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

Decannulation protocol in pediatric patients: case series study

OBJECTIVE

The aim of this study was to describe the phases of a decannulation protocol and the results from its application in hospitalized children.

METHODS

This is a retrospective, observational study. Data were collected from medical records of decannulated patients followed up in a pediatric hospital in Belo Horizonte, Minas Gerais between 2011 and 2021.

RESULTS

Among the children followed up in the service (n=526), 23% (n=120) were successfully decannulated. Children aged between 2 months and 16 years, with a mean age of 4 years, 69% of whom were male, were evaluated. About 75% of the patients have tracheostomy due to upper airway obstruction and 60% of these due to acquired subglottic stenosis. At the beginning of the decannulation protocol, 5.5% of the patients had moderate oropharyngeal dysphagia, while 80.4% had normal swallowing. Correction in the upper airway pre-decannulation was performed in 39.5% of the patients, dilation in 63.8%, and endoscopic correction was performed in 55.3%. After performing the decannulation, none of the patients had complications.

CONCLUSIONS

The described decannulation protocol is safe, since no complications such as death and need for recannulation happened.

Percutaneous Tracheostomy Via Grigg's Technique in Children: Does Age and Size Matter?

OBJECTIVES

Percutaneous tracheostomy is rarely performed in children, especially in infants. In the present study, we aimed to evaluate the complications and outcomes of PT via the Griggs technique according to the age and size of pediatric patients.

METHODS

This study included 110 PICU patients who underwent PT using the Griggs technique between 2012 and 2020. The patients were divided into six groups according to their age, demographic data, primary disease, mean duration of intubation before PT, mean duration of PICU and hospitalization after PT, complications, and decannulation outcomes were compared between these groups.

RESULTS

The mean age and mean weight of the patients were 43.6 ± 58.9 months (1 month-207 months) and 14.6 ± 14.9 kg (2.6-65 kg), respectively. Mean intubation times before the procedures were 64.6 ± 40 days and 38.6 ± 37.9. Thirty-seven (33.6%) infants were under 6 months of age(Group 1). There were no intraoperative complications. Tracheostomy site stenosis was significantly greater in Group 1 than in the other age groups (p = 0.032). Granuloma formation and dermatitis incidence were similar in all age groups.

CONCLUSION

PT is a safe and feasible procedure even in small infants. The accidental decannulation risk is lower than standard tracheostomy. Interacting with rigid bronchoscopy guidance is essential to perform a safer procedure. The first tracheostomy change after PT in small infants under 6 months of age, the possibility of tracheostomy site (stoma) stenosis should be considered.

LEVEL OF EVIDENCE

Level III Laryngoscope, 2024.

Long-term outcomes of standardized training for caregivers of children with tracheostomies: The IStanbul PAediatric Tracheostomy (ISPAT) project

BACKGROUND AND OBJECTIVES: Children with tracheostomies are at increased risk of tracheostomy-related complications and require extra care. Standardized training programs for caregivers can improve tracheostomy care and reduce complications. In this study, we compared caregiver knowledge and skill scores after a standardized theoretical and practical training program on tracheostomy care (IStanbul PAediatric Tracheostomy (ISPAT) project) immediately and 1 year post-training and evaluated how this training affected the children's clinical outcomes.

MATERIALS AND METHODS

We included 32 caregivers (31 children) who had received standardized training a year ago and administered the same theoretical and practical tests 1 year after training completion. We recorded tracheostomy-related complications and the number and reasons for admission to the healthcare centers. All data just before the training and 1 year after training completion were compared.

RESULTS

After 1 year of training completion, the median number of correct answers on the theoretical test increased to 16.5 from 12 at pretest (p < 0.001). Compared with pretest, at 1-year post-training practical skills assessment scores, including cannula exchange and aspiration, were significantly higher (both p < 0.001) and mucus plug, bleeding, and stoma infection reduced significantly (p = 0.002, 0.022, and 0.004, respectively). Hands-on-training scores were better than pretest but declined slightly at 1 year compared to testing immediately after training. Emergency admission decreased from 64.5% to 32.3% (p = 0.013). Hospitalization decreased from 61.3% to 35.5% (p = 0.039).

