Author's Accepted Manuscript

Pediatric tracheostomy
Paolo Campisi MSc, MD, FRCSC, FAAP, Vito
Forte MD, FRCSC

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PII: S1055-8586(16)00028-7 surg

DOI: http://dx.doi.org/10.1053/j.sempedsurg.2016.02.014
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To appear in: Seminars in Pediatric Surgery

Cite this article as: Paolo Campisi MSc, MD, FRCSC, FAAP, Vito Forte MD,
FRCSC, Pediatric tracheostomy, Seminars in Pediatric Surgery, http://dx.doi.org/
10.1053/j.sempedsurg.2016.02.014

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1

Pediatric Tracheostomy

Paolo Campisi, MSc, MD, FRCSC, FAAP and Vito Forte, MD, FRCSC

Paolo Campisi MSc, MD, FRCSC, FAAP

Professor and Vice Chair of Education
The Hospital for Sick Children
Department of Otolaryngology – Head & Neck Surgery
University of Toronto, Toronto, Canada

Vito Forte MD, FRCSC

Professor
The Hospital for Sick Children
Department of Otolaryngology – Head & Neck Surgery
University of Toronto, Toronto, Canada
Corresponding Author:
P. Campisi MSc, MD, FRCSC, FAAP
The Hospital for Sick Children
555 University Avenue
Toronto, Ontario
Canada M5G 1X8
Tel. 416-813-2192
Fax. 416-813-5036
Email: paolo.campisi@sickkids.ca
2

Abstract:

Tracheotomy refers to a surgical incision made into a trachea. Tracheostomy, on the

other hand, refers to a surgical procedure whereby the tracheal lumen is positioned in

close proximity to the skin surface. Tracheostomy is an uncommon procedure in the

pediatric population. When required tracheostomy is typically performed as an open

surgical procedure under general anesthesia with the patient intubated. However, it may

need to be performed under local anaesthesia or over a rigid bronchoscope in the

patient with a precarious airway. Over the past half century, the primary indication for

pediatric tracheostomy has shifted from acute infectious airway compromise to the need

for prolonged ventilatory support in neurologically compromised children. The surgical

technique, choice of tracheostomy tube and post-operative care requires a nuanced

approach in infants and young children. This chapter will review these topics in a

comprehensive fashion.

Key words:Tracheostomy, Pediatric Indication, Complication, Technique, Post-

operative care.
3

Indications for Tracheostomy in Children:

In adults and in children, the indications for tracheotomy include: 1) a means to bypass

an acute or chronic upper airway obstruction; 2) facilitation of the care of patients

requiring long term ventilatory support; 3) protection from aspiration by providing access

for tracheobronchial toilet; 4) prevention of laryngotracheal stenosis in patients requiring

long term intubation; and 5) facilitation of weaning from a ventilator by eliminating

ventilatory dead space. In children, common indications for tracheostomy include

congenital and acquired airway stenosis, neurologic conditions requiring long-term

ventilation or pulmonary toilet, bilateral vocal fold insufficiency and infectious

compromise of the upper airway.1-4

In 1988, Arcand and Granger reported their experience with pediatric tracheostomy at a

single institution over two consecutive decades.5 This group observed a marked

reduction in the overall number of tracheostomies with a shift in the primary indication

from acute airway obstruction due to an infectious etiology to congenital airway

abnormality. Wetmore and colleagues reported in two separate studies the Children’s

Hopsital of Philadelphia long-term experience with pediatric tracheostomy from 1971-

1992.6,7 A similar decreasing trend in the total number of tracheostomies performed per

year was observed along with an increase in long term tracheostomies.

In 1988, Crysdale and colleagues analyzed the Hospital for Sick Children (Toronto,

Canada) experience in pediatric tracheostomy and compared their findings to a similar

study from the same institution performed 15 years earlier by Friedberg and Morrison.8,9

Once again, they noted a decline in the number of tracheostomies performed per year
4

and a shift in primary indication away from acute airway obstruction due to infection.

These studies have demonstrated that within a single institution the average number of

tracheotomies per year had decreased by half. This decline was attributed mainly to a

change in the management of supraglottitis.

