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36. Naumovski L, Schaffer K, Fleisher B. Ingestion of a laryngoscope

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37 Tracheotomy

38 Thoracostomy

39 Pericardiocentesis

40 Gastric and Transpyloric Tubes

41 Gastrostomy

42 Neonatal Ostomy and Gastrostomy Care

VII Tube Replacement

251

Hosai Hesham

Gregory J. Milmoe

37 Tracheotomy

A. Indications (1–5)

1. Prolonged need for ventilator support—most common

2. Acquired subglottic stenosis after prolonged intubation

3. Craniofacial abnormalities with severe airway obstruction (e.g., Pierre-Robin sequence, Pfeiffer syndrome,

Treacher Collins syndrome)

4. Congenital bilateral vocal cord paralysis

5. Laryngeal web, subglottic hemangioma

6. Congenital tracheal stenosis, severe tracheomalacia

7. Congenital neuromuscular disease with insufficient

respiratory effort

8. Neurologic disease with aspiration risk, central apnea,

or intractable seizures

B. Contraindications

1. Unstable physiology—wait until stabilized

a. Sepsis

b. Pneumonia not yet controlled

c. Pulmonary instability requiring high inspiratory

pressures (peak inspiratory pressure >35 to 40 cms

H2O) or need for high-frequency ventilation

d. Cardiovascular instability (e.g., shunting, arrhythmia, or hypotension)

e. Evolving renal or neurologic injuries

2. Distal obstruction not relievable by tracheostomy

a. Congenital stenosis at the carina

b. External compression from mediastinal mass

3. Congenital anomalies that make the 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

C. Precautions

1. Patient should be stable (see B); anticipate need for

increased pulmonary support temporarily to counter

atelectasis and reactive secretions from surgical stimulation.

2. Tracheotomy tubes allow for air leak through the stoma

and larynx. In contrast, an endotracheal tube fits more

snugly at the cricoid, creating a more closed system for

ventilation.

3. Neonates are less able to tolerate bacteremia; use perioperative antibiotic to cover skin flora.

4. If the patient is not currently intubated, have endoscopy equipment available and discuss intubation

options with the anesthesiologist.

5. The infant larynx differs from that of the adult and

older child (Fig. 37.1).

a. More pliable and mobile

b. Relatively higher in neck

c. Thymus and innominate artery can override trachea

in surgical field

6. This procedure should be done only in a facility where

there is appropriate support for postoperative management.

D. Equipment

All Sterile

1. Prep tray with brushes, towels, and Betadine

2. Tracheotomy tray

a. Scalpel with no. 15 blade

b. Hemostats

c. Small scissors (iris, tenotomy, small Mayo)

d. Retractors—Senn or Ragnell

e. Suction—no. 7 Frazier

f. Forceps—Adson

3. Sutures: 3-0 and 4-0 nonabsorbable on small, curved

needles

4. Neonatal tracheotomy tubes

a. Have several calibers available

b. Standard tubes are noncuffed, but in special circumstances, a cuff may be needed.

E. Technique

1. Check instruments, sutures, and available tracheotomy

tubes.