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Current trends in paediatric tracheostomies
International Journal of Pediatric Otorhinolaryngology (2007) 71, 1563—1567
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Current trends in paediatric tracheostomies Claudio Parrilla a,*, Emanuele Scarano a, Maria Lavinia Guidi b, Jacopo Galli a, Gaetano Paludetti a a b
Institute of Otolaryngology, Sacro Cuore Catholic University, Rome, Italy Institute of Anaesthesiology, Sacro Cuore Catholic University, Rome, Italy
Received 13 March 2007; received in revised form 29 May 2007; accepted 2 June 2007 Available online 12 July 2007
KEYWORDS Paediatric tracheostomies; Tracheostomy indications; Tracheostomy complications
Summary Objective: In the 1970s, the most common indication for tracheostomy in children was acute inflammatory airway obstruction. Modern neonatal intensive care units have turned long-term intubation into an alternative to tracheostomy. Long-term intubation itself has become the most important indication for tracheostomy combined with subglottic stenosis. Methods: Retrospective analysis in a tertiary referral center. A total of 38 patients who underwent tracheostomy for respiratory failure and upper airway obstruction from 1 November 1998 to 30 November 2004. Results: Total complication rate was 42.1%. In children under 1 year of age the complication rate was 47.4%, in children over 1 year the complication rate was 26.3%. Decannulation was attempted in 12 patients with a cannulation time of 22 months. Conclusions: Long-term intubation and its sequelae have now become one of the most important indication for tracheostomy. The change of indication has also entailed a decrease of the average age of children who require tracheostomy. A longer period before decannulation and a lower average age have changed the complication rate of tracheostomy in paediatric patients. # 2007 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Scientific reports suggest that over the last 30 years the role and the indications of tracheostomy in children have been changing considerably, whereas * Corresponding author at: Department of Otolaryngology, Sacro Cuore Catholic University, ‘‘A. Gemelli’’ Polyclinic, Largo A. Gemelli n. 8, 00168 Rome, Italy. Tel.: +39 0630154439; fax: +39 063051194. E-mail address: [email protected] (C. Parrilla).
indications and implications of tracheostomy in adults are widely described and well defined, although some controversy still exists. Paediatric tracheostomy is technically more demanding than the one performed on adults, due to the smaller, more pliable trachea and to the limited extension of the operating field. It has a higher mortality, morbidity and complication rate, well supported with documentary evidence especially among pre-term infants [1—3].
0165-5876/$ — see front matter # 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2007.06.009
1564 In the 1970s, the most common indication for tracheostomy in children were acute inflammatory airway obstructions such as acute epiglottitis, croup and diphtheria. The use of vaccines against Haemophilus influenzae and Corynebacterium diphteriae, combined with modern neonatal intensive care units, has turned long-term intubation into an alternative to tracheostomy. However, children who require ventilatory support for many weeks or months need tracheostomies in order to facilitate pulmonary toilet and to reduce chronic laryngotracheal lesions related to long-term intubation, such as subglottic stenosis or tracheomalacia. Therefore, long-term intubation itself and the relevant sequelae have become the most important indication for tracheostomy [2,4]. A complete analysis of the available literature shows that indications, epidemiology and complications are changing, and that no definite guidelines have been established. We present our experience of tracheostomies performed in paediatric patients from 1998 to 2004 at our hospital (Catholic University in Rome), a major hospital with a catchment population of over three million people. We analyzed retrospectively our paediatric tracheostomies, in terms of indications and complications, and compared our data with those made available by the international literature.
