Continuing Education Activity

Pediatric respiratory compromise may result from upper airway obstruction, impaired central ventilatory drive, neuromuscular weakness, or chronic pulmonary disease, leading to inadequate oxygenation, ventilation, or both. Etiologies include congenital anomalies, acquired subglottic or tracheal stenosis, craniofacial abnormalities, laryngeal dysfunction, infection, trauma, and mass lesions. Initial management consists of supplemental oxygen, noninvasive positive pressure ventilation, endotracheal intubation, and targeted medical or surgical therapy. However, these interventions may be inadequate in cases of fixed structural obstruction, prolonged ventilator dependence, intolerance of noninvasive support, or extended intubation that poses a significant risk of laryngeal and subglottic injury.

Tracheostomy is a surgical procedure that creates an airway through the anterior neck into the trachea, providing direct ventilatory access and bypassing upper airway obstruction. This intervention alleviates respiratory compromise from structural blockage, neuromuscular weakness, or chronic ventilator dependence. Contraindications include uncorrectable coagulopathy and limited life expectancy. Essential equipment includes tracheostomy tubes of appropriate size, suction devices, and emergency resuscitation tools.

Limitations include the need for ongoing care, risk of decannulation, and complications such as infection, bleeding, tracheal stenosis, granuloma formation, and tracheoesophageal fistula. Tracheostomy aftercare is complex and demanding, requiring comprehensive caregiver education and coordinated support from an interprofessional team to optimize patient outcomes.

This activity for healthcare professionals is designed to enhance the learner's competence when evaluating candidates for pediatric tracheostomy. Participants will deepen their understanding of relevant anatomy and physiology, as well as the procedure's indications, contraindications, preparation requirements, and proper technique, fostering seamless interprofessional collaboration in pediatric airway management.

Objectives:

• Assess pediatric candidates for tracheostomy, considering clinical presentation, indications, contraindications, and anticipated postoperative needs.
• Apply evidence-based best practices when performing a pediatric tracheostomy, including appropriate equipment selection, precise surgical technique, optimal patient positioning, and effective immediate postoperative airway management.
• Assess indications and relative contraindications for pediatric tracheostomy to guide evidence-based procedural decision-making.
• Collaborate with interprofessional team members, including pediatric surgeons, otolaryngologists, and intensivists, to deliver efficient, comprehensive, and coordinated care for pediatric patients with complex airway conditions.

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Introduction

Tracheostomy is one of the oldest known surgical procedures. In 1718, Lorenz Heister coined the term tracheostomy to describe the creation of an opening in the neck and the insertion of a tube into the trachea.[1] Pediatric tracheostomies are performed by otolaryngologists and pediatric surgeons working within healthcare teams that provide essential support for long-term stoma care, family education, equipment supply, and mechanical ventilation when indicated. Care pathways may differ between hospitals; however, consensus guidelines have been established to standardize management across disciplines.[2]

Modern tracheostomy techniques can be traced back to Armand Trousseau, who used the procedure to treat diphtheria-induced respiratory distress in the mid-1800s. Chevalier Jackson later standardized the tracheostomy process in the early 1900s.

The procedure poses risks to all age groups; however, it has historically had higher morbidity and mortality in the pediatric population. This increased risk reflected the greater medical complexity of premature and syndromic infants compared to that of adult tracheostomy recipients. Historical use of tracheostomy as a last-resort airway intervention for patients with end-stage infectious airway obstruction, such as acute diphtheria, also contributed to elevated morbidity and mortality. Advances in the management of congenital anomalies, effective immunization protocols, and improved perioperative care algorithms have significantly increased survival rates among pediatric tracheostomy recipients.[3]

This activity focuses on general knowledge, operative considerations, wound care recommendations, and long-term strategies for pediatric tracheostomy based on current literature. This activity also addresses controversies surrounding decannulation protocols and highlights the role of the interprofessional team in caring for patients who undergo this procedure.

