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Namavarian A, Levy BB, Tepsich M, McKinnon NK, Siu JM, Propst EJ, Wolter NE. Percutaneous tracheostomy in the pediatric population: A systematic review. Int J Pediatr Otorhinolaryngol 2024; 177:111856. [PMID: 38185003 DOI: 10.1016/j.ijporl.2024.111856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 12/25/2023] [Accepted: 01/02/2024] [Indexed: 01/09/2024]
Abstract
OBJECTIVE Percutaneous tracheostomy is routinely performed in adult patients but is seldomly used in the pediatric population due to concerns regarding safety and limited available evidence. This study aims to consolidate the current literature on percutaneous tracheostomy in the pediatric population. METHODS A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted. MEDLINE, EMBASE, CINAHL, and Web of Science were searched for studies on pediatric percutaneous tracheostomy (age ≤18). The Joanna Briggs Institute and ROBINS-I tools were used for quality appraisal. RESULTS Twenty-one articles were included resulting in 143 patients. Patient age ranged from 2 days to 17 years, with the largest subpopulation of patients (n = 57, 40 %) being adolescents (age between 12 and 17 years old). Main indications for percutaneous tracheostomy included prolonged ventilation (n = 6), respiratory insufficiency (n = 5), and upper airway obstruction (n = 5). One-third (n = 47) of percutaneous tracheostomies were completed at the bedside in an intensive care unit. Select studies reported on surgical time and time from intubation to tracheostomy with a mean of 13.8 (SD = 7.8) minutes (n = 27) and 8.9 (SD = 2.8) days (n = 35), respectively. Major postoperative complications included tracheoesophageal fistula (n = 4, 2.8 %) and pneumothorax (n = 3, 2.1 %). There were four conversions to open tracheostomy. CONCLUSION Percutaneous tracheostomy had a similar risk of complications to open surgical tracheostomy in children and adolescents and can be performed at the bedside in a select group of patients if necessary. However, we feel that consideration must be given to the varying anatomical considerations in children and adolescents compared with adults, and therefore suggest that this procedure be reserved for adolescent patients with a thin body habitus and clearly demarcated and palpable anatomical landmarks who require a tracheostomy. When performed, we strongly support using endoscopic guidance and a surgeon who has the ability to convert to an open tracheostomy if required.
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Affiliation(s)
- Amirpouyan Namavarian
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada
| | - Ben B Levy
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | | | - Nicole K McKinnon
- Hospital for Sick Children, Toronto, ON, Canada; Department of Paediatrics, University of Toronto, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, ON, Canada
| | - Jennifer M Siu
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada; Hospital for Sick Children, Toronto, ON, Canada
| | - Evan J Propst
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada; Hospital for Sick Children, Toronto, ON, Canada
| | - Nikolaus E Wolter
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada; Hospital for Sick Children, Toronto, ON, Canada.
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Schemm J, Danis DO, Howard D, Rodriguez E, Dong K, Fazelpour S, Levi JR. Open and percutaneous pediatric tracheostomy: comorbidities and in-hospital mortality. ANNALS OF PEDIATRIC SURGERY 2023. [DOI: 10.1186/s43159-023-00239-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Abstract
Background
Tracheostomy procedures are used to establish a surgical airway in patients when non-invasive methods fail to offer adequate support. In pediatric patients, this procedure is relatively rare, and data on patients is scarce, limiting the ability of physicians to contextualize patient outcomes and identify those most at risk. This can be crucial, as research has shown that early tracheostomy in pediatric patients may improve clinical outcomes. The objective of this study is to characterize the comorbidities of pediatric patients undergoing open and percutaneous tracheostomies and examine their association with in-hospital mortality, as well as to compare patient demographics and comorbidity frequency between the two approaches. The 2016 Kids’ Inpatient Database was used to identify patients younger than 21 with ICD-CM-10 codes for open or percutaneous tracheostomies to determine demographic characteristics and identify the most frequent comorbidities in these patient cohorts.
