Overview of Pediatric Tracheostomy

A tracheostomy is a very old type of surgery that involves creating an opening in the neck to insert a tube into the windpipe, so the patient can breathe. The term ‘tracheostomy’ was first used in 1718 by Lorenz Heister. Over the years, doctors and surgeons have significantly improved this procedure used to help someone breathe.

Currently, ear, nose, and throat doctors, as well as pediatric surgeons, can carry out this surgery on children. But the doctors aren’t alone in this – a whole team of healthcare providers is needed to take care of the patient after the surgery. This includes teaching the family about caring for the opening, providing necessary supplies, and aiding with a machine used for breathing, if needed.

Even though different hospitals may have slightly varied ways of after-surgery care, there are agreed-upon rules available for everyone to follow. This ensures that care is standardized and everyone knows what they should be doing. To build up these rules, doctors and researchers rely on the latest scientific information.

The practice of tracheostomies has evolved a lot over time. Armand Trousseau first used it to help people with breathing difficulties cause by a disease called diphtheria in around the 1800s. A few years later, Chevalier Jackson made this a more formal process. Until recent times, it was thought that tracheostomies are more dangerous for kids than adults. But thankfully, things are changing. Now, we see that premature babies and those with severe birth defects, who survive due to modern medical techniques, may need tracheostomies and can benefit from it.

In the old days, tracheostomies were commonly done when a person couldn’t breathe due to infections like diphtheria. Today, it’s done to help with long-term breathing support, or to help with problems such as narrowing of the windpipe, nerve disorders, trauma, or blocked airways due to facial abnormalities. While there may still be some debate about how risky a tracheostomy is for a child, recent studies indicate that the risks may not be as large as previously thought.

Anatomy and Physiology of Pediatric Tracheostomy

The trachea, often referred to as the windpipe, is a partly flexible airway that assists in taking in and expelling air from our body. It’s somewhat like a tube, about 1.5 to 2 cm wide and 10 to 13 cm long in adults. The trachea begins from near your larynx, or voice box, and extends down to the chest area where it splits into two main airways to the lungs, called the bronchi. The trachea is made up of around 20 cartilage rings that are connected by soft, smooth muscle tissue and fibers.

The structure and function of the trachea can differ between kids and adults, and these differences can matter, especially during certain medical procedures like a tracheostomy, which is a surgery to create an opening in the trachea for breathing. For instance, children have a larger head size compared to their body size, larger tongues, smaller jaws, as well as shorter necks. Further, in kids, the voice box is situated higher, and the cricoid cartilage – a ring below the voice box that helps protect your windpipe – changes its location as a person grows older. Even the airways look different: in adults they have more of an oval shape, while in children they are more rounded.

Not all parts of the trachea lie perpendicular to each other. The vocal cords, the tissues generating voice, slope down to the back. In kids, the part of the trachea called the epiglottis, which helps prevent food from entering the windpipe, has a ‘U’ shape and can potentially obstruct the entrance to the voice box. Another difference between kids and adults is where the narrowest point in their airways is. In kids, it’s the cricoid cartilage, and in adults, it’s the vocal cord level. The windpipe in children is more soft and pliable, which increases the likelihood of obstructions, especially during a procedure that requires negative pressure ventilation, like some types of breathing therapy.

The airway system undergoes major changes, especially within the first two years of life. As a child grows older, these differences with the adult trachea slowly reduce and by the time they’re about 6 to 8 years old, a child’s respiratory system becomes quite similar to an adult’s.

The trachea in kids has specific features. It’s closer to the back, shorter, and narrower than that of an adult. The higher position of the voice box in children also means they tend to have more cartilage rings around the trachea. Interestingly, the number of these rings decreases as a person ages. An infant typically has 10 rings, which reduces to about 8 in teenagers, and falls further to 6 or fewer in adults. Overall, the trachea in infants is much smaller compared to an adult’s – about half the length, a third of the diameter, and only 15% of the area!

It’s still unclear how the trachea grows as we age. A study in 1986 examined the tracheae of 130 children aged under 6 using CT scans and found that by the end of teenage years, the trachea’s length doubles and its width continues to grow. Throughout childhood, with increasing age, the trachea’s shape slowly becomes more rounded. By around 18 years of age, the front to back diameters typically overshoot the side-to-side diameters.

