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G513(P) Tracheostomy challenges: how small is too small?

Background and aims This report describes a 30 week baby girl born growth-restricted at 703 grams with Pierre Robin Sequence. We wish to raise awareness of the possibility of tracheostomy placement in extremely low birth weight babies, to describe use of bespoke tracheostomy tubes, and to tell the story of one of the smallest ever babies to have emergency tracheostomy for undiagnosed airway malformation. Methods Baby girl was born prematurely by C-section for IUGR and absent end diastolic flow. She required inflation and ventilation breaths at birth, then definitive airway placement for respiratory distress. Although easy to aerate the lungs with effective jaw thrust, intubation by experienced neonatal, ENT and anaesthetic consultants proved unsuccessful. Following multiple failed attempts in delivery suite to secure an airway in this otherwise stable baby, she underwent uncomplicated emergency tracheostomy in theatre. In view of her tiny size, conventional tracheostomy tubes were ineffective, and bespoke devices were fashioned using cut 2.5mmendotracheal tubes. Results Other than some unscheduled tracheostomy tube changes due to secretions or dislodgement, baby remains well on our unit, growing uneventfully with tracheostomy PEEP (4 cm of water) in air. Her tracheostomy site has healed well. Of note, serum microarray was normal. Conclusions We have demonstrated that, with the use of bespoke tubes in the setting of very short tracheal lengths involved, and careful post-tracheostomy care, it is feasible and safe to carry out tracheostomy where necessary in ELBW babies with difficult airways.