KEY POINTS
- 1.
Chronic cardiopulmonary and neurologic disorders are the most common indications for neonatal tracheostomy, overtaking upper airway obstruction.
- 2.
Noninvasive ventilation of neonates is likely reducing indications and the need for tracheostomy.
- 3.
Neonatal tracheostomy is associated with high overall mortality and morbidity and lower quality of life.
- 4.
Postoperative and long-term care is necessary to help mitigate and manage the increased risks associated with neonatal tracheostomy.
- 5.
Tracheostomies have impact in all domains of neurodevelopment.
Introduction
Tracheostomy has played a critical role in the care of infants since the early 1900s. Prior to the 1800s, tracheostomies were viewed with skepticism and criticism because these procedures were performed for acute airway obstruction and associated with high mortality rates. The relative success of tracheostomy in the treatment of children with diphtheria helped increase acceptance of the procedure. Holinger published a 30-year review of infant tracheostomy in 1965, demonstrating more acceptance of the procedure, improved technology of tracheostomy tubes, and an increasing list of indications, primarily for airway obstruction. Unfortunately, the mortality changed very little during that time period, with mortality rates approximately 30% for these infants.
The mid 1900s heralded great advances in neonatal resuscitation and ventilation. In 1953 Donald and Lord published a description of an infant mechanical ventilation device. , In 1965, McDonald and Stocks demonstrated success in longer-term intubation and ventilation in neonates. , Continuous positive pressure ventilation for respiratory distress of newborns was published in 1971. The 1960s also saw the establishment of the first neonatal intensive care units, and more infants were surviving conditions that in decades past were considered fatal.
The history of neonatal tracheostomy has been an evolving story of changing indications, technological advancements, and improvements in survival.
An understanding of the history of neonatal tracheostomy and neonatal care provides insight into the current evidence-based management of neonatal tracheostomy and the challenges now faced. The landscape of neonatal tracheostomy is changing. Very low birth weight preterm infants are now surviving, and noninvasive methods of respiratory support for these infants are reducing morbidity. Young children with severe chronic cardiopulmonary or neurologic disorders are managed with ventilators both in the neonatal intensive care unit (NICU) and out of the hospital. Some of the questions we now face for neonatal tracheostomy center on appropriate timing for tracheostomy, improving postoperative care pathways, decreasing morbidity of the procedure and subsequent care, facilitating adaptive neurodevelopment and communication, and improving quality of life after tracheostomy.
Pathophysiology
Multiple factors impact the pathophysiology and indications of neonatal tracheostomy. Unique neonatal anatomy, physiology, and medical conditions associated with prematurity influence tracheostomy decisions in the neonatal period.
The infant and neonatal airway diameter and length will vary by gestational age. The narrowest portion of the infant airway is at the glottis and subglottis, and these locations are the most common sites of postintubation stenosis. For a newborn, the subglottis has a 3.5- to 4-mm inner diameter. The tracheal length from glottis to carina is about 40 mm. Premature infants may have a subglottic airway of less than 3 mm. Airflow and effective ventilation in these small airways are influenced by Bernoulli’s and Poiseuille’s equations. Small changes in airway size will have significant effects on airway pressure, dynamic collapse, and resistance to flow. The clinical implication for many preterm infants is that airway edema or stenosis changes at the 1-mm level or less can destabilize effective ventilation, requiring increased support or tracheostomy. Subglottic stenosis occurred in 12% to 20% of infants with prolonged intubation in the 1960s. With contemporary neonatal respiratory care, rates of stenosis are typically around 1%. , Tracheostomy can be used to bypass levels of stenosis or decrease the need for respiratory support by removing upper airway resistance.
Typical indications for neonatal tracheostomy are prolonged ventilation, facilitation of ventilator weaning, upper airway obstruction, subglottic stenosis, or infectious etiologies. Although Holinger demonstrated infectious etiologies and airway obstruction as the most common indication for neonates in the 1960s, chronic cardiopulmonary and neurologic disorders are now the primary indications for tracheostomy. Multiple studies have described this shift from infectious indications for tracheostomy to cardiopulmonary and neurologic indications in neonates who have comorbid conditions. , , , , ,
Clinical Features and Indications
When tracheostomy is required, the decisions of timing and patient selection are critical to reduce morbidity. However, a limiting factor is the size of the neonatal airway in relation to the smallest available tracheostomy tube outer diameter (OD). The inner diameter of a full-term neonatal trachea is approximately 3.5 to 4 mm. Extremely premature infants may have an inner diameter of 2 mm or smaller. Currently the smallest OD tracheostomy tube is the 2.5 Tracoe with an OD of 3.6 mm or a 2.5 NEO Bivona TTS cuffed trach with an OD of 4.0 mm. Tracheal length also may be a factor in being able to accommodate the 30 mm of length of the tracheostomy tubes. These anatomic constraints are critical when considering airway interventions prenatally. Since the 1990s, ex utero intrapartum treatment procedures created the possibility of prenatal airway management for cases of congenital high airway obstruction (CHAOS), airway tumors, laryngeal and tracheal stenosis, and lymphatic malformations.
