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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4510_Библиотеки_им_академика_М_И_Перельмана.pdf
Pediatric Tracheostomy
139
Fig. 3 (a) Child and (b)
adolescent undergoing
tracheostomy for tumoral
airway obstruction at the
Brazilian National Cancer
Institute (INCA) in 2016
a
b
Injuries related to tracheal tubes (mostly subglottic stenosis) in all age groups
have been reported in the literature for decades. In adolescents and adults, these
have been mainly associated with overinated cuffs, while in children they have
been linked with oversized tubes [10].
Adults receiving invasive ventilatory support by orotracheal intubation usually
have an early indication for a surgical airway (at 2–10 days), especially when
140
Table 2 Trachsel and Hammer criteria favoring tracheostomy indication in children
Children requiring long-term ventilation/
pulmonary toilet Children with upper airway obstruction
Young age with a high risk of midfacial
deformation from mask pressure
Ventilator dependency for most of the day
(more than 12hours per day)
Inability to cope with a mask (full face or nasal
mask)
Recurrent aspirations (gastroesophageal reux,
laryngeal incompetence) with signicant
benet from pulmonary toilet
Safety measures and local experience highly in
favor of invasive ventilation
Adapted from Trachsel and Hammer [22], with permission
Low chance of denitive, spontaneous
resolution within a reasonable time (weeks)
Low probability that surgery can denitely
correct the cause
High risk of critical upper airway obstruction
with simple respiratory tract infections or
minor bleeding (epistaxis)
High risk of or previous history of
difculties in airway management in the
event of an emergency
Difcult-to-control gastroesophageal reux
P.C.M. Filho et al.
prolonged intubation is anticipated, with an intention to avoid laryngeal damage [9].
Some studies have also related it to lower mortality in comparison with a delayed
procedure [6].
However, the timing of tracheostomy in intubated children is controversial (from
>14days to >90days) [6]. Some infants may tolerate orotracheal tubing for weeks
to months without adverse laryngeal effects [6, 9, 22]. Additionally, the higher com-
plication rates, especially in younger pediatric patients, may overcome the benets
of a surgical airway in some pediatric intensivists’ judgment. Some have reported
that they would consider tracheostomy only after a number of failed extubations [6].
Nevertheless, long intubation periods interfere with children’s normal development
and may cause laryngotracheal damage [6, 9]. Besides, a surgical airway may allow
home care assistance (dehospitalization) for severely impaired children and prevent
midfacial hypoplasia [22].
The lack of guidelines makes the indication for intubated pediatric patients still
mostly empirical. Trachsel and Hammer have suggested some criteria that might
help (see Table2), but maybe a specialized multidisciplinary team approach (pedia-
trician, surgeon, nurse, physiotherapist, speech therapist) would be a reasonable
way to manage such complex decisions [21, 22].
Preoperative Evaluation
As discussed previously, the current conventional pediatric patient with an indication for tracheostomy can be dened as young (newborn or infant), suffering from a
chronic condition usually associated with multiple comorbidities, intubated, and
ventilator dependent. Therefore, most cases nowadays should be classied as elective procedures, and careful preoperative evaluation must be done.
The International Pediatric Otolaryngology Group (IPOG) consensus [23] recommends the following:
Pediatric Tracheostomy
141
• The medical history should be taken and a physical examination should be per-
formed, including assessment of anatomical landmarks and neck mobility for
intraoperative extension.
• Laboratory investigations, including a complete blood cell count and coagulation
studies (international normalized ratio (INR) and prothrombin time (PTT))
should be performed; further investigations may depend on the patient’s underly-
ing medical comorbidities.
• Patients and their caregivers should be provided with adequate information and
education regarding the nature of the procedure and its benets, risks, and
expected postoperative course.
• Emotional support should be provided to patients and their families as appropriate.
• When appropriate, a preoperative evaluation by a communication and/or feeding
specialist in speech and/or feeding rehabilitation should be performed.
It is also advisable to check if a range of tracheostomy tube sizes and models are
available before starting the procedure. Later in this chapter, the options of pediatric
tubes will be discussed.
