MINI-SYMPOSIUM: TRACHEOSTOMY IN CHILDREN
Indications for tracheostomy in children
Daniel Trachsel*and Ju ¨rg Hammer
Division of Paediatric Intensive Care and Pulmonology, University Children’s Hospital Basel, Ro ¨mergasse 8,
CH-4059 Basel, Switzerland
The history oftracheostomy portrays thehistory ofmedical
advance and of progress in material engineering. Depicted
on Egyptian tablets as early as 3600 BC, tracheostomy has
been a subject of medical debate ever since. Despite this, it
did not enter routine medical practice until the 19th
century, when doctors became increasingly open-minded
towards the procedure as a means of providing immediate
relief to patients with acute laryngeal obstruction, the
majority of cases at that time being related to diphtheria.1,2
Although a variety of indications for tracheostomy, for
example ‘pulmonary toilet’ or application of anaesthetics,
were sporadically proposed, scepticism prevailed in view of
an unacceptably high mortality. The procedure therefore
remained the last resort for acute life-threatening upper
airway obstruction.3This only changed in the early 20th
century, when Chevalier Jackson standardised the proce-
dure and its after care measures, reducing morbidity and
mortality related to the intervention.4In the years to come,
the list of indications for tracheostomy gradually increased
to comprise diseases of the entire respiratory apparatus, a
development that gained momentum with the famous
Copenhagen poliomyelitis epidemic of 1952.5Tracheost-
omy became standard of care for basically all patients with
through the mouth dates back to Hippocrates (460–375
BC), who objected to the idea of tracheostomy for fear of
injuring the carotid arteries, attempts to do this were not
undertaken until the 19th century.6Advances in material
engineering and technical refinements, however, have since
allowed a circumvention of tracheostomy in various areas
of respiratory care. The replacement of rubber and sterling
silver tubes by thermosensitive polyvinyl chloride tubes
reduced the discomfort and laryngeal damage associated
PAEDIATRIC RESPIRATORY REVIEWS (2006) 7, 162–168
Summary Vaccination programs, improvements in material engineering and anaes-
thetic skills have dramatically reduced the number of emergency tracheostomies
performed for acute upper airway obstruction. Today, the indication to tracheotomise
a child is generally ruled by the anticipation of long-term (cardio)respiratory compromise
due to chronic ventilatory or, more rarely, cardiac insufficiency, or by the presence of a
fixed upper airway obstruction that is unlikely to resolve for a significant period of time.
As many of the younger candidates for tracheostomy have complex medical conditions,
the indication for this intervention is often complicated by ethical, funding and socio-
economic concerns that necessitate a multidisciplinary approach. Unfortunately, these
considerations are frequently not made until the first catastrophe has occurred, even in
those patients in whom imminent cardiorespiratory failure has been foreseeable. Non-
invasive ventilation via a face mask and newer developments such as the in-exsufflator
device have gained importance as an alternative to tracheostomy in selected patients.
? 2006 Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: +41 61 685 6565;
Fax: +41 61 685 5004.
E-mail address: email@example.com (D. Trachsel).
1526-0542/$ – see front matter ? 2006 Elsevier Ltd. All rights reserved.
with prolonged transpharyngeal intubation.7Thus, modern
high-volume, low-pressure cuffed tubes have rendered
endotracheal intubation via the oropharyngeal or the
nasopharyngeal route an attractive and feasible alternative
for even extended periods of intubation, and the decision
to proceed to tracheostomy is generally guided by the
anticipation of long-term respiratory compromise. Similarly,
the ability to modulate face masks individually to each
patient’s facial contours, along with the excellent tolerance
towards the new materials, provides opportunity for long-
term non-invasive positive-pressure ventilation in many
patients with neuromuscular diseases.8,9In addition, the
introduction of fibreoptic intubation has made nasophar-
yngeal intubation a valuable alternative in difficult airway
management.10As a consequence, the indications for
tracheostomy have changed during the years, and they
continue to do so.
Publications suggest that the range of indications for tra-
cheostomy has broadened over the past decades. This is
strictly speaking not true because tracheostomy in children
is indicated for the same reasons as before; i.e. either it
being instituted for long-term respiratory support and/or
pulmonary toilet.11,12What has changed, however, is the
range of underlying conditions that may warrant tracheost-
omy (Table 1). Upper airway obstruction as an indication is
decreasing in frequency and ventilator-dependence is the
evolving indication in developed countries.
