1.  The incidence of tracheotomy has decreased because of use of steroids, racemic 
 epinephrine and intubation.

2.  Intubation is the method of choice to establish a neonatal airway.

3.  Neonates can be intubated at three months without a significant increase in complications.

4.  The tracheal incision must be horizontal. 

5.  There is a very high mortality rate .2% from tracheotomy complications.

TECHNIQUE:
    Horizontal Skin Incision
    Vertical Tracheal Incision
    3-0 silk retraction suture through tracheal incision
    Sew in and tie in tube
 
 
 

Concepts:

Stenosis problems arise from two regions:
    1.  Where the tube enters the trachea:
                Too large a tube may produce stenosis
                A horizontal incision in newborn may bend the superior tracheal wall
    2.  Where cuff or end of tube touches the trachea:
                Very small tubes have no cuffs
                Rigid tubes (Jackson) transmit torque, soft tubes (Dover) do not transmit 
                    torque as stenosing may develop but dislodgement out of the trachea is
                    more common

Intracuff pressure (ICUP) approximates the cuff trachea pressure (CTP)

Minimal Leak:  Leakage of air (squeaking sound) during the last 1/3 of inspiration.

Humidity is always important to prevent crusting and plugging of the tube.  Cuffs of either endotracheal tubes or tracheotomy tubes can cause problems.  However, cuffs of tracheotomy tubes cannot injure the subglottic area. 

The incidence of Pediatric Tracheostomies is declining3  and the procedure has dropped from 0.9% to 0.4% of pediatric admissions.4   Three reasons are cited:
    1.  The management of acute epiglottis with intubation.
    2.  The use of steroids and racemic epinephrine in laryngotracheal bronchitis.
    3.  The use of the cricoid split instead of tracheotomy in the difficult-to-extubate
            newborn.5 6 7 

Most tracheotomies performed in the pediatric population are for chronic problems and are long-term.

In the adult, complications from endotracheal tubes have a high incidence after 10 days of intubation.  Tracheotomy complications are high.

In the pediatric patient, there is a higher incidence of complications from tracheotomy.  Major complications from tracheotomy are:
        1.  Stenosis
        2.  Obstruction
        3.  Decannulation
        4.  Pneumothorax (immediate complication)

Indication for Tracheotomies in the Pediatric Patient (Wetmore:1982)
        1.  Upper airway obstruction    29%
                    Laryngotracheobronchitis    30%
                    Subglottic Stenosis    21%
                    Acute Epiglottis    15%
        2.  CNS Disorder    24%
        3.  Misc. Disorders    18%
        4.  Congenital Heart Disease    17%
        5.  Resp. Distress Syndrome    12%
        6.  Craniofacial Disorders    6%
 

Prolonged intubation in infants greater than 50 days should consider tracheotomy.

Tracheotomy Mortality
        3.2% to 8.5% have now decreased due to nighttime cardiac monitors.
        Overall mortality is 22%, tracheotomy related deaths 3% (line:1986).
        Overall mortality is 28%, tracheotomy related deaths 2% (Wetmore:1982).
 

Early Complications (Wetmore:1982)
        1.  Decannulation    24%
        2.  Pneumonia    24%
        3.  Pneumothorax    9%    (Always get CXR)
        4.  Subcu-emphysema    7%    (Do not close incision tightly)
        5.  Tube obstruction    6%
        6.  Hemorrhage    6%
        7.  Stomal infection    6%
        8.  Tracheitis    6%
        9.  Pneumomediastinum    4%
        10.  Others    8%
 

Late Complications (Wetmore:1982)
        1.  Tracheocutaneous fistula    9%
        2.  Accidental decannullation    18%
        3.  Tracheogranuloma    14%
        4.  Stomal granulation    11%
        5.  Obstructive tube    10%
        6.  Hemorrhage    10%
        7.  Stomal infection    8%
        8.  Tracheaomalacia    5%    (When the tracheotomy has been present for 12-18 months, this is 42%)
        9.  Some swallowing problems
 

HOME CARE 8

Mortality rate at home is 1.81 to 0.13/100 months
Average time to discharge after tracheotomy is 2  5 to 4 weeks.

Parents need instruction on:
        1.  Suctioning the tracheotomy
        2.  Postural drainage
        3.  CPR
        4.  Emergency care
                   plug/obstruction
                        decannulation
 

Equipment needed for the home:
        1.  Portable suction machine
        2.  Spare tracheotomy tube
        3.  Tracheotomy care kits
        4.  Suction kits
        5.  Sleep apnea monitor will not work, need a cardiac monitor since a plugged
            tracheotomy will cause increase in chest movements and not apnea.
 

Problems:
        1.  Tracheotomy play – children
        2.  Plugging
        3.  Decannulation
        4.  Family centers around child and the child gets secondary gain
        5.  Child sleeps in parents room
        6.  Parents never leave child
 

SPEECH CONCERNS
        1.  Most move enough air to cry and learn speech
        2.  Needs rehabilitation
        3.  Trach and do not present speech development

Once a child is decannulated, you must closely observe him/her for the development of tracheogranulations which can cause airway obstruction 2 to 4 weeks postextubation.  Often present as having a “URI” to the local doctor.

Closure of the tracheocutaneous fistula is done with care since often the child may be using it to supplement his airway.
 

References:

1.      Fry, T.L., Jones, O., et. al.   Comparisons of Tracheostomy Incisions in Pediatric Model.   Annals of Otology, Rhinology and Laryngology.   94:450-453, 1985.

2.      Galoob, H.D., and Toledo, P.S.   Comparison of Five Types of Tracheostomy Tubes in the Intubated Trachea. Annals of Otology, Rhinology and Laryngology.   87:99-108, 1978.

3.      Line, S.W., Hawkins, D.B., et. al.   Tracheotomy in Infants and Young Children:  The Changing Perspective 1979-1985.   The Laryngoscope  96:510-515, 1986.

4.      Wetmore, R.F., et al.   Pediatric Tracheostomy. Annals of Otology, Rhinology and Laryngology.  91:628-640, 1982.

5.      Cotton, R., and Seid, A:  Management of the Extubation Problem in the Premature Child.  Annals of Otology, Rhinology and Laryngology.  89:508-511, 1980.

6.      Grundfast, K.M., Coffman, A.C., and Milmoe, G.   Anterior Cricoid Split:  A “Simple” Surgical Procedure and a Potentially Complicated Care Problem.   Annals of Otology, Rhinology and Laryngology.  94:445-449, 1985.

7.      Miller, R.H., and Weatherly, R.A.   Experience with Anterior Cricoid Split for Difficult Neonatal Extubation.   Archives of Otolaryngology.  112:972-975.

8.      Ruben, R.J., et al.   Home Care of the Pediatric Patient with Tracheotomy. Annals of Otology, Rhinology and Laryngology.   91:633-640, 1977.

9.      Ross, G.S.   Language Functioning and Speech Development of Six Children Receiving Tracheotomy in Infancy.   Journal of Communication Disorders.  15:95-111, 1982.