Tracheostomy in Infants

Abstract

Tracheostomy is usually performed because of significant upper airway compromise and a need for better tracheobronchial toilet, for prolonged positive pressure, or for ventilatory support. The major indications include airway obstruction, long-term respiratory support, and facilitation of secretion clearance. Tracheostomy is associated with a significant impact on the psychosocial development of the child. Therefore, any alternative treatment option prior to proceeding with tracheostomy should be evaluated. In contrast to adults, tracheostomy is carried out in an open fashion. Percutaneous dilatational tracheostomy is not as suitable for children because the airway is small and often unstable. Complications during the procedure include damage to surrounding structures, hemorrhage, or pneumothorax/pneumomediastinum. The most common long-term complications are partial obstruction of the cannula and accidental decannulation. Therefore, extensive education of the caregivers along with preparation of a safe home environment is essential for a successful transition to home care. When the initial indication for a tracheostomy no longer exists, the child can be decannulated. This process includes confirmation of airway patency, weaning/capping, and closure of the tracheocutaneous fistula. The latter usually happens spontaneously; surgical closure is necessary in only <10% of cases. If congenital high airway obstruction is diagnosed prenatally, tracheostomy during ex utero intrapartum therapy (EXIT) is a special indication. Rarely, a pediatric surgeon may be required to emergently obtain an airway at the bedside via incisional or needle cricothyroidotomy in an infant who is too unstable for transport to the operating room. Despite the morbidity of the procedure, tracheostomy nowadays is a routine surgical procedure which can be performed safely in experienced institutions.