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A twenty year (1971–1990) review of tracheostomies in a major paediatric hospital
International Journal of Pediatric Otorhinolaryngology 35 (1996) I-9
ELSEVIER
Rl!i!E
Laryngdogy
A twenty year (1971- 1990) review of tracheostomies in a major paediatric hospital Martin
J. Donnelly,
Peter D. Lacey, Andrew J. Maguire”
The Department of‘ Otolaryngology, Our Lady’s Hospital ,Gr Sick Children, Crumlin, Dublin 12, Ireland Received 9 December 1992; revision received 15 June 1995: accepted I8 June 1995
Abstract Changing trends in the indications for paediatric tracheostomies, with decreasing numbers of tracheostomies being performed, have been reported in the literature. In a retrospective analysis of the period 1971 to 1990 the experience of tracheostomies in children under the age of 15 at Our Lady’s Hospital (Dublin) is reviewed. Only 29 tracheostomies were performed during this time with an increase in numbers (90%) performed during the second 10 year period. The major underlying indication for tracheostomy in both 10 year periods was fol the management of an airway problem secondary to congenital abnormalities (65%). In 14 children the operation was performed during the first year of life. However, while 90% of the children were under the age of one in the period 1971- 1980 this fell to 26% during 1981-1990. Complications occurred in 41% overall, however, in the under 1 year old group 64% developed complications. There were no deaths as a direct result of the tracheostomy or its complications, but six children died because of the severity of the underlying disease. The average length of time before decannulation was 2.1 years, with decannulation difficulties occurring infrequently (11%). Kqwords:
Tracheostomy;
* Corresponding
Paediatric
author
0165-5876~96:$15.00 9 1996 Elsevier Science Ireland Ltd. All rights reserved SSDI 0165-5876(95)01255-A
2
M.J. Donnrliy
et cd. / ht. J. Pediutr. Otorhinoluryngoi.
35 (1996) l-9
1. Introduction
Relief of airway obstruction by tracheostomy is an ancient procedure although its application to children is comparatively recent [17]. During the nineteenth century large numbers of tracheostomies were performed on children, with a significant mortality rate. The introduction of endotracheal intubation and the development of vaccines for Diphtheria and Polio dramatically reduced the need for tracheostomies in children. A further decline in the number of tracheostomies being performed has been reported more recently as the development of safer endotracheal tubes have allowed for longer intubation times in children [2,5,11,12,16]. We present the experience of tracheostomies in paediatric patients from 1971 to 1990 at Our Lady’s Hospital for Sick Children (OLHSC). This is the largest childrens hospital in Ireland, with a catchment population of over one million people as well as being a tertiary referral centre for paediatric airway problems. The purpose of this study was to determine the indications for this procedure and identify any changes which occurred. In addition the duration, complications and decannulation problems related to the tracheostomy were analysed.
2. Methods
A retrospective analysis was carried out on the clinical records of children who had tracheostomies performed at OLHSC, and who had management of their tracheostomies at OLHSC during the period 1971- 1990. The records of children admitted to the intensive care unit (ICU) for management of airway problems over the same period, were also examined. The tracheostomies were all performed in the operating theatre under general anaesthesia. A sandbag was placed beneath the shoulders, taking care not to overextend the neck. Hyperextension of the head and neck may draw the thoracic trachea into the neck particularly in small infants resulting in low tracheostomies. A horizontal skin crease incision is made dividing the subcutaneous tissue. The strap muscles are retracted laterally and the thyroid isthmus is divided if it lies over the intended tracheostomy site. Particular care is taken not to stray from the midline in order to avoid injury to the great vessels. Non-absorbable stay sutures are inserted below the second tracheal ring on either side of the midline. These sutures are left in situ until the first tube change. A vertical incision is made in the trachea between the stay sutures, through the second and third or third and fourth tracheal ring, taking care not to perforate the posterior tracheal wall and oesophagus. The tracheostomy tube is inserted after the endotracheal tube has been withdrawn to the upper limit of the tracheotomy. The type of tracheostomy tube used include the Great Ormond Street, Portex and Shiley designs. Once in position the tube is initially secured by suturing the flanges to the skin of the neck, and the stay sutures are taped to the chest.
M.J. Domell~* 1’1al. )/Int. J. Prdiatr.
Ororllinoklr?,nRol.
