Ten-year review of pediatric tracheotomy

Effect of Speaking Valves on Tracheostomy Decannulation

Introduction  Despite several pediatric tracheostomy decannulation protocols there remains tremendous variability in practice. The effect of tracheostomy capping on decannulation has been studied but the role of speaking valves (SVs) is unknown. Objective  Given the positive benefits SVs have on rehabilitation, we hypothesized that SVs would decrease time to tracheostomy decannulation. The purpose of the present study was to evaluate this in a subset of patients with chronic lung disease of prematurity (CLD). Methods  A retrospective chart review was performed at a tertiary care children's hospital. A total of 105 patients with tracheostomies and CLD were identified. Data collected included demographics, gestational age, congenital cardiac disease, airway surgeries, granulation tissue excisions, SV and capping trials, tracheitis episodes, and clinic visits. Statistics were performed with logistic and linear regression. Results  A total of 75 patients were included. The mean gestational age was 27 weeks (standard deviation [SD] = 3.6) and the average birthweight was 1.1 kg (SD = 0.6). The average age at tracheostomy was 122 days (SD = 63). A total of 70.7% of the patients underwent decannulation and the mean time to decannulation (TTD) was 37 months (SD = 19). A total of 77.3% of the patients had SVs. Those with an SV had a longer TTD compared to those without (52 versus 35 months; p  = 0.008). Decannulation was increased by 2 months for every increase in the number of hospital presentations for tracheitis ( p  = 0.011). Conclusion  The present study is the first, to our knowledge, to assess the effect of SVs on tracheostomy decannulation in patients with CLD showing a longer TTD when SVs are used.

The use of tracheostomy to support critically ill children receiving orthotopic liver transplantation: a single-center experience

BACKGROUND

Children with end-stage liver disease and multi-organ failure, previously considered as poor surgical candidates, can now benefit from liver transplantation (LT). They often need prolonged mechanical ventilation (MV) post-LT and may need tracheostomy to advance care. Data on tracheostomy after pediatric LT are lacking.

METHOD

Retrospective chart review of children who required tracheostomy in the peri-LT period in a large, freestanding quaternary children's hospital from 2014 to 2019.

RESULTS

Out of 205 total orthotopic LTs performed in 200 children, 18 (9%) required tracheostomy in the peri-transplant period: 4 (2%) pre-LT and 14 (7%) post-LT. Among those 14 needing tracheostomy post-LT, median age was 9 months [IQR = 7, 14] at LT and 10 months [9, 17] at tracheostomy. Nine (64%) were infants and 12 (85%) were cirrhotic at the time of LT. Seven (50%) were intubated before LT. Median MV days prior to LT was 23 [7, 36]. Eight (57%) patients received perioperative continuous renal replacement therapy (CRRT). The median MV days from LT to tracheostomy was 46 [33, 56]; total MV days from initial intubation to tracheostomy was 57 [37, 66]. Four (28%) children died, of which 3 (21%) died within 1 year of transplant. Total ICU and hospital length of stay were 92 days [I72, 126] and 177 days [115, 212] respectively. Among survivors, 3/10 (30%) required MV at home and 8/10 (80%) were successfully decannulated at 400 median days [283, 584].

CONCLUSION

Tracheostomy though rare after LT remains a feasible option to support and rehabilitate critically ill children who need prolonged MV in the peri-LT period.

Factors affecting tracheostomy in critically ill paediatric patients in Japan: a data-based analysis

BACKGROUND

There has been an increasing number of children surviving with high medical needs, for whom tracheostomy and/or home ventilation is part of their chronic disease management. The purpose of this study was to describe the indications, epidemiology, frequency, and associated factors for tracheostomy in critically ill paediatric patients using the data available in the Japanese Registry of Paediatric Acute Care (JaRPAC).

METHODS

This multicentre epidemiologic study collected data concerning paediatric tracheostomy from the JaRPAC database. Patients were divided into two groups: those with or without tracheostomies when they were discharged from the Intensive Care Unit (ICU) or Paediatric Intensive Care Unit (PICU). Consecutive patients aged ≤16 years who did not undergo tracheostomy when admitted to ICU or PICU between April 2014 and March 2017 were included.

RESULTS

A total of 23 hospitals participated, involving 6199 paediatric patients registered in the JaRPAC database during the study period. Of the registered paediatric patients, 5769 (95%) patients were admitted to the ICUs or PICUs without tracheostomies. Among the patients, 181 patients (3.1%) had undergone tracheostomies. There were significant differences in chronic conditions (134, 74.0% versus 3096, 55.4%, p <  0.01), chromosomal anomalies (19, 10.5% versus 326, 5.8%, p <  0.01), urgent admission (151, 83.4% versus 3093, 55.4%, p <  0.01). More tracheostomies were performed on patients who were admitted for respiratory failure (61, 33.7% versus 926, 16.1%, p <  0.01) and for post-cardiac pulmonary arrest (CPA) resuscitation (40, 22.1% versus 71, 1.1%, p <  0.01).

CONCLUSIONS

This is the first report to use a large-scale registry of critically ill paediatric patients in Japan to describe the interrelated factors of tracheostomies. Chronic conditions (especially for neuromuscular disease), chromosomal anomaly, admission due to respiratory failure, or treatment for post-CPA resuscitation all had the possibility to be risk factors for tracheostomy.

Surgical management of suprastomal tracheal collapse in children

OBJECTIVE

Suprastomal collapse is a complication of pediatric tracheotomy with a potential impact on decannulation success. The aim of this study was to review the experience in the management of pediatric suprastomal collapse in a tertiary-care center, detailing the surgical technique employed.

METHODS

This study included 12 tracheotomised children with the diagnosis of suprastomal collapse in the last 5 years. All patients of the study underwent surgical intervention to manage suprastomal collapse to achieve tracheotomy decannulation. The surgical procedure entailed dissection of the pre-existing tracheotomy tract down to the trachea, then excision of the tract flush with the anterior tracheal wall. The tracheal opening was closed transversely with 3-4 interrupted absorbable sutures placed in craniocaudal direction.

RESULTS

At the end of treatment all patients were decannulated successfully. No intraoperative complications were reported. Minor postoperative complications were reported in 3 children in the form of mild surgical emphysema (n = 2) and wound infection (n = 1). Those patients were successfully managed conservatively.

CONCLUSION

This technique is a simple and effective procedure enabling immediate decannulation with very low morbidity. In a long term follow up period, no recurrence has been reported and all patients returned to their usual quality of life.

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.

Revealing the needs of children with tracheostomies

INTRODUCTION

Small children with tracheostomy are at potential risk and have very specific needs. International literature describes the need for tracheostomy in 0.5% to 2% of children following intubation. Reports of children submitted to tracheostomy, their characteristics and needs are limited in developing countries and therefore there is a lack of health programs and government investment directed to medical and non-medical care of these patients. The aim of this study was to describe the characteristics of these children and identify problems related to or caused by the tracheostomy.