2. Materials and methods We performed a retrospective review of children who underwent tracheostomy at the Catholic University of Rome between November 1998 and November 2004. The records of children admitted to the intensive care unit (ICU) for the management of airway problems over the same period were also examined. This study was approved by the Ethics Committee of the Medical Faculty of the Catholic University in Rome. Patients were evaluated as long as indications, complications and mortality were observed. A total of 38 paediatric tracheostomies (18 females and 20 males) out of 1228 children admitted to the ICU over a 6-year period were performed. All tracheostomies were performed electively, under general anesthesia and using the same surgical procedure. Only the main indication for tracheostomy was recorded, although in some cases multiple indications were present. The standard tracheostomy procedure at our institution consists of a horizontal midline skin incision, converted to a vertical one in lower skin layers to better protect large vessels of the thyroid plexus
C. Parrilla et al. and the thyroid gland. The thyroid isthmus is preserved, when possible. Once the trachea is exposed, a horizontal incision is made along the anterior tracheal wall and two parallel silk stay sutures, which are left long until the first tube change, are placed on either side of the incision; then a small oval window centred on the trachea is opened. The tracheostomy tube is inserted after applying anterolateral traction on the stay sutures. Other techniques to mature the stoma with sutures to the skin, such as starplasty tracheotomy, have never been used; percutaneous tracheostomy has never been used, either, and the open technique was the preferred procedure. All patients joined the paediatric intensive care unit after surgery. Pre- and/or post-operative direct laryngoscopy was performed, in order to assess the airway anatomy and the results of the prolonged intubation, or to confirm the tube’s position. Tracheostomy tubes were changed bedside, 7—9 days after surgery. The mean age of the patients’ population was 27.5 months, ranging from 20 days to 14 years. Fifty percent of patients (19) were under 1 year of age at the time of tracheostomy. The main indication was respiratory failure and upper airway obstruction, but a combination of several indications was often present. The underlying conditions were in 17 cases (44.7% of all tracheostomies) neuromuscular or respiratory problems, in 8 cases (21.1%) congenital malformations (4 laryngotracheal anomaly, 3 cardiovascular anomaly, 1 pulmonary anomaly), in 6 cases (15.8%) craniofacial syndromes/OSA syndromes, in 5 cases (13.2%) acquired subglottic stenosis, in 1 case tracheo-oesophageal burn, and in 1 case trauma (Table 1).
3. Results Our departmental database and our operating theatre records showed that in our study, the intubation Table 1
Primary indications of tracheotomy
Neuromuscular or respiratory problems Congenital malformations (four laryngo-tracheal anomaly, three cardiovascular anomaly, one pulmonary anomaly) Craniofacial syndromes/OSA syndromes Acquired subglottic stenosis Tracheo-oesophageal burn Trauma
No.
%
17
44.7
8
21.1
6
15.8
5 1 1
13.2 2.6 2.6
Paediatric tracheostomies
1565
period before tracheostomy ranged from 1 to 69 days (M = 34). Total complication rate in our group of patients was 36.8% (14 patients). However, no early complications (such as emphysema, pneumomediastinum, pneumothorax, bleeding) nor fatal ones (such as decannulation and cannula obstruction) were observed. In children under 1 year of age we observed six stomal granulomas, two tracheocutaneous fistulae (closed after 6 months of observation) and one suture abscess (Table 2). In other words, complications were present in 9 out of 19 children (47.4%). In children over 1 year of age we observed a total of five complications (26.3%): three stomal granulomas, one tracheal stenosis and one tracheocutaneous fistula (Table 3). Decannulation was attempted in 12 patients, with an average time lapse of 22 months after tracheotomy. Children with respiratory or neuromuscular problems could not be decannulated. One child required a reopening of his tracheostomy in order to allow major unrelated surgery. Finally, overall mortality rate was 39.2%. All deaths were due to the primary illness, and no case of death was directly related to tracheostomy.
4. Discussion Indications, techniques, and complications of paediatric tracheostomy have changed over the past couple of decades. Heterogeneity of different studies available in the international literature can be helpful for the sake of specificity, but the subclassification of groups makes them much smaller, thus causing their comparison to be less meaningful. In fact, analysing the data, differences in terms of indications, age groups, surgical technique and choice of investigated complications are quite evident. However, some considerations can be made. Several series found that the total number of paediatric tracheostomies declined over the past decades [5—7], except in one report [8]. In the 1970s, tracheostomy was commonly performed for an acute upper airway involvement due to infectious diseases. Over the last 30 years, with Table 2 Complications rate of tracheotomy in children <1 year No.