35 (19%) l-9
3. Results Of 26 tracheostomies performed at OLHSC, the records of 25 were available. Five children were transferred to OLHSC for management after a tracheostomy was performed elsewhere. In total 29 children are included, 15 male and 14 female. Ten tracheostomies were performed during 1971~ 1980 and 19 were performed during 198 1-- 1990. The age of children at the time of tracheostomy ranged from 5 days to 14 years with children under the age of 1 year accounting for 48% [14] of the overall cases. Looking at the two decades separately, 90% [9] of the children in the first period were less than 1 year old whereas in the second period only 26% [5] were in this age group (Fig. 1). This is a statistically significant difference (P = 0.05 Fisher’s test). The indications for tracheostomies fell into two main groups (1) for relief of airway obstruction, and (2) for positive pressure ventilation and airway toilet (Table 1). The majority of tracheostomies were performed for relief of airway obstruction with 22 (76%) in this group. Only seven (24%) required a tracheostomy for ventilation purposes. In the overall group the main underlying medical problems requiring a tracheostomy for management were congenital abnormalities. This was seen in 65% of the cases but rose from 60% in the first 10 year period to 70% in the second 10 year period, however this is not statistically significant using Fisher’s test (P = 0.65). The types of congenital abnormalities are presented in Table 2. Significantly a tracheostomy was required on only one occasion in the management of an acute upper airway infection. Complications are divided into early and late, depending upon whether they occur within the first post-operative week or later (Table 3). The overall complication rate was 41%. Early complications occurred in 14X, the most common being 10
Age category
8
(in years) 6
Number of Patients
4I 2 1
0
1971-1980 Fig. I. Age distribution
1981-1990 of children at tracheostomy
Table I Indications for tracheostomy
Airway
obstruction
1981 1990
3
5 4 2 I I 1 I I
(22129)
Congenital airway abnormality Craniofacial abnormality Subglottic stenosis (acquired) Tracheal stenosis (acquired) Laryngeal papillomatosis Laryngeal Epidermolysis Bullosa Accidental strangulation Palatal haematoma Laryngotracheobronchitis Ventilation
1971-1980
and airnq~
toilet
CNS lesions CVS lesions Guillian Barre syndrome
2
I
(j: 29)
2 2
I I 1
accidental decannulation. Late complications were seen in 34% and were mainly lower respiratory tract infections. Looking specifically at the children under 1 year, there was a complication rate of 64% equally divided between early and late. No deaths occurred as a result of the tracheostomy but six children in the series died because of the severity of their underlying disease. These included a child with a trachea-oesophageal fistula and children with CVS and CNS abnormalities. The duration of the tracheostomy ranged from 3 days to 7 years with an average of 2.1 years. Successful decannulation was possible in 78% of casesThe technique used for decannulation included admission of the child to hospital followed by occlusion of the tracheostomy tube for 24-48 h. If there were no difficulties, decannulation proceeded. However, if airway difficulties occurred the airway was examined endoscopically under general anaesthesia. Decannulation difficulties ocTable 2 Congenital abnormalities requiring tracheostomy (numbers in brackets)
~___
Laryngomalacia Tracheomalacia Subglottic stenosis Tracheal stenosis
(2) (1)
Craniofacial (3)
Treacher Collins syndrome Pierre-Robin Syndrome Severe micrognathia
(1) (1) (1)
CNS (3)
Cerebral degeneration Central apnoea
(2) (1)
cvs (3)
Pulmonary atresia (1) Cardiomyopathy (1) Complex cyanotic heart disease (1)
Airway (8)
(3)
(2)
Table 3 Tracheostomy
complications
Louer respirator) tract infection Accidental decannulation Pneumothorax Chylothorax Tracheitih Granulations ~~ stoma1 tracheal Stoma1 cellulitis Tracheocutaneous fistula Total
Early ( < 1 week post operatively)
Late ( > 1 week post operatively)
2 2 I I I
7 I
I I I 2 7 (in 4 patients)
I4 (in IO patients)
cut-red in two patients, in one because of tracheal granulations, and no mechanical obstruction was found in the second. Both were eventually decannulated successfully. Five children still required their tracheostomy due to persistence of the underlying condition. Unfortunately the records from the ICU were incomplete, with the years I97 1, 1973, 1987 and 1988 missing. However, there were 8 years in the two periods of the 100
Age category 80
Number of Patients
(in years)
6.
40
1971-1980*
1981-1990t
* 1971 and 1973 not Included t 1987 and 1988 not included Fig. 2. Age distribution problems.
of children admitted to the intensive care unit (ICU) for management of airuaq
6
M.J.
Donnrll~~
et cd.
1771. J. Prrhtr.
Otorl7inolu~~~n~ol.