METHODS

A retrospective cohort study was performed based on a common database applied in four high complexity healthcare facilities to children submitted to tracheostomy from January 2013 to December 2015. Data concerning children's demographics, indication for tracheostomy, early and late complications related to tracheostomy, airway diagnosis, comorbidities and decannulation rates are reported. Patients who did not present a complete database or had a follow-up of less than six months were excluded.

RESULTS

A total of 160 children submitted to tracheostomy during the three-year period met the criteria and were enrolled in this study. Median age at tracheostomy was 6.9 months (ranging from 1 month to 16 years, interquartile range of 26 months). Post-intubation laryngitis was the most frequent indication (48.8%). Comorbidities were frequent: neurologic disorders were reported in 40%, pulmonary pathologies in 26.9% and 20% were premature infants. Syndromic children were 23.1% and the most frequent was Down's syndrome. The most common early complication was infection that occurred in 8.1%. Stomal granulomas were the most frequent late complication and occurred in 16.9%. Airway anomalies were frequently diagnosed in follow-up endoscopic evaluations. Subglottic stenosis was the most frequent airway diagnosis and occurred in 29.4% of the cases followed by laryngomalacia, suprastomal collapse and vocal cord paralysis. Decannulation was achieved in 22.5% of the cases in the three-year period. The main cause for persistent tracheostomy was the need for further treatment of airway pathology. Mortality rate was 18.1% during this period but only 1.3% were directly related to the tracheostomy, the other deaths were a consequence of other comorbidities.

CONCLUSION

Tracheostomies were performed mostly in very small children and comorbidities were very common. Once a tracheostomy was performed in a child in most cases it was not removed before a year. The most common early complication was stoma infection followed by accidental decannulation. The most frequent late complication was granuloma and suprastomal collapse. Airway abnormalities were very frequent in this population and therefore need to be assessed before attempting decannulation.

Tracheostomy in Children

Tracheostomy is more hazardous in children than in adults, and carries special risks in the very young. The past 20 years have seen a large shift in the age distribution of tracheostomy. Whereas formerly the operation was done largely for management of epiglottitis and laryngotracheobronchitis, today the prime indication is subglottic stenosis in infants consequent upon intubation for respiratory distress syndrome and prematurity. We have reviewed experience with 57 tracheostomies in 56 children under 12 years old managed from a university hospital.

All operations were done as elective procedures, in standard fashion, by otolaryngologists. Forty (70%) were in children under 1 year old, the indications being upper airways obstruction (41), failed extubation (11), and long-term assisted ventilation (5). Subglottic stenosis was the commonest cause of obstruction (21 operations). In 91.4 accumulated years with a tracheostomy there were 11 complications related to tracheostomy, one of which (a blocked tube) was fatal. Thirty-nine children were decannulated, the mean duration of cannulation being 21 months.

In this series we suggest that the low morbidity and mortality rates were due to management by otolaryngologists; to postoperative intensive care; and, for the majority cared for at home, to careful education of parents and visits by specialist nurses.

Postoperative management of pediatric tracheostomy: Results of a nationwide survey

OBJECTIVE: A survey was undertaken to document the postoperative care of pediatric tracheostomies by otolaryngologists.

STUDY DESIGN: This study represents the results of a national survey of 564 otolaryngologists covering a broad scope of postoperative pediatric tracheostomy issues considered for patients younger than 2 years and patients older than 5 years.

RESULTS: Of the surveys sent, 134 responses were received, portraying a certain standard management scheme that seems to be used by most respondents.

CONCLUSIONS: Very little difference was seen in respondents' management of patients younger than 2 years of age as compared with those who are older than 5 years. Furthermore, agreement between actual practice and published recommendations seems to vary with some management issues. The results of this study provide a means by which otolaryngologists may familiarize themselves with national trends in the postoperative management of pediatric tracheostomies.

Pediatric Suprastomal Granuloma: Management and Treatment

OBJECTIVE: Suprastomal granulomas (SSG) are a common complication of pediatric tracheotomy. Occasionally excision is indicated for obstructive granulomas. We report on our experience on the management of SSG requiring excision.

STUDY DESIGN AND SETTING: A retrospective chart review of 68 patients who underwent SSG excision at a tertiary referral pediatric hospital between July 1997 and November 2002. The medical charts were reviewed for excision techniques and outcomes.

RESULTS: A total of 106 excisions of SSG were performed on 68 patients. Of the patients, 25 (36.8%) required multiple excisions. Removal techniques included sphenoid punch (34.9%), optical forceps (34.0%), open excision (22.6%), electrocautery (4.7%), and hook and eversion (3.8%).

CONCLUSION: The majority of SSG do not require removal. If excision is indicated, we recommend using optical forceps for soft and friable lesions and the sphenoid punch for fibrous and firm granulomas. For granulomas that have a broad base, are very large, or where endoscopic instrumentation is not possible, we recommend open excision.

Two-year mortality, complications, and healthcare use in children with medicaid following tracheostomy

OBJECTIVES/HYPOTHESIS

To assess patient characteristics associated with adverse outcomes in the first 2 years following tracheostomy, and to report healthcare utilization and cost of caring for these children.

STUDY DESIGN

Retrospective cohort study.

METHODS

Children (0-16 years) in Medicaid from 10 states undergoing tracheostomy in 2009, identified with International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes and followed through 2011, were selected using the Truven Health Medicaid Marketscan Database (Truven Health Analytics, Inc., Ann Arbor, MI). Patient demographic and clinical characteristics were assessed with likelihood of death and tracheostomy complication using chi-square tests and logistic regression. Healthcare use and spending across the care continuum (hospital, outpatient, community, and home) were reported.

RESULTS

A total of 502 children underwent tracheostomy in 2009, with 34.1% eligible for Medicaid because of disability. Median age at tracheostomy was 8 years (interquartile range 1-16 years), and 62.7% had a complex chronic condition. Two-year rates of in-hospital mortality and tracheostomy complication were 8.9% and 38.8%, respectively. In multivariable analysis, the highest likelihood of mortality occurred in children age < 1 year compared with 13+ years (odds ratio [OR] 7.3; 95% confidence interval [CI], 3.2-17.1); the highest likelihood of tracheostomy complication was in children with a complex chronic condition versus those without a complex chronic condition (OR 3.3; 95% CI, 1.1-9.9). Total healthcare spending in the 2 years following tracheostomy was $53.3 million, with hospital, home, and primary care constituting 64.4%, 9.4%, and 0.5% of total spending, respectively.

CONCLUSION

Mortality and morbidity are high, and spending on primary and home care is small following tracheostomy in children with Medicaid. Future studies should assess whether improved outpatient and community care might improve their health outcomes.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:2611-2617, 2016.

The role of polysomnography in tracheostomy decannulation of the paediatric patient

INTRODUCTION

Tracheostomy decannulation in the paediatric patient is usually considered when there is resolution or significant improvement in the original indication for the tracheostomy. The child's cardiorespiratory function needs to be optimized and assessment of the readiness for decannulation is generally by endoscopic evaluation to confirm airway patency and vocal cord mobility. Functional airway assessment procedures include downsizing the tracheostomy, adding fenestration, speaking valves and capping the tracheostomy tube. Few objective measures have been demonstrated to accurately predict the likelihood of successful decannulation. This study aims to evaluate the usefulness of polysomnography (PSG) with a capped tracheostomy tube, as an adjunct to airway endoscopy and traditional decannulation procedures, to predict decannulation outcome.

