Duration of tracheostomy dependence and development of tracheocutaneous fistula in children

Time Toxicity: Quantifying Healthcare Utilization Attributable to Pediatric Home Ventilation

OBJECTIVE

Determine the "time toxicity," or time burden patients experience when pursuing health-related interventions, of pediatric invasive home ventilation.

STUDY DESIGN

Retrospective chart review.

METHODS

We identified all patients from a single neonatal intensive care unit who received a tracheostomy with/without home ventilation (T + /-HV) from 2016 to 2024. After matching the gestational week distribution of this cohort, five controls were randomly selected for each T + /-HV patient. Healthcare encounters in the electronic medical record were compared for the cohort versus controls. All encounters on a single calendar day were counted as 1 day of healthcare utilization.

RESULTS

We identified 62 patients with T + /-HV and 310 controls. Mortality was 35.5% among the T + /-HV cohort and 9% among controls. Median inpatient hospitalizations (7.0 vs. 2.0), total healthcare encounters (64.0 vs. 15.5), days of healthcare utilization (296 vs. 46), and healthcare utilization ratio (0.4 vs. 0.1) were all significantly higher for the T + /-HV cohort compared with controls. Differences were greatest in the first year of life. Among survivors in the T + /-HV cohort, decannulated patients had significantly greater healthcare utilization than those not decannulated.

CONCLUSIONS

This proof-of-concept analysis quantified "time toxicity" for pediatric invasive home ventilation and demonstrated that neonates who receive a tracheostomy during their initial admission spent over half of all days in their first 2 years of life interacting with the healthcare system. "Time toxicity" could add objective information to better prepare families for what life looks like with a child using a ventilator at home.

Primary vs. secondary closure of tracheocutaneous fistulas: A prospective cohort study

OBJECTIVE

To prospectively compare outcomes and complications of the two most common techniques for closure of tracheocutaneous fistulas (TCFs): surgical excision of the tract with primary closure (PC), and de-epithelialization with healing by secondary intention (SI).

STUDY DESIGN

Prospective cohort study.

SETTING

Tertiary academic center.

METHODS

All patients who underwent closure of a TCF between 5/1/2022 and 5/30/2023 were eligible for inclusion in the study. Data was prospectively collected and included demographics, tracheostomy history, intraoperative data (including fistula size and closure technique), postoperative recovery and any complications.

RESULTS

There were 15 patients who underwent PC, and 10 patients who underwent closure by SI. Both cohorts were premature and had tracheostomies for at least 2 years prior to decannulation. The length of time from decannulation to closure was longer in the primary vs secondary group (p = .01). The operative time was significantly longer in the PC group (p = .002) and the PC group experienced a significantly higher number of postoperative respiratory complications (p = .05) during their postoperative admission. The average TCF size was larger in the SI group compared to the PC group (p < 0.001).

CONCLUSION

This prospective study demonstrated fewer postoperative respiratory complications for SI closure of TCFs compared to PC.

Management of respiratory problems in children on home invasive mechanical ventilation

The management of respiratory problems in children on home invasive mechanical ventilation (HIMV) is a complex and challenging task. In recent years, with appropriate family education, these patients have been able to be discharged from the hospital and continue their treatment at home. The population of pediatric patients dependent on HIMV has been increasing worldwide, presenting unique and varying care needs. Management of these patients involves addressing ventilator settings, monitoring respiratory status, ensuring airway safety, and providing continuous support and education to patients and their caregivers. Despite the completion of home settings and family education, children on HIMV may encounter various respiratory problems during home follow-up. Prevention and timely management of these complications are crucial to improving patient outcomes. This article summarizes the most significant respiratory problems in children on HIMV and the management strategies for each problem are discussed, emphasizing the importance of appropriate aspiration techniques, regular monitoring, adequate training of caregivers, and a well-prepared emergency plan.

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.

Pediatric tracheostomy decannulation: what's the evidence?

PURPOSE OF REVIEW

Pediatric decannulation failure can be associated with large morbidity and mortality, yet there are no published evidence-based guidelines for pediatric tracheostomy decannulation. Tracheostomy is frequently performed in medically complex children in whom it can be difficult to predict when and how to safely decannulate.

