Tracheostomy in Children

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The spectrum of diseases requiring intubation or tracheostomy in infants and small children differs from that of the adult. Congenital malformations of the nasopharynx, oral cavity, neck, larynx, and trachea or laryngeal hemangioma may be indications for urgent intubation. Acute laryngeal inflammatory processes including acute epiglottitis and laryngotracheal bronchitis, as well as acute laryngeal edema, sometimes due to allergic phenomena, may be emergency problems. Diphtheria is fortunately very rare and poliomyelitis has become so as well. The tiny size of the airway in the newborn or young child requires special skill in intubation. Nasotracheal tubes are preferred for comfort, especially if respiratory support is necessary. Cuffed tubes are not necessary for ventilation of infants and small children. In order to avoid erosive damage, the diameter of the tube is selected so that it will not impinge on the airway throughout its length. Severe and lengthy malacia or stenosis may result if a tube of excessive diameter remains in firm contact with the trachea for long. A tight fit at the glottic level may injure the cords and commissures, and result in stenosis. A tight fit at the cricoid level may produce subglottic stenosis.20 Infants and small children are carried for longer periods with endotracheal tubes, in order to avoid tracheostomy with its additional problems. On the other hand, the same trade-off of laryngeal injury is seen in children as in adults, although problems at the tracheal stoma may be eliminated (see Chapter 11, "Postintubation Stenosis").

Tracheostomy in an infant or child should be done over a previously established airway and under general anesthesia. Hendren and Kim recommended insertion of a rigid bronchoscope, which elevates the trachea and makes it easy to identify.21 A limited horizontal skin incision is preferred, placed below the cricoid. It is often necessary to divide the thyroid isthmus. The cartilaginous rings of the juvenile trachea are so tiny and soft that it seems preferable to divide vertically the third and fourth rings rather than the second and third as in the adult. It is important to avoid subglottic laryngeal injury. No tracheal wall is excised. Tracheostomy tubes fashioned specifically for infants and small children, such as those introduced by Aberdeen, are selected, avoiding tubes of too large a diameter (Figure 10-3).22 The curve of such tubes is unlikely to produce anterior granuloma or erosion from the tube tip. A degree of flexibility allows the tube to adapt to the curve of the airway. Modern humidification techniques permit the elimination of the inner cannula. The tube flanges slope upward so that the tapes do not tend to pull out the tube. The tubes are designed to accept a tracheostomy connector proximally, regardless of their basic internal diameter.

With such precautions and with use of tubes especially designed for pediatric use, decannulation problems are reduced. The underlying lesion or a complication of the tracheostomy is probably the most common cause for difficulty in decannulation. Gradual progression to smaller tracheostomy tubes to smoothen the process of decannulation is sometimes advisable.

The soft, thin wall of the infant trachea is easily deformed by a tracheostomy tube. In a number of children who have had tracheostomy tubes in place for some time, the anterior wall of the trachea just superior to the stoma becomes depressed by tube pressure. This deformity, together with thickening of the lower margin of the depressed flap, may cause obstruction on decannulation. Insertion of a small sized Montgomery Silastic T tube, with or without minimal excision of the tip of thickened scar at the lower end of the flap, restores the lumen. The tube is left in place for 3 months or more to allow the flap to become fixed in this more normal position. The T tube is then withdrawn and the child observed carefully for airway obstruction. A further period of splinting may be necessary. Residual cartilaginous structure must be

Laryngeal Hemangioma

figure 10-3 Pediatric tracheostomy tube. Pictured is a size 4 (ID 5.5 mm, OD 8 mm, length 4.6 cm) silicone tube (Shiley, Mallinckrodt Inc., St. Louis, MO). The curve of the tube and arrangement of the flanges are adapted for infants and small children, following the Great Ormond St. design. Note the standard size of the proximal adaptor end.

figure 10-3 Pediatric tracheostomy tube. Pictured is a size 4 (ID 5.5 mm, OD 8 mm, length 4.6 cm) silicone tube (Shiley, Mallinckrodt Inc., St. Louis, MO). The curve of the tube and arrangement of the flanges are adapted for infants and small children, following the Great Ormond St. design. Note the standard size of the proximal adaptor end.

present in the depressed flap to obtain permanent correction in this way. If the tracheal wall has been extensively replaced by scar, a stenosis will follow, requiring resection. It must be cautioned that T tubes are sometimes poorly tolerated in small children, probably because of the tiny diameters of their tracheae.3

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