The changing indications for paediatric tracheostomy

Effectiveness of Training: Airway Management of Tracheostomized Pediatric Patients by Pediatric Residents and Anesthesiology Residents

To evaluate the effect of training on increasing baseline knowledge of pediatrics and anesthesia residents about airway management of pediatric patients with tracheostomy. It is a prospective, descriptive, before and after survey study. A questionnaire was conducted to measure the baseline knowledge of pediatrics and anesthesia residents about airway management in patients with pediatric tracheotomy. The same questionnaire was repeated after the education. Of the 63 participants, 42 were pediatric residents and 21 were anesthesiology residents. While the number of participants who answered the cuff part, inner cannula part, obturator part and balloon part of the tracheostomy tube correctly before the training was 27, 4, 10, and 12, respectively, these numbers increased to 53, 52, 57, and 55 after the training. There was a statistically significant improvement after the training in the correct response of the cuff, inner cannula, obturator, and balloon sections. A statistically significant improvement was observed in the answers received after the training for all 7 questions regarding the clinical scenario of accidental decannulation and tracheostomy bleeding compared to the pre-training. There was a statistical improvement in part where the participants rated themselves. In conclusion, training increases the ability of healthcare professionals to cope with life-threatening complications related to pediatric tracheotomy. A standardized education program on pediatric tracheostomy should be included in the routine programs of associated departments such as emergency medicine, anesthesia, and pediatrics residencies.

Caregiver quality of life after pediatric tracheostomy

OBJECTIVE

To determine the impact of a child with a tracheostomy on caregiver quality of life.

METHODS

A repeated cross-sectional analysis included families with tracheostomy-dependent children between 2019 and 2021. Caregivers were surveyed using the PedsQL™ Family Impact Module with assessments at tracheostomy placement and during ambulatory office visits.

RESULTS

Two-hundred and fifty-five surveys were performed with 66 at tracheostomy placement (26%) and 189 at follow-up visits (74%). Compared to families with healthy children, total scores at placement (77.2 vs. 87.6, P < .001) and follow-up visits (78.9 vs. 87.6, P < .001) were significantly lower among pediatric tracheostomy families. Caregivers were likely to report significant improvement in emotional functioning (6.2 points; 95% CI: 0.5-12, P = .03) and worry (9 points, 95% CI: 2.1-15.9, P = .01) over time. Demographic variables demonstrated no confounding or interactive effects.

CONCLUSIONS

The presence of a tracheostomy is associated with lower caregiver quality of life scores in the short- and long-term compared to caregivers of healthy children. Providers should be sensitive to these challenges and provide appropriate support for families of tracheostomy-dependent children.

The impact of pediatric tracheostomy on the quality of life of caregivers

OBJECTIVE

Pediatric tracheostomy is a challenge in otolaryngology practice and it is associated with greater morbidity and mortality than in adults; hence, constant vigilance by the designated family caregiver is critical. This study was designed to assess the impact of on quality of life of caregivers in a homecare setting as a result of the presence of child with a tracheostomy.

METHODS

This was a combined retrospective and prospective cohort study with caregivers of children younger than 16 years who had undergone a tracheostomy, had been discharged home with a tracheostomy tube and completed 6 months of domiciliary tracheostomy care. The consenting primary caregivers were assessed for their quality of life based on the PedsQL v 4.0 questionnaires across various domains.

RESULTS

We identified the primary caregivers of 85 children who had undergone a tracheostomy during the study period. The children's median age was 3.5 years (range, 9 months to 14 years). The mean caregiver health-related quality of life (HRQOL) score was 59.3, the mean family functioning score was 62.8, and the mean total family impact score was 54.7 with relative deficits seen in caregiver's social functioning (56.9) and emotional functioning (53.2). Good or average quality of physical and social function was seen among 74 % and 65 % of caregivers respectively while only 55 % were reported having good or average emotional function. Emotional disturbance, interfering with everyday family activities, and sleep disturbance were the major concerns among caregivers.

CONCLUSION

The biopsychosocial consequences of caring for a child with a tracheostomy are profound for the family, affecting the quality of life of caregivers and adding to the emotional and social burden of the child's family.

[Modern causes of tracheostomy in children]

The purpose of work is to analyze the causes of tracheostomy in children hospitalized in a large multidisciplinary pediatric hospital.

MATERIAL AND METHODS

Retrospective analysis of case of children treated in a multidisciplinary urgent hospital - GBUZ «Morozovskaya CCCH of MDH», which in the period from 01.01.16 to 31.12.18 was made operation «tracheostomy» was conducted.

RESULTS

Tracheostomy was performed in 138 (0.064%) among 216 469 hospitalized children. Age at the time of tracheostomy ranged from 2 weeks to 17.5 years (on average 67.9±59.84 months, Me=47.5 months), and 36.2% of children had tracheostomy was done on the 1^st year of life. 126 (91.3%) patients required prolonged tracheal intubation prior to tracheostomy placement; the duration of intubation ranged from 1 to 95 days (on average 19.9±13.42 days, Me=14 days). The main reasons of tracheostomy were the need for long-term mechanical ventilation/respiratory support; the need for constant sanitation of the lower respiratory tract with bulbar/pseudobulbar disorders; upper respiratory paths obstruction. The diseases that led to this condition can be grouped into 4 categories: CNS pathology - 76 (55.1%) patients; brain / spinal cord tumors - 36 (26.1%); neurodystrophy and stenosis of the upper respiratory tract of various etiology - 13 (9.4% each) patients. 68.1% of patients were found incurable and required palliative care. Mortality among patients with a known catamnesis was 39.1%, mainly due to progression of the underlying disease; the lethality associated with tracheal cannulation was 1.4%.

CONCLUSION

Currently, pediatric tracheostomy is moving into the category of predominantly planned surgical interventions. More than 2/3 of children requiring tracheostomy are patients in need of palliative care with severe pathology of the central nervous system; in which the main indications for surgery are the need for respiration support and regular tracheobronchial care..

Microbiological profiles of tracheostomy patients: a single-center experience

Background

This study compared the prevalence of common microorganisms in obstructed and non-obstructed cases across the four quarters on the first post-tracheostomy year.

Methods

A retrospective chart review of the microbiological profiles of all adult patients who underwent a tracheostomy was conducted between June 2015 and September 2019 at our hospital. Based on the tracheostomy indications, patients were allocated to obstructed or non-obstructed group. Any patient with at least one positive sample was followed up quarterly for a year. The first culture result obtained was recorded at least one month following the last antibiotic dose in each quarter.

Results

Out of the 65 tracheal aspirate results obtained from 58 patients (mean age, 57.5±16.48 years), the most common procedure and indications were surgical tracheostomy (72.4%) and non-obstructed causes (74.1%), respectively. Moreover, 47.7% of the culture results indicated Pseudomonas aeruginosa, which showed significantly different proportions across the quarters (p=0.006). Among obstructed patients, P. aeruginosa was the most common (35%), followed by methicillin-resistant Staphylococcus aureus (MRSA; 23.5%).

Conclusions

The most common post-tracheostomy microorganism was P. aeruginosa. MRSA showed a strong association with tracheostomy for obstructive indications.

Tracheostomy in Pediatric Intensive Care Unit-A Two Decades of Experience

Aim and objective

To study the profile, indications, related complications, and predictors of decannulation and mortality in patients who underwent tracheostomy in the pediatric intensive care unit (PICU).

Materials and methods

Retrospective analysis of prospectively collected data of tracheostomies was done on patients admitted at PICU. Demographics, primary diagnosis, indication of tracheostomy, and durations of endotracheal intubation, mechanical ventilation, and tracheostomy cannulation were recorded. The indication was recorded in one of the four categories—upper airway obstruction (UAO), central neurological impairment (CNI), prolonged mechanical ventilation, and peripheral neuromuscular disorders).

