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How to perform an emergency tracheotomy on a child
Pediatric Tracheotomy | Pediatric ENT St. Petersburg
What is a tracheotomy?
The TRACHEA is the part of the AIRWAY (or breathing passage) commonly known as the “windpipe”. A tracheotomy is a surgical procedure that creates a temporary opening in the trachea. The hole itself is called a tracheotomy. The tube that is placed through this hole is called a tracheotomy tube.
What are the indications for a tracheotomy?
A tracheotomy is a temporary or permanent treatment for a variety of causes of BREATHING DIFFICULTIES in which the creation of a new breathing pathway is required, by-passing the nose, mouth, and throat. A tracheotomy is usually considered when an endotracheal (ET) tube (a tube that goes in the throat through the mouth) either will not be effective (in some emergencies for example) or would be required for a long time. Sometimes, a tracheotomy is performed when an ET tube cannot be placed due to narrowing of the windpipe or blockage of the voice box (larynx).
The reasons for performing a tracheotomy in children generally fall into three major categories:
To bypass an obstruction in the airway (most common reason)
To help with long-term ventilation in patients who cannot do this on their own (patients with respiratory muscle problems or lung problems)
To provide a temporary airway while reconstructive surgery is performed that may cause breathing problems
Who can perform a tracheotomy?
You may have heard of situations in which a tracheotomy was performed in an emergency, outside of the hospital. This procedure is called a cricothyroidotomy and is strongly discouraged even when the person performing it has some experience. It is a difficult procedure to perform in an adult, and even more dangerous on a child, as the child’s airway is much smaller and more difficult to locate than in adults. If a patient is choking and unable to breathe, the Heimlich maneuver (hands pushing in and up on the abdomen) should usually be the first option considered.
A tracheotomy is traditionally performed in a hospital setting by a physician who has extensive experience in this procedure. With advances in airway management, the number of tracheotomies required has been reduced. This procedure is usually performed by an ear, nose, and throat specialist, especially in children.
What is involved with a tracheotomy in a pediatric patient?
The airway anatomy is different in a child compared to an adult; therefore, the surgical technique used is different for pediatric (child) patients.
In the child, a tracheotomy is almost always performed under general anesthesia (patient fully asleep). Because of the small size (like a straw) of the airway, this procedure may be performed with a BRONCHOSCOPE or endotracheal tube in place during the procedure to help localize the trachea. The patient is placed on the back and a rolled towel is placed under the shoulders and neck to put the trachea in its most accessible position. A cut is carefully made in a specific location in the trachea and sutures (stitches) are placed on each side of the cut to help easily locate the new hole (tracheotomy). A tracheotomy tube is placed into this hole and tied securely in place. After the tracheotomy tube has been tested to make sure airflow is adequate, the bronchoscope or endotracheal tube is removed. Sometimes, a chest x-ray is taken to check for proper placement.
The tracheotomy tube will be changed 3 to 4 days after surgery. After this, parents are thoroughly educated in the care of the tracheotomy tube before the child goes home.
How long does the tracheotomy tube need to remain in place?
The length of time a tracheotomy tube needs to remain in place depends on the exact reason the tube was needed. For a temporary breathing problem, the tracheotomy tube may be removed after just a few months. Home health nursing is usually arranged for some time after discharge. The ear, nose, and throat surgeon and other health care providers perform close follow-ups. Speech/language pathologists are usually involved with your child as well. They will help with swallowing and speech while the tracheotomy tube is present.
How is a tracheotomy tube removed?
The name for tracheotomy tube removal is decannulation. Decannulation is always performed in the hospital setting. First, the patient’s airway is re-examined depending on the situation, there are several different ways decannulation may be carried out. Among these are:
Simply remove the tube and allow the tracheotomy site to heal
Put in a smaller tracheotomy tube in and plug over the hole of the tube during awake hours only until the child can tolerate plugging comfortably for one month
If the airway is being reconstructed (a small airway being enlarged for example), the tracheotomy tube may be removed along with this procedure or after the surgical site heals.
Remove the tracheotomy tube during a surgical procedure with surgical closure of the opening
What are the risks and complications involved with a tracheotomy?
Early Complications that may arise during the tracheotomy procedure or soon thereafter include:
Air trapped underneath the skin around the tracheotomy (subcutaneous emphysema) or in deeper layers of skin in the chest (pneumomediastinum) that may leak around the lungs (pneumothorax)
Damage to the tube going to the stomach (esophagus)
Injury to the nerve that moves the vocal cords (recurrent laryngeal nerve)
However, many of these early complications can be avoided or dealt with appropriately with an experienced surgeon in a hospital setting.
