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Pediatric tracheostomy: Long-term evaluation
Pediatric Tracheostomy: Long-Term Evaluation By Bradley M. Rodgers, J. James Rooks, and James L. Talbert Gainesville, Florida 9 Considerable debate exists in the literature concerning the immediate and long-term risks of tracheostomy in the pediatric age group. Much has been written of the hazards of decannulation in these patients. A review of the experience of tracheostomy in patients under 18 yr of age at the Shands Teaching Hospital was undertaken. One hundred and eight children underwent tracheostomy between January, 1 9 6 7 , and August, 1 9 7 6 . There w e r e 7 4 males and 3 4 females. Twenty-eight patients (27 % ) w e r e less than 30 days of age at the time of tracheostomy and 68 (63 % ) w e r e less than 1 yr of age. The indications for tracheostomy w e r e varied, but 73 w e r e performed because of mechanical airway obstruction or respiratory insufficiency. The vast majority (106) were performed on an elective basis and most of the cannulas employed w e r e either silastic or polyvinyl chloride (88). Complications of tracheostomy were minor with 11 instances of pneumomediastinum or pneumothorax. Two patients have developed secondary tracheal stenosis that may have been caused by the tracheostomy. The overall mortality was 4 4 % with 7 patients succumbing from complications of the tracheostomy itself. Four of these were in homemanaged patients. Forty-four of 49 patients considered candidates for decannulation have been successfully extubated. Tracheostomy in the pediatric age group appears to be well-tolerated as long as meticulous care is taken in the performance of the procedure and in follow-up, Decannulation has not been a significant problem in our series. INDEX WORDS: Pediatric tracheostomy.
is one of the most T RACHEOSTOMY ancient procedures in the surgical armamentarium. In spite of its obvious life-saving capabilities in many cases, there remains a reluctance on the part of some pediatricians to utilize tracheostomy because of concern about the From the Department of Surgery, University of Florida College of Medicine, Division of Pediatric Surgery, Gainesville, Fla. Presented before the 27th Annual Meeting of the Surgical Section of the American Academy of Pediatrics, Chicago, Illinois, October 22-23, 1978. Address reprint requests to Bradley M. Rodgers, M.D., Department of Surgery, University of Florida College of Medicine, Division of Pediatric Surgery, Box J-286, JHM Health Center, Gainesville, Fla. 32610. 9 1979 by Grune & Stratton, Inc. 0022-3468/79/1403~)008501.00/0 258
reported high rate of complications and difficulty in achieving decannulation in young patients. A review of the experience with tracheostomy in patients under 18 yr of age at the W. A. Shands Teaching Hospital of the University of Florida serves as the basis of the present report. A retrospective analysis was made of records of all children undergoing tracheostomy between January, 1967, and August, 1976, thereby allowing a minimum follow-up of 24 mo after the performance of the tracheostomy. MATERIALS AND METHODS Successfu] tracheostomy in infants and children requires meticulous attention to surgical details. Ideally, the procedure should be performed in elective fashion with preoperative airway control. Only in cases of severe trauma or inflammation where endotracheal intubation may prove impossible should an emergency tracheostomy without such control be undertaken. Most procedures should be performed in an operating room or a well-equipped pediatric intensive care unit, with the benefit of anesthesia assistance. The patient should be placed in a position of moderate hyperextension. Care should be taken in small infants to avoid extreme hyperextension of the neck, which often pulls the intrathoracic trachea into the operative field. The low tracheotomy incision that may result from this derrangement often enhances subsequent displacement of the tracheostomy cannula. The neck is prepared with antiseptic solution and draped with the infant's head left uncovered. A small transverse incision is made in a neck crease, midway between the larynx and suprasternal notch, and blunt dissection is used to identify the pretracheal fascia. This fascia is carefully elevated and opened in the midline vertically to expose the trachea. Rarely is anything more than simple cephalad retraction of the isthmus of the thyroid necessary. A vertical tracheotomy incision is preferred, traversing the second, third, and fourth tracheal rings in the midline. The endotracheal tube is then withdrawn to the proximal border of the tracheotomy and the margins of the stoma are reflected laterally by small hook retractors. A silastic cannula is placed carefully under direct vision and immediate confirmation of proper placement is made by passage of a small suction catheter into the distal tracheo-bronchial tree and by listening for airway noises with chest compression. Meticulous hemostasis should be achieved and the skin edges left unapproximated. The tracheostomy tube should be securely tied with the infant's neck in a flexed position to avoid subsequent dislodgement. The tapes should be inspected within 4 hr of completion of the procedure to confirm proper tension. For the first 7 days post-tracheostomy, the infant should be maintained in an intensive care facility with close