RECENT FINDINGS

Published studies regarding pediatric decannulation are limited to reviews and case series from single institutions, with varying populations, indications for tracheostomy, and institutional resources. This article will provide a review of published decannulation protocols over the past 10 years. Endoscopic airway evaluation is required to assess the patency of the airway and address any airway obstruction prior to decannulation. There is considerable variability in tracheostomy tube modification between published protocols, though the majority support a capping trial and downsizing of the tracheostomy tube to facilitate capping. Most protocols include overnight capping in a monitored setting prior to decannulation with observation ranging from 24 to 48 h after decannulation. There is debate regarding which patients should have capped polysomnography (PSG) prior to decannulation, as this exam is resource-intensive and may not be widely available. Persistent tracheocutaneous fistulae are common following decannulation. Excision of the fistula tract with healing by secondary intention has a lower reported operative time, overall complication rate, and postoperative length of stay.

SUMMARY

Pediatric decannulation should occur in a stepwise process. The ideal decannulation protocol should be safe and expedient, without utilizing excessive healthcare resources. There may be variability in protocols based on patient population or institutional resources, but an explicitly described protocol within each institution is critical to consistent care and quality improvement over time. Further research is needed to identify selection criteria for who would most benefit from PSG prior to decannulation to guide allocation of this limited resource.

Incidence of Persistent Tracheocutaneous Fistula After Pediatric Tracheostomy Decannulation

OBJECTIVES

To determine the incidence of tracheocutaneous fistula (TCF) and identify characteristics associated with persistence.

STUDY DESIGN

Prospective cohort.

METHODS

All successfully decannulated children (<18 years) between 2014 and 2020 at a tertiary children's hospital were included. Revision tracheostomies, concomitant major neck surgery, or single-stage laryngotracheal reconstructions were excluded. A persistent TCF was defined as a patent fistula at 6 weeks after decannulation.

RESULTS

A total of 77 children met inclusion criteria with a persistent TCF incidence of 65% (50/77). Children with a persistent TCF were younger at placement (1.4 years (SD: 3.3) vs. 8.5 years (SD: 6.5), p < 0.001) and tracheostomy-dependent longer (2.8 years (SD: 1.3) vs. 0.9 years (SD: 0.7), p < 0.001). On univariate analysis, placement under 12 months of age (86% vs. 26% p < 0.001), duration of tracheostomy more than 2 years (76% vs. 11% p < 0.001), short gestation (64% vs. 26%, p = 0.002), congenital malformations (64% vs. 33%, p = 0.02), newborn complications (58% vs. 26%, p = 0.009), maternal complications (40% vs. 11%, p = 0.009) and chronic respiratory failure (72% vs. 41%, p = 0.01) were associated with persistent TCF. Logistic regression analysis associated duration of tracheostomy (OR: 0.14, 95% CI: 0.05-0.35, p < 0.001) and congenital malformations (OR: 0.25, 95% CI: 0.06-0.99, p = 0.049) with failure to spontaneously close.

CONCLUSIONS

Two-thirds of children will develop a persistent TCF after tracheostomy decannulation. Persistent TCF is correlated with a longer duration of tracheostomy and congenital malformations. Anticipation of this event in higher-risk children is necessary when caring for pediatric tracheostomy patients.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:417-422, 2023.

Outcomes and complications of simple layered closure of persistent tracheocutaneous fistula after tracheostomy in childhood

BACKGROUND

Up to half of all children who have a tracheostomy will develop a persistent tracheo-cutaneous fistula (TCF) after decannulation. Surgical closure of the TCF is technically easy but post-operative complications can be immediate and life-threatening. These include air leak from the tracheal repair leading to massive surgical emphysema or pneumothorax. We reviewed our experience of TCF closure to try to identify potential risk factors for complications.

METHOD

Retrospective case record review of all children (0-16 years) who underwent surgical TCF closure between January 2010 and December 2021 following development of a persistent TCF after decannulation of a tracheostomy.

