Pediatric Tracheotomy and Decannulation

Introduction and History

Tracheotomy was first credited to Asclepiades, c.100 BCE, in an ultimately unsuccessful attempt at saving a life. Paul d’Egine reported the first successful tracheotomy more than a century and a half later. The procedure was extended to treat severe respiratory infections by Armand Trousseau in the 1800s, and Chevalier Jackson eventually formalized and popularized the surgery in the 1900s. Almost 5000 tracheotomies are performed annually on children in the United States. Because of advances in pediatric critical care and a reduction in infectious sources of airway obstruction, the incidence of pediatric tracheotomy has recently declined. Notably, although little has changed over the last few decades in terms of surgical technique or tracheotomy hardware, the indications for tracheotomy in children have significantly shifted. Because of the increasing survival of children with long-term respiratory needs, there has been a trend toward longer-lasting tracheotomies, which necessitate prolonged care by pediatric otolaryngology and other disciplines. This chapter reviews the entire course of care for pediatric tracheotomy from successful presurgical selection to eventual decannulation.

Indications

The declining rate of pediatric tracheotomy ^, is at least partly caused by technologic and medical advances. Vaccination programs targeting Haemophilus influenzae have reduced the incidence of epiglottitis and consequently the frequency of emergent tracheotomy for infectious airway compromise. The ubiquity of flexible and rigid fiberoptic laryngoscopes has allowed for less invasive intubation, obviating the need for tracheotomy to secure difficult airways. Consequently even less experienced centers may be able to manage patients with craniofacial anomalies such as micrognathia and Pierre Robin sequence without a surgical airway. Additionally, the widespread use of low-pressure cuffed endotracheal tubes (ETTs), which allow for longer periods of intubation in premature infants, has reduced rates of subglottic stenosis. Yet the indications for tracheotomy have remained largely unchanged ( Box 32.1 ).

The goal of tracheotomy is to allow safe respiration or ventilation while bypassing the glottis. Indications include the need for prolonged ventilation, laryngotracheal or upper airway obstruction, pulmonary toilet and suctioning, and facilitating ventilator weaning in patients who are unable to tolerate extubation. As infectious and craniofacial indications have become less common, a greater proportion of tracheotomies are performed for prolonged ventilation and congenital disorders. Previously fatal neurologic and neuromuscular conditions can now be meaningfully palliated or treated. Many patients with chromosomal anomalies that were previously considered fatal can live well into adulthood if early airway obstruction is alleviated. A 1999 study demonstrated that 34% of children who underwent tracheotomy had otherwise normal airways, and according to the author’s experience, this proportion may actually be higher at some centers. Children with chronic conditions may be given the option of a tracheotomy, whereas in the past they would have been offered only end-of-life care to ease a quick demise. Improved survival and quality of life (QOL) for chronic conditions will only increase the need for tracheotomy over time and its prolonged management in children.