35 (1996)
1~ 9
study for analysis (Fig. 2). In the first decade (1971 1980) 149 children were admitted for management of airway problems, with 66% under the age of 1 year. During the second 10 year interval (1981-1990) there were 154 admissions for airway management. In this group 61% of the children were under the age of 1 year. 4. Discussion
There has been a change in the indications for paediatric tracheostomies over the last two decades [2,17]. Previously this operation was performed mainly for the relief of upper airway obstruction, secondary to acute infectious disorders such as epiglottitis and laryngotracheobronchitis. With the development of better anaesthetic techniques and safer endotracheal intubation [I], the management of these conditions no longer required a tracheostomy. As a result of this the number of paediatric tracheostomies performed in large centres declined dramatically from the mid 1970s [5,11], with congenital malformations becoming the most common indication for this procedure. Although many children are now remaining intubated for increasing periods of time, tracheostomies are still necessaryin some. Opinions differ regarding the length of time endotracheal tubes may be safely left in place before a tracheostomy should be performed [19], although Dankle et al. [6] have shown that endotracheal intubation is safe for extended periods. The decision to perform a tracheostomy in our hospital is made in consultation with the ENT surgeon, the anaesthetist and the paediatrician based on the needs of the individual child. At OLHSC long-term endotracheal intubation was introduced in the management of airway problems since the early 1970s following the reports of its safe utilisation. This is reflected in the similar number of admissions to the ITU for airway management in the two decadesof the study and the small size of the series. During the 20 years covered in this study we have noticed an increase of 90% in the numbers of tracheostomies carried out when comparing the 1970s to the 1980s a reversal of the previously described downward trend. It is important to note that this trend occurred despite no significant change in the number of admissions to the ITU for management of airway problems. Although the numbers are small, this may reflect the improvement in the survival of critically ill infants using modern intensive care techniques. Many of these children require intubation and ventilation shortly after birth, often for prolonged periods, before a tracheostomy is eventually performed. Also, the age of the children at tracheostomy was significantly different between the two 10 year periods. From 1971 to 1980, 90% of the children were less than 1 year old whereas from 1981 to 1990 only 26% were less than 1 year of age. The ICU numbersshow that this change took place despite no significant decrease in the number of younger children being admitted for airway management. This is an indication of the evolution of a more conservative approach to the management of airway problems in the very young. The adoption of a conservative attitude is understandable in the light of the high complication rates seen in tracheostomies performed in very young children.
M.J. Donnelly et al. ! hr. J. Pediatr. Otorhinoiaryngol.
35 (1996) I-9
7
A tracheostomy was required only once for a severe upper respiratory tract infection, illustrating the shift from tracheostomy to endotracheal intubation in the management of this condition. The main indication for tracheostomy in both these periods was in the management of children with congenital abnormalities requiring bypass of an airway obstruction or requiring prolonged ventilation and airway toilet (60% and 70% respectively, this difference not being statistically significant). The most common type of congenital abnormality seen involved the larynx or trachea. Other indications include airway obstruction secondary to craniofacial abnormalities. In children, tracheostomy is a procedure associated with a significant morbidity and mortality rate. The complication rate in our series (41”/0) is well within the range 30-46.5% reported [ 17,181.It is important to anticipate a higher complication rate in very young children. In this group of patients the complication rate of 64% in children less than 1 year old is similar to that of other series [lo]. Generally those complications occurring within the first post operative week are the most life threatening. One patient developed a chylothorax shortly after surgery. This potentially dangerous complication can be minimised by avoiding low tracheostomies. Early accidental decannulation occurred on two occasions, but fortunately no deaths resulted. In one of these cases a false passage was created on replacing the tube, and following positive pressure ventilation, a pneumothorax resulted. Lower respiratory tract infections are a well recognised complication in patients with tracheotomies [14,15]; micro-organisms have easier access to the respiratory tract and the coughing action is less powerful in these patients. This can be a significant problem particularly when previous lung problems existed, often requiring intravenous antibiotics and intensive physiotherapy. Despite regular nursing care and humidification, pneumonia was the most common complication seen in this series, occurring in nine patients. Granulations in the tracheal lumen or stoma occur so commonly that some authors do not consider them as complications unless they obstruct the airway [4]. Most commonly granulations occur at the superior aspect of the tracheostomy site. Intraluminal tracheal lesions can occur and are due to such factors as excessivetube movement, the use of too large a tube or an overinflated cuff, devascularisation of the trachea at surgery, cartilage excision and tracheal infection [15]. Careful surgical technique and meticulous postoperative nursing care should reduce the risk of significant long-term tracheal narrowing. Problematic granulations requiring bronchoscopic removal was seen in two cases,with decannulation being delayed in one of the children. The mortality rate associated with tracheostomies is O-8.7% with accidental decannulation, tube obstruction and pneumothorax accounting for most fatalities [20]. Deaths in this study were attributable to the underlying diseaserather than to the tracheostomy. Those children who died had severe abnormalities incompatible with life. Many children now require a tracheostomy for extended periods of time because of the nature of the underlying disease.It may be expected that prolonged duration of the tracheostomy can lead to decannulation difficulties [7]. In children suitable for removal of the tracheostomy tube, decannulation has not been a major problem
8
M.J. Donnel!,~ et al. /ht.