Anatomy and Physiology

The trachea is a partially flexible tube measuring approximately 1.5 to 2 cm in width and 10 to 13 cm in length in adults. This structure extends from the lower part of the larynx, at the level of the sixth to seventh cervical vertebra, to the level of the fourth or fifth thoracic vertebra, where it divides into the 2 mainstem bronchi. The tracheal wall comprises approximately 20 incomplete hyaline cartilage rings forming the anterior and lateral circumference. The posterior wall consists of smooth muscle surrounded by a fibrous membrane of elastic connective tissue. The smooth muscle contains longitudinal and transverse fibers. The transverse fibers form the trachealis muscle and connect the posterior ends of the cartilaginous rings.[4]

Anatomy and physiology differ between pediatric and adult tracheas in clinically meaningful ways. Pediatric patients have a larger head-to-body ratio, a prominent occipital protuberance, and a shorter neck, complicating positioning during tracheostomy. Infants and children also have larger tongues and smaller mandibles compared to adults. Research demonstrates that the adult airway is more elliptical than the pediatric airway. The larynx is positioned at a higher level in children, and the location of the cricoid cartilage varies with age—at birth, it is at the C4 vertebral level, and in adulthood, at C6.[5]

Pediatric vocal cords are not positioned perpendicular to the trachea but incline from anteroinferior to posterosuperior. The epiglottis is U-shaped in pediatric patients and may obstruct the laryngeal inlet. The narrowest point of the airway in children is at the cricoid cartilage, whereas in adults, it is at the vocal cords. The cartilaginous airway in children is softer and more flexible than in adults, increasing the risk of obstruction during negative-pressure ventilation, particularly in the presence of partial airway compromise. The mucous membrane covering the supraglottic and subglottic airway is loose in infants and more susceptible to edema when injured or inflamed.

Significant somatic and functional changes occur throughout the airway, from the nasal passages to the alveoli, particularly during the first 2 years of life. Airway distinctions between children and adults diminish with age, and the respiratory system of a 6- to 8-year-old closely resembles that of an adult.[6]

The trachea in children exhibits characteristics distinct from the adult trachea. The pediatric trachea is shorter, narrower, and angled posteriorly. Due to the higher position of the larynx in pediatric patients, the cervical segment of the trachea appears to contain more cartilaginous rings than that in adults. Newborns typically have 10 tracheal rings proximal to the sternal notch, adolescents have 8, and adults have 6 or fewer. In infancy, the tracheal length is approximately 50%, the diameter 36%, and the cross-sectional area 15% of those of an adult trachea.

The growth pattern of the trachea remains a subject of debate. Griscom et al (1986) analyzed the tracheas of 130 children younger than 6 using computed tomography imaging. The study described changes in tracheal length, diameter, and cross-sectional area from birth to adolescence. Findings indicated that tracheal length doubles by the end of adolescence, and the mean transverse diameter exceeds the mean anteroposterior diameter until age 6 years. Both diameters continue to increase throughout childhood and adolescence, gradually equalizing to form a rounder tracheal cross-section. The anteroposterior diameter typically becomes slightly larger around age 18 years.[7]

Initially, the tracheal growth pattern was believed to follow a direct linear relationship from approximately 18 weeks of gestation until age 14 years in girls, with boys exhibiting tracheal enlargement, but not lengthening, after height growth ceased. However, Luscan et al recently demonstrated that tracheal development parallels overall height growth and confirmed that the trachea is not round in shape.[8]

Indications

Critically premature infants and children with complex cardiopulmonary conditions, such as bronchopulmonary dysplasia, have demonstrated improved survival rates in recent years. With advancements in care for premature and medically complex neonates worldwide, prolonged ventilation has become the primary indication for pediatric tracheostomy.[9] Other common indications include the following:

• Benign airway tumors, such as recurrent respiratory papillomatosis
• Cervical tumors compromising tracheal integrity, such as cystic hygroma [10]
• Conditions that intrinsically or extrinsically obstruct the airway
• Congenital anatomical abnormalities, including bilateral vocal cord paralysis, laryngomalacia, and subglottic web [11]
• Infectious diseases compromising the airway, such as epiglottitis and laryngotracheobronchitis
• Need for pulmonary toilet [12]
• Genetic conditions associated with airway anomalies, including Treacher Collins syndrome, Nager syndrome, Beckwith-Wiedemann syndrome, and the Pierre-Robin sequence [13][14][15]
• Prevention of laryngotracheal stenosis in cases of long-term intubation [16]
• Avoidance of aspiration resulting from an unprotected airway, such as in laryngeal cleft or bulbar palsy [17]
• Provision of ventilatory access in cases of difficult intubation, including retropharyngeal abscess, posttonsillectomy hemorrhage, obstructive sleep apnea, tracheal foreign body, or facial burns

Pediatric tracheostomy aims to establish a secure airway and improve ventilation. The procedure further supports recovery and reduces the risk of airway-related complications.