Journal of Pediatric Surgery, Vol. 14, No. 3 (June), 1979
PEDIATRIC TRACHEOSTOMY
259
mo. There were 68 patients (63%) 12 mo of age or younger at the time of the performance of the tracheostomy, with 28 procedures performed in newborn infants (Fig. 1). There were 106 procedures performed on an elective basis, either within the operating room or the pediatric intensive care unit. Of these patients, 84 (79%) had the benefit of airway control prior to the performance of the tracheostomy, either by the use of an endotracheal tube or a bronchoscope. In the most recent years included in this review, almost all elective procedures have been accomplished with airway control. Two patients underwent emergency tracheostomy, both without preoperative airway control. The indications for tracheostomy in this entire group of patients were divided into five major categories: mechanical airway obstruction, secretory obstruction, neuromuscular disorders, respiratory failure, and prophylactic tracheostomy. There were 31 patients, 29% of the entire series, who underwent tracheostomy for mechanical airway obstruction (Fig. 2A). The median age of these patients at the time of tracheostomy was 2 too. Thirteen of these patients underwent the procedure as newborn infants, most for the treatment of congenital airway narrowing. The older children in this group underwent tracheostomy for such problems as laryngeal papillomatosis, Pierre-Robin syndrome, oropharyngeal hemangiomas, or cystic hygromas. Three patients within this group have been lost to follow-up. Eight patients have expired, four of complications directly related to the tracheostomy. Three of the four deaths occurred suddenly
nursing observation. Humidified oxygen should be provided and suctioning with sterile suction catheters used as indicated. The child should be nursed with a small cloth roll between his shoulders, in mild hyperextension, to avoid occlusion of the tracheostomy cannula by redundant neck tissues. A duplicate tracheostomy tube and tracheostomy instruments should be maintained at the bedside. Proper long-term follow-up of these patients requires repeated bronchoscopic evaluations and resection or cryotherapy of granulation tissues as it develops, either at the proximal border of the tracheostomy stoma or distally at the tip of the tracheostomy cannula. Often this tissue may be resected readily by passing instruments through the tracheostomy stoma and working under direct vision through the endoscope. By resecting this tissue before it becomes bulky and organized, significant obstruction in these regions is prevented. When the patient is considered ready for decannulation, elective admission to the hospital is arranged and complete airway endoscopy performed. In the absence of mechanical airway obstruction in the form of residual stenoses, granulation tissue, or tracheoma[acia, the patient is admitted to lhe intensive care unit and the tracheostomy cannula removed. Attempts at plugging the cannula are inappropriate in small patients in whom the tracheostomy cannula itself may occupy the majority of the airway. The tracheostomy stoma is left unobstructed for the first 24 hr following decannu[ation and then is covered with a light dressing. CLINICAL
EXPERIENCE
Between January, 1967 and August, 1976, 108 patients under the age of 18 yr underwent tracheostomy at the University of Florida. Most of these procedures were performed by resident physicians under close supervision of the attending staff of three surgical divisions: Pediatric Surgery, Otolaryngology, and Cardiovascular Surgery. There were 74 male and 34 female patients within this group. The median age of these patients at the time of tracheostomy was 7
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Fig. 1. Long-term follow-up of 108 pediatric patients who received a tracheostomy over a 91/z-yr period at the University of Florida.
260
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in children who had been discharged from the hospital with their tracheostomies in place and were presumed to be secondary to airway obstruction occurring at home. The fourth patient had undergone several stenting procedures for severe congenital subglottic stricture and died in the postoperative period following one of these operations. Of the remaining 20 patients who were candidates for removal of the tracheostomy, 17 (85%) have been successfully decannulated without significant difficulty. Only three patients in this group remain intubated because of failure to relieve their primary obstruction. Two of these patients have congenital subglottic stenoses and are currently under
treatment while the third is a child who has continued with a tracheostomy for 61/2 yr while undergoing cryosurgery for laryngeal papillomatosis. Four patients (4%) underwent tracheostomy for secretory obstruction (Fig. 2B). Most of these patients were in an older age group and two had cystic fibrosis. Two of these patients have succumbed to their primary diseases and their deaths were completely unrelated to the presence of a tracheostomy. The remaining two have been successfully decannulated. Twenty-seven patients, 25% of the entire series, underwent tracheostomy primarily f o r management of neuromuscular disorders (Fig.