CONCLUSION

Our findings indicate that caregiver training can lead to a persistent increase in knowledge and skill for as long as 1 year, as well as improvements in several measurable outcomes, although a slight decrease in scores warrants annual repetitions of the training program.

External peri-stomal skin granulations in paediatric tracheostomy: Incidence, outcomes and a proposed treatment algorithm

BACKGROUND

External peri-stomal skin granulations after tracheostomy in children are common and may interfere with routine tube changes. This study is the first attempt to describe the incidence and outcomes, along with a proposed treatment algorithm.

METHODS

A retrospective review of all inpatient children with a tracheostomy between January 2020 and May 2022 at the Royal Hospital for Children (RHC) in Glasgow. The presence of external peri-stomal granulation, date of onset and resolution, recurrence and treatment modalities were noted. All tracheostomy tubes used during the study period were made of silicone.

RESULTS

A total of 50 episodes of peri-stomal granulation were identified in 27 children (52 %). Median age at the end of the study period was 4.3 years, with younger children experiencing more frequent granulation. 3 episodes interfered with tracheostomy tube changes. Time to resolution of the granulation was significantly longer with topical steroid/antimicrobial ointment monotherapy, but recurrence was less common when this was used a first treatment modality.

CONCLUSION

Non-invasive measures such as topical anti-microbials should be used in the first instance when managing external stoma-site granulations. More invasive measures, such as silver nitrate cautery and surgical excision, should be considered if the granulation tissue is not improving or when it poses a risk to safe tube changes.

Microbiology and management of respiratory infections in children with tracheostomy

Tracheostomy-related respiratory infections are common, though the diagnosis and management can be challenging in children. The goal of this review article was to provide an overview of the current knowledge known about recognizing and treating respiratory infections in this population and to emphasize future areas for further research. While several small and retrospective papers attempt to provide information, there remain more questions than answers. We have reviewed ten published articles to understand this topic, bringing to light significant variation in clinical practices across institutions. While identifying the microbiology is important, it is also crucial to recognize when to treat. Differentiating acute infection, chronic infection, and colonization are important features that influence the treatment of lower respiratory tract infection in children with a tracheostomy.

Factors influencing quality of life in children with tracheostomy with emphasis on home care visits: a multi-centre investigation

OBJECTIVE

Only a few studies have assessed the quality of life in children with tracheostomies. This study aimed to evaluate the quality of life and the factors influencing it in these children.

METHOD

This cross-sectional, two-centre study was conducted on paediatric patients living in the community with a tracheostomy by using the Pediatric Quality of Life Inventory. Clinical and demographic information of patients, as well as parents' socioeconomic factors, were obtained.

RESULTS

A total of 53 patients met our inclusion criteria, and their parents agreed to participate. The mean age of patients was 6.85 years, and 21 patients were ventilator-dependent. The total paediatric health-related quality of life score was 59.28, and the family impact score was 68.49. In non-ventilator-dependent patients, multivariate analyses indicated that social functioning and health-related quality of life were negatively affected by the duration of tracheostomy. The Quality of Life of ventilator-dependent patients was influenced by care visits and the presence of pulmonary co-morbidities.

CONCLUSION

Children with tracheostomies have a lower quality of life than healthy children do. Routine care visits by a respiratory therapist and nurses yielded significantly improved quality of life in ventilator-dependent children.

Risk of death at home or on hospital readmission after discharge with pediatric tracheostomy

OBJECTIVE

To evaluate outcomes of patients discharged home following tracheostomy, including the timing and place of death for non-survivors.

STUDY DESIGN

We retrospectively reviewed medical records of infants undergoing tracheostomy between 2006 and 2017, within the first year of life for congenital or acquired neonatal conditions.

RESULTS

Of the 224 patients discharged after tracheostomy, 127 (57%) required home mechanical ventilation (MV). Overall, 40 (18%) patients died (65% were on MV); 38% of the deaths occurred at home and 63% at a subsequent hospitalization. Having tube feeding was identified as significantly associated with increased mortality on multivariate analysis. Having a tracheostomy for upper airway obstruction was the only variable significantly associated with increased risk of death at home on multivariate analysis.

