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Tracheotomy in children – indications and complications
Lidia Zawadzka-Głos, Mieczysław Chmielik
Department of Paediatric Otorhinolaryngology, The Medical University of Warsaw, Poland
Head: Prof. Mieczysław Chmielik M.D.
Tracheostomy is a life-saving procedure when performed with an appropriate indication and surgical technique. There is a limited indication for tracheostomy procedures in paediatric surgery. It is rarely applied to the paediatric patient because they can be kept intubated for a longer period compared to adults. Indications for tracheostomy are prolonged intubation, subglotic stenosis, general body trauma, tracheomalasia, cervical tumour pressing the trachea and larynx, congenital diseases of the larynx, burn injuries of the trachea, and foreign body aspiration. In the last decade the number of cases with tracheotomy increased due to the development of new intensive care units, the use of mechanical ventilation, and the increasing number of patients needing prolonged ventilation support. Tracheotomy in children has been associated with significant operative and post-operative complications. When long-term tracheotomy is needed, parent education, together with special equipment and environment may allow the return of the tracheotomised child to home in secure conditions.
Tracheotomy is a medical procedure that has been known for centuries. This type of operation was probably performed in ancient Egypt (3600 B.C.) and Babylon (1000 B.C.). However, it was Asklepiades (128-56 B.C.) who described a manoeuvre close to tracheotomy in the first century B.C. and is considered to be the father of this procedure. The first tracheotomy in a child was performed in 1856 by Eugene Bonchut. For centuries different methods of tracheotomy have been developed, the surgical equipment has improved and new models of tracheotomy tubes have been sought (4, 15, 19, 22).
Originally tracheotomy was an urgent life-saving procedure. Nowadays intubation eliminates in most cases the necessity of tracheotomy in urgent cases. It is widely known that complications from emergency tracheotomy, though performed by an experienced doctor, occur more frequently than when they are performed as planned procedures. Planned tracheotomy, if possible, should be preceded by evaluation of the respiratory tract (laryngotracheoscopy, bronchoscopy) and by evaluation of the cervical anatomical structures (vascular ring, thyroid and thymus location, degree of spinal curvature) (1, 6, 20, 21).
Contemporary indications for tracheotomy include the group of diseases connected with upper airways patency impairment, general diseases affecting the patency of lower airways and in patients requiring prolonged mechanical ventilation.
I. Upper airways patency impairment.
1.Congenital malformations of larynx and trachea (congenital infraglottic laryngeal constriction, laryngomalacia, laryngeal fins, laryngeal cysts, congenital vocal fold paralysis).
2.Congenital facial skeleton anomalies including micrognathia and microglossia.
3.Mechanical, thermal, chemical, and iatrogenic trauma of larynx and trachea (laryngeal or tracheal fracture, foreign body wedging or obturating laryngeal lumen, thermal or corrosive burns, prolonged or traumatic intubation).
4.Maxillofacial trauma with severe oedema of soft tissues and falling back of the tongue.
5.Acute laryngeal oedema precluding intubation (inflammatory or allergic).
6.Tumours of the larynx or trachea (haemangioma, neoplasmatic tumours).
7.Bilateral vocal fold paralysis.
8.Laryngeal and tracheal compression by adjacent structures (vascular anomalies, cervical tumours).
II. Respiratory tract patency impairment due to general diseases.
1.Retention of secretion in lower airways (balance impairment between secretion and elimination).
2.The lack of cough reflex
3.Impaired function of oesophageal constrictors and/or vocal folds (saliva or gastric and oesophageal contents penetrating the bronchial tree).
III. Patients requiring chronic mechanical ventilation
4.Chronic diseases of pulmonary tissue.
There are no direct contra-indications for tracheotomy. Severe bleeding tendency is a relative contra-indication.
Tracheotomy in a young child requires particularly precise execution and due consideration of indications. The size of upper airway anatomical structures in a young child, elasticity and mobility of larynx and trachea, adjacent large cervical vessels, high situation of the pleural cupula and large vascular trunks (arterial and venous brachiocephalic trunk) and a highly situated mediastinum increase the risk of complications. The larynx in new-borns and young children differs considerably from the larynx of an adult. Knowing the topographic anatomy of a young child's larynx is essential for carrying out a safe tracheotomy. The diameter of the respiratory tract in children is significantly less than that of adults. The dimensions of larynx and trachea aree given in table 1. Knowing these dimensions allows an appropriate selection of the tracheotomy tube, thus decreasing the number of late complications.