METHODS

A retrospective review was conducted for patients who underwent "capped" PSG prior to a trial of tracheostomy decannulation at the Sydney Children's Hospitals Network. The charts were reviewed for clinical data and PSG results.

RESULTS

30 children with a total of 40 PSG reports were included in this study. There was a statistically significant difference in mean oxygen saturation, minimum oxygen saturation, total apnoea/hypopnoea index, desaturations >3%, and desaturations >3% index between those that had successful decannulation compared to failed decannulation. The measures with the greatest significance, and therefore, the best predictors of decannulation outcome were total apnoea/hypopnoea index (3.35events/h vs. 18.5events/h, p=0.004) and desaturation events (20.33 events vs. 192 events, p=0.001).

CONCLUSIONS

PSG with a capped tracheostomy tube is a useful, objective tool to complement endoscopy and functional airway assessment in the consideration of decannulation in the paediatric population.

Indications, Hospital Course, and Complexity of Patients Undergoing Tracheostomy at a Tertiary Care Pediatric Hospital

OBJECTIVE

The purpose of this study was to review inpatients undergoing tracheostomies at a tertiary care pediatric hospital in a 24-month period and to identify the indications, comorbidities, hospital course, patient complexity, and predischarge planning for tracheostomy care. The goal was to analyze these factors to highlight potential areas for improvement.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary care pediatric hospital.

SUBJECTS

Ninety-five inpatients at Boston Children's Hospital requiring a primary or revision tracheostomy during the 24-month period encompassing 2010 to 2011.

METHODS

Inpatients undergoing tracheostomy during the study period were identified using 2 different databases: the Boston Children's Hospital Department of Otolaryngology and Communication Enhancement database and institution-specific information from the Child Health Corporation of America's Pediatric Health Information System (PHIS). We extracted the specified metrics from the inpatient charts.

RESULTS

Patients undergoing tracheostomy are complex, with an average of 3.4 comorbidities and 13.6 services involved in their care. The tracheostomy was mentioned in 97.9% of physician and 69.5% of nurse discharge notes, and 42.5% of physician discharge notes contained a plan or appointment for follow-up. Of the patients, 33.7% were discharged home (27.3% of the nonanatomic group and 52.4% of the anatomic group). Overall, 8.4% of tracheostomy patients died before discharge.

CONCLUSION

The complexity of pediatric tracheostomy patients presents challenges and opportunities for optimizing quality of care for these children. Future directions include the introduction and assessment of multidisciplinary tracheostomy care teams, tracheostomy nurse specialists, and tracheostomy care plans in the pediatric setting.

Bacterial biofilms and increased bacterial counts are associated with airway stenosis

OBJECTIVES

Most airway stenoses are acquired secondary to the use of prolonged endotracheal intubation. Antibiotics have been shown to decrease local inflammation and granulation tissue formation in the trachea. However, antibiotic therapy is not 100% effective in preventing or treating granulation tissue formation. Development of bacterial biofilms may explain this finding. This study evaluates the difference between tracheal stenotic segments and normal trachea in terms of (1) presence of bacterial biofilms, (2) quantitative bacterial counts, and (3) inflammatory markers.

STUDY DESIGN

Cross-sectional study.

SETTING

Tertiary care academic medical center.

SUBJECTS

A total of 12 patients were included in the study. Tissue from stenotic segments from 6 patients with airway stenosis undergoing open airway procedures were compared with tracheal tissue from 6 patients without airway stenosis undergoing tracheostomy.

METHODS

Scanning electron microscopy for biofilm detection, quantitative polymerase chain reaction for quantitative analysis of bacterial count, and immunohistochemistry were performed for inflammatory markers transforming growth factor β1 (TGF-β1) and SMAD3.

RESULTS

Compared with the patients without airway stenosis, patients in the airway stenosis group showed presence of bacterial biofilms, a significantly higher expression of 16S rRNA gene copies per microgram of tissue (187.5 vs 7.33, P = .01), and higher expression of TGF-β1 (91% vs 8%, P < .001) and SMAD3 (83.5% vs 17.8%, P < .001).

CONCLUSION

Bacterial biofilms, increased bacterial counts, and higher expression of TGF-β1 and SMAD3 are associated with airway stenosis.

Patient characteristics associated with in-hospital mortality in children following tracheotomy

OBJECTIVES

To identify children at risk for in-hospital mortality following tracheotomy.

DESIGN

Retrospective cohort study.

SETTING

25 746 876 US hospitalisations for children within the Kids' Inpatient Database 1997, 2000, 2003 and 2006.

PARTICIPANTS

18 806 hospitalisations of children ages 0-18 years undergoing tracheotomy, identified from ICD-9-CM tracheotomy procedure codes.

MAIN OUTCOME MEASURE

Mortality during the initial hospitalisation when tracheotomy was performed in relation to patient demographic and clinical characteristics (neuromuscular impairment (NI), chronic lung disease, upper airway anomaly, prematurity, congenital heart disease, upper airway infection and trauma) identified with ICD-9-CM codes.

RESULTS

Between 1997 and 2006, mortality following tracheotomy ranged from 7.7% to 8.5%. In each year, higher mortality was observed in children undergoing tracheotomy who were aged <1 year compared with children aged 1-4 years (mortality range: 10.2-13.1% vs 1.1-4.2%); in children with congenital heart disease, compared with children without congenital heart disease (13.1-18.7% vs 6.2-7.1%) and in children with prematurity, compared with children who were not premature (13.0-19.4% vs 6.8-7.3%). Lower mortality was observed in children with an upper airway anomaly compared with children without an upper airway anomaly (1.5-5.1% vs 9.1-10.3%). In 2006, the highest mortality (40.0%) was observed in premature children with NI and congenital heart disease, who did not have an upper airway anomaly.

CONCLUSIONS

Congenital heart disease, prematurity, the absence of an upper airway anomaly and age <1 year were characteristics associated with higher mortality in children following tracheotomy. These findings may assist provider communication with children and families regarding early prognosis following tracheotomy.

Tracheostomy in children: a population-based experience over 17 years

INTRODUCTION

Tracheostomy is a lifesaving intervention with numerous complications.

OBJECTIVES

We describe the natural history of tracheostomy in children in a defined geographical area over a 17-year period. Our primary aim is to stress the need for a consensus on pediatric tracheostomy care.

METHODS

This retrospective study reviewed the charts of 72 children who had tracheostomy between January 1990 and January 2007. Indications for the procedure were divided into 3 groups: (1) upper airway obstruction at a well-defined anatomic site (32 patients); (2) upper airway obstruction with a complex medical condition (24 patients); and (3) need for an access to the lower airway for long-term ventilation and pulmonary care with normal airway anatomy (16 patients).