CONCLUSIONS

Having tube feeding was associated with increased risk of death overall and having the tracheostomy for obstructive airway conditions was associated with death occurring at home.

Timing of Tracheostomy in Critically Ill Infants and Children With Respiratory Failure: A Pediatric Health Information System Study

OBJECTIVES

Tracheostomy placement in infants and children with respiratory failure has steadily increased over time, yet there is no consensus for optimal timing. We sought to: 1) describe tracheostomy timing and associated demographic and clinical characteristics in a large ICU cohort and 2) compare clinical outcomes between subgroups based on tracheostomy timing.

DESIGN

Retrospective observational study using the Pediatric Health Information System (PHIS).

SETTING

Neonatal ICUs and PICUs in the United States.

PATIENTS

PHIS was queried for patients less than 18 years who underwent tracheostomy from 2010 to 2020. Patients were included if admitted to an ICU with need for mechanical ventilation (MV) prior to tracheostomy in the same hospitalization. Patients were categorized as early tracheostomy (ET) (placement at MV day ≤ 14), late tracheostomy (LT) (MV days 15-60), and extended tracheostomy (ExT) (MV day > 60). Primary endpoints included demographic and clinical characteristics. Secondary endpoints included patient outcomes: in-hospital mortality, length of stay (LOS), hospital-acquired pneumonia (HAP), and hospital costs.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Sixteen thousand one hundred twenty-one patients underwent tracheostomy at 52 children's hospitals. Ten thousand two hundred ninety-five had complete data and were included in the analysis. Thirty-nine percent (4,006/10,295) underwent ET, 40% (4,159/10,295) underwent LT, and 21% (2,130/10,295) underwent ExT. Majority of patients in all subgroups had complex chronic conditions. Median age was significantly different between subgroups with ET being the oldest ( p < 0.001). A multivariable regression analysis showed that ET was associated with lower in-hospital mortality ( p < 0.001), shorter hospital LOS ( p < 0.001), shorter ICU LOS ( p < 0.001), shorter post-tracheostomy LOS ( p < 0.001), decreased HAP ( p < 0.001), and lower hospital costs ( p < 0.001) compared with those who underwent LT or ExT.

CONCLUSIONS

In a large cohort of pediatric patients with respiratory failure, tracheostomy placement within 14 days of MV was associated with improved in-hospital outcomes. ET was independently associated with decreased mortality, LOS, HAP, and hospital costs.

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.

Adapting user-centered design principles to improve communication of peer parent narratives on pediatric tracheostomy

BACKGROUND

Parents who have to make tracheostomy decisions for their critically ill child may face forecasting errors and wish to learn from peer parents. We sought to develop an intervention with peer parent narratives to help parents anticipate and prepare for future challenges before making a decision.

METHODS

To ensure that the intervention reflects parents' needs (rather than experts' opinions), we adapted a user-centered design (UCD) process to identify decision-critical information and refine the presentation format by interviewing parents who had tracheostomy decision making experience. Phase 1 (n = 10) presented 15 possible forecasting errors and asked participants to prioritize and justify the problematic ones. It also asked participants to comment on the draft narratives and preferred delivery mode and time of the intervention. Phase 2 (n = 9 additional parents and 1 previous parent) iteratively collected feedback over four waves of user interviews to guide revisions to the informational booklet.

RESULTS

Phase 1 revealed that parents wanted information to address all forecasting errors as soon as tracheostomy becomes an option. They also highlighted diverse family situations and the importance of offering management strategies. The resulting prototype booklet contained five sections: introduction, child's quality of life, home care, practical challenges, and resources. Feedback from Phase 2 focused on emphasizing individualized situations, personal choice, seriousness of the decision, and caregiver health as well as presenting concrete illustrations of future challenges with acknowledgement of positive outcomes and advice. We also learned that parents preferred to use the booklet with support from the care team rather than read it alone.

CONCLUSIONS

A UCD process enabled inclusion of parental perspectives that were initially overlooked and tailoring of the intervention to meet parental expectations. Similar UCD-based approaches may be valuable in the design of other types of patient communications (e.g., decision aids).

