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Paediatric Tracheostomy - A Complete Guide

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1. Definition

• Tracheotomy: A surgical opening made in the trachea.
• Tracheostomy: Creation of a stoma at the skin surface that leads into the tracheal lumen (i.e., a permanent or semi-permanent opening).

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2. Why Paediatric Tracheostomy Is Unique

• The paediatric trachea is shorter, narrower, softer, and more mobile
• The cricoid cartilage is the narrowest point of the paediatric airway (vs. the glottis in adults)
• The pretracheal tissues are loose - structures move more easily during dissection and neck extension
• The thyroid is relatively larger and often overlies the trachea
• Overextension of the neck in infants brings intrathoracic trachea into the operative field, risking an incision that is too low
• The great vessels at the root of the neck are closer to the operative field in infants

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3. Indications for Paediatric Tracheostomy

1. Relieve upper airway obstruction
2. Prevent complications of prolonged intubation
3. Reduce anatomical dead space
4. Allow suction toilet of the trachea

Causes of Upper Airway Obstruction Requiring Tracheostomy

Important Note on Changing Indications

• The availability of good paediatric intensive care has allowed many airway surgeries to be done without a covering tracheostomy (the "single-stage" approach - post-operative intubation instead).
• Subglottic haemangioma: propranolol and surgical excision have largely replaced tracheostomy.
• Subglottic stenosis: anterior cricoid split procedure has also reduced the need for tracheostomy.
• Increasing numbers of tracheostomies are now performed for ventilatory support in neurologically impaired or premature children with chronic lung disease.

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4. Surgical Anatomy

• Thyroid isthmus - crosses the trachea at the level of tracheal rings 2-4; must be divided or retracted superiorly
• Cricoid cartilage - must be identified before making the tracheal incision; incision too high risks subglottic stenosis
• Great vessels - especially in infants where the innominate artery sits higher and the operative field is compact
• Thyroid gland - relatively large in children and may obscure the trachea
• Pretracheal fascia - must be dissected cleanly in the midline

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5. Pre-operative Preparation

• Procedure is always performed under general anaesthesia in children (never local anaesthesia)
• The anaesthetist maintains the airway via an oral or nasotracheal tube throughout the procedure
• The anaesthetist must be skilled in paediatric airway management
• A senior paediatric anaesthetist must always be present
• A bronchoscope should be available
• The correct-sized tracheostomy tube must be selected and ready before the incision is made
• A spare tube of the same size and one size smaller must be present on the table

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6. Operative Technique (Step by Step)

Step 1 - Positioning

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Step 2 - Skin Incision

• In adult practice, a horizontal incision halfway between the cricoid and sternal notch is standard.
• In paediatric practice, a vertical skin incision has become standard in most major children's units over the last two decades.
• Advantages of vertical incision in children:
  • Keeps dissection in the midline
  • Reduces tendency to stray from the trachea
  • Allows easier placement of maturation sutures
• The incision is placed halfway between the cricoid ring and the sternal notch.
• The incision does not need to be much longer than required to insert the tube - skin retraction during surgery makes the defect appear larger than the original incision.

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Step 3 - Removal of Subcutaneous Fat and Maturation Sutures

• A disc of subcutaneous fat around the incision is removed after completing the skin incision.
• This allows skin edges to invert slightly, creating a stoma lined with healthy squamous epithelium.
• Maturation sutures: Interrupted absorbable sutures are placed between the skin edge and the tracheal wall. These serve to:
  • Stabilise the tracheostomy tract immediately post-operatively
  • Reduce the risk of creating a false passage during tube change
  • Reduce the risk of surgical emphysema if the tube is accidentally dislodged
• Some surgeons also place stay sutures on either side of the tracheal incision to allow traction and identification of the trachea in an emergency.

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Step 4 - Deep Dissection

• Incise the subcutaneous fat and platysma in the midline
• Separate the strap muscles (sternohyoid) in the midline using blunt dissection - no muscle is cut
• Identify and retract or divide the thyroid isthmus
• Identify the cricoid cartilage as the landmark for the correct level

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Step 5 - Tracheal Incision

• A vertical incision is made in the midline, usually through tracheal rings 3-4
• It is vital to identify the cricoid cartilage before making the incision - an incision too high (at ring 1 or 2) predisposes to subglottic stenosis, which is a serious complication
• Various tracheal incision types have been described:
  • Simple vertical incision (currently favoured by most)
  • Excision of an anterior tracheal window
  • Superiorly or inferiorly based tracheal flap sutured to skin
  • Cruciate incision with tracheal edges apposed to skin
• Tracheal flaps were advocated for increased tract stability, but animal experiments suggest they increase the risk of long-term stenosis - hence simple vertical incision remains most popular

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Step 6 - Tube Insertion

• The anaesthetist partially withdraws the existing endotracheal tube just before the tracheal incision is made
• The tracheostomy tube is inserted into the trachea under direct vision
• The anaesthetist confirms ventilation
• The original ETT is then fully withdrawn

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Step 7 - Securing the Tube

• Initially secured with inelastic linen tapes (supplied with the tube), tied with a secure knot
• Sufficiently tight to allow one finger to be inserted between the tapes and the neck skin
• Tapes should be tightened with the neck in flexion (not in the extended operative position), because neck extension will loosen the tapes once the patient is in normal position
• Suturing the flange to the skin should be avoided in children - infant skin is too thin and flexible to provide a secure anchor
• After 7 days, the first tube change is performed and linen tapes can be replaced by Velcro fastening, which is easier to change and less traumatic to the skin

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7. Tracheostomy Tubes in Children