RESULTS

The most common indication for tracheostomy was upper airway obstruction due to subglottic stenosis (15 patients, 21%) or as part of a complex craniofacial syndrome (15 patients, 21%). The duration of intubation prior to tracheostomy and the duration of hospitalization after tracheostomy varied markedly. Tracheocutaneous fistulae complicated 15 of the 38 (37%) decannulated patients. Tracheostomy infection occurred in 90% of the patients and tracheal granulation in 56%. Eleven (15%) deaths occurred, 10 were due to the underlying medical illness and 1 to a mucous plug.

CONCLUSION

The complications of tracheostomy in children are substantial. Surveillance and prompt interventions are necessary to overcome life-threatening sequelae. A multidisciplinary (medical-surgical) approach provides better care for these highly vulnerable children. A consensus on pediatric tracheostomy care is needed.

Predictors of clinical outcomes and hospital resource use of children after tracheotomy

OBJECTIVES

The objectives are to describe health outcomes and hospital resource use of children after tracheotomy and identify patient characteristics that correlate with outcomes and hospital resource use.

PATIENTS AND METHODS

A retrospective analysis of 917 children aged 0 to 18 years undergoing tracheotomy from 36 children's hospitals in 2002 with follow-up through 2007. Children were identified from ICD-9-CM tracheotomy procedure codes. Comorbid conditions (neurologic impairment [NI], chronic lung disease, upper airway anomaly, prematurity, and trauma) were identified with ICD-9-CM diagnostic codes. Patient characteristics were compared with in-hospital mortality, decannulation, and hospital resource use by using generalized estimating equations.

RESULTS

Forty-eight percent of children were <or=6 months old at tracheotomy placement. Chronic lung disease (56%), NI (48%), and upper airway anomaly (47%) were the most common underlying comorbid conditions. During hospitalization for tracheotomy placement, children with an upper airway anomaly experienced less mortality (3.3% vs 11.7%; P < .001) than children without an upper airway anomaly. Five years after tracheotomy, children with NI experienced greater mortality (8.8% vs 3.5%; P <or= .01), less decannulation (5.0% vs 11.0%; P <or= .01), and more total number of days in the hospital (mean [SE]: 39.5 [4.0] vs 25.6 [2.6] days; P <or= .01) than children without NI. These findings remained significant (P < .01) in multivariate analysis after controlling for other significant cofactors.

CONCLUSIONS

Children with upper airway anomaly experienced less mortality, and children with NI experienced higher mortality rates and greater hospital resource use after tracheotomy. Additional research is needed to explore additional factors that may influence health outcomes in children with tracheotomy.

Non-invasive ventilation in children with upper airway obstruction

OBJECTIVE

The aim of this paper is to highlight our experience with the use of non-invasive positive pressure ventilation (NIPPV) in children, neonates and pre-term infants with upper airway obstruction.

METHODS

This was a retrospective review of our recent experience in using NIPPV for the management of upper airway obstruction in paediatric patients.

RESULTS

NIPPV was successful in preventing tracheostomy in patients with significant laryngo-tracheomalacia as well as being used to optimise the timing of surgery in subglottic stenosis. Furthermore, it proved beneficial in stabilising the airway after aryepiglottoplasty and also had a role in the management of obstructive sleep apnoea.

CONCLUSION

The use of NIPPV in children with upper airway obstruction can be a safe and effective alternative to invasive mechanical ventilation. NIPPV can potentially be beneficial in avoiding prolonged invasive ventilation, avoiding tracheostomy, stabilizing the airway after extubation or decannulation, and management of obstructive sleep apnoea.

Surgical management of severe suprastomal cricotracheal collapse complicating pediatric tracheostomy

OBJECTIVE

Suprastomal tracheal collapse may interfere with decannulation in tracheostomized patients. The purposes of the study are to evaluate the role of tracheotomy technique in the ethiology of suprastomal cricotracheal collapse and to report our results in the treatment of this complication.

METHODS

A retrospective review of children showing severe suprastomal collapse during the period 1990-2007, in a tertiary care children's hospital, was performed. Medical records were assessed for the following data: sex, age, original indication for tracheotomy, surgical technique, endoscopic findings, type of surgical correction, complications, result, and follow-up.

RESULTS

Fourteen patients were included in the study, nine girls and five boys. Average age at tracheotomy was 17 months (range: 21 days-8 years), and prolonged ventilatory support was the most common indication (57%). Horizontal H-type tracheotomy was the most frequent technique in patients with suprastomal collapse (n=9), whereas only one patient with a vertical tracheotomy showed this complication (p<0.05). In every case bronchoscopy disclosed a suprastomal tracheal obstruction of at least 50% of the lumen. Mean age at surgical decannulation was 38 months (range: 12-147 months). Two surgical techniques have been used in the treatment of suprastomal collapse: anterior cricotracheal suspension (n=13) and reconstruction with autologous cartilage graft (n=1). All the patients were successfully decannulated although in one case two procedures were required. No recurrence has been observed during long-term follow-up (mean: 8.6 years).

CONCLUSIONS

Endoscopical examination is essential for the diagnosis of suprastomal collapse and to rule out other causes of decannulation failure. In our experience, the tracheotomy technique seems to have an ethiologic role, and anterior cricotracheal suspension is a simple and effective procedure in the treatment of this tracheostomy related complication.

Current trends in paediatric tracheostomies

OBJECTIVE

In the 1970s, the most common indication for tracheostomy in children was acute inflammatory airway obstruction. Modern neonatal intensive care units have turned long-term intubation into an alternative to tracheostomy. Long-term intubation itself has become the most important indication for tracheostomy combined with subglottic stenosis.

METHODS

Retrospective analysis in a tertiary referral center. A total of 38 patients who underwent tracheostomy for respiratory failure and upper airway obstruction from 1 November 1998 to 30 November 2004.

RESULTS

Total complication rate was 42.1%. In children under 1 year of age the complication rate was 47.4%, in children over 1 year the complication rate was 26.3%. Decannulation was attempted in 12 patients with a cannulation time of 22 months.

CONCLUSIONS

Long-term intubation and its sequelae have now become one of the most important indication for tracheostomy. The change of indication has also entailed a decrease of the average age of children who require tracheostomy. A longer period before decannulation and a lower average age have changed the complication rate of tracheostomy in paediatric patients.

Indications for tracheostomy in children

Vaccination programs, improvements in material engineering and anaesthetic skills have dramatically reduced the number of emergency tracheostomies performed for acute upper airway obstruction. Today, the indication to tracheotomise a child is generally ruled by the anticipation of long-term (cardio)respiratory compromise due to chronic ventilatory or, more rarely, cardiac insufficiency, or by the presence of a fixed upper airway obstruction that is unlikely to resolve for a significant period of time. As many of the younger candidates for tracheostomy have complex medical conditions, the indication for this intervention is often complicated by ethical, funding and socio-economic concerns that necessitate a multidisciplinary approach. Unfortunately, these considerations are frequently not made until the first catastrophe has occurred, even in those patients in whom imminent cardiorespiratory failure has been foreseeable. Non-invasive ventilation via a face mask and newer developments such as the in-exsufflator device have gained importance as an alternative to tracheostomy in selected patients.