PEDIATRIC TRACHEOSTOMY
2C). As with those patients undergoing the procedure for secretory obstruction, most of these patients fell within an older age group, with a median age of 7 yr. Many of the individuals requiring tracheostomy were comatose as a result of cerebral trauma or intracranial neoplasms, although other indications included spinal cord trauma, myesthenia gravis, and Guillain-Barre syndrome. Six of these patients were transferred to chronic care facilities in communities closer to their homes and have been lost to adequate follow-up by our institution. Eight patients in this group died of their primary diseases. In all instances, these deaths were completely unrelated to the presence of the tracheostomy. Of the remaining 13 patients considered candidates for removal of the tracheostomy tube, 12 (92%) have been successfully decannulated without difficulty. A single patient who underwent tracheostomy at age 5 yr for cerebral trauma remains intubated, having recently returned to our attention after being lost to follow-up for 4 yr. Forty-two patients (39%) underwent tracheostomy for respiratory insufficiency (Fig. 2D). The median age in this group of patients was 3 mo, with 14 of these procedures (33%) performed in newborn patients. The primary indications for the procedure were respiratory distress syndrome or postoperative respiratory insufficiency. Three of these patients have been lost to follow-up and 29 patients (69%) have succumbed to their primary disease. Of these deaths, three were considered related to the presence of a tracheostomy. Two of these infants had undergone tracheostomy for respiratory insufficiency following cardiac procedures for complex congenital anomalies. Both of these infants suffered cardiac arrest during tracheostomy suctioning in the intensive care unit and could not be resuscitated. A third infant had a tracheostomy for relief of respiratory insufficiency following correction of a duodenal atresia. This child, who had been discharged to home care at 3 mo of age with a tracheostomy in place, was found dead in her crib 3 mo later, presumably of airway obstruction. Of the remaining 10 patients, all but one have been successfully extubated at the present time. The single patient still intubated underwent tracheostomy at age 1 mo for respiratory insufficiency, following surgery
261
for necrotizing enterocolitis. He remains intubated presently, 35/12yr later, because of persistent severe tracheomalacia. Four patients (4%) underwent prophylactic tracheostomy prior to surgery for massive head and neck tumors or complicated cardiac defects (Fig. 2E). All of these patients were successfully extubated in the postoperative period and none have demonstrated long-term sequelae of the procedure. In reviewing the entire series of 108 patients, 11 early complications of tracheostomy were identified in 8 patients. Isolated pneumomediastinum or subcutaneous emphysema was encountered in four patients and resolved spontaneously, without specific therapy. Pneumothorax was seen in five patients following tracheostomy, with a bilateral pneumothorax in one instance. All of these patients had undergone tracheostomy on an elective basis and all had airway control prior to the performance of the procedure. In only four instances have the pneumothoraces been sufficiently large to require chest tube insertion and all of these patients were being maintained on positive pressure ventilation. Three of the patients developing pneumothorax were 1 yr of age or younger at the time of tracheostomy. Two patients, 6 wk and 1 yr of age at the time of tracheostomy, had displacement of the tracheostomy cannula in the immediate postoperative period. In both cases, displacement was noted immediately and the cannula was reinserted without difficulty. Eight patients developed late complications considered secondary to the tracheostomy. One patient, a 5-yr-otd boy who underwent primary tracheostomy for cerebral trauma after 16 days of endotracheal intubation, developed a severe subglottic stricture. This patient has only recently returned to our attention after being lost to follow-up at our institution for 4 yr. Active therapy for this stricture has been instituted. The child continues to have a tracheostomy. One 6-yr-old patient who underwent tracheostomy for severe cerebral trauma developed significant granulation tissue at the site of the tracheostomy stoma and was noted to have respiratory stridor following extubation. A cuffed metal tracheostomy tube had been employed in this patient and bronchoscopy was not performed prior to extubation. Both of these factors undoubtedly contributed to the
RODGERS, ROOKS, AND TALBERT
262
development of this complication. No other tracheal strictures following tracheostomy have ben identified in this group of patients, despite careful follow-up for a median of 5 yr following decannulation. Six patients had persistent tracheocutaneous fistulae that required later surgical revision. Three of these patients were less than one year of age at the time of tracheostomy and all had had a tracheostomy for seven months or longer. In 4 patients, a silastic tracheostomy tube had been employed and in 2, metallic tubes were used. DISCUSSION
Although recommended sporadically by the ancients, tracheostomy had earned the reputation as the "scandal of surgery" by the early Renaissance period. ~ In spite of dramatic improvements in operative technique and better cannula design and materials, many myths persist regarding tracheostomy, often without strict scientific basis. Recently, attempts have been made to place this operation in proper perspective and several large collective series have been reported. Meaningful comparisons between these various reports are extraordinarily difficult because of differences in the indications for tracheostomy, patient population, and definitions of complications. A review of our series indicates that tracheostomies performed primarily for mechanical airway obstruction or respiratory insufficiency will include a greater proportion of newborns and small infants. Patients within these groups often harbor multiple congenital anomalies, thereby increasing the expected mortality rate. In addition, with increasing skills in the management of endotracheal intubation in these young patients, subsequent complications of this technique have been considerably reduced and tracheostomy is reserved for a very select and critically ill patient population. The overall mortality in our patients of 44% compares favorably with the series reported by Hawkins and Williams 2 and reflects the high incidence of tracheostomy in patients under the age of a year in our hospital. On the other hand, the series of Oliver et al. 3 reports an overall mortality of 20%, but includes a greater proportion of older children with pulmonary infections, patients less likely to succumb to their
