Pediatric Tracheostomy

The following video demonstrates the authors’ method for performing a tracheostomy in a pediatric patient. Details of important anatomical landmarks and surgical technique are demonstrated in the video.

Chrystal Lau, BA. University of Arkansas for Medical Sciences.
Brad Stone, BA. University of Arkansas for Medical Sciences.
Austin DeHart, MD. Arkansas Children’s Hospital.
Michael Kubala, MD. University of Arkansas for Medical Sciences.
Gresham Richter, MD. Arkansas Children’s Hospital.

Tracheostomy performed in a 4-month-old infant with severe obstructive sleep apnea requiring chronic oxygen supplementation.
Tracheostomy is becoming an increasingly performed surgical procedure in pediatric populations. Once an emergency procedure primarily indicated for acute airway obstruction secondary to infectious etiologies, tracheostomy is now more commonly seen in children requiring prolonged ventilator support due to cardiopulmonary or neurological impairment. Other indications for tracheostomy include congenital upper airway obstruction, failure to wean from conventional ventilation, and pulmonary toilet. These patients are most often very premature patients less than one year of age, with this demographic likely reflecting today’s increasing survival rates of preterm infants and those undergoing cardiac repair.
Relative contraindications to elective tracheostomy include: uncorrectable coagulopathy, anatomic distortions (aberrant vasculature, scarring from previous neck surgery, tumor, etc), the inability to extend the cervical neck, and active local inflammation or infection.
An appropriately sized tracheostomy tube should be selected and checked prior to the procedure. If a cuffless tube is being utilized, the cuff should be evaluated for leaks. Shoulder roll and head ring will be used to extend the patient's neck and stabilize the head. Standard prep and sterile drape should be used.
Careful preoperative evaluation of the patient is necessary to assure that no other intervention can be undertaken that may avoid a tracheostomy procedure: microlaryngoscopy and bronchoscopy, chest x-ray, blood tests, cardiology review if suspicious for cardiac pathology.
Although the basic tracheostomy technique is similar between adult and pediatric patients, infants have shorter necks with more fatty tissue. This can make the cricoid and thyroid cartilages more difficult to palpate. The infant larynx is approximately 1/3 the adult size, is more pliable, and is situated more superiorly and anteriorly in the neck.
In pediatric patients, tracheostomy tubes are secured to the neck with cotton twill ties instead of being sutured to skin. This is because skin in pediatric patients is very lax and can result in accidental decannulation going unnoticed.
Bleeding/hemorrhage, pneumothorax, pneumomediastinum, accidental decannulation, tracheoinnominate fistula, granuloma formation, subglottic stenosis, and skin breakdown.
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