Results

Two hundred ninety cases were analyzed. UAO (42%) and CNI (48.2%) were main indications in the halves of the study period, respectively. Decannulation was successful in 188 (64.8%) patients. Seventy-seven percentage UAO patients were decannulated successfully [OR (odds ratio); 95% CI (confidence interval), 2.647; 1.182–5.924, p = 0.018]. Age <1 year (0.378; 0.187–0.764; p = 0.007), nontraumatic, noninfectious central neurological diseases (0.398; 0.186–0.855; p = 0.018), and malignancy (0.078; 0.021–0.298; p <0.001), durations of posttracheostomy ventilation (0.937; 0.893–0.983; p = 0.008), and stay in the PICU (0.989; 0.979–0.999; p = 0.029) were predictors of unsuccessful decannulation. There were 91 (31.4%) deaths. Age <1 year (2.39 (1.13–5.05; p = 0.02), malignancy (17.55; 4.10–75.11; p <0.001), durations of posttracheostomy ventilation (1.06; 1.006–1.10; p = 0.028), and hospital stay (1.007; 1.0–1.013; p = 0.043) were independent predictors of mortality. Indication of UAO favored survivor (0.24; 0.09–0.57; p <0.001).

Conclusion

The indications for tracheostomy in children had changed over the years. Infancy, primary diagnosis, length of posttracheostomy ventilation, and stay in the PICU and hospital were independent predictors of decannulation and mortality.

What This Adds

Similar to developed countries, the age at the time of tracheostomy and indication are changing. Inability to decannulate and mortality were associated with the age of a child at the time of tracheostomy, indication, medical diagnosis, and duration of postprocedure mechanical ventilation and stay in the hospital.

How to cite this article

Sachdev A, Chaudhari ND, Singh BP, Sharma N, Gupta D, Gupta N, et al. Tracheostomy in Pediatric Intensive Care Unit—A Two Decades of Experience. Indian J Crit Care Med 2021;25(7):803–811.

Tracheostomy, respiratory support, and developmental outcomes in neonates with severe lung diseases: Retrospective study in one center

OBJECTIVES

Pediatric tracheostomy has evolved significantly in the past few decades and the optimal timing to perform it in children with respiratory assistance is still debated. The objective of this study was to describe the indications, timing, complications, and outcomes of infants on respiratory support who had a tracheostomy in a tertiary pediatric intensive care unit (PICU).

METHODS

All children younger than 18 months of corrected age requiring respiratory support for at least 1 week and who had a tracheostomy between January 2005 and December 2015 were included. Their demographic and clinical data and their outcomes at 24 months of corrected age were collected and analyzed after approval from the CHU Sainte-Justine ethics committee.

RESULTS

During the study period, 18 children (14 preterm infants, 4 polymalformative syndromes, and 2 diaphragmatic hernias) were included. The median corrected age at tracheostomy was 97 days (0-289 days) and 94.4% were elective. The indications for tracheostomy were ventilation for more than 7 days with (61.1%) or without (38.9%) orolaryngotracheal anomaly. The median number of consultants involved per patient was 16 consultants (10-23 consultants). The median hospital length of stay was 122 days (8-365 days) before tracheostomy and 235 days (22-891 days) after tracheostomy. The median invasive ventilation time was 68 days (8-168 days) before tracheostomy and 64 days (5-982 days) after tracheostomy. In terms of complications, there were nine cases of tracheitis and five cases of tracheal granulomas. At 24 months of corrected age, 17 of 18 children survived, one of/17 was still hospitalized, three of 17 were decannulated, three of 17 received respiratory support via their tracheostomy, 11 of 17 were fed with a gastrostomy, and all had neurodevelopmental delay.

CONCLUSION

Tracheostomy in infants requiring at least 1 week of ventilation is performed for complex cases and is favored for orolaryngotracheal anomalies. Clinicians should anticipate the need for developmental care in this population.

Epidemiology of Pediatric Tracheostomy and Risk Factors for Poor Outcomes: An 11-Year Single-Center Experience

OBJECTIVE

Children with long-term tracheostomies are at higher risk of complications. This study aims to describe the epidemiology, outcomes, and factors associated with successful decannulation in children undergoing tracheostomy.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary hospital.

SUBJECTS AND METHODS

A retrospective analysis was conducted on pediatric tracheostomies performed from 2006 to 2016. Demographics, preexisting comorbidities, indications for tracheostomy, and pretracheostomy ventilatory requirements were collected. A multivariate regression model with covariates of age, failure to thrive (FTT), and comorbidities was used to identify factors associated with successful decannulation. Secondary outcomes were ventilation and oxygen requirements at hospital discharge, hospital and intensive care unit length of stay, and complications.

RESULTS

In total, 105 patients received a tracheostomy at a median age of 8.0 months (interquartile range, 2.0-45.0). The most common indication was anatomic airway obstruction (55 of 105, 52.5%). Forty-four (41.9%) patients had preexisting FTT. In-hospital mortality was 14 of 105 (13.3%). None were directly related to tracheostomy. At discharge, 40 of 91 (44.0%) and 12 of 91 (13.2%) required home mechanical ventilation and supplemental oxygen, respectively. Forty-one (39%) patients underwent successful decannulation at a median 408 days (interquartile range, 170-1153) posttracheostomy. On adjusted analysis, unsuccessful decannulation was more common in patients with FTT and neurologic comorbidities. Postoperative complications were more common in younger patients and those with a longer time to decannulation.

CONCLUSION

Neurologic comorbidities and FTT were risk factors for unsuccessful decannulation after pediatric tracheostomy. Nutritional interventions may have a role in improving long-term outcomes following pediatric tracheostomies and should be investigated in future studies.

Pediatric Tracheotomy: Comparison of surgical technique with early and late complications in 273 cases

Objectives:

This study was aimed to compare the early and late complications of tracheotomy in pediatric patient, with respect to surgical techniques.

Methods:

The relationship between demographic characteristics, surgical techniques obtained from the files of the children and complications developing after surgery were compared retrospectively.

Results:

One hundred fifty two out of 273 developed complications after tracheotomy. Among these, 75 were early complications and 77 were late complications. Results obtained concerning early complications showed a significant difference between Skin incision and Bleeding and Accidental decannulation; Tracheal incision and Subcutaneous emphysema; surgical time and accidental decannulation and tube/ventilation problem; Surgeon’s skill level and bleeding. As regards late complications there was a significant difference between Intubation Time and Stomal-tracheal granulation; Tracheal incision and Stomal infection; Surgeon’s skill level and Stomal-tracheal granulation.

Conclusions:

In pediatric tracheotomy the preferred skin incision and tracheal incision, surgeon’s experience, tracheotomoy time and intubation time are important as regards development of early or late complications.

Indications for tracheostomy in children with head and neck lymphatic malformation: analysis of a nationwide survey in Japan

PURPOSE

Airway obstruction caused by lymphatic malformation (LM) in the head and neck may require a tracheostomy. We present the results of our analysis of a nationwide survey on the indications for tracheostomy in children with head and neck LM.

METHODS

We analyzed data in relation to tracheostomy based on a questionnaire about 518 children with head and neck LM without mediastinal involvement.

RESULTS

Tracheostomy was performed for 43 of the 518 children. Most (32/43) of these children were younger than 1 year of age and the tracheostomy was almost always performed for airway obstruction (40/43). The lesion was in contact with the airway in 32 (72%) of these children, but in only 58 (12%) of the 473 children who were managed without tracheostomy. When the maximum circumferential area of contact was compared, only 20 (27%) of 74 patients with maximum contact of less than a half-circle required tracheostomy, whereas 11 of 13 with maximum contact of more than a half-circle required tracheostomy (P = 0.0001). Six patients without airway contact required tracheostomy because of acute swelling caused by hemorrhage, infection, or both.

