Maturation sutures for the paediatric tracheostomy – an extra safety measure

Pediatric Tracheotomy Stomal Maturation and Tracheocutaneous Fistulas

OBJECTIVE

The purpose of this study is to determine whether tracheostomy stomal maturation affects the risk of tracheocutaneous fistula (TCF) in children.

METHODS

A retrospective chart review was conducted for all children who both underwent a tracheostomy and were decannulated between 2012 and 2021 at a tertiary children's hospital. Charts were analyzed for demographics, surgical technique, and development of a TCF. TCF was defined as a persistent fistula following 3 months after decannulation.

RESULTS

179 children met inclusion criteria. The median (interquartile range) age at tracheostomy was 1.5 (82.4) months, average (standard deviation [SD]) duration of tracheotomy was 20.0 (20.6) months, and length of follow-up after decannulation (range; SD) was 39.3 (4.4-110.0; 26.7) months. 107 patients (60.0%) underwent stomal maturation and 98 patients developed a TCF (54.7%). Younger age at tracheostomy placement was significantly associated with increased risk of TCF, mean (SD) age 28.4 (51.4) version 80.1 (77.5) months (p < 0.001). Increased duration of tracheostomy was significantly associated with increased risk of TCF, 27.5 (18.4) version 11.0 (18.2) months (p < 0.001). Stomal maturation was not significantly associated with the risk of TCF, including on multivariable analysis adjusting for age at tracheostomy and duration of tracheostomy (p = 0.089).

CONCLUSION

Tracheostomy stomal maturation did not affect the risk of TCF in children, even after adjusting for age and duration of tracheostomy.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:2941-2944, 2024.

Flowchart for selecting an appropriate surgical airway in neurologically impaired pediatric intubated patients: a case series

OBJECTIVE

Medical advances have resulted in increased survival rates of neurologically impaired children who may require mechanical ventilation and subsequent tracheostomy as a surgical airway. However, at present, there is no definite consensus regarding the timing and methods for placement of a surgical airway in a neurologically impaired intubated child who needs to be cared for over a long-term period. We therefore created a flowchart for the selection of a surgical airway for Neurologically Impaired Pediatric Patients (NIPPs).

METHODS

The flowchart includes information on the patients' backgrounds, such as intubation period, prognosis related to reversibility, and history of aspiration pneumonia. To evaluate the importance of the flowchart, first we conducted a survey of pediatricians regarding selection of a surgical airway, and we also evaluated the appropriateness of the flowchart among pediatricians and caregivers through questionnaire surveys which include satisfaction with the decision-making process, and postoperative course after discharge.

RESULTS

A total of 21 NIPPs with intubation underwent surgery and a total of 24 participants (14 pediatricians and 10 caregivers) completed the survey. The answers regarding the importance of the flowchart showed that eleven pediatricians had experience selecting of surgical airways, nine of whom had had experiences in which they had to make a difficult decision. The answers regarding the appropriateness of the flowchart revealed that all pediatricians and caregivers were satisfied with the decision-making process and postoperative course after discharge using the flowchart.

CONCLUSIONS

The present study demonstrated the effectiveness of our flowchart for selecting an appropriate surgical airway in NIPP. By referring to our flowchart, pediatricians and caregivers are likely to be able to select an appropriate surgical airway, leading to increased satisfaction with the decision-making process and postoperative course.

LEVEL OF EVIDENCE: 4

Pediatric tracheostomy first tube change: When is it safe?

OBJECTIVES

The first tracheostomy tube change is typically performed on days 5-7 post-operatively, however recent international consensus guidelines suggested that, with maturation sutures, days 3-5 is appropriate. We evaluate whether a first tube change on day 2 post-operatively is safe and effective.

METHODS

We carried out a retrospective review of all patients undergoing tracheostomy between 2009 and 2018. Exclusion criteria were patients on whom the senior authors did not operate, operations done elsewhere, cases where maturation sutures were not used or a patient died prior to first tube change. We noted patient details, indication for tracheostomy, the need for long-term ventilation, timing of the first tube change, decannulation and need for surgical closure of persistent tracheocutaneous fistula.

RESULTS

93 patients were identified, of which 83 were included. The age range was 0-16 years, with the youngest day one of life and an overall mean age of 1.91 years. 59% of patients required long-term ventilation due to various co-morbidities. 26 patients (31%) underwent a first tube change on day 2 post-operatively. All these were uneventful and were irrespective of the patient's need for ventilation. Of the 42 patients who have subsequently been decannulated, 33 (79%) were noted to have a persistent tracheocutaneous fistula requiring surgical closure, four of whom needed revision closure.

CONCLUSIONS

This study shows that a first tube change on day 2 post-operatively is safe, facilitating earlier discharge from intensive care, allowing shorter length of sedation, earlier start to parent/carer training and wound assessment.