Contraindications

Tracheostomy has no absolute contraindications. Relative contraindications may arise from comorbidities or procedure-specific factors. General medical conditions constituting relative contraindications include coagulopathy, severe medical instability, and poor long-term prognosis.[18] Procedure-specific relative contraindications include an anterior cervical mass, difficult surgical access due to distorted anatomy, a high-riding innominate artery, and local infection.[19][20][21]

Equipment

Only a few essential pieces of equipment and items are required during emergencies, when the most senior airway specialist cannot perform ventilation or intubation. These supplies include a #15 scalpel, a suction device with appropriate tubing, a headlamp or surgical spotlight, an endotracheal or tracheostomy tube, and a ventilation apparatus, either a bag-valve-mask device or a mechanical ventilator.[22] This list expands considerably for a planned tracheostomy with an ideal setup. Proper patient positioning requires a stable surface, ideally an adjustable operating room table, as well as a shoulder roll and a pillow or donut headrest.

Intraoperative monitoring and confirmation of tube placement require pulse oximetry, capnometry, and a stethoscope. A flexible fiberoptic bronchoscope or laryngoscope serves as a useful adjunct. Emergency airway equipment, a crash cart, and resuscitation equipment must always be immediately available.

Equipment specific to pediatric tracheostomy includes:

• 5- and 10-mL syringes
• A functioning suction apparatus with catheters of various sizes
• A scalpel with an 11- or 15-blade
• Monopolar and bipolar electrocautery
• Soft tissue retractors, such as Army-Navy or Senn retractors
• Soft tissue handling forceps, such as DeBakey forceps
• A cricoid hook
• Tracheal forceps and dilators
• Tracheostomy tubes in multiple sizes
• Sutures, needle drivers, and tracheostomy ties [23] 

Equipment should be verified for proper function and stored where it can be accessed without delay. Emergency setups must allow rapid intervention in cases of airway compromise. For elective procedures, thorough bedside preparation minimizes the risk of perioperative complications.

Personnel

Essential personnel required for a pediatric tracheostomy include a primary surgeon, a surgical first assistant, an anesthesiologist, a surgical technician, and a circulating or operating room nurse. All core functions must be covered, although personnel assignments may be adapted based on staff availability and the urgency of the procedure.

Preparation

Ensuring that all equipment is available and fully functional is essential. Informed consent should be obtained before the procedure if it is not emergent.

Standard American Society of Anesthesiologists monitors are applied after the patient arrives in the operating theater. General anesthesia should be administered according to the anesthesia provider's preference. Intubation should be performed if patient factors permit.

The patient should be positioned supine with the neck extended over a roll or pillow to bring the trachea closer to the skin. The skin should be sterilized using betadine or chlorhexidine. When chlorhexidine is used, the product must be allowed to dry for the required 3 minutes to reduce flammability.[24] Any pooling or wet areas of the skin preparation must be resolved before initiating the procedure.

Technique or Treatment

Microlaryngoscopy and bronchoscopy may be performed after the induction of general anesthesia to evaluate the airway. This assessment guides tracheostomy size selection. An appropriately sized endotracheal tube is then inserted and secured.[25] The patient's position is adjusted with a small shoulder roll to extend the neck.

The sternal notch, cricoid cartilage, and thyroid cartilage serve as landmarks to identify the midline. A horizontal or vertical skin incision is made below the cricoid cartilage, typically between the second and fourth tracheal rings. In younger patients, a vertical incision is preferred due to the narrower spacing between the anterior jugular veins. Subcutaneous fat is removed above the strap muscles. The strap muscles are divided along the median raphe to expose the laryngotracheal structures from the cricoid to the second or third tracheal rings. Monopolar electrocautery is discontinued at this point.