CONCLUSIONS

Children with head and neck LM required tracheostomy to relieve airway obstruction. Tracheostomy should be considered if the lesion is in contact with the airway and surrounds more than a half-circle, and when it causes acute swelling.

Polysomnography Provides Useful Clinical Information in the Liberation from Respiratory Technology: A Retrospective Review

Background The prevalence of respiratory-technology dependent children is increasing although for most children the goal is liberation from technology. Liberation from home mechanical ventilation (HMV) and decannulation strategies vary due to the lack of clinical practice standards. The primary objective of this study was to describe our practice utilizing a polysomnography (PSG) in the liberation from respiratory-technology process. Methods Retrospective study of tracheostomized children with and without HMV who underwent an evaluation for decannulation between January 2006 and June 2016. Patient demographics, indication for tracheostomy, indication for PSG, PSG results and interventions performed after the PSG were collected. RESULTS: We identified 153 decannulation attempts in 148 children. Ninety-nine children had a tracheostomy only and 49 children had a tracheostomy with HMV. There were 190 PSGs performed. Almost two-thirds of the children (N = 92) had at least one PSG, 37 children (25%) had two and 19 children (13%) had more than 2 PSGs. Children with tracheostomy and HMV had more PSGs compared to children with tracheostomy only. PSGs were performed at four points: (1) prior to tracheostomy placement (N = 23); (2) to titrate HMV (N = 19); (3) off-HMV support (N = 43); and with a capped tracheostomy (N = 101). Most of the off-HMV PSGs (N = 39) were favorable for discontinuing HMV. About two-thirds of the capped PSGs (N = 73) were favorable for decannulation; of the unfavorable capped PSGs (N = 28), thirteen required airway surgeries following the unfavorable PSG. CONCLUSION: : Overnight PSG provides useful information to the liberation process, particularly when determining readiness for discontinuing HMV and decannulation.

Revealing the needs of children with tracheostomies

INTRODUCTION

Small children with tracheostomy are at potential risk and have very specific needs. International literature describes the need for tracheostomy in 0.5% to 2% of children following intubation. Reports of children submitted to tracheostomy, their characteristics and needs are limited in developing countries and therefore there is a lack of health programs and government investment directed to medical and non-medical care of these patients. The aim of this study was to describe the characteristics of these children and identify problems related to or caused by the tracheostomy.

METHODS

A retrospective cohort study was performed based on a common database applied in four high complexity healthcare facilities to children submitted to tracheostomy from January 2013 to December 2015. Data concerning children's demographics, indication for tracheostomy, early and late complications related to tracheostomy, airway diagnosis, comorbidities and decannulation rates are reported. Patients who did not present a complete database or had a follow-up of less than six months were excluded.

RESULTS

A total of 160 children submitted to tracheostomy during the three-year period met the criteria and were enrolled in this study. Median age at tracheostomy was 6.9 months (ranging from 1 month to 16 years, interquartile range of 26 months). Post-intubation laryngitis was the most frequent indication (48.8%). Comorbidities were frequent: neurologic disorders were reported in 40%, pulmonary pathologies in 26.9% and 20% were premature infants. Syndromic children were 23.1% and the most frequent was Down's syndrome. The most common early complication was infection that occurred in 8.1%. Stomal granulomas were the most frequent late complication and occurred in 16.9%. Airway anomalies were frequently diagnosed in follow-up endoscopic evaluations. Subglottic stenosis was the most frequent airway diagnosis and occurred in 29.4% of the cases followed by laryngomalacia, suprastomal collapse and vocal cord paralysis. Decannulation was achieved in 22.5% of the cases in the three-year period. The main cause for persistent tracheostomy was the need for further treatment of airway pathology. Mortality rate was 18.1% during this period but only 1.3% were directly related to the tracheostomy, the other deaths were a consequence of other comorbidities.

CONCLUSION

Tracheostomies were performed mostly in very small children and comorbidities were very common. Once a tracheostomy was performed in a child in most cases it was not removed before a year. The most common early complication was stoma infection followed by accidental decannulation. The most frequent late complication was granuloma and suprastomal collapse. Airway abnormalities were very frequent in this population and therefore need to be assessed before attempting decannulation.

The outcomes of children with tracheostomy in a tertiary care pediatric intensive care unit in Turkey

Aim

We aimed to describe which clinical characteristics were associated with the outcome of tracheostomy in our tertiary care pediatric intensive care unit.

Material and Methods

This was a retrospective review of medical records of pediatric patients who underwent tracheostomy in our Pediatric Intensive Care unit from 2008 to 2014 in Turkey.

Results

Sixty-three patients were included the study. The median age of patients was 11 (range, 1-195) months. Twenty-five (39.7%) patients were female. The tracheostomy rate was 8.5% over a six-year period. Forty-nine (77.7%) patients were able to be discharged and sent home. The decannulation rate was 12.6% (n=8). The indications for tracheostomy were upper airway obstruction (n=9) and prolonged mechanical ventilation (n=54). The median intubation period before tracheostomy was 32 (range, 1-122) days and the median duration of pediatric intensive care unit stay after tracheostomy was 37 days. A total of 21 (52.5%) patients were weaned off mechanical ventilation. The rate of successful weaning from mechanical ventilation was higher in patients with upper airway obstruction than in those in the prolonged mechanical ventilation group (p=0.021). The complication rate was 25.3% in the pediatric intensive care unit and 11.1% at home.

Conclusions

Tracheostomy seems safe and improves pediatric patients' outcomes. The most important factor that affects the prognosis of children who underwent tracheostomy is the indication for tracheostomy. The outcomes are always better if the tracheostomy has been performed because of upper airway obstruction. Performing tracheostomy helps weaning from and off ventilator support and finally the discharge of patients with prolonged mechanical ventilation from the pediatric intensive care unit setting.

Indications and outcome of tracheostomy in Ilorin, North Central Nigeria: 10 years review

Background:

The study aims to highlight common indications as well as outcome of treatment among patients with tracheostomy in Ilorin, North-Central Nigeria.

Methods:

A review of clinical records of all patients with tracheostomy over a period of ten years (2002-2011), using the Theatre, Ward, ICU and the emergency register after approval from the ethical review committee. Data retrieved included; demographic profile, primary diagnosis, indication for tracheostomy, surgical technique, hospital admission and care outcome of management. All information retrieved input and analysed using an SPSS version 17.0 and data analyzed descriptively.

Results:

Seventy-six patients had complete data for analysis, age range from 1-89yrs, and mean age of 41.9yrs. There are 48males and 28 females with M:F ratio of 1.6:1. Majority of the patients were in the 3rd–5th decade. About 47.4% had temporary tracheostomy. The commonest indication for tracheostomy is upper airway obstruction secondary to aerodigestive tract tumors in 60.5%, then trauma in 26.3%. The complications are higher among the under tens’. Out of the 36 temporary tracheostomy only 18 were successfully decannulated. The mean hospital stay was 22±2days. Overall 15% mortality was recorded.

Conclusion:

Common reason for tracheostomy is essentially same earlier documentation in developing countries, common among males, emergency type still most common, neoplasm, prolonged intubation and trauma are the commonest indications, its complication is still high among the under tens’. The outcome is good with 15% mortality due to the primary disease and not from tracheostomy.

A 12-year-experience with tracheostomy for neonates and infants in northern Taiwan: Indications, hospital courses, and long-term outcomes

BACKGROUND

Tracheostomy is a valuable procedure in infants and neonates with chronic respiratory failure or severe airway obstruction. The aim of this study is to identify the indication, hospital course, and long-term outcome in a cohort of infants who required tracheostomy in a neonatal and pediatric tertiary care center in northern Taiwan.