Results
A weighted total of 5229 cases were analyzed. Congenital cardiopulmonary defects, newborn respiratory diseases, and traumatic lung or brain injury were the most common comorbidities for tracheostomy patients. In open tracheostomies, there was an increased likelihood of in-hospital mortality in patients aged less than one (OR = 2.2; 95% CI, 1.6–3.0) and in patients with atrial septal defects (OR = 1.9; 95% CI, 1.5–2.5), patent ductus arteriosus (OR = 2.5, 95% CI, 2.0–3.3), bronchopulmonary dysplasia (OR = 2.1; 95% CI, 1.6–2.8), and acute kidney injury (OR = 5.6, 95% CI, 4.3–7.2). Trauma-related comorbidities were more common in patients who underwent percutaneous procedures and were not associated with an increased likelihood of mortality. Patient age < 1 was associated with an increased risk of in-hospital mortality in both the open (OR = 2.2; 95% CI, 1.6–3.0) and percutaneous (OR = 2.3, 95% CI (1.3–3.9) approaches.
Conclusion
There are many indications for pediatric tracheostomy, and patients often present with complicated disease profiles and complicated courses of care. Broadly, we found that congenital cardiopulmonary defects were associated with a higher likelihood of in-hospital patient mortality, especially in younger patients undergoing an open-approach procedure. Patients undergoing a percutaneous-approach procedure were more likely to have trauma-related comorbidities such as pneumothorax or brain hemorrhage that were not associated with in-hospital mortality.
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Butler EK, Killien EY, Groner JI, Arbabi S, Vavilala MS, Rivara FP. Optimal Timing of Tracheostomy in Injured Adolescents. Pediatr Crit Care Med 2021; 22:629-641. [PMID: 34192728 PMCID: PMC8259766 DOI: 10.1097/pcc.0000000000002681] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To evaluate the optimal timing of tracheostomy for injured adolescents. DESIGN Retrospective cohort study. SETTING Trauma facilities in the United States. PATIENTS Adolescents (age 12-17 yr) in the National Trauma Data Bank (2007-2016) who were ventilated for greater than 24 hours and survived to discharge. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS After stratifying by traumatic brain injury diagnosis, we compared ICU and hospital length of stay, pneumonia, and discharge disposition of patients with tracheostomy prior to three cut points (3, 7, and 14 d after admission) to 1) patients intubated at least as long as each cut point and 2) patients with tracheostomy on or after each cut point. Of 11,045 patients, 1,391 (12.6%) underwent tracheostomy. Median time to tracheostomy was 9 days (interquartile range, 6-13 d) for traumatic brain injury and 7 days (interquartile range, 3-12 d) for nontraumatic brain injury patients. Nontraumatic brain injury patients with tracheostomy prior to 7 days had 5.6 fewer ICU days (-7.8 to -3.5 d) and 5.7 fewer hospital days (-8.8 to -2.7 d) than patients intubated greater than or equal to 7 days and had 14.8 fewer ICU days (-19.6 to -10.0 d) and 15.3 fewer hospital days (-21.7 to -8.9 d) than patients with tracheostomy greater than or equal to 7 days. Similar differences were observed at 14 days but not at 3 days for both traumatic brain injury and nontraumatic brain injury patients. At the 3- and 7-day cut points, both traumatic brain injury and nontraumatic brain injury patients with tracheostomy prior to the cut point had lower risk of pneumonia and risk of discharge to a facility than those with tracheostomy after the cut point. CONCLUSIONS For injured adolescents, tracheostomy less than 7 days after admission was associated with improved in-hospital outcomes compared with those who remained intubated greater than or equal to 7 days and with those with tracheostomy greater than or equal to 7 days. Tracheostomy between 3 and 7 days may be the optimal time point when prolonged need for mechanical ventilation is anticipated; however, unmeasured consequences of tracheostomy such as long-term complications and care needs must also be considered.
