About Tracheostomy
A tracheostomy is an artificial opening into the windpipe (trachea) which is held open by a tracheostomy tube. This helps your child to breathe more easily. Air now goes in and out through the tracheostomy tube and bypasses the nose and mouth. The decision to perform a tracheostomy will have been reached as a result of investigations and tests. There are a variety of reasons why a child may need a tracheostomy, ranging from a narrow airway to the need for long term mechanical respiratory support from, for example, a ventilator.
The indications for tracheostomy include:
prolonged intubation during the course of a critical illness subglottic stenosis from prior trauma
obstruction from obesity for sleep apnea
congenital (inherited) abnormality of the larynx or trachea
severe neck or mouth injuries
inhalation of corrosive material smoke or steam
presence of a large foreign body that occludes the airway
paralysis of the muscles that affect swallowing causing a danger of aspiration
long term unconsciousness or coma
Meet the team
There may seem to be a great many people looking after your child while you are in hospital and after you return home. Some people you will meet include:
Tracheostomy nurse specialist: she will probably be your first port of call for any questions you have and will be the main person training you to care for your child’s tracheostomy.
Ward nurses: they will be responsible for your child’s day-to-day care and for teaching you to look after your childs tracheostomy.
Play specialist: who will help you to prepare your child for the operation. He or she will show your child a photo book of children who already have a tracheostomy and maybe a special doll who also has a tracheostomy.
Speech and language therapists: they will work with you in managing your child’s communication development and help if there are any difficulties in swallowing.
Social worker: they are available to see any family who needs support or a listening ear. They can also offer help and advice about benefits and other services, financial help, planning for going home and liaising with your local social services department, and what help might be available to you when your child is discharged.
Remember that all the team are here to help you and will always be on the end of a telephone if you need help and advice. Once you get home, you will have the support of your community team which will include your health visitor or community paediatric nurse and your GP.
Your hospital stay
Your child’s surgeon will explain the operation in detail, discuss any worries you may have, and ask you to sign a consent form. The operation will be carried out under a general anaesthetic.
Your child will stay in hospital for a minimum of two weeks after the operation. This is so that you can learn the necessary skills to care for your child’s tracheostomy at home. This may seem a daunting prospect at this stage but you will be supported throughout your stay. You may be discharged straight home or via your local hospital.
Back from theatre
After the operation, your child will return to the ward with a suitably sized tracheostomy tube, held in place with cotton tapes and temporary stay sutures. Stay sutures are long stitches, brought out through the wound and taped down onto your child’s chest. These sutures keep the hole open if the tube has to be changed early.
After the operation, your child will not be allowed any food or drink (whether by mouth or feeding tube) for a minimum of three hours until the anaesthetic wears off. After this, your child will be allowed to have his or her normal diet. Occasionally some children experience difficulties with their swallowing. This is normally a temporary problem that resolves itself. If it does persist, a speech and language therapist may help in assessing and managing his or her swallowing abilities.
During the two weeks after the operation, you can expect the following events. This is a rough guide, so do not worry if things do not always go to plan.
Indications for tracheostomy
To relieve upper airway obstruction
Foreign body
Trauma
Acute infection - acute epiglottitis, diphtheria
Glottic oedema
Bilateral abductor paralysis of the vocal cords
Tumours of the larynx
Congenital web or atresia
To improve respiratory function
Fulminating bronchopneumonia
Chronic bronchitis and emphysema
Chest injury and flail chest
Respiratory paralysis
Unconscious head injury
Bulbar poliomyelitis
Tetanus
Advantages of tracheostomy over endotracheal intubation
Reduces patient discomfort
Reduces need for sedation
Improves ability to maintain oral and bronchial hygiene
Reduces risk of glottic trauma
Reduces dead space and reduces work of breathing
Augments process of weaning from ventilatory support
Tracheostomy technique
Patient positioned supine with sandbag between scapulae
Transverse cervical skin incision 1 cm above sternal notch
Incision should extend to the sternomastoid muscles
Dissect through fascial planes and retract anterior jugular veins
Retract the strap muscles
Divide thyroid isthmus and oversew to prevent bleeding
Place cricoid hook on 2nd tracheal ring
Stoma fashioned between 3rd and 4th tracheal rings
Anterior portion of tracheal ring removed
No advantage in creating a tracheal flap
Endo-tracheal tube withdrawn to sub-glottis
Tracheostomy tube inserted using obturator
When confirmed that in correct position the ET tube removed
Tube secured with tapes
Complications of tracheostomy
Immediate
Haemorrhage
Surgical trauma - oesophagus, recurrent laryngeal nerve
Pneumothorax
Intermediate
Tracheal erosion
Tube displacement
Tube obstruction
Subcutaneous emphysema
Aspiration & lung abscess
Late
Persistent tracheo-cutaneous fistula
Laryngeal and tracheal stenosis
Tracheomalacia
Tracheo-oesophageal fistula
Post-operative tracheostomy care
Maintain patent airway
Frequent atraumatic suction
Humidification of inspired air and oxygen
Mucolytic agents
Coughing and physiotherapy
Occasional bronchial lavage
Prevent infection and complications
Aseptic tube suction, handling and tube changing
Prophylactic antibiotics
Deflate cuff for 5 minutes every hours
Avoid tube impinging on posterior tracheal wall
Percutaneous tracheostomy
Indicated in patients likely to require ventilatory support for more than 2 weeks
Usually performed at the bedside in an ITU
Has significant cost benefits compared to open procedure
Performed using a guide-wire and dilators
Bronchoscopic guidance may reduce the complication rate
May be associated with a reduced risk of bleeding and infection
Success rates of 98% have been reported
Mortality related to the procedure is less than 0.5%
Complications occur in 5-15% of patients
Complications are similar to those following the open procedure
Re-insertion of a displaced tube may be more difficult