Development and implementation of a pre-tracheostomy multidisciplinary conference: An initiative to improve patient selection

OBJECTIVE

To describe our institutional experience in implementing a pre-tracheostomy multidisciplinary conference and assess its effects on patient selection and communication between team members and with families.

METHODS

Descriptive study and retrospective review of patient outcomes in a period prior to (4/2016-1/2018) and following (2/2018-11/2019) implementation of the conference and conference participant survey.

RESULTS

In the 21 months prior to the conference, 53 patients out of 67 consults (79%) went on to have a tracheostomy. After implementation, 96 patients, 42 females and 54 males, between 2 weeks and 22 years of age were discussed. 58 (60%) of patients referred for tracheostomy ultimately underwent surgery. Of those managed without tracheostomy, 16% were extubated, 11% were managed with noninvasive respiratory support, and 13% of families chose to redirect care. There was no difference in time between consultation and surgery (p = 0.9), or post-surgical length of stay after the conference was implemented (p = 0.9). Survey responses were gathered from 34 conference participants. Respondents agreed that the conference was useful in facilitating communication among the care team (91%), promoting understanding of the patient's treatment options (85%), promoting understanding about long-term outcomes and progression of underlying disease process (79%), clarifying risks, benefits, and alternatives of treatment options (82%), and informing discussions with the family (70%).

DISCUSSION

Potential benefits of a multidisciplinary pre-tracheostomy conference include improved provider communication and shared decision making between the medical team and family. We found a reduction in the proportion of patients who ultimately underwent tracheostomy as a result of a formal multidisciplinary discussion, but did not find either any delays in care, or reduction in post-operative length of stay.

IMPLICATIONS FOR PRACTICE

A multidisciplinary team approach to patient selection can foster communication between team members, identify barriers to discharge and quality care at home, and provide caregivers with information necessary to make an informed decision about their child's care.

Prolonged Weaning: S2k Guideline Published by the German Respiratory Society

Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by respiratory muscle insufficiency and/or lung parenchymal disease; that is, when other treatments such as medication, oxygen administration, secretion management, continuous positive airway pressure (CPAP), or nasal high-flow therapy have failed. MV is required for maintaining gas exchange and allows more time to curatively treat the underlying cause of respiratory failure. In the majority of ventilated patients, liberation or "weaning" from MV is routine, without the occurrence of any major problems. However, approximately 20% of patients require ongoing MV, despite amelioration of the conditions that precipitated the need for it in the first place. Approximately 40-50% of the time spent on MV is required to liberate the patient from the ventilator, a process called "weaning". In addition to acute respiratory failure, numerous factors can influence the duration and success rate of the weaning process; these include age, comorbidities, and conditions and complications acquired during the ICU stay. According to international consensus, "prolonged weaning" is defined as the weaning process in patients who have failed at least 3 weaning attempts, or require more than 7 days of weaning after the first spontaneous breathing trial (SBT). Given that prolonged weaning is a complex process, an interdisciplinary approach is essential for it to be successful. In specialised weaning centres, approximately 50% of patients with initial weaning failure can be liberated from MV after prolonged weaning. However, the heterogeneity of patients undergoing prolonged weaning precludes the direct comparison of individual centres. Patients with persistent weaning failure either die during the weaning process, or are discharged back to their home or to a long-term care facility with ongoing MV. Urged by the growing importance of prolonged weaning, this Sk2 Guideline was first published in 2014 as an initiative of the German Respiratory Society (DGP), in conjunction with other scientific societies involved in prolonged weaning. The emergence of new research, clinical study findings and registry data, as well as the accumulation of experience in daily practice, have made the revision of this guideline necessary. The following topics are dealt with in the present guideline: Definitions, epidemiology, weaning categories, underlying pathophysiology, prevention of prolonged weaning, treatment strategies in prolonged weaning, the weaning unit, discharge from hospital on MV, and recommendations for end-of-life decisions. Special emphasis was placed on the following themes: (1) A new classification of patient sub-groups in prolonged weaning. (2) Important aspects of pulmonary rehabilitation and neurorehabilitation in prolonged weaning. (3) Infrastructure and process organisation in the care of patients in prolonged weaning based on a continuous treatment concept. (4) Changes in therapeutic goals and communication with relatives. Aspects of paediatric weaning are addressed separately within individual chapters. The main aim of the revised guideline was to summarize both current evidence and expert-based knowledge on the topic of "prolonged weaning", and to use this information as a foundation for formulating recommendations related to "prolonged weaning", not only in acute medicine but also in the field of chronic intensive care medicine. The following professionals served as important addressees for this guideline: intensivists, pulmonary medicine specialists, anaesthesiologists, internists, cardiologists, surgeons, neurologists, paediatricians, geriatricians, palliative care clinicians, rehabilitation physicians, intensive/chronic care nurses, physiotherapists, respiratory therapists, speech therapists, medical service of health insurance, and associated ventilator manufacturers.