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Affiliation(s)
- Elissa K. Butler
- Harborview Injury Prevention & Research Center, University of Washington, 325 9 Ave Box 359960, Seattle, WA 98122 USA
- Department of Surgery, University of Washington, 1959 NE Pacific Street, WA 98195 USA
- Department of Surgery, SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY 13210 USA
| | - Elizabeth Y. Killien
- Harborview Injury Prevention & Research Center, University of Washington, 325 9 Ave Box 359960, Seattle, WA 98122 USA
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington and Seattle Children’s Hospital, 4800 Sand Point Way NE, Seattle, WA 98105 USA
| | - Jonathan I. Groner
- Center for Pediatric Trauma Research and Department of Pediatric Surgery, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205 USA
| | - Saman Arbabi
- Harborview Injury Prevention & Research Center, University of Washington, 325 9 Ave Box 359960, Seattle, WA 98122 USA
- Department of Surgery, University of Washington, 1959 NE Pacific Street, WA 98195 USA
| | - Monica S. Vavilala
- Harborview Injury Prevention & Research Center, University of Washington, 325 9 Ave Box 359960, Seattle, WA 98122 USA
- Department of Anesthesiology & Pain Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA 98195 USA
| | - Frederick P. Rivara
- Harborview Injury Prevention & Research Center, University of Washington, 325 9 Ave Box 359960, Seattle, WA 98122 USA
- Division of General Pediatrics, Department of Pediatrics, University of Washington and Seattle Children’s Hospital, 4800 Sand Point Way NE, Seattle, WA 98105 USA
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Carratola M, Hart CK. Pediatric tracheal trauma. Semin Pediatr Surg 2021; 30:151057. [PMID: 34172217 DOI: 10.1016/j.sempedsurg.2021.151057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Tracheal trauma is an uncommon but potentially serious cause of airway injury in children. Presentation may be acute in cases of blunt or penetrating trauma, or delayed in cases of chronic irritation or indwelling endotracheal tubes. Symptoms include dyspnea, progressive respiratory distress, neck and chest swelling and ecchymosis, and dysphonia. Workup is pursued as allowed by the patient's clinical status and may include plain radiography, computed tomography, and endoscopy. Accuracy and efficiency of diagnosis is paramount for those at risk of rapid decompensation. Treatment may include observation, elective and strategic intubation, or primary surgical repair.
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Affiliation(s)
- Maria Carratola
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 2018, Cincinnati, OH 45229, USA
| | - Catherine K Hart
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 2018, Cincinnati, OH 45229, USA.
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Rossetti E, Bianchi R, Germani A, Chiusolo F, Appierto L, Picardo S. Percutaneous dilation tracheostomy by Melker cricothyrotomy set in PICU: retrospective evaluation of a new combined approach. Paediatr Anaesth 2016; 26:569-71. [PMID: 27059422 DOI: 10.1111/pan.12892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Emanuele Rossetti
- Paediatric Intensive Care Unit, Department of Emergency, Anaesthesia and Intensive Care (DEA-ARCO), Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Roberto Bianchi
- Paediatric Intensive Care Unit, Department of Emergency, Anaesthesia and Intensive Care (DEA-ARCO), Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alessandro Germani
- Paediatric Intensive Care Unit, Department of Emergency, Anaesthesia and Intensive Care (DEA-ARCO), Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Fabrizio Chiusolo
- Paediatric Intensive Care Unit, Department of Emergency, Anaesthesia and Intensive Care (DEA-ARCO), Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Linda Appierto
- Paediatric Intensive Care Unit, Department of Emergency, Anaesthesia and Intensive Care (DEA-ARCO), Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Sergio Picardo
- Paediatric Intensive Care Unit, Department of Emergency, Anaesthesia and Intensive Care (DEA-ARCO), Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Browne GA. Quick Response Tracheotomy: A Novel Surgical Procedure. J Intensive Care Med 2016; 31:276-84. [PMID: 26905541 DOI: 10.1177/0885066615627141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 12/23/2015] [Indexed: 11/16/2022]
Abstract