METHODS

Medical records of infants, who underwent tracheostomy between January 2002 and December 2013, were retrospectively reviewed. Demographics, indication for tracheostomy, hospital course, discharge disposition, further hospitalization and surgery, and long-term outcome data were collected.

RESULTS

Fifty-six patients were enrolled. The median gestational age was 38.0 weeks, and median birth weight was 2770 g. he median age at tracheostomy was 104.5 days. The primary indications for tracheostomy were airway obstruction in 35 patients (62.5%), craniofacial anomalies in 7 (12.5%), neuromuscular disorder in 7 (12.5%), cardiopulmonary disorder in 5 (8.9%), and brain injury-related problem in 2 (3.6%). Twenty-two patients (39.3%) were decannulated successfully, and the median time from tracheostomy to decannulation was 2.1 years. Overall mortality rate was 3.6%, but no death was related to tracheostomy. Forty-nine patients underwent regular follow-up at our hospital, and 46 patients (93.9%) required further hospitalization, and 30 (61.2%) underwent further surgery related to a respiratory problem or tracheostomy. Ratio of delayed growth at the time of tracheostomy (28.6%) did not have significant difference at 1 year of age (21.4%) and 2 years of age (25.0%).

CONCLUSION

In this study, the most common indication for tracheostomy in neonates and infants was airway obstruction. Excluding patients with neuromuscular diseases, a successful decannulation rate of >50% can be achieved.

Pediatric tracheotomy: A comparison of outcomes and lengths of hospitalization between different indications

OBJECTIVES

To assess outcomes of pediatric tracheotomy and duration of associated hospital stay according to indications.

SUBJECTS AND METHODS

In this retrospective study, subjects were 142 consecutive pediatric patients (<18 years old) who underwent tracheotomy at a tertiary referral medical center, National Taiwan University Hospital, in 1997-2012. Age, sex, indications, pre-operative status (oxygen demand, number of repeated intubations), and post-operative status (duration of weaning, length of hospital stay, mortality) were analyzed.

RESULTS

The indications included craniofacial anomalies (n = 19, 13.4%), upper airway obstruction (n = 41, 28.9%), neurological deficit (n = 58, 40.8%), prolonged ventilation (n = 15, 10.6%), and trauma (n = 9, 6.3%). Ninety-one patients (64.1%) were successfully weaned off ventilation after tracheotomy (40% in the prolonged ventilation group). Total hospital stay and duration of ventilation before tracheotomy were longest in patients with craniofacial anomalies (150.9 ± 98.8 days, p = 0.004; 108.8 ± 88.2, p < 0.001). The early tracheotomy group had a shorter duration of post-tracheotomy mechanical ventilation support than the late tracheotomy group (14.4 ± 19.0, n = 49 vs. 34.9 ± 58.6, n = 80, p = 0.004). Decannulation was successful in 20 patients (14.1%), with the highest rate in the upper airway obstruction group (n = 14, 34.1%) and lowest in the prolonged ventilation group (none). Thirteen patients (9.2%) died during admission from causes unrelated to tracheotomy.

CONCLUSION

Outcomes of pediatric tracheotomy and duration of hospitalization depend on indications. Children with craniofacial anomalies had earlier tracheotomy age and longer mechanical ventilation before tracheotomy resulted in longer hospitalization. Earlier tracheotomy can shorten the duration of post-tracheotomy mechanical ventilation in several conditions.

First Clinical Consensus and National Recommendations on Tracheostomized Children of the Brazilian Academy of Pediatric Otorhinolaryngology (ABOPe) and Brazilian Society of Pediatrics (SBP)

Introduction

Tracheostomy is a procedure that can be performed in any age group, including children under 1 year of age. Unfortunately health professionals in Brazil have great difficulty dealing with this condition due to the lack of standard care orientation.

Objective

This clinical consensus by Academia Brasileira de Otorrinolaringologia Pediátrica (ABOPe) and Sociedade Brasileira de Pediatria (SBP) aims to generate national recommendations on the care concerning tracheostomized children.

Methods

A group of experts experienced in pediatric tracheostomy (otorhinolaryngologists, intensive care pediatricians, endoscopists, and pediatric pulmonologists) were selected, taking into account the different regions of Brazil and following inclusion and exclusion criteria.

Results

The results generated from this document were based on the agreement of the majority of participants regarding the indications, type of cannula, surgical techniques, care, and general guidelines and decannulation.

Conclusion

These guidelines can be used as directives for a wide range of health professionals across the country that deal with tracheostomized children.

A decade of pediatric tracheostomies: Indications, outcomes, and long-term prognosis

OBJECTIVE

To define the mortality and long-term outcomes of children undergoing tracheostomy.

DESIGN

Retrospective chart and Texas Department of Health Bureau of Vital Statistics review of patients admitted to a Pediatric Intensive Care Unit who underwent a tracheostomy between 2001 and 2011. Mortality and decannulation rates were compared based on tracheostomy indication and age.

SUBJECTS

A total of 426 patients admitted to a Pediatric Intensive Care Unit in a large tertiary children's hospital.

RESULTS

The median patient age was 1.5 years (3 days-24 years). Primary indications for tracheostomy included (a) airway obstruction, (b) congenital neurologic disease, (c) acquired neurologic disease, (d) congenital respiratory disease, and (e) acquired respiratory disease. Overall, 98 patients (23%) died during the study period, and 75th percentile survival time was 5.9 years (95%CI: 3-8). Patients undergoing a tracheostomy for airway obstruction were the least likely to die; while patients with acquired neurologic disease were most likely to die. A total of 163 patients (38%) were decannulated, and 50% were decannulated at 1.2 years (95%CI: 0.9-1.5). Patients with congenital neurologic disease were the least likely to undergo decannulation. Over half of the patients were discharged from the hospital requiring some form of mechanical respiratory support in addition to their tracheostomy.

CONCLUSIONS

In this largest cohort of long-term follow-up to date, we have shown the overall risk of mortality varied according to the indication for the tracheostomy. We were unable to determine exact causes of death. The likelihood of being decannulated also correlates with the underlying indication for the tracheostomy. Pediatr Pulmonol. 2017; 52:946-953. © 2017 Wiley Periodicals, Inc.

Starplasty tracheostomy: case series and literature review

OBJECTIVES

The starplasty tracheostomy (SPT) technique has been suggested to reduce the short-term complications of tracheostomy, including accidental decannulation and pneumothorax. The aim of the present study was to conduct a review of key parameters prior to and following treatment of neonates and children with the SPT technique, including indications, complications, perioperative department stay, and overall length of stay in one University-Affiliated Medical Center.

METHODS

A retrospective chart review of all children under the age of 18 underwent SPT in a single center between February 2006 and January 2012.

RESULTS

Among the 39 patients reviewed, the median age at the time of surgery was 14.5 months, ranging from 3 days to 8.8 years. The most common indication for SPT was respiratory insufficiency resulting from central nervous system disorders (15, 38.4%) followed by neuromuscular disorders (14, 35.9%). Ten (25.6%) operations were performed on neonatal intensive care unit (NICU) patients and 29 (74.4%) on pediatric intensive care unit (PICU) patients. The median postoperative hospital stay was 19.5 days (range of 3-207 days); however, the median postoperative stay in the PICU was 13.5 days. There were no decannulations or any other short-term complications after SPT, and no SPT-related deaths occurred.

CONCLUSIONS

In our series, pediatric SPT was not associated with any major complications. Therefore, we conclude that SPT should be considered as a safe and advantageous alternative for traditional tracheotomy, especially in patients with low probability of future decannulation, and, therefore, at low risk of a persistent tracheocutaneous fistula.

