Tracheostomy

Abstract

Tracheostomy may be required for a number of congenital and acquired conditions of infancy and childhood. Thus, the well-trained pediatric surgeon should be comfortable in his or her knowledge of the current indications and should be able to perform this procedure under urgent or elective conditions. While we occasionally encounter neonates that require urgent attention to their airway, most require a tracheos-tomy due to the need for long term ventilation. Pre-natal diagnosis now allows us to identify some infants at risk or requiring emergency airway access so that one can plan to attend the delivery in anticipation of requiring some sort of urgent intervention. Examples of this would be an infant with a congenital teratoma or massive cystic hygroma or laryngeal atresia. These are all cases of a Congenital High Airway Obstruction Syndrome or CHAOS, for which the pediatric surgical team is prepared to perform any necessary bronchoscopy, intubation or tra-cheostomy with the infant still connected to the placental circulation. A controlled situation then exists to allow ample time for accurate diagnosis and initial management, which may include a tracheostomy. Otherwise, neonatology and technology have made great advances over the last few decades. Because of the routine use of surfactant and steroids, it is rare now to see a ventilator dependant infant from lung disease alone, and it is neither unusual nor unsafe to leave an infant on a ventilator with an endotracheal tube in place for months on end. Today nearly the only infants who need a tracheostomy do so because of an inadequate airway due to stenosis or laryngotracheo malacia. These infants otherwise are ready for discharged to go home or to a facility for technologically dependent children, but still require ventilatory assistance. Older children are more likely to require a tracheostomy for acquired problems such as trauma or tumor management. The need for airway management in the course of trauma and burn care probably exceeds that required for the management of tumors. Some neurologically devastated children, regardless of the cause, also require a tracheostomy for optimal airway management. This chapter will discuss the indications for and techniques for insertion and maintenance of a tracheostomy in infants and children. © 2009 Springer Berlin Heidelberg.