Congenital upper airway anomalies resulting in a difficult
airway that cannot be secured by other means frequently
necessitate transient or permanent tracheostomy, espe-
cially in infants and young children with compromised nasal
breathing (Fig. 1).13,14Chronic lung disease of infancy and
complex congenital heart disease are other important
entities associated with the occasional need for tracheost-
omy, in heart disease mostly for long-term ventilation
because of ongoing cardiac failure, tracheobronchomalacia
or postoperative diaphragmatic paresis. Most of these
children can eventually be decannulated.15,16
Most cohorts of tracheotomised children contain a
significant number of infants (32%).17A recent survey
estimated the US-wide caseload of tracheostomy in infancy
to be around 40 tracheostomy-related hospital discharges
per 100 000 child–years.17Adolescents representasecond
important subset, contributing another third to the total.
Although pulmonary disease and congenital anomalies
account for the majority of underlying diagnoses in infancy,
more than three-quarters of tracheostomies performed in
adolescents are on injury victims, a third of them having
suffered severe traumatic brain injury.17There is a pre-
ponderance of males (64%) subjected to tracheostomy –
INDICATIONS FOR TRACHEOSTOMY IN CHILDREN163
including disorders occasionally requiring emergency tracheostomy)
Indications for tracheostomy and examples of underlying conditions (not
Indications for tracheostomy Examples
Upper airway obstruction
Cystic hygroma, haemangioma
Craniofacial and laryngeal tumours
Bilateral vocal cord paralysis
Obstructive sleep apnoea
Laryngeal traumaBurn, fracture
Long-term ventilation/pulmonary toilet
Pulmonary diseaseBronchopulmonary dysplasia
Scoliosis with restrictive pneumopathy
Postoperative diaphragmatic paresis
Duchenne muscular dystrophy
Spinal muscle atrophy type I
Congenital central hypoventilation syndrome
Traumatic brain and spinal injury
Congenital heart disease
Adapted from references [12,26].
X-linked inherited diseases and high-risk behaviour in males
may contribute to this gender distribution.
Tracheostomy as a bypass for upper airway
For the past 150 years, acute life-threatening upper airway
obstruction in a child who cannot be intubated via the
pharyngeal route for any reason, whether technical or
anatomical, has indicated an emergency tracheostomy.
As epiglottitis and laryngotracheitis were the most impor-
tant causes of severe acute upper airway obstruction, the
widespread implementation of vaccination programmes
against diphtheria and Haemophilus influenzae type b, as
well as refinements in anaesthetic techniques, have dra-
matically reduced the number of emergency tracheos-
tomies.18,19Studies reporting on changing trends in
paediatric tracheostomy have described a significant pro-
portional decrease in tracheostomies performed for infec-
tious upper airway obstruction from more than 50% in the
early 1970s to almost none today.19–26
Forty years ago, children with infectious acute upper
airway obstruction were frequently tracheotomised. Now
the airway can be secured mostly via the transpharyngeal
164 D. TRACHSEL, AND J. HAMMER
stabilisation. A magnetic resonance imaging scan of the same infant on the right demonstrates the narrow upper airway anatomy. Lower
panels: An infant with cystic hygroma resulting in a critical airway. A magnetic resonance imaging scan of the same child on the right
demonstrates impressive infiltration of the upper airway structures. (Reproduced with parental consent.)
