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Pediatric Tracheostomy

Overview

Background

Asclepiades is said to have performed the first tracheostomy in 100 BC. In the 19th century, tracheostomy became widely used in the treatment of diphtheria in children, and by 1887, approximately 20,000 of these operations had been reported in Western Europe and the United States.

The scope of the procedure broadened when Galloway reported using the procedure for the respiratory care of patients with poliomyelitis. The poliomyelitis epidemics of the early 1950s stimulated the use of tracheostomy for positive-pressure ventilation, and this opened the doors for similar treatment in tetanus, cardiac surgery, severe burns, and the care of preterm infants.

The incidence of and indications for pediatric tracheostomy have changed over the years. Upper airway obstruction secondary to infectious disorders was once the most common indication for tracheostomy.
Currently, however, the most common indication is for prolonged ventilation necessitated by neuromuscular or respiratory problems.

The old dictum that tracheostomy should be performed as soon as it comes to mind may not hold true now. This article outlines the indications for and performance of tracheostomy in children. It should be kept in mind that these indications may vary, depending on the facilities available in the institution where the patient is admitted and on the expertise of the individual surgeon.

Indications

Vaccination programs, improvements in material engineering, and anesthetic skills have dramatically reduced the number of emergency tracheostomies performed for acute upper airway obstruction. Today, the main indications for tracheostomy in a child generally involves either (1) anticipated long-term cardiorespiratory compromise resulting from chronic ventilatory (or, rarely, cardiac) insufficiency or (2) the presence of a fixed upper airway obstruction that is unlikely to resolve for a significant period of time.

In one series, subglottic stenosis (31.4%), bilateral vocal cord paralysis (22.2%), congenital airway malformations (22.2%), and tumors (11.1%) were the most common conditions that necessitated pediatric tracheostomy.
Conditions that have increased the frequency of pediatric tracheostomy over the past decade include respiratory papillomatosis, caustic alkali ingestion, and craniofacial syndromes. Conditions in which tracheostomy are now used less frequently include subglottic hemangioma and laryngeal clefts.

Contraindications

A tracheostomy is contraindicated during surgical repair of a type IV laryngotracheoesophageal cleft, because it may erode the posterior suture line and result in a breakdown of the repair. It is preferable to managing the airway with a nasotracheal or orotracheal tube during the postoperative period with the child kept paralyzed, although many children ultimately require tracheostomy when the repair is soundly healed because of tracheomalacia, which prevents extubation.

Technical Considerations

Performing a tracheostomy is difficult in pediatric patients, because a child’s neck is anatomically different from an adult’s neck in the following ways:

The dome of the pleura extends into the neck and is thus vulnerable to injury

The trachea is pliable and can be difficult to palpate

The trachea can be easily retracted to a great extent with little pull, and care must be taken distinguish it from the carotid vessels

The neck is short, and there is significantly less working space

The cricoid can be injured if it is not correctly identified

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