Perioperative management of a child with a tracheostomy

Learning objectives.

By reading this article, you should be able to:

• •List the common indications for tracheostomy insertion in children.
• •Describe the different types of tracheostomy tubes used commonly in children.
• •Outline the perioperative management of children presenting for tracheostomy insertion and of children with an existing tracheostomy.
• •Safely manage emergencies related to tracheostomy in children.

Key points.

• •Most tracheostomies in paediatrics are performed in children with complex care needs to facilitate long-term ventilation, and manage upper airway obstruction or bronchopulmonary secretions.
• •A high proportion of children requiring a tracheostomy have a difficult airway. In some patients, tracheal intubation is impossible.
• •Tracheostomy in children is primarily an open surgical procedure.
• •The most commonly used paediatric tracheostomy tubes are uncuffed and do not contain inner cannulae.
• •Children with a tracheostomy are at high risk of adverse events most potentially preventable. They should be cared for by a multidisciplinary team trained in the routine and emergency management of paediatric tracheostomies.

There are key differences in the routine and emergency care of children with a tracheostomy in comparison to adults. In the past decade, there have been significant changes in the management of tracheostomies in paediatrics, including structured guidelines from the UK Paediatric Working Group of the National Tracheostomy Safety Project (NTSP).¹ This article provides an up-to-date review of the relevant literature, including the perioperative and emergency management of tracheostomies in paediatrics.

Indications for tracheostomy in children

Tracheostomies are increasingly performed in children with complex chronic conditions. They are most commonly inserted to facilitate long-term respiratory support, aid the clearance of secretions, or treat fixed upper airway obstruction (Table 1).2, 3, 4, 5, 6, 7

Table 1.

Indications for insertion of a tracheostomy in children.

Indication	Examples
Long-term ventilatory support	Chronic lung disease Neurological or neuromuscular disease •Muscular dystrophies •Cerebral palsy Decreased respiratory drive •Congenital hypoventilation syndrome •Brainstem lesions Tracheobronchomalacia
Clearance of bronchopulmonary secretions
Protection of the airway from aspiration	Neuromuscular disorders Bulbar palsy
Airway obstruction	Supraglottic/laryngeal/subglottic stenosis (congenital/acquired) Laryngotracheomalacia Bilateral vocal cord palsy Head/neck/laryngeal masses •Cystic hygroma •Haemangioma •Recurrent respiratory papillomatosis Craniofacial syndromes •Pierre Robin sequence •Treacher Collins syndrome •Beckwith–Wiedemann syndrome
Failed intubation
Trauma	Caustic alkali ingestion Burns Fractures
Surgical	Airway support during head/neck surgery

The indications for tracheostomy in children have changed significantly over the past 50 yrs, reflecting successful vaccination programmes that have dramatically reduced the incidence of acute infections that may compromise the airway (e.g. Haemophilus influenzae causing epiglottitis and Corynebacterium diphtheriae causing diphtheria). In some children with viral infections associated with respiratory muscle weakness, a tracheostomy is required for long-term ventilation. Advances in the management of critically ill children together with improved airway management techniques and equipment (e.g. videolaryngoscopes) have resulted in a reduction in the number of emergency tracheostomies being performed in children.8, 9, 10, 11, 12

Approximately one third of tracheostomies are performed in children under 1 yr of age and two thirds in children under 4 yrs of age.^2,13,14 Rarely, causes of airway obstruction diagnosed before birth, such as an obstructive neck mass (e.g. cervical teratoma, vascular lymphatic malformation, cystic hygroma, and neuroblastoma), congenital high airway obstruction syndrome, micrognathia, and obstructive chest masses, are managed with a tracheostomy performed as an ex utero intrapartum treatment (EXIT) procedure.^2,15

During an EXIT procedure, the baby's head and torso are delivered via an extended Caesarean section. The airway is secured in a controlled manner, whilst the uteroplacental gas exchange is maintained before the umbilical cord is cut.

