Surveillance endoscopy in pediatric tracheostomy: A systematic review

Case report: The Montgomery T tube may be the preferred transition option for achieving a smooth extubation after tracheotomy when complicating airway pathology is present

Prolonged retention of tracheostomy tubes post-procedure often leads to complications, including granulation tissue overgrowth, airway narrowing, and laryngeal edema, necessitating delayed removal of the tracheostomy tube. Currently, a definitive therapeutic regimen capable of simultaneously resolving these complications and expediting tracheostomy decannulation remains elusive. Herein, we present an efficacious strategy addressing these airway morbidities and facilitating rapid tube removal. A 44-year-old male patient, who had undergone tracheostomy due to underlying disease, demonstrated substantial recovery following rehabilitation and was poised for tracheostomy tube extraction. However, bronchoscopic examination revealed severe granulation tissue at the stoma site and laryngeal edema, posing challenges to immediate decannulation. To tackle these issues concurrently while aiming for swift tube removal, we performed bronchoscopic intervention for granulation tissue excision, subsequently replacing the conventional tracheostomy tube with a Montgomery T tube as a transitional measure to restore normal ventilation. With additional rehabilitation fostering respiratory function enhancement, follow-up bronchoscopies confirmed no recurrence of granulations and significant reduction in laryngeal edema, thereby enabling the successful removal of the Montgomery T tube 2 months later, restoring the patient's unassisted respiratory capacity. This case underscores a clinically pertinent insight: following resolution of local airway abnormalities impeding tracheostomy decannulation, the strategic implementation of a Montgomery T tube as a transitional phase merits serious consideration among clinicians managing patients with long-term tracheostomies. Our findings contribute to the development of more streamlined approaches to overcoming complexities associated with tracheostomy tube removal in clinical practice.

Tracheal A-frame deformity and suprastomal collapse after pediatric tracheostomy

Objectives

To determine the incidence of A-frame deformity and suprastomal collapse after pediatric tracheostomy.

Study design

Retrospective cohort.

Methods

All patients (<18 years) that had a tracheostomy placed at a tertiary institution between 2015 and 2020 were included. Children without a surveillance bronchoscopy at least 6 months after tracheostomy were excluded. Operative reports identified tracheal A-frame deformity or suprastomal collapse.

Results

A total of 175 children met inclusion with 18% (N = 32) developing A-frame deformity within a mean of 35.8 months (SD: 19.4) after tracheostomy. For 18 children (18/32, 56%), A-frame developed within a mean of 11.3 months (SD: 15.7) after decannulation. There were 96 children developing suprastomal collapse (55%) by a mean of 17.7 months (SD: 14.2) after tracheostomy. All suprastomal collapse was identified prior to decannulation. Older age at tracheostomy was associated with a lower likelihood of collapse (OR: 0.92, 95% CI: 0.86-0.99, p = .03). The estimated 5-year incidence of A-frame deformity after tracheostomy was 32.8% (95% CI: 23.0-45.3) and the 3-year incidence after decannulation was 36.1% (95% CI: 24.0-51.8). Highly complex children had an earlier time to A-frame development (p = .04). At 5 years after tracheostomy, the estimated rate of suprastomal collapse was 73.7% (95% CI: 63.8-82.8).

Conclusions

Tracheal A-frame deformity is estimated to occur in 36% of children within 3 years after tracheostomy decannulation. Suprastomal collapse, which approaches 74% at 5 years after tracheostomy, is more common when tracheostomy is placed at a younger age. Surgeons caring for tracheostomy-dependent children should recognize acquired airway obstruction and appropriately monitor these outcomes.

Level of evidence

3.

Tracheostomy in Severe Bronchopulmonary Dysplasia-How to Decide in the Absence of Evidence

Infants with the most severe forms of bronchopulmonary dysplasia (BPD) may require long-term invasive positive pressure ventilation for survival, therefore necessitating tracheostomy. Although life-saving, tracheostomy has also been associated with high mortality, postoperative complications, high readmission rates, neurodevelopmental impairment, and significant caregiver burden, making it a highly complex and challenging decision. However, for some infants tracheostomy may be necessary for survival and the only way to facilitate a timely and safe transition home. The specific indications for tracheostomy and the timing of the procedure in infants with severe BPD are currently unknown. Hence, centers and clinicians display broad variations in practice with regard to tracheostomy, which presents barriers to designing evidence-generating studies and establishing a consensus approach. As the incidence of severe BPD continues to rise, the question remains, how do we decide on tracheostomy to provide optimal outcomes for these patients?

Neonatal Laryngotracheal Anomalies

Respiratory distress in the neonate is one of the most common reasons for referral to a tertiary NICU, accounting for more than 20% of admissions. (1) The cause of respiratory distress can range from parenchymal lung disease to anomalies of any portion of the neonatal airway including the nose, pharynx, larynx, trachea, or bronchi. This review will focus on airway anomalies at or immediately below the level of the larynx. Although rare, those with such congenital or acquired laryngotracheal anomalies often require urgent evaluation and surgical intervention. This review describes 1) the pathophysiology associated with congenital and acquired laryngotracheal deformities in the neonate, 2) the clinical presentation and diagnostic evaluation of these anomalies, and 3) the current medical and surgical strategies available in the NICU and after discharge.

Pediatric tracheostomy surveillance

We report an unusual case of a 14-month-old ex-28 week, ventilator-dependent male with a history of bronchopulmonary dysplasia and tracheostomy at 2 months of age. Lost to follow-up, at age 9 months, he presented to the emergency department with worsening respiratory distress. The patient was taken to the operating room at which time direct visualization of the airway demonstrated a mass filling the entire glottic inlet without supraglottic or pharyngeal mucosal attachments. The solid, nonvascular, mass appeared to be emanating from a suprastomal site. Excision proved to relieve the airway obstruction and postoperatively the patient has thrived.