In addition to tracheal size and gestational age, patient weight is a consideration. Studies of other procedures have shown increased morbidity and mortality in procedures performed in neonates weighing less than 2.5 kg.
There is no established weight requirement for a tracheostomy procedure. Tracheostomy performed in infants with weights between 2.0 and 2.5 kg is common. Rawal et al. did not find increased morbidity when comparing infants <2.5 kg and >2.5 kg in an American College of Surgeons National Surgical Quality Improvement Program–Pediatric (ACS NSQIP-P) Database study. The data regarding appropriate timing of tracheostomy in infants is based on retrospective studies. It appears that the timing of tracheostomy does not decrease the duration of mechanical ventilation in the majority of infants.
Advances in noninvasive ventilation of newborns have improved morbidity and mortality through decreasing intubations and related iatrogenic lung and laryngotracheal injury. Systematic reviews have demonstrated the efficacy and safety of these methods compared with traditional orotracheal intubation. The implications of these advances for neonates requiring tracheostomy are varied. The total number of infants requiring tracheostomy may be decreasing, along with the aforementioned decrease in subglottic stenosis rates. , However, tracheostomy rates may be increasing in certain subpopulations of very low birth weight premature infants with more severe cardiopulmonary disease. , In some of these critical ill neonates, the risk of tracheostomy may be unacceptable. Highly unstable pulmonary hypertension or cardiopulmonary disease can be relative contraindications. If the neonate is unable to be transported safely to the operating room, be manipulated and positioned for surgery, and tolerate exchange of the endotracheal tube to a tracheostomy tube, then surgery should be delayed or deferred. Table 66.1 lists common indications and relative contraindications for neonatal tracheostomy.
| Indications | Contraindications (Relative) |
|---|---|
| Chronic cardiopulmonary disease (bronchopulmonary dysplasia, pulmonary hypertension, etc.) | Critically ill and unable to tolerate general anesthesia or transportation to the operating room |
| Neurologic disorders, congenital and acquired | Critical mid to low tracheal stenosis or agenesis |
| Acquired or congenital glottic, subglottic, or tracheal stenosis | Craniofacial and cervical dysmorphia that prevents surgical access |
| Craniofacial syndromes and disorders (Robin sequence, Treacher Collins, Goldenhar, etc.) | Congenital cardiac disease requiring sternotomy, which may be contaminated by presence of tracheostomy |
| CHAOS (congenital high airway obstruction syndrome) a | |
| Vascular malformations or tumors |
Management
Discussion of management can be organized into preoperative planning, intraoperative procedure, postoperative care, and long-term care.
Preoperative
Preoperative planning is crucial for neonates with complex and critical medical status who require a tracheostomy. The workup for tracheostomy should be tailored to the indications and status of the infant. Neurologic evaluation, magnetic resonance and computed tomography imaging, echocardiography, chest x-ray, laryngoscopy, bronchoscopy, and laboratory studies may all be used for preoperative workup. Coordination with a multidisciplinary team of neonatologists, pulmonologists, cardiologists, surgeons, social workers, and family can expedite care and improve quality of care. For infants with critical congenital cardiac disease that requires repair, tracheostomy may be deferred to reduce wound infections and morbidity. ,
Early family integration in the decision, planning, and timing of the tracheostomy helps counseling of both short- and long-term implications of a neonatal tracheostomy on family care. Estimated 2-year healthcare costs associated with infants receiving tracheostomy range from $1643 to $112,608, with costs for the care of some children much higher. In addition to cost, there is a social and personal burden and decreased quality of life for families and caregivers. Family counseling and tracheostomy care education are important in the success and safety of neonatal tracheostomies. Families should be prepared for routine and emergency care of infants with tracheostomy, with early guidance to assist with expectations and to avoid misconceptions before the surgery is performed. , Families and caregivers may experience a significant burden in quality-of-life, financial, social, and relational domains. Quality of life is lower in families of neonates with tracheostomy compared with neonates without tracheostomy. Neonates with tracheostomy are more likely to have readmissions, outpatient visits, and fewer parents with full-time employment. ,