Endovascular stenting of tracheoinnominate fistula after tracheostomy in a 14-year-old boy

Tracheoinnominate artery fistula is a rare, fatal complication of tracheostomy, and prompt diagnosis and management are imperative. We report the case of tracheoinnominate artery fistula after tracheostomy in a 14-year-old boy with a history of severe periventricular leukomalacia, hydrocephalus, cerebral palsy, and epilepsy. The tracheoinnominate artery fistula was successfully treated with a stent graft insertion via the right common femoral artery. Endovascular repair of the tracheoinnominate artery fistula via stent grafting is a safe, effective, and minimally invasive treatment for patients in poor clinical conditions and is an alternative to traditional open surgical treatment.

Tracheotomy in the Preschool Population: Indications and Outcomes

OBJECTIVE: Although more tracheotomy procedures are performed within the first year of life than in any other age group, preschool-aged children requiring tracheotomy remain understudied. We characterize the indications and outcomes for patients between the ages of 3 and 6 years undergoing tracheotomy.

METHODS: Out of 480 pediatric tracheotomy procedures performed at a tertiary-care hospital between 1988 and 2004, 15 patients underwent primary tracheotomy between 3 and 6 years of age.

RESULTS: Most (60%) procedures were performed for pulmonary toilet. Upper-airway obstruction represented the second most common indication (40%), and trauma necessitated tracheotomy procedures more often than had been predicted (40%). The decannulation rate was 40%; 2 patients died.

CONCLUSION: Trauma contributed to both upper-airway obstruction as well as requirements for pulmonary toilet. These procedures performed secondary to trauma will likely continue to increase.

SIGNIFICANCE: Tracheotomy procedures in the preschool population remain uncommon; however, nearly half of those studied were performed as a direct result of otherwise preventable trauma.

Tracheostomy in children: a ten-year experience from a tertiary center in southern Brazil

INTRODUCTION

Children may require tracheostomy due to many different health conditions. Over the last 40 years, indications of tracheostomy have endorsed substantial modifications.

OBJECTIVE

To evaluate pediatric patients warranted tracheostomy at our Hospital, in regard to their indications, associated comorbidities, complications and decannulation rates.

METHODS

Retrospective study concerning patients under 18 years of age undergoing tracheostomy in a tertiary health care center, from January 2006 to November 2015.

RESULTS

123 children required a tracheostomy after ENT evaluation during the study period. A proportion of 63% was male, and 56% was under one year of age. Glossoptosis was the most common indication (30%), followed by subglottic stenosis (16%) and pharyngomalacia (11%). The mortality rate was 31%. By the end of this review, 35 children (28.4%) had been decannulated, and the fewer the number of comorbidities, the greater the decannulation rate (0.77±0.84 vs. 1.7±1.00 comorbidities; p<0.001).

CONCLUSION

Tracheostomy in children is a relatively frequent procedure at our hospital. The most common indications are glossoptosis and subglottic stenosis. A high mortality rate was found, potentially substantiated by the high number of critical care patients with chronic neurological conditions in this cohort. Our decannulation rate is slightly below other series, probably because of the greater amount of patients with comorbidities.

Liberation from home mechanical ventilation and decannulation in children

BACKGROUND

The prevalence of children requiring outpatient invasive long-term mechanical ventilation is increasing. For some children, liberation from home mechanical ventilation (HMV) and decannulation is the desired outcome. This study describes our experience liberating tracheostomy and HMV (T-HMV) dependent children from respiratory technologies.

METHODS

We reviewed charts of T-HMV dependent children who were cared for at our institution and decannulated between July 1999 and December 2011. Patient characteristics, diagnoses, and important steps leading to decannulation were recorded.

RESULTS

Forty-six children achieved HMV independence and decannulation. The most common indications for T-HMV were lower airway and parenchymal lung disease. The median ages at tracheotomy, initiation of HMV, initiation of tracheostomy collar (TC) trials, HMV independence, and decannulation were 3.5, 6.0, 12.0, 25.5, and 40.5 months, respectively. Twenty-five children (54%) skipped either using a speaking valve, tracheostomy capping, or both without increased likelihood of recannulation. (P = 0.03). Common procedures prior to decannulation were airway surgery, bronchoscopy, and polysomnography (n = 30, 46, and 46 children, respectively). A median of 9.5 clinic visits and 5 hospitalizations occurred from initial hospital discharge to just prior to decannulation. HMV was primarily weaned as an outpatient.

CONCLUSION

Liberation from respiratory technology is a complex, multi-step process that can be accomplished in medically complex children with varying underlying disease processes at relatively young ages. Five major steps (tracheotomy, initiation of HMV, initiation of TC trials, HMV independence, and decannulation) performed in conjunction with clinic visits, procedures, and home nursing support were integral in the successful decannulation process. Pediatr Pulmonol. 2016;51:838-849. © 2016 Wiley Periodicals, Inc.

Outcomes following neuromuscular blockade in patients receiving tracheostomies

OBJECTIVE

The purpose of this study is to determine whether the use of neuromuscular blockade agents (NMBAs) in pediatric patients following tracheostomy is associated with increased rates of complications or a prolonged length of stay.

METHODS

This was a single-center retrospective chart review of pediatric patients undergoing tracheostomy placement between 2010 and 2013 who were admitted to the pediatric or neonatal intensive care units and did or did not receive NMBA within 7 days post-procedure.

RESULTS

Out of 114 included patients, 26 (23%) received NMBAs during the postoperative period. Patients receiving NMBAs were more likely to have cardiac disease and preoperative respiratory failure but less likely to have neurologic disease. Patients receiving NMBAs had a longer median postoperative length of stay (33 vs. 23 days, p=0.043) and were more likely to have postoperative ileus (12% vs. 3%, p=0.037).

CONCLUSION

In patients undergoing tracheostomy placement, use of NMBAs is associated with prolonged postoperative hospital courses. NMBAs are not associated with a higher likelihood of postoperative complications.

Paediatric tracheostomy-An 11 year experience at a Scottish paediatric tertiary referral centre

AIMS

The aim of this paper was to review the indications, complications and outcomes for tracheostomy at a Scottish paediatric tertiary referral hospital.

METHODS

All patients undergoing tracheostomy between January 2001 and September 2012 were identified. A retrospective case note analysis was performed.

RESULTS

111 tracheostomies were done in the study period. The mean number per year was 11 (3-12). Full data was available for 95 patients. There were 56 (59%) males and 39 (41%) females. Age at time of tracheostomy ranged from one day to 15 years, the mean age of tracheostomy insertion was 69 weeks. The majority of patients, 75 (79%), were under one year old when they had their tracheostomy. The most common indication was long-term ventilation (20%), followed by craniofacial abnormality causing airway obstruction (18%), followed by subglottic stenosis (14%). 37% of patients were decannulated.

CONCLUSIONS

This series reflects current trends in the indications for paediatric tracheostomy, with chronic lung disease of prematurity being the most common indication.

Changing indications for paediatric tracheostomy and the role of a multidisciplinary tracheostomy clinic

Objective:

This paper presents our experience of managing children with a tracheostomy in a multidisciplinary team clinic consisting of an ENT consultant, paediatric respiratory consultant, a nurse specialist, and speech and language therapist.

Method:

A retrospective case note review was conducted of all children seen in the multidisciplinary team tracheostomy clinic (at a tertiary paediatric hospital) between February 2009 and September 2014.

Results:

Ninety-seven patients were examined. The most common indications for tracheostomy were: lower airway and respiratory problems (66 per cent), upper airway obstruction (64 per cent), and neurodevelopmental problems (60.8 per cent).

Conclusion:

Children with a tracheostomy are a diverse group of patients. The most common indications for paediatric tracheostomy have changed from infective causes to airway obstruction and anomalies, long-term ventilation requirement, and underlying neuromuscular or respiratory problems. Our unified approach empowers the carers and patient, as a home management plan, long-term plan and goals are generated at the end of each appointment.