Table 1. The trachea dimensions (according to S. Engel: Die Lunge des Kindes; Thieme, Stuttgart).
||Sagittal cross-section (mm)
||Coronal cross-section (mm)
The larynx in new-borns is situated higher than in adults. The epiglottis lies at cervical vertebra C1 height, and the cricoid cartilage at C4 height. During a child's development the larynx descends to reach C6 for cricoid cartilage in the 13th year of age. The hyoid bone in new-borns adjoins the thyroid cartilage and covers its upper limit. The cricoid cartilage is closely connected with the thyroid cartilage lower limit, the cricothyroid membrane is short and difficult to evaluate in palpation, unlike adults in whom it is much easier to perform conicotomy. The laryngeal and tracheal chondral skeleton of a young child is soft and easily moved in the coronal plane. This can be the reason for localising the trachea during the tracheotomy (14, 15).
Elevated large vascular trunks (arterial and venous brachiocephalic trunk) or vascular anomalies may result in severe intraoperative complications. Therefore, if the state of the patient allows, tracheotomy is a planned procedure to eliminate the possibility of vascular ring or other anomalies (2-3, 5, 14).
An additional difficulty when performing tracheotomy in a young child is the short neck and well-developed adiposus layer (14, 18).
In the Warsaw Clinic of Paediatric Otolaryngology classic tracheotomy is executed through a transverse incision of the skin over the zygomatic incisure of the sternum. While performing tracheotomy it is important to remember to divide the tissues in the median line when exposing the anterior wall of the trachea. This area is safe and quite distant from large cervical vessels. At present the terms of "upper” and "lower” tracheotomy do not exist in children. Incision of the trachea should be carried out longitudinally through 3rd-4th cartilage. Tracheotomy is not to be executed through the cricoid or first tracheal cartilage because this makes it impossible to remove the tracheotomy tube (decannulation) due to secondary constriction of the larynx and trachea. An appropriate selection of the tracheotomy tube size regarding the trachea size is important to decrease the risk of late complications, such as tracheo-oesophageal fistula, malacia of the tracheal anterior wall, the process of granulation tissue growth, and decubitus ulcer in the trachea.
Apart from classical tracheotomy (SDT) methods of transcutaneous tracheotomy (PDT) have developed. Indications to perform transcutaneous tracheotomy using alternatives to standard surgical methods are similar, though they are mainly performed in intensive care units. There are no particular contra-indications to the execution of transcutaneous tracheotomy. However, performing classical tracheotomy is always important in life-saving conditions. Moreover the uncertain topographic anatomy of the surroundings inclines towards the classical method (9-11, 15).
There are many different techniques of transcutaneous tracheotomy applied presently, such as: Ciagliae, Griggs, Schachner or Fantoni techniques. Only Fantoni techniques can be applied in children under 12 years of age, while the rest are reserved for adults. Transcutaneous tracheotomy is a one or multistage technique of pretracheal tissue division. A constant element of the procedure, independent of the method applied, is locating the leader in the tracheal lumen through tracheopunction. The number and quality of complications are similar to the complications of classical tracheotomy (15).
The tracheotomy may result in early and late complications. Early complications appear while performing the tracheotomy, or directly after it. This group includes: oedema (subcutaneous, mediastinal, pleural), bleedings and haemorrhages, a sudden oxygen saturation decrease with respiratory and cardiac arrest, general and peripheral wound infections, dysphagia with choking, and stomach content aspiration into the respiratory tract. The reasons for and conduct in early complications are presented in table 2 (1, 2, 7, 9, 14).