Prior knowledge suggested the trachea grew in a straight line from about 18 weeks of pregnancy until the age of 14 in girls, with enlargement in boys continuing to occur even after height growth stopped. However, recent studies suggest that tracheal growth follows a pattern similar to height and that the trachea does not have a round shape progress.

Why do People Need Pediatric Tracheostomy

A tracheostomy is a medical procedure typically performed on children to secure the airway, aid breathing, and encourage recovery. This procedure is generally needed when a child requires a ventilator for an extended period of time. Thanks to improved medical care, this procedure has resulted in increased survival rates for premature babies or children with complicated heart and lung conditions such as bronchopulmonary dysplasia.

There are other reasons a child might need a tracheostomy. Some of these include:

– Harmless airway tumors, for example, recurrent respiratory papillomatosis.
– Neck tumors that can damage the trachea – the airway connecting the throat to the lungs, such as cystic hygroma.
– Conditions that can naturally block the airway.
– Inborn physical abnormalities like bilateral vocal cord paralysis, laryngomalacia (a condition where the voice box is too soft), and subglottic web (a narrowing of the airway below the voice box).
– Infectious diseases, like epiglottitis and laryngotracheobronchitis, which can hinder the airway.
– Diseases that may require pulmonary toilet – a term meaning clearing of the airways.
– Syndromes associated with abnormal airways, such as Treacher-Collins, Nager, or Beckwith-Wiedemann syndromes, or the Robin sequence.

Other reasons why a child might need a tracheostomy include the following:

– Making it easier for them to be weaned off a ventilator.
– Preventing a disorder of the larynx or windpipe caused by long-term intubation – the process of inserting a tube through the mouth and then into the airway.
– Stopping aspiration, which is when food or other material ends up in the lungs due to an unprotected airway, commonly seen in conditions such as a laryngeal cleft or bulbar palsy.
– Helping with ventilation in situations where intubation is challenging, for example, with a retropharyngeal abscess, post-tonsillectomy bleeding, obstructive sleep apnea, a tracheal foreign body, or facial burns.

When a Person Should Avoid Pediatric Tracheostomy

In general, there aren’t any fixed situations where a tracheostomy (a surgically made hole in the windpipe for breathing) should always be avoided. However, certain circumstances or medical conditions might make it more complicated or riskier.

Health conditions that exist along with the primary illness, known as comorbidities, could pose additional challenge to a tracheostomy procedure. These conditions include problems with blood clotting (coagulopathy), severe instability in a person’s overall health, and a negative forecast for long-term health.

A tracheostomy could be complicated by specific conditions related to the procedure itself. These can include the presence of a mass in the front part of the neck, a complicated surgical approach due to abnormal or hard-to-work-with anatomy, a high-located innominate artery (major blood vessel near the neck), and an ongoing local infection.

Equipment used for Pediatric Tracheostomy

During a procedure called a tracheostomy, doctors use different types of tools and equipment. These tools and equipment can be grouped into different categories to help remember them more easily.

The safety of the patient and the healthcare workers is of utmost importance. Therefore, before the procedure begins, the patient must give their informed consent, which means they understand and agree to the procedure. Also, healthcare workers must wear personal protective equipment. This includes a mask, gown, gloves, and eye protection to prevent the spread of germs.

The proper positioning of the patient is also very important during the procedure. To make sure the patient is in the right position, a sandbag of the right size, a neckroll, and a head ring are used.

Equipment is used throughout the surgery to monitor the patient and confirm if the tracheostomy tube is in the right place. This equipment may include devices to measure oxygen levels and carbon dioxide output (pulse oximetry and capnometry), as well as a fiberoptic bronchoscope (a tiny camera that lets the doctor see inside the throat) and a stethoscope. Emergency airway equipment, a crash cart filled with emergency medical supplies, and equipment used for resuscitation must be readily available as well.

