.prepsa.courses.aap.org

  8. Laryngeal Anomaly: Glottic Web wiki.uiowa.edu

  9. Neoplasm: Lymphangioma openi.nlm.nih.gov

  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 emedicine.medscape.com

  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 primehealthchannel.com

  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 sciencedirect.com

  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 tracheostomy.com Utmb.edu

  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 readcube.com

  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 tracheostomy.com

  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 Child’s Age Inner 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

  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 24-72 hrs

More Related