Airway Skills 15:
Tracheotomy in Infants
PEDS: As this portal pertains entirely to pediatric patients, the text is not underlined.
Tracheotomy in infants is complicated by the fact that an infant airway in the neck is very mobile. The carotid artery and the internal jugular vein are in close proximity to the trachea. An infant’s trachea itself is relatively soft compared to that of an adult and may be seriously damaged. Here is a safe way to accomplish tracheotomy in infants using transtracheal needle ventilation (TTNV) as a temporizing maneuver.
- Make a vertical skin incision over the cricothyroid membrane area in order to accurately identify and puncture it. Using a #15 scalpel, make a midline incision over the thyroid cartilage and the trachea. Carry this incision down into the subcutaneous tissue until the thyroid cartilage and the cricoid cartilage are easily palpated with a finger. Extend the incision over the proximal trachea because the TTNV will be converted to a tracheotomy. Sharp dissection using fine Adson pickups and a curved dissecting scissor is much safer than using spreading technique with a forcep. The cricoid cartilage is relatively large and soft with a small internal diameter. Percutaneous TTNV may be unsuccessful because the needle easily compresses the trachea in an anterior-posterior direction. Do not hesitate to perform the puncture under direct vision.
- Insert the exploring needle of the TTNV set (Cook Co. 6.0 French cath/guidewire/needle set) through the cricothyroid membrane. Air aspirated through the needle confirms correct placement. Angle the needle so that the guidewire travels down the trachea. If the child is gagging or coughing, insert a fine tracheotomy hook (News tracheal retractor, Sklar Instruments) into the cricothyroid membrane to stabilize the larynx while the procedure is performed.
- Remove the needle. Advance the 6 French cannula and dilator contained in the Cook kit over the guidewire into the trachea. Remove the guidewire and dilator, but keep both sterile for replacement later. Attach the syringe to the cannula and aspirate air again to reconfirm correct placement.
- Connect a modified 18 French tracheal suction catheter to wall oxygen (50 psi) flowmeter. Attach a BP cuff adapter (Luer connector) to the distal end and connect the other end to oxygen tubing. Set the flow rate at 5 L/min for a newborn infant and at about 10 L/min as a starting point for older children.
Achieve ventilation by covering and uncovering the T port with your thumb.Increase or decrease the flow rate to result in the kind of rise and fall of the chest you would expect to achieve with a bag-valve device. Expiration must be at least twice as long as inspiration: recite breathe—exhale, exhale to achieve the correct rhythm. You must constantly hold the cannula so that it does not inadvertently get pulled out. The person performing ventilation should hold the cannula. This is his or her sole responsibility.
If need be, TTNV may be conducted for hours, so there is no critical need to move on to tracheotomy immediately. Monitor O2 sats and blood gases.
Conversion from TTNV to Tracheotomy
- While ventilation with TTNV continues, use blunt Metzenbaum dissecting curved scissors to sharply open the tissues in front of the trachea. Pick up each thin layer of tissue with pickups as shown. Use a finger to check for the presence of the trachea directly underneath. Repeat frequently.
- When the tracheal rings come into view, place a 000 suture on a noncuttingneedle around a tracheal ring on each side. These will be used as stay sutures to provide traction and to maintain ready access to the tracheotomy site.
- Reinsert the guidewire into the TTNV cannula and remove the cannula. Using the 2 stay sutures, pull up the trachea so that you can see it well. Now make a longitudinal incision in the trachea using a #15 scalpel (as shown) dividing one or two rings.
- Insert a shortened 3.0 ET tube into the trachea (as shown). Alternatively, use a size 00 Shiley tracheotomy tube. Remove the guidewire and secure the ET tube.
Tape the 2 stay sutures to the child’s chest in case the airway is lost or needs revision.
- Secure the tracheostomy tube firmly in place. The 00 Shiley tracheotomy tube has tabs with holes for twill tape. This feature is an advantage because of the small tolerance for movement of the tube. Tie the twill around the neck with just enough tension to allow the passage of the tip of your little finger under the twill.
The infant TTNV and tracheotomy tray should contain these pieces listing them from left to right:
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A News trachea retractor to hold the airway stable if the child gags or swallows;
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A #15 scalpel;
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Needle holder;
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Two curved 5-inch mosquito clamps;
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Curved, 7-inch, delicate Metzenbaum dissecting scissors;
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Suture scissors;
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Adson dressing forcep (pickup), delicate, 4¾ inch, without teeth;
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Alm self-retaining retractor, 2¾ inch, blunt teeth;
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Cook Critical Care 6 French cannula with dilator, guidewire, and exploring needle for TTNV (C-DTJV-6.0-3.5-7.5-ER);
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00 Shiley tracheostomy tube and an 8 French pediatric feeding tube for use as a guide. A shortened 3.0 ET tube is an alternative;
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000 or 0000 silk suture for use as stay sutures.
Reference
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Seid AB, Gluckman JL: Tracheostomy in Otolaryngology, 3rd ed. Zorab R, Ed. WB Saunders: Philadelphia, 1991; 2429-2437.