© Borgis - New Medicine 2/2002, s. 49-52
Lidia Zawadzka-Głos, Mieczysław Chmielik
Tracheotomy in children – indications and complications
Department of Paediatric Otorhinolaryngology, The Medical University of Warsaw, Poland
Head: Prof. Mieczysław Chmielik M.D.
Tracheostomy is a life-saving procedure when performed with an appropriate indication and surgical technique. There is a limited indication for tracheostomy procedures in paediatric surgery. It is rarely applied to the paediatric patient because they can be kept intubated for a longer period compared to adults. Indications for tracheostomy are prolonged intubation, subglotic stenosis, general body trauma, tracheomalasia, cervical tumour pressing the trachea and larynx, congenital diseases of the larynx, burn injuries of the trachea, and foreign body aspiration. In the last decade the number of cases with tracheotomy increased due to the development of new intensive care units, the use of mechanical ventilation, and the increasing number of patients needing prolonged ventilation support. Tracheotomy in children has been associated with significant operative and post-operative complications. When long-term tracheotomy is needed, parent education, together with special equipment and environment may allow the return of the tracheotomised child to home in secure conditions.
Tracheotomy is a medical procedure that has been known for centuries. This type of operation was probably performed in ancient Egypt (3600 B.C.) and Babylon (1000 B.C.). However, it was Asklepiades (128-56 B.C.) who described a manoeuvre close to tracheotomy in the first century B.C. and is considered to be the father of this procedure. The first tracheotomy in a child was performed in 1856 by Eugene Bonchut. For centuries different methods of tracheotomy have been developed, the surgical equipment has improved and new models of tracheotomy tubes have been sought (4, 15, 19, 22).
Originally tracheotomy was an urgent life-saving procedure. Nowadays intubation eliminates in most cases the necessity of tracheotomy in urgent cases. It is widely known that complications from emergency tracheotomy, though performed by an experienced doctor, occur more frequently than when they are performed as planned procedures. Planned tracheotomy, if possible, should be preceded by evaluation of the respiratory tract (laryngotracheoscopy, bronchoscopy) and by evaluation of the cervical anatomical structures (vascular ring, thyroid and thymus location, degree of spinal curvature) (1, 6, 20, 21).
Contemporary indications for tracheotomy include the group of diseases connected with upper airways patency impairment, general diseases affecting the patency of lower airways and in patients requiring prolonged mechanical ventilation.
I. Upper airways patency impairment.
1.Congenital malformations of larynx and trachea (congenital infraglottic laryngeal constriction, laryngomalacia, laryngeal fins, laryngeal cysts, congenital vocal fold paralysis).
2.Congenital facial skeleton anomalies including micrognathia and microglossia.
3.Mechanical, thermal, chemical, and iatrogenic trauma of larynx and trachea (laryngeal or tracheal fracture, foreign body wedging or obturating laryngeal lumen, thermal or corrosive burns, prolonged or traumatic intubation).
4.Maxillofacial trauma with severe oedema of soft tissues and falling back of the tongue.
5.Acute laryngeal oedema precluding intubation (inflammatory or allergic).
6.Tumours of the larynx or trachea (haemangioma, neoplasmatic tumours).
7.Bilateral vocal fold paralysis.
8.Laryngeal and tracheal compression by adjacent structures (vascular anomalies, cervical tumours).
II. Respiratory tract patency impairment due to general diseases.
1.Retention of secretion in lower airways (balance impairment between secretion and elimination).
2.The lack of cough reflex
3.Impaired function of oesophageal constrictors and/or vocal folds (saliva or gastric and oesophageal contents penetrating the bronchial tree).
III. Patients requiring chronic mechanical ventilation
4.Chronic diseases of pulmonary tissue.
There are no direct contra-indications for tracheotomy. Severe bleeding tendency is a relative contra-indication.
Tracheotomy in a young child requires particularly precise execution and due consideration of indications. The size of upper airway anatomical structures in a young child, elasticity and mobility of larynx and trachea, adjacent large cervical vessels, high situation of the pleural cupula and large vascular trunks (arterial and venous brachiocephalic trunk) and a highly situated mediastinum increase the risk of complications. The larynx in new-borns and young children differs considerably from the larynx of an adult. Knowing the topographic anatomy of a young child´s larynx is essential for carrying out a safe tracheotomy. The diameter of the respiratory tract in children is significantly less than that of adults. The dimensions of larynx and trachea aree given in table 1. Knowing these dimensions allows an appropriate selection of the tracheotomy tube, thus decreasing the number of late complications.
Table 1. The trachea dimensions (according to S. Engel: Die Lunge des Kindes; Thieme, Stuttgart).
|Age||Length (cm)||Sagittal cross-section (mm)||Coronal cross-section (mm)|
The larynx in new-borns is situated higher than in adults. The epiglottis lies at cervical vertebra C1 height, and the cricoid cartilage at C4 height. During a child´s development the larynx descends to reach C6 for cricoid cartilage in the 13th year of age. The hyoid bone in new-borns adjoins the thyroid cartilage and covers its upper limit. The cricoid cartilage is closely connected with the thyroid cartilage lower limit, the cricothyroid membrane is short and difficult to evaluate in palpation, unlike adults in whom it is much easier to perform conicotomy. The laryngeal and tracheal chondral skeleton of a young child is soft and easily moved in the coronal plane. This can be the reason for localising the trachea during the tracheotomy (14, 15).
Elevated large vascular trunks (arterial and venous brachiocephalic trunk) or vascular anomalies may result in severe intraoperative complications. Therefore, if the state of the patient allows, tracheotomy is a planned procedure to eliminate the possibility of vascular ring or other anomalies (2-3, 5, 14).
An additional difficulty when performing tracheotomy in a young child is the short neck and well-developed adiposus layer (14, 18).
In the Warsaw Clinic of Paediatric Otolaryngology classic tracheotomy is executed through a transverse incision of the skin over the zygomatic incisure of the sternum. While performing tracheotomy it is important to remember to divide the tissues in the median line when exposing the anterior wall of the trachea. This area is safe and quite distant from large cervical vessels. At present the terms of "upper” and "lower” tracheotomy do not exist in children. Incision of the trachea should be carried out longitudinally through 3rd-4th cartilage. Tracheotomy is not to be executed through the cricoid or first tracheal cartilage because this makes it impossible to remove the tracheotomy tube (decannulation) due to secondary constriction of the larynx and trachea. An appropriate selection of the tracheotomy tube size regarding the trachea size is important to decrease the risk of late complications, such as tracheo-oesophageal fistula, malacia of the tracheal anterior wall, the process of granulation tissue growth, and decubitus ulcer in the trachea.
Apart from classical tracheotomy (SDT) methods of transcutaneous tracheotomy (PDT) have developed. Indications to perform transcutaneous tracheotomy using alternatives to standard surgical methods are similar, though they are mainly performed in intensive care units. There are no particular contra-indications to the execution of transcutaneous tracheotomy. However, performing classical tracheotomy is always important in life-saving conditions. Moreover the uncertain topographic anatomy of the surroundings inclines towards the classical method (9-11, 15).
There are many different techniques of transcutaneous tracheotomy applied presently, such as: Ciagliae, Griggs, Schachner or Fantoni techniques. Only Fantoni techniques can be applied in children under 12 years of age, while the rest are reserved for adults. Transcutaneous tracheotomy is a one or multistage technique of pretracheal tissue division. A constant element of the procedure, independent of the method applied, is locating the leader in the tracheal lumen through tracheopunction. The number and quality of complications are similar to the complications of classical tracheotomy (15).
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