underlying diseases. In only 7 of our patients was death considered related to the tracheostomy, giving a 6.5% incidence of mortality from the procedure itself. Four (57%) of these tracheostomy-related deaths occurred in patients managed at home by parents or guardians. A total of 27 of our young patients with tracheostomies, 25% of the entire series, have been managed outside of the hospital setting. This incidence is higher than that reported in most series of pediatric patients. We have emphasized home management of infants and children with tracheostomy because of the economic and social needs of our rural families and the psychologic and emotional needs of these young patients. Home management of these patients is attempted only after the parent or guardian has been carefully instructed in proper tracheostomy management prior to discharge from the hospital. These individuals are taught the techniques of sterile suctioning as well as changing of the tracheostomy tubes. In most cases, they spend 2 to 7 days on an ambulatory care unit under the supervision of nurseclinicians as they learn to be self-sufficient in the care of their child's tracheostomy. Close followup is maintained after discharge using local public health nurses as well as return visits to our outpatient clinic. In spite of the fact that 21 of these patients underwent tracheostomy for mechanical airway obstruction, complications within this group of patients have been minimal. Four patients succumbed suddenly at home, presumably from acute airway obstruction. All of these patients had their tracheostomies performed at 3 mo of age or younger, 3 for mechanical airway obstruction. Three patients succumbed within 6 mo and the fourth within a year following discharge from the hospital. The ages of these patients correspond quite closely with the age considered to be at risk by Okamoto et al. in their careful analysis of home care deaths in pediatric tracheostomy patients. 4 Nonetheless, the risk of home management appears somewhat lessened, when one considers that two other infants in our series succumbed while being suctioned within the pediatric intensive care unit under maximal supervision. The complication rate noted in our series of patients is considerably less than that experienced in several other pediatric series 5'6 and is directly attributable to careful attention to the
PEDIATRIC TRACHEOSTOMY
263
details of the technique of tracheostomy and close follow-up in these young patients. Although all of the procedures in which complications were encountered were performed on an elective basis, 3 of the patients developing pneumothorax were 1 yr of age or less. It is this group of small patients in whom it is especially important to confine surgical dissection to the tissues immediately overlying the trachea. The two patients in whom displaced cannuli were encountered also were within this young age group. It is extremely important in this group to avoid extreme hyperextension of the neck with a subsequent low-lying tracheotomy incision. With flexion of the neck following the operative procedure, displacement of the tracheostomy cannula is enhanced by a tracheotomy in this position. The success in decannulation of 90% of our patients without difficulty indicates that this aspect of tracheostomy is less complicated and hazardous than many series would suggest. 7'8 As with the performance of the original tracheostomy, strict adherence to a routine is necessary to achieve successful decannulation. We believe that plugging the tracheostomy tube is hazardous in these patients and serial reductions in cannula size unnecessary. The simple removal of the tube under close nursing supervision, leaving the tracheostomy stoma unobstructed as an accessory airway, has been successful in achieving decannulation in all of our young patients. Despite close long-term follow-up, late conse-
quences of tracheostomy in these pediatric patients have been minimal. The two instances of persistent airway strictures associated with tracheostomy are attributable to deviations from ideal follow-up management in these patients. The six patients with persistent tracheo-cutaneous fistulae have been easily managed with excellent cosmetic results. These patients are admitted to the hospital for elective bronchoscopy prior to closure of the fistula, to rule out upper airway obstruction. The fistula is then excised with a transverse elliptical incision and the anterior wall of the trachea closed with absorbable suture material. In summary, a properly-performed tracheostomy appears to be well tolerated in the pediatric patient. Complications of the procedure should be minimal and should relate more to technical misadventure than to the age of the patient undergoing operation. Although the overall mortality rate of patients undergoing tracheostomy is considerable, the vast majority of these patients succumb to the primary disease and in only a small percentage is death attributable to the tracheostomy itself. A review of our experience indicates that home management is safe and frequently presents a preferable alternative for the pediatric patient. With proper attention to the details of operative technique and close follow-up, including repeated endoscopic evaluation, long-term sequelae of tracheostomy are uncommon.