Surgical Procedure andTechniques
Although adult tracheostomy has routinely been done at the bedside in an intensive
care unit (ICU), pediatric tracheostomy is usually performed in an operating room
(OR), with general anesthesia and anesthesiologist support [6, 11]. We do agree
with this, considering that it is a technically difcult procedure that carries high
complication rates. Adolescents and older children may be an exception to this recommendation, and bedside tracheostomies have been performed in this age group,
including by a percutaneous technique [6, 24].
Steps intheConventional Technique
1. Positioning (see Fig.4): Supine position with the neck in extension, using a
cylindrical pillow or a rolled sheet under the shoulders. That may be the key to a
successful tracheostomy in general and may be the most important step in pedi-
atrics. As already explained, young children have a short neck with a tendency to
keep it exed, naturally obstructing and “hiding” the airway. The right position-
ing increases neck and trachea exposure, bringing the trachea closer to the sur-
face. Head support must be provided to avoid cervical spine injury.
2. Neck examination: Once the patient is positioned, cervical surface landmarks
must be identied (palpation of the thyroid cartilage, cricoid cartilage, and
suprasternal notch). These landmarks are often difcult to palpate in children,
though [11]. At this moment, care must be taken to identify prominent vascular
pulsations suggestive of a high-riding innominate artery [20]. The surgical site
can then be prepared and draped in sterile fashion.
142
P.C.M. Filho et al.
Fig. 4 Positioning an
infant for tracheostomy. (a)
Top: patient in a supine
position without neck
extension. (b) Bottom:
patient correctly
positioned, with neck
extension. Part of the
rolled sheet can be seen
under the right shoulder
(outlined in red). Observe
the marked improvement
of neck exposure and
notice that the back of the
head is fully supported
a
b
3. Skin incision (see Fig.5a): In our routine practice, we prefer a 3cm horizontal
skin incision, halfway between the cricoid cartilage and the sternal notch (at the
second and third tracheal ring level). For us, vertical incisions go against cervical
skin tension lines and do not provide much better exposure than horizontal inci-
sions. In our opinion and of other authors, there is no reason for using vertical
skin incisions in an elective procedure [20]. Surveys among surgeons report an
approximate 60% preference for horizontal skin incisions [25]. On the other
hand, some authors recommend vertical skin incisions for emergency proce-
dures, providing fast access to the trachea and minimizing the risk of vascular
injury and excessive bleeding [15, 20]. Others claim that vertical incisions may
offer an improved anatomical orientation—especially in infants, whose impor-
tant anatomical landmarks, such as the cricoid and thyroid cartilages, may not be
easily palpable—and may reduce the risk of pneumothorax by minimizing the
need for dissection lateral to the trachea [25].
4. Dissection until the thyroid gland space (see Fig.5b): Two skin aps (one superior
and other inferior) are made through horizontal dissection of the subcutaneous fat
and platysma, reaching the strap muscles. At this point, the dissection turns in a
vertical direction, separating the strap muscles along the midline raphe, with the
auxiliary surgeon providing lateral retraction until the thyroid gland space is entered.
ad
Pediatric Tracheostomy
e
b
f
143
c
g
THYROID ISTHMUS
TRACHEA
Fig. 5 Infant undergoing conventional tracheostomy for prolonged ventilatory support. (a)
Horizontal skin incision. (b) Horizontal subplatysmal dissection. (c) Vertical dissection with lateral retractors. (d) Vertical tracheostomy with three absorbable suture xation points. (e) Uncuffed
tracheal tube. (f) Tube positioned; note the stay suture below the tube (red arrow) used for traction
of the inferior tracheostomy border during the rst tube change. (g) Tube xated with ties around
the neck
5. Trachea exposure and hemostasis (see Fig.5c): Pretracheal fat tissue is dissected
laterally and superiorly, while blood vessels below the isthmus are controlled
and the thyroid gland is pushed up with retractors, exposing the anterior tracheal
wall. Eventually, the isthmus needs to be divided vertically (and sutured hemo-
statically) for better exposure of the tracheal rings. Some authors advocate rou-
144
P.C.M. Filho et al.