Endoscopic percutaneous dilatational tracheotomy: a prospective evaluation of 500 consecutive cases

OBJECTIVES/HYPOTHESIS

An evaluation of 500 adult, intubated, intensive care unit patients undergoing endoscopic percutaneous tracheotomy using the multiple and single dilator techniques was conducted to assess the feasibility and safety of the procedure as it compares with surgical tracheotomy. Endoscopy was used in all cases and evaluated as an added safety measure in reducing complications.

STUDY DESIGN

A prospective evaluation of endoscopic percutaneous dilatational tracheotomy in 500 consecutive adult, intubated intensive care unit patients.

METHODS

Between 1990 and 2003, endoscopically guided percutaneous dilatational tracheotomy (PDT) was performed in 500 consecutive adult, intubated patients in the intensive care units (ICU) of three tertiary care adult hospitals. The first 191 patients underwent PDT using the Ciaglia Percutaneous Tracheostomy Introducer Kit (Cook Critical Care Inc., Bloomington, Indiana) and in the remaining 309 patients the Ciaglia Blue Rhino Single Dilator Kit (Cook Critical Care Inc., Bloomington, Indiana) was used. The procedure was contraindicated in the following situations: 1) children, 2) unprotected airway, 3) emergencies, 4) presence of a midline neck mass, 5) inability to palpate the cricoid cartilage, and 6) uncorrectable coagulopathy. The following parameters were recorded preoperatively: age, sex, diagnosis, American Society of Anesthesia (ASA) class, body mass index (BMI), and number of days intubated. Recorded hematologic parameters included hemoglobin (Hgb), platelets, prothrombin time (PT), partial thromboplastin time (PTT), and the international normalized ratio (INR) since it became available in 1998. All patients were ventilated on 100% oxygen and vital signs were continuously monitored. Tracheotomy was carried out under continuous endoscopic guidance using a series of graduated dilators in the first 191 cases, and a single, tapered dilator in the remaining 309 patients. The preoperative data on each patient, along with the type of dilator used, the size of the tube, the intraoperative and postoperative complications, and blood loss information were recorded prospectively and maintained in a computer spreadsheet. Univariate analyses were used in each group separately for each type of dilator to assess the risks of a complication within subgroups defined by each parameter/characteristic, and the statistical significance assessed with a chi test, or Fisher exact test.

RESULTS

The total complication rate was 9.2% (13.6% in the multiple dilator group, and 6.5% in the single dilator group), with more than half of these considered minor. Overall, the two most common complications were oxygen desaturation in 14 cases and bleeding in 12 cases. The absence of serious complications such as pneumothorax and pneumomediastinum are attributable to the use of bronchoscopy. There was no significant association between the rate of complications and age, gender, ASA, weeks intubated, tracheostomy tube size, Hgb levels, platelets, PT, PTT, or INR. There was a statistically significant relationship between experience and the likelihood of complications in the multiple dilator group (P < .0001), with a higher rate of complications in the first 30 patients (40%) compared with 8.7% in the remaining 161 patients. This relationship did not exist for the first 30 patients in the single dilator group. Patients with a BMI of 30 or higher experienced a significantly greater (P < .05) number of complications (15%), compared with an 8% complication rate in patients with a BMI of less than 30. This risk was even more significant for patients with a BMI of 30 or greater who were also in ASA class 4 (11/56 or 20%) (P < .02).

CONCLUSIONS

Endoscopic PDT is associated with a low complication rate and is at least as safe as surgical tracheotomy in the ICU setting. Bronchoscopy significantly decreases the incidence of complications and should be used routinely. While embraced by critical care physicians, endoscopic PDT has been infrequently performed by otolaryngologists. As the airway experts, otolaryngologists are in the best position to learn and teach the procedure as it should be done.

Outcome of patients requiring tracheostomy in a pediatric intensive care unit

BACKGROUND

Although tracheostomy is a commonly performed procedure, there is a lack of studies in the pediatric intensive care unit (PICU) setting that describe its association with patient outcome and especially hospital mortality. Our goal was to evaluate the outcome of patients receiving a tracheostomy, while on mechanical ventilation (MV), in a PICU.

METHODS

Records of 260 children were reviewed retrospectively regarding PICU mortality, PICU length of stay (PICU LOS), duration of MV and a cost indicator (weighted hospital days; WHD).

RESULTS

Nineteen patients received tracheostomy (7.3%). The mortality of patients submitted to tracheostomy in the longer term was significantly higher compared to patients who were not (52.6%vs. 27.6%; P = 0.04) despite having a significantly lower severity of illness at admission (Pediatric Risk of Mortality score--PRISM) (10.9 vs. 13.7; P < 0.001). The mortality of patients without tracheostomy, however, was significantly higher within 30 days (24.8%vs. 5.2%, P < 0.001). Tracheostomized patients had significantly higher mean PICU LOS (68 days vs. 8 days; P < 0.001), duration of MV (62 days vs. 4 days; P < 0.001) and higher WHD (171.5 vs. 21.5; P < 0.001).

CONCLUSION

Contrary to findings in critically ill adult patients, ventilated children receiving a tracheostomy had less favorable outcomes compared with non-tracheostomized patients. In view of the greater use of resources, further studies are needed to confirm and to identify the subgroups of mechanically ventilated patients who will benefit most from this procedure.

Detection of Pseudomonas aeruginosa type III antibodies in children with tracheostomies

Pseudomonas aeruginosa is often cultured from the airways of children with tracheostomies. P. aeruginosa produces exotoxin A (ETA) and type III cytotoxins. This study tested the hypothesis that children with tracheostomies are colonized by P. aeruginosa that express these virulence factors and will have antibodies directed against these virulence factors, indicating infection rather than only colonization. A convenience sample of 30 patients, ranging in age from 2 months-22 years, was recruited. Serum was tested for the presence of antibodies to ETA and components of the type III system by Western blot analysis. Twenty-one of 39 patients (70%) had antibodies to components of the type III system. Fifteen of 30 (50%) were seropositive for ETA. Sera from patients who were antibody-positive for ETA were also seropositive for either ExoS or ExoU. Nine of 30 patients (30%) did not possess antibodies to ETA or components of the type III system. In conclusion, these data identified a seropositive reaction to P. aeruginosa cytotoxins in some patients with tracheostomies, suggestive of infection by cytotoxic strains of P. aeruginosa. Future studies will determine the utility of measuring seroconversion to these cytotoxins as an early indication of infection in children with tracheostomies.

Starplasty: revisiting a pediatric tracheostomy technique

OBJECTIVE

To determine the efficacy the "starplasty" pediatric tracheostomy technique in reducing the incidence of major complications and tracheotomy-related death.

METHODS

Retrospective chart analysis of all the cases of starplasty performed at 2 tertiary care centers between 1990 and 2002.