A more recent audit of tracheostomy practice at the Hospital for Sick children suggests

a further decline in the number of tracheostomies required (unpublished data) (Figure

1). Factors that have sustained the trend of a decrease in the total number of

tracheotomies performed per year include 1) the introduction of the Hib vaccine in

Canada in 1988 and the resulting decrease in cases of epiglottitis, 2) the decrease in

the number of patient referrals to our institution since 2000, as other regional centers in

Ontario established tertiary pediatric care, 3) technological improvements in ICU care

settings with non-invasive ventilatory assistance, 4) the use of flexible endoscopes for

securing the airway in patients requiring advanced craniofacial surgery and 5) a more

comprehensive discussion about withdrawal of care in complex patients. However,

there has been a significant increase in the number of tracheostomies performed for

long-term mechanical ventilation in patients with neurologic conditions. This observed

‘shift’ in surgical indication has decreased decannulation rates because of the need for

prolonged ventilatory support.

Figure 1
5

Complications: Intra-operative, Early and Late Post-Operative

The surgical complications associated with tracheostomy can be classified temporally

as occurring in the intra-operative period, early postoperative (first 7 days), and late

post-operative periods (after 7 days or after the first tracheostomy tube change) (see

Table 1).

A review of the literature of pediatric tracheostomy (Table 2) reveals a complication rate

ranging from 10%-55% and a mortality rate ranging from 0%-3.6%. Meticulous attention

to the pre-operative evaluation, the surgical technique, selection of tracheostomy tube,

and post-operative care are key to minimizing the risk of morbidity and mortality. These

topics will be addressed in the remaining sections of the chapter.

Pre-operative Evaluation:

A thorough pre-operative evaluation of the patient is required to confirm the

appropriateness of the decision to proceed with tracheostomy. This includes a review of

the overall medical status of the patient as well as a detailed examination of the entire

airway from the nasal cavity to the distal bronchi. The examination may reveal

secondary areas of obstruction that if corrected may prevent the need for tracheostomy.

In addition, the examination will provide reassurance that the tracheostomy will indeed

bypass the area of obstruction (when obstruction is the indication for the procedure).

Examination of the external neck provides an estimate of the complexity of the

procedure to be undertaken. An inability to palpate airway landmarks, the presence of

6

external scars from previous neck and chest surgery, or the palpation of arterial

pulsations above the sternal notch are indications of potential hazards that may be

encountered during the procedure.

The cardiorespiratory status of the patient must be evaluated by the appropriate medical

services (critical care, anesthesia, respiratory medicine and cardiology) to ensure that

the patient is medically optimised for the anesthetic and surgical challenge. Moreover, a

medical assessment may help to anticipate post-operative complications such as post-

obstructive pulmonary edema or loss of respiratory drive in chronically hypercarbic

patients.
7

Surgical Technique:

As with any surgical procedure, a surgical checklist should be used to ensure that all

necessary equipment and a range of tracheotomy tube sizes are available and

functioning properly prior to commencing the procedure. A detailed intra-operative

airway management plan should be established with the anaesthesia and nursing

teams prior to bringing the patient into the operating theatre. In addition, during the

procedure there should be ongoing communication between the surgeon and

anaesthetist to ensure control of the airway.

The patient should be placed in the supine position with a rolled towel placed under the

shoulders to maintain the neck in extension. The surface landmarks of the neck should

be palpated to locate the thyroid cartilage, cricoid cartilage and suprasternal notch. The

surgeon should also palpate for prominent vascular pulsations suggestive of a high

riding innominate artery. The surgical site can then be prepared and draped in sterile

fashion.

Step 1:

Palpate the surface landmarks to identify the cricoid cartilage and sternal notch. A

horizontal incision is made midway between these two landmarks. This location will

typically correspond with the second and third tracheal rings. Infiltrate the skin and

subcutaneous tissues with a local anaesthetic with adrenaline. This will minimize

bleeding during the procedure and will blunt any patient response to stimulation when

dissection approaches the trachea.