%
Stomal granulomas Tracheocutaneous fistulae Suture abscess
6 2 1
31.5 10.6 5.3
Total
9
47.4
Table 3 Complications rate of tracheotomy in children >1 year No.
%
Stomal granulomas Tracheal stenosis Tracheocutaneous fistula
3 1 1
15.7 5.3 5.3
Total
5
26.3
the introduction of endotracheal intubation, Haemophilus Influenzae type B vaccine for acute epiglottitis and ICU care, the indications of tracheostomy for infectious acute diseases declined dramatically. There are series [5] in which such indication declined from 50 to 3%, comparing the period from 1970 to 1975 with the one from 1980 to 1985, and several other series that confirmed such statement [8]. Conversely, among the indications for tracheostomy, an increase of acquired subglottic stenosis, neuromuscular diseases, premature birth, congenital anomalies could be observed [5,8]. The increase of acquired subglottic stenosis is certainly due to prolonged endotracheal intubation, which became the most important indication for tracheostomy in several reports, ranging from 28 to 36% [6,9—11]. Several authors suggest a weekly fiber optic control or an early tracheostomy (when indicated) for children who are intubated for a long-term period, in order to avoid subglottic or tracheal stenosis [12,13]. In our report no tracheostomies were performed for acute airways infection and, as in other series (Wetmore 53%; Carron 61%) [2,4], the most common indication was prolonged ventilation due to respiratory problems and/or neuromuscular disease (44.7% of all tracheostomy), followed by congenital anomalies (21.1%), craniofacial syndromes (OSA syndromes, 15.8%) and subglottic stenosis (13.2%). Due to the change of indications and improved ICU care for premature birth, a downward shift in the average age of children undergoing tracheostomy could be observed. In our report 50% of patients were under 1 year of age, compared with 65% of Midwinter et al. [13], 48% of Donelly et al. [14], whereas older series show 32.5 and 30% [15,16]. The concept on the intubation period before tracheostomy has also changed over the last 30 years. In the 1970s, for a child in need of ventilation for over 8 days, a prophylactic tracheostomy was recommended. Now this period is fixed individually, according to clinical and endoscopic findings [13,17], ranging from 2 to 134 days. In our series, the average intubation period before tracheostomy was 34 days. Our overall complication rate (36.8%) was comparable to those reported by other authors
1566 [2,18,19]. Younger children (under 1 year of age) had a higher complication rate (47.4%) than older cases (26.3%), as in other series [11,13,15], in which complication rates of 63, 64 and 70%, respectively, were observed in children belonging to the same age group. The much higher rate of complications in younger children seems to be related to the narrow inner radius of the small and very pliable trachea. In fact, the airflow through a tube depends on the fourth power of the radius exponentially, if viscosity is constant and dynamic. The airway diameter at 6 months of age is 6 mm. Therefore, even a slight reduction of the endotracheal diameter can potentially obstruct the airway. In addition, some authors observed that almost half of the patients under 1 year of age suffer from a bronchopulmonary dysplasia, which prompts the development of viscous and abundant bronchial secretion, thus increasing the risk of significant early and long-term tracheal complications [12,20]. No early and/or life-threatening complications (such as fatal cannula obstruction or accidental decannulation) were observed in the present study, perhaps because tracheostomies were never urgently performed, as required in patients with acute airway infection. The increase in the rate of late complications is presumably related to the increase of cannulation period after tracheostomy in patients with neuromuscular diseases, chronic respiratory problems and subglottic stenosis [4,7,11,21]. In our study, neurologically impaired children could not be decannulated, due to their chronic condition and to their high mortality rate (related to the primary illness). We considered all granulations in the tracheal lumen or stoma as complication, but they are so common and harmless that some authors do not consider them such, unless they compromise the airway. The same authors believe that granulations are more correctly listed as sequelae, since no proven technique is able to prevent this occurrence [22,23]. Again, some authors observed that in children who wear their tracheostomy for over 2 years, a persistent tracheocutaneous fistula is more likely [4]. For such reason, listing tracheocutaneous fistula as a complication should be reconsidered, being a known and expected outcome of this procedure, especially in long-term tracheostomized patients. Additionally, the adoption of newer techniques that mature the stoma with sutures to the skin (such as starplasty tracheostomy) increase the incidence of this complication. In fact, the drawback of this technique, which proves to reduce the incidence of major complications including pneumothorax and
C. Parrilla et al. accidental decannulation, is that a secondary reconstruction of a tracheocutaneous fistula is then required [24,25]. In conclusion, the prolonged period before decannulation (months or years) observed over the past few decades has entailed an increase of late complications such as persistent tracheocutaneous fistulae and stomal or tracheal granulomas, that should presently be considered as sequelae of this surgical procedure rather than complications. The change of indications has also determined a lower average age among children who require tracheostomy, thus increasing the complication rate related to paediatric tracheostomies.
