Surgical Management of Tracheostomies and Tracheal Diversion in Children with Cerebral Palsy

Abstract

Children with cerebral palsy are most likely to have a tracheostomy placed for upper airway obstruction, although it may also aid in pulmonary toilet. The tracheostomy procedure is most safely performed in the operating room under general, endotracheal anesthesia. Initial postoperative care occurs in an intensive care unit until the first tracheostomy tube change, usually on postoperative day 5. However, a large percentage of children who receive a tracheostomy experience one or more complications. Complications are classified as immediate (occurring during surgery), early (occurring prior to the first tracheostomy tube change), or late (occurring after the first tracheostomy tube change) with late complications being by far the most common. While most complications are minor, accidental decannulation, tube obstruction, and bleeding from a tracheo-innominate fistula can be life-threatening. The surgical technique for tracheostomy should include the use of stay sutures and stomal maturation sutures as these help to minimize immediate and early postoperative complications. Children, particularly those who have already received a tracheostomy, with significant difficulties maintaining pulmonary hygiene or with recurrent aspiration pneumonia may benefit from a procedure to separate the airway from the digestive tract. Two such procedures are the laryngotracheal separation and tracheoesophageal diversion.