Tracheostomy

Fernando Stein

Jorge M. Karam

Nadeem I. Shafi

A tracheostomy is an opening created surgically through the neck and into the trachea (windpipe). A tracheostomy tube usually is placed through this opening to provide a permanent airway and to remove secretions from the lungs. The indications for tracheostomy in children are divided into three categories: airway obstruction, pulmonary toilet, and mechanical ventilation (Table 447.1).

A tracheostomy can help in managing patients with chronic lung disease, pulmonary fibrosis, interstitial lung disease, bronchiolitis obliterans, bronchopulmonary dysplasia, and certain neonatal conditions by decreasing airway dead space and facilitating pulmonary toilet.

TABLE 447.1. INDICATIONS FOR TRACHEOSTOMY

Types of Airway Obstruction
Static	Dynamic
Choanal atresia Macroglossia Micrognathia Subglottic and laryngeal stenosis Laryngomalacia Tracheomalacia	Vocal cord paralysis Physical trauma of the face Epiglottitis Laryngotracheobronchitis Paralysis of the muscles that affect swallowing Foreign body Neck or mouth injuries Intubation Inhalation of toxic gases or steam Burns by corrosive chemicals
Conditions Requiring Mechanical Ventilation
Neuromuscular	Pulmonary
Brain damage Long-term unconsciousness or coma Poliomyelitis Tetanus Guillain-Barré syndrome Paraneoplastic neurologic syndromes Duchenne muscular dystrophy	Preterm neonate Cardiac surgery Critical illness Short-term intubation (<3 weeks) Long-term intubation (>3 weeks)

In a 12-year review of indications for tracheostomy at Children’s Hospital of Pittsburgh, Pennsylvania, the indications for 80% of the procedures were assisted ventilation and pulmonary toilet; the remaining procedures were performed for upper airway obstruction. With small variations, the same is true for most children’s hospitals in the United States.

The assessment of urgency is the most important factor in choosing and planning the most appropriate and safest technique of securing the airway. Whenever time and conditions allow, a tracheostomy should be performed by the most expert personnel available, and the procedure should be undertaken in the operating room.

An endotracheal tube should be in place before the tracheostomy procedure begins, except in case of extreme obstructive emergencies. This procedure should be performed with the patient under general controlled anesthesia; use of local anesthesia usually is inappropriate. The neck is cleaned and draped. Surgical cuts are made to expose the tough cartilaginous rings that make up the anterior wall of the trachea. The surgeon cuts two of these rings and inserts a tracheostomy tube. After the tracheostomy has been performed, provision of warmed, filtered, and humidified air is important because the tube bypasses the nasopharynx. Most patients require 24 to 72 hours to adapt to breathing through a tracheostomy tube.

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