Surgical management of severe suprastomal cricotracheal collapse complicating pediatric tracheostomy

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.

Validation of the Seattle Suprastomal Safety Score (5S): A Novel Measure in Pediatric Tracheostomy-Dependent Patients

OBJECTIVE

Suprastomal collapse and granulation are common sequelae of pediatric tracheostomy. We present the first measure of suprastomal obstructive pathology, the Seattle Suprastomal Safety Score (5S), an instrument with 2 domains: collapse and granulation.

STUDY DESIGN

Cross-sectional repeated testing survey.

SETTING

Electronic survey.

METHODS

A library of images was assembled from still pictures of the suprastomal area in 50 patients who previously underwent trachea-bronchoscopy at a quaternary children's hospital. Five pediatric otolaryngologists and 2 pediatric pulmonologists reviewed the images in random, blinded fashion and provided 5S scores. Participants repeated this process 2 to 4 weeks later. Interrater agreement was calculated with an intraclass correlation coefficient (ICC) with a 2-way random-effects model and Fleiss's κ. Intrarater agreement was measured with an ICC using a 2-way mixed-effects model as well as with test-retest correlations using Spearman rank coefficient. All measures were performed separately on collapse and granulation domains.

RESULTS

ICC for interrater agreement was 0.88 (95% CI, 0.82-0.93) for collapse and 0.97 (95% CI, 0.96-0.98) for granulation, indicating almost perfect agreement. Fleiss's κ demonstrated moderate agreement for collapse and almost perfect agreement for granulation. ICC for intrarater agreement was 0.95 (95% CI, 0.93-0.97) and 0.99 (95% CI, 0.98-0.99) for collapse and granulation, respectively, indicating almost perfect agreement. Spearman rank correlation for test-retest demonstrated substantial agreement for collapse and almost perfect agreement for granulation.

CONCLUSION

The 5S demonstrates excellent interrater and intrarater agreement, making it highly reliable as a novel measure of suprastomal collapse and granulation in tracheostomy-dependent pediatric patients.

Starplasty contributes to reduce tracheostomal granulation in pediatric tracheostomy

BACKGROUND

Starplasty tracheostomy for pediatric patients has been suggested to reduce complications, including accidental decannulation and granulation.

OBJECTIVES

This study, based in a single hospital, aims to evaluate whether starplasty tracheostomy decreases the incidence of postoperative granulation of tracheostoma.

MATERIAL AND METHODS

A retrospective review was performed of patients that underwent tracheostomy under the age of 10 years in a single center between January 2001 and August 2020.

RESULTS

Of the 46 patients reviewed, 18 were males and 28 were females, and the median age at the initial operation was 6 months. Methods of tracheostomy were starplasty in 16 patients, vertical in 15 patients, horizontal H-shaped in 10 patients, fenestration in 3 patients, and trap door/inverted U-shaped in two patients. During observation, tracheostoma granulation was found in 25 patients and bleeding from tracheostoma occurred in one patient. No other major complications were observed. The incidence of postoperative tracheostoma granulation was significantly lower in patients that underwent starplasty tracheostomy compared with patients that underwent other types of tracheostomy (p = .007). There was no difference in survival outcomes or ratio of decannulations.

CONCLUSIONS

Starplasty tracheostomy was shown to decrease the incidence of tracheostoma granulation compared with other types of tracheostomy.

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.

International Pediatric Otolaryngology Group (IPOG) consensus recommendations: Management of suprastomal collapse in the pediatric population

INTRODUCTION

Suprastomal Collapse (SuStCo) is a common complication of prolonged tracheostomy in children. There is a paucity of literature on this subject, especially regarding how to manage significant suprastomal collapse that prevents safe decannulation.

OBJECTIVE

Provide a definition, classification system, and recommend management options for significant suprastomal collapse in children with tracheostomy.

METHODS

Members of the International Pediatric Otolaryngology Group (IPOG) who are experts in pediatric airway conditions were surveyed and results were refined using a modified Delphi method.

RESULTS

Consensus was defined as > 70% agreement on a subject. The experts achieved consensus: CONCLUSION: This consensus statement provides recommendations for medical specialists who manage infants and children with tracheostomies with significant Suprastomal Collapse. It provides a classification system to facilitate diagnosis and treatment options for this condition.

Surgical options in suprastomal collapse-induced severe airway obstruction

Purpose

A single institutions experience with various surgical options in the treatment of severe suprastomal collapse (SSC).

Methods

The study included 18 tracheostomized children with SSC treated between January 2012 and December 2018. Data included: patient demography, initial airway lesions, comorbidities, indication and age at tracheostomy, prior airway surgery, stomal demography, type of surgery, postoperative management, complications and treatment outcomes.

Results

Four techniques were used to correct SSC. The surgical choice was dependent on stoma demography and associated airway lesions. Excision was done in eight patients and rib cartilage augmentation in five. Three patients had single stage tracheal resection and anastomosis. Two patients received stomal rigidification and temporary placement of Montgomery T tube. Three patients with anterior rib graft augmentation required additional lateral tracheal wall rigidification. Three patients (two with cartilage augmentation, and one with stomal rigidification) developed minimal granulation tissue in the postoperative period. Complete SSC resolution was seen in all except two patients who had a partial response to the treatment. All patients were successful decannulated and are currently asymptomatic.