J. Pediarr. Otorhinolaryngol,
35 (1996) l-9
in this series. The two caseswhich occurred are typical of the most common causes of difficult decannulation tracheal granulations, and physiological dysfunction of the upper airway [9]. If difficulties arise during decannulation, the airway should be assessedendoscopically, as significant tracheal granulations may be present in 15% of cases[8]. After removal of these granulations decannulation is usually successful. In some children, decannulation is problematic despite no obvious anatomical airway obstruction. This was felt to be due to a psychological dependency and became commonly referred to as ‘decannulation panic’ [13]. Black et al. [3] have suggested a more likely explanation based on physiological changes in the dead space volume and laryngeal reflexes caused by the tracheostomy. In order to reduce anxiety in children and their parents, it is important that tracheostomy decannulation is carried out in a controlled and reassuring manner. In conclusion, the widespread use of endotracheal intubation in the management of paediatric airway problems has, in our experience, limited the spectrum of indications for tracheostomies. In this series very few tracheostomies were necessary in the management of acute upper airway infections. Most operations were performed on children with compromised airways often resulting from congenital conditions. Significantly we note that tracheostomies were performed less frequently in younger children during the most recent years of the study period. The complication rate was higher in children less than 1 year old. Decannulation difficulties were infrequently encountered, even in children who had their tracheostomy for extended periods. References [I] Allen, T.H. and Steven, I.M. (1972) Prolonged nasotracheal intubation in infants and children. Brit. J. Anaest. 44, 8355839. [2] Arcand, P. and Granger, J. (1988) Paediatric tracheostomies: changing trends. J. Otlaryngol. 17, 121-124. [3] Black, R.J., Baldwin, D.L. and Johns, A.N. (1984) Tracheostomy ‘decannulation panic’ in children: fact or fiction?. J. Laryngol. Otol. 98, 297-304. [4] Carter, P. and Benjamin, B. (1983) Ten year review of paediatric tracheotomy. Ann. Otol. Rhinol. Laryngol. 92 3988400. [5] Crysdale. W.S., Feldman, R.I. and Naito, K. (1988) Tracheotomies: A IO year experience in 319 children. Ann. Otol. Rhino]. Laryngol. 97, 439-443. [6] Dankle, SK., Schuller, D.E. and McClead, R.E. (1987) Prolonged intubation of Neonates. Arch. Otolaryngol. Head Neck Surg. 113, 841-843. [7] Filston, H.C., Johnston, D.G. and Crumrine. R.S. (1978) Infant tracheostomy: A new look with a solution to the difficult cannulation problem. Am. J. Dis. Child. 132, 1172--l 176. [8] Gilmore, B.B. and Mickelson. S.A. (1986) Paediatric Tracheotomy Controversies in management. Otolaryngol. Clin. North Am. 19, 141-151. [9] Kearns. D.B.. Albert, D.M., Choa. D.I., Wickstead, M. Bailey, M. and Evans J.N.G. (1990) Functional assessmentof the paediatric laryngeal airway. Clin. Otolaryngol. 15. 53-58. [IO] Kenna, M.A.. Reilly, J.S. and Stool, S.E. (1987) Tracheotomy in the preterm infant. Ann. Otol. Rhino]. Laryngol. 96. 68-71. [I I] Line, W.S., Hawkins, D.B.. Kahlstrom, E.J. MacLaughlin, E.F. and Ensley, J.L. (1986) Tracheotomy in infants and young children: The changing perspective 1970-1985. Laryngoscope 96, 510-515.
[12] Newlands, W.J. and McKerrow, W.S. (1987) Paediatric tracheostomy Fifty-seven operations on fifty-three children. J. Laryngol. Otol. 101, 9299935. [13] Pracy, R., Siegler, J.. Stell, P.M. and Rogers. J. (1981) Ear, Nose and Throat Surgery and Nursing. Hodder and Stoughton, London, 187 pp. [14] Rogers, J.H. (1987) Tracheostomy and decannulation. In: Kerr, A.J., Groves, J. and Evans. J.N.G. (Eds.). Scott - Brown’s Otolaryngology, Vol. 6. Butterworth, London. 479 pp. [15] Stool, S.E. and Eavey, R.D. (1990) Tracheotomy. In: Bluestone, C.D.. Stool, S.E. and Scheetz, M.E. (Eds.). Pediatric Otoiaryngology, Vol. 2. Saunders, Philadelphia. pp. 1235 1236. [16] Swift, A.C. and Rogers, J.H. (1987) The outcome of tracheostomy in children. J. Laryngol. Otol. 101, 9366939. [I71 Swift, A.C. and Rogers, J.H. (1987) The changing indications for tracheostomy in children. J. Laryngol. Otol. 101, 1258- 1262. [I81 Tucker, J.A. and Silberman, H.D. (1972) Tracheotomy in Pediatrics, Ann. Otol. Rhinol. Laryngol. 81, 8188824. [19] Watson, C.B. (1983) A survey of intubation practices in critical care medicine. Ear Nose Throat J. 62, 4944501. [20] Wetmore, R.F., Handler, S.D. and Potsic, W.P. (1982) Pediatric tracheostomy: Experience during the past decade. Ann. Otol. Rhinol. Laryngol. 91. 6288632.