RESULTS

We identified 67 children. They ranged in age from 14 months to 16 years (median 3 years 10 months) at the time of the TCF closure. Major medical comorbidities were present in 90%. Pre-operative pulse oximetry with the fistula occluded was used in 29 children (43%). An underwater leak test was performed in 28 (42%). A non-suction drain was used in 29 children (43%). Prophylactic antibiotics were prescribed for 30 children (45%). Post-operative complications occurred in 15 children (22%). Life-threatening air leak occurred in the immediate post-operative period in 2 children (3%). Respiratory distress occurred in 3 children (4%) in the recovery area immediately after surgery. None required re-tracheostomy. Three children suffered post-operative pneumonia (4%), and wound infections occurred in 8 children (12%). We were unable to show a significant association between patient or surgical factors and complications.

DISCUSSION

Complications for TCF closure are unfortunately common and it is unclear from the available evidence how best to prevent them. Further research is required.

Silver nitrate therapy for persistent tracheocutaneous fistula following prolonged tracheostomy and invasive ventilation: A case report

We report the case of a man with severe Guillain-Barré syndrome who developed a persistent tracheocutaneous fistula (TCF) following prolonged tracheostomy and mechanical ventilation. Following tracheostomy decannulation, the TCF had a deleterious effect on non-invasive positive pressure ventilation efficacy and ability to effectively clear airway secretions due to air leaking from the patent stoma. This case highlights a non-surgical approach to TCF management that is not well-described in the literature and presents an alternative management option for cohorts of patients in which the risk associated with surgical interventions may be undesirable.

An Analysis of Tracheostomy Complications in Pediatric Patients With Scoliosis

OBJECTIVES/HYPOTHESISAL

To analyze tracheostomy-related complications in pediatric patients with scoliosis.

STUDY DESIGN

Retrospective chart review.

METHODS

A retrospective chart review of all patients with tracheostomy and scoliosis was performed at a single institution. The charts were reviewed for variables including difficulties with tracheostomy tube changes, poor positioning of tube, abnormal appearance of trachea, and emergency room visits and admissions for complications. Decannulation rates were also identified.

RESULTS

About 102 patients met inclusion criteria, 96 (94.1%) had scoliosis involving the thoracic spine, and 4 had scoliosis involving the cervical spine; 13 (12.8%) patients had documented poor positioning on tracheoscopy; 31 patients (30.3%) had at least one emergency room visit or admission for complications, such as accidental decannulation or bleeding from the tracheostomy; 19 (18.6%) patients required at least one tube change due to poor positioning, with 7 (6.9%) requiring multiple changes; 18 (17.7%) had reported difficulties with home tube changes. Custom length tubes were required in 9 patients (8.8%). The level of scoliosis was not associated with any of these complications. Abnormalities of the trachea, such as tortuosity, obstructive granulomas, or tracheomalacia, were seen in 35 patients (34.3%) on bronchoscopy. Scoliosis repair was performed in 18 patients (17.65%), of which two achieved decannulation. Ten patients (9.8%) overall were decannulated.

CONCLUSION

A portion of patients with scoliosis who are tracheostomy-dependent have anatomical abnormalities of the trachea and poor positioning of the tracheostomy tube. Decannulation rates are also lower in this population compared to the literature. Further work is required to elucidate if scoliosis predisposes patients toward tracheostomy-related complications.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

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.

Tracheocutaneous Fistula After Pediatric Open Airway Reconstruction

OBJECTIVES

Tracheocutaneous fistula (TCF) is a common occurrence after pediatric tracheostomy decannulation. However, the persistence of TCF after staged reconstruction of the pediatric airway is not well-described. The primary objective was to determine the rate of persistent TCF after successful decannulation in children with staged open airway reconstruction.

METHODS

A case series with chart review of children who underwent decannulation after double-stage laryngotracheal reconstruction between 2017 and 2019.

RESULTS

A total of 26 children were included. The most common open airway procedure was anterior and posterior costal cartilage grafting (84.6%, 22/26). Median age at decannulation was 3.4 years (IQR: 2.8-4.3) and occurred 7.0 months (IQR: 4.3-10.4) after airway reconstruction. TCF persisted in 84.6% (22/26) of children while 15.4% (4/26) of stomas closed spontaneously. All closures were identified by the one-month follow-up visit. There was no difference in age at tracheostomy (P = .86), age at decannulation (P = .97), duration of tracheostomy (P = .43), or gestational age (P = .23) between stomas that persisted or closed. Median diameter of stent used at reconstruction was larger in TCFs that persisted (7.0 mm vs 6.5 mm, P = .03). Tracheostomy tube diameter (P = .02) and stent size (P < .01) correlated with persistence of TCF on multivariable logistic regression analysis. There were 16 surgical closure procedures, which occurred at a median of 14.4 months (IQR: 11.4-15.4) after decannulation. Techniques included 56.3% (9/16) by primary closure, 18.8% (3/16) by secondary intention and 25% (4/16) by cartilage tracheoplasty. The overall success of closure was 93.8% (15/16) at latest follow-up.

