Death following elective tracheostomy decannulation in chronic neonatal lung disease

Pediatric tracheostomy tube decannulation with or without polysomnography: A PRO-CON debate

Determining the timing for decannulation in children with a tracheostomy is a complex process, as the appropriate timing varies based on the initial indication for the tracheostomy tube as well as individual patient characteristics. The original condition for which a tracheostomy was created may improve over time with decannulation being a very important long-term goal for many families and multidisciplinary teams. However, decannulation is an inherently risky procedure associated with morbidity and mortality. Therefore, careful planning is required to ensure the safety of the procedure. Although routine airway endoscopy is an important component of decannulation protocols, guidelines are less prescriptive regarding the definition of a complete endoscopic airway evaluation and the routine use of polysomnography. This review will summarize the important PRO and CON arguments of integrating polysomnography into pediatric decannulation protocols.

Polysomnography Provides Useful Clinical Information in the Liberation from Respiratory Technology: A Retrospective Review

Background The prevalence of respiratory-technology dependent children is increasing although for most children the goal is liberation from technology. Liberation from home mechanical ventilation (HMV) and decannulation strategies vary due to the lack of clinical practice standards. The primary objective of this study was to describe our practice utilizing a polysomnography (PSG) in the liberation from respiratory-technology process. Methods Retrospective study of tracheostomized children with and without HMV who underwent an evaluation for decannulation between January 2006 and June 2016. Patient demographics, indication for tracheostomy, indication for PSG, PSG results and interventions performed after the PSG were collected. RESULTS: We identified 153 decannulation attempts in 148 children. Ninety-nine children had a tracheostomy only and 49 children had a tracheostomy with HMV. There were 190 PSGs performed. Almost two-thirds of the children (N = 92) had at least one PSG, 37 children (25%) had two and 19 children (13%) had more than 2 PSGs. Children with tracheostomy and HMV had more PSGs compared to children with tracheostomy only. PSGs were performed at four points: (1) prior to tracheostomy placement (N = 23); (2) to titrate HMV (N = 19); (3) off-HMV support (N = 43); and with a capped tracheostomy (N = 101). Most of the off-HMV PSGs (N = 39) were favorable for discontinuing HMV. About two-thirds of the capped PSGs (N = 73) were favorable for decannulation; of the unfavorable capped PSGs (N = 28), thirteen required airway surgeries following the unfavorable PSG. CONCLUSION: : Overnight PSG provides useful information to the liberation process, particularly when determining readiness for discontinuing HMV and decannulation.

Pre-decannulation flexible bronchoscopy in tracheostomized children

OBJECTIVES

This study was aimed to evaluate the utility and benefits of flexible fiberoptic bronchoscopy (FFB) prior to tracheostomy decannulation.

METHODS

Besides demographic data, initial cause of tracheostomy, primary diagnosis, pre-tracheostomy and pre-decannulation bronchoscopic findings and duration of tracheostomy were collected from medical charts. The type of active intervention following bronchoscopy and outcome after decannulation were recorded. Departmental decannulation policy and procedure were used in all patients.

RESULTS

Forty-nine tracheostomized patients who underwent decannulation attempt were included. The median age of the children at the time of decannulation was 3 years (range 4 months-16 years). The median duration of tracheostomy was 8 months (range 1-86 months). Prolonged mechanical ventilation was the commonest indication for tracheostomy. There were 45 abnormal findings on FFB in 36 patients. Airway granulation was the commonest abnormality (23/45, 51%). Successful decannulation without any intervention was possible in 23 (46.9%) cases. 12 of these had normal bronchoscopy. Fifteen (30.6%) patients required surgical interventions before attempting decannulation. In five patients decannulation failed, while in six children decannulation was not attempted after FFB.

CONCLUSION

Pre-decannulation flexible fiberoptic bronchoscopy in children with tracheostomy helps in identifying the possible causes of decannulation failure and helps in deciding the appropriate intervention.

Tracheostomy decannulation at the Royal Hospital for Sick Children in Glasgow: Predictors of success and failure

BACKGROUND

Tracheostomy techniques, indications and care are extensively covered in the literature. However, little is written about the process of removing the tracheostomy tube. At the Royal Hospital for Sick Children in Glasgow we use a stepwise ward-based protocol for safe tracheostomy decannulation. Our aim therefore was to review all the paediatric tracheostomy decannulations that we attempted over the last 3 years to evaluate our protocol, to determine our success rate and to see whether any modifications to the protocol are required.

METHOD

We reviewed all patients who had undergone ward decannulation between January 2012 and May 2015. We extracted data from clinical records including patient characteristics, indications for tracheostomy, timing of decannulation and success or failure of the process.

RESULTS

The 45 children in the study underwent 57 attempts at decannulation during the study period. 25 were male (56%) and 20 were female (44%), and they were aged between 1 day and 16 years 6 months at the time of the original tracheostomy operation. 33 attempts were successful (58%). 10 children had more than one attempt at decannulation. Children were found to fail at every stage of the protocol, with the commonest point of failure being day 2 when the tracheostomy tube was capped.

DISCUSSION

We have demonstrated that our current protocol for ward decannulation is effective and safe, and that all five days of the protocol are required.

Tracheostomy care in the hospital

Long-term tracheostomy in infants and children is associated with significant morbidity. The majority of paediatric patients experience tracheostomy-related complications during cannulation and/or after decannulation. A large proportion of these complications are, however, preventable or may be minimised by good tracheostomy care and clinical evaluation of the patients at regular intervals, tailored to the needs of the individual child. By and large, infants and children benefit from a specialist tracheostomy service. In this article, we review different aspects of hospital-based care, covering a wide range of topics including the selection of tracheostomy tubes and adjuncts, clinical evaluation, speech/communication, and late complications and their prevention.

Can we develop a protocol for the safe decannulation of tracheostomies in children less than 18 months old?

Expanding indications for airway and head and neck surgery have led to a number of children under 18 months of age being deemed suitable for decannulation of their tracheostomies. We present four cases to illustrate the particular problems encountered in this age group and suggest modifications to our previously-published decannulation protocol.

Complications of surgical closure of tracheo-cutaneous fistula in pediatric patients - two case reports

Tracheocutaneous fistula is seen frequently in decannulated children and respiratory complications associated with primary surgical closure can be potentially fatal. Cough is a precipitating factor for an air leak and we report two cases in which this occurred. A tracheotomy was performed on a 5-month-old girl for mechanical ventilation. Decannulation was successful at the first attempt. One year later, she presented with a persistent tracheo-cutaneous fistula. After surgical closure without drainage, she developed subcutaneous emphysema during a coughing episode. Sutures were removed. A 9-month-old boy presented with oxygen-dependence after lung disease and a tracheotomy was performed for respiratory support. Decannulation was successful at the first attempt 6 months later. He developed a pneumomediastinum after surgical closure of a tracheo-cutaneous fistula. Sutures were removed but replacement of a tracheotomy tube was required. In both cases the wounds were allowed to heal by secondary intention.