ELSEVIER
Rl!i!E
Laryngdogy
A twenty year (1971- 1990) review of tracheostomies in a major paediatric hospital Martin
J. Donnelly,
Peter D. Lacey, Andrew J. Maguire”
The Department of‘ Otolaryngology, Our Lady’s Hospital ,Gr Sick Children, Crumlin, Dublin 12, Ireland Received 9 December 1992; revision received 15 June 1995: accepted I8 June 1995
Abstract Changing trends in the indications for paediatric tracheostomies, with decreasing numbers of tracheostomies being performed, have been reported in the literature. In a retrospective analysis of the period 1971 to 1990 the experience of tracheostomies in children under the age of 15 at Our Lady’s Hospital (Dublin) is reviewed. Only 29 tracheostomies were performed during this time with an increase in numbers (90%) performed during the second 10 year period. The major underlying indication for tracheostomy in both 10 year periods was fol the management of an airway problem secondary to congenital abnormalities (65%). In 14 children the operation was performed during the first year of life. However, while 90% of the children were under the age of one in the period 1971- 1980 this fell to 26% during 1981-1990. Complications occurred in 41% overall, however, in the under 1 year old group 64% developed complications. There were no deaths as a direct result of the tracheostomy or its complications, but six children died because of the severity of the underlying disease. The average length of time before decannulation was 2.1 years, with decannulation difficulties occurring infrequently (11%). Kqwords:
Tracheostomy;
* Corresponding
Paediatric
author
0165-5876~96:$15.00 9 1996 Elsevier Science Ireland Ltd. All rights reserved SSDI 0165-5876(95)01255-A
2
M.J. Donnrliy
et cd. / ht. J. Pediutr. Otorhinoluryngoi.
35 (1996) l-9
1. Introduction
Relief of airway obstruction by tracheostomy is an ancient procedure although its application to children is comparatively recent [17]. During the nineteenth century large numbers of tracheostomies were performed on children, with a significant mortality rate. The introduction of endotracheal intubation and the development of vaccines for Diphtheria and Polio dramatically reduced the need for tracheostomies in children. A further decline in the number of tracheostomies being performed has been reported more recently as the development of safer endotracheal tubes have allowed for longer intubation times in children [2,5,11,12,16]. We present the experience of tracheostomies in paediatric patients from 1971 to 1990 at Our Lady’s Hospital for Sick Children (OLHSC). This is the largest childrens hospital in Ireland, with a catchment population of over one million people as well as being a tertiary referral centre for paediatric airway problems. The purpose of this study was to determine the indications for this procedure and identify any changes which occurred. In addition the duration, complications and decannulation problems related to the tracheostomy were analysed.
2. Methods
A retrospective analysis was carried out on the clinical records of children who had tracheostomies performed at OLHSC, and who had management of their tracheostomies at OLHSC during the period 1971- 1990. The records of children admitted to the intensive care unit (ICU) for management of airway problems over the same period, were also examined. The tracheostomies were all performed in the operating theatre under general anaesthesia. A sandbag was placed beneath the shoulders, taking care not to overextend the neck. Hyperextension of the head and neck may draw the thoracic trachea into the neck particularly in small infants resulting in low tracheostomies. A horizontal skin crease incision is made dividing the subcutaneous tissue. The strap muscles are retracted laterally and the thyroid isthmus is divided if it lies over the intended tracheostomy site. Particular care is taken not to stray from the midline in order to avoid injury to the great vessels. Non-absorbable stay sutures are inserted below the second tracheal ring on either side of the midline. These sutures are left in situ until the first tube change. A vertical incision is made in the trachea between the stay sutures, through the second and third or third and fourth tracheal ring, taking care not to perforate the posterior tracheal wall and oesophagus. The tracheostomy tube is inserted after the endotracheal tube has been withdrawn to the upper limit of the tracheotomy. The type of tracheostomy tube used include the Great Ormond Street, Portex and Shiley designs. Once in position the tube is initially secured by suturing the flanges to the skin of the neck, and the stay sutures are taped to the chest.
M.J. Domell~* 1’1al. )/Int. J. Prdiatr.
Ororllinoklr?,nRol.
