- Email: [email protected]
Stenosing processes due to endotracheal intubation and tracheostomy in children
International Journal of Pediatric Otorhinolaryngology, ElsevierINorth-Holland Biomedical Press
3 (1981)
199-203
STENOSING PROCESSES DUE TO ENDOTRACHEAL AND TRACHEOSTOMY IN CHILDREN *
199
INTUBATION
0. BLAHOVA and P. BREZOVSKP Children’s ORL Clinics, University of Prague, Prague (Czechoslovakia) (Received June 20th, 1981) (Accepted March 2nd, 1981)
SUMMARY
In 1976-1978 there were 15 children hospitalized in the Children’s ORL Clinics in Prague and treated for larynx trauma caused by long-term endotracheal intubation. Tracheostomy was performed in all cases, the changes in the larynx were mostly treated in a conservative manner. In one instance we used laryngofissura; however, further dilatations had be carried out. With a single exception, all the patients have been healed successfully. Plastic operations were performed to make decannulation easier. INTRODUCTION
Within the past two decades, tracheostomy, formerly the only method applied in the cases of the larynx obstruction, has frequently been substituted by long-term endotracheal intubation. Compared with tracheostomy, intubation is undoubtedly much more advantageous; easy management is the most important trait of the method [ll]. However, agreement has not yet been reached regarding the period of time after which a particular instance of intubation should be called long-term. In our opinion every instance where the endotracheal tube has been left in the respiratory passages for any time longer than that which is necessary for the anesthesia during the operation, can be called long-term intubation. The nature of the complications It was soon discovered that intubation can cause complications in the form of larynx trauma, often with persistent effects. It can be classified into 6 groups 1121: (1) simple edema; (2) ulceration; (3) granulation; (4) damage * Originally presented at the First European Congress of Pediatric Otorhinolaryngology, Warsaw, Poland, in October, 1979. 0165-5876/81/0000-0000/$02.75
@ 1981 Elsevier/North-Holland
Biomedical Press
200
to the glottis membranes; (5) fibrinous adhesion and (6) stenoses. In applying the intubation method, the damage to the larynx can be caused by the following factors [ 91: (1) the respiratory epithelium of the subglottic area is not conditioned to resist long-lasting irritation by a foreign body, and (2) the complete ring of the cricoid cartilage prevents the edema from expending to the surrounding area and thus promotes spreading in the lumen. In children, the edema in this area is particularly dangerous since, for example, in a 12-month-old child the mucous membrane swollen by 1 mm makes the larynx lumen narrower by 50% [l,lO]. The frequency of larynx damage due to intubation is high and lately it has even increased. The general condition and age of the child, respiratory infection, the material of the tube and the intubation time are the decisive factors in the larynx trauma. It is an interesting fact that newborn babies resist intubation best, perhaps because they move only very little [ 3,5]. Out of all types of stenosing laryngitis, acute epiglottitis is the case where intubation is most convenient to apply; the rapidly receding edema and intact larynx make early intubation possible. The situation is more complicated in acute laryngotracheobronchitis. In this case the intubation is likely to aggravate the already existing edema of the subglottic area and thus to cause stenosis. It is for this very reason that intubation may be rejected in these cases and tracheotomy performed instead. As opposed to intubation, larynx trauma cannot arise as the effect of tracheostomy; in the case complications appear, they must be ascribed to an incorrect operational technique [ 1,2], The treatment of the complications caused by intubation depends on the types of these complications, and is carried out either in a conservative or an operational way. The most conservative attitude characterized by the slogan: ‘wait and watch’, is based on two premises: the child will ‘grow out’ of the stenosis and a surgical treatment could interfere with the larynx growth. On the other hand, the larynx obstruction tends to cause minilarynx [8]. General as well as local application of corticosteroids and antibiotics together with dilatation rank among the conservative methods. Dilatations are successful especially in fine membranes in the glottis. The operational treatment can be divided into 6 groups [12] : (1) tracheostomy; (2) endolaryngeal procedures; (3) laryngofissure; (4) arytenoidectomy; (5) chordopexis and (6) resection of the stenosis and anastomosis end to end. Fearon and Cotton [4] see the cause of the problem in the cricoid cartilage. Endolaryngeal stent is something in-between the conservative and operational methods, since it mostly presupposes discission of the stenosis. Having removed the stent, however, it is sometimes necessary to perform dilatations [ 71. MATERIALS
AND METHODS
Within three years (1976-1978) there were 972 children hospitalized in the Children’s ORL Clinics in Prague with the diagnosis of acute laryngo-
