FRCA Notes

Paediatric Tracheostomies

The curriculum wants us to know how to manage 'complications of tracheostomy in children e.g. obstruction and displacement'.

One might wish to read this page alongside its adult tracheostomy counterpart.

Resources

  • Tracheostomies are less common in the paediatric population when compared to adults, because:
    • They are technically more challenging to insert due to various anatomical and technical factors (small, pliable and poorly palpable trachea, limited access due to short neck, proximity of vasculature and pleura)
    • Specialist service input is required including management of psychosocial challenges, especially if home ventilation is required
    • Paediatric patients tolerate tracheal intubation for longer than adults
    • There is a lack of consensus on appropriate time to be intubated for and therefore timing of tracheostomy insertion
  • 1/3rd of all paediatric tracheostomies are performed in those <1yr
  • 2/3rds are performed in those <4yr
  • Rarely, airway obstruction diagnosed prior to birth is managed with a tracheostomy via the ex utero intrapartum treatment (EXIT) procedure

  • Only approximately 2% of children on ICU have a tracheostomy (vs. 7-19% of adults)
  • However, if a tracheostomy is inserted:
    • More likely to require a permanent tracheostomy than adults
    • Even temporary tracheostomies commonly remain in situ for 1-2yrs


Long-term ventilation Aspiration protection Bypass airway obstruction Trauma Craniofacial syndromes
Chronic lung disease Neuromuscular disease Tracheomalacia Burns Pierre-Robin
Neuromuscular disease Bulbar palsies Bilateral vocal cord palsy Inhalational injury Treacher-Collins
Cerebral palsy Aid secretion clearance Tumours e.g. cystic hygroma Corrosive ingestion Beckwith-Wiedemann
Brainstem lesions Failed intubation
Tracheo-bronchomalacia Acquired subglottic stenosis
Congenital hyopoventilation syn. Peri-glottic obstruction e.g. epiglottitis

  • Paediatric patients with tracheostomies should have:
    • A paediatric emergency tracheostomy box, which accompanies them at all times following insertion
    • Bedhead signs detailing type, size, length and suction catheter calibre
  • In addition, there should be local policies for the management of paediatric tracheostomies and an MDT approach to their care

Initial assessment

  • Call for help; 222 paediatric emergency call
  • Open native airway
  • Apply high flow oxygen to tracheostomy/stoma AND face
  • Check airway patency by applying capnography and look/listening/feeling

Check for patency

  • Remove HME filter, speaking valve, cap etc.
  • Remove inner tube if present

  • Attempt to pass suction catheter to the pre-determined depth indicated on the bedhead sign
    • Rule of thumb; suction catheter approximately 2x the internal diameter of the tube e.g. size 4 tube can accommodate size 8 suction catheter
    • Should suction no more than 0.5cm beyond the tip of the tracheostomy to prevent airway damage; this length should be documented prior to insertion

  • If possible to pass suction catheter, tracheostomy is at least partially patent
    • Suction to remove obstruction if present e.g. secretions
    • Continue ABCDE approach

  • If unable to pass suction catheter then tracheostomy is not patent

Emergency tube change

  • Deflate cuff (if present)
  • If stay sutures are present, pulling these up/out can aid the process of successful tube change
  • Perform emergency tracheostomy tube change, up to three times if there is unsuccessful tube change:
    1. Same size, and reassess e.g. capnography, look/listen/feel, attempt to pass suction catheter
    2. Half-size below existing tracheostomy, and reassess
    3. Half-size below existing tracheostomy but attempted insertion over a suction catheter as a guide, and reassess

  • If during reassessment there is successful oxygenation and breathing/ventilation, then continue with ABCDE approach
  • If unsuccessful and patient is not breathing, remove the tracheostomy tube and proceed to next step

Paediatric resuscitation

  • If patient is not breathing give 5 rescue breaths via either nose/mouth if patent upper airway or tracheostome if obstructed upper airway

  • If signs of life are present, prepare for definitive airway insertion and continue ABCDE approach
  • If no signs of life:
    • Start CPR 15:2
    • Paediatric emergency call if not already
    • Access difficult airway equipment and senior airway personnel (Anaesthetics, ENT) for definitive airway insertion

    • Attempt definitive airway insertion
    • If upper airway patent
      • Cover stoma with hands/gauze
      • Oxygenate via mouth using standard oxygenation methods e.g. BVM, Guedel, SAD
      • Oral intubation using ETT a half size smaller than tracheostomy, with tip advanced beyond the stoma