RESULTS

There were 94 children in our cohort ranging in age from 2 days to 14 years. Of the patients, 47 (50%) were females and 47 (50%) were males and 60 of the children (64%) were younger than 1 year of age. Forty-one patients (44%) had neurologically related airway problems as their primary indication for tracheostomy, 34 (36%) had upper airway obstruction, and the remainder had pulmonary diseases, prolonged intubation, or metabolic-related airway problems. There were 41 short-term complications including 5 cases of tracheal tube dislodgement. There were no instances of pneumothorax or tracheostomy-related death. There were 26 long-term complications. There were no cases of clinically relevant suprastomal collapse that compromised decannulation and no instances of tracheal stenosis. Twenty-six patients underwent decannulation, all of whom developed a tracheocutaneous fistula (TCF). Two patients had spontaneous closure of the TCF; 9 patients underwent surgical repair of their fistulas, 53 patients remain tracheostomy-dependent, and 8 patients died of their primary disease.

CONCLUSION

The need for pediatric tracheotomy has increased as a consequence of our success in treating chronically ill children. Starplasty reduces the incidence of major complications, including pneumothorax and death from accidental decannulation. Its major drawback is the need for secondary reconstruction of a tracheocutaneous fistula.

EBM RATING

C.

Endoscopic KTP laser excision of severe tracheotomy-associated suprastomal collapse

OBJECTIVE

The purpose of this study was to investigate the feasibility, safety, and clinical utility of potassium-titanium-phosphate (KTP) laser bronchoscopy for excision of severe, obstructing tracheotomy-associated suprastomal collapse.

METHODS

A retrospective review was performed of six children at a tertiary care children's hospital with severe tracheotomy-associated collapse of the suprastomal anterior tracheal wall cartilage, precluding decannulation. All subjects had undergone KTP laser endoscopic excision of the collapsed segment of suprastomal tracheal cartilage. Medical records were assessed for: (1) endoscopic demonstration of relief of suprastomal collapse, and (2) successful tracheotomy decannulation.

RESULTS

All six patients had endoscopic evidence of relief of suprastomal airway obstruction after KTP laser therapy. Five of six (83%) subsequently underwent successful decannulation. There was one case of minimal thermal airway injury associated with a laser fire during use of the KTP laser, the effects of which were fortunately transient.

CONCLUSIONS

KTP laser bronchoscopic excision of severe tracheotomy-associated suprastomal collapse: (1) is a feasible technique; (2) results in relief of suprastomal obstruction with subsequent successful decannulation in selected patients; and (3) avoids the need for more extensive open neck procedures. However, risks of KTP laser therapy are not negligible and strategies must be in place to minimize the occurrence of complications.

Pediatric tracheostomy: a 13-year experience

Pediatric tracheostomy has been reported to be a surgical procedure with significant morbidity and mortality. The use of tracheostomy in airway management has changed over time as regards indication and outcome. A review of the last 13 years' experience in our institution was carried out to focus on this group of patients and the recent trends in airway management. A retrospective analysis of hospital records was done and information collected with respect to age, gender, indication for tracheostomy, duration, complications, and follow-up. Thirty-nine tracheotomies were done in 36 patients, of whom males outnumbered females 2:1. The mean patient age was 41.6 months while nearly a third were newborns. The indications were congenital and acquired obstructive lesions. Apart from nine cases, all have been treated and decannulated. Follow-up ranged from 1 month to 8 years, and decannulation time from 48 h to 45 months. Home tracheostomy care was very well managed by the parents. One tracheostomy-related death was encountered. Complications were minor and transient and occurred post-decannulation in our series, in contrast to the major complications, both acute and chronic, reported in the literature. More neonates and infants are undergoing tracheostomy and surviving. Pediatric tracheostomy is a safe procedure with home care by parents feasible.

Microsurgical tracheotomy: a pediatric model in growing rats

Previous studies described controversial opinions about pediatric tracheotomy concerning type of tracheal incision and long-term results, which remain as important research subjects. Experimental studies on rat tracheas are scarce, probably because of technical difficulties related to the structures' small dimensions. As many rat organ and system operative procedures were studied successfully by using microsurgical techniques, we decided to develop a pediatric tracheotomy model in growing rats which would permit long-term studies. Forty-four Wistar EPM-1 growing rats weighing 86 g and aged 35 days were divided into three groups: submitted to longitudinal, transverse, and segment excision of the trachea. Under sterile technique and intramuscular anesthesia (ketamine/xylazine), the trachea was exposed and incised, according to group, and a hand-made endotracheal cannula was inserted into the organ. This cannula was assembled using a segment of 1.5-cm-long 3 French silicone catheter passed through hexagonal-shaped silicone screen. The tracheal cannula was removed after 7 days, when we evaluated body weight, secretions, and dehiscence. In conclusion, this microsurgical tracheotomy model in growing rats is feasible, allowing studies on long-term repercussions of pediatric tracheotomy.

Six cases of children with a benign cervical tumor who required tracheostomy

Cervical tumors sometimes cause airway obstruction. We have treated six children with benign cervical tumors who required tracheostomy. Two cervical and one glossal lymphangiomata treated with local injection of OK432 after creating a tracheostomy were successfully decannulated after the treatment. One patient with a giant cervical lymphangioma needed an EXIT (ex utero intrapartum treatment) procedure. He underwent tracheostomy at 10 months of age after long-term endotracheal intubation, but he died of sepsis and hypoxic brain damage at 18 months. One patient with a subglottic hemangioma treated with steroids finally achieved closure of the tracheostomy at 2 years of age. A 7-year-old girl with a tracheal schwannoma underwent tracheostomy performed a week after admission, but she already had hypoxic brain damage resulting from problems with intubation. Most patients with a lymphangioma or hemangioma in the cervical region have required early tracheostomy before commencing treatment with OK-432 or steroids. If there is any sign of possible airway compromise, then it is vital to perform an early tracheostomy, even for benign tumors.

Tracheotomy in growing rats: histological aspects

PURPOSE: To compare morphologically three different types of tracheotomy in growing rats, applying microsurgical technique. METHODS: EPM-1 Wistar growing rats (n=57) weighing 88gm and aged 35 days were randomized in four groups, according tracheotomy incision type (longitudinal, transverse and tracheal segment excision), and sham group. Following intramuscular anesthesia with ketamine and xylazine, the trachea was exposed and incised, according to the group, and a hand-made endotracheal cannula was inserted into the organ, under sterile conditions. This cannula was removed after 7 days, and animals have been sacrificed 30 days later. Tracheas samples were submitted to histological study, stained by hematoxylin-eosin and Masson trichrome, evaluating fibrosis, inflammatory infiltrate and epidermoid metaplasia. RESULTS: There was more frequency of inflammatory infiltrate at the tracheal epithelium in the tracheal segment excision group (87%) compared to the longitudinal (40%) and transverse (36%) incision groups (p=0.009). Evaluating epidermoid metaplasia, tracheal segment excision and the longitudinal groups presented 33% and 40%, respectively, compared to 0% of the transverse group (p=0.03). Concerning to fibrosis, in a global comparison (p=0.1) among the three groups there was no difference, however, compared to the longitudinal group the transverse group showed lower level of fibrosis (p=0.04). Sham group did not present any relevant morphologic alterations and it was used as reference pattern. CONCLUSION: Taken together, our data show that tracheal segment excision promotes more epithelium aggression and transverse tracheal incision shows less morphologic alterations.

