Tracheotomy in neonates

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.

Topographic variations in anatomical structures of the anterior neck of children: an ultrasonographic study

OBJECTIVE

Tracheostomies in children are frequently used for temporary airway support during surgical procedures. In pediatric patients with congenital craniofacial malformations, preoperative assessment of the delicate anatomy of the airway is necessary. The purpose of this study was to assess the ultrasonographic anatomy of the anterior neck with regard to the performance of tracheostomy.

STUDY DESIGN

Ultrasonographic investigation was done in 50 pediatric patients (age range, 6 to 15 years) to analyze the relationships among the anatomical structures that are of practical interest with respect to tracheostomy.

RESULTS

The data reveal that information concerning variations in anatomical structures lying in the immediate vicinity of the tracheostomy site was readily obtainable with the techniques used.

CONCLUSIONS

In pediatric patients requiring tracheostomy for surgical treatment of severe congenital craniofacial malformations, preoperative ultrasonography may be used to diagnose individual anatomical variations at the tracheostomy site.

Therapeutic reintubation for post-intubation laryngotracheal injury in preterm infants

The failure to extubate a preterm infant after prolonged intubation is often caused by laryngotracheal injury. This condition is treated by tracheotomy, anterior cricoid split, or often, by reintubation and subsequent extubation attempts in a later stage. To assess the value of reintubation as treatment of post-intubation injury, we retrospectively studied a group of preterm infants from the neonatal intensive care unit in the Sophia Children's Hospital. Three categories of injury were distinguished according to the findings at laryngobronchoscopy: (a) edema or superficial lesions, (b) ulcerations and edema and (c) granulations. Twenty-three infants were therapeutically reintubated after post-intubation injury was diagnosed, for a mean period of 17 days. The therapy was successful in 22 patients, and a failure in one. The follow-up period was a mean 34 months. The result and the duration of the treatment vary with the category of the injury and the condition of the patient. Therapeutic reintubation is compared with alternatives such as anterior cricoid split and tracheotomy. We conclude that reintubation is a valuable therapy that should precede the decision for surgery.

Tracheotomy in the first year of life

Much has been written concerning complications of pediatric tracheotomies, but few studies have reviewed the complication rates of tracheotomies performed in the first 12 months of life. We reviewed the records of 60 patients who underwent tracheotomy in the first year of life between 1976 and 1988. This study includes 30 full-term infants and 30 premature infants, 16 of whom were very low birth weight preterm infants (less than or equal to 32 weeks' gestation and less than 1,500 g birth weight). Overall complication rates were 3% intraoperative, 13% early postoperative, and 38% late postoperative. The early postoperative complication rate in preterm infants was nearly double that of full-term infants. The late postoperative complication rate of patients undergoing tracheotomy for airway obstruction was more than double that of patients requiring tracheotomy for pulmonary indications. Duration of tracheotomy, however, was felt to be the most important factor in the development of a late postoperative complication.

Tracheotomy revision in infants: to facilitate extubation and restore phonation

The formation of tracheal 'granuloma' in the tracheostomized infant, as a cause of aphonia and an obstacle to decannulation has long been recognized. Endobronchial or transtomal removal has been recommended; however, a number of these lesions were resected in conjunction with complete tracheostomy revision and found to be very much larger than suspected endoscopically and consisting of dense mature scar tissue. It is, therefore, suggested that resection of these lesions endoscopically or transtomally may be quite inadequate and an open procedure preferred.

Risk factors for neonatal acquired subglottic stenosis

Endotracheal intubation has proven to be a relatively safe and effective means of securing the airway in neonates. Some concern remains, however, regarding airway management in critically ill infants who require assisted ventilation for extended periods. Among the various risk factors associated with the complication of acquired subglottic stenosis in neonates, the one most frequently cited has been "prolonged" intubation, although opinion varies regarding the definition of this term. Various recommendations exist that attempt to establish the limits of "safe" periods of intubation for infants. Some feel that tracheotomy is indicated when airway support is required beyond those limits. In an attempt to define important risk factors involved in the development of neonatal subglottic stenosis, a retrospective analysis of infants admitted to the Neonatal Intensive Care Unit of Columbus Children's Hospital who required intubation during a 3-year period from 1977 to 1980 was undertaken. Of 343 infants who survived hospitalization, five patients were identified as having acquired subglottic stenosis. The average duration of intubation for these five patients was 56.2 days. The incidence of subglottic stenosis for infants whose duration of intubation ranged from 3 to 50 days was 0.4% (1/245). Infants with birth weights less than 1,500 g appeared more susceptible to the development of intubation-related laryngeal injury. The conclusion of this study is that endotracheal intubation is an appropriate means of long-term airway management in neonates hospitalized in a pediatric intensive care unit, providing other known risk factors are minimized.

Prolonged orotracheal intubation in the newborn

One hundred seventy-four consecutive cases of newborn infants who required orotracheal intubation for longer than three days were studied retrospectively. The duration of intubation varied from 3 to 211 days with an overall mortality rate of 22.9%. There was one complication directly related to orotracheal intubation. One tracheotomy was performed. Orotracheal intubation is felt to be superior to nasal tracheal intubation and tracheotomy in managing infants in this age group who require prolonged assisted ventilation.

Airway management in the premature infant

Out of 262 premature newborn patients admitted with a diagnosis of respiratory distress, it was necessary to treat 70 with a ventilator. Of these 70, 25 eventually underwent tracheostomy. Indications for tracheostomy were that of an infant needing prolonged endotracheal intubation greater than one week. The procedure itself was easily performed and an overall complication rate of 7% was the result. Of the patients who underwent tracheostomy, 8% had significant complications. There was no death attributable to the treatment regime. We feel, therefore, that a combination approach starting with the endotracheal tube and progressing to tracheostomy when necessary, provided the best care for premature infants requiring intensive airway management.

Intermittent positive pressure ventilation in infants and children. The Long term effects in 74 survivors

Seventy-four infants and children surviving after more than 12 hours IPPV are discussed with reference to long-term physical and mental development.