    • If obstructed upper airway
      • Oxygen via tracheostoma inc. via SAD applied to stoma
      • Intubation of stoma using size 3.0 ETT or tracheostomy

  • If this fails, further options include:
    • Intubating endoscope e.g. Bonfils, Hopkins rod, flexible bronchoscope
    • Emergency cricothyroidotomy
    • Emergency surgical exploration
    • ECMO

Perioperative management of the child either with a tracheostomy or undergoing insertion of a tracheostomy


  • Typically elective open surgical procedures, although percutaneous techniques are possible
  • Typically uncuffed although cuffed may be required if high risk of aspiration or high ventilatory pressures
  • Typically lack an inner tube to avoid further increase in resistance to airflow

  • MDT involvement essential including anaesthetics, ENT, maxillofacial surgeons, paediatricians, physiotherapists
  • Management in a suitable centre e.g. access to ENT, PICU

History and examination

  • Comorbidities including associated syndromes
  • Previous airway interventions

  • Airway assessment inc. (if relevant) existing tracheostomy type, size, suction catheter size/length, last change, history of complications
  • Respiratory system including existing oxygenation/ventilatory requirements
  • Cardiac disease
  • Neuromuscular diseases

Equipment

  • Standard paediatric anaesthetic equipment e.g. appropriately sized monitoring, IV access, circuits, warming devices
  • Paediatric airway equipment
  • Tracheostomy equipment
  • Paediatric difficult airway/MAST trolley
  • Appropriate airway management brief with entire perioperative team including recovery ± ward staff

Airway

  • Likely to have a difficult or impossible to navigate upper airway, which may be exacerbated by intercurrent critical illness or dependence on invasive ventilation
  • Management dependent on patient factors including indications for tracheostomy in the first place
  • Ensure presence of ENT surgeon at induction in case rigid bronchoscopy or emergency tracheostomy required

  • If an existing tracheostomy is in situ, inhalational induction is often performed
  • This may be slower than anticipated due to restricted airflow through or leak around the tracheostomy
  • Once anaesthetised airway management may include keeping existing trache, changing it for a different type/size (e.g. cuffed) or removing and using an endotracheal tube instead, depending on the surgical and patient factors at play

Procedure

  • Supine with roll placed under shoulders to extend the neck ± chin pulled up and secured to operating table with tape
  • Check all equipment sizing, connections and function prior to insertion
  • Infiltration of adrenaline/local anaesthetic
  • Skin incision to expose trachea
  • Cartilage windows are avoided to prevent stenotic segments
  • Stay sutures are placed around the tracheal rings on either side of the planned incision to expose and anchor the trachea
  • Vertical incision between 3rd and 4th tracheal rings
  • Absorbable maturation sutures placed between anterior tracheal wall and skin to accelerate stoma formation
  • Oral tracheal tube withdrawn to above the incision site
  • Tracheostomy tube inserted and ventilation via the tube is attempted, confirmed by end-tidal CO2 ± fibreoptic evaluation

  • Post-operative care in a place where there is suitable monitoring and staff training e.g. PICU, paediatric HDU or suitable ENT ward
  • Humidified oxygen via tracheostomy mask
  • Post-operative CXR to check for position, pneumothorax
  • Ensure presence of:
    • Bedhead signs, including indication it is a NEW tracheostomy
    • Paediatric emergency tracheostomy box including spare tube, half-size smaller tube, scissors to cut sutures, suction catheter(s) of the appropriate size

  • Removal of stay sutures ~1 week post-insertion as this is when the tracheostome is deemed mature enough in new tracheostomies

  • Morbidity associated with tracheostomy as high as 43% overall, although early complications (11%) are less common than late complications (up to 69%)
  • Early complications may be more common in pre-term infants

  • Mortality for inpatients who undergo tracheostomy quoted as 2-10% although generally relates to underlying indication for tracheostomy rather than the intervention itself
  • Mortality associated with tracheostomy complications is 0.7%
Early/intermediate Late
Obstruction Granuloma formation
Displacement or accidental removal Vascular erosion
Bleeding Subglottic/tracheal stenosis
Pneumothorax Tracheal - oesophageal fistula
Pneumomediastinum Skin or stoma site breakdown
Surgical emphysema Dysphagia
Oesophageal injury
Infection
Recurrent laryngeal nerve injury