Later Complications that may occur while the tracheotomy tube is in place include:
Accidental removal of the tracheotomy tube (accidental decannulation)
Infection in the trachea and around the tracheotomy tube
These complications can usually be either prevented or quickly dealt with if the caregiver has proper knowledge of how to care for the tracheotomy site.
Delayed Complications that may result after the long-term presence of a tracheotomy include:
Thinning (erosion) of the trachea from the tube rubbing against it
Development of a small connection from the trachea to the esophagus
Development of bumps (granulomas) that may need to be surgically removed before decannulation can occur
Narrowing or collapse of the airway above the site of the tracheotomy, possibly requiring an additional surgical procedure to repair it
Once the tracheotomy tube is removed, there may remain a small hole between the trachea and the skin, which may need surgical closure
A clean tracheotomy site, good tracheotomy tube care, and regular examination of the airway by an otolaryngologist should minimize the occurrence of any of these complications. The doctors at our Pediatric ENT offices are amazing and ready to help your child.
Emergency airway puncture Information | Mount Sinai
Emergency airway puncture is the placement of a hollow needle into the airway in the throat. It is done to treat life-threatening choking.
An emergency airway puncture may be performed if all efforts to dislodge an object from the throat have failed. The procedure involves inserting a hollow needle into the throat just below the thyroid cartilage and should only be performed by a medical professional.
The cricoid cartilage (Adam's apple) is the portion of the throat used to insert a hollow needle to assist in breathing when other attempts have failed. This procedure is also known as an emergency airway puncture or cricothyrotomy.
The larynx is a tubular structure in the neck, through which air passes to the lungs. The thyroid and cricoid cartilage form the narrowest section of this airway.
Emergency airway puncture is done in an emergency situation, when someone is choking and all other efforts to assist with breathing have failed.
A hollow needle or tube can be inserted into the throat, just below the Adam's apple (thyroid cartilage), into the airway. The needle passes between the thyroid cartilage and the cricoid cartilage.
In a hospital, before inserting the needle, a small cut may be made in the skin and the membrane between the thyroid and cricoid cartilages.
Why the Procedure Is Performed
A needle cricothyrotomy is an emergency procedure to relieve an airway obstruction until surgery can be done to place a breathing tube (tracheostomy).
If the airway blockage occurs with trauma to the head, neck, or spine, care must be taken to avoid further injury to the person.
Risks for this procedure include:
Injury to the voice box (larynx), thyroid gland, or esophagus
Risks for any surgery are:
How well the person does depends on the cause of the airway blockage and how quickly the person receives proper breathing support. Emergency airway puncture provides enough breathing support for only a very short period of time.
Cattano D, Piacentini AGG, Cavallone LF. Percutaneous emergency airway access. In: Hagberg CA, Artime CA, Aziz MF, eds. Hagberg and Benumof's Airway Management. 4th ed. Philadelphia, PA: Elsevier; 2018:chap 27.
Hebert RB, Thomas D. Cricothyrotomy and percutaneous translaryngeal ventilation. In: Roberts JR, Custalow CB, Thomsen TW, eds. Roberts and Hedges' Clinical Procedures in Emergency Medicine and Acute Care. 7th ed. Philadelphia, PA: Elsevier; 2019:chap 6.
Last reviewed on: 10/12/2020
Reviewed by: Jesse Borke, MD, CPE, FAAEM, FACEP, Attending Physician at Kaiser Permanente, Orange County, CA. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A. D.A.M. Editorial team.
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"There are fewer and fewer children"
Artur Shein: I immediately told them to carry a knife
Artur Shein, father hero
"I've been working for a very long time, but I've never seen anything like this." So doctors speak of the courageous act of a resident of the Moscow region, who saved the life of his son Robert by cutting his throat with an ordinary knife. Arthur Shein himself told the VZGLYAD newspaper why his child could die and how he managed to carry out a complex operation at home.
On Friday, June 1, it became known that a tragedy almost occurred late in the evening in the Ramensky district of the Moscow region in the village of Novoye Minino. According to RIA Novosti, 10-month-old Robert Shein's tongue sunk down, he practically stopped breathing. The father, Arthur Shein, who was not taken aback in an emergency, made an incision in the baby's trachea with an ordinary knife and inserted a drainage - a tube from a ballpoint pen.
And he was practically not breathing anymore. Turn blue right before our eyes!
When the boy was taken by an ambulance to the Roshal Clinic (Research Institute of Emergency Children's Surgery and Traumatology), the doctors were shocked. They have never experienced anything like this in their practice.
“As it turned out later, during the examination of the child, the father did not perform a tracheotomy. But he almost did it! You know, I've been working for a very long time, but I've never seen anything like this. At the same time, the father has no medical education. This morning at the conference they discussed this issue, who is dad - a doctor, a paramedic? No, he just served in the army,” Maya Bukhrashvili, chief physician of the Research Institute of Emergency Pediatric Surgery and Traumatology, told the VZGLYAD newspaper.
