Tracheostomy

Indications

• Prolonged intubation with failure to extubate

• Chronic ventilation requirement

  • Neuromuscular disease or injury

  • Chronic pulmonary disease requiring prolonged ventilation

• Refractory OSA

  • Particularly common in patients with cranio-facial syndromes

• Known difficult airway requiring prolonged or repeated intubations

Patient Considerations

• Reason for trach? Will this complicate anesthetic?

  • Patients with severe pulmonary disease and pulmonary hypertension are less likely to tolerate the low FiO2s and the interrupted ventilation required for tracheostomy placement

Disease Specific Considerations

• Poor lung function

  • Ventilation may be challenging

  • FiO2 requirement may be high

• Neuro problems (spinal cord, HIE, etc)

• Difficult airway?

• Pulmonary HTN

  • How will the patient display signs of Pulmonary Hypertension?

    • Is there a shunt that will act as a pop-off?

      • Pulmonary hypertension may demonstrate as desaturation

    • If no pop-off, the right heart may fail

Associated Comorbidities/Syndromes

• Pulmonary HTN 2/2 hypoxic pulmonary vasoconstriction

  • Hypoxia leads to hypoxic pulmonary vasoconstriction

    • Chronic hypoxia leads to vascular remodeling and a chronic increase in pulmonary vascular resistance

      • This increases the pressure the Right Ventricle is forced to overcome

        • The RV was not designed to function in a high-pressure system and may fail

• Anesthetic Management:

  • Case Planning

    • Thorough Pre-Anesthetic Evaluation including identification and optimization of comorbid conditions (as allowed)

    • Patients are frequently already intubated (ICU Transport)

  • Specific or Unique Room Set-Up Requirements

    • Airway

      • Frequently patients arrive with an established airway

      • Children with chronic OSA presenting tracheostomy are at high risk for airway obstruction and may be a difficult airway

    • Drugs/Infusions

      • Consider paralytic and controlled ventilation

      • Narcotics such as fentanyl may help attenuate hemodynamic stress

    • Monitors

      • Standard ASA monitors

      • EtCO2 monitoring for transport

    • Blood Availability

      • Consider if anemia or coagulopathy is present at baseline

  • PICU Bed Availability

    • Patient should be taken to PICU intubated and well-sedated post-op

  • Anesthetic Considerations

    • Anesthesia Transport to OR (EtCO2, benzo, paralytic)

    • Limit FiO2 during cautery to avoid airway fire

      • Very ill patients may not tolerate prolonged decreases in FiO2

        • Communicate with surgeon if increased FiO2 is necessary

    • Surgeon will ask for ETT to be pulled back under visualization

      • Keep ETT at or below the cords until successful ventilation through tracheostomy is established

        • May leave ETT in trachea until successful arrival in PICU

      • Be ready to reintubate from above!!!

    • When surgeon enters trachea, they will place tracheostomy tube

      • Be prepared to hand anesthesia circuit over to surgeon

        • Have an accordion piece attached to the circuit for additional flexibility

        • Verify EtCO2 ASAP and notify surgeon IMMEDIATELY if ventilation is inadequate

    • Induction

      • IV (paralytic, benzo, narcotic)

      • Inhalational

        • Via existing ETT

    • Positioning

      • Supine, bed not turned

    • Maintenance

      • Inhalational plus additional paralytic and narcotic as indicated

      • Avoid Nitrous Oxide during dissection as it predisposes to airway fire

    • Hemodynamic/Physiologic goals

      • Avoid hypoxia

      • Limit increases in PA Pressures

  • Surgical Considerations (such as neuromonitoring, muscle relaxation, anticipated blood loss)

    • Close communication with surgeon is essential

    • Limit FiO2 during cautery to avoid airway fire

    • Surgeon will ask ETT to be pulled back under visualization

    • Be ready to reintubate from above if needed

    • When surgeon enters trachea, they will place trach

      • Be prepared to hand anesthesia circuit over to surgeon

  • Emergence/Disposition

    • Return to PICU with generous sedation

  • Post-Op Pain Management

    • IV narcotics

  • Case-Specific Complications

    • Hypoxia

      • May be due to inadequate oxygenation during dissection or existing pulmonary disease

    • Pulmonary HTN crisis

      • Nitric Oxide may be required to treat severe pulmonary hypertension

    • Bronchospasm

      • Patients requiring mechanical ventilation for pulmonary infectious processes are particularly likely to experience bronchospasm

    • Fistula formation

      • Traumatic TE Fistula may occur during tracheostomy tube placement

    • Loss of Airway/Trach Dislodgement

      • Attempting to replace a fresh trach may result in intubation of false passage

        • Fiberoptic guidance is likely to be unsuccessful in the setting of fresh bleeding

      • Intubate from above in an emergency