Considerations

Up to a quarter of children requiring a tracheostomy have a difficult airway, and in a similar proportion tracheal intubation is impossible.¹⁶ In contrast to adult practice, just over 2% of children in the ICU have a tracheostomy.¹⁷ The reasons for this low rate include both technical and psychosocial challenges associated with paediatric tracheostomies. There is a lack of consensus about the length of time a child's trachea should remain intubated before a tracheostomy is performed. Moreover, children tolerate tracheal intubation (particularly with a nasal tube) for longer periods than adults, and the trachea of some preterm infants remains intubated for months before a tracheostomy is considered.⁸

Tracheostomies in children may be temporary or permanent. Decannulation rates are higher in children with airway obstruction compared to children requiring prolonged ventilation, and have decreased as the indications for tracheostomy have evolved.⁴ Children are more likely than adults to require permanent tracheostomy.¹ Temporary paediatric tracheostomies commonly remain in situ for an average of 1–2 yrs.^4,13,18 To achieve successful decannulation, children may need to grow (e.g. children with tracheomalacia or Pierre Robin sequence) or undergo staged reconstructive/corrective surgery (e.g. laryngotracheal reconstruction for subglottic stenosis or excision of cystic hygroma).

A child's suitability for decannulation is determined on an individual case-by-case basis. In the first instance, the indication for a tracheostomy must have been successfully treated, and there should be no planned, upcoming procedures that require airway support. The ideal staged decannulation protocol should include a reduction in the tracheostomy tube (TT) size, endoscopic evaluation of the airway, a trial of daytime capping of the TT at home, a capped sleep study, and admission for decannulation and observation for 24–48 h. In the majority of children, the tracheostoma will heal spontaneously. However, some will require surgical closure for persistent tracheocutaneous fistula several months after decannulation.

Paediatric TTs

The first paediatric TTs were made from sterling silver and stainless steel. They caused minimal stoma tissue reaction, but they did not conform to the airway well, causing irritation and bleeding of the tracheal mucosa.⁸ Since the mid-1960s, they have been replaced by TTs made of synthetic materials (silicone and polyvinyl chloride) that offer improved flexibility and comfort. Paediatric TTs are designed with variable lengths and are classified by their internal diameter. For the same internal diameter, neonatal TTs are shorter than the paediatric equivalents. Most TTs have 15 mm connectors. Each TT is provided with an obturator to facilitate insertion, twill ties to secure it, and a 15 mm wedge to aid disconnection.

The narrow calibre of the paediatric airway creates a higher resistance to airflow. Therefore, to allow for the maximum internal diameter, most paediatric TTs do not have an inner tube or cannula. The majority are also uncuffed to prevent damage to the tracheal mucosa. Cuffed TTs are used for positive-pressure ventilation and to protect the lower airways from aspiration or secretions. Cuffs can be filled with air, water, or foam depending on the tube design (blue, clear, and red inflation ports, respectively). Tracheostomies with inner tubes/cannulas are available for older children.

The different types of paediatric TTs in common use are shown in Table 2.

Table 2.

Commonly used paediatric TTs.

TT	Special features/advantages	Disadvantages/cautions
Cuffed or uncuffed
Bivona Smiths Medical	Reinforced with a ferromagnetic coil; flexible and kink resistant Commonly used because of its comfort and versatility Paediatric (standard length); neonatal (shorter length) Three different flange shapes to suit a variety of neck shapes and ages Latex free and hydrophobic, hindering protein adhesion; limited secretion build-up and bacterial colonisation Monthly tube change needed Reusable (five times)	Not compatible with MRI
Bivona FlexTend	Beneficial for children requiring ventilation or with neck masses Fixed kink-resistant flange	Not compatible with MRI
Bivona Hyperflex	Designed and customised based on the required style and dimensions Useful to bypass distal anomalies or to fit an abnormally short trachea Adjustable flange permitting the alteration of the tube length	Not compatible with MRI Temporary tube Unsafe external holding clip; can easily be opened by children
Shiley, Medtronic	Neonatal (shorter length); paediatric (standard length); long paediatric length available for 5.0–6.5 sizes Latex-free polyvinyl chloride: increased rigidity and easier to insert in an emergency MRI compatible	Weekly tube change Single use Increased rigidity; less comfort
Cuffed
Bivona TTS (tight to shaft)	Useful when weaning children from ventilator Cuff can be deflated completely to assume the profile of an uncuffed tube High-pressure low-volume cuff requires filling with the minimal volume of sterile water to achieve effective ventilation	Not compatible with MRI Not first-line tube for ventilator support Risk of tracheal necrosis if cuff is overfilled Requires regular deflations
Bivona Fome	Self-inflating tube, high level of protection from aspiration with optimal comfort Auto-expanding foam in cuff fills and conforms to the unique contours of the trachea	Not compatible with MRI Insertion and removal very different from other tubes; requires a three-way tap (seek advice)
Bivona Aire	Air-inflated cuff that provides useful protection against aspiration and optimisation of ventilation	Not compatible with MRI Requires 4 hourly pressure checks with manometer
Uncuffed
Montgomery T-Tube, Boston Medical Products	Soft silicone tube that is shaped like a ‘T’ Stents the upper airway after laryngotracheal reconstructive surgery Changed under general anaesthesia	Requires adaptor for resuscitation and artificial ventilation
Silver Tubes	Very thin walls; can be used with inner tubes without compromising airflow Minimal stoma inflammation Monthly tube change Reusable	Rigid; uncomfortable High initial outlay cost Require adaptors for resuscitation and artificial ventilation Not compatible with MRI May distort CT images