8

Step 2:

Following the horizontal skin incision, the deeper fat and platysma layers are transected

in the horizontal plane and retracted superiorly and inferiorly. This exposes the

underlying ‘strap’ muscles that are divided vertically along the midline raphe. The ‘strap’

muscles are then retracted laterally to expose the anterior trachea.

Step 3:

With the ‘strap’ muscles retracted, the thyroid isthmus may be encountered overlying

the trachea. The thyroid isthmus may need to be divided vertically to fully expose the

tracheal rings. The isthmus can be divided with cautery. However, the ends may need

to be sutured to control bleeding.

In an acute airway emergency, there may not be enough time for Steps 1-3 described

above. In those instances, a vertical skin incision may be required for rapid access to

the trachea. The vertical dissection also minimizes the risk of vascular injury and

excessive bleeding. The vertical incision should not be used routinely as it is

cosmetically unappealing.

Step 4:

Once the trachea is fully exposed, a cricoid hook is used to pull the cricoid superiorly.

This stabilizes the laryngo-tracheal complex which is an essential step prior to making

an incision into the trachea. Retention sutures may also be placed bilaterally prior to the

tracheal incision. The anaesthesia team should be notified that the tracheal incision is
9

being performed as ventilation may become challenging with the expected air leak

through the tracheotomy. The tracheal incision can be made vertically or horizontally

according to surgeon preference between the second and 4th tracheal rings. Placement

of the incision and insertion superior to the 2nd ring may predispose to the development

of subglottic stenosis.

Step 5:

A tracheal (Trusseau) dilator or forceps is used to dilate the tracheal incision and

visualize the tracheal lumen. The anesthesiologist is then instructed to deflate

the cuff of the endotracheal tube (if present) and retract the endotracheal tube to

just above the tracheal incision.

Step 6:

The tracheotomy tube with the obturator in the tube is then inserted into the trachea.

There should not be any resistance while inserting the tube. When the tracheostomy

tube is inserted, the obturator is removed and the inner cannula inserted (if the tube has

an inner cannula). The tubing from the ventilator is then moved from the endotracheal

tube to the tracheostomy tube. The cuff on the tracheotomy tube (if present) is inflated.

The anesthetist then confirms that ventilation is established and a carbon dioxide

tracing is obtained on the capnograph.

10

Step 7:

The position of the tip of the tracheostomy tube should be verified by flexible

bronchoscopy to ensure that the tip is above the carina and that there is no blood or

mucus blocking the lower airways.

Step 8:

When the appropriate position of the tracheostomy tube is confirmed, the cricoid hook,

tracheal dilator and retractors are removed.

Step 9:

Depending on the size of the incision, the lateral aspects of the incision may need to be

sutured to decrease the size of the wound. A non-adherent dressing is tailored and

placed under the flanges of the tracheostomy tube.

Step 10:

The tracheostomy tube is sutured to the neck skin at 4 points to secure the tube to the

patient. The tube is further secured with ties which wrap around the patient’s neck. In

the adult, the ties should be snug to allow only two fingers between the ties and the

neck. In the child, the ties should be tighter allowing only one finger but remains

comfortable.

The following considerations and modifications to the standard tracheostomy procedure

should be considered in pediatric patients to minimize the risk of complications:

11

• If possible maintain spontaneous respiratory effort. This is particularly beneficial

in the setting of acute airway compromise and after the tracheotomy (Step 4) due

to the resultant airway leak and difficulty to ventilate effectively.

• Pre-select and have available on the surgical set an appropriately sized

tracheostomy tube and a second tube that is one size smaller in case of inability

to insert the tube.

• Excise peri-stomal subcutaneous adipose tissue and suturing the edges of the

tracheotomy to the skin to mature the tracheostoma (maturation sutures).

• Place vertically oriented stay sutures on either side of the vertical tracheotomy

around a tracheal ring. When pulled, stay sutures approximate the tracheotomy

edges to the skin surface. This will facilitate the insertion of the tracheostomy

tube and the re-insertion of a tube if 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

sparing is key to the prevention of suprastomal collapse and tracheomalacia.

• Meticulous hemostasis is important to prevent hemorrhage and the need to

return to the operating theatre.