When the procedure is performed on children, some specific pieces of equipment are needed, which include:

* Syringes (5 and 10 ml)
* A proper working suction device and different sized catheter tubes
* A kidney tray (a shallow, flat-bottomed tray), sponge holder, and dressing gauge for wound care
* A scalpel with a size 11 or 15 blade
* Small Langenbach retractors, which are used to hold back tissues
* Small and medium artery forceps used to hold arteries and prevent bleeding
* A cricoid hook, which is used to help secure the airway
* Tracheal forceps and dilators, which are used to insert and position the tracheostomy tube
* Tracheostomy tubes of different sizes
* Sutures, needle holders, and tracheostomy tapes, which are used to secure the tracheostomy tube in place.

Who is needed to perform Pediatric Tracheostomy?

To carry out a tracheostomy on a child, which is a surgery to create an opening in the throat to help with breathing, there are several healthcare professionals involved. The primary surgeon is the lead doctor who conducts the surgery. The surgical first assistant aids this surgeon during the operation. The anesthetist is responsible for giving the child anesthesia, which is medication to help the child sleep and not feel any pain during the procedure.

Additionally, a surgical technician or operating room nurse helps in the operating room by handling surgical instruments and other tasks. A circulating nurse is also present in the operating room, responsible for managing the surgical supplies and maintaining a sterile environment. Lastly, either an occupational therapy assistant or a respiratory therapist is also part of the team; they help the child with breathing exercises and other activities after the surgery to ensure a safe recovery.

Preparing for Pediatric Tracheostomy

Before any medical procedure, it’s crucial that all medical instruments are in place and in working order. With proper equipment set-up, the doctor can make sure the procedure runs smoothly. Additionally, the doctor will need to explain the process, potential risks, and benefits to the patient before the procedure can start. This is called informed consent, a critical step to ensure that the patient knows what will take place and has agreed to it.

Once the patient arrives in the operating room, certain standard monitors will be connected to them. These monitors, recommended by the American Society of Anesthesiologists (ASA), are used to carefully track the patient’s vital signs during the procedure. General anesthesia, a medication to make the patient unconscious during the procedure, will be used. The specific method will depend on the anesthesiologist’s judgement. A process called orotracheal intubation, which involves placing a flexible plastic tube into the windpipe to maintain an open airway and deliver anesthesia or oxygen, will also be performed.

Positioning of the patient is important for successful completion of the procedure. The patient will be positioned lying flat on their back (supine position). To help the procedure, a sandbag will be placed between the shoulder blades and the neck will be extended over a roll or pillow. This helps bring the windpipe close to the skin of the neck, making the procedure easier for the doctor.

How is Pediatric Tracheostomy performed

When a patient requires a tracheostomy, which is a surgery that creates an opening in the neck to allow for breathing, the anesthesiologist will usually induce general anesthesia which means you won’t feel or remember the surgery. First, the medical team uses special instruments for looking into the throat (known as microlaryngoscopy and bronchoscopy) to assess the airway. This helps them decide the required size of the tracheostomy. Once they agree that a tracheostomy is necessary, they insert and secure a tube with a small balloon on the end (endotracheal tube) into the windpipe. Then they adjust your body in a way that your neck is stretched back slightly.

Using landmarks on your neck like the sternal notch, cricoid cartilage, and thyroid cartilage, the surgeon will identify the center line for the cut. The surgeon will then make a cut, usually between second and fourth rings of the windpipe, which are just below the cricoid cartilage (the ring-like cartilage around your windpipe). Layers of skin and fat above certain neck muscles (strap muscles) are moved to expose the windpipe. At this point, they stop using electric energy (electrocautery) to make cuts or coagulate blood.

“Stay sutures” or stitches that are not meant to be absorbed are placed on either side of the planned tracheostomy site. These stitches can help lift the windpipe during preparation for the tracheostomy and guide tube placement. Following this, the opening for the tracheostomy is made in the windpipe, usually between the second and third or third and fourth rings, depending on what works best anatomically. This opening should be just the right size to enable smooth placement of the tracheostomy tube.

It’s important to know that the International Pediatric Otolaryngology Group recommends using stay sutures in all cases. They also suggest assessing the entire airway during the procedure and possibly inspecting the tube placement after the surgery using a thin, flexible viewing instrument known as a bronchoscope.