Patient and caregiver experiences at a Multidisciplinary Tracheostomy Clinic

INTRODUCTION

Children with tracheostomy are a heterogeneous population requiring care from multiple specialties. Multidisciplinary approaches to treating such patients helps to improve the quality of care they receive. Our institution established a Multidisciplinary Tracheostomy Clinics (MDTC) to address outpatient care coordination for tracheostomy patients by providing care from multiple disciplines at a single visit. We report patient/caregivers' experiences of our MDTC.

METHODS

Patients with tracheostomy or their caregivers were prospectively recruited between Dec 2017-Oct 2019 to complete surveys assessing their experience at the MDTC. Demographic and satisfaction questionnaires were sent electronically by a REDCap survey distribution tool. Demographic data were collected, such as patient's residence and education level. Medical care variables assessed included history of MDTC attendance, commute time, medical specialties seen, tracheostomy "Go-Bag" use, home-care nursing, and MDTC satisfaction ratings.

RESULTS

Twenty-nine patients/caregivers completed the satisfaction survey and 22 completed both the satisfaction survey and demographics questionnaire. Patient ages ranged from 11 months to 36 years. Twenty-three (79%) participants commuted for up to 2 h to the MDTC, and 6 (21%) commuted for more than 2 h. The median number of medical specialties seen at the MDTC was 3. All participants were satisfied that they saw all requested specialties. Tracheostomy supplies were checked for 25 of 28 patients. Twenty-three of 28 subjects rated staff teamwork as "excellent." Twenty-four of 28 patients were "highly likely" to recommend the MDTC. Twenty-three of 28 participants were "highly likely" to return, and 4 were "somewhat likely" to return.

CONCLUSION

This study demonstrates that patients with tracheostomy and caregivers were satisfied with the improved coordination and facilitation of care through a Multidisciplinary Tracheostomy Clinic.

Pediatric tracheostomies in patients less than 2 years of age: Analysis of complications and long-term follow-up

PURPOSE

Identify variables that are predictive of morbidity and mortality in children under the age of two undergoing tracheostomy and to provide longitudinal data on this patient population.

METHODS

Patients were retrospectively identified using Current Procedural Terminology codes 31600, 31601, 31610 from 2009 to 2016.

RESULTS

Median age at time of tracheostomy was 0.43 years (interquartile range, 0.27-0.61). Patients were followed for a median of 1.39 years (range 0.03-4.25). Overall mortality rate in this cohort was 23.5% with the majority (81.3%) of deaths occurring >30 days following tracheostomy. The most frequently encountered major complication was cardiopulmonary arrest (10.29%) in the short-term follow up period (<30 days) and accidental decannulation (32.81%) during long-term follow up (>30 days). Peristomal skin breakdown was less likely to develop in patients who did not receive paralytics following tracheostomy. Most patients (54.4%) were discharged to home following initial admission and experienced a mean of 2.10 readmissions for any reason during the follow-up period. 64.4% of patients underwent surveillance direct laryngoscopy and bronchoscopy during the follow-up period and suprastomal granuloma formation was detected in 31.2% of these patients. 9 patients underwent decannulation at a median of 2 years from original tracheostomy placement.

CONCLUSION

Pediatric patients under the age of 2 undergoing tracheostomy exhibit high morbidity during both the initial hospital admission and the subsequent months following discharge. However, major complications were low and mortality was not directly related to tracheostomy status in any case.