tine isthmus division, despite greater operative tissue traumatization and the
resulting risks [15]. Kremer etal. maintain that there is a risk of chondritis on the
rst or second tracheal cartilage ring, which is caused by the upward pull on the
cannula, if the isthmus has not been cut. In addition, they consider it a denite
advantage to bisect the isthmus, for this enables installation of the cannula with-
out force and helps avoid not only damage to the front and rear walls of the tra-
chea, but also faulty installation of the cannula in the mediastinum and
uncontrolled tissue damage [15]. Bleeding control must be reviewed before
opening the trachea, and a Valsalva maneuver should be performed by the anes-
thesiologist to help evidence occult lower pressure bleeding. It is worth remem-
bering that normal blood volume in pediatrics is only about 85mL/kg [5] and
that multiple combined diseases are the rule in those patients. Therefore, little
blood waste may be “a lot” in such conditions, and minimum losses must be
achieved.
6. Tracheostomy (see Fig.5d and Fig.6): Once the trachea is fully exposed, a cri-
coid hook is used to pull the cricoid superiorly. This stabilizes the laryngotra-
cheal complex—an essential step prior to making an incision in the trachea
[20]. Many types of incision are used for opening the anterior wall of the tra-
chea: vertical; horizontal (between two cartilaginous rings); with part of a ring
resection (oval window); Björk ap (inferior stalked to a skin cartilage ap—
developed in 1960); and H-shaped incisions (horizontal incision associated
with both superior and inferior aps). None of these types has achieved a con-
sensus (most authors report no differences in the frequency or severity of com-
plications among types of tracheal fenestration performed), although specic
complications and advantages have been more frequently related to specic
types of tracheostomy (see Table3). The tracheal incision can be made verti-
cally or horizontally according to the surgeon’s preference, since it is between
the second and fourth tracheal ring-because placement of the incision and inser-
tion superior to the second ring may predispose the patient to developing sub-
glottic stenosis [20]. Regardless of the type of incision, in children it is advisable
to use xation sutures at the borders of the tracheostomy, reducing the chance
of tube false passage. Some prefer maturation of the tracheal borders to the skin
1
2
3
4
Fig. 6 Types of fenestration (incisions for tracheostomy) in red. From left to right: vertical, hori-
zontal, oval window, inferior cartilage ap (Björk ap), superior and inferior cartilage ap
(H-shaped).
The tracheal cartilages are numbered from rst to fourth; note the incisions’ placement between
the second and fourth tracheal rings
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
Pediatric Tracheostomy
Table 3 Advantages and complications specically related to each type of tracheostomy (tracheal
incision)
Type of
tracheostomy
Vertical – Deformation of the anterior
Horizontal Less suprastomal granulation formation
Oval window – Tracheomalacia (a large window
Björk ap Facilitates placement of a cannula and
Reported advantages
[25]
decreases the risk of pneumomediastinum
[15]
Reduces the danger of tracheostomal
collapse during cannula exchange or
during accidental decannulation [15]
Reported complications
tracheal wall and pressure
lesions on the cartilage [15]
–
might destabilize the tracheal
wall) [15]
Higher incidence of granuloma
in the stoma [15]
Higher risk of tracheal stenosis
[15]
145
and remove subcutaneous fat from the skin incision for a better t of the suture.
Surveys performed at three time points showed that most surgeons used stay
sutures (85–94%), routine removal of subcutaneous fat (62%), and a vertical
tracheal incision (75–87%), while only 5–10% of responding surgeons made a
horizontal tracheal incision [25].
7. Tracheostomy tube passage (see Fig.5e–g): There should not be any resistance
while inserting the tube, and correct ventilation must be conrmed by the anes-
thesiologist. Campisi etal. recommend that the position of the tip of the trache-
ostomy tube should be veried by exible bronchoscopy to ensure that the tip is
above the carina and that there is no blood or mucus blocking the lower airways
[20]. Although bronchoscopy is not our routine practice, we do recommend post-
operative chest radiography (see Fig.7), also for excluding other complications
(pneumothorax).
Pearls andPitfalls
Campisi etal. [20] propose certain considerations and modications for the standard tracheostomy procedure in pediatric patients to minimize the risk of
complications:
• If possible, maintain spontaneous respiratory effort. This is particularly bene-
cial in the setting of acute airway compromise and after the tracheostomy (step4)
due to the resultant airway leak and difculty of effective ventilation.
• Preselect—and have available in the surgical set—an appropriately sized trache-
ostomy tube and a second tube that is one size smaller in case of inability to
insert the tube.