Quick response tracheostomy (QRT) is a novel open surgical technique to emergently establish an airway. The method is simple; the skills necessary to perform this procedure are rapidly acquired; and it is expedient, minimally traumatic, and remarkably devoid of complications often encountered with percutaneous dilatational tracheotomies, including those complications seen with cricothyroidotomies. Unlike all other tracheotomies in which considerable blunt dissection is required, QRT avoids tissue crushing because sharp dissection alone is used to acquire surgical access to the trachea. The QRT does not entail inserting a guidewire into the trachea, a standard feature for percutaneous tracheal access; it avoids any risk of unintended laceration of the posterior tracheal wall and proximal subjacent esophagus. The technique averts tracheal ring fracture and tracheoesophageal fistula complications. The QRT has a uniquely low incidence of inducing hemorrhage, and it requires no steps that cause temporary tracheal occlusion and will therefore not facilitate hypoxia. The QRT contributes minimally to conditions favorable for generating subglottic stenosis, and the procedure is swiftly executed with very low probability for external tracheal placement of the tracheostomy tube. The QRT is not a blind procedure. No special instruments are required for its execution nor is concurrent tracheoscopy required at any stage while performing a QRT as is specified for percutaneous tracheotomies.
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Affiliation(s)
- Graeme A Browne
- Department Emergency Medicine, Mayo Health Care System Austin, Austin, MN, USA
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Abstract
The etiologies of pediatric lung injury requiring surgical intervention can be infectious, traumatic, congenital, or iatrogenic. Childhood pneumonia is a significant global health problem affecting 150 million children worldwide. Sequelae of pulmonary infections potentially requiring surgery include bronchiectasis, lung abscess, pneumatocele, and empyema. Trauma, congenital conditions such as cystic fibrosis and iatrogenic injuries can result in pneumothoraces, chylothoraces, or bronchopleural fistulae. Recurrence rates for spontaneous pneumothorax treated non-operatively in pediatric patients approach 50-60%. Chylothoraces in newborns may occur spontaneously or due to birth trauma, whereas in older children the etiology is almost always iatrogenic. This article examines the surgical management for the complications of lung injury in pediatric patients. In addition, we review the available pediatric evidence for early tracheostomy as well as treatment strategies for the negative ramifications of tracheostomy.
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Affiliation(s)
| | - Chad Hamner
- Cook Children׳s Medical Center, Fort Worth, Texas.
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8
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Holscher CM, Stewart CL, Peltz ED, Burlew CC, Moulton SL, Haenel JB, Bensard DD. Early tracheostomy improves outcomes in severely injured children and adolescents. J Pediatr Surg 2014; 49:590-2. [PMID: 24726119 DOI: 10.1016/j.jpedsurg.2013.09.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Revised: 08/03/2013] [Accepted: 09/01/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND Early tracheostomy has been advocated for adult trauma patients to improve outcomes and resource utilization. We hypothesized that timing of tracheostomy for severely injured children would similarly impact outcomes. METHODS Injured children undergoing tracheostomy over a 10-year period (2002-2012) were reviewed. Early tracheostomy was defined as post-injury day ≤ 7. Data were compared using Student's t test, Pearson chi-squared test and Fisher exact test. Statistical significance was set at p<0.05 with 95% confidence intervals. RESULTS During the 10-year study period, 91 patients underwent tracheostomy following injury. Twenty-nine (32%) patients were < 12 years old; of these, 38% received early tracheostomy. Sixty-two (68%) patients were age 13 to 18; of these, 52% underwent early tracheostomy. Patients undergoing early tracheostomy had fewer ventilator days (p=0.003), ICU days (p=0.003), hospital days (p=0.046), and tracheal complications (p=0.03) compared to late tracheostomy. There was no difference in pneumonia (p=0.48) between early and late tracheostomy. CONCLUSION Children undergoing early tracheostomy had improved outcomes compared to those who underwent late tracheostomy. Early tracheostomy should be considered for the severely injured child. SUMMARY Early tracheostomy is advocated for adult trauma patients to improve patient comfort and resource utilization. In a review of 91 pediatric trauma patients undergoing tracheostomy, those undergoing tracheostomy on post-injury day ≤ 7 had fewer ventilator days, ICU days, hospital days, and tracheal complications compared to those undergoing tracheostomy after post-injury day 7.
