70. Tracheotomy


1. High airway obstruction


Congenital


Craniofacial dimorphism


Paralysis of the vocal chords


Subglottic hemangioma


Subglottic membrane


Upper subglottic or tracheal stenosis


Pharyngeal collapse


Severe laryngomalacia


Acquired


Secondary subglottic stenosis


Severe obstructive sleep apneas


Papillomatosis


Burn injuries


Tumors


2. Prolonged need of MV


Congenital


Neuromuscular disorders


Central hypoventilation


Diaphragmatic hernia


Severe bronchopulmonary dysplasia


Acquired


Traumatic chest injuries


CNS tumors


Severe chronic lungs damage


Severe scoliosis


3. Lung hygiene




The decision to perform a tracheotomy will depend on the degree of obstruction, possibility of spontaneous resolution within a reasonable amount of time, and the possibility of definitive corrective surgery. Currently, the main indications for tracheotomy in cases of airway obstruction are those that allow elective intervention, such as subglottic stenosis secondary to prolonged intubation during the neonatal stage, bilateral vocal cord paralysis, and injury to the high airway, such as burns and fractures, generally requiring temporary tracheotomy. Subglottic stenosis is one of the main indications for tracheotomy in children. Mature newborns have a lumen of at least 4 mm; a smaller lumen is considered stenosis. In older children, the reduction of subglottic caliber is determined by age and graded by percentage following the Myer–Cotton system (Table 70.2).


Table 70.2

Classification of degree of subglottic obstruction




























 

From


To


I degree


../images/441522_1_En_70_Chapter/441522_1_En_70_Figa_HTML.gif


No obstruction


../images/441522_1_En_70_Chapter/441522_1_En_70_Figb_HTML.gif


50% of lumen obstruction


II degree


../images/441522_1_En_70_Chapter/441522_1_En_70_Figc_HTML.gif


51% of lumen obstruction


../images/441522_1_En_70_Chapter/441522_1_En_70_Figd_HTML.gif


70% of lumen obstruction


III degree


../images/441522_1_En_70_Chapter/441522_1_En_70_Fige_HTML.gif


71% of lumen obstruction


../images/441522_1_En_70_Chapter/441522_1_En_70_Figf_HTML.gif


99% of lumen obstruction


IV degree


No detectable lumen

 

Most instances of stenosis in children happen as a result of endotracheal intubation, because the sub glottis, contained by the cricoid cartilage —a full ring that cannot dilate nor accommodate— becomes swollen at the epithelium by the mechanical injury of the tube, reducing the caliber of the airway. When these scars narrow, the result is subglottic stenosis. Grade IV stenosis by Myer–Cotton’s system has an absolute indication of tracheotomy, but for grade II and III stenosis it will depend on the degree of respiratory compromise.


For patients with respiratory failure caused by severe lung disease or by neuromuscular, neurological, or heart diseases, who also depend on mechanical ventilation for over 12 hours a day, tracheotomy is considered. In the case of acute respiratory failure requiring mechanical ventilation for over 21 days, tracheotomy may also be considered. The benefit of prolonged mechanical ventilation through tracheotomy lies in the reduction of laryngeal damage, improving the level of comfort for the patient, and improving their daily activities like mobility, speech, and oral feeding.


Tube Selection


Once the tracheotomy has been performed, it is necessary to insert a tube in order to keep the airway open and permeable. This tube is the tracheotomy cannula. There are different kinds of tubes designed to adjust to the appropriate needs of each patient.




By material:



  • Metal (stainless steel, silver): rigid tubes



  • PVC (polyvinyl chloride): may be rigid or flexible



  • Polyurethane



  • Silicone: these tubes are preferred for their flexibility, as they adapt to the size and shape of the patient’s trachea



By structure:



  • Simple or double tube



  • With cuff or balloon: there is an inflatable device on the distal end of the tube. These tubes may be: high volume/low pressure, low volume/high pressure, and foam balloon. High volume/low pressure is the preferred option given their lower injury risk to the airway. Indications for using balloon are given mainly to lower the risk of aspiration, need of mechanical ventilation at high pressure, night ventilation, and for patients with chronic aspiration.