Key Principles

• Paediatric tracheostomy tubes are uncuffed in most cases (the narrow cricoid creates a natural seal)
• Cuffed tubes are used only when positive pressure ventilation requires a seal, or to prevent aspiration
• Modern tubes are made from silicone (less reactive than PVC or metal, reducing granulation formation)

Commonly Used Tubes in UK

• Shiley® tubes: Available in neonatal and paediatric lengths, and paediatric long (PDL) for older children
• Bivona® tubes: Available in neonatal and paediatric lengths
• Bivona® Flexextend™: Silicone tube with a longer external component - useful for ventilated children and very small infants with limited chin-to-chest distance

• Bivona® Hyperflex™: Adjustable flange allowing change of effective tube length - useful for anatomical constraints (e.g., bypassing low tracheal obstruction)
• Custom-made tubes are available for specific anatomical difficulties

Tube Features

Speaking Valves

• One-way valves (e.g., Passy-Muir valve) that allow inhalation through the tube but force exhalation upward through the glottis
• Benefits:
  • Allow phonation and speech
  • May improve lung function
  • May reduce aspiration
  • Help the child get used to expiration through the normal airway pre-decannulation
• Must only be used with an uncuffed tube or with the cuff deflated
• Should not be used when large suprastomal granulations are present (blocks exhalation pathway)

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8. Post-operative Care

Immediate Post-operative Period

• Child should be nursed in PICU or high dependency unit initially
• Continuous monitoring: SpO2, heart rate, respiratory rate
• Two competent caregivers should be present at all times
• Spare tube of same size and one size smaller must be at bedside
• Humidified oxygen must be provided

Humidification

• Inspired air is cold and dry
• Secretions thicken and can block the tube
• Heat and moisture exchangers (HME / "Swedish nose") are attached to the tube connector to passively humidify
• Active heated water humidifiers are used in ventilated children

Suctioning

• Regular, careful suctioning using appropriate-sized catheters to keep the tube clear of secretions
• Excessive or traumatic suctioning must be avoided - it causes mucosal damage and stimulates granulation tissue formation
• Sterile technique should be used in hospital; clean technique may be acceptable at home

Wound and Stoma Care

• Keep the stoma clean and dry
• Change the foam/gauze dressing beneath the flange regularly
• Inspect for peristomal granulations at each change
• Tube change protocol: first change at 7 days (tracheostomy tract has matured sufficiently); thereafter according to unit protocol

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9. Complications

Early Complications (within 7 days)

Late Complications

Granulation Tissue in Detail

• Peristomal granulation: At the skin edge of the tract - discharges, bleeds, makes tube changing difficult. Managed with topical steroid/antibiotic preparations; bipolar diathermy if severe. Silver nitrate should be used cautiously as it can enter the trachea.
• Suprastomal granulation: Almost universal (reported in 80% of tracheostomies at bronchoscopy). Located on the anterior tracheal wall above the tube. Can obstruct the supraglottic airway - making accidental decannulation more dangerous. Can make speaking valve use impossible.

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10. Decannulation

Prerequisites for Decannulation

• Underlying cause of tracheostomy has resolved
• Child can breathe adequately through the upper airway
• Laryngeal function is adequate (assessed by microlaryngoscopy and bronchoscopy)
• Swallowing is safe
• Family and community support is in place

Decannulation Protocol (Standard Approach)

1. Endoscopy first: Microlaryngoscopy and bronchoscopy to assess the airway, identify any granulation or stenosis, and confirm adequate lumen above the tube
2. Downsizing: Progressively smaller tubes to encourage breathing around the tube and through the larynx
3. Speaking valve use: To acclimatise child to laryngeal exhalation before decannulation
4. Tube occlusion: Block the tube during the day; unblock at night for the first 24 hours
5. Full occlusion: If day occlusion tolerated, occlude for a full 24 hours
6. Decannulation: Remove tube if 24-hour occlusion is tolerated
7. Airway monitoring: Post-decannulation observation in a monitored setting for at least 24 hours
8. Stoma management: Apply an airtight dressing (gauze squares + occlusive dressing) to occlude the stoma; change whenever an air leak appears; most stomata close spontaneously within days to weeks
9. Persistent fistula: If it fails to close, silver nitrate cautery first; formal surgical closure (excision of tract down to anterior tracheal wall, multi-layer closure) for those that fail

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11. Discharge Home and Community Care

Requirements Before Discharge

• Parents/carers trained in tube change, suctioning, and emergency management
• At least two competent adults should be available at home at all times
• Home must have adequate space, heating, electricity, telephone, and access to transport

Essential Equipment at Home (Non-ventilated Child)

• Correct-sized tracheostomy tubes and one size smaller
• Neck ties and scissors (for emergency tube change)
• Lubricant for tube insertion
• Suction catheters (appropriate size)
• Two suction machines (one portable); most children keep a third at school
• HME / Swedish nose
• Speaking valves
• Saturation monitor (portable version for outside home)
• Ambu bag
• Oxygen cylinders / concentrator
• Gauze, dressings, sterile saline for stoma care
• Gloves, aprons, protective goggles

Additional Requirements for Home-Ventilated Children

• Home ventilator
• Backup ventilator
• Pulse oximeter
• Alarm systems
• Nursing support overnight (typically required)

Community Support

• District nurse, community paediatrician, health visitor, GP
• Hospital-based tracheostomy specialist nurse
• Hospital hotline for parents
• Speech and language therapist
• Physiotherapist
• Children with tracheostomies (without other significant disabilities) can attend mainstream schooling in many cases, though swimming, water-based sports, and contact sports must be avoided

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12. Key Points Summary (Quick Reference)

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