References [1] R.J. Perrotta, W.S. Schley, Pediatric tracheostomy–—a five year comparison study, Arch. Otolaryngol. 104 (1978) 319—321. [2] R.F. Wetmore, S.D. Handler, W.P. Potsic, Paediatric tracheostomy: experience during the past decade, Ann. Otol. Rhinol. Laryngol. 91 (1982) 628—632. [3] M.A. Kenna, J.S. Reilly, S.E. Stool, Tracheostomy in the preterm infant, Ann. Otol. Rhinol. Laryngol. 96 (1986) 68—71. [4] J.D. Carron, C.S. Derkay, G.L. Strope, J.E. Nosonchuk, D.H. Darrow, Pediatric tracheostomies: changing indications and outcomes, Laryngoscope 110 (2000) 1099—1104. [5] P. Arcand, J. Granger, Pediatric tracheostomies: changing trends, J. Otolaryngol. 17 (1988) 121—125. [6] W.S. Line, D.B. Hawkins, E.J. Kahlstrom, E.F. Maclaughlin, J.L. Ensley, Tracheostomy in infants and young children: the changing perspective 1970—1985, Laryngoscope 96 (1986) 510—515. [7] W.J. Newlands, W.S. McKerrow, Paediatric tracheostomy. Fifty-seven operations on fifty-three children, J. Laryngol. Otol. 101 (1987) 929—935. [8] P.J. Hadfield, R.V. Lloyd-Faulconbridge, J. Almeyda, D.M. Albert, C.M. Bailey, The changing indications for paediatric tracheostomy, Int. J. Pediatr. Otorhinolaryngol. 67 (2003) 7—10. [9] A. Waddell, R. Appleford, C. Dunning, B.C. Papsin, C.M. Bailey, The great Ormond street protocol for ward decannulation of children with tracheostomy: increasing safety and decreasing cost, Int. J. Pediatr. Otorhinolaryngol. 39 (1997) 111—118. [10] C.S. Butnaru, M.P. Colreavy, S. Ayari, P. Froehlich, Tracheotomy in children: evolution in indications, Int. J. Pediatr. Otorhinolaryngol. 70 (2006) 115—119. [11] C.E. Cox, S.S. Carson, G.M. Holmes, A. Howard, T.S. Carey, Increase in tracheostomy for prolonged mechanical ventilation in North Carolina, 1993—2002, Crit. Care Med. 32 (2004) 2219—2226. [12] B. Kremer, A.I. Botos-Kremer, H.E. Eckel, G. Schlondorff, Indications, complications, and surgical technique for pediatric tracheostomies–—an update, J. Pediatr. Surg. 37 (2002) 1556—1562. [13] K.I. Midwinter, D. Hodgson, M. Yardley, Paediatric epiglottitis, the influence of the Haemophilus influenzae b vaccine: a ten-year review in the Sheffield region, Clin. Otolaryngol. 24 (1999) 447—448.