35 (19%) l-9
3. Results Of 26 tracheostomies performed at OLHSC, the records of 25 were available. Five children were transferred to OLHSC for management after a tracheostomy was performed elsewhere. In total 29 children are included, 15 male and 14 female. Ten tracheostomies were performed during 1971~ 1980 and 19 were performed during 198 1-- 1990. The age of children at the time of tracheostomy ranged from 5 days to 14 years with children under the age of 1 year accounting for 48% [14] of the overall cases. Looking at the two decades separately, 90% [9] of the children in the first period were less than 1 year old whereas in the second period only 26% [5] were in this age group (Fig. 1). This is a statistically significant difference (P = 0.05 Fisher’s test). The indications for tracheostomies fell into two main groups (1) for relief of airway obstruction, and (2) for positive pressure ventilation and airway toilet (Table 1). The majority of tracheostomies were performed for relief of airway obstruction with 22 (76%) in this group. Only seven (24%) required a tracheostomy for ventilation purposes. In the overall group the main underlying medical problems requiring a tracheostomy for management were congenital abnormalities. This was seen in 65% of the cases but rose from 60% in the first 10 year period to 70% in the second 10 year period, however this is not statistically significant using Fisher’s test (P = 0.65). The types of congenital abnormalities are presented in Table 2. Significantly a tracheostomy was required on only one occasion in the management of an acute upper airway infection. Complications are divided into early and late, depending upon whether they occur within the first post-operative week or later (Table 3). The overall complication rate was 41%. Early complications occurred in 14X, the most common being 10
Age category
8
(in years) 6
Number of Patients
4I 2 1
0
1971-1980 Fig. I. Age distribution
1981-1990 of children at tracheostomy
Table I Indications for tracheostomy
Airway
obstruction
1981 1990
3
5 4 2 I I 1 I I
(22129)
Congenital airway abnormality Craniofacial abnormality Subglottic stenosis (acquired) Tracheal stenosis (acquired) Laryngeal papillomatosis Laryngeal Epidermolysis Bullosa Accidental strangulation Palatal haematoma Laryngotracheobronchitis Ventilation
1971-1980
and airnq~
toilet
CNS lesions CVS lesions Guillian Barre syndrome
2
I
(j: 29)
2 2
I I 1
accidental decannulation. Late complications were seen in 34% and were mainly lower respiratory tract infections. Looking specifically at the children under 1 year, there was a complication rate of 64% equally divided between early and late. No deaths occurred as a result of the tracheostomy but six children in the series died because of the severity of their underlying disease. These included a child with a trachea-oesophageal fistula and children with CVS and CNS abnormalities. The duration of the tracheostomy ranged from 3 days to 7 years with an average of 2.1 years. Successful decannulation was possible in 78% of casesThe technique used for decannulation included admission of the child to hospital followed by occlusion of the tracheostomy tube for 24-48 h. If there were no difficulties, decannulation proceeded. However, if airway difficulties occurred the airway was examined endoscopically under general anaesthesia. Decannulation difficulties ocTable 2 Congenital abnormalities requiring tracheostomy (numbers in brackets)
~___
Laryngomalacia Tracheomalacia Subglottic stenosis Tracheal stenosis
(2) (1)
Craniofacial (3)
Treacher Collins syndrome Pierre-Robin Syndrome Severe micrognathia
(1) (1) (1)
CNS (3)
Cerebral degeneration Central apnoea
(2) (1)
cvs (3)
Pulmonary atresia (1) Cardiomyopathy (1) Complex cyanotic heart disease (1)
Airway (8)
(3)
(2)
Table 3 Tracheostomy
complications
Louer respirator) tract infection Accidental decannulation Pneumothorax Chylothorax Tracheitih Granulations ~~ stoma1 tracheal Stoma1 cellulitis Tracheocutaneous fistula Total
Early ( < 1 week post operatively)
Late ( > 1 week post operatively)
2 2 I I I
7 I
I I I 2 7 (in 4 patients)
I4 (in IO patients)
cut-red in two patients, in one because of tracheal granulations, and no mechanical obstruction was found in the second. Both were eventually decannulated successfully. Five children still required their tracheostomy due to persistence of the underlying condition. Unfortunately the records from the ICU were incomplete, with the years I97 1, 1973, 1987 and 1988 missing. However, there were 8 years in the two periods of the 100
Age category 80
Number of Patients
(in years)
6.
40
1971-1980*
1981-1990t
* 1971 and 1973 not Included t 1987 and 1988 not included Fig. 2. Age distribution problems.
of children admitted to the intensive care unit (ICU) for management of airuaq
6
M.J.
Donnrll~~
et cd.
1771. J. Prrhtr.
Otorl7inolu~~~n~ol.
