Why Would A Child Need A Tracheostomy?

A tracheostomy, a procedure to cut a hole in the throat to clear an airway to the lungs, is used to insert a tube into the trachea to provide assisted ventilation to children who are unable to breathe, or have difficulty breathing on their own.

Pediatric tracheostomy is a surgical procedure performed in children to create a small opening (stoma) in the airway (trachea) below the vocal cords. The stoma is used to insert a tube into the trachea which allows air to flow into the lungs if the upper airway is blocked, or to provide assisted ventilation to children who are unable to breathe, or have difficulty breathing on their own.

A child may require a tracheostomy if they are unable to breathe spontaneously. Currently, the most common reason for pediatric tracheostomy is a prolonged requirement for assisted ventilation because of respiratory or neuromuscular disorders.

Tracheostomy was originally developed as a treatment for children whose upper airway was blocked due to infectious diseases such as diphtheria and poliomyelitis. Vaccination has now successfully eradicated these diseases in most of the world. 

Pediatric tracheostomy is now mainly performed in the following situations:

• Anticipated long-term insufficiency in lung and/or heart function
• Presence of upper airway obstruction that is unlikely to resolve for a significant period of time

Some of the conditions affecting the upper airway (mouth, nose, throat and larynx) which require a pediatric tracheostomy include the following:

• Subglottic stenosis (narrowing of the airway below the glottis, an opening in the folds of the vocal cords)
• Bilateral vocal cord paralysis
• Congenital airway malformations
• Respiratory papillomatosis (benign or malignant airway tumors)
• Ingestion of any corrosive substance
• Craniofacial syndromes (congenital malformation of the skull or face)

A pediatric tracheostomy is more difficult than an adult tracheostomy because a child’s tissues are delicate and underdeveloped. Certain anatomical characteristics of a child’s neck may complicate a pediatric tracheostomy, include the following:

• The dome of the lung’s membrane (pleura) extends into the neck increasing the risk of lung injury.
• The trachea is very pliable and difficult to identify by palpating the throat.
• The trachea may be deep in the throat and great care is required to distinguish it from the carotid blood vessels.
• The neck is very short, which allows much smaller working space.
• The cricoid cartilage around the larynx can be injured if it is not properly identified.

A pediatric surgeon performs the pediatric tracheostomy with the patient under general anesthesia. The procedure may take up to 45 minutes.

Preparation

• The surgeon selects a tracheostomy tube with appropriate diameter and length, based on the age and weight of the child.
• The child has to stop eating and drinking a few hours prior (in elective procedures).
• The pediatric anesthesiologist administers general anesthesia and places an endotracheal tube through the mouth, unless the child is already intubated for assisted ventilation.
• If the child has a nasogastric feeding tube, it is removed.
• The child lies on their back with a roll under the shoulders to extend the neck.

Procedure

The surgeon will likely complete the following steps:

• Injects a local anesthesia in the throat area.
• Makes a horizontal incision in the skin halfway between the cricoid cartilage and the top of the sternum (sternal notch).
• Retracts the skin and cuts through the fat and muscle layers and cauterizes them to prevent bleeding and infection.
• Cuts or retracts the thyroid isthmus, the central part of the thyroid, which connects the right and left lobes of the thyroid gland, and exposes the trachea.
• Places nonabsorbable stay sutures on both sides of the trachea’s midline, which will be left in place after the surgery.
• Elevates the trachea to the skin surface.
• Makes a vertical incision in the midline of the trachea.
• Sutures the skin flaps to the trachea.
• Inserts the tracheostomy tube while simultaneously withdrawing the endotracheal tube.
• Connects the ventilator to the tracheostomy tube and makes sure the tube is clear and functioning properly.
• Tapes the stay sutures on the chest and applies gauze dressing on the tracheostomy.

Post-procedure

The child undergoes imaging tests to evaluate the tube’s position and the lung condition, in case of possible collapse (pneumothorax). The child will be in intensive care for approximately a week, till the stoma heals and the first tube can be changed.

The tracheostomy tube is removed (decannulation), as soon as the child is able to breathe spontaneously through the upper airway and is no longer dependent on assisted ventilation. If decannulation is difficult, a bronchoscopy or microlaryngoscopy may be performed to check for obstruction in the airway and mobility of the larynx.

The tube is first plugged to check if the child is able to breathe without support. Once the tube is removed, the opening is taped shut and the wound normally heals and closes within a week, but may sometimes require a surgical closure.

Most tracheostomies are temporary, until the underlying condition is treated. Premature babies may require a tracheostomy tube in place for a few weeks depending on their gestational age.

Tracheostomy may be permanent for some children if there is permanent damage or loss of function in the upper airway or larynx. The tube size will be appropriately changed as the child grows.

Children who require tracheostomy for prolonged periods can be cared for at home. The family or caregiver is required to first undergo a structured training program in the hospital before starting home care for the child. Following are some of the essential components of home care for a child with a tracheostomy:

• Cleaning and changing the tube
• Keeping the tube clear by suctioning secretions
• Humidification of the inhaled air
• Application of medications
• Keeping the stoma and tube clean and sterile to prevent infections
• Dressing and protecting the stoma

Complications of a tracheostomy include the following:

Early complications

• Pneumomediastinum (air leak into the chest space [mediastinum] between the lungs)
• Pneumothorax
• Subcutaneous emphysema (passage and trapping of air under the skin tissue)
• Acute hemorrhage
• Accidental tube dislodgement
• Tube obstruction

Intermediate complications

• Infection at the stoma leading to excessive growth of new tissue (granulation), which makes it difficult to remove or change the tube

Late complications

• Difficulty in decannulation because of granulation in the stoma
• Obstruction of trachea from tracheal granulation
• Accidental decannulation as the child develops more mobility
• Subglottic stenosis
• Tracheal stenosis
• Suprastomal collapse (collapse of the part of trachea above the stoma)
• Tracheocutaneous fistula (formation of an abnormal channel between the trachea and subcutaneous tissue)
• Problems with speech and language development