CONCLUSIONS

Persistent TCF occurs in 85% of children who are successfully decannulated after staged open airway reconstruction. Spontaneous closure could be identified by 1 month after decannulation and was more likely when smaller stents and tracheostomy tubes were utilized. Surgeons should counsel families on the frequency of TCF and the potential for additional procedures needed for closure.

Complications of tracheostomy in children: a systematic review

Introduction

Tracheostomy is a procedure that can be associated with several well-described complications in the literature, which can be divided into transoperative, early postoperative and late postoperative. When performed in children, these risks are more common than in adults.

Objective

To perform a systematic review of complications, including deaths, in tracheostomized pediatric patients.

Methods

A search was carried out for articles in the Latin American and Caribbean Health Sciences Literature and PubMed databases. Cohort studies and series reports were selected, in addition to systematic reviews, published between January 1978 and June 2020, with patients up to 18 years old, and written in English, Spanish or Portuguese.

Results

1560 articles were found, of which 49 were included in this review. The average complication rate was 40%, which showed an association with age, birth weight, prematurity, comorbidities, and emergency procedures. The most common complications were cutaneous lesions and granulomas. Mortality related to the procedure reached up to 6% in children and was mainly related to cannula obstruction or accidental decannulation.

Conclusion

Pediatric tracheostomy is associated with several complications. The tracheostomy-related mortality rate is low, but the overall mortality of tracheostomized patients is not negligible.

Diagnostic considerations prior to pediatric tracheocutaneous fistula closure

INTRODUCTION

An airway assessment often occurs prior to tracheocutaneous fistula (TCF) closure in children. Bronchoscopy (MLB) with or without fistula-occluded polysomnography (PSG) helps determine candidacy and localize potential obstruction. To date, little has been published on MLB or PSG findings in children before surgically closing a TCF.

METHODS

A case series with chart review of children between 2017 and 2020 who underwent repair of a TCF after tracheostomy decannulation.

RESULTS

Thirty-six children were included for review. Mean age was 5.9 years (95% CI: 4.5-7.3), 58.3% were male, and 50% had chronic lung disease. Surgery occurred 13.3 months (95% CI: 11.9-14.8) after decannulation, with 80.6% by primary closure and 19.4% by secondary intention. There was one unsuccessful closure and two patients (5.6%) presented with a postoperative complication. An MLB was performed in 97.2% of children, where 22.9% identified supraglottic pathology, 11.4% had grade 2 subglottic stenosis, and 11.4% had difficult exposure of the larynx. Further, one child had a non-obstructing subglottic cyst, one had a supraglottoplasty for redundant arytenoid mucosa, and two children had suprastomal granulomas requiring removal. A PSG was obtained in 36.1%, with a mean Apnea-Hypopnea Index of 2.4 events/hour (95% CI: 0.9-3.9), nadir Oxygen saturation of 90.5% (95% CI: 87.9-93.0), and peak end-tidal CO₂ of 46.1 mmHg (95% CI: 43.7-48.5).

CONCLUSION

The selection of candidates for pediatric TCF closure requires careful evaluation of the airway. Surgeons should be familiar with the potential findings on MLB and PSG prior to closure.