35 (1996)
1~ 9
study for analysis (Fig. 2). In the first decade (1971 1980) 149 children were admitted for management of airway problems, with 66% under the age of 1 year. During the second 10 year interval (1981-1990) there were 154 admissions for airway management. In this group 61% of the children were under the age of 1 year. 4. Discussion
There has been a change in the indications for paediatric tracheostomies over the last two decades [2,17]. Previously this operation was performed mainly for the relief of upper airway obstruction, secondary to acute infectious disorders such as epiglottitis and laryngotracheobronchitis. With the development of better anaesthetic techniques and safer endotracheal intubation [I], the management of these conditions no longer required a tracheostomy. As a result of this the number of paediatric tracheostomies performed in large centres declined dramatically from the mid 1970s [5,11], with congenital malformations becoming the most common indication for this procedure. Although many children are now remaining intubated for increasing periods of time, tracheostomies are still necessaryin some. Opinions differ regarding the length of time endotracheal tubes may be safely left in place before a tracheostomy should be performed [19], although Dankle et al. [6] have shown that endotracheal intubation is safe for extended periods. The decision to perform a tracheostomy in our hospital is made in consultation with the ENT surgeon, the anaesthetist and the paediatrician based on the needs of the individual child. At OLHSC long-term endotracheal intubation was introduced in the management of airway problems since the early 1970s following the reports of its safe utilisation. This is reflected in the similar number of admissions to the ITU for airway management in the two decadesof the study and the small size of the series. During the 20 years covered in this study we have noticed an increase of 90% in the numbers of tracheostomies carried out when comparing the 1970s to the 1980s a reversal of the previously described downward trend. It is important to note that this trend occurred despite no significant change in the number of admissions to the ITU for management of airway problems. Although the numbers are small, this may reflect the improvement in the survival of critically ill infants using modern intensive care techniques. Many of these children require intubation and ventilation shortly after birth, often for prolonged periods, before a tracheostomy is eventually performed. Also, the age of the children at tracheostomy was significantly different between the two 10 year periods. From 1971 to 1980, 90% of the children were less than 1 year old whereas from 1981 to 1990 only 26% were less than 1 year of age. The ICU numbersshow that this change took place despite no significant decrease in the number of younger children being admitted for airway management. This is an indication of the evolution of a more conservative approach to the management of airway problems in the very young. The adoption of a conservative attitude is understandable in the light of the high complication rates seen in tracheostomies performed in very young children.
M.J. Donnelly et al. ! hr. J. Pediatr. Otorhinoiaryngol.
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7
A tracheostomy was required only once for a severe upper respiratory tract infection, illustrating the shift from tracheostomy to endotracheal intubation in the management of this condition. The main indication for tracheostomy in both these periods was in the management of children with congenital abnormalities requiring bypass of an airway obstruction or requiring prolonged ventilation and airway toilet (60% and 70% respectively, this difference not being statistically significant). The most common type of congenital abnormality seen involved the larynx or trachea. Other indications include airway obstruction secondary to craniofacial abnormalities. In children, tracheostomy is a procedure associated with a significant morbidity and mortality rate. The complication rate in our series (41”/0) is well within the range 30-46.5% reported [ 17,181.It is important to anticipate a higher complication rate in very young children. In this group of patients the complication rate of 64% in children less than 1 year old is similar to that of other series [lo]. Generally those complications occurring within the first post operative week are the most life threatening. One patient developed a chylothorax shortly after surgery. This potentially dangerous complication can be minimised by avoiding low tracheostomies. Early accidental decannulation occurred on two occasions, but fortunately no deaths resulted. In one of these cases a false passage was created on replacing the tube, and following positive pressure ventilation, a pneumothorax resulted. Lower respiratory tract infections are a well recognised complication in patients with tracheotomies [14,15]; micro-organisms have easier access to the respiratory tract and the coughing action is less powerful in these patients. This can be a significant problem particularly when previous lung problems existed, often requiring intravenous antibiotics and intensive physiotherapy. Despite regular nursing care and humidification, pneumonia was the most common complication seen in this series, occurring in nine patients. Granulations in the tracheal lumen or stoma occur so commonly that some authors do not consider them as complications unless they obstruct the airway [4]. Most commonly granulations occur at the superior aspect of the tracheostomy site. Intraluminal tracheal lesions can occur and are due to such factors as excessivetube movement, the use