Conclusion

Decannulation failures may be due to severe suprastomal collapse that could be either unique or associated with obstructing laryngotracheal lesions. Therefore, it is essential to select the most appropriate surgical treatment to obtain overall favorable outcomes.

Electronic supplementary material

The online version of this article (10.1007/s00405-020-06339-3) contains supplementary material, which is available to authorized users.

Bioabsorbable Microplates as an External Stent for Suprastomal Collapse: A Retrospective Review

OBJECTIVE/HYPOTHESIS

To assess the long-term decannulation outcomes of bioresorbable microplates as an external stent for pediatric tracheostomy patients with suprastomal collapse.

STUDY DESIGN

Retrospective cohort study.

METHODS

Hospital records of all patients who underwent a bioresorbable microplate for suprastomal collapse from 2016 to 2019 were reviewed at a single institution. The primary outcome measure was tracheostomy decannulation.

RESULTS

A total of nine patients underwent placement of bioabsorbable microplates to treat suprastomal collapse. After initial tracheostomy, four patients received a laryngotracheal reconstruction prior to their external stent placement, and one patient received a mandibular distraction. The average age at the time of external stent placement was 32 (±21) months, excluding one patient who received a stent at the age of 29 years. Eight patients (88.9%) were successfully decannulated following the procedure. Decannulated patients were followed for an average of 21 (±12.5) months postoperatively, and all these patients have remained decannulated since their initial procedure. This is a total of 173 months (14.4 years) of observation postprocedure in which these patients have remained decannulated. One patient experienced postoperative crepitus requiring washout but still maintained decannulation.

CONCLUSION

Bioabsorbable microplates have a reasonable chance of long-term successful decannulation when an appropriate patient is selected. Decannulation is maintained beyond the 6-month time frame in which the 85:15 poly(L-lactide-co-glycolide) polymer that comprises the external stent takes to bioabsorb. This procedure should be considered for the often difficult problem of pediatric tracheostomy with isolated suprastomal collapse.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E631-E634, 2021.

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.

Pre-decannulation Peristomal Findings in Tracheostomized Cases and Their Effect on the Success of Decannulation

Decannulating a patient on a tracheostomy is a procedure that has to be dealt with vigilantly. This study evaluated both external and telescopic/bronchoscopic findings at the peristomal level of subjects being considered for decannulation. The patients did not undergo any intervention after above observations and before attempting decannulation. Thereafter peristomal findings and their contribution towards failure to decannulate were correlated. Thirty subjects were studied prospectively, of whom 21 (70 %) demonstrated peristomal complications including granulation tissue, ulceration, mucopurulent discharge, suprastomal granulations, suprastomal collapse and suprastomal flap. Complications were more common in the younger age group (p = 0.007) as well as in tracheostomies of longer duration with mean duration >20 months (p = 0.045). However there was no statistically significant correlation between the success of decannulation and various peristomal findings. Therefore the success of decannulation in a particular case cannot always be correctly predicted by peristomal assessment.

Resolution of airflow obstruction on polysomnography after laryngotracheal reconstruction with anterior tracheal wall suspension in a patient with DiGeorge Syndrome

DiGeorge Syndrome (DGS) may be associated with airway abnormalities including laryngomalacia and suprastomal collapse of the trachea (SCT), which may lead to sleep disordered breathing (SDB). We present a 4-year-old boy with DGS, SCT, and SDB by polysomnography (PSG) while the tracheostomy tube was capped. The patient underwent anterior tracheal wall suspension (ATWS) with concurrent tracheostomy decannulation. Following the repair, the patient experienced improved airway patency visually and by PSG with resolution of obstructive sleep apnea and hypoventilation. ATWS is an effective method to repair SCT in selected patients and may lead to early decannulation and improvement of SDB.

Tracheostomy in young patients: indications and long-term outcome

Diagnostic and treatment modalities have changed substantially over the past years in the field of pediatrics and neonatal medicine. As a result, the indications and outcome after tracheostomy in young patients have evolved. The aim of this study is to present our experience with pediatric tracheostomies and provide an up-to-date review of the literature with special focus on current trends. The complete medical records of 85 children and adolescents (up to age 18) which underwent tracheostomy from January 1990 until March 2008 were reviewed. Telephone interviews were conducted to evaluate the childrens further clinical course. The indications for tracheostomy were upper airway obstruction (27%), craniofacial syndromes (3.5%), long-term mechanical ventilation (22.3%), neurological deficit (25.9%), trauma and sequelae (16.5%) and bilateral vocal cord paralysis (4.7%). The average age of patients at the time of tracheostomy was 4.7 years (range, 2 days-18 years) but there were significant differences between the six indication groups. Children under the age of 7 years comprised 72.9% of all patients. The mean cannulation time was 21.6 months; 50.6% of the patients could be successfully decannulated. Life-threatening complications occurred in 6 patients (7%). The total mortality rate was 18.8%; the tracheostomy related mortality rate was 0%. In the past 30 years, short-term tracheostomy was commonly performed for infectious causes such as epiglottitis. Nowadays, the majority of patients are very young children with severe and chronic diseases. This fact accounts for the relatively low decannulation rates, long cannulation times and high mortality. The tracheostomy related mortality on the other hand, is comparatively low.