Outcome in pediatric tracheotomy

OBJECTIVE

To investigate the outcome and related factors in pediatric tracheotomy.

DESIGN

Retrospective chart review.

SETTING

Tertiary pediatric academic hospital setting.

PATIENTS

The study included 181 children below the age of 18 years who underwent 185 tracheotomies between 1991 and 1995.

MAIN OUTCOMES AND MEASURES

Presenting symptoms and signs, indications, duration of follow-up, therapeutic and interval procedures, early and late complications, mortality, time to and success in decannulation.

RESULTS

There were 108 (59.7%) male patients and 73 (40.3%) female patients. The average age of the children at the time of tracheotomy was 3.8 +/- 5.3 years. The majority of the children were less than 1 year of age (n = 99, 54.7%). Airway obstruction was the leading indication for tracheotomy (59.6%), followed by ventilatory support (30.4%) and pulmonary toilet (9.9%). The average duration of follow-up was 931 +/- 790 days. There were no perioperative complications. Early postoperative complications were seen in 28 (15.5%) children including 12 (6.8%) major complications and 22 (12.2%) minor complications. Late complications were seen in 115 (63.5%) children, including 8 (4.4%) major complications and 107 (59.1%) minor complications. Overall mortality rate was 13.3%, but only 1 tracheotomy-related death was caused by tube displacement. Therapeutic procedures were performed in 43% of the children, including laryngotracheal reconstruction (13%), laser excision of the lesion (5%), and supraglottoplasty (3.9%). Decannulation was accomplished in 116 (64.1%) of the children with an average of 365 +/- 388 days with tracheotomy.

CONCLUSION

Tracheotomy is relatively safe in the pediatric population. Decannulation may be possible relatively quickly with resolution of the underlying problem.

The changing indications for paediatric tracheostomy

OBJECTIVE

To investigate whether the incidence and indications for paediatric tracheostomy in this unit have changed over recent years.

METHODS

All paediatric tracheostomies performed between 1993 and 2001 were identified from our departmental database. The indications for these were ascertained by retrospective case note review.

RESULTS

Over the 9-year period studied 362 tracheostomies were performed, the number increased slightly between the first and second half of the period, with peaks in 1997 and 1999. The commonest indication was prolonged ventilation due to neuromuscular or respiratory problems.

CONCLUSIONS

This large series shows that the increase in frequency of paediatric tracheostomy performed in this unit over the past decade has been due to conditions such as subglottic and tracheal stenosis, respiratory papillomatosis, caustic alkali ingestion and craniofacial syndromes. Conditions in which tracheostomy are now less common are subglottic haemangioma and laryngeal clefts. Prolonged ventilation remains the commonest indication overall.

KTP laser treatment of suprastomal obstruction prior to decannulation in paediatric tracheostomy

OBJECTIVE

Decannulation following tracheostomy in the paediatric patient is often complicated by the development of secondary suprastomal obstruction. We describe the technique of bronchoscopic KTP laser therapy in the management of such conditions, and have audited the results of this treatment with 12 children treated with this modality before attempted decannulation over the last 2 years at Great Ormond Street Hospital for Children (GOSH).

METHOD

Via a retrospective record review.

RESULTS

Eight (67%) were successfully decannulated, with four being unsuccessful. All children with less than 50% suprastomal obstruction were successfully decannulated following bronchoscopic KTP laser treatment.

CONCLUSIONS

Bronchoscopic KTP laser therapy is a useful tool in the abolition of suprastomal obstruction prior to decannulation following paediatric tracheostomy. Children with greater than 50% obstruction are likely to require an open procedure.

Indications, complications, and surgical techniques for pediatric tracheostomies--an update

BACKGROUND

With the decrease of life-threatening obstructive upper airway infections and the ongoing improvement of intensive care medicine, the role of tracheostomy in children has been changing considerably, until now. The aim of this study was to establish data regarding indications, complications, and techniques of pediatric tracheostomy, which would reflect the current state of science.

METHODS

The authors analyzed the international literature as well as their own experience with 25 children less than 6 years of age who were operated on between 1980 and 1996.

RESULTS

Literature proved to be very heterogeneous in terms of terminology, patient groups, operation techniques, indications, and complications. Within the past decades, long-term intubation and congenital anomalies of the upper respiratory tract have become increasingly prevalent, whereas inflammatory diseases were less and less an indication for tracheostomy. Endotracheal intubation as an alternative has resulted in less frequent tracheostomies in general. Today, children can be ventilated for months without considerable complications. However, individual, clinical, and fiberoptical controls are necessary. Tracheostomy-related complications have not changed significantly. Fatalities are mostly caused by the underlying disease. The most frequent causes of tracheostomy-related death are cannula obstruction and accidental decannulation. The most frequent early complications are pneumomediastinum, pneumothorax, wound complications, and bleedings. Subsequent complications most often are granulations and tracheal stenosis.

CONCLUSIONS

The authors' research agreed widely with that in the literature. However, no tracheostomy-related death occurred. Possibly, this was because of their operative technique. In the opinion of the authors, establishing a cartilage window facilitates cannula exchange and reduces the risk of a fatal accidental decannulation.

The role of postoperative chest radiography in pediatric tracheotomy

A postoperative chest radiograph has traditionally been obtained after tracheotomies to evaluate for the presence of a pneumothorax and to assess tube position. Several recent studies in adults have questioned the usefulness of routine postoperative chest radiography in uncomplicated cases, but the role of post-operative chest radiography in pediatric patients has not been previously reviewed. We performed this study to examine the clinical utility of post-tracheotomy chest radiography in pediatric patients and determine if this routine practice impacts patient management enough to merit continued usage. A retrospective review was performed of 200 consecutive pediatric patients who underwent tracheotomies by the otolaryngology service in a tertiary care pediatric hospital from January 1994 to June 1999. All patients received postoperative chest radiographs. Five of 200 patients had a new postoperative radiographic finding, with three requiring interventions. Two patients required chest tube placement for pneumothorax, and one patient required tracheostomy tube change for repositioning. Fifty-one patients, including both pneumothoraces, exhibited clinical signs of pneumothorax (decreased breath sounds or oxygen saturation) in the immediate postoperative period. Chest X-ray ruled out a pneumothorax in the remaining 49 patients. The majority of these 51 patients were less than 2 years old (94%, P=0.002) or weighed less than 17 kg (89%, P=0.004). Postoperative chest X-rays yielded clinically relevant information in 168 patients that fell into one or more of four high risk categories: age less than 2, weight less than 17 kg, emergent procedures, or concomitant central line placement. Avoiding chest X-rays in the remaining 32 patients would have resulted in potential savings of $5000, which does not reflect the actuarial cost of a missed complication. Since the majority of our patients (84%) fell into a high-risk category, we feel it would be prudent to continue obtaining postoperative chest radiographs following all pediatric tracheotomies.

Pediatric tracheotomies: changing indications and outcomes

OBJECTIVE/HYPOTHESIS

To study the outcomes and complications associated with pediatric tracheotomy, as well as the changing trend in indications and outcomes since 1970.

