Pediatric Tracheostomy

Indications & Timing - Why & When We Pipe

• Upper Airway Obstruction (UAO):
  • Congenital: Severe laryngomalacia, subglottic stenosis, craniofacial anomalies (e.g., Pierre Robin).
  • Acquired: Bilateral vocal cord palsy, severe infections (e.g., supraglottitis), trauma, tumors.
• Prolonged Mechanical Ventilation (PMV):
  • Facilitates weaning, ↑ patient comfort, ↓ risk of laryngeal injury.
  • Timing: Generally considered after 7-14 days of translaryngeal intubation; individualized based on prognosis.
• Pulmonary Toilet:
  • Ineffective clearance of lower airway secretions (e.g., neuromuscular disorders, cystic fibrosis).

⭐ Prolonged intubation beyond 1-2 weeks significantly increases risk of laryngeal complications like subglottic stenosis, guiding tracheostomy timing decisions in children on PMV.

Pediatric Airway Anatomy - Tiny Tubes Territory

• Larynx: Higher (C3-C4 vs. C5-C6 in adults), more anterior; facilitates nasal breathing.
• Epiglottis: Large, U-shaped or omega (Ω), floppy; can obscure laryngeal view.
• Subglottis: Funnel-shaped (conical), soft tissues prone to edema.

  ⭐ Narrowest point: Unyielding cricoid cartilage ring (vs. glottis in adults).

• Trachea: Shorter (4-5.7 cm in neonates), narrower diameter, more compliant/collapsible walls.
• Bronchi: Right main bronchus less vertical, more symmetrical take-off angles than adults.

Tracheostomy Procedure - The Surgical Snippet

• Positioning: Supine, neck hyperextended (shoulder roll).
• Incision: Horizontal (cosmesis) or Vertical midline; between cricoid & suprasternal notch.
• Dissection: Platysma, deep fascia divided. Strap muscles retracted. Thyroid isthmus divided/retracted.
• Tracheal Entry:
  • Stay sutures (Prolene/Silk) on rings 2-4.
  • Vertical incision (rings 2-4); avoid ring 1 & cricoid.
  • Bjork flap (inferiorly based) an option.
• Tube Insertion: Appropriate size, cuff inflated (if used), secured.
• Confirmation: Auscultation, capnography, flexible endoscopy, CXR.

⭐ High-Yield: In children, a vertical tracheal incision is preferred as it heals better and causes less stenosis. Avoid dividing the cricoid cartilage to prevent subglottic stenosis.

Complications & Management - Uh Ohs & Fixes

• Immediate (<48h): 📌 DOPE
  • Displacement/Dislodgement
  • Obstruction (mucus, blood)
  • Pneumothorax
  • Equipment failure (e.g., cuff leak)
  • Bleeding, Apnea
• Early (days-weeks): Infection (stoma, tracheitis), granulation tissue, accidental decannulation.
• Late (weeks-years): Tracheal stenosis, tracheomalacia, tracheo-innominate fistula (TIF), tracheoesophageal fistula (TEF).

Management:

• Airway Crisis (Ref. DOPE):
  • Dislodgement: Attempt re-insertion (same/smaller tube).
  • Obstruction: Suction vigorously.
  • If failed: Bag-mask (cover stoma), intubate orally/nasally.
• Bleeding: Pressure.

  ⭐ TIF: Sentinel bleed (pulsatile) → OR STAT! Digital pressure, overinflate cuff.

• Granulation: Cautery (AgNO₃), steroids.
• Stenosis: Dilatation, reconstruction.

Post-Op Care & Decannulation - Homeward Bound Breaths

• Immediate Post-Op: Patent airway. Humidification crucial. Regular suctioning (PRN, sterile). Stoma care: clean, dry; check infection, granulation.
• Home Care: Emergency kit (spare tubes: same & smaller, obturator, suction). Parent training vital.
• Decannulation Criteria: Indication resolved/improved. Tolerates >24h capping. Patent airway on endoscopy. Normal PSG.
• Decannulation Pathway:

⭐ Commonest cause of decannulation failure in children: persistent upper airway obstruction (e.g., subglottic stenosis, granulation, tracheomalacia).

High‑Yield Points - ⚡ Biggest Takeaways

• Key indications: Prolonged ventilation, upper airway obstruction (e.g., subglottic stenosis).
• Neonates/Infants: Prefer uncuffed tubes to prevent tracheal mucosal injury.
• First tube change: Usually 5-7 days post-op, by experienced personnel.
• Emergency: Accidental decannulation requires immediate reinsertion or oral intubation.
• Late complications: Granulation tissue, tracheomalacia, tracheal stenosis.
• Speaking valves: Require cuff deflation for phonation.
• Decannulation: Preceded by endoscopic airway assessment for patency.