12

Selection of the Appropriate Tracheostomy Tube:

The selection of an appropriately sized tracheostomy tube is critical for the success of

the procedure and the prevention of complications. Typically, the choice of tube size,

specifically the diameter of the tube, corresponds with the age of the patient. However

there are instances where this general rule does not apply such as when the size of the

patient is inconsistent with the chronological age. Figure 2 demonstrates a variety of

standard and specialized tracheostomy tubes.

Figure 2

In addition to the diameter, the length and curvature of the tube change according to

tracheostomy tube size. As such, length and curvature must also be considered when

selecting a tracheostomy tube. Ideally, the length of the tube should extend at least 2

cm beyond the stoma and the tip no closer than 1-2 cm from the carina.12 The distal end

of the tube should be parallel with the trachea to avoid abutting the anterior or posterior

wall of the trachea. Chronic abutment may cause granulation, and erosion into the

esophagus or the innominate artery causing life-threatening hemorrhage. If the

curvature is not ideal, the standard polyvinyl chloride tubes may need to be replaced

with silicon tubes that will more readily conform to airway shape.

Typically cuffed tracheostomy tubes are not required for children unless there is a need

for ventilation with high pressures or if the child is at high risk of aspiration.12 If a cuff is
13

required and must be inflated for long periods of time, this may predispose to tracheal

granulation and stenosis. When deflating a cuff, there is a risk of aspiration of secretions

that have likely collected above the cuff. To minimize the risk of aspiration, suctioning

before and after cuff deflation is strongly recommended.

Tracheostomy tubes are also available with fenestrations that are designed to facilitate

trans-laryngeal airflow and phonation. However, the use of fenestrated tubes in pediatric

populations is controversial. It has been observed that fenestrated tubes promote the

formation of granulation tissue in the area of the fenestration.12 Preferable strategies to

promote phonation include downsizing of the tracheostomy tube to allow airflow around

the tube or the use speaking valves such as the Passy-Muir valve.

Several manufacturers of tracheostomy tubes provide adjustable length tubes or the

ability to custom manufacture tube lengths according to patient needs. The use of these

modified tubes must be planned for well in advance. There are delays in the preparation

of these tubes as well as considerable costs. Modification of tubes by physicians is not

recommended due to potential changes in the integrity of the tube. However, in an

emergency setting modified tubes can be used until a custom tube becomes available.
14

Post-Operative Care of the Tracheostomy Tube:

The care of the tracheostomy tube begins in the immediate post-operative period. A

debrief with the accepting critical care team (medical, nursing and respiratory therapy) is

required. During the handover, the requirement for humidification, the suctioning

protocol (frequency, depth of suctioning), and an algorithm for the management of an

accidental decannulation (reverting to an endotracheal intubation or the re-insertion of

the tracheostomy tube with the use of stay sutures) need to be clearly outlined. The

location of a spare tracheostomy tube must be obvious. Typically, the obturator is taped

to the head of the bed for easy access.

The first tracheostomy tube change should be performed by the surgical team with

supporting services present. The team should be prepared for an endotracheal

intubation if there is loss of the airway due to inability to re-insert the tracheostomy tube.

The first change is performed after one week to allow for sufficient maturation of the

stoma. The head and neck are placed in extension with a shoulder role. The

tracheostomy tube should be suctioned before and after changing. The new tube is

inserted at an angle of 45 degrees from the vertical plane and is straightened while

being inserted.

Prior to discharge from hospital, the caregivers (a primary and a secondary) must

become proficient in the routine care of the tracheostomy tube. Specifically, they must

be able to identify problems such as need for suctioning, respiratory difficulty and

mucus plugging. They must be prepared to change a tracheostomy tube efficiently and

expeditiously. They must be trained to perform cardiopulmonary resuscitation.

15

At the home, supplies such as spare tracheostomy tubes, suction catheters, and sterile

saline and equipment (portable suction machines, humidifier, oxygen saturation

monitor) must be in place and functioning properly. Homecare nursing is a requirement

in most jurisdictions.

Routine tracheostomy tube changes are performed weekly. However, depending on the

patient, changes may occur more or less frequently. Regular visits in the outpatient

clinic are also required to ensure the tracheostomy remains healthy and well cared for.