Little Robert was brought to Roshal's clinic on duty by Deputy Director for Science, Doctor of Medical Sciences Olga Karaseva.
“I would not make this case public. Whether a tracheotomy was performed is highly questionable. There are no convincing and objective signs indicating a tracheotomy. Well, to perform tracheoscopy, just to ask if it was or not, we, of course, will not do it either, ”Olga Karaseva told the VZGLYAD newspaper.
Despite the fact that Dr. Karaseva is shocked by the act of the pope, she advises no one to take an example from Artur Shein.
“The act of the pope is very welcome – he tried to save his child. But I would not advise taking an example from him - this is a very difficult manipulation. For us, it is still unclear whether there was a tracheotomy or only an attempt to do it, and the child simply breathed. The reason for the cessation of breathing is also still unclear. According to the results of computed tomography, there are no data on aspiration syndrome. Perhaps these were the equivalents of convulsions that went away on their own.
Mother Venera and little Robert will be discharged from the Roshal clinic in a few days (Photo: personal archive)
Now everything is fine. And dad, of course, deserves great respect, because he tried with all his might to save his child, ”continues Olga Karaseva.
“As a doctor, would you advise non-specialists to perform such manipulations?” - we ask Karaseva.
“Oh... All is well when it ends well,” Olga Vitalievna replies. - This situation may be the only way out when a child has aspiration at home with a foreign body above the tracheostomy - the upper airways in the larynx are blocked. Or with swelling of the larynx with croup. Just the case that is described by Bulgakov in the story "Steel Throat". That's when it's really the only way to save the child. In all other cases, this will not save the child in any way, but it is fraught with serious complications.
Artur Shein himself says that he simply had no other choice.
VZGLYAD: Artur Vladimirovich, how did you even decide on this?
Artur Shein: When your child dies, you will do everything - both what you can and what you cannot.
VZGLYAD: How did it all start? Did he have a viral infection?
A.Sh.: Robert fell ill with a common cold. The temperature persisted for four days. And on Thursday evening he drank tea, then lay on his tummy and choked. We all sat on the couch together. And the wife suddenly noticed that he was not moving. And he was barely breathing. Almost suffocated. It was really scary - it turned blue right before our eyes! The airways were closed.
VZGLYAD: What did you start doing?
A.Sh.: I had to turn it over. Then I started sticking my hand into my mouth. And Robert has already lost his tongue. What should I do? We live in the Ramensky district. Until the ambulance arrives ... Something urgent had to be done. But the cut had to be done very carefully. When you make an incision, the ichorus can disappear into the pulmonary part, and then you need double drainage, intercostal, to suck out the blood that accumulates in the lungs.
VZGLYAD: I understand everything, but cut your own child's throat? To do this, you need to have some specific knowledge, at least. By the way, there is a similar episode in one of the episodes of "Doctor House" - did you see it there?
A. Sh.: There was a very difficult moment in my life - I lost my entire platoon in the army.
VZGLYAD: Did you serve in Chechnya?
A. Sh.: No, I served in the Volga-Urals district. In one... well, a special unit. But I'm not a commando. It was a firing squad. Over 22 years ago.
I have no one left in my service, except for one friend from Novorossiysk. So I've seen these things happen.
VIEW: That is, you remembered what you once saw, and...
A.Sh.: I immediately said to bring a knife. There was no other way out. Then he made a puncture in the upper part of the trachea in order to put some kind of drainage there. In the army, we usually used either straw or bamboo for this. To get air into the lungs. If air does not enter, then the person dies. It is only with strong training that professional divers can hold their breath for a long time. And as soon as I made a puncture, Robert began to breathe. I don't know if that had an effect or something else. Because when my son was examined in the hospital, the doctors said that it was unlikely that I had a tracheotomy.
VZGLYAD: What happened next?
A. Sh.: Robert immediately began to breathe, after 20 minutes an ambulance arrived. And, of course, questions arose - was there a knife fight here? But we live very friendly, all from good families.
LOOK: You seem to know anatomy very well.
A. Sh.: So it happened.
VZGLYAD: Are you related to medicine?
A. Sh.: No, but my uncle headed one of the serious clinics in the Volgograd region together with my aunt.
VZGLYAD: What do you do?
A. Sh.: I work for the Moscow Property Department.
VZGLYAD: How did your wife react? Did you faint?
A. Sh.: She was there. Of course she was in shock. But we love our child very much, so we had to get together and do everything that depended on us. That day we celebrated Robert's little birthday - he turned 10 months old. The second birthday.
LOOKING: Robert is not afraid of you now? Still, dad with a knife, cuts his throat.