A tracheostomy timeout should be performed to delineate procedural steps involving all operating room personnel and critical equipment before any manipulation of the airway. During this timeout, the tracheostomy cuff must be tested, required sutures prepared, and the anesthesiologist's maneuvers with the endotracheal tube discussed.

The anesthesiologist deflates the balloon and advances the endotracheal tube so that the balloon is ideally distal to the tracheostomy site, which may not be possible in small pediatric patients. The balloon is then reinflated, and normal ventilation is resumed. Nonabsorbable rescue or stay sutures are placed bilaterally, slightly lateral to the midline, over the intended tracheostomy site. Stay sutures facilitate tracheal elevation during stomal maturation and guide tube placement. Stomal maturation can be enhanced before making the tracheal incision by suturing the peristomal skin to the tracheal perichondrium using absorbable sutures in a half-mattress fashion at 4 quadrants.

Primary closure of the lateral edges is possible following a horizontal skin incision. Stomal maturation may be performed after the tracheal incision by suturing the skin to the trachea with simple interrupted sutures when it has not yet been completed. The tracheal incision is typically vertical, positioned between the second and third or third and fourth tracheal rings, depending on the patient's anatomy. The incision length should permit smooth tracheostomy insertion without resistance.

The International Pediatric Otolaryngology Group (IPOG) recommends using stay sutures in all cases, taking into account stomal maturation, completion of airway endoscopy during the same anesthesia, and potential postoperative flexible tracheoscopy to verify proper tube placement. The IPOG's review did not address a specific technique for performing the tracheal incision.[26]

The anesthesiologist slowly withdraws the endotracheal tube until it is proximal to the tracheostomy site but distal to the vocal cords. An appropriately sized tracheostomy tube is inserted into the tracheal lumen and connected to the ventilatory circuit. The endotracheal tube remains in place until the tracheostomy tube is properly positioned, allowing rapid reestablishment of the airway with the endotracheal tube if ventilation through the tracheostomy is inadequate. The distal end of the tracheostomy tube is positioned approximately 2 to 3 rings above the carina, as confirmed with a flexible fiberoptic bronchoscope. The tracheostomy tube is secured with tracheostomy ties, and stay sutures are labeled as right or left and taped to the anterior chest wall. The faceplate may also be sutured to the skin using nonabsorbable sutures.

Complications

Only 0.2% of hospitalized patients in pediatric referral centers undergo tracheostomy. Mortality among children with tracheostomy varies and has been reported to be as high as 20%, although device-specific mortality is difficult to determine due to frequent medical and surgical comorbidities. For example, a study reported an inpatient mortality of 23.8% in patients undergoing tracheostomy concurrent with congenital heart surgery, compared to 8.6% in patients undergoing congenital heart surgery without tracheostomy.[27]

Morbidity associated with adult tracheostomy has been reported in up to 15% of patients.[28] Data on complications related to pediatric tracheostomy remain limited. Up to 19% of children experience a tracheostomy-related complication.[29]

Tracheostomy complications may be categorized as early or delayed and range from mild and self-limited to life-threatening. The most common causes of death in children with tracheostomy include tube obstruction, tube misplacement, and accidental decannulation.

Early Complications

Subcutaneous emphysema, pneumothorax, and pneumomediastinum occur in 3% to 9% of pediatric tracheostomies. Chest radiography is routinely recommended upon return to the intensive care or stepdown unit to confirm tube placement and assess thoracic status.

Intraoperative bleeding is controlled with judicious use of cautery and meticulous hemostasis. Bleeding most commonly presents as capillary oozing from the thyroid gland or the inferior thyroid vein. Significant hemorrhage may arise from aberrant vessels or vascular anomalies. Children with coagulation disorders or thrombocytopenia require thorough preoperative evaluation.