Closure of Persistent Tracheocutaneous Fistulas in Pediatric Burn Patients*

Tracheocutaneous fistula (TCF) is a common complication that occurs after decannulation of a long-term tracheostomy. Numerous studies have demonstrated the incidence of TCF formation to positively correlate with an increasing duration of cannulation, specifically in children. Treatment of a persistent TCF in a child has been well described in the literature, with good response to local measures such as curettage and silver nitrate. When this fails, fistulectomy followed by primary closure of the skin or secondary intention yields good results. However, there is a lack of knowledge on TCF formation in pediatric burn-injured patients, where a persistent TCF is a particularly challenging problem to correct given the paucity of supple tissue in the neck and potential for contractures after a large burn injury; effectively making the surgical repairs and management algorithms described in the available literature largely not applicable to this patient population. In this manuscript, we describe a series of pediatric burn patients with persistent TCF, successfully treated with a multilayered closure involving local tissue rearrangement in the form of medial mobilization of the strap muscles of the neck.

Indications and outcomes of paediatric tracheotomy: a descriptive study using a Japanese claims database

OBJECTIVE

To examine the incidence of and indications for paediatric tracheotomy to clarify the disease burden relevant to tracheotomy in a population-based context.

DESIGN

A descriptive analysis of a retrospective cohort.

SETTING

This study utilised a nationwide claims database in Japan constructed by JMDC (Tokyo, Japan). The database includes claims data for approximately 3.75 million insured persons (approximately 3.1% of the population of Japan) comprising mainly company employees and their family members.

PARTICIPANTS

We identified children registered to have undergone tracheotomy from 2005 to 2017 among about 1.2 million children aged 0-15 years.

MAIN OUTCOME MEASURES

The characteristics of the study population, and indications for tracheotomy, duration of hospital stay, duration of mechanical ventilation, duration of tracheotomy dependence, complications related to tracheotomy and death were assessed. When there were multiple indications, classification for a child into multiple groups was allowed.

RESULTS

The study included 215 children (120 males, 56%). The median age at tracheotomy was 0.8 years. The most common age at tracheotomy was less than 12 months (n=127, 59.1%). The most common indications for tracheotomy were chronic lung disease (n=79, 36.7%), followed by neuromuscular disease (n=77, 35.8%), cardiovascular disease (n=53, 24.3%), upper airway obstruction (n=43, 20%), premature birth and related conditions (n=34, 15.8%), trauma (n=16, 7.4%), prolonged ventilation due to other causes (n=12, 5.6%) and malignancy (n=9, 4.2%). The median duration of tracheotomy dependence was 17.2 months. During the follow-up period, decannulation was achieved in 84 children (39.1%), and the median time from tracheotomy to decannulation was 12.0 months.

CONCLUSIONS

Most paediatric tracheotomies were performed due to chronic underlying diseases, and the mean duration of tracheotomy dependence was nearly 1-½ years. The long-term duration of tracheotomy dependence might have some impacts on patients' physical and mental development and the quality of life.

Pediatric tracheocutaneous fistula closure following tracheostomy decannulation

OBJECTIVE

To determine the frequency and risk factors that lead to the development of persistent TCF (tracheocutaneous fistula) formation in children following tracheostomy decannulation at our institution.

METHODS

A retrospective chart review of all pediatric patients at Children's Hospital Colorado who underwent tracheostomy decannulation and were being followed between January 1, 2007 and December 31, 2013. TCF was defined as a persistent fistula six months following decannulation. We determined patient demographics, age at tracheotomy, primary indication for tracheotomy, tracheostomy-tube size, medical comorbidities, age at decannulation, date of TCF closure, and method of TCF closure.

RESULTS

One hundred twenty-nine patients ranging from 51 days to 19 years of age underwent tracheostomy decannulation. 63 (49%) patients underwent surgical closure of TCF. Compared to those with spontaneous closure by multivariable analysis, those with surgical closure were younger at tracheostomy placement (p = 0.0002), had a tracheostomy for a longer duration (p = 0.0025), and were diagnosed with tracheobronchomalacia (p = 0.0051). The likelihood of spontaneous closure decreased over time. Tracheostomy tube internal diameter correlated with age (R = 0.64, p < 0.0001).

CONCLUSIONS

Approximately 50% of pediatric tracheostomy stoma sites will close spontaneously. Development of a persistent TCF was associated with younger age at placement, longer duration of tracheostomy, and the presence of tracheobronchomalacia. These observations may help clinicians anticipate outcomes following tracheostomy decannulation in children.