tracheobronchitis. As a result of complex treatment and corticotherapy, it was possible to cure most of the children in a conservative manner. In 9 children (0.9%) tracheostomy had to be performed, and 3 children (0.3%) had to be intubated. There was no death record and decannulation never proved difficult. Of the 3 patients to whom endotracheal intubation had been applied, two had to undergo tracheostomy later and soon were decannulated. Within the same period, 12 children had been transferred to our clinic with anamnese including eudotracheal intubation. Out of these, only 3 children did not have any changes in the larynx due to the intubation. The occurrence of complications is seen in Table I. In these children tracheostomy had to be performed. Endoscopic findings in intubated children Using direct laryngoscopy we have found the following pathological changes. This type of complication belongs (1) Edema of the subglottic area. among the simplest damages of the larynx. It persists particularly in the case of altb. We diagnosed the edema in 3 children; relieving tracheostomy was sufficient to cure the edema. At the time of decannulation, all children were under one year of age. This complication was also not very serious. We (2) Membrane glottis. found it in 2 children, 15- and &months of age. Both children were decannulated after dilatation. (3) Paresis of the vocal cord. This complication was found in a 3-yearold child with altb. The paresis probably arises as the consequence of fibrous
TABLE I COMPLICATIONS OF INTUBATION Number of intubations
Length of intubation (days) 2 5 5 6 7 8 9 17 93
210
Laryngeal injury
1 1 1 1
Edema Edema and ulceration Subglottic stenosis Edema and ulceration
1 Subglottic stenosis 1 Glottic membrane 1 DisIoc of an arytenoid cartilge Cicatrical laryngeal stenosis 1 Glottic membrane 1 Vocal cord paralysis
Number of days with tracheostomy in place
5 7 17 9 53 63 To present 244 903
202
changes in the joint. This patient had been intubated for 210 days, which is perhaps a world record. Despite this, we succeeded in decannulation without any surgical action. (4) Stenosis of the subglottic area. The stenosis proved to be a serious problem. The most difficult case was recorded in a 12-year-old patient, who had intubated for a fortnight because of grand mal. Not only did circular stenosis of the subglottic area arise, but also luxation of the cricoarytenoid joint occurred. We tried dilatations, the instilation of corticosteroids into the stenosis and Montgomery’s T-tube, all with quite noticeable success, although unfortunately not sufficient for the purpose of decannulation. In another two children of the suckling age the stenosis arose after intubation due to altb. Here we succeeded with repeated dilatations. In 1979 we cured 6 other children with larynx trauma caused by intubation, using tracheostomy and consequent dilatations. Only in a single case, that of a lo-month-old child, did we cut the stenosis in the subglottic area through the laryngofissure. After the operation, however, we had to perform repeated dilatations which, after 3 months, led finally to decannulation. The plastic operation of the tracheostoma made the decannulation easier in all our patients. This operation is indicated in these cases, where the decannulation is impossible although the larynx had been found free. There are several factors which cause the difficulties, two of them being of most serious import: mechanical irritation of the trachea with granulation formation and retention of the greater amount of the secretion. In these cases we proceed in the following way: prior to decannulation, the elastic cannula is substituted with a metallic one with a so-called ‘speaking window’. In case the child with this cannula blocked is able to breathe through the upper respiratory passage for 24 hours, we perform a circumcision of the tracheostoma, remove the granulations and leave the wound open. The next day after the operation the child is decannulated and stroma is left free to close itself spontaneously. DISCUSSION
Despite the unquestionable advantages intubation offers, frequent complications can be observed in the form of larynx damage. It is necessary to consider the convenience of the endotracheal intubation in the cause of altb. We are of the opinion that in some more serious cases it is better to perform tracheostomy immediately. Thus, intubation applied in the case of acute epiglottitis is the method of choice. The persevering edema of the subglottic area as an effect of endotracheal intubation is mostly cured by tracheostomy; more gross changes require interventions that are a great burden to the child. In these cases, we prefer dilatations and general treatment by corticosteroids to surgical actions. These are often necessary in cases of stenosis of the subglottic area, although they are not always successful. A possible reason why applying stent to our patient was not successful is that the stenosis
203