REFERENCES
1. Nelson TG: Tracheotomy: A Clinical and Experimental Study. Baltimore, Williams & Wilkins, 1958, pp 1 13 2. Hawkins DB, Williams EH: Tracheostomy in infants and young children. Laryngoscope86:331-340, 1976 3. Oliver P, Richardson JR, Clubb RW, et al: Tracheotomy in children. N Engl J Med 267:631-637, 1962 4. Okamoto E, Fee WE, Boles R, et al: Safety of hospital vs home care of infant tracheotomies. Trans Am Acad Ophthal Otolaryngol 84:92 99, 1977 5. Perrotta R J, Schley WS: Pediatric tracheotomy: A
five-yearcomparison study. Arch Otolaryngol 104:318-321, 1978 6. Tucker JA, Silberman HD: Tracheotomyin pediatrics. Ann Oto181:818 824, 1972 7. Lewis RS, Ludman H: Decannulation after tracheostomy in infants and young children. J LaryngolOtol 79:435441, 1965 8. Sasaki CT, Daudet PT, Peerless A: Tracheostomy decannulation. Am J Dis Child 132:266-269, 1978
is one of the most T RACHEOSTOMY ancient procedures in the surgical armamentarium. In spite of its obvious life-saving capabilities in many cases, there remains a reluctance on the part of some pediatricians to utilize tracheostomy because of concern about the From the Department of Surgery, University of Florida College of Medicine, Division of Pediatric Surgery, Gainesville, Fla. Presented before the 27th Annual Meeting of the Surgical Section of the American Academy of Pediatrics, Chicago, Illinois, October 22-23, 1978. Address reprint requests to Bradley M. Rodgers, M.D., Department of Surgery, University of Florida College of Medicine, Division of Pediatric Surgery, Box J-286, JHM Health Center, Gainesville, Fla. 32610. 9 1979 by Grune & Stratton, Inc. 0022-3468/79/1403~)008501.00/0 258
reported high rate of complications and difficulty in achieving decannulation in young patients. A review of the experience with tracheostomy in patients under 18 yr of age at the W. A. Shands Teaching Hospital of the University of Florida serves as the basis of the present report. A retrospective analysis was made of records of all children undergoing tracheostomy between January, 1967, and August, 1976, thereby allowing a minimum follow-up of 24 mo after the performance of the tracheostomy. MATERIALS AND METHODS Successfu] tracheostomy in infants and children requires meticulous attention to surgical details. Ideally, the procedure should be performed in elective fashion with preoperative airway control. Only in cases of severe trauma or inflammation where endotracheal intubation may prove impossible should an emergency tracheostomy without such control be undertaken. Most procedures should be performed in an operating room or a well-equipped pediatric intensive care unit, with the benefit of anesthesia assistance. The patient should be placed in a position of moderate hyperextension. Care should be taken in small infants to avoid extreme hyperextension of the neck, which often pulls the intrathoracic trachea into the operative field. The low tracheotomy incision that may result from this derrangement often enhances subsequent displacement of the tracheostomy cannula. The neck is prepared with antiseptic solution and draped with the infant's head left uncovered. A small transverse incision is made in a neck crease, midway between the larynx and suprasternal notch, and blunt dissection is used to identify the pretracheal fascia. This fascia is carefully elevated and opened in the midline vertically to expose the trachea. Rarely is anything more than simple cephalad retraction of the isthmus of the thyroid necessary. A vertical tracheotomy incision is preferred, traversing the second, third, and fourth tracheal rings in the midline. The endotracheal tube is then withdrawn to the proximal border of the tracheotomy and the margins of the stoma are reflected laterally by small hook retractors. A silastic cannula is placed carefully under direct vision and immediate confirmation of proper placement is made by passage of a small suction catheter into the distal tracheo-bronchial tree and by listening for airway noises with chest compression. Meticulous hemostasis should be achieved and the skin edges left unapproximated. The tracheostomy tube should be securely tied with the infant's neck in a flexed position to avoid subsequent dislodgement. The tapes should be inspected within 4 hr of completion of the procedure to confirm proper tension. For the first 7 days post-tracheostomy, the infant should be maintained in an intensive care facility with close
Journal of Pediatric Surgery, Vol. 14, No. 3 (June), 1979
PEDIATRIC TRACHEOSTOMY
259
