This document discusses pediatric tracheostomy procedures. It begins by providing a brief history of tracheostomies, noting they were originally used in the 19th century for diphtheria and other inflammatory conditions until vaccines were developed. It then discusses current indications for pediatric tracheostomies, including relieving upper airway obstruction, prolonged intubation, reducing anatomical dead space, and airway toilet. The rest of the document provides details on techniques for performing tracheostomies, including patient positioning, incision types, dissection methods, tracheal incision, tube insertion, securing and caring for the tube, and potential red flags to watch for after the procedure.

1. Pediatric tracheostomy
(Tricks)
Dr. Hazem M. Abdel Tawab
Professor and Consultant of ORL, HNS
Medical Doctorate of ORL, HNS
Faculty of Medicine, Cairo University, Egypt
Dr Hazem M. Abdel Tawab, ENT, Cairo 1

2. History
• In the nineteenth century after Trousseau for upper respiratory tract
obstruction with Diphtheria.
• In inflammatory conditions as laryngitis and epiglottitis till
vaccines evolved.
• Some congenital malformations.
Dr Hazem M. Abdel Tawab, ENT, Cairo 2

3. Incidence nowadays
Up to 7 per 100000 child population with a peak in the first
year of life then another peak in the teen age.
Dr Hazem M. Abdel Tawab, ENT, Cairo 3

4. Indications in pediatric population
Relieve upper airway obstruction
Prolonged intubation
Reduce anatomical dead space
Toilet of the airway.
Dr Hazem M. Abdel Tawab, ENT, Cairo 4

5. Upper respiratory tract obstruction
Oropharynx, tongue base: Macroglossia, Treacher
Collins/Goldenhar syndrome, Cystic hygroma
Supraglottis: Supraglottic cyst
Glottis: Vocal cord palsy, Trauma
Subglottis: Subglottic stenosis, hemangioma
High tracheal stenosis
Dr Hazem M. Abdel Tawab, ENT, Cairo 5

6. Prolonged intubation
Ulceration then stenosis
Premature infants tolerate more
Usually 2-3 weeks before thinking of tracheostomy
Dr Hazem M. Abdel Tawab, ENT, Cairo 6

7. Tricks in the technique
Position:
Rolled towel
Elastoplast
Extension: atlantoaxial subluxation, great vessels
Take care from excessive dissection
Auscultation of the chest
Dr Hazem M. Abdel Tawab, ENT, Cairo 7

8. Skin incision
Horizontal? Scar
Vertical
Advantages: easy, rapid, emergency
You should remove subcutaneous fat
Dr Hazem M. Abdel Tawab, ENT, Cairo 8

9. Dissection
Monopolar
Bipolar
Isthmus cut and transfix
Isthmus cut only?
Stay on trachea
Nasogastric tube?
Dr Hazem M. Abdel Tawab, ENT, Cairo 9

10. Tracheal incision
• Vertical incision/ midline/ tracheal
rings 3–4
• Stay sutures/ Non absorbable
/Stay sutures till the first tube change
• Slit/ cut piece?/ tracheal flap?
Dr Hazem M. Abdel Tawab, ENT, Cairo 10

11. Maturation sutures
Absorbable sutures
Safe stoma
Before insertion
Dr Hazem M. Abdel Tawab, ENT, Cairo 11

12. Insertion of the tracheostomy tube
Dr Hazem M. Abdel Tawab, ENT, Cairo 12

13. Insertion of the tracheostomy tube
Test the tube first if cuffed?
Slightly remove ETT step by step and Don't
remove till confirmation
Tapes on the chest, Don't remove, RIGHT
LEFT
Dr Hazem M. Abdel Tawab, ENT, Cairo 13

14. Secure the tube around the neck
Flex
Tape
ETT cut with tape inside to avoid pressure
on the neck
Sutures to the skin?
Dr Hazem M. Abdel Tawab, ENT, Cairo 14

15. Early care: Suction
Double the size of tracheostomy
Measure the length just 0.5 cm after the
distal end of tube
Trained personnel
0.9% saline
Dr Hazem M. Abdel Tawab, ENT, Cairo 15

16. First tube change
One week
Same size
Stay sutures
Seldinger technique/ smaller size
Dr Hazem M. Abdel Tawab, ENT, Cairo 16

17. Pediatric tracheostomy red flags
1- Air way red lags
Child suddenly able to talk/audible air leaks/bubbles seen at
mouth
Suction catheter not passing through tracheostomy
Stridor
Dr Hazem M. Abdel Tawab, ENT, Cairo 17

18. Pediatric tracheostomy red flags
2- Breathing red flags
Apnea
Increasing ventilator support
Increasing oxygen requirements
 Respiratory distress – Accessory muscle use – Increased
respiratory rate – Higher airway pressures – Lower tidal
volume
Noisy breathing
Dr Hazem M. Abdel Tawab, ENT, Cairo 18

19. Pediatric tracheostomy red flags
3- Tracheostomy related red flags
Visibly displaced tracheostomy tube
Bleeds, if in doubt then tube to be assessed
Dr Hazem M. Abdel Tawab, ENT, Cairo 19

20. Pediatric tracheostomy red flags
4- General red flags
Changes related to:
Respiratory rate
Heart rate
Blood pressure
Level of consciousness restlessness
Dr Hazem M. Abdel Tawab, ENT, Cairo 20

21. Thank you
Dr Hazem M. Abdel Tawab, ENT, Cairo 21