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Monday, 21 September 2020

Paediatric Tracheostromy

ENT

History

Started in the nineteenth century initially developed by Trousseau to relieve airway obstruction in children with diphtheria. Then until the 1970s used to relieve upper airway obstruction in acute airway infections like epiglottitis and acute laryngotracheal bronchitis.

Indications

The first indication is to relieve upper airway obstruction. Obstruction can occur at different levels. At the oropharynx and tongue base there can be macroglossia which is enlargement of the tongue, cystic hygroma which is a fluid filled sac due to blockage in the lymphatic system, Treacher Collins syndrome. Nose and nasopharyngeal can have choanal atresia which is blockage at the back of the nose. At the larynx you can get a supraglottic cyst, vocal cord palsy, physical trauma, stenosis which means narrowing or hemangioma which is a non cancerous growth of blood vessels. The other indication is to prevent complications of prolonged intubation. Stenosis and cicatrization of glottis and sub glottis. 2 -3 weeks of intubation should necessitate it to be done though there is no clear concensus on the timing. The other indication is long term and home ventilation where by there are some conditions which cause this like failure of control of breathing, chest wall dysfunction, disorders of lung parenchyma, large airway disease, central sleep apnoea or thoracic dystrophy. Also to reduce anatomical dead space and allow suction toilet of the trachea.

Technique

The child is put in supine position with the neck extended with sand bag and head ring placed. An incision is made horizontally halfway between the cricoid and sternal notch. This can be done after injecting lignocaine and adrenaline on the incision site. Then you go through superficial fascia, platysma, deep cervical fascia, strap muscles before reaching the thyroid isthmus and pretracheal fascia then the trachea. A vertical incision is made on the trachea between rings 3 and 4. Stay sutures are left in situ until after first tracheal tube change mostly after 7 days.

Tracheostomy care - This is done by regular suctioning , humidification via nebulizers, tracheostomy mask or humidifiers and skin care.

Things to look for in a tracheostomy tube are diameter which should be age appropriate and usually range from 3mm to 6mm and length should sit comfortably proximal to the carina – ideally should be at least 2cm inside stoma and 1-2cm clear of the carina. Material most commonly used is silicone which is relatively flexible and reduces risk of mucosal trauma. It can have a speaking valve mostly a one way valve. Fenestration is not encouraged due to formation of granulation tissue and downsizing is the appropriate form. Cuffed tubes are also generally not used unless in certain specific cases.

Complications can be general, early post operative which is within seven days and late post operative which is after one week. General can be tube obstruction, accidental decannulation, general complications of surgery or anaesthesia or death. Early post operative include bleeding, pneumothorax which is air inside the lungs, subcutaneous emphysema which is air within the tissues, infections and apnoea which is cessation of breathing for more than 10 seconds. Late post operative complications include granulation, bleeding, suprastomal collapse, skin complications, aphonia and speech delay, psychological factors and adverse effects on family.

When it comes to removal of the tracheostomy tube, it is downsized, blocked for 12 hrs from 8 am, if successful continue overnight for a further 12 hrs, decannulate and occlude stoma with adhesive tape and dressing, observe further in the ward before discharge. If the child will be required to be discharged with the tracheostomy tube then  certain requirements are needed. Generally two responsible adults, a home with adequate space, heating, electricity, telephone, access to transport and support from a health worker.

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Posted
one year ago
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