252 Section VII ■ Tube Replacement

2. Apply monitors, check IV line, and confirm satisfactory

ventilation through endotracheal tube.

3. Have anesthesia team proceed with inhalation agents,

oxygen supplementation, and IV agents, as needed for

satisfactory level of general anesthesia.

4. Position patient with neck extended, using shoulder roll.

5. Remove nasogastric tube to avoid confusion when palpating trachea. Do not place esophageal stethoscope.

6. Inject skin incision and the deeper tissues with local

anesthetic (0.5 to 1 mL of 50% lidocaine with 1:200,000

epinephrine).

7. Prep the surgical site from above the chin to below the

clavicles. Give IV antibiotic to cover skin flora.

8. Drape the patient with surgical towels, allowing the

anesthesiologist access to the endotracheal tube and

the securing tape.

9. Identify the following landmarks: Suprasternal notch,

chin, midline, trachea, and cricoid. In small neonates,

the cricoid may be difficult to palpate.

10. Make the skin incision approximately midway between

the sternal notch and the cricoid, either vertically or horizontally. Incisions in either plane tend to heal as a circular stoma; however, the horizontal has a slightly better

cosmetic effect, whereas the vertical allows more exposure in the midline.

11. Excise excess subcutaneous fat with cautery.

12. Identify the strap muscles and repeatedly palpate the

trachea to confirm the midline. Split the raphe to separate the muscles.

13. Grab the fascia of the strap muscles with hemostats to

retract them outward and laterally, thereby exposing

the thyroid gland, cricoid, and trachea.

14. Place Senn retractors on either side of the trachea for

optimal visibility.

15. Displace the thyroid gland, using blunt dissection to

expose the tracheal rings. If this is not possible, divide

the thyroid isthmus, suture, and ligate.

16. Place vertical stay sutures in paramedian position at the

level where tracheal entry is planned—usually the third

and fourth ring (Fig. 37.2).

17. Incise trachea vertically for two or three rings, depending on the size needed for the tube employed.

18. Have the anesthesiologist loosen the tape and withdraw

the endotracheal tube until the tip is just visible

(Fig. 37.3).

19. Place the appropriate tracheostomy tube with the

flange parallel to the trachea so that the tube more easily enters the trachea and passes posteriorly, then rotate

the flange 90 degrees.

20. Have the anesthesiologist confirm placement by checking end-tidal carbon dioxide and oxygen saturation, as

well as auscultation of both sides of the chest.

Fig. 37.1. Sagittal section. Larynx lies more cephalad than in

adult. Note the proximity of the thyroid isthmus to the tracheal

rings. (Drawing contributed by John Bosma, MD)

Fig. 37.2. Placement of stay sutures through the tracheal wall.

Fig. 37.3. Artistic conception of view through tracheal incision

with the tip of the endotracheal tube visible. Stay sutures hold cartilages open.