Long-term ventilation for children with chronic lung disease of infancy

PURPOSE OF REVIEW

Modern medical advances have resulted in an increased survival after extremely preterm birth. However, some infants will develop severe bronchopulmonary dysplasia (BPD) and fail to wean from invasive or noninvasive positive pressure support. It remains unclear which infants will benefit from tracheostomy placement for chronic ventilation. Once the decision to pursue chronic ventilation has been made, questions remain with respect to the timing of tracheotomy surgery, optimal strategies for mechanical ventilation, and multidisciplinary care in both the inpatient and outpatient settings. The appropriate time for weaning mechanical ventilation and tracheostomy decannulation has similarly not been determined.

RECENT FINDINGS

Although there remains a paucity of randomized controlled trials involving infants with severe BPD, a growing body of evidence suggests that chronic ventilation via tracheostomy is beneficial to support the growth and development of severely affected preterm children. However, delivering such care is not without risk. Chronic ventilation via tracheostomy requires complex care coordination and significant resource utilization.

SUMMARY

When chronic respiratory insufficiency limits a preterm infant's ability to grow and develop, chronic invasive ventilation may facilitate neurodevelopmental progress and may lead to an improved long-term outcome.

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.

Pediatric Tracheostomy Decannulation: 11-Year Experience

OBJECTIVE

To determine the successful decannulation rate with a published pediatric tracheostomy decannulation protocol.

STUDY DESIGN

Case series with chart review.

SETTING

A single tertiary care institution.

SUBJECTS AND METHODS

A chart review was performed for patients aged ≤5 years who underwent tracheostomy. Extracted data included demographic data, indication for tracheostomy, age at tracheostomy and decannulation, comorbidities, and surgical complications. Records were searched for documentation of early decannulation failure (within 1 month of decannulation) or late failure (within 1 year).

RESULTS

Forty patients with a tracheostomy aged ≤5 years underwent attempted decannulation during the 11-year study period. Seventeen patients were excluded from the study for documentation of nonprotocol decannulation. The final study population of 23 patients underwent a total of 27 decannulations, 26 of which were performed by protocol. Of the 26 protocol decannulations, 22 were successful, for a failure rate of 15%.

CONCLUSION

Twenty-six protocol decannulations were attempted among 23 patients, 4 of which were unsuccessful for an overall failure rate of 15%. This result is consistent with rates reported in other published decannulation protocols. We believe that our protocol minimizes resource utilization in its use of pulse oximetry over polysomnography, while maximizing patient safety and success through the use of capping trials for very young and very small pediatric patients.

Perioperative management of tracheocutaneous fistula closure in children: A review of 96 cases

BACKGROUND

A tracheocutaneous fistula is a known complication following tracheostomy decannulation. Although surgical techniques for its repair are well described, there is no consensus about perioperative management and this procedure may generate significant airway and respiratory complications intraoperatively, and in the early postoperative period. We aimed to describe variations in perioperative management in tracheocutaneous fistula closure, estimate the incidence of early airway and respiratory complications, and identify any predisposing factors.

METHODS

The otorhinolaryngology surgical database identified 118 tracheocutaneous fistula closures from August 1994 to September 2015. Ninety-seven case notes were located generating 96 procedures for retrospective review. The data collected included demographics, comorbidities, anesthetic, and surgical technique, and complications up to 24 hours postoperatively.

RESULTS

The median age at surgery was 5 years 10 months (range 1 year 8 months to 19 years 6 months). Preoperatively, 72% of patients had a "mini" sleep study (where the tracheocutaneous fistula is covered and saturations measured overnight). Ninety percent had an inhalational induction and 96% a tracheal intubation. Intraoperatively, laryngospasm occurred in 2% and there was difficulty ventilating in another 2%. A "leak test" to check fistula repair airtightness was recorded in 35%. Postoperatively 24% had one or more episodes of oxygen desaturation. Major complications occurred in five patients (incidence 5%, 95% CI 0.8-9.7); four patients had pneumothoraxes with two needing postoperative mechanical ventilation and one patient developed life-threatening subcutaneous emphysema.

CONCLUSION

Perioperative care for children undergoing tracheocutaneous fistula closure was not standardized. Advocated tests such as preoperative "mini" sleep studies and "leak test" intraoperatively were not consistently performed. Intraoperative anesthetic complications were uncommon; however, major postoperative respiratory complications were 5%.