Upper panels: An infant with severe cervical kyphosis and dwarfism, resulting in a highly critical airway until surgical
route. Consequently, several recent studies listed no emer-
gency tracheostomy among their cohorts.23,27In the rare
instances where emergency tracheostomy became neces-
sary, injury of the larynx and the mid-face or congenital
upper airway anomalies usually necessitated the interven-
tion.28–31The inherent downside of this development is
that many paediatricians have little opportunity to gain
experience in emergency tracheostomy. Training in animal
laboratories might help to improve skills but will be difficult
to implement on a broad scale.32
Today, the main indication for tracheostomy in acquired
upper airway obstruction has shifted to causes allowing an
elective intervention, such as subglottic stenosis from pro-
longed intubation in the neonatal period, bilateral vocal
cord paralysis and upper airway trauma, i.e. burns and
fractures. These tracheostomies are often temporary mea-
sures until corrective surgery can be performed or the
infant has outgrown his or her susceptibility to critical
Tracheostomy in the paediatric intensive
Early reports of long-term intubation in adults suggested an
increasing risk of laryngeal damage from the second week
of intubation onwards.33,34Although no official guidelines
exist, it is a frequently adopted policy in adult intensive care
units to tracheotomise patients after 1–2 weeks of intuba-
tion if a need for long-term invasive respiratory support is
expected. The rationale for this, however, is not only based
on worries about laryngeal complications, but also on
economic constraints requiring patients to be moved
rapidly from intensive care.35Managing an adult patient
cost-effective as less sedation, less monitoring and hence
fewer personnel are needed.
In paediatric patients, the risks and implications of
tracheostomy are not the same as they are in adults. No
time limit for the transition to tracheostomy has ever met
with wide acceptance. Transpharyngeal intubation is usually
continued for prolonged periods as long as neuromuscular
or pulmonary recovery is expected. Positive experience
with prolongedtranspharyngealintubationwas gained early
in the discipline of paediatric intensive care.36,37In a retro-
spective study, Lee et al. showed that the duration of
intubation was not predictive of the likelihood of tracheost-
omy in children, and that the decision to tracheotomise a
the observation that prolonged intubation does not seem
to be a significant risk factor for post-extubational laryngeal
complications in children, thereby negating the argument
for early tracheostomy.39,40
Whether this holds true in burn patients remains con-
troversial. An adverse impact of prolonged transpharyngeal
intubation has been described in 36 severely burned
paediatric patients, in whom transition to tracheostomy
before day 10 after the burn was associated with less
subglottic stenosis (15%) compared with delayed tra-
cheostomy from day 10 onwards (>50%).28Although this
suggests that pressure and friction on the burned laryngeal
tissue contribute to constrictive scarring, the pathogenesis
of subglottic stenosis has not been clearly elucidated.28
Other arguments enforced by proponents of early tra-
cheostomy in severely burned paediatric patients include
easier handling during dressing changes, superiority in the
management of severe respiratory failure and mucus plug-
ging, and safety, bearing in mind the potentially disastrous
results of accidental extubation in those in whom significant
upper airway swelling precludes rapid reintubation.29,41
Others prefer a more conservative approach indicating a
low overall incidence ofcomplications with transpharyngeal
intubation.42A reasonable practice may be to perform
elective tracheostomy if significant (supra)glottic oedema is
present on laryngoscopy, because this subgroup is at high
risk of critical airway incidences.30
Tracheostomy for long-term ventilation/
Ethical questions need to be answered before the indica-
tions for long-term ventilation and tracheostomy can be
discussed. Physicians tend to underestimate their patients’
quality oflife,their prediction ofwhatlife-savingprocedures
a patient would want more closely reflecting their own
personal preferences than those of their patients.43,44
When a decision to tracheotomise a child is made, the
goal must be clearly defined and discussed with the family
beforehand. The issue is complicated because ventilation is
often commenced in an acute crisis, leaving no opportunity
to discuss the possibility of long-term ventilation in advance
and thereby offering little choice to the child and the family.
Unfortunately, even when the need for ventilatory support
can be anticipated early, as in older paediatric patients with
progressive disorders, long-term ventilation and end-of-life
care are often not discussed with the patient and the family.
There are no comprehensive recommendations for an
invasive versus a non-invasive mode of ventilatory support
in ventilator-dependent children. Recent surveys suggest
that young age, ventilator-dependency for most of the day
and frequent episodes of respiratory exacerbation with
need for intubation increase the likelihood of being tra-
cheotomised.45–47An increasing number of studies, how-
ever, report successful long-term, non-invasive ventilation
via a nasal or face mask in infants and young children.8,9,48,49
Experience in the non-invasiveventilationof young children
and a proficient technical service capable of providing
individually adjusted interfaces are prerequisites for success
because ventilator–patient asynchrony and pressure sores
are not uncommon problems.9,50
In addition, secondary mid-face hypoplasia has emerged
as a worrisome complication of long-term mask application
inyoung children.9,51This isnotonlyacosmetic issue:italso
INDICATIONS FOR TRACHEOSTOMY IN CHILDREN165
has a significant effect on dentition and on nasopharyngeal
patency in patients susceptible to upper airway obstruction.