Tracheostomy accessories

Speaking valves

These plastic attachments are one-way valves that sit on the end of the TT. The valve opens as the child breathes in and closes as the child breathes out, directing air up through the larynx and out of their mouth, allowing phonation or the creation of other sounds for communication. Not all children will tolerate a speaking valve, as a sufficient air leak around and above the tube is required. The speaking valve must not be used whilst the child is asleep or when using a cuffed TT because of the risk of increased airway resistance and work of breathing.

Tracheostomy humidification devices

Maintenance of the humidity and warmth of inspired air is an essential part of tracheostomy management, as the normal functions of the upper respiratory tract have been bypassed. The commonly used humidification methods include heat and moisture exchangers, saline nebulisers, and continuous humidification via a water humidifier.

Perioperative management of the child for insertion of tracheostomy

Tracheostomy in children is primarily an open surgical procedure because of the increased technical difficulty and higher risk of perioperative complications compared with adults.^2,4,11,14,18, 19, 20 Surgical access is limited, particularly in infants, by a shorter neck and a large head. The trachea in children, especially in infants and neonates, is small and pliable with a tendency to collapse, and the airway mucosa is more prone to oedema. Other technical considerations include the extension of the pleura into the neck. Percutaneous and hybrid techniques are described, but they are generally only considered to be feasible in older children.^1,8 Awake tracheostomy under local anaesthesia is rarely performed in children.

The majority of tracheostomies in paediatrics are performed on an elective or semi-elective basis.3, 4, 5, 6, 7^,14,21 Emergency tracheostomies are mostly performed in children who have a difficult airway caused by craniofacial abnormalities or acute airway obstruction, and they require urgent ventilatory support.¹⁶

Preoperative assessment should include a detailed history and examination, with particular attention to previous airway management, evaluation of associated conditions, and a thorough assessment of the airway. Appropriate airway and tracheostomy equipment should be available, and the airway management plan(s) should be discussed with the entire perioperative team, including the nursing staff providing support to both the anaesthesia and surgical teams. In patients with severe airway compromise, the ear, nose, and throat (ENT) surgeon should be present at induction of anaesthesia ready to rescue the airway via rigid bronchoscopy or emergency tracheostomy. The anaesthetic and airway management techniques will depend on the predicted difficulty of the airway and urgency of the procedure. A detailed description is outside the remit of this article and is described elsewhere.²²

The child is positioned supine in the operating table with a roll placed under the shoulders and the neck extended to expose the trachea. In infants and smaller children, the chin may also be pulled up and secured with adhesive tape to the head of the operating table. Clear surgical drapes allow visualisation of the child during surgery, and facilitate upper airway manipulation and withdrawal of the tracheal tube by the anaesthetist before TT insertion by the surgeon. TT and connectors are checked, and the length that the TT should be suctioned to is measured and recorded using an appropriately sized tracheal suction catheter (double that of the TT size). The TT should be suctioned no further than 0.5 cm from the distal tip to prevent damage to the tracheal mucosa and granuloma formation.²³

The surgical site is identified and infiltrated with local anaesthetic with adrenaline to aid haemostasis. The skin is then incised to expose the upper trachea. Before the tracheal incision, 100% oxygen is administered. To avoid creating a stenotic segment at the site of the tracheostomy, cartilage windows are ideally avoided in children. Two ‘stay sutures’ are placed around the tracheal rings on either side of the planned tracheal incision to expose and anchor the trachea. A vertical tracheotomy incision is made in the third and fourth tracheal rings. Absorbable ‘maturation sutures’ are placed between the anterior tracheal wall and the skin to accelerate stoma formation. Once the trachea has been incised, the tracheal tube is withdrawn into the upper trachea, the TT is inserted, and the anaesthetic circuit is reconnected. Ventilation is confirmed by end-tidal carbon dioxide and auscultation. Fibreoptic evaluation can be used to determine the position of the tracheostomy in relation to the carina. At the end of the procedure, the stay sutures are taped to the chest wall and are not removed until the first TT change 1 week later. Traction on the stay sutures opens the tracheal stoma and facilitates TT reinsertion in the event of TT dislodgement.