was tough. Having removed the stent, we found the larynx to be free; the next day, however, the stenosis arose anew to the same extent. In the case of difficult decannulation with free respiratory passages, we recommend plastic operation of the tracheostoma. The success of this method can be explained by the fact that the time which has passed between the revision and the spontaneous healing of the tracheostoma is long enough for the inflammative changes around the cannula to retreat and for the cessation of the secretion which the child has coughed out through the tracheostoma. At any rate, larynx trauma caused by endotracheal intubation brings about great difficulties of treatment, particularly in children, and requires intensive individual care. REFERENCES 1 Baker, D.C., Jr. and Sawetsky, L., Decannulation problems in infants, Ann. Otol. (St. Louis), 81 (1972) 555-557. 2 BlBhova, 0. and Drastik, J., The difficult decannulation in children, Acta Univ. Carol. Med. (Praha), 13 (1967) 215. 3 Bryce, D.P., Briant, T.D.H. and Pearson, F.G., Laryngeal and tracheal complications of incubation, Ann. Otol. (St. Louis), 77 (1968) 442-461. 4 Fearon, B. and Cotton, R., Surgical correction of subglottic stenosis of the larynx in infants and children, Ann. Otol. (St. Louis), 83 (1974) 428-431. 5 Ferlic, R.M., Tracheostomy or endotracheal intubation, Ann. Otol. (St. Louis), 83 (1974) 739-744. 6 Flaum, F.G., Disorders of the Larynx. Current Pediatric Therapy, W.B. Saunders, Philadelphia, 1978. 7 Good, R.I. and Shinn, J.B., Long term stenting in the treatment of subglottic stenosis, Ann. Otol. (St. Louis), 86 (1977) 795-798. 8 Grahne, B., Operative treatment of severe chronic traumatic laryngeal stenosis in infants up to three years old, Acta oto-laryng. (Stockh.), 72 (1971) 134-137. 9 Hilding, A.C., Laryngotracheal damage during intratracheal anesthesia, Ann. Otol. (St. Louis), 80 (1971) 565-581. 10 Holinger, P.H., Kutnick, S.L., Schild, J.A. and Holinger, L.D., Subglottic stenosis in infants and children, Ann. Otol. (St. Louis), 85 (1976) 591-599. 11 Schulz-Coulon, H.J., Langzeit-Intubation oder Tracheotomie bei Kindern, HNO (Berlin), 24 (1976) 283-288. 12 Tonkin, J.P. and Harrison, G.A., The surgical management of the laryngeal complications of prolonged intubation, Laryngoscope (St. Louis), 81 (1971) 297-307.
3 (1981)
199-203
STENOSING PROCESSES DUE TO ENDOTRACHEAL AND TRACHEOSTOMY IN CHILDREN *
199
INTUBATION
0. BLAHOVA and P. BREZOVSKP Children’s ORL Clinics, University of Prague, Prague (Czechoslovakia) (Received June 20th, 1981) (Accepted March 2nd, 1981)
SUMMARY
In 1976-1978 there were 15 children hospitalized in the Children’s ORL Clinics in Prague and treated for larynx trauma caused by long-term endotracheal intubation. Tracheostomy was performed in all cases, the changes in the larynx were mostly treated in a conservative manner. In one instance we used laryngofissura; however, further dilatations had be carried out. With a single exception, all the patients have been healed successfully. Plastic operations were performed to make decannulation easier. INTRODUCTION
Within the past two decades, tracheostomy, formerly the only method applied in the cases of the larynx obstruction, has frequently been substituted by long-term endotracheal intubation. Compared with tracheostomy, intubation is undoubtedly much more advantageous; easy management is the most important trait of the method [ll]. However, agreement has not yet been reached regarding the period of time after which a particular instance of intubation should be called long-term. In our opinion every instance where the endotracheal tube has been left in the respiratory passages for any time longer than that which is necessary for the anesthesia during the operation, can be called long-term intubation. The nature of the complications It was soon discovered that intubation can cause complications in the form of larynx trauma, often with persistent effects. It can be classified into 6 groups 1121: (1) simple edema; (2) ulceration; (3) granulation; (4) damage * Originally presented at the First European Congress of Pediatric Otorhinolaryngology, Warsaw, Poland, in October, 1979. 0165-5876/81/0000-0000/$02.75
@ 1981 Elsevier/North-Holland
Biomedical Press
200
to the glottis membranes; (5) fibrinous adhesion and (6) stenoses. In applying the intubation method, the damage to the larynx can be caused by the following factors [ 91: (1) the respiratory epithelium of the subglottic area is not conditioned to resist long-lasting irritation by a foreign body, and (2) the complete ring of the cricoid cartilage prevents the edema from expending to the surrounding area and thus promotes spreading in the lumen. In children, the edema in this area is particularly dangerous since, for example, in a 12-month-old child the mucous membrane swollen by 1 mm makes the larynx lumen narrower by 50% [l,lO]. The frequency of larynx damage due to intubation is high and lately it has even increased. The general condition and age of the child, respiratory infection, the material of the tube and the intubation time are the decisive factors in the larynx trauma. It is an interesting fact that newborn babies resist intubation best, perhaps because they move only very little [ 3,5]. Out of all types of stenosing laryngitis, acute epiglottitis is the case where intubation is most convenient to apply; the rapidly receding edema and intact larynx make early intubation possible. The situation is more complicated in acute laryngotracheobronchitis. In this case the intubation is likely to aggravate the