mo. There were 68 patients (63%) 12 mo of age or younger at the time of the performance of the tracheostomy, with 28 procedures performed in newborn infants (Fig. 1). There were 106 procedures performed on an elective basis, either within the operating room or the pediatric intensive care unit. Of these patients, 84 (79%) had the benefit of airway control prior to the performance of the tracheostomy, either by the use of an endotracheal tube or a bronchoscope. In the most recent years included in this review, almost all elective procedures have been accomplished with airway control. Two patients underwent emergency tracheostomy, both without preoperative airway control. The indications for tracheostomy in this entire group of patients were divided into five major categories: mechanical airway obstruction, secretory obstruction, neuromuscular disorders, respiratory failure, and prophylactic tracheostomy. There were 31 patients, 29% of the entire series, who underwent tracheostomy for mechanical airway obstruction (Fig. 2A). The median age of these patients at the time of tracheostomy was 2 too. Thirteen of these patients underwent the procedure as newborn infants, most for the treatment of congenital airway narrowing. The older children in this group underwent tracheostomy for such problems as laryngeal papillomatosis, Pierre-Robin syndrome, oropharyngeal hemangiomas, or cystic hygromas. Three patients within this group have been lost to follow-up. Eight patients have expired, four of complications directly related to the tracheostomy. Three of the four deaths occurred suddenly
nursing observation. Humidified oxygen should be provided and suctioning with sterile suction catheters used as indicated. The child should be nursed with a small cloth roll between his shoulders, in mild hyperextension, to avoid occlusion of the tracheostomy cannula by redundant neck tissues. A duplicate tracheostomy tube and tracheostomy instruments should be maintained at the bedside. Proper long-term follow-up of these patients requires repeated bronchoscopic evaluations and resection or cryotherapy of granulation tissues as it develops, either at the proximal border of the tracheostomy stoma or distally at the tip of the tracheostomy cannula. Often this tissue may be resected readily by passing instruments through the tracheostomy stoma and working under direct vision through the endoscope. By resecting this tissue before it becomes bulky and organized, significant obstruction in these regions is prevented. When the patient is considered ready for decannulation, elective admission to the hospital is arranged and complete airway endoscopy performed. In the absence of mechanical airway obstruction in the form of residual stenoses, granulation tissue, or tracheoma[acia, the patient is admitted to lhe intensive care unit and the tracheostomy cannula removed. Attempts at plugging the cannula are inappropriate in small patients in whom the tracheostomy cannula itself may occupy the majority of the airway. The tracheostomy stoma is left unobstructed for the first 24 hr following decannu[ation and then is covered with a light dressing. CLINICAL
EXPERIENCE
Between January, 1967 and August, 1976, 108 patients under the age of 18 yr underwent tracheostomy at the University of Florida. Most of these procedures were performed by resident physicians under close supervision of the attending staff of three surgical divisions: Pediatric Surgery, Otolaryngology, and Cardiovascular Surgery. There were 74 male and 34 female patients within this group. The median age of these patients at the time of tracheostomy was 7
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Fig. 1. Long-term follow-up of 108 pediatric patients who received a tracheostomy over a 91/z-yr period at the University of Florida.
260
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in children who had been discharged from the hospital with their tracheostomies in place and were presumed to be secondary to airway obstruction occurring at home. The fourth patient had undergone several stenting procedures for severe congenital subglottic stricture and died in the postoperative period following one of these operations. Of the remaining 20 patients who were candidates for removal of the tracheostomy, 17 (85%) have been successfully decannulated without significant difficulty. Only three patients in this group remain intubated because of failure to relieve their primary obstruction. Two of these patients have congenital subglottic stenoses and are currently under
treatment while the third is a child who has continued with a tracheostomy for 61/2 yr while undergoing cryosurgery for laryngeal papillomatosis. Four patients (4%) underwent tracheostomy for secretory obstruction (Fig. 2B). Most of these patients were in an older age group and two had cystic fibrosis. Two of these patients have succumbed to their primary diseases and their deaths were completely unrelated to the presence of a tracheostomy. The remaining two have been successfully decannulated. Twenty-seven patients, 25% of the entire series, underwent tracheostomy primarily f o r management of neuromuscular disorders (Fig.