The amount and duration of pressure applied by strapping
the maskto the face as well as periods of growth spurt, may
have an impact on the incidence and extent of this com-
Diaphragmatic pacing has the potential to reduce the
need for a bulky mechanical ventilator with certain causes
of ventilator-dependence.52Technological refinements,
enhanced expertise and reasonable pricing would increase
its role in managing ventilator-dependent children. Most
children will, however, still require a tracheostomy or
continuous positive airway pressure to prevent upper air-
way obstruction during electrically stimulated inspirations.
Other developments, for example the mechanical in-exsuf-
flator, might decrease the need for invasive mechanical
ventilation by facilitating and prolonging the non-invasive
management of chronic respiratory failure in children with
neuromuscular diseases.53In accordance with common
practice elsewhere,45–47the authors currently favour pri-
mary tracheostomy in young children and infants who are
ventilator-dependent, while older children (over 8 years of
age) who are able to sustain spontaneous breathing during
the daytime are good candidates for non-invasive ventila-
tion. This age limit, however, is by no means absolute.
Instead, it represents an arbitrary consensus aiming at
minimising the risk of mid-facial hypoplasia.
How to approach the indication for
With the increasing complexity of the underlying medical
problems, the decision to tracheotomise a child has
become an interdisciplinary process involving intensive care
and pulmonology specialists, paediatric otorhinolaryngolo-
gists, paediatric surgeons, social care workers and respira-
tory nurses. The attitudes of patients and caregivers
influence the choice of treatment just as much as socio-
support at home. Questions that may help the decision to
undertake a tracheostomy are proposed in Table 2. Rare
relative contraindications – local skin infections, refractory
eczema, the presence of an engorged pretracheal venous
plexus in patients with advanced superior vena cava syn-
drome, and self-mutilation in mentally handicapped chil-
dren – are generally insufficient reasons not to undertake a
Percutaneous dilational tracheostomy has increased in
popularity for temporary respiratory management in adult
intensive care units.35,54Little experience, however, exists
in children.55Provided that dilators and cannulas of appro-
priate sizes are available, percutaneous dilational tracheost-
omy might be an alternative in selected patients, for
example children with Guillain-Barre ´ syndrome or trau-
matic brain injury. Similarly, transtracheal oxygen catheters
used for long-term oxygen therapy in adult patients have
not gained widespread acceptance in paediatric practice;
these are not without complications (dislodging, mucus
plugging, local infection).56Reported advantages include
cosmetic benefits, a reduction in oxygen flow rates com-
pared with nasal cannulae, and an avoidance of conven-
The indications for tracheostomy have changed over time.
Few children are now tracheotomised for airway emer-
gencies; instead, the procedure is mostly performed for
long-term problems. As a consequence, there is in most
clinical situations no unity of approach, and the indication
for tracheostomy is influenced by multiple circumstantial
166 D. TRACHSEL, AND J. HAMMER
Table 2Criteria favouring tracheostomy in children
The child with upper airway obstruction
U Low chance of definitive, spontaneous resolution within
a reasonable time (weeks)
U Low probability that surgery can definitely correct the
U High risk of critical upper airway obstruction with
simple respiratory tract infections or minor bleeding
U High risk of or previous history of difficulties in
airway management in case of an emergency
U Difficult-to-control gastro-oesophageal reflux
The child requiring long-term ventilation/ pulmonary toilet
U Young age with a high risk of mid-facial deformation
from mask pressure
U Ventilator dependency for most of the day (more than
12 hours per day)
U Inability to cope with a mask (full face or nasal mask)
U Recurrent aspirations (gastro-oesophageal reflux,
laryngeal incompetence) with significant benefit from
U Safety-measures and local experience highly in favour
of invasive ventilation
? In patients with progressive neuromuscular or
respiratory disease,the possibility of tracheostomy
should be discussed with the caregivers and the
patient before a foreseeable emergency situation
? Tracheostomy in burn patients should be consid-
ered early if significant mucosal damage is seen by
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168 D. TRACHSEL, AND J. HAMMER