Chapter 37 ■ Tracheotomy 253

21. Secure the tracheostomy tube with twill tape tied firmly

around the neck. Once tied, only one finger should fit

between the tape and the neck when the baby’s neck is

in neutral position.

22. Secure the stay sutures to the chest with tape labeled as

to correct side (Fig. 37.4).

23. Transport the patient back to the intensive care unit

with a backup endotracheal tube and laryngoscope.

24. Obtain chest radiograph on arrival in unit, to check

tube position and lung status.

F. Postoperative Management

1. Provide intensive nursing (see C).

2. Keep spare tracheostomy tubes at bedside (same size

and one smaller).

3. Replace nasogastric tube for nutrition and to avoid

aerophagia.

4. Suction secretions as needed to avoid plugging. For first

24 hours, be liberal with saline irrigation.

5. Make sure the ventilator tubing is not pulling on the

tracheostomy tube.

6. Be aggressive with wound care so that stoma heals

quickly and, thereby, limits granulation. Clean once a

shift with half-strength peroxide and cotton swabs, then

apply antibiotic ointment.

The first tracheostomy change is performed by surgical team in 4 to 7 days. Thereafter, weekly changes are

sufficient.

G. Early Complications (0 to 7 days)

1. Bleeding: Thyroid, venous, arterial

2. Accidental decannulation or displacement in neck—

stay sutures are the child’s lifeline back to the trachea to

allow replacement of the tube.

3. Plugging of tube with secretions (Fig. 37.5)

Fig. 37.4. Fixation of stay sutures. As soon as the position of the

tracheostomy tube is confirmed and stomal ventilation is started, the

tube may be fixed. Equal tension is kept on the stay sutures during

taping. Right suture is marked to avoid confusion in future placement.

A B

Fig. 37.5. Total obstructions of tracheostomy tubes. A: Mucus plug incompletely suctioned. B: Dry

mucus plug pushed deeper by a suction catheter.

254 Section VII ■ Tube Replacement

a. Avoid by increasing humidity, saline irrigation, and

suctioning.

4. Infection of wound or pneumonia—avoid by local care

and by taking care of secretions.

5. Air leaks

a. Pneumothorax—may need chest tube

b. Pneumomediastinum—serial films

c. Subcutaneous emphysema—usually limited (avoid

occlusive dressing)

6. Tracheoesophageal fistula—iatrogenic

H. Late Complications (after 1 week)

1. Obstruction and decannulation remain ongoing risks

that require vigilant care.

2. Stomal infection and granulation—avoided by careful

wound care

3. Proximal tracheal granuloma—commonly occurs at the

point where the tube rubs against the superior aspect of

the tracheal opening, creating an obstruction between

the vocal cords and the tube that can impede routine tracheostomy tube changes. This requires operative removal.

4. Distal tracheal granulation—from overly aggressive

suctioning or tube angulation causing rubbing of the

tip against the tracheal wall. Hallmark sign is bloody

secretions.

5. Stenosis—preventing decannulation later on

a. Part of original pathology for which tracheotomy

was performed

b. Ongoing obliteration from active inflammatory

factors

c. Consequence of procedure itself; from stomal

collapse or distal cicatrix

6. Tracheocutaneous fistula after tube removal—normal

physiologic sequela, but needs secondary procedure for

closure

References

1. Sisk EA, Kim TB, Schumacher R, et al. Tracheotomy in very low

birth weight neonates: indications and outcomes. Laryngoscope.

2006;116:928.

2. Wooten CT, French LC, Thomas RG, et al. Tracheotomy in the

first year of life: outcomes in term infants, the Vanderbilt experience. Otolaryngol Head Neck Surg. 2004;134:365.

3. Kremer B, Botos-Kremer AI, Eckel HE, et al. Indications, complications and surgical techniques for pediatric tracheostomies—an

update. J Pediatr Surg. 2002;37:1556.

4. Crysdale WS, Feldman RI, Naito K. Tracheostomies: a

10 year experience in 319 children. Ann Oto Laryngol. 1988;97:

439.

5. Sidman JD, Jaquan A, Couser RJ. Tracheostomy and decannulation rates in a level 3 neonatal intensive care unit: a 12 year study.

Laryngoscope. 2006;116:136.