Paediatric tracheostomies [14] M.J. Donnelly, P.D. Lacey, A.J. Maguire, A twenty-year (1971—1990) review of tracheostomies in a major pediatric clinic, Int. J. Pediatr. Otorhinolaryngol. 35 (1996) 1—9. [15] P.T. Gaudet, A. Peerless, C.T. Sasaki, J.A. Kirchner, Pediatric tracheostomy and associated complications, Laryngoscope 88 (1978) 1633—1641. [16] J.A. Tucker, H.D. Silbermann, Tracheostomy in paediatrics, Ann. Otol. Rhinol. Laryngol. 81 (1972) 818—824. [17] R.F. Ward, J. Jones, J.F. Carew, Current trends in pediatric tracheotomy, Int. J. Pediatr. Otorhinolaryngol. 32 (1995) 233—239. [18] M.M. Carr, C.P. Poje, L. Kingston, D. Kielma, C. Heard, Complications in pediatric tracheostomies, Laryngoscope 111 (2001) 1925—1928. [19] P.M. Palmer, J.M. Dutton, T.M. McCulloch, R.J. Smith, Trends in the use of tracheotomy in the pediatric patient: the Iowa experience, Head Neck 17 (1995) 328—333. [20] J.S. Schlessel, R.G. Harper, H. Rappa, K. Kenigsberg, S. Khanna, Tracheostomy: acute and long-term mortality and
1567
[21]
[22]
[23]
[24]
[25]
morbidity in very low birth weight premature infants, J. Pediatr. Surg. 28 (7) (1993) 873—876. H.T. Joseph, P. Jani, J.M. Preece, C.M. Bailey, J.N. Evans, Paediatric tracheostomy: persistent tracheocutaneous fistula following decannulation, Int. J. Pediatr. Otorhinolaryngol. 22 (1991) 231—236. A. Rozsasi, S. Kuhnemann, S. Gronau, T. Keck, A single-center 6-year experience with two types of pediatric tracheostomy, Int. J. Pediatr. Otorhinolaryngol. 69 (5) (2005) 607—613. P. Carter, B. Benjamin, Ten-year review of pediatric tracheotomy, Ann. Otol. Rhinol. Laryngol. 92 (4 Pt 1) (1983) 398—400. P.J. Koltai, Starplasty–—a new technique of pediatric trachestomy, Arch. Otolaryngol. Head Neck Surg. 124 (10) (1998) 1105—1111. N.B. Sautter, P.R. Krakovitz, C.A. Solares, P.J. Koltai, Closure of persistent tracheocutaneous fistula following ‘‘starplasty’’ tracheostomy in children, Int. J. Pediatr. Otorhinolaryngol. 70 (1) (2006) 99—105.
www.elsevier.com/locate/ijporl
Current trends in paediatric tracheostomies Claudio Parrilla a,*, Emanuele Scarano a, Maria Lavinia Guidi b, Jacopo Galli a, Gaetano Paludetti a a b
Institute of Otolaryngology, Sacro Cuore Catholic University, Rome, Italy Institute of Anaesthesiology, Sacro Cuore Catholic University, Rome, Italy
Received 13 March 2007; received in revised form 29 May 2007; accepted 2 June 2007 Available online 12 July 2007
KEYWORDS Paediatric tracheostomies; Tracheostomy indications; Tracheostomy complications
Summary Objective: In the 1970s, the most common indication for tracheostomy in children was acute inflammatory airway obstruction. Modern neonatal intensive care units have turned long-term intubation into an alternative to tracheostomy. Long-term intubation itself has become the most important indication for tracheostomy combined with subglottic stenosis. Methods: Retrospective analysis in a tertiary referral center. A total of 38 patients who underwent tracheostomy for respiratory failure and upper airway obstruction from 1 November 1998 to 30 November 2004. Results: Total complication rate was 42.1%. In children under 1 year of age the complication rate was 47.4%, in children over 1 year the complication rate was 26.3%. Decannulation was attempted in 12 patients with a cannulation time of 22 months. Conclusions: Long-term intubation and its sequelae have now become one of the most important indication for tracheostomy. The change of indication has also entailed a decrease of the average age of children who require tracheostomy. A longer period before decannulation and a lower average age have changed the complication rate of tracheostomy in paediatric patients. # 2007 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Scientific reports suggest that over the last 30 years the role and the indications of tracheostomy in children have been changing considerably, whereas * Corresponding author at: Department of Otolaryngology, Sacro Cuore Catholic University, ‘‘A. Gemelli’’ Polyclinic, Largo A. Gemelli n. 8, 00168 Rome, Italy. Tel.: +39 0630154439; fax: +39 063051194. E-mail address: [email protected] (C. Parrilla).