  • Fenestrations: they improve trans-laryngeal flux and phonation, while also improving the handling of discharges. However, different studies have shown that these promote the emergence of granulomas on the fenestration area, so the use of the technique has been limited.



  • Internal cannula: these tubes are indicated for patients with abundant thick discharges that stick to the walls of the tube. In this way, it is only necessary to remove the internal cannula during the cleaning procedure, thus avoiding frequent tracheotomy tube switching.


It is of the utmost importance to choose the precise cannula for each patient. The tracheotomy tube must be of the right size for the airway, with the exact shape and length to keep the tube secured to the airway without pressing the structures lying next to the trachea or the neck (Table 70.3). When choosing, the following parameters must be considered:



  • Age: patients under 1 year must use cannulas that are specially designed for newborns.



  • Reason for tracheotomy: in case of upper airway obstruction or if prolonged mechanical ventilation is needed.



  • Diameter and curvature of the tube: the size of tracheotomy tubes is based on internal diameter, much like the selection of endotracheal tubes. When choosing the right diameter, many factors must be considered, including lung mechanics, upper airway resistance, need for ventilation/union, and procedure indications. The diameter must be wide enough to avoid damage to the wall of the trachea, minimize respiratory work, and promote laryngeal airflow. It should not exceed two thirds of the diameter of the trachea, thus avoiding damage to the wall of the trachea and allowing trans-laryngeal flow. Its curvature must be such that the distal portion of the cannula becomes aligned and concentric toward the trachea. It is recommended to confirm both position and adequate size of the cannula the first time it is placed in the larynx through a neck X-ray or a fibrobronchoscopy.



  • Length of the cannula: the length of the cannula must be at least 2 cm beyond the stoma and remain 1–2 cm over the carina.




Table 70.3

Characteristic of tracheotomy cannulas







































































































































































































































 

Age


PT-1 m


1–6 m


6–18 m


18 m -3a


3–6 a


6–9 a


9–12 a


12–14 a


Trachea


Diameter (mm)


5


5–6


6–7


7–8


8–9


9–10


10–13


13


Shiley


Size


3.0


3.5


4.0


4.5


5.0


5.5


6.0


6.5


ID (mm)


3.0


3.5


4.0


4.5


5.0


5.5


6.0


6.5


ED (mm)


4.5


5.2


5.9


6.5


7.1


7.7


8.3


9.0


Length NB (mm)


30


32


34


36






Length PED (mm)


39


40


41


42


44∗


46∗




Length PDL (mm)






50∗


52∗


54∗


56∗


Portex


Size


2.5


3.0


3.5


4.0


4.5


5.0


5.5



ID (mm)


2.5


3.0


3.5


4.0


4.5


5.0


5.5



ED (mm)


4.5


5.2


5.8


6.5


7.1


7.7


8.3



Length NB (mm)


30


32


34


36






Length PED (mm)


30


36


40


44


48


50


52



Tracoe


Size


2.5–3.0


3.5


4.0


4.5


5.5


5.5


6.0



ID (mm)


2.5–3.0


3.5


4.0


4.5


5.5


5.5


6.0



ED (mm)


3.6–4.3


5.0


5.6


6.3


7.0


7.6


8.4



Length NB (mm)


30 32


34


36







Length PED (mm)


32 36


40


44


48


50


55


62



Rüsch


Size



3.0


4.0



5.0



6.0



ID (mm)



3.0


4.0



5.0



6.0



ED (mm)



4.8


6.0



7.0



8.2




m months, y years, ID internal diameter, ED external diameter, NB newborn, PED pediatric, PDL pediatric long


*with balloon

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Nov 7, 2020 | Posted by in Uncategorized | Comments Off on 70. Tracheotomy
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