A chest X-ray is taken immediately after surgery in the PACU or ICU to confirm correct tube placement and to exclude the possibility of a pneumothorax. Humidified air/oxygen is given via a tracheostomy mask, combined with regular sterile suctioning to prevent crusting and blockage.

A tracheostomy stoma is mature when the tract has epithelialised and the open edges of the tracheal wall have secured to the subcutaneous tissues.²⁴ In children, this occurs between days 3 and 7 after surgery.^10,25,26 TT changes before full maturation of the stoma risk the creation of a false passage. It is recommended that the first tracheostomy change should be performed by an ENT surgeon or other professional trained in early changes of the TT.

Postoperative care should take place in a location where the ward staff are trained and are familiar with the management of children with a new tracheostomy. In most institutions, high-risk patients will go to the ICU until after their first TT change. Risk stratification tools are used in some centres to estimate the risk of perioperative airway compromise, which will be influenced by the neck and upper airway access. Following NTSP guidance, all children with a tracheostomy should be provided with:¹

• (i)A paediatric emergency tracheostomy box containing spare TT (same size), half-size smaller TT, round-ended scissors, spare tapes and dressing, KY jelly, syringe and saline, and a suction catheter should accompany the child at all times from the time he/she leaves the operating theatre.
• (ii)There should be bedhead signs stating the child's details, tracheostomy internal diameter and distal length, calibre of the suction catheter and length to be inserted, and details of the upper airway patency and ease of management. Initially, a ‘new tracheostomy’ bedhead sign is displayed, and then after the first TT change a ‘tracheostomy’ one. The reverse of these signs details the basic and advanced emergency tracheostomy management responder algorithms (Fig. 1).
• (iii)Upon patient discharge, this paired information becomes the patient's ‘tracheostomy passport’ and remains within the emergency tracheostomy box.

Fig 1.

National Tracheostomy Safety Project emergency paediatric tracheostomy management algorithm.¹ The Paediatric NTSP National Working Party was formed in 2013 comprising a multidisciplinary team of paediatric ENT surgeons, PICU consultants, paediatric anaesthetists, and specialist paediatric tracheostomy care nurses from paediatric hospitals across the UK and Ireland to develop guidelines for the management of paediatric tracheostomy emergencies. The guidelines comprise the emergency algorithm and a paired bedhead sign, and are directed at all multidisciplinary staff, parents, and carers. The focus of the guidelines is the management of post-placement incidents and potentially life-threatening complications.

Complications

Children with a tracheostomy have a higher risk of serious morbidity and mortality, which is mostly related to their chronic underlying diseases rather than the tracheostomy. The incidence of tracheostomy-related complications in children has been reported between 10% and 58% with a severity ranging from mild to life threatening.^8,19,27 The most common tracheostomy-related cause of death is TT obstruction, followed by TT misplacement and accidental decannulation. Complications can happen during the immediately perioperative period, later during the inpatient stay, or after discharge to the community (Table 3). They occur more frequently during emergency tracheostomy insertion, and in the severely ill and younger children. The majority of the tracheostomy-related events are potentially preventable. Early recognition and adequate management are essential to prevent serious harm.

Table 3.

Complications of tracheostomy in paediatrics.²²

Time	Complications
Immediate (first few hours)	Loss of airway
	Bleeding
	Pneumothorax
	Pneumomediastinum
	Surgical emphysema
	Oesophageal injury
	Recurrent laryngeal nerve damage
Intermediate (first 10 days)	Tube dislodgement
	Tube obstruction with secretions
	Bleeding
	Infection
Long term	Granuloma (stoma or tube tip from suctioning)
	Vascular erosion
	Suprastomal collapse
	Swallowing problems
	Issues with neck skin integrity
	Tracheal stenosis
	Tracheo-oesophageal fistula (rare)

Perioperative management of the child with an established tracheostomy in situ

Children with a tracheostomy often have complex medical problems and receive input from multiple multidisciplinary teams. Preoperative assessment should focus on the underlying indication for tracheostomy; evaluation of the respiratory system (oxygen requirement, bronchodilators, and recent infectious exacerbations); other relevant comorbidities (cardiac and neuromuscular diseases); and, where applicable, the documentation of previous upper airway management. Specific considerations include the size and type of the TT, suction catheter size and length, last TT change, and any related problems. In patients receiving artificial ventilation at home, the ventilator settings, duration of ventilation, supplemental oxygen, recent changes, and last review by a respiratory specialist should be ascertained.

