1. Patient should be stable but this is always relative

2. This procedure should be done only in facilities where there is appropriate support for postoperative management

3. Anticipate anomalies that make trachea relatively inaccessible

a. Massive cervical hemangioma—bleeding issues

b. Massive cervical lymphangioma—severe distortion of neck anatomy

c. Massive goiter—might be manageable medically

d. Chest syndromes with severe kyphoscoliosis or tracheal distortion

4. Anticipate need for increased pulmonary support afterward to counter atelectasis and increased secretions immediately postop. Tracheostomy tubes allow for air leak through the stoma and larynx (even with cuff). In contrast, an endotracheal tube fits more snugly at the cricoids, creating a more closed system for ventilation.

5. Neonates are less able to tolerate bacteremia. Use perioperative antibiotic to cover skin flora.

6. If the patient is not currently intubated, have endoscopy equipment available and discuss intubation options with the anesthesiologist.

7. The infant larynx differs from that of the adult and older child (Fig. 40.1)

a. More pliable and mobile

b. Relatively higher in the neck

c. Thymus and innominate artery can override the trachea in the surgical field

Note: The first tracheostomy tube change is to be performed by the surgical team and the timing is at the discretion of
the surgeon (varies between postop days 3 and 7, majority between days 5 and 7) (4).

1. Provide bedside nursing and respiratory therapy care in intensive care setting with nurses and therapists who are trained and competent in the care of infants with upper airway disorders and tracheostomies. These nurses and respiratory therapists need to be skilled in respiratory assessment, routine tracheostomy management, and can anticipate and manage tracheostomy emergencies (6).

2. Keep spare tracheostomy tubes at bedside at all times (one of the same size and one size smaller) (4, 6, 7, 8).

3. Airway information sheet at bedside needs to include: Tracheostomy brand and tube size, suction catheter size, suction depth including any adapter (Fig. 40.5) (7, 8).

4. Airway management

a. Humidification: Provide adequate humidification via assisted ventilation or heated humidification tracheostomy collar.

(1) Rationale: Normally the nasal airway warms and humidifies air that enters the body; however, a tracheostomy bypasses the nasal airway allowing less humidified air to enter. Air that is not humidified can thicken secretions and increase the risk of mucus plugging.

(2) Precaution: Condensation from the water vapor can collect on the tubing walls and in the tubing and can be a potential source of bacterial growth (7).

b. Ventilation: Wean ventilator setting with a goal of tracheostomy collar unless patient is chemically paralyzed (see Chapter 7)

(1) Keep head of bed (HOB) elevated 20 to 30 degrees (4).

(2) Precaution: Correct tracheostomy tube placement is essential. Continually monitor respiratory status, including vital signs and clinical appearance of adequate oxygenation and ventilation. Infants can exhibit diminished breath sounds, changes in color, increased peak pressures, increased work of breathing, and change in mental status and increase in agitation if the tube becomes dislodged, blocked, or misplaced (8).

c. Suctioning: Suction every 4 hours and as needed (4).

(1) Indication: Suctioning may be required if the patient exhibits increased work of breathing, respiratory distress, desaturation, increased restlessness, visible secretions, audible respirations, tachypnea (7).

(2) Precaution: Careful suctioning practices must be followed to avoid complications, including hypoxemia, bronchospasm, hypo- or hypertension, laryngospasm, atelectasis, decreased lung compliance, airway trauma, and increased intracranial pressure (4, 7).