indications and implications of tracheostomy in adults are widely described and well defined, although some controversy still exists. Paediatric tracheostomy is technically more demanding than the one performed on adults, due to the smaller, more pliable trachea and to the limited extension of the operating field. It has a higher mortality, morbidity and complication rate, well supported with documentary evidence especially among pre-term infants [1—3].
0165-5876/$ — see front matter # 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2007.06.009
1564 In the 1970s, the most common indication for tracheostomy in children were acute inflammatory airway obstructions such as acute epiglottitis, croup and diphtheria. The use of vaccines against Haemophilus influenzae and Corynebacterium diphteriae, combined with modern neonatal intensive care units, has turned long-term intubation into an alternative to tracheostomy. However, children who require ventilatory support for many weeks or months need tracheostomies in order to facilitate pulmonary toilet and to reduce chronic laryngotracheal lesions related to long-term intubation, such as subglottic stenosis or tracheomalacia. Therefore, long-term intubation itself and the relevant sequelae have become the most important indication for tracheostomy [2,4]. A complete analysis of the available literature shows that indications, epidemiology and complications are changing, and that no definite guidelines have been established. We present our experience of tracheostomies performed in paediatric patients from 1998 to 2004 at our hospital (Catholic University in Rome), a major hospital with a catchment population of over three million people. We analyzed retrospectively our paediatric tracheostomies, in terms of indications and complications, and compared our data with those made available by the international literature.
2. Materials and methods We performed a retrospective review of children who underwent tracheostomy at the Catholic University of Rome between November 1998 and November 2004. The records of children admitted to the intensive care unit (ICU) for the management of airway problems over the same period were also examined. This study was approved by the Ethics Committee of the Medical Faculty of the Catholic University in Rome. Patients were evaluated as long as indications, complications and mortality were observed. A total of 38 paediatric tracheostomies (18 females and 20 males) out of 1228 children admitted to the ICU over a 6-year period were performed. All tracheostomies were performed electively, under general anesthesia and using the same surgical procedure. Only the main indication for tracheostomy was recorded, although in some cases multiple indications were present. The standard tracheostomy procedure at our institution consists of a horizontal midline skin incision, converted to a vertical one in lower skin layers to better protect large vessels of the thyroid plexus
C. Parrilla et al. and the thyroid gland. The thyroid isthmus is preserved, when possible. Once the trachea is exposed, a horizontal incision is made along the anterior tracheal wall and two parallel silk stay sutures, which are left long until the first tube change, are placed on either side of the incision; then a small oval window centred on the trachea is opened. The tracheostomy tube is inserted after applying anterolateral traction on the stay sutures. Other techniques to mature the stoma with sutures to the skin, such as starplasty tracheotomy, have never been used; percutaneous tracheostomy has never been used, either, and the open technique was the preferred procedure. All patients joined the paediatric intensive care unit after surgery. Pre- and/or post-operative direct laryngoscopy was performed, in order to assess the airway anatomy and the results of the prolonged intubation, or to confirm the tube’s position. Tracheostomy tubes were changed bedside, 7—9 days after surgery. The mean age of the patients’ population was 27.5 months, ranging from 20 days to 14 years. Fifty percent of patients (19) were under 1 year of age at the time of tracheostomy. The main indication was respiratory failure and upper airway obstruction, but a combination of several indications was often present. The underlying conditions were in 17 cases (44.7% of all tracheostomies) neuromuscular or respiratory problems, in 8 cases (21.1%) congenital malformations (4 laryngotracheal anomaly, 3 cardiovascular anomaly, 1 pulmonary anomaly), in 6 cases (15.8%) craniofacial syndromes/OSA syndromes, in 5 cases (13.2%) acquired subglottic stenosis, in 1 case tracheo-oesophageal burn, and in 1 case trauma (Table 1).