[Analysis of tracheostomies in a pediatric intensive care unit during the period 2003-2013]

INTRODUCTION

Tracheotomy in pediatric patients is a rare procedure. In this pediatric series, perioperative complications, mortality related to surgical procedure and overall mortality are analyzed.

PATIENTS AND METHODS

This is a retrospective study conducted from January 2003 to December 2013. Data were retrieved from patients who were tracheotomized and admitted to our PICU in the postoperative period.

RESULTS

Data were collected from 25 tracheotomized patients admitted during the study period. The mean age was 3.3 months (median 14 months, range 1-144 months), and PICU length of stay was 53 days (median 37 days, range 1-338 days). Most patients (68%) had comorbidities before their admission, with a higher prevalene of craniofacial anomalies/polymalformative syndromes (32%) and prematurity related disorders (12%) being obserevd. The most common etiologies related to the procedure were congenital airway obstruction (16%) and several types of spinal cord injury (16%), followed by tracheobronchomalacia (12%) and subglottic stenosis (12%). Some kind of complication was detected in 40% of patients, with accidental decannulation being the most frequent. Accidental or unexpected decannulation was present in a percentage as high as 20% of our patients, mainly in the first 24 hours after surgery. One of the patients died as a result of this.

CONCLUSIONS

The postoperative course of a tracheotomy is associated with a high rate of complications, some of them related to life-threatening events.

Role of Polysomnography in the Development of an Algorithm for Planning Tracheostomy Decannulation

Objective

To examine the role of polysomnography (PSG) in helping determine readiness of tracheostomized patients for decannulation.

Study Design

Case series with chart review of pediatric patients who underwent PSG with tracheostomy tube in place with the goal of decannulation.

Setting

Tertiary care pediatric center.

Subjects and Methods

Twenty-eight tracheostomized patients who underwent PSG from January 2006 to March 2012 were included. Outcome measures were successful decannulation, PSG results, surgical procedures, and medical comorbidities.

Results

Of the 28 patients, 20 (71.4%) were decannulated and 8 (28.6%) were not. One (3.6%) patient failed long-term decannulation. The average apnea-hypopnea index (AHI) with a capped tracheostomy for those successfully decannulated was 2.75 (range, 0.6-7.6), while the AHI for those not decannulated was 15.99 (range, 3.2-62). Factors associated with success or failure to decannulate were assessed, and an algorithm was developed to plan for successful decannulation. Laryngotracheal reconstruction was a significant factor in those successfully decannulated. Those who were not decannulated had multiple medical comorbidities, multilevel airway obstruction, need for additional surgery, or chronic need for pulmonary toilet.

Conclusions

Polysomnography may be a useful adjunctive study in the process of determining a patient’s readiness for decannulation. Our current algorithm for decannulation includes upper airway endoscopy with identification of levels of obstruction, followed by surgical correction of those obstructions; capped PSG to determine patency of the airway and help assess lung function; and overnight intensive care unit admission for capping trial, with decannulation the following day if well tolerated.

Changes in pediatric tracheostomy 1982-2011: a Canadian tertiary children's hospital review

BACKGROUND

Pediatric tracheostomy has undergone notable changes in frequency and indication over the past 30 years. This study investigates pediatric tracheostomy at British Columbia Children's Hospital (BCCH) over a 30-year period.

METHODS

A retrospective chart review of tracheostomy cases at BCCH from 1982 to 2011 was conducted. Charts were reviewed for demographics, date of tracheostomy, indication, complications, mortality and date of decannulation. Data from three 10-year time periods were compared using Fisher's Exact test to examine changes over time.

RESULTS

251 procedures (154 males) performed on 231 patients were reviewed. Mean age at tracheostomy was 3.74 years with 48% of procedures undertaken before the age of one year. Frequency of procedure by year has generally declined into the early 2000's. Upper airway obstruction was the most common indication accounting for 33% of procedures. The rate of complication across the entire cohort was 22% with 63% of patients being decannulated. Tracheostomy related mortality occurred in 2.0% of cases reviewed.

CONCLUSIONS

Changes occurred in primary indications with infections indicating less procedures and neurological impairments indicating more procedures over time. Complications increased and the decannulation rate decreased over this 30-year review. Pediatric tracheostomy is considered a safe and effective procedure at BCCH.

The safety of tracheostomy speaking valve use during sleep in children: a pilot study

PURPOSE

One of the disadvantages of having a tracheostomy tube is not being able to vocalize. A speaking valve connected to a tracheostomy tube allows patients to vocalize. Some studies have shown that tracheostomy-speaking valve can improve swallowing, respiratory secretion management, and expedite decannulation. There is scant research about speaking valve use during sleep. The aim of this study is to evaluate the safety of tracheostomy-speaking valve overnight, during sleep.

MATERIALS AND METHODS

Children, ages 1-18 years, with tracheostomy tubes who were using a tracheostomy-speaking valve during daytime/awake periods, were included in this study. The subjects had baseline monitoring of their heart rate, respiratory rate, oxygen saturation, and end tidal carbon dioxide measurement the night prior to the intervention, throughout the night at scheduled intervals. The tracheostomy-speaking valve was placed the following night and the same parameters were monitored and recorded throughout the study night.

RESULTS

A total of 9 patients were recruited. In all subjects, the mean values of the overnight parameters showed no significant clinical variations between the baseline night and the study night. Repeated measure ANOVA analysis revealed no significant changes in the parameters over the 8 hours of recorded time. No major adverse events were recorded during the study night.

CONCLUSION

This pilot study reveals that use of a tracheostomy-speaking valve during sleep, was not associated with adverse cardiopulmonary events. This is the first study to show that a tracheostomy-speaking valve might be safely used during sleep, in children.

Pediatric tracheotomy: indications and decannulation outcomes

OBJECTIVES/HYPOTHESIS

The objective of this study was to determine if there are differences in decannulation rates and duration of cannulation between pediatric patients undergoing tracheotomy for different indications.

STUDY DESIGN

Retrospective chart review.

METHODS

Medical records for pediatric patients (age 0-18 years) undergoing tracheotomy between January 1, 2003, and May 31, 2012, were retrospectively reviewed. Patients were assigned an indication for tracheotomy from five categories: neurological, cardiopulmonary, upper airway obstruction, craniofacial anomalies, and maxillofacial/laryngotracheal trauma.

RESULTS

Initial chart review identified 124 patients, 113 for whom complete data was available. Of these patients, the indications for tracheotomy were cardiopulmonary disease in 24 (21.2%), craniofacial anomalies in 12 (10.6%), neurological impairment in 44 (38.9%), traumatic injury in 11 (9.7%), and upper airway obstruction in 22 (19.5%). The time to decannulation was shorter for trauma patients compared to cardiopulmonary (P = 0.044) and neurological patients (P = 0.001). A total of 32 (31.9%) patients were decannulated during the study period, with a higher rate in trauma patients (72.7%) and a lower rate in those with upper airway obstruction (36.4%) than would be expected under homogeneity. Of the 32 patients who were decannulated, 11 (30.6%) were decannulated during the same hospitalization in which the tracheotomy was performed.

CONCLUSION

This study demonstrates a difference in overall decannulation rates and a shorter time to decannulation in children undergoing tracheotomy for maxillofacial and laryngotracheal trauma compared to cardiopulmonary and neurological indications.

Retrospective, cross-sectional review of delayed discharge after paediatric tracheostomy

Objectives:

To investigate reasons for prolonged hospitalisation of children with tracheostomies once they are medically fit for discharge.

Methods:

Retrospective, cross-sectional study of 101 children undergoing tracheostomy between 2000 and 2010.