When the tracheostomy tube is ready to be placed, the anesthesiologist is asked to partially take out (withdraw) the endotracheal tube but it stays below the vocal cords. Then, the tracheostomy tube is inserted into the windpipe and attached to a device for assisted breathing. The position of the bottom end of the tracheostomy tube is confirmed to be approximately 2 to 3 rings above the spot where the windpipe divides into two (the carina) using a flexible fibreoptic bronchoscope. The tracheostomy tube is finally secured with ties around the neck.

The stay sutures are attached around the tracheostomy incision and labelled as right or left, then they are taped on the front of your chest. This helps the medical team quickly identify the new tracheostomy site in case the tube accidentally comes out.

Possible Complications of Pediatric Tracheostomy

Tracheostomy, a surgery that creates an opening in the neck to connect a tube into the windpipe to help with breathing, is not a common procedure to have performed in pediatric patients in referral hospitals; roughly only 0.2% of hospitalized kids need to go through it. The survival rate following this procedure varies and can be as grim as one out of every five children not making it. The main reason children might not survive isn’t generally the surgery itself, but rather, the serious health conditions they might have alongside. Any complications or deaths directly related to the surgery are pretty rare these days.

For adults getting a tracheostomy, about 15% could face complications afterwards. As for kids, we don’t have much data, but it seems about up to 19% might experience complications related to the surgery. Most of the time, other health issues the child might have affect how well they do after surgery, while complications from the actual tracheostomy device aren’t common. The problems a child might face can range from being minor and not needing any treatment, all the way to being life-threatening. Sadly, obstructions or dislocations of the tube, along with accidental removal of it, are the most common causes of death in kids who’ve had a tracheostomy.

These complications can happen either soon after surgery or might take a while to appear:

Within 3% to 9% of children who’ve had a tracheostomy might experience the trapping of air under their skin or in their chest or lung area. Consequently, a chest x-ray is usually taken once they’re back to their room after surgery to make sure the tube is in the right spot and to check their chest condition.

Bleeding during surgery can generally be controlled through careful use of a tool that uses heat to stop bleeding and paying close attention to making sure the blood flow is stopped. Identifying structures in the area of the operation before making the cut can help prevent injury to the vocal cords and esophagus, which has been reported before.

Another potential issue is that the sudden relief of a blocked upper airway might lead to fluid buildup in the lungs in pediatric patients. Depending on how forcefully the tube is inserted or if the cut into the windpipe is too small, the back wall of the windpipe might tear, or larger tubes might be unintentionally put in the main windpipe.

It’s essential to use the correct tube size and place it correctly and to use proper care techniques to prevent the accidental removal of the tube in the immediate postoperative period. Blockage of the tube by mucus can cause breathing difficulties, but it can be avoided by adequate care of the surgical area, humidification, and regular tube changes.

Over time, the constant rubbing of the tube and chronic inflammation can cause tissue to grow around the surgical area. Proper local wound care and regular changes of the tube and dressing can help prevent this complication. Scar tissue formation around the surgical area might make changing the tube harder, and sometimes surgical removal of the scar tissue is necessary.

Kids who need a tracheostomy for a long time might develop a hole between the skin and windpipe due to the skin sticking to the lining of the windpipe. Long-standing pressure on the first and second windpipe rings can cause inflammation and weakening of the ring, resulting in the windpipe collapsing in the upper chest area. If the tube is placed very high in the airway, it might lead to narrowing under the voice box. Careful placement of the tube and adequate care of the surgical area can help prevent this.

Finally, feeding changes might occur due to the windpipe being anchored to muscles in the neck area. The tube’s cuff might increase pressure in the esophagus and lower part of the throat, causing difficulty swallowing. However, having a tracheostomy should not prevent a child from eating by mouth.

What Else Should I Know About Pediatric Tracheostomy?

A tracheostomy is a common surgical procedure carried out on children which involves making an opening in the neck to insert a tube into the windpipe. This helps the patient breathe more easily, especially when they need help from a breathing machine for a long time. This type of surgery can make breathing less effortful, lower the need for heavy sedation, enhance comfort, and make it easier to keep the airways clean.