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Affiliation(s)
| | | | | | - Clay Cothren Burlew
- University of Colorado School of Medicine, Aurora, CO, USA; Denver Health Medical Center, Denver, CO, USA
| | - Steven L Moulton
- University of Colorado School of Medicine, Aurora, CO, USA; Children's Hospital Colorado, Aurora, CO, USA
| | | | - Denis D Bensard
- University of Colorado School of Medicine, Aurora, CO, USA; Denver Health Medical Center, Denver, CO, USA.
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Añón JM, Araujo JB, Escuela MP, González-Higueras E. [Percutaneous tracheostomy in the ventilated patient]. Med Intensiva 2013; 38:181-93. [PMID: 23347906 DOI: 10.1016/j.medin.2012.11.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 11/21/2012] [Accepted: 11/22/2012] [Indexed: 11/25/2022]
Abstract
The medical indications of tracheostomy comprise the alleviation of upper airway obstruction; the prevention of laryngeal and upper airway damage due to prolonged translaryngeal intubation in patients subjected to prolonged mechanical ventilation; and the facilitation of airway access for the removal of secretions. Since 1985, percutaneous tracheostomy (PT) has gained widespread acceptance as a method for creating a surgical airway in patients requiring long-term mechanical ventilation. Since then, several comparative trials of PT and surgical tracheostomy have been conducted, and new techniques for PT have been developed. The use of percutaneous dilatation techniques under bronchoscopic control are now increasingly popular throughout the world. Tracheostomy should be performed as soon as the need for prolonged intubation is identified. However a validated model for the prediction of prolonged mechanical ventilation is not available, and the timing of tracheostomy should be individualized. The present review analyzes the state of the art of PT in mechanically ventilated patients--this being regarded by many as the technique of choice in performing tracheostomy in critically ill patients.
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Affiliation(s)
- J M Añón
- Servicio de Medicina Intensiva, Hospital Virgen de la Luz, Cuenca, España.
| | - J B Araujo
- Servicio de Medicina Intensiva, Hospital Virgen de la Luz, Cuenca, España
| | - M P Escuela
- Servicio de Medicina Intensiva, Hospital Virgen de la Luz, Cuenca, España
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Susarla SM, Peacock ZS, Alam HB. Percutaneous dilatational tracheostomy: review of technique and evidence for its use. J Oral Maxillofac Surg 2011; 70:74-82. [PMID: 21820231 DOI: 10.1016/j.joms.2011.04.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2011] [Accepted: 04/05/2011] [Indexed: 11/28/2022]
Abstract
Tracheostomy is a technique for airway management commonly used by surgeons who care for critically ill patients. Patients with traumatic facial injuries, severe odontogenic infections, and head and neck malignancies are often recipients of tracheostomies. As such, the oral and maxillofacial surgeon who frequently treats such patients should be well-trained in tracheostomy placement. For decades, the standard technique for tracheostomy was the open surgical technique. However, during the past 20 years, the use of percutaneous dilatational tracheostomy has increased. The purpose of the present report is to review the percutaneous dilatational tracheostomy technique, describe the use of intensive care units as proxies for the operating room, and review the available evidence comparing percutaneous dilatational tracheostomy to open tracheostomy.
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