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A Journal on Anesthesiology, Resuscitation, Analgesia and Intensive Care
ANESTHESIA IN PEDIATRICS SMART 2002 Milan, May 29-31, 2002
Minerva Anestesiologica 2002 May;68(5):433-42
Tracheostomy in pediatrics patients
Fantoni A., Ripamonti D.
Azienda Ospedaliera San Carlo Borromeo - Milano Anestesia e Rianimazione
This is a case study of 79 children who under-went a tracheostomy with three different techniques, used in succession on three different groups of patients: surgical, percutaneous with progressive probes and translaryngeal technique. The pediatric patient, only under the age of 10, starts showing clear-cut anatomical differences compared to an adult, which gradually become more marked the younger the patient is. The causes of increased difficulties that can normally be found in these patients are obviously due to the reduced diameter of the airway and, above all, the high degree of pliability of the cartilaginous frame. After the discovery that even minimal external pressure can cause the collapse of the tracheal walls, it was decided to adopt the systematic use of a rigid bronchoscope, in order to be able to offer internal support to the anterior wall. The following advantages were obtained in the various techniques:
— In surgery it permitted the reduction, through the protrusion of the trachea, of the size of the operatory field, of the tracheal opening and consequently of the local trauma. It also caused less bleeding and reduced the risk of lesion to the pleural dome which are very frequent when a bronchoscope is not used.
— In the percutaneous method the bronchoscope allowed the application of the technique without complications, even in infants of only a few months’ old, because it eliminated tracheal squashing, caused by the introduction of the needle, dilators and especially cannula, and the relative danger of lesion to the posterior wall of the trachea. This complication which was always impending in the original technique, which does not involve the use of a rigid bronchoscope, is the main reason which lead to the ban on PDT for patients younger than 16-18.
— In the translaryngeal method the advantages are of minor importance because they are limited to the initial stage of the procedure, the introduction of the needle and guide wire which are quicker and more precise.
As regard the dilation, the TLT mode has a high level of intrinsic safety and is perfectly suitable to the anatomy of the child. In fact it is carried out from the inside towards the outside, causing a tendency to evertion of the tracheal wall which the physician must even limit with external pressure. It is remarkable that this contrast in pressure and the resulting compression of the peristomal tissues creates advantages, which are essential in younger children, that cannot be found in other tracheal techniques. These advantages are the complete absence of loss of blood, minimal local trauma and a perfect adherence of the stoma to the cannula, particularly effective at level of the tracheal wall.