It must be emphasized that caring for a child with a tracheostomy may have significant

psychosocial and financial implications for the parents or caregivers. The increase in

demands for ongoing medical care and constant supervision will have a profound effect

on family dynamics, relationships with the community and economics. Support, financial

and psychological, can be effectively resourced by including social work services on the

healthcare team.
16

Decannulation Protocol:

Before considering decannulation, the patient must be assessed to determine if the

initial reason for the tracheostomy has resolved or has been corrected. It is

recommended that a formal airway assessment be performed in the operating theatre to

ensure that there are no other lesions that may prevent safe decannulation such as

vocal fold insufficiency, stomal granulation, suprastomal collapse, distal tracheal

granulation or tracheomalacia.

In patients that have had a tracheostomy for a prolonged period of time, the stoma may

become epithelialized. In these instances, there is a high probability of developing a

tracheo-cutaneous fistula after decannulation. This may be problematic due to the

spillage of secretions through the fistula, a persistent risk of water penetration during

bathing, or issues with ventilation if the patient requires assistance with continuous

positive airway pressure. If a tracheo-cutaneous fistula is anticipated, a stomal revision

may be required prior to decannulation at a later date. Closure of the stoma by

secondary intention is preferred. Decannulation and stomal closure with sutures is not

recommended as this may predispose to infection and the development of

subcutaneous emphysema.

When proceeding with decannulation, most protocols begin with gradual downsizing of

the tracheostomy tube to promote gradual closure of the stoma and to train the patient

to breath around the tracheostomy tube. If tolerable, the patient should be downsized to

a size 3-0 tracheostomy tube. The patient is then capped during daytime hours to

assess tolerance. Parents and caregivers should be cautioned about not leaving the
17

child with a capped tracheostomy tube unattended or to maintain capping during naps

and nighttime without oxygen saturation monitoring.

Once the patient tolerates daytime capping, the patient is admitted to hospital for 24-

hour capping with monitoring. If successful, the tube is removed and covered with an

occlusive dressing to promote closure. Monitoring is continued as an inpatient for an

additional 48 hours or until the stoma is closed. If the stoma has not closed, the patient

can be discharged if the breathing remains stable with follow up in the outpatient clinic

setting.
18

Recommended Reading:

Ismail-Koch, Jonas N. Paediatric Tracheostomy. Open Access Atlas of Otolaryngology,

Head & Neck Operative Surgery. Johan Fagan (Editor) www.entdev.uct.ac.za

Deutsch ES. Tracheostomy: Pediatric considerations. Respir Care. 2010;55(8):1082-

1090.

Sherman JM, Davis S, Albamonte-Petrick S, Chatburn RL, Fitton C, Green C, Johnston

J, Lyrene RK, Myer C, Othersen HB, Wood R, Zach M, Zander J, Zinman R. Care of the
child with a chronic tracheostomy. Am J Respir Crit Care Med 2000;161:297-308.

References

1) Mahadevan M, Barber C, Salkeld L, et al. Pediatric tracheotomy: 17 year review.

Int J Pediatr Otorhinolaryngol 2007; 71: 1829-1835

2) Davis MG. Tracheostomy in children. Paediatr Respir Rev 2006; 7: S206-S209

3) Parrilla C, Scarano E, Guidi ML, et al. Current trends in paediatric

tracheostomies. Int J Pediatr Otorhinolaryngol 2007; 71:1563-1567

4) Carron JD, Derkay CS, Strope GL, et al. Pediatric tracheotomies: changing

indications and outcomes. Laryngoscope 2000;110: 1099-1104

5) Arcand P and Granger J. Pediatric tracheostomies: changing trends. J

Otolaryngol 1988; 17: 121–124

6) Wetmore RF, Handler SD, Potsic WP. Paediatric tracheostomy: experience

during the past decade. Ann Otol Rhinol Laryngol 1982; 91: 628–632

7) Wetmore RF, March RR, Thompson ME, et al. Pediatric tracheostomy: a

changing procedure. Ann Otol Rhinol Laryngol 1999; 108: 695–699

19

8) Friedberg J, Morrison MD. Paediatric tracheostomy. Can J Otolaryngol 1974;

3:147-155

9) Crysdale WS, Feldman R.I, Naito K. Tracheotomies: a 10 year experience in 319

children. Ann Otol Rhinol Laryngol 1988; 97: 439-443

10) Ozmen S, Ozmen OA, Unal OF. Pediatric tracheotomies: a 37-year experience in

282 children. Int J Pediatr Otorhinolaryngol 2009; 73: 959-961

11) Carr MM, Poje CP, Kingston L, et al. Complications in pediatric tracheostomies.

