3.3 Tracheostomy Devices & Routine Care

3.3 Tracheostomy Devices & Routine Care

Pediatric tracheostomy is indicated when translaryngeal endotracheal intubation is anatomically impossible, surgically contraindicated, or clinically inappropriate for long-term respiratory care. On the NBRC NPS examination, candidates must master tracheostomy cannula selection, specialized cuff mechanics, bedside safety equipment protocols, emergent accidental decannulation algorithms, and decannulation readiness criteria.

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Clinical Indications for Pediatric Tracheostomy

Pediatric tracheostomies are performed for three major clinical categories:

1. Structural and Congenital Upper Airway Obstruction

• Severe Subglottic Stenosis (SGS): Congenital narrowing or acquired scarring (Myer-Cotton Grade III [71–99% luminal obstruction] or Grade IV [complete obstruction]) secondary to prolonged intubation or laryngeal trauma.
• Craniofacial Syndromes: Severe micrognathia and glossoptosis, such as Pierre Robin sequence, Treacher Collins syndrome, and Goldenhar syndrome, where extreme retrognathia causes refractory pharyngeal airway collapse.
• Severe Laryngotracheobronchomalacia: Dynamic collapse of cartilaginous airway walls during exhalation or agitation, causing life-threatening intrathoracic airway obstruction that fails noninvasive positive pressure ventilation.
• Laryngeal Clefts, Webs, and Vascular Anomalies: Complete tracheal rings, subglottic hemangiomas, or double aortic arch compressing the mid-trachea.

2. Prolonged Mechanical Ventilation & Chronic Respiratory Failure

• Bronchopulmonary Dysplasia (BPD) / Chronic Lung Disease of Infancy (CLDI): Premature infants requiring months of high positive end-expiratory pressure (PEEP) and mechanical ventilation who cannot be extubated without recurrent cardiopulmonary decompensation. Tracheostomy placement reduces anatomic dead space, decreases airway resistance, permits developmental mobility, and facilitates safe home mechanical ventilation.

3. Neuromuscular Disorders & Central Hypoventilation

• Spinal Muscular Atrophy (SMA Type 1), Congenital Myopathies, High Cervical Spinal Cord Injury: Progressive respiratory muscle fatigue, diaphragm paralysis, and loss of cough effectiveness leading to recurrent atelectasis and pneumonia.
• Congenital Central Hypoventilation Syndrome (CCHS): Severe loss of metabolic respiratory drive during sleep requiring lifelong nocturnal or 24-hour mechanical ventilatory support.

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Pediatric Tracheostomy Cannula Types and Engineering

Unlike adult tracheostomy tubes, pediatric tracheostomy tubes rarely feature an inner cannula due to the small internal diameter of the shaft; an inner cannula would excessively reduce luminal area and drastically increase airway resistance. Therefore, pediatric tracheostomies consist primarily of a single-lumen design.

1. Shiley Neonatal (NEO) vs. Pediatric (PED) Cannulas

• Shiley Neonatal (NEO): Specifically engineered for the anatomical proportions of preterm and term neonates. Features a shorter shaft length and a more acute angle of curvature to prevent the distal tip from impinging against the sensitive posterior or anterior tracheal wall in an infant's short neck. Available in uncuffed and cuffed designs.
• Shiley Pediatric (PED): Features a longer cannula length and a more gradual radius of curvature designed for the expanding tracheal dimensions of growing infants and children.
• Clinical rule: “Neonatal” and “pediatric” labels commonly indicate different cannula lengths, not merely different diameters. Use the prescribed manufacturer, size, length, curvature, and extended-length designation; an overly long tube can contact the carina or enter a main bronchus.

2. Bivona Tight-to-Shaft (TTS) Silicone Tracheostomy Tubes

The Bivona TTS tube is manufactured from flexible, biocompatible silicone and features a unique cuff profile:

• Water-Inflation Requirement (Critical Material Science Principle): The cuff of a Bivona TTS tube MUST be inflated exclusively with sterile water—NEVER with air. Silicone is an elastomer that is semi-permeable to ambient gas molecules. If air is injected into a silicone cuff, the gas molecules rapidly diffuse outward across the silicone wall into surrounding tissues and air, resulting in progressive cuff deflation, loss of positive pressure ventilation, and micro-aspiration. Sterile water molecules do not diffuse across the silicone barrier, maintaining a stable volume and seal.
• Tight-to-Shaft Profile: When completely deflated, the silicone cuff collapses flush against the tube shaft, mimicking the outer profile of an uncuffed tube. This reduces insertion trauma, simplifies tube exchanges, and facilitates airflow around the cannula during speaking trials.

3. Bivona Flextend Tracheostomy Tubes

The Bivona Flextend features an elongated, flexible proximal shaft that extends 20 to 30 mm beyond the stomal flange:

• Clinical Utility: Designed specifically for infants and children with extreme retrognathia (severe chin recession), short chubby necks, severe cervical flexion contractures, or high stomas. The extended shaft directs ventilator circuits, inline suction adapters, and heat-moisture exchangers (HMEs) away from the chin and chest wall, eliminating mechanical skin breakdown and preventing circuit traction on the stoma.

Table 3.2.1: Pediatric Tracheostomy Cannula Comparison

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Bedside Emergency Setup & Routine Tracheostomy Care

Every neonatal and pediatric patient with an artificial airway must have a standardized, dedicated bedside emergency kit ("Trach Go-Bag") present at all times—at the bedside, during transport, and at home.

Mandatory Bedside Emergency Setup

1. Two Spare Tracheostomy Tubes:
   • One exact-size tube: Same internal diameter and model as the currently placed tube.
   • One half-size smaller tube (0.5 mm down): Essential if stomal edema, granulation, or spasm prevents reinsertion of the primary tube.
2. Dedicated Obturators: Taped clearly to the head of the bed or kept with the corresponding spare tubes.
3. Water-Soluble Lubricating Jelly: Surgical lubricant to facilitate atraumatic insertion. Petroleum jelly (Vaseline) is contraindicated due to chemical pneumonitis risk.
4. Appropriately Sized Suction Catheters & Operational Vacuum Source: Suction catheter size calculated as $(\text{ETT size} - 1) \times 2$.
5. Manual Resuscitator with Pressure Manometer: Self-inflating or flow-inflating resuscitation bag equipped with an inline pressure relief valve (pop-off) and manometer, alongside a pediatric resuscitation face mask sized to seal over the mouth and nose.
6. Spare Tracheostomy Ties & Split Gauze Sponges: Pre-cut Velcro collars or cotton twill ties.

Routine Stoma & Tie Care

• Cleaning should be performed daily with sterile normal saline. Avoid routine hydrogen peroxide on a healing or healthy stoma because it can irritate tissue. Clean with the solution and technique in the tracheostomy plan—often sterile water or saline in the early period and mild soap and water after healing—and use any antiseptic only when specifically directed.
• Tie changes must always be performed as a two-person procedure: one clinician manually stabilizes the tracheostomy flange firmly against the neck while the second clinician removes old ties and secures the new collar. Allow one finger-width of clearance beneath the tie to prevent jugular venous congestion or pressure necrosis.

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