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 important causes of severe acute upper airway obstruction, the widespread implementation of vaccination programms against diphtheria and Haemophilus influenzae type b, as well as refinements in anaesthetic techniques, have dramatically reduced the number of emergency tracheostomies.
Studies reporting on changing trends in paediatric tracheostomy have described a significant proportional decrease in tracheostomies performed for infectious upper airway obstruction from more than 50% in the early 1970s to almost none today.
Forty years ago, children with infectious acute upper airway obstruction were frequently tracheotomised. Now the airway can be secured mostly via the transpharyngeal route. Consequently, several recent studies listed no emergency tracheostomy among their cohorts.
In the rare instances where emergency tracheostomy became necessary, injury of the larynx and the mid-face or congenital upper airway anomalies usually necessitated the intervention.
Today, the main indication for tracheostomy in acquired upper airway obstruction has shifted to causes allowing an elective intervention, such as subglottic stenosis from prolonged intubation in the neonatal period, bilateral vocal cord paralysis and upper airway trauma, i.e. burns and fractures. These tracheostomies are often temporary measures until corrective surgery can be performed or the infant has outgrown his or her susceptibility to critical airway compromise.
Some favorable criteria for tracheostomy:
- The child with upper airway obstruction
- Low chance of definitive, spontaneous resolution within
a reasonable time (weeks) - Low probability that surgery can definitely correct the
cause - High risk of critical upper airway obstruction with
simple respiratory tract infections or minor bleeding - High risk of or previous history of difficulties in
airway management in case of an emergency - Difficult-to-control gastro-oesophageal reflux
- The child requiring long-term ventilation or suctioning
- Young age with a high risk of mid-facial deformation
from mask pressure - Ventilator dependency for most of the day (more than
12 hours per day) - Inability to cope with a mask (full face or nasal mask)
- Recurrent aspirations (gastro-oesophageal reflux,
laryngeal incompetence) with significant benefit from suctioning - Safety-measures and local experience highly in favour
of invasive ventilation
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