NTSP signs detailing the patient's and tracheostomy information should be displayed above the patient's bed. The emergency tracheostomy box should accompany the patient at all times, including when in the operating theatre. Its contents should be checked before induction of anaesthesia.

Induction of anaesthesia is commonly performed using an inhalation technique via the tracheostomy. In some children, the TT size is small for the child's age, which causes a considerable leak around it. This will make the inhalation induction slow, and occasionally, it is necessary to revert to using a face mask for induction with the tracheostomy occluded.

Airway management depends on factors specific to the patient, the surgery, and the TT. The main options include (i) leaving the existing TT in situ, (ii) replacing the existing uncuffed TT for a cuffed TT, and (iii) replacing the TT with a cuffed reinforced tracheal tube. The ultimate decision will be based on factors related to anaesthesia (e.g. the need for positive-pressure ventilation), technical factors (e.g. equipment available within the institution), and surgical factors (e.g. considerations regarding exposure of the operating site), and should be agreed in advance by the perioperative team before induction of anaesthesia. At the end of the case, the patient's original TT should be reinserted if appropriate.

The location for postoperative care is determined on an individual basis and should be planned before surgery. Some children are discharged the same day, whereas others may require hospital admission or postoperative ventilation in paediatric ICU (PICU) or high-dependency unit.

Management of tracheostomy emergencies

The Paediatric Working Group of the NTSP has developed multidisciplinary guidelines and an algorithm for the management of paediatric tracheostomy emergencies (Fig. 1).¹ Their recommendations focus on:

• (i)Prioritising oxygenation
• (ii)Summoning expert help early
• (iii)Bedside signs with all the relevant information about the airway and TT
• (iv)Bedside tracheostomy boxes containing essential equipment for each patient
• (v)Regular training of staff and carers in the routine and emergency management of children with tracheostomies.

The initial assessment includes airway opening manoeuvres, high-flow oxygen to both the face and tracheostomy, and a call for help and equipment. Tracheostomy patency should then be assessed using a suction catheter. If unable to pass, the tracheostomy is likely to be blocked or displaced, and it should be removed. Up to three attempts at replacement of the TT are recommended (same-size TT, half-size smaller TT, and half-size smaller TT over a suction catheter). If unsuccessful, the priority should be oxygenation using basic techniques via the upper airway or tracheostoma. If this fails, secondary oxygenation techniques should be attempted.

Conclusions

Tracheostomy in paediatrics is most commonly an elective surgical procedure performed in children with chronic and complex care needs. It remains a cause of significant morbidity and mortality. With the aim of improving safety and reducing complications, the NTSP guidelines offer a standardised multidisciplinary approach for the routine and emergency management of children with a tracheostomy.

Acknowledgments

The authors would like to thank the Paediatric Working Group of the National Tracheostomy Safety Project for their work in developing the guidelines and for granting permission to reproduce their algorithm.

Biographies

Ijeoma Okonkwo BMedSci (Hons) MSc FRCA is a clinical fellow in paediatric anaesthesia at Great Ormond Street Hospital. Her clinical and research interests are the difficult airway in paediatrics and anaesthesia for craniofacial and spinal surgery.

Lesley Cochrane BSc (Hons) MD FRCS is a consultant paediatric ear, nose, and throat surgeon, and is the lead surgeon for the cochlear implant and the cleft lip and palate teams at Great Ormond Street Hospital.

Elena Fernández LMS FRCA is a consultant paediatric anaesthetist at Great Ormond Street Hospital and honorary senior lecturer at University College London Institute of Child Health. She is departmental airway lead and college tutor. Her major clinical and research interests are the paediatric difficult airway, and anaesthesia for ear, nose, and throat, maxillofacial and neurosurgery.

Matrix codes: 1B04, 2A01, 3A01

Declaration of interest

The authors declare that they have no conflicts of interest.

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