Quattro Flap Tracheotomy-The impact of a novel surgical technique for young infants

BACKGROUND

Tracheotomy for pediatric patients is a surgical procedure with greater technical difficulty and higher rates of morbidity and mortality than that in adults. We report a new technique for pediatric tracheotomy that reduces the issue of granulation and recannulation after accidental decannulation.

METHODS

Clinical data were retrospectively reviewed for 32 pediatric patients aged 3weeks-32months who underwent Quattro Flap Tracheotomy (QFT) at our hospital. The technique for the procedure is described and illustrated in detail. We analyzed the complications of surgery and the prognosis of patients.

RESULTS

Twenty-seven out of 32 pediatric tracheotomy patients were aged <12months. Overall, one patient with subglottic stenosis developed granulation and required a resection. Three patients with granulation were cured using conservative treatment. Neither pneumothorax nor accidental decannulation and failure to reinsert the cannula occurred with QFT. No tracheotomy-related deaths occurred. The overall rate of postoperative complications was lower in the study group (4/32 cases, 12.5%) than in the control group (12/32 cases, 37.5%; p=0.041).

CONCLUSION

QFT is a new method for pediatric tracheotomy that should be performed in younger infants. If performed appropriately, QFT may reduce the incidence of complications and death in many cases that involve persistent granulation.

LEVELS OF EVIDENCE

IV.

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.

Percutaneous tracheostomy by Griggs technique under rigid bronchoscopic guidance is safe and feasible in children

OBJECTIVE

The aim of this study is to report prospective data of pediatric cases that underwent percutaneous tracheostomy (PT) to show that PT is a safe and feasible procedure in children even in small infants.

PATIENTS AND METHODS

PT was done in 51 consecutive patients. Demographic data, indications, complications and outcome were recorded prospectively. Initial 6 PT was done by Giaglia technique whereas the Griggs technique was used in the consecutive 45 patients.

RESULTS

Fifty-one patients with mean age of 38±54months (1month-17years) and, mean weight of 12.4±13kg underwent PT. The only major complication was perforation of esophagus (n=1, 2%) which was recognized early and immediately repaired by cervical approach. This complication occurred in the 6th case done with the Giaglia technique. After conversion to the Griggs technique no major complication was encountered in the consecutive 45 procedures. The mean period of follow up was 21±13.7months. Narrowing of the stoma site requiring simple dilation was developed in 3 (5.8%) patients.

CONCLUSION

PT is a safe and easy procedure and a less invasive alternative to surgical tracheostomy even in small infants. We strongly recommend PT done by Griggs technique in children. It is important that it should be done in an operating room setting and under rigid bronchoscopic guidance.

Indications of pediatric tracheostomy over the last 30 years: Has anything changed?

IMPORTANCE

Recent reports have shown that the indications for pediatric tracheostomy have evolved over time.

OBJECTIVE

To review the indications for pediatric tracheostomy over the last 30 years.

DESIGN

Retrospective chart review.

SETTING

Tertiary referral children's hospital.

PARTICIPANTS

Patients who underwent tracheostomy.

INTERVENTION

Surgical tracheostomy placement.

MAIN OUTCOMES AND MEASURES

Medical records for patients who underwent surgical tracheostomy over the 30-year study period (1984-2014) were reviewed. Patient characteristics including age, gender, birth-weight, gestational age and death were collected and compared with the primary indication for tracheostomy using bivariable analysis.

RESULTS

Five hundred and one patients met inclusion criteria. The most common primary indications for tracheostomy were cardiopulmonary disease (34%) and neurological impairment (32%), followed by airway obstruction (19%), craniofacial (11%), and traumatic injury (4%). Over the last five years (2010-14) cardiopulmonary disease became the most common indication for tracheostomy.

CONCLUSIONS

and

RELEVANCE

The indications for pediatric tracheostomy have evolved over the past 30 years. Infectious causes of airway obstruction and tracheostomy have almost disappeared. Tracheostomy is now most commonly performed in very premature patients with cardiopulmonary or neurological impairment who require prolonged ventilator support.