Procedure
In a standard neonatal tracheostomy, the patient is positioned with a small shoulder roll and extended neck position. The critical landmarks of the sternal notch, trachea, cricoid, and thyroid cartilage are palpated and marked. Careful palpation deep to the sternal notch is performed to identify any abnormally high location of large vessels. The proposed incision is injected with lidocaine and epinephrine with a dose as appropriate for weight. The patient is then prepped and draped in a sterile fashion but should be draped in a manner to allow access to the endotracheal tube for removal at the time of tracheostomy tube placement. Typically, a 1.5-cm horizontal incision is made just below the cricoid in the midline. Subcutaneous fat is removed to expose the cervical fascia and strap muscles. The midline raphe is identified to separate the strap muscles vertically, being careful to remain in midline. The cricoid cartilage and thyroid gland isthmus are identified and the isthmus is divided. Tracheal rings 2 through 4 are isolated and identified using the cricoid cartilage as a landmark ( Fig. 66.1 ). The endotracheal tube cuff is deflated to avoid inadvertent cuff puncture, and tracheal retraction sutures are placed through 2 tracheal rings oriented vertically with 3-0 Prolene “stay” sutures. They are labeled with “left” and “right” identifiers. These stay sutures are placed to facilitate tube reinsertion should accidental decannulation occur postoperatively.
Using 5-0 chromic sutures, the skin edges can be tacked to the superior and inferior edges of the trachea to help mature the tracheostomy stoma. Next, a vertical incision is made through tracheal rings 2 through 4 in the midline between the two retraction sutures. Simultaneously, the endotracheal tube is pulled back just above the tracheostomy site. A tracheostomy tube is then placed into the incision, and confirmation of correct placement is made with auscultation of lung fields, end tidal CO 2 measurement, and visualization through the tracheostomy tube lumen using a small fiberoptic scope. The tracheostomy tube is then secured with ties, and skin-protecting dressing (DuoDERM, Mepilex) to limit skin breakdown during the healing process can be applied to the neck, chin, and chest ( Fig. 66.2 ).
Tracheostomy Tube Sizes
Neonatal tracheostomy tube choices vary by diameter size and length. The principal manufacturers in the United States are Smiths Medical Bivona, Shiley, and TRACOE. These manufacturers offer both cuffed and uncuffed options ( Fig. 66.3 ). The decision for type and style of tracheostomy may depend on ventilation pressure requirements and the size of the trachea for a given infant. The numeric sizes of the tracheostomy tubes are in reference to their inner diameter. Additionally, designations of NEO (neonatal) versus PEDs (pediatric) tracheostomy reflect differences in overall length of the tracheostomy tube. Even small changes in diameter from 2.5 mm to 3.0 mm will have a dramatic effect on airflow resistance according to Poiseuille’s law. Length also affects resistance but to a lesser degree. Table 66.2 lists neonatal tracheostomy tube options.
| Tracheostomy Tube | ID (mm) | OD (mm) | Distal Length (mm) | Cuff Option | Material | Suction Size | |
|---|---|---|---|---|---|---|---|
| Bivona (Neonatal) | |||||||
| 2.5 | 2.5 | 4 | 30 | Y | Silicone | 6 Fr | |
| 3 | 3 | 4.7 | 32 | Y | Silicone | 6–8 Fr | |
| 3.5 | 3.5 | 5.3 | 34 | Y | Silicone | 8 Fr | |
| 4 | 4 | 6 | 36 | Y | Silicone | 8 Fr | |
| Shiley (Neonatal) | |||||||
| 2.5 | 2.5 | 4.2 | 28 | Y | PVC | 6 Fr | |
| 3 | 3 | 4.8 | 30 | Y | PVC | 6–8 Fr | |
| 3.5 | 3.5 | 5.4 | 32 | Y | PVC | 8 Fr | |
| 4 | 4 | 6.0 | 34 | Y | PVC | 8 Fr | |
| 4.5 | 4.5 | 6.7 | 36 | Y | PVC | 8 Fr | |
| Tracoe | |||||||
| 2.5 | 2.5 | 3.6 | 30 | Y | Silicone/PVC a | 6 Fr | |
| 3 | 3 | 4.3 | 32 | Y | Silicone/PVC | 6–8 Fr | |
| 3.5 | 3.5 | 5.0 | 34 | Y | Silicone/PVC | 8 Fr | |
| 4 | 4 | 5.6 | 36 | Y | Silicone/PVC | 8 Fr | |
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