of too large a tube or an overinflated cuff, devascularisation of the trachea at surgery, cartilage excision and tracheal infection [15]. Careful surgical technique and meticulous postoperative nursing care should reduce the risk of significant long-term tracheal narrowing. Problematic granulations requiring bronchoscopic removal was seen in two cases,with decannulation being delayed in one of the children. The mortality rate associated with tracheostomies is O-8.7% with accidental decannulation, tube obstruction and pneumothorax accounting for most fatalities [20]. Deaths in this study were attributable to the underlying diseaserather than to the tracheostomy. Those children who died had severe abnormalities incompatible with life. Many children now require a tracheostomy for extended periods of time because of the nature of the underlying disease.It may be expected that prolonged duration of the tracheostomy can lead to decannulation difficulties [7]. In children suitable for removal of the tracheostomy tube, decannulation has not been a major problem
8
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in this series. The two caseswhich occurred are typical of the most common causes of difficult decannulation tracheal granulations, and physiological dysfunction of the upper airway [9]. If difficulties arise during decannulation, the airway should be assessedendoscopically, as significant tracheal granulations may be present in 15% of cases[8]. After removal of these granulations decannulation is usually successful. In some children, decannulation is problematic despite no obvious anatomical airway obstruction. This was felt to be due to a psychological dependency and became commonly referred to as ‘decannulation panic’ [13]. Black et al. [3] have suggested a more likely explanation based on physiological changes in the dead space volume and laryngeal reflexes caused by the tracheostomy. In order to reduce anxiety in children and their parents, it is important that tracheostomy decannulation is carried out in a controlled and reassuring manner. In conclusion, the widespread use of endotracheal intubation in the management of paediatric airway problems has, in our experience, limited the spectrum of indications for tracheostomies. In this series very few tracheostomies were necessary in the management of acute upper airway infections. Most operations were performed on children with compromised airways often resulting from congenital conditions. Significantly we note that tracheostomies were performed less frequently in younger children during the most recent years of the study period. The complication rate was higher in children less than 1 year old. Decannulation difficulties were infrequently encountered, even in children who had their tracheostomy for extended periods. References [I] Allen, T.H. and Steven, I.M. (1972) Prolonged nasotracheal intubation in infants and children. Brit. J. Anaest. 44, 8355839. [2] Arcand, P. and Granger, J. (1988) Paediatric tracheostomies: changing trends. J. Otlaryngol. 17, 121-124. [3] Black, R.J., Baldwin, D.L. and Johns, A.N. (1984) Tracheostomy ‘decannulation panic’ in children: fact or fiction?. J. Laryngol. Otol. 98, 297-304. [4] Carter, P. and Benjamin, B. (1983) Ten year review of paediatric tracheotomy. Ann. Otol. Rhinol. Laryngol. 92 3988400. [5] Crysdale. W.S., Feldman, R.I. and Naito, K. (1988) Tracheotomies: A IO year experience in 319 children. Ann. Otol. Rhino]. Laryngol. 97, 439-443. [6] Dankle, SK., Schuller, D.E. and McClead, R.E. (1987) Prolonged intubation of Neonates. Arch. Otolaryngol. Head Neck Surg. 113, 841-843. [7] Filston, H.C., Johnston, D.G. and Crumrine. R.S. (1978) Infant tracheostomy: A new look with a solution to the difficult cannulation problem. Am. J. Dis. Child. 132, 1172--l 176. [8] Gilmore, B.B. and Mickelson. S.A. (1986) Paediatric Tracheotomy Controversies in management. Otolaryngol. Clin. North Am. 19, 141-151. [9] Kearns. D.B.. Albert, D.M., Choa. D.I., Wickstead, M. Bailey, M. and Evans J.N.G. (1990) Functional assessmentof the paediatric laryngeal airway. Clin. Otolaryngol. 15. 53-58. [IO] Kenna, M.A.. Reilly, J.S. and Stool, S.E. (1987) Tracheotomy in the preterm infant. Ann. Otol. Rhino]. Laryngol. 96. 68-71. [I I] Line, W.S., Hawkins, D.B.. Kahlstrom, E.J. MacLaughlin, E.F. and Ensley, J.L. (1986) Tracheotomy in infants and young children: The changing perspective 1970-1985. Laryngoscope 96, 510-515.
[12] Newlands, W.J. and McKerrow, W.S. (1987) Paediatric tracheostomy Fifty-seven operations on fifty-three children. J. Laryngol. Otol. 101, 9299935. [13] Pracy, R., Siegler, J.. Stell, P.M. and Rogers. J. (1981) Ear, Nose and Throat Surgery and Nursing. Hodder and Stoughton, London, 187 pp. [14] Rogers, J.H. (1987) Tracheostomy and decannulation. In: Kerr, A.J., Groves, J. and Evans. J.N.G. (Eds.). Scott - Brown’s Otolaryngology, Vol. 6. Butterworth, London. 479 pp. [15] Stool, S.E. and Eavey, R.D. (1990) Tracheotomy. In: Bluestone, C.D.. Stool, S.E. and Scheetz, M.E. (Eds.). Pediatric Otoiaryngology, Vol. 2. Saunders, Philadelphia. pp. 1235 1236. [16] Swift, A.C. and Rogers, J.H. (1987) The outcome of tracheostomy in children. J. Laryngol. Otol. 101, 9366939. [I71 Swift, A.C. and Rogers, J.H. (1987) The changing indications for tracheostomy in children. J. Laryngol. Otol. 101, 1258- 1262. [I81 Tucker, J.A. and Silberman, H.D. (1972) Tracheotomy in Pediatrics, Ann. Otol. Rhinol. Laryngol. 81, 8188824. [19] Watson, C.B. (1983) A survey of intubation practices in critical care medicine. Ear Nose Throat J. 62, 4944501. [20] Wetmore, R.F., Handler, S.D. and Potsic, W.P. (1982) Pediatric tracheostomy: Experience during the past decade. Ann. Otol. Rhinol. Laryngol. 91. 6288632.