3. Results Our departmental database and our operating theatre records showed that in our study, the intubation Table 1
Primary indications of tracheotomy
Neuromuscular or respiratory problems Congenital malformations (four laryngo-tracheal anomaly, three cardiovascular anomaly, one pulmonary anomaly) Craniofacial syndromes/OSA syndromes Acquired subglottic stenosis Tracheo-oesophageal burn Trauma
No.
%
17
44.7
8
21.1
6
15.8
5 1 1
13.2 2.6 2.6
Paediatric tracheostomies
1565
period before tracheostomy ranged from 1 to 69 days (M = 34). Total complication rate in our group of patients was 36.8% (14 patients). However, no early complications (such as emphysema, pneumomediastinum, pneumothorax, bleeding) nor fatal ones (such as decannulation and cannula obstruction) were observed. In children under 1 year of age we observed six stomal granulomas, two tracheocutaneous fistulae (closed after 6 months of observation) and one suture abscess (Table 2). In other words, complications were present in 9 out of 19 children (47.4%). In children over 1 year of age we observed a total of five complications (26.3%): three stomal granulomas, one tracheal stenosis and one tracheocutaneous fistula (Table 3). Decannulation was attempted in 12 patients, with an average time lapse of 22 months after tracheotomy. Children with respiratory or neuromuscular problems could not be decannulated. One child required a reopening of his tracheostomy in order to allow major unrelated surgery. Finally, overall mortality rate was 39.2%. All deaths were due to the primary illness, and no case of death was directly related to tracheostomy.
4. Discussion Indications, techniques, and complications of paediatric tracheostomy have changed over the past couple of decades. Heterogeneity of different studies available in the international literature can be helpful for the sake of specificity, but the subclassification of groups makes them much smaller, thus causing their comparison to be less meaningful. In fact, analysing the data, differences in terms of indications, age groups, surgical technique and choice of investigated complications are quite evident. However, some considerations can be made. Several series found that the total number of paediatric tracheostomies declined over the past decades [5—7], except in one report [8]. In the 1970s, tracheostomy was commonly performed for an acute upper airway involvement due to infectious diseases. Over the last 30 years, with Table 2 Complications rate of tracheotomy in children <1 year No.
%
Stomal granulomas Tracheocutaneous fistulae Suture abscess
6 2 1
31.5 10.6 5.3
Total
9
47.4
Table 3 Complications rate of tracheotomy in children >1 year No.