It’s necessary for doctors who specialize in treating children (pediatricians), ear, nose, and throat doctors (otolaryngologists), and those experts in managing patients’ breathing and pain during surgeries (anesthesiologists) to understand when, why and how the procedure should be performed. They also need to be aware of the conditions in which it should not be performed (contraindications) and any potential side effects.

Frequently asked questions

1. What are the specific reasons why my child needs a tracheostomy? 2. What are the potential risks and benefits of a tracheostomy for my child? 3. How will the tracheostomy be performed and what equipment will be used during the procedure? 4. What kind of care will my child need after the tracheostomy surgery? 5. What is the expected survival rate and long-term outlook for children who undergo a tracheostomy?

Pediatric tracheostomy can have different effects on children compared to adults due to the anatomical differences in their trachea. Children have a larger head size, larger tongues, smaller jaws, and shorter necks, which can impact the procedure. The trachea in children is also closer to the back, shorter, narrower, and has more cartilage rings compared to adults. Understanding these differences is important for the success and safety of pediatric tracheostomy procedures.

There could be several reasons why a pediatric tracheostomy may be necessary. Some possible reasons include: 1. Severe respiratory distress: If a child is experiencing severe difficulty breathing or is unable to breathe on their own, a tracheostomy may be performed to provide a secure airway and assist with breathing. 2. Airway obstruction: If there is a blockage or narrowing of the upper airway, such as due to a tumor, infection, or congenital abnormality, a tracheostomy may be needed to bypass the obstruction and allow for adequate airflow. 3. Long-term ventilator support: Some children with chronic respiratory conditions or neuromuscular disorders may require long-term mechanical ventilation. A tracheostomy can provide a more stable and secure airway for the attachment of a ventilator. 4. Difficulty with swallowing or aspiration: If a child has difficulty swallowing or is at risk of aspirating food or fluids into their lungs, a tracheostomy may be performed to prevent aspiration pneumonia and provide a safer means of feeding. 5. Access for frequent suctioning or medical procedures: In certain medical conditions, such as cystic fibrosis or bronchiectasis, excessive mucus production may require frequent suctioning. A tracheostomy can provide easier access for suctioning and other necessary medical procedures. It is important to note that the decision to perform a pediatric tracheostomy is made on a case-by-case basis, taking into consideration the specific medical needs and circumstances of the child.

A pediatric tracheostomy should be avoided if the child has comorbidities such as blood clotting problems, severe instability in overall health, or a negative long-term health forecast. Additionally, complications related to the procedure itself, such as the presence of a neck mass, abnormal anatomy, a high-located innominate artery, or an ongoing local infection, can make the tracheostomy more risky or complicated.

The recovery time for Pediatric Tracheostomy can vary depending on the individual child and their specific condition. However, it generally involves a period of healing and adjustment after the surgery, which can last several weeks to months. During this time, the child will need ongoing care and support from a team of healthcare providers to ensure proper healing and management of the tracheostomy.

To prepare for a pediatric tracheostomy, the patient should ensure that all medical instruments are in place and in working order. They should also understand and give their informed consent for the procedure. Additionally, the patient should be properly positioned during the surgery, and standard monitors will be connected to track vital signs.

The complications of Pediatric Tracheostomy include trapping of air under the skin or in the chest or lung area, bleeding during surgery, fluid buildup in the lungs, tear in the back wall of the windpipe, unintentional placement of larger tubes in the main windpipe, accidental removal of the tube, blockage of the tube by mucus, tissue growth around the surgical area, scar tissue formation, hole between the skin and windpipe, windpipe collapsing in the upper chest area, narrowing under the voice box, and difficulty swallowing.

The text does not provide specific symptoms that require Pediatric Tracheostomy. However, some reasons a child might need a tracheostomy include conditions that block the airway, inborn physical abnormalities, infectious diseases that hinder the airway, syndromes associated with abnormal airways, and situations where intubation is challenging.

The provided text does not mention anything about the safety of Pediatric Tracheostomy in pregnancy. Therefore, it is not possible to determine the safety of Pediatric Tracheostomy in pregnancy based on the given information.

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