146
BORDER
ad
SUPERIOR STAY SUTURE
INFERIOR
STAY
SUTURE
P.C.M. Filho et al.
e
b
f
c
g
INFERIOR
TRACHEOTOMY
Fig. 7 Child undergoing conventional horizontal tracheostomy. (a) Patient positioned with neck
extension. (b) Horizontal skin incision and dissection. (c) Horizontal fenestration and positioning
of stay sutures on the inferior and superior borders of the trachea. (d) Stay sutures matured in the
skin. (e) Cuffed tracheal tube, size 4.5mm, inside the maturated tracheostomy. (f) Tracheostomy
concluded and postoperative chest radiography in the operation room. (g) Chest radiography showing the position of the tube and no signs of pneumothorax
Pediatric Tracheostomy
147
• Excise peristomal subcutaneous adipose tissue and suture the edges of the tra-
cheostomy to the skin to mature the tracheostoma (maturation sutures).
• Place vertically oriented stay sutures on either side of the vertical tracheostomy
around a tracheal ring. When pulled, stay sutures approximate the tracheostomy
edges to the skin surface. This will facilitate the insertion of the tracheostomy
tube and the reinsertion of a tube if it is accidentally decannulated. The stay
sutures should be taped to the chest wall and labeled as “left” and “right.”
• Do not remove any tracheal cartilage to create the tracheostomy. Cartilage spar-
ing is the key to the prevention of suprastomal collapse and tracheomalacia.
• Meticulous hemostasis is important to prevent hemorrhage and the need to return
to the OR.
Recently, the IPOG published a consensus document [23] recommending the
following intraoperative considerations:
• Use of stay sutures is important in case of accidental decannulation. Consider
4-0 Prolene, nylon, or Vicryl. Consider color coding (to distinguish left from
right) or labeling of “left” and “right.”
• You may consider maturing the stoma (see Fig.7) in case of accidental decan-
nulation in the small infant or neonate.
• Suggestions for xation of the tracheostomy tube in place include Velcro ties
without skin suturing; Velcro ties without skin suturing but with consideration of
suturing the Velcro to itself so it cannot be opened; cotton ties; skin suturing; trach
gauze, Exu-Dry, or Mepilex dressing under the anges ± under the neck ties.
• Consider exible tracheoscopy at the end of the case in order to assess the distance
from the tip of the tracheostomy tube to the carina, as well as the presence of distal
compression/obstruction. Consider a complete airway examination during the same
anesthetic either prior to the tracheostomy or after the tracheostomy tube is in place.
• Consider antibiotic prophylaxis until the rst tracheostomy tube change in all patients.
• The timing of the rst tracheostomy tube change should be at the discretion of
the surgeon. Among IPOG members, this varies between 3 and 7days, with the
majority performing the change between 5 and 7days.
Oncological Tracheostomy: Technical Peculiarities
Skin Incision: Adjustments must be made in cases of large cervical tumors with
airway displacement, so the skin incision will be properly positioned. Diagnostic
imaging examinations may help in planning the incision (see Fig.8). Besides, larger
incisions should be considered (see Fig.9).
Trachea Exposure and Hemostasis: When indicated for treatment of oncological
obstructive conditions, especially in transtumoral tracheostomies, anomalous large
blood vessels (collateral circulation) and friable tumoral masses are potentially
causes of severe bleeding (see Figs.8 and 9). Achieving bleeding control may be a
challenge. Besides anesthesiologist support (blood transfusion reservation, invasive
148
ad
e
b
f
P.C.M. Filho et al.
c
Fig. 8 Child undergoing oncological tracheostomy. (a) Patient with left cervical mass, airway
deviated to the right. (b) Chest radiography showing a large left cervicothoracic mass (red arrow).
(c) Tomography showing a large tumor pushing the trachea (red arrow) toward the right; note the
position of the spinal vertebra (black arrow) as a reference for the central position. (d) Planed inci-
sion (blue line). (e) Note the large venous blood vessel (black arrow) crossing in front of the tra-
chea. (f) Trachea more visible after blood vessel removal. (g) Tracheal tube positioned; note the
two stay sutures for traction of the superior and inferior tracheostomy borders
g