Table 2. Early complications of tracheotomy (
|Subcutaneous, mediastinal, pleural oedema
||Too wide incision of the trachea,
Improper insertion of the tube,
Damaged pleural cupula
|Conservative treatment, or mediastinal drainage,
|Acute haemorrhage, bleeding
|Revision of the postoperative wound, or haematogenic fluid transfusion,Haematologist consultation
|Sudden saturation decrease and breathing impairment
Tube obturation by secretions, clots, foreign bodies (gauze, cotton-wool, catheter)
|Tube exchange,Aspiration of
Bronchoscopy - foreign body removal
||Insufficient postoperative wound nursing,
|Culturing the wound material, intravenous
||Wrong size or curvature of the tube,
Tracheo-oesophageal fistula due to damage of tracheal and oesophageal posterior wall.
|Tube exchange, surgical intervention.
Late complications appear at a distant time from the performed procedure, and may be life-threatening or impair decannulation. They include: dyspnoea due to the lack of tracheotomy tube patency, tracheostomy infections, recurrent lower airway infections, bleedings and haemorrhages, infraglottic stenosis, tracheal cartilage intussusception above the stoma, tracheo-oesophageal or tracheo-cutaneous (after decannulation) fistula, growth of granulation tissue around the stoma and in the trachea. The specification and discussion over these complications is presented in table 3 (1, 2, 16, 18).
Table 3. Late complications of tracheotomy.
|Sudden breathing impairment
||Tube falling out,
Tube obturation (secretions, foreign body, granulation)
Tube exchange or bronchoscopy - foreign body removal
|Infections around the stoma
||Improper stoma nursing,
Soft tissue compression by the tube (decubitus ulcer),
Infrequent tube exchange
|Local anti-inflammatory treatment,
Correction of the tube location
Tube exchange at least twice a week
|Bleeding and haemorrhages
Innominate artery fistula (overcurved tube - anterior wall compression)
|Removal with bronchoscopy help or externally around the
Vascular surgeon intervention
||Failed tracheotomy (upper tracheotomy or conicotomy)
|Tracheal cartilage intussusception above the stoma
||Local inflammatory process of the tracheal cartilageInsufficient incision of the
Traumatic tube exchange
|Plastic surgery of the trachea
|Tracheo-cutaneous fistula after decannulation
||Prolonged tracheostomy (> 1 year)
||Surgical closure of the fistula unless it closes in one year after decannulation
||Posterior tracheal wall compression by the tube (short tube, severe scoliosis, or kyphosis of cervical spine)
||Surgical closure of the fistula
Every tracheotomy tube change, no matter what technique for performing the procedure is applied, can become a source of complications and clinical problems. However, the classical tracheotomy through a wide incision of trachea and extensive preparation of pretracheal tissues gives favourable conditions for exchanging the tube. Poor and traumatic tube exchange can result in complications in the same way as the tracheotomy.
The first tracheotomy tube exchange should be performed 6-7 days after the tracheotomy. By this time the stoma is already well-formed. This procedure should be executed in the same conditions as the tracheotomy. The patient should be in the tracheotomy position, there should be sufficient illumination of the stoma, access to a source of oxygen, an efficient sucking device with a set of catheters of different calibres, a set of instruments and catheters to widen the stoma, and tracheotomy tubes. Fixing threads left during a classical tracheotomy on the tracheal rings positively facilitate the first tracheotomy tube exchange. The next tube changes should take place at least once a week. Looking after a child with a tracheostomy may be fulfilled at home in particular cases. The conditions of such proceedings are as follows:
1. The stoma has to be well-formed to allow free exchange.
2. Parents have to be educated how to exchange the tube, suck the secretions from the airways, nurse the stoma, and oblige themselves to the permanent contact with the ENT specialist or paediatrician.
3. Parents are able to supply the child with the necessary equipment and medical devices i.e. an electric sucking device, sterile catheters, tracheotomy tubes, air humidifier.
4. Parents will contact the ENT specialist once a week in order to exchange the tube.
5. Parents must be informed by the ENT specialist about the dangers to life and health of a child with tracheotomy while staying at home.
Non-compliance with the above requirements disqualifies the patient from being discharged.
Taking a decision on tracheotomy in a child, one should consider the possibility of numerous early and late complications, difficult nursing, and the influence of tracheotomy on the anatomic and physiological development of larynx and trachea. Therefore, the indications for a procedure burdened with such complicatio
s, though sometimes necessary, should be particularly well considered.
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New Medicine- 2/2002 vol. 5