%
Stomal granulomas Tracheal stenosis Tracheocutaneous fistula
3 1 1
15.7 5.3 5.3
Total
5
26.3
the introduction of endotracheal intubation, Haemophilus Influenzae type B vaccine for acute epiglottitis and ICU care, the indications of tracheostomy for infectious acute diseases declined dramatically. There are series [5] in which such indication declined from 50 to 3%, comparing the period from 1970 to 1975 with the one from 1980 to 1985, and several other series that confirmed such statement [8]. Conversely, among the indications for tracheostomy, an increase of acquired subglottic stenosis, neuromuscular diseases, premature birth, congenital anomalies could be observed [5,8]. The increase of acquired subglottic stenosis is certainly due to prolonged endotracheal intubation, which became the most important indication for tracheostomy in several reports, ranging from 28 to 36% [6,9—11]. Several authors suggest a weekly fiber optic control or an early tracheostomy (when indicated) for children who are intubated for a long-term period, in order to avoid subglottic or tracheal stenosis [12,13]. In our report no tracheostomies were performed for acute airways infection and, as in other series (Wetmore 53%; Carron 61%) [2,4], the most common indication was prolonged ventilation due to respiratory problems and/or neuromuscular disease (44.7% of all tracheostomy), followed by congenital anomalies (21.1%), craniofacial syndromes (OSA syndromes, 15.8%) and subglottic stenosis (13.2%). Due to the change of indications and improved ICU care for premature birth, a downward shift in the average age of children undergoing tracheostomy could be observed. In our report 50% of patients were under 1 year of age, compared with 65% of Midwinter et al. [13], 48% of Donelly et al. [14], whereas older series show 32.5 and 30% [15,16]. The concept on the intubation period before tracheostomy has also changed over the last 30 years. In the 1970s, for a child in need of ventilation for over 8 days, a prophylactic tracheostomy was recommended. Now this period is fixed individually, according to clinical and endoscopic findings [13,17], ranging from 2 to 134 days. In our series, the average intubation period before tracheostomy was 34 days. Our overall complication rate (36.8%) was comparable to those reported by other authors
1566 [2,18,19]. Younger children (under 1 year of age) had a higher complication rate (47.4%) than older cases (26.3%), as in other series [11,13,15], in which complication rates of 63, 64 and 70%, respectively, were observed in children belonging to the same age group. The much higher rate of complications in younger children seems to be related to the narrow inner radius of the small and very pliable trachea. In fact, the airflow through a tube depends on the fourth power of the radius exponentially, if viscosity is constant and dynamic. The airway diameter at 6 months of age is 6 mm. Therefore, even a slight reduction of the endotracheal diameter can potentially obstruct the airway. In addition, some authors observed that almost half of the patients under 1 year of age suffer from a bronchopulmonary dysplasia, which prompts the development of viscous and abundant bronchial secretion, thus increasing the risk of significant early and long-term tracheal complications [12,20]. No early and/or life-threatening complications (such as fatal cannula obstruction or accidental decannulation) were observed in the present study, perhaps because tracheostomies were never urgently performed, as required in patients with acute airway infection. The increase in the rate of late complications is presumably related to the increase of cannulation period after tracheostomy in patients with neuromuscular diseases, chronic respiratory problems and subglottic stenosis [4,7,11,21]. In our study, neurologically impaired children could not be decannulated, due to their chronic condition and to their high mortality rate (related to the primary illness). We considered all granulations in the tracheal lumen or stoma as complication, but they are so common and harmless that some authors do not consider them such, unless they compromise the airway. The same authors believe that granulations are more correctly listed as sequelae, since no proven technique is able to prevent this occurrence [22,23]. Again, some authors observed that in children who wear their tracheostomy for over 2 years, a persistent tracheocutaneous fistula is more likely [4]. For such reason, listing tracheocutaneous fistula as a complication should be reconsidered, being a known and expected outcome of this procedure, especially in long-term tracheostomized patients. Additionally, the adoption of newer techniques that mature the stoma with sutures to the skin (such as starplasty tracheostomy) increase the incidence of this complication. In fact, the drawback of this technique, which proves to reduce the incidence of major complications including pneumothorax and
C. Parrilla et al. accidental decannulation, is that a secondary reconstruction of a tracheocutaneous fistula is then required [24,25]. In conclusion, the prolonged period before decannulation (months or years) observed over the past few decades has entailed an increase of late complications such as persistent tracheocutaneous fistulae and stomal or tracheal granulomas, that should presently be considered as sequelae of this surgical procedure rather than complications. The change of indications has also determined a lower average age among children who require tracheostomy, thus increasing the complication rate related to paediatric tracheostomies.
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