STUDY DESIGN

Retrospective chart review at a major tertiary care children's hospital.

METHODS

On children who underwent tracheotomy at Children's Hospital of the King's Daughters (Norfolk, VA) between 1988 and 1998, inpatient and outpatient records were reviewed. Of 218 tracheotomies, sufficient data were available on 204. Indications for tracheotomy were placed into the following six groups: craniofacial abnormalities (13%), upper airway obstruction (19%), prolonged intubation (26%), neurological impairment (27%), trauma (7%), and vocal fold paralysis (7%).

RESULTS

The average age at tracheotomy was 3.2 +/- 0.6 years. Although the prolonged intubation group was significantly younger than all others, the neurological impairment and trauma groups were significantly older. Decannulation was accomplished in 41%. Time to decannulation was significantly higher in the neurological impairment and prolonged intubation groups, but was significantly shorter in the craniofacial group. Complications occurred in 44%. Overall mortality was 19%, with a 3.6% tracheotomy-related death rate. Comparison of our series to other published series of pediatric tracheotomies since 1970 shows fewer being performed for airway infections and more for chronic diseases, with a corresponding increase in duration of tracheotomy and decreased decannulation rates.

CONCLUSIONS

Tracheotomy is a procedure performed with relative frequency at tertiary care children's hospitals. While children receiving a tracheotomy have a high overall mortality, deaths are usually related to the underlying disease, not the tracheotomy itself.

Totally obstructing tracheotomy-associated suprastomal granulation tissue

Although tracheotomy-associated suprastomal granulation tissue is quite common, suprastomal granulation tissue that totally obstructs the airway is relatively rare and can be associated with serious complications. In this report the complications and management of six cases of totally obstructing suprastomal granulation tissue (TOSGT) are presented. Complications associated with the presence or management of TOSGT included progression of subglottic stenosis, development of posterior laryngeal stenosis, development of supraglottic stenosis following CO(2) laser supraglottoplasty, and dislodgement of the TOSGT with distal tracheal obstruction resulting in anoxic brain injury. It is recommended that the tracheotomy tube remains in position at all times during attempted removal, and that if endoscopic removal is not possible, that open tracheoplasty is the safest method for removal. Measures that may decrease the chances of recurrence include diligent diagnosis and treatment of gastroesophageal reflux disease (GERD) and bacterial infection. TOSGT may be a marker for some patients with abnormal wound healing.

Postoperative management of pediatric tracheostomy: results of a nationwide survey

OBJECTIVE

A survey was undertaken to document the postoperative care of pediatric tracheostomies by otolaryngologists.

STUDY DESIGN

This study represents the results of a national survey of 564 otolaryngologists covering a broad scope of postoperative pediatric tracheostomy issues considered for patients younger than 2 years and patients older than 5 years.

RESULTS

Of the surveys sent, 134 responses were received, portraying a certain standard management scheme that seems to be used by most respondents.

CONCLUSIONS

Very little difference was seen in respondents' management of patients younger than 2 years of age as compared with those who are older than 5 years. Furthermore, agreement between actual practice and published recommendations seems to vary with some management issues. The results of this study provide a means by which otolaryngologists may familiarize themselves with national trends in the postoperative management of pediatric tracheostomies.

Maturation of the pediatric tracheostomy stoma: effect on complications

The pediatric tracheostomy stoma can be matured via a technique that places 4-quadrant sutures from the tracheal cartilage to the dermis. This has the potential of decreasing the risk of accidental decannulation and the formation of granulation tissue. A retrospective analysis of 149 tracheostomies performed between January 1989 and December 1996 was done for the following factors: age, underlying diagnosis, indication for tracheostomy, type of tracheal incision, maturation of stoma, duration of tracheostomy, and early and late (>7 days) complications. Maturation of the stoma was performed in 88 (59.1%) of the 149 tracheostomies. There was an overall complication rate of 21.5% (32/149, not including granulation tissue formation). There were 9 (6.0%) early complications and 23 (15.4%) late complications. The overall incidence of tracheocutaneous fistulas occurred in 11 (11.2%) of the 98 decannulated patients: 6 (10.2%) of the 59 matured stomas and 5 (12.8%) of the 39 nonmatured stomas. Granulation tissue was found on subsequent laryngoscopy in 24 (27.3%) of the 88 matured stomas versus 23 (37.7%) of the 61 nonmatured stomas. There were no tracheostomy-related mortalities. Maturing the tracheostomy stoma resulted in a decreased morbidity from accidental decannulations and did not increase the incidence of tracheocutaneous fistulas or granulation tissue formation.

Obstructive suprastomal granulation tissue following percutaneous tracheostomy

Percutaneous dilatational tracheostomy is frequently performed as an alternative to traditional surgical open tracheostomy with many reported benefits. Despite its relative safety and widespread acceptance, complications can be associated with the procedure itself or long-term. We present four cases where there was difficulty with decannulation because of exuberant obstructive granulation tissue. In each case, the percutaneous tracheostomy involved the cricoid cartilage.

Paediatric tracheostomy: an analysis of 40 cases

Tracheostomy in the paediatric patient has been associated with significant morbidity and mortality compared to that in the adult. A retrospective analysis was made of 40 patients up to the age of 12 years having tracheostomies. Upper airway obstruction made up the commonest (32 patients, or 80 per cent) indication for paediatric tracheostomy in our series where males slightly outnumbered females. The majority (31 patients, or 77.5 per cent) underwent the operation under general anaesthesia with endotracheal intubation. Thirty-four (85 per cent) patients underwent 'planned' tracheostomies and six (15 per cent) underwent 'crash' procedures. Thirteen (32.5 per cent) patients were under the age of one year when tracheostomies were performed. The maximum duration of tracheostomies was between one week to within a month and after one month to within three months; each containing 11 (27.5 per cent) patients. Sixty-four different surgical procedures were performed on these patients in which laryngoscopy and bronchoscopy were the commonest procedures. Nine (22.5 per cent) had early post-operative and 14 (35 per cent) had late post-operative complications. Among these 40 children with tracheostomies, one (2.5 per cent) died due to a tracheostomy-related cause and 10 (25 per cent) due to the primary disease process itself. Tracheostomies performed to provide access for general anaesthesia for other surgical procedures were associated with a better prognosis.

Role of polysomnography in tracheostomy decannulation in the paediatric patient

Tracheostomy in infants and children has been the subject of controversy in the medical literature, but decannulation in the paediatric patient is even more controversial. Various approaches and techniques have been used for decannulation, however in spite of all efforts it continues to be a problem. The objective of our study was to assess the role of polysomnography (PSG) in predicting readiness for decannulation. All subjects (n = 31) of the study were less than 12 years of age, and tracheostomized for periods of at least six months to ensure a minimum period of dependence on the tube. All had clinical, radiological and endoscopic clearance before PSG was performed. Twenty-one out of 22 patients with favourable PSG data were successfully decannulated. Attempts to decannulate all the nine patients with unfavourable PSG failed. The conclusion of the study was that PSG is a useful adjunct to the many methods of evaluating readiness for decannulation in children with long-term tracheostomy tubes.