Results:

Of the study patients, 44.6 per cent did not spend any time in hospital once medically fit, 19.8 per cent spent up to two weeks, 12.9 per cent spent between two weeks and one month, and 22.8 per cent spent over one month. Of the 56 cases with delayed discharge, the majority (22 children, 39.3 per cent) were delayed due to time taken obtaining parental competencies in tracheostomy management. A number of external factors were identified in these delays: parental substance abuse; single parenting; concerns about parenting ability, and English not being the parents' first language.

Conclusion:

Paediatric tracheostomy may lead to prolonged hospitalisation, but this is often influenced by social factors. Better use of dedicated specialist paediatric tracheostomy nurses may reduce unnecessary hospitalisation.

The influence of peak airway pressure and oxygen requirement on infant tracheostomy

OBJECTIVE

To determine if and how the preoperative peak airway pressure and oxygen requirement of an infant (less than 6 months of age) who requires mechanical ventilation influences the physician's decision to perform a tracheostomy on that infant.

STUDY DESIGN

Nationwide survey.

SUBJECTS

Pediatric Otolaryngologists.

METHODS

A web-based survey was developed and sent to all members of the American Society of Pediatric Otolaryngology.

RESULTS

150 of the 348 surveys were returned (43%). The majority of respondents do not consider the patient's requirement for elevated peak airway pressure (PAP) or the patient's requirement for a high percentage of oxygen as a contraindication to performing a tracheostomy in that patient (54.7 and 72.1% respectively). The presence of preoperative high PAP influenced 68.2% of respondents to consider using a cuffed tracheostomy tube. In the immediate postoperative period, the most common complication resulting in significant morbidity or mortality was mucous plugging, and the majority of respondents attributed postoperative morbidity and mortality to preoperative pulmonary comorbidity.

CONCLUSIONS

Preoperative PAP and the patient's oxygen requirement do not influence the surveyed otolaryngologists' decision whether or not to perform a tracheostomy in the infant population. However, PAP do influence whether or not a cuffed tracheostomy tube is used.

[Pediatric tracheotomy]

Tracheotomies are increasingly performed in the pediatric population in the context of long-term treatment. There are specific pediatric aspects that require attention: differences in the pediatric compared to adult anatomy, the necessity for later reconstruction and the negative impact on oral feeding and speech development. Caring for pediatric tracheostomy patients is more challenging compared to adult patients. This needs to be addressed by a dedicated team during both in- and outpatient treatment.

Tracheostomy in children: a population-based experience over 17 years

INTRODUCTION

Tracheostomy is a lifesaving intervention with numerous complications.

OBJECTIVES

We describe the natural history of tracheostomy in children in a defined geographical area over a 17-year period. Our primary aim is to stress the need for a consensus on pediatric tracheostomy care.

METHODS

This retrospective study reviewed the charts of 72 children who had tracheostomy between January 1990 and January 2007. Indications for the procedure were divided into 3 groups: (1) upper airway obstruction at a well-defined anatomic site (32 patients); (2) upper airway obstruction with a complex medical condition (24 patients); and (3) need for an access to the lower airway for long-term ventilation and pulmonary care with normal airway anatomy (16 patients).

RESULTS

The most common indication for tracheostomy was upper airway obstruction due to subglottic stenosis (15 patients, 21%) or as part of a complex craniofacial syndrome (15 patients, 21%). The duration of intubation prior to tracheostomy and the duration of hospitalization after tracheostomy varied markedly. Tracheocutaneous fistulae complicated 15 of the 38 (37%) decannulated patients. Tracheostomy infection occurred in 90% of the patients and tracheal granulation in 56%. Eleven (15%) deaths occurred, 10 were due to the underlying medical illness and 1 to a mucous plug.

CONCLUSION

The complications of tracheostomy in children are substantial. Surveillance and prompt interventions are necessary to overcome life-threatening sequelae. A multidisciplinary (medical-surgical) approach provides better care for these highly vulnerable children. A consensus on pediatric tracheostomy care is needed.

Indications and outcome of pediatric tracheostomy: results from a Nigerian tertiary hospital

BACKGROUND

There is a change in the concept of pediatric tracheostomy. This study investigates the indications and outcomes of pediatric tracheostomy in a Nigerian teaching hospital finding out whether there is also a change in the trend in our environment as compared to other centers.

METHODS

A retrospective chart review of 46 patients aged between 2 months and 15 years who presented to our Otorhinolaryngological facility and had tracheostomy between January 2000 and December 2008.

RESULTS

The age range was 2 months to 15 years. There were 29 males and 17 females. Thirty two (69.6%) patients were in the age range 6-10 years. Forty tracheostomies (87%) were performed as emergency while 6 (13%) as elective procedures. The commonest indication for tracheostomy was upper airway obstruction (n = 29, 63%). Transverse skin incision was employed in all the cases. No intra-operative complication was recorded. The post-operative complication rate was 15.2%. The duration of tracheostomy ranged from 5 days to 3 months. All the patients were successfully decannulated. The overall mortality was 8 (17.4%). There was no tracheostomy related mortality.

CONCLUSIONS

There is no increase in the incidence of tracheostomy in patients under 1 year of age and the commonest indication for the procedure in Nigeria has remained relief of upper airway obstruction. Pediatric tracheostomy is safe when performed in the tertiary hospital setting.

Anesthetic experience of 100 pediatric tracheostomies

BACKGROUND

Tracheostomy is more hazardous in the pediatric population than in adults (Paediatr Nurs, 17, 2005, 38; Int J Pediatr Otorhinolaryngol, 67, 2003, 7; J R Soc Med, 89, 1996, 188). Airway management in these children and infants is potentially challenging. Previous case series of pediatric tracheostomy published in the surgical journals make little mention of anesthetic techniques used and do not describe airway management. The aim of this study was to review the anesthetic, and in particular the airway management of children undergoing tracheostomy at Great Ormond Street Hospital (GOSH).

METHODS

Between September 2004 and December 2007, the ENT surgical database showed that 109 children had a surgical tracheostomy performed at GOSH. We were only able to locate the notes of 100 of these cases. The anesthetic records of these 100 patients undergoing tracheostomy were analyzed retrospectively.

RESULTS

Ninety-four percent (94/100) of tracheostomies were elective, and 6% (6/100) were emergency. In this study, 26% (26/100) of children were recorded as difficult to intubate. These difficult airways were managed as follows: 10/26 used a laryngeal mask airway (LMA), 5/26 were managed with facemask alone, 3/26 had fiber-optic intubation, 5/26 had surgical intubation and 2/26 were intubated with the aid of a bougie and cricoid pressure.

CONCLUSIONS

This case series demonstrates that intubation is difficult in up to 26% of children presenting for tracheostomy. While intubation of the trachea remains the preferred option when anesthetizing children for tracheostomy, the LMA or facemask can provide a successful airway where intubation is not possible. The use of the LMA or facemask may therefore be life saving in the unintubatable child.

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.

Systematic review of health-related quality of life measures for children with respiratory conditions

Patient-reported outcomes (PROs) are increasingly used in both clinical trials and clinical care to evaluate patient benefits. The purpose of this review was to identify currently available PROs for children with pulmonary conditions and to make recommendations regarding future development and application of these measures. Systematic searches were conducted and disease-specific health-related quality of life (HRQOL) measures, a type of PRO, were identified for asthma, cystic fibrosis (CF), vocal cord dysfunction and sleep-related breathing disorders. Psychometric properties, age-appropriateness, respondent burden and minimal clinically importance difference scores were evaluated in accordance with the Food and Drug Administration guidelines. For both asthma and CF there are several psychometrically sound, well-established measures; however, for vocal cord dysfunction and sleep-related breathing disorders there are no measures children can complete for themselves. In summary, this review indicated that although significant progress has been made, there are still a number of pulmonary conditions for which there is no disease-specific HRQOL measure.