PEDIATRIC TRACHEOSTOMY
2C). As with those patients undergoing the procedure for secretory obstruction, most of these patients fell within an older age group, with a median age of 7 yr. Many of the individuals requiring tracheostomy were comatose as a result of cerebral trauma or intracranial neoplasms, although other indications included spinal cord trauma, myesthenia gravis, and Guillain-Barre syndrome. Six of these patients were transferred to chronic care facilities in communities closer to their homes and have been lost to adequate follow-up by our institution. Eight patients in this group died of their primary diseases. In all instances, these deaths were completely unrelated to the presence of the tracheostomy. Of the remaining 13 patients considered candidates for removal of the tracheostomy tube, 12 (92%) have been successfully decannulated without difficulty. A single patient who underwent tracheostomy at age 5 yr for cerebral trauma remains intubated, having recently returned to our attention after being lost to follow-up for 4 yr. Forty-two patients (39%) underwent tracheostomy for respiratory insufficiency (Fig. 2D). The median age in this group of patients was 3 mo, with 14 of these procedures (33%) performed in newborn patients. The primary indications for the procedure were respiratory distress syndrome or postoperative respiratory insufficiency. Three of these patients have been lost to follow-up and 29 patients (69%) have succumbed to their primary disease. Of these deaths, three were considered related to the presence of a tracheostomy. Two of these infants had undergone tracheostomy for respiratory insufficiency following cardiac procedures for complex congenital anomalies. Both of these infants suffered cardiac arrest during tracheostomy suctioning in the intensive care unit and could not be resuscitated. A third infant had a tracheostomy for relief of respiratory insufficiency following correction of a duodenal atresia. This child, who had been discharged to home care at 3 mo of age with a tracheostomy in place, was found dead in her crib 3 mo later, presumably of airway obstruction. Of the remaining 10 patients, all but one have been successfully extubated at the present time. The single patient still intubated underwent tracheostomy at age 1 mo for respiratory insufficiency, following surgery
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for necrotizing enterocolitis. He remains intubated presently, 35/12yr later, because of persistent severe tracheomalacia. Four patients (4%) underwent prophylactic tracheostomy prior to surgery for massive head and neck tumors or complicated cardiac defects (Fig. 2E). All of these patients were successfully extubated in the postoperative period and none have demonstrated long-term sequelae of the procedure. In reviewing the entire series of 108 patients, 11 early complications of tracheostomy were identified in 8 patients. Isolated pneumomediastinum or subcutaneous emphysema was encountered in four patients and resolved spontaneously, without specific therapy. Pneumothorax was seen in five patients following tracheostomy, with a bilateral pneumothorax in one instance. All of these patients had undergone tracheostomy on an elective basis and all had airway control prior to the performance of the procedure. In only four instances have the pneumothoraces been sufficiently large to require chest tube insertion and all of these patients were being maintained on positive pressure ventilation. Three of the patients developing pneumothorax were 1 yr of age or younger at the time of tracheostomy. Two patients, 6 wk and 1 yr of age at the time of tracheostomy, had displacement of the tracheostomy cannula in the immediate postoperative period. In both cases, displacement was noted immediately and the cannula was reinserted without difficulty. Eight patients developed late complications considered secondary to the tracheostomy. One patient, a 5-yr-otd boy who underwent primary tracheostomy for cerebral trauma after 16 days of endotracheal intubation, developed a severe subglottic stricture. This patient has only recently returned to our attention after being lost to follow-up at our institution for 4 yr. Active therapy for this stricture has been instituted. The child continues to have a tracheostomy. One 6-yr-old patient who underwent tracheostomy for severe cerebral trauma developed significant granulation tissue at the site of the tracheostomy stoma and was noted to have respiratory stridor following extubation. A cuffed metal tracheostomy tube had been employed in this patient and bronchoscopy was not performed prior to extubation. Both of these factors undoubtedly contributed to the
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development of this complication. No other tracheal strictures following tracheostomy have ben identified in this group of patients, despite careful follow-up for a median of 5 yr following decannulation. Six patients had persistent tracheocutaneous fistulae that required later surgical revision. Three of these patients were less than one year of age at the time of tracheostomy and all had had a tracheostomy for seven months or longer. In 4 patients, a silastic tracheostomy tube had been employed and in 2, metallic tubes were used. DISCUSSION
Although recommended sporadically by the ancients, tracheostomy had earned the reputation as the "scandal of surgery" by the early Renaissance period. ~ In spite of dramatic improvements in operative technique and better cannula design and materials, many myths persist regarding tracheostomy, often without strict scientific basis. Recently, attempts have been made to place this operation in proper perspective and several large collective series have been reported. Meaningful comparisons between these various reports are extraordinarily difficult because of differences in the indications for tracheostomy, patient population, and definitions of complications. A review of our series indicates that tracheostomies performed primarily for mechanical airway obstruction or respiratory insufficiency will include a greater proportion of newborns and small infants. Patients within these groups often harbor multiple congenital anomalies, thereby increasing the expected mortality rate. In addition, with increasing skills in the management of endotracheal intubation in these young patients, subsequent complications of this technique have been considerably reduced and tracheostomy is reserved for a very select and critically ill patient population. The overall mortality in our patients of 44% compares favorably with the series reported by Hawkins and Williams 2 and reflects the high incidence of tracheostomy in patients under the age of a year in our hospital. On the other hand, the series of Oliver et al. 3 reports an overall mortality of 20%, but includes a greater proportion of older children with pulmonary infections, patients less likely to succumb to their