Laryngoscope 2001; 111: 1925-1928

12) Sherman JM, Davis S, Albamonte-Petrick S, et al. Care of the child with a

chronic tracheostomy. Am J Respir Crit Care Med 2000; 161: 297-308

Acknowledgement:

The authors acknowledge the contribution of Yamilet Tirado, MD for her work on the
audit of tracheostomy practice at the Hospital for Sick Children, 2000-2009.
20

Figure 1. Indications for tracheostomy at the Hospital for Sick Children (Toronto,
Canada) between 1963 and 2009.

1963-19704

Infection
5% 1%

49% Airway
45% Abnormality
Neurologic
Deficit
Craniofacial
Abnormality

1976-19855
Infection

27% 14% Airway

41% Abnormality
18%
Neurologic
Deficit
Craniofacial
Abnormality

2000-2009

Infection
8% 3%
Airway
31% 58% Abnormality
Neurologic
Deficit
Craniofacial
Abnormality
21

Figure 2. Standard and specialized tracheostomy tubes.

3-0 Shiley pediatric traceostomy tube and obturator. This tube has a single lumen and no cuff and is the
most common design used in the pediatric population. The tube has a standard 15 mm connector.

4-0 Shiley, pediatric, cuffed tracheostomy tube.

6-0 Shiley, cuffed, and fenestrated tracheostomy tube. The tube has an inner and outer cannula. During
exhalation, air travels through the fenestration and vibrates the vocal folds to allow phonation.
22

3-0 Bivona, pediatric, armoured, single lumen, adjustable length tracheostomy tube. This tube is very
flexible but is protected from collapse by the metal rings within the cannula.

Metal pediatric tracheostomy tubes (Fearon-Hollinger modified tube with 15 mm connector). These
tubes are used in the setting of a long-term subglottic stent after laryngotracheal reconstruction.
23

Table 1. Surgical complications associated with tracheostomy in children.

Intra-Operative Early Postoperative Late Postoperative

Hemorrhage Hemorrhage Stomal and tracheal

granulation

Pneumothorax or Dysphagia and aspiration Suprastomal collapse

pneumomediastinum

Esophageal injury Wound infection Tracheal stenosis

Recurrent laryngeal nerve Tube obstruction (blood Tracheomalacia

injury clot, mucus plug)

Loss of airway Accidental decannulation Tracheo-esophageal fistula

Creation of a false passage Tube displacement into Tracheo-innominate fistula

false passage

Cardiac arrest and death Subcutaneous emphysema Tracheo-cutaneous fistula

24

Table 2. Review of the literature summarizing published complication and mortality

rates associated with pediatric tracheostomy.

Author Year Country Number of Period Complication Mortality

Published Patients Studied Rate (%) Rate (%)

Ozmen et al.10 2009 Turkey 282 1968-2005 19 1.0

1
Mahadevan et al. 2007 New Zealand 112 1987-2003 51 1.6

Parilla et al.3 2007 Italy 38 1998-2004 35.8 0

Carr et al.11 2001 USA 142 1990-1999 43 0.7

Carron et al.4 2000 USA 204 1988-1998 44 3.6

7
Wetmore et al. 1999 USA 373 1981-1992 19 (early) 0.5

58 (late)

Arcand & Granger5 1988 Canada 189 1970-1975 53 1.0

30 1980-1985 57 3.3

Crysdale et al.9 1988 Canada 319 1976-1985 43 0.9

Wetmore et al.6 1982 USA 420 1971-1980 50 2.0

8
Friedberg & Morrison 1974 Canada 63.3/year 1963-1970 10 3.0