Upper aerodigestive tract sequelae in severe enterovirus 71 infection: predictors and outcome

OBJECTIVE

Enterovirus 71 (EV71) infection sequelae can be severe and life-threatening, and long-term follow-up outcomes remain unknown. Therefore, we conducted a retrospective follow-up study to review airway and neurological sequelae development in patients with severe EV71 infection. We also studied the incidence and risk factors for tracheotomy and gastrostomy requirement.

PATIENTS AND METHODS

We investigated 202 EV71-infected children according to their disease stage. Seventy-two of them were diagnosed to have EV71 encephalitis, which was characterized by myoclonus, ataxia, nystagmus, oculomotor palsy and bulbar palsy or combinations of these conditions. All the 72 patients required endotracheal intubation due to respiratory failure or ventilator dependence; among these, 14 underwent tracheostomy and 10 underwent gastrostomy. All patients were followed-up for at least 3 years after discharge. Predictors of tracheostomy and gastrostomy requirement were age <2 years, body weight <10th percentile, pulmonary hemorrhage or edema, meningeal symptoms and magnetic resonance imaging (MRI) findings of upper spinal cord and brainstem. We determined outcome based on persistent tracheostomy or gastrostomy requirement and whether patients developed positive neurological sequelae.

RESULTS

Significant tracheostomy and gastrostomy predictors were age <2 years, pulmonary edema or hemorrhage, hypotension, hemiparesis and positive MRI findings. Statistical analysis revealed pulmonary edema and hypotension as index predictors of tracheostomy requirement and pulmonary edema as the significant risk factor for gastrostomy.

CONCLUSIONS

Long-term neuropsychological impact was observed on children who present the signs of the pulmonary edema or hypotension in the early onset of the EV71 infection. EV71-infected patients who develop neurological pulmonary edema or hypotension should be hemodynamically stabilized and undergo early tracheostomy to prevent further complications. This may improve the decannulation success rate after the brainstem function recovers.

Pediatric tracheotomy: 17 year review

OBJECTIVE

To study the outcomes, complications, and indications for pediatric tracheotomies performed at a major tertiary care children's hospital, Starship Children's Hospital in Auckland, New Zealand, over the period 1987-2003.

METHODS

A retrospective review of hospital records from 1987 to 2003 was conducted to assess all pediatric patients who had undergone tracheotomies.

RESULTS

A total of 122 tracheotomies (119 surgical, 3 percutaneous) were performed on patients less than 16 years of age. Upper airway obstruction (including craniofacial dysmorphism, n=40, and subglottic stenosis, n=18) was the most common indication for surgery (n=86; 70%) with a lesser number (n=36; 30%) requiring tracheotomy for prolonged ventilation. The median age at tracheotomy was 4.5 months in patients with upper airway obstruction and 16 months in those requiring prolonged ventilation. Decannulation was carried out successfully in 92 patients (75%), although 6 (6.5%) subsequently required recannulation. The overall complication rate was 51% (n=62). Early postoperative complications occurred in a total of 9 (7.4%) patients, including difficulties with ventilation in intensive care due to inadequate seal or tube position in 5 (4.1%), and accidental decannulation in 3 (2.5%). Late complications included localized granulation in most patients, for which 15 (12.3%) required intervention whilst under a routine planned general anesthetic. Major vascular erosion was not encountered in any patient, although 5 (4.1%) required intervention for minor bleeding associated with granulation tissue. Suprastomal collapse occurred in 13 patients (10.7%); but did not affect their subsequent decannulation, although 2 (1.6%) developed tracheotomy-related subglottic stenosis. Closure of tracheocutaneous fistulas was required in 16 (13.1%) decannulated patients. Only 2 patients (1.6%) died from tracheotomy-related complications, with an overall mortality rate of 14%.

CONCLUSIONS

Pediatric tracheotomies performed at Starship Children's Hospital between 1987 and 2003 were associated with a low incidence of procedure-related mortality and morbidity and successful decannulation in most cases. The majority of procedures were performed to treat upper airway obstruction, most commonly caused by craniofacial dysmorphism or subglottic stenosis.

Current trends in paediatric tracheostomies

OBJECTIVE

In the 1970s, the most common indication for tracheostomy in children was acute inflammatory airway obstruction. Modern neonatal intensive care units have turned long-term intubation into an alternative to tracheostomy. Long-term intubation itself has become the most important indication for tracheostomy combined with subglottic stenosis.

METHODS

Retrospective analysis in a tertiary referral center. A total of 38 patients who underwent tracheostomy for respiratory failure and upper airway obstruction from 1 November 1998 to 30 November 2004.

RESULTS

Total complication rate was 42.1%. In children under 1 year of age the complication rate was 47.4%, in children over 1 year the complication rate was 26.3%. Decannulation was attempted in 12 patients with a cannulation time of 22 months.

CONCLUSIONS

Long-term intubation and its sequelae have now become one of the most important indication for tracheostomy. The change of indication has also entailed a decrease of the average age of children who require tracheostomy. A longer period before decannulation and a lower average age have changed the complication rate of tracheostomy in paediatric patients.

Tracheostomy--a 10-year experience from a UK pediatric surgical center

BACKGROUND/PURPOSE

Tracheostomy in the pediatric population is associated with significant morbidity and mortality compared to adult practice. This study highlights evolving experience from a UK children's hospital.

PATIENTS AND METHODS

All children undergoing tracheostomy between 1995 and 2004 were identified. Indications, complications, and outcomes were evaluated.

RESULTS

Complete case records were reviewed for 112 children (age range, newborn-18 years). Indications included congenital birth defects--craniofacial disorders, esophageal atresia, laryngeal cleft, cystic hygroma, vascular malformations. Acquired upper airway pathology (15.5%) and malacia (12.1%) were additional criteria. Tracheostomy was also required for long-term ventilation in patients with neuromuscular disorders (12.1%) or ventilator dependency (26.7 %). Fifty-eight (50%) tracheostomies were created in infants <1 year. One hundred and nine were elective procedures with only 7 (6%) for emergency airway management. Morbidity included wound problems (14, 14.4%), tube displacement or obstruction (14, 14.4%), tracheocutaneous fistula (6, 6.2%), and pneumothorax (4, 4.1%). There were no acute hemorrhagic complications. Two children died after accidental tube displacement/obstruction.

CONCLUSION

Tracheostomy at this UK center is largely undertaken as an elective procedure. Children less than 1 year form an increasing patient group. Complications may be minimized by meticulous surgical technique and ensuring a comprehensive tracheostomy care program.

Incidence and description of dysphagia in infants and toddlers with tracheostomies: a retrospective review

OBJECTIVE

An increasing number of infants and toddlers with tracheostomies were identified at a large paediatric referral hospital in South Africa. They are at risk for swallowing and feeding difficulties, however, there is limited literature reporting the incidence and describing the dysphagia in this population, and no literature specific to a developing country. The purpose of this study was therefore to report the incidence and describe the dysphagia in infants and toddlers with tracheostomies at a large paediatric referral hospital in South Africa.

METHOD

A retrospective, descriptive review of the medical records of 80 infants and toddlers (0-3 years) with tracheostomies between 2002 and 2004 was conducted.

RESULTS

Eighty percent (64/80) of the participants presented with dysphagic symptoms. Oral phase dysphagia was reported in 81.25% (52/64), pharyngeal phase dysphagia in 60.9% (39/64) and oesophageal phase dysphagia in 79.7% of the dysphagic participants.

CONCLUSIONS

Infants and toddlers with tracheostomies are at increased risk for dysphagia. Multiple risk factors for dysphagia associated with tracheostomies, underlying medical conditions and the context of a developing country were identified in the study population.