underlying diseases. In only 7 of our patients was death considered related to the tracheostomy, giving a 6.5% incidence of mortality from the procedure itself. Four (57%) of these tracheostomy-related deaths occurred in patients managed at home by parents or guardians. A total of 27 of our young patients with tracheostomies, 25% of the entire series, have been managed outside of the hospital setting. This incidence is higher than that reported in most series of pediatric patients. We have emphasized home management of infants and children with tracheostomy because of the economic and social needs of our rural families and the psychologic and emotional needs of these young patients. Home management of these patients is attempted only after the parent or guardian has been carefully instructed in proper tracheostomy management prior to discharge from the hospital. These individuals are taught the techniques of sterile suctioning as well as changing of the tracheostomy tubes. In most cases, they spend 2 to 7 days on an ambulatory care unit under the supervision of nurseclinicians as they learn to be self-sufficient in the care of their child's tracheostomy. Close followup is maintained after discharge using local public health nurses as well as return visits to our outpatient clinic. In spite of the fact that 21 of these patients underwent tracheostomy for mechanical airway obstruction, complications within this group of patients have been minimal. Four patients succumbed suddenly at home, presumably from acute airway obstruction. All of these patients had their tracheostomies performed at 3 mo of age or younger, 3 for mechanical airway obstruction. Three patients succumbed within 6 mo and the fourth within a year following discharge from the hospital. The ages of these patients correspond quite closely with the age considered to be at risk by Okamoto et al. in their careful analysis of home care deaths in pediatric tracheostomy patients. 4 Nonetheless, the risk of home management appears somewhat lessened, when one considers that two other infants in our series succumbed while being suctioned within the pediatric intensive care unit under maximal supervision. The complication rate noted in our series of patients is considerably less than that experienced in several other pediatric series 5'6 and is directly attributable to careful attention to the
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details of the technique of tracheostomy and close follow-up in these young patients. Although all of the procedures in which complications were encountered were performed on an elective basis, 3 of the patients developing pneumothorax were 1 yr of age or less. It is this group of small patients in whom it is especially important to confine surgical dissection to the tissues immediately overlying the trachea. The two patients in whom displaced cannuli were encountered also were within this young age group. It is extremely important in this group to avoid extreme hyperextension of the neck with a subsequent low-lying tracheotomy incision. With flexion of the neck following the operative procedure, displacement of the tracheostomy cannula is enhanced by a tracheotomy in this position. The success in decannulation of 90% of our patients without difficulty indicates that this aspect of tracheostomy is less complicated and hazardous than many series would suggest. 7'8 As with the performance of the original tracheostomy, strict adherence to a routine is necessary to achieve successful decannulation. We believe that plugging the tracheostomy tube is hazardous in these patients and serial reductions in cannula size unnecessary. The simple removal of the tube under close nursing supervision, leaving the tracheostomy stoma unobstructed as an accessory airway, has been successful in achieving decannulation in all of our young patients. Despite close long-term follow-up, late conse-
quences of tracheostomy in these pediatric patients have been minimal. The two instances of persistent airway strictures associated with tracheostomy are attributable to deviations from ideal follow-up management in these patients. The six patients with persistent tracheo-cutaneous fistulae have been easily managed with excellent cosmetic results. These patients are admitted to the hospital for elective bronchoscopy prior to closure of the fistula, to rule out upper airway obstruction. The fistula is then excised with a transverse elliptical incision and the anterior wall of the trachea closed with absorbable suture material. In summary, a properly-performed tracheostomy appears to be well tolerated in the pediatric patient. Complications of the procedure should be minimal and should relate more to technical misadventure than to the age of the patient undergoing operation. Although the overall mortality rate of patients undergoing tracheostomy is considerable, the vast majority of these patients succumb to the primary disease and in only a small percentage is death attributable to the tracheostomy itself. A review of our experience indicates that home management is safe and frequently presents a preferable alternative for the pediatric patient. With proper attention to the details of operative technique and close follow-up, including repeated endoscopic evaluation, long-term sequelae of tracheostomy are uncommon.
REFERENCES
1. Nelson TG: Tracheotomy: A Clinical and Experimental Study. Baltimore, Williams & Wilkins, 1958, pp 1 13 2. Hawkins DB, Williams EH: Tracheostomy in infants and young children. Laryngoscope86:331-340, 1976 3. Oliver P, Richardson JR, Clubb RW, et al: Tracheotomy in children. N Engl J Med 267:631-637, 1962 4. Okamoto E, Fee WE, Boles R, et al: Safety of hospital vs home care of infant tracheotomies. Trans Am Acad Ophthal Otolaryngol 84:92 99, 1977 5. Perrotta R J, Schley WS: Pediatric tracheotomy: A
five-yearcomparison study. Arch Otolaryngol 104:318-321, 1978 6. Tucker JA, Silberman HD: Tracheotomyin pediatrics. Ann Oto181:818 824, 1972 7. Lewis RS, Ludman H: Decannulation after tracheostomy in infants and young children. J LaryngolOtol 79:435441, 1965 8. Sasaki CT, Daudet PT, Peerless A: Tracheostomy decannulation. Am J Dis Child 132:266-269, 1978