Injury to surrounding structures is minimized with careful surgical technique, including identification of the cricoid cartilage and tracheal rings before incision. Subglottic stenosis may result from an incision through the cricoid cartilage. Recurrent laryngeal nerve and esophageal injuries have been reported during pediatric tracheostomy.[30]

Sudden relief of upper airway obstruction following tracheostomy may result in reexpansion pulmonary edema, also termed postobstructive pulmonary edema, in pediatric patients. Rapid washout of retained carbon dioxide and loss of ventilatory drive can precipitate respiratory arrest during the procedure.[31]

Creation of a false passage may occur if the tracheostomy tube is advanced forcefully or if the tracheal incision is undersized. These circumstances may also cause laceration of the posterior tracheal wall, and larger tubes may result in cannulation of a mainstem bronchus.

Accidental decannulation may occur in the immediate postoperative period and is prevented by proper patient positioning, securement of the tracheostomy with sutures and circumferential ties, and appropriate selection and placement of the tube.

Mucous plugs can obstruct the tracheostomy tube, causing respiratory distress. Prevention requires appropriate stoma care, humidification, and regular tube changes.

Delayed Complications

Friction from tracheostomy tube movement and chronic inflammation may result in peristomal granulation tissue. Local wound care and regular tracheostomy tube and dressing changes prevent this complication.[32]

Scar tissue formation around the stoma may complicate tube changes. Surgical revision with excision of scar tissue is sometimes required.

Tracheocutaneous fistulae develop when skin apposes the tracheal mucosa and are common in chronically tracheostomy-dependent children. Suprastomal granulomas are also widely reported and may be diagnosed via fiberoptic bronchoscopy.[33]

The distal tracheostomy tube may erode the posterior trachea or the anterior esophagus. Such erosion can result in the formation of a tracheoesophageal fistula.

Chronic pressure on the first and second tracheal rings can cause chondritis and localized weakening, ultimately resulting in suprastomal tracheomalacia.[34] High tracheostomy tube placement may contribute to subglottic stenosis. Additional factors include prolonged endotracheal intubation and chronic inflammation. Careful tube placement and stoma management reduce the risk of subglottic stenosis.[35]

Cuffed tracheostomy tubes may increase pressure on the esophagus and hypopharynx, causing dysphagia. Tracheostomy is not a contraindication to oral feeding, and these issues can be mitigated by reducing cuff pressure, using a cuffless tube when feasible, and coordinating therapy with a speech-language pathologist.

Clinical Significance

Tracheostomy is a critical surgical procedure in pediatric patients. The procedure has become a viable intervention for conditions requiring prolonged mechanical ventilation, offering reduced airway resistance, decreased sedation requirements, improved patient comfort, and facilitation of airway care. Anesthesiologists, pediatricians, and otolaryngologists must understand the indications, contraindications, and potential adverse effects of the procedure.

Enhancing Healthcare Team Outcomes

Pediatric tracheostomy is not a benign procedure. Most posttracheostomy deaths are attributed to underlying chronic conditions rather than the procedure itself, most commonly the condition necessitating tracheostomy. Tracheostomy-related complications are well documented, with approximately 20% of patients experiencing at least 1 associated complication.

Children with tracheostomy require complex, interprofessional care involving pulmonologists, pediatricians, anesthesia providers, otolaryngologists, cardiologists, respiratory therapists, primary care practitioners, nurses, neurologists, and equipment specialists to optimize outcomes. Many pediatric patients experience fragmented care and poor interprofessional communication, contributing to adverse outcomes.

Multiple studies have demonstrated that tracheostomy-related adverse events can be significantly reduced by implementing dedicated tracheostomy care teams.[36][37] Data from the previous decade in adult tracheostomy populations have reached similar conclusions.[38][39][40]

The IPOG published recommendations in 2016 for perioperative care of pediatric patients with tracheostomy.[41] These recommendations focused on patients with recent tracheostomies and addressed preoperative, intraoperative, and postoperative management, sedation, enteral feeding algorithms, and bedside information sheets. Although formal validation studies are lacking, the recommendations represent an important step toward standardization of pediatric tracheostomy care.

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Disclosure: Russell De Jong declares no relevant financial relationships with ineligible companies.

Disclosure: Andrew Sutton declares no relevant financial relationships with ineligible companies.