Pediatric tracheostomy first tube change: When is it safe?

Tracheostomy Tube Exchange Failure Under General Anesthesia: A Case Report and Retrospective Analysis

A 54-year-old man with squamous cell carcinoma of the tongue underwent bilateral cervical lymph node dissection, total tongue resection, forearm flap reconstruction, and tracheostomy. The plan was to replace the oral endotracheal tube (ETT) with a cuffed tracheostomy tube at the end of the surgical case while the patient was still under general anesthesia. No major complications were expected as the tracheal foramen was visible once surgical access was obtained. However, removal of the ETT and subsequent placement of the tracheostomy tube failed twice. Successful ventilation was not observed via capnography, and the patient's peripheral oxygen saturation (SpO2) dropped to 70%. The anesthesiologist concluded that securing the airway through the tracheostomy would be difficult. The patient was immediately reintubated orally at which time his SpO2 was 38%, and he was successfully resuscitated and recovered without any sequelae. This rare situation was one we had not encountered previously, so we retrospectively analyzed all tracheostomy cases performed by our department from the past 3 years. Data from 54 patients who underwent tracheostomy tube exchange after tracheostomy were aggregated from their medical records and compared with our patient. Excluding the conditions during surgery, we surmised that tracheal depth, S/H ratio, and body weight were identified as potentially significant risk factors for failed tracheal tube placement or exchange.

The Predictors of Persistent Posttracheostomy Tracheocutaneous Fistula and Successful Surgical Closure

OBJECTIVE

Persistent tracheocutaneous fistula is a well-described complication of prolonged tracheostomy, with a prevalence of about 70% when decannulation is performed after more than 16 weeks. Predictors of its occurrence and outcome of treatment in adults remain unclear. The aim of the study was to describe our experience with the treatment of persistent posttracheostomy tracheocutaneous fistula in adults and to investigate factors associated with its formation and with the success of surgical closure.

STUDY DESIGN

Retrospective cohort.

SETTING

Tertiary medical center.

METHODS

Patients who underwent open-approach tracheostomy between 2000 and 2020 were identified by database review. Data on background, need for surgical closure, and the surgical outcome was collected from the medical files and analyzed statistically between groups.

RESULTS

Of 516 patients identified, 127 with sufficient long-term follow-up data were included in the study. Compared to patients whose fistula closed spontaneously (n = 85), patients who required surgical closure (n = 42) had significantly higher rates of smoking, laryngeal or thyroid malignancy, and airway obstruction as the indication for tracheostomy, on both univariate and multivariate analysis. In a comparison of patients with successful (n = 29) or failed (n = 11) surgical closure, factors significantly associated with failure were prior radiotherapy and lower preoperative albumin level, on univariate analysis.

CONCLUSION

Smoking, thyroid or laryngeal malignancy, and airway obstruction indication are risk factors for persistent posttracheostomy tracheocutaneous fistula. Patients should be closely followed after tracheostomy and referred for surgery if the fistula fails to close. Before surgery, careful evaluation of the patient's nutritional status and consideration of prior radiation treatment is mandatory.

Tracheostomy in children: Recommendations for a safer technique

Over the last few decades, tracheostomy has been increasingly performed in children with various complex and chronic conditions. We have seen a dramatic change in indications for tracheostomy in pediatric patients due to better survival of premature infants and those suffering from severe congenital anomalies. There is no consensus about the timing of tracheostomy in pediatric patients. Although percutaneous tracheostomy has become the standard of care for adults, there is not sufficient evidence to start performing it routinely in pediatric patients. The indications, preoperative considerations, and different procedures for tracheostomy in children are reviewed. Surgical tracheostomy is described step by step placing an emphasis on safety measures to minimize complications. There is also a great variability in tracheostomy care protocols in the literature. Post-operative tracheostomy care is discussed for the early and late post-operative periods. There is no general consensus on decannulation protocols, but prevailing expert opinion is presented. There is growing evidence in support for an interdisciplinary approach to pediatric tracheostomized patients. The focus of this paper is the review of the literature regarding safety improvement strategies from the surgical and post-operative point of view.

Update on Pediatric Tracheostomy: Indications, Technique, Education, and Decannulation

Purpose of Review

Tracheostomy in a child demands critical pre-operative evaluation, deliberate family education, competent surgical technique, and multidisciplinary post-operative care. The goals of pediatric tracheostomy are to establish a safe airway, optimize ventilation, and expedite discharge. Herein we provide an update regarding timing, surgical technique, complications, and decannulation, focusing on a longitudinal approach to pediatric tracheostomy care.

Recent Findings

Pediatric tracheostomy is performed in approximately 0.2% of inpatient stays among tertiary pediatric hospitals. Mortality in children with tracheostomies ranges from 10–20% due to significant comorbidities in this population. Tracheostomy-specific mortality and complications are now rare. Recent global initiatives have aimed to optimize decision-making, lower surgical costs, reduce the length of intensive care, and eliminate perioperative wound complications. The safest road to tracheostomy decannulation in children remains to be both patient and provider dependent.

Summary

Recent literature provides guidance on safe, uncomplicated, and long-term tracheostomy care in children. Further research is needed to help standardize decannulation protocols.

Early Tracheostomy Change in Neonates: Feasibility and Benefits

OBJECTIVES

To compare outcomes of early and late tracheostomy change in neonatal patients. Early tracheostomy change (ETC) occurred 3 to 4 days after surgery, and late tracheostomy change (LTC) occurred 5 to 7 days after surgery.

STUDY DESIGN

Retrospective cohort.

SETTING

Tertiary neonatal/pediatric intensive care unit.

METHODS

A retrospective review of patients who underwent tracheostomy from 2015 to 2019 was performed for infants <1 year old. Data were recorded regarding age at tracheostomy, days until tracheostomy tube change, postoperative complications, and total number of days on sedative or paralytic drugs.

RESULTS

Forty-six patients were included: 18 (39%) were male, with a mean age of 140 days (SD, 78). Of these, 28 (61%) received ETC. There were no accidental decannulation events in either group. Wound breakdown developed in 4 (14%) patients with ETC versus 5 (28%) with LTC (P = .3). Use of FlexTend tracheostomy tubes was associated with decreased odds of breakdown (odds ratio, 0.03; P = .01). Postoperatively, 46 (100%) patients received sedation, and 12 (26%) received paralysis. Mean duration of paralysis was 0.5 days in ETC as opposed to 2.2 days in LTC (P = .02) on univariate analysis, but the significance was not maintained on multivariate regression (P = .07).

CONCLUSIONS

ETC appears to be feasible in children less than a year of age. There does not appear to be an increased risk of accidental decannulation events or false passage tracts. Further investigations are warranted to investigate safety and possible impact on wound breakdown.

Pediatric tracheostomy care updates

PURPOSE OF REVIEW

The aim of this review is to provide an update on the management of pediatric tracheostomies.

RECENT FINDINGS

Recent literature has focused on optimization of care for children with tracheostomies including prevention and management of skin breakdown, timing of tracheostomy tube changes, the role of multidisciplinary and team-based approaches to education and management of tracheostomy patients, ideal timing of surveillance endoscopy, and the emerging role of telemedicine in the care of tracheostomy patients.

SUMMARY

A focus on quality improvement and a systematic, team-based approach to care has the potential to improve the quality of care for pediatric tracheostomy patients.

Timing the First Pediatric Tracheostomy Tube Change: A Randomized Controlled Trial

OBJECTIVE

The first pediatric tracheostomy tube change often occurs within 7 days after placement; however, the optimal timing is not known. The primary objective was to determine the rate of adverse events of an early tube change. Secondary objectives compared rates of significant peristomal wounds, sedation requirements, and expedited intensive care discharges.

STUDY DESIGN

Prospective randomized controlled trial.

SETTING

Tertiary children's hospital between October 2018 and April 2020.

METHODS

A randomized controlled trial enrolled children under 24 months to early (day 4) or late (day 7) first tracheostomy tube changes.

RESULTS

Sixteen children were enrolled with 10 randomized to an early change. Median age was 5.9 months (interquartile range, 5.4-8.3), and 86.7% required tracheostomy for respiratory failure. All tracheostomy tube changes were performed without adverse events. There were no accidental decannulations. Significant wounds developed in 10% of children with early tracheostomy tube changes and 83.3% of children with late tracheostomy tube changes (odds ratio [OR], 45.0; 95% CI, 2.3-885.6; P = .01). This significant reduction in wound complications justified concluding trial enrollment. Hours of dexmedetomidine sedation (P = .11) and boluses of midazolam during the first 7 days (P = .08) were no different between groups. After the first change, 90% of the early group were discharged from intensive care within 5 weeks compared to 33.3% of patients in the late group (OR, 18.0; 95% CI, 1.2-260.9; P = .03).

CONCLUSION

The first tracheostomy tube change in children can occur without adverse events on day 4, resulting in fewer significant peristomal wounds and earlier intensive care discharge.

Tracheostomy in Infants in the Neonatal Intensive Care Unit

Approximately half of all pediatric tracheostomies are performed in infants younger than 1 year. Most tracheostomies in patients in the NICU are performed in cases of chronic respiratory failure requiring prolonged mechanical ventilation or upper airway obstruction. With improvements in ventilation and management of long-term intubation, indications for tracheostomy and perioperative management in this population continue to evolve. Evidence-based protocols to guide routine postoperative care, prevent and manage tracheostomy emergencies including accidental decannulation and tube obstruction, and attempt elective decannulation are sparse. Clinician awareness of safe tracheostomy practices and larger, prospective studies in infants are needed to improve clinical care of this vulnerable population.