already existing edema of the subglottic area and thus to cause stenosis. It is for this very reason that intubation may be rejected in these cases and tracheotomy performed instead. As opposed to intubation, larynx trauma cannot arise as the effect of tracheostomy; in the case complications appear, they must be ascribed to an incorrect operational technique [ 1,2], The treatment of the complications caused by intubation depends on the types of these complications, and is carried out either in a conservative or an operational way. The most conservative attitude characterized by the slogan: ‘wait and watch’, is based on two premises: the child will ‘grow out’ of the stenosis and a surgical treatment could interfere with the larynx growth. On the other hand, the larynx obstruction tends to cause minilarynx [8]. General as well as local application of corticosteroids and antibiotics together with dilatation rank among the conservative methods. Dilatations are successful especially in fine membranes in the glottis. The operational treatment can be divided into 6 groups [12] : (1) tracheostomy; (2) endolaryngeal procedures; (3) laryngofissure; (4) arytenoidectomy; (5) chordopexis and (6) resection of the stenosis and anastomosis end to end. Fearon and Cotton [4] see the cause of the problem in the cricoid cartilage. Endolaryngeal stent is something in-between the conservative and operational methods, since it mostly presupposes discission of the stenosis. Having removed the stent, however, it is sometimes necessary to perform dilatations [ 71. MATERIALS
AND METHODS
Within three years (1976-1978) there were 972 children hospitalized in the Children’s ORL Clinics in Prague with the diagnosis of acute laryngo-
tracheobronchitis. As a result of complex treatment and corticotherapy, it was possible to cure most of the children in a conservative manner. In 9 children (0.9%) tracheostomy had to be performed, and 3 children (0.3%) had to be intubated. There was no death record and decannulation never proved difficult. Of the 3 patients to whom endotracheal intubation had been applied, two had to undergo tracheostomy later and soon were decannulated. Within the same period, 12 children had been transferred to our clinic with anamnese including eudotracheal intubation. Out of these, only 3 children did not have any changes in the larynx due to the intubation. The occurrence of complications is seen in Table I. In these children tracheostomy had to be performed. Endoscopic findings in intubated children Using direct laryngoscopy we have found the following pathological changes. This type of complication belongs (1) Edema of the subglottic area. among the simplest damages of the larynx. It persists particularly in the case of altb. We diagnosed the edema in 3 children; relieving tracheostomy was sufficient to cure the edema. At the time of decannulation, all children were under one year of age. This complication was also not very serious. We (2) Membrane glottis. found it in 2 children, 15- and &months of age. Both children were decannulated after dilatation. (3) Paresis of the vocal cord. This complication was found in a 3-yearold child with altb. The paresis probably arises as the consequence of fibrous
TABLE I COMPLICATIONS OF INTUBATION Number of intubations
Length of intubation (days) 2 5 5 6 7 8 9 17 93
210
Laryngeal injury
1 1 1 1
Edema Edema and ulceration Subglottic stenosis Edema and ulceration
1 Subglottic stenosis 1 Glottic membrane 1 DisIoc of an arytenoid cartilge Cicatrical laryngeal stenosis 1 Glottic membrane 1 Vocal cord paralysis
Number of days with tracheostomy in place
5 7 17 9 53 63 To present 244 903
202
changes in the joint. This patient had been intubated for 210 days, which is perhaps a world record. Despite this, we succeeded in decannulation without any surgical action. (4) Stenosis of the subglottic area. The stenosis proved to be a serious problem. The most difficult case was recorded in a 12-year-old patient, who had intubated for a fortnight because of grand mal. Not only did circular stenosis of the subglottic area arise, but also luxation of the cricoarytenoid joint occurred. We tried dilatations, the instilation of corticosteroids into the stenosis and Montgomery’s T-tube, all with quite noticeable success, although unfortunately not sufficient for the purpose of decannulation. In another two children of the suckling age the stenosis arose after intubation due to altb. Here we succeeded with repeated dilatations. In 1979 we cured 6 other children with larynx trauma caused by intubation, using tracheostomy and consequent dilatations. Only in a single case, that of a lo-month-old child, did we cut the stenosis in the subglottic area through the laryngofissure. After the operation, however, we had to perform repeated dilatations which, after 3 months, led finally to decannulation. The plastic operation of the tracheostoma made the decannulation easier in all our patients. This operation is indicated in these cases, where the decannulation is impossible although the larynx had been found free. There are several factors which cause the difficulties, two of them being of most serious import: mechanical irritation of the trachea with granulation formation and retention