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R E L A T E D

The Virtual Children's Hospital: Upper Airway Problems in Children

S I G H T S

On-line Airway Atlas John Sherry II, MD

The Virtual Children's Hospital:

Anatomy Images

Respiratory Videos

S O U N D S

Courtesy of the R.A.L.E. Repository, which offers digital recordings of respiratory sounds in health and disease.

R E F E R E N C E S

Friedman Y. Comparison of percutaneous and surgical tracheostomies. Chest 1996;110:480-5.

Gracey DR. Ventilator care beyond the intensive care unit. Mayo Clin Proc 1995;70:595-7.

Heffner JE. Tracheostomy in the intensive care unit. Part 1: Indications, technique, management. Chest 1986;90:269-73.

Heffner JE. Medical indications for tracheotomy. Chest 1989;96:186-90.

Heffner JE. Timing of tracheotomy in mechanically ventilated patients. Am Rev Respir Dis 1993;147:768-71.

Marx WH. Some important details in the technique of percutaneous dilatational tracheostomy via the modified Seldinger technique. Chest 1996;110:762-6.

tracheostomy
/indications

The indications for tracheostomy have gradually been usurped by the indications for endotracheal intubation. By and large, tracheostomy is now indicated only in those cases in which intubation is not feasible.

There are three broad groups of patients in which tracheostomy needs to be performed:

airway obstruction

Tracheostomy is needed in cases of upper airway obstruction when laryngeal intubation is not possible. Examples of such cases include patients with laryngeal or subglottic stenosis, physical trauma to the face, jaws, oral or pharyngeal cavities, and burns by corrosive chemicals or inhalation of smoke or gases.

dead space and secretions

Tracheostomy aids in conditions like chronic lung disease, bronchopulmonary dysplasia, and certain neonatal conditions by decreasing the dead space and easing pulmonary toilet.

ventilation

Tracheostomy may be indicated for the provision of positive pressure ventilation in patients with poliomyelitis, tetanus, brain damage, as an adjunct to cardiac surgery, in severe burns, and in the preterm neonate. Intubation may be employed for the short term (for periods up to 3 weeks) but for prolonged treatment the tracheostomy becomes easier to manage. Improvements in technique now permit intubation for periods of several months. Therefore some authors now argue that a tracheostomy becomes a necessity only when prolonged endotracheal intubation poses the threat of laryngotracheal injury.

Some specific indications for tracheostomy are given below:

congenital laryngeal abnormalities

1. bilateral vocal cord paralysis (video)

2. congenital subglottic stenosis (MPEG video and helical CT) and cysts

• subglottic stenosis (multimedia index)

3. laryngeal webs

4. subglottic hemangiomata

5. laryngomalacia (video) (cine CT)

• tracheo/laryngomalacia (multimedia index)

prolonged ventilation

An ideal clinical study, comparing the risks and benefits of tracheostomy with prolonged translaryngeal intubation has not been performed (Heffner 1989, Heffner 1993). Nevertheless, the use of a tracheostomy for providing access to the patient's airway has become commonplace in ICUs and other areas of the hospital for treating patients who are difficult to wean from mechanical ventilation (Gracey 1995). Additionally, the technique of percutaneous dilatational tracheostomy has added to the cost-effectiveness and ease with which this procedure can be performed at the bedside (Marx 1996, Friedman 1996). Taken together, these factors may explain the more frequent and earlier use of tracheostomy for patients in need of prolonged ventilatory support.

Benefits of a tracheostomy in long-term mechanical ventilation include improved airway suctioning, better patient comfort, absence of laryngeal complications, easier tube changes and capabilities for oral nutrition. Also, ventilator-dependent patients may tolerate weaning attempts better when spontaneously breathing through a tracheostomy that contributes less to airway resistance than an oral endotracheal tube.

Optimal timing, however, for conversion from endotracheal intubation to tracheostomy in most patients is controversial. A decision to continue endotracheal intubation for several weeks is encouraged by the avoidance of tracheostomy complications such as tracheal stenosis at the stoma site, the increased bacterial colonisation of the airway associated with tracheostomy, and the natural inclination to maintain the tracheal cannulation longer than needed once a tracheostomy has been placed.

Prolonged endotracheal intubation, however, is not risk free; there is potential for laryngeal stenosis, which progresses in severity with duration of intubation. Data from various prospective studies indicate that endotracheal intubation and tracheostomy both present inherent hazards for long term airway management. For the patient requiring chronic mechanical ventilation, however, endotracheal intubation is less comfortable, provides less efficient suctioning than through a tracheostomy tube, and risks laryngeal damage related to the duration of ventilation. Therefore, based on the available clinical data, most authors recommend endotracheal tube intubation for patients requiring assisted ventilation for less than 7 days (Heffner 1986). After 7 days of intubation the patient is re-evaluated; if extubation appears likely before the 11th day, then tracheostomy is not performed, but if extubation cannot be foreseen on the 7th day, conversion to tracheostomy should be strongly considered.

Realising that no general principle works for every patient, the decision to perform tracheostomy must often be individualized; the agitated difficult-to-sedate patient may benefit from earlier surgery, while the patient at higher risk for surgical complications may be allowed more time for possible extubation.

supralaryngeal obstruction

1. Pierre-Robin Syndrome

Virtual Children's Hospital: Pierre-Robin Syndrome

OMIM: Pierre Robin Syndrome

2. Craniofacial injury

  trauma.org: Airway management of the trauma victim.

3. Obstructive sleep apnea

Tracheostomies for the management of obstructive sleep apnea have a number of disadvantages including aesthetic patient disfigurement, an imposed strict hygienic regime, occasional voice damage and the risk of tracheal stenosis. Therefore close adherence to indications for tracheostomy should be observed. If the patient is not a candidate for a uvulopalatopharyngoplasty because of morbid obesity, a small mandible or a nonvisible endolarynx by mirror examination due to excessive hypopharyngeal tissue, tracheostomy is considered in the following clinical situations:

• considerable social and occupational disability from excessive daytime hypersomnolence,
• sleep related cardiovascular complications,
• polysomnographic documentation of numerous obstructive apneas with arterial oxygen desaturation,
• confirmation of obstruction in the supraglottic region by fibreoptic endoscopy of the pharyngeal airway.

acquired laryngeal abnormalities

1. Acquired subglottic stenosis

2. Laryngeal papillomatosis

Virtual Hospital: Radiology case

acute infection

1. Epiglottitis

Acute Epiglottitis (video)

2. Acute laryngotracheobronchitis

Croup Syndromes (video)

miscellaneous

1. diphtheria

2. Inhaled foreign body

history		postoperative care
anatomy		long-term care
indications		percutaneous tracheostomy
surgical procedure		complications
tracheostomy for sleep apnea		decannulation