Multidisciplinary guidelines for the management of paediatric tracheostomy emergencies

Temporary and permanent tracheostomies are required in children to manage actual or anticipated long-term ventilatory support, to aid secretion management or to manage fixed upper airway obstruction. Tracheostomies may be required from the first few moments of life, with the majority performed in children < 4 years of age. Although similarities with adult tracheostomies are apparent, there are key differences when managing the routine and emergency care of children with tracheostomies. The National Tracheostomy Safety Project identified the need for structured guidelines to aid multidisciplinary clinical decision making during paediatric tracheostomy emergencies. These guidelines describe the development of a bespoke emergency management algorithm and supporting resources. Our aim is to reduce the frequency, nature and severity of paediatric tracheostomy emergencies through preparation and education of staff, parents, carers and patients.

The usefulness of the stay suture technique in tracheostomy

OBJECTIVE

Tracheostomy tube displacement may occur at any time in the course of patient management. Although an infrequent occurrence, such displacement is potentially serious. The purpose of this study was to evaluate the advantages and complications of the stay suture technique in tracheostomy.

STUDY DESIGN

Prospective cohort study.

METHODS

The SST involves the placement of sutures between the anterior tracheal wall and the skin in order to hasten the formation of a mature stoma. The study patients were divided into two groups. One group underwent tracheostomy with the SST (n =104), and the other group was treated with a conventional tracheostomy (n = 101). The postoperative complications for each group were then reviewed.

RESULTS

The most common indication for tracheostomy was prolonged endotracheal intubation (79.3%), and the most common complication in each group was postoperative stoma infection. Unexpected decannulation occurred in three patients from the conventional tracheostomy group, causing death of the patients. However, the SST group did not show any occurrence of unexpected decannulation.

CONCLUSIONS

Unexpected decannulation was a fatal complication. Because this complication was not observed in any patients who underwent the SST, our study recommends use of this method as a countermeasure for unexpected decannulation.

LEVEL OF EVIDENCE

4.

Tracheocutaneous fistula following paediatric tracheostomy--a 14-year experience at Alder Hey Children's Hospital

OBJECTIVE

To assess the rate of tracheocutaneous fistula requiring surgical repair and the complications and outcomes following it in the ENT department of a tertiary referral university paediatric hospital.

METHODS

A retrospective review of all children requiring airway support with a tracheostomy between 1995 and 2009 and subsequently requiring closure of tracheocutaneous fistula.

RESULTS

One hundred and ninety-three children underwent 196 tracheostomies. Seventy-three children were successfully decannulated until now. Twenty-three children (11.9%) required subsequent surgical closure of their tracheocutaneous fistula. In all these children the age at tracheostomy was less than 1 year old, and the median age at decannulation was 4 years old, (range 2-9 yo). Surgical repair was undertaken 6-12 months after decannulation. There were 4 minor complications in the postoperative period (wound infection, haemorrhage and early recurrence) and no major complications. None of the patients have experienced any degree of significant airway stenosis and there was no need for a repeat tracheotomy in any of the tracheocutaneous fistula closure patients. The cosmetic results were deemed to be good.

CONCLUSIONS

Our rate of tracheocutaneous fistula compares well with the reported rates in the literature (13-43%). There appears to be a significant relation to age at tracheostomy and duration of tracheostomy.

Safe reliable atraumatic replacement of misplaced paediatric tracheostomy tubes

OBJECTIVE

Displacement of tracheostomy tubes, especially soon after insertion has a high morbidity and mortality rate. We present a safe atraumatic reliable method of tracheostomy tube replacement.

SETTING

Tertiary paediatric centre.

MATERIALS AND METHODS

The method involves using a suction catheter placed in the trachea. Its position can be confirmed by suctioning tracheal secretions. The catheter can be used to employ the Seldinger technique for replacement of the tracheostomy tube and can be used to jet ventilate the patient if there is failure to site a tube. This buys time while a surgical airway is placed. We also outline the minimum contents of the emergency box, which should be carried at all times by the carers of a child with a tracheostomy.

CONCLUSIONS

Use of a suction catheter is a safe reliable atraumatic way of replacing a tracheostomy tube.

Surgical aspects of tracheostomy in children

Tracheostomy involves the surgical formation of a stoma between the trachea and the skin. It is classically thought of as a treatment to alleviate airway obstruction; however, its clinical applications are varied and include long-term ventilatory support, being an aid in pulmonary toilet and use as a covering procedure during airway surgery. In this article, we review the surgical aspects of tracheostomy, including preoperative considerations, tracheostomy tube choice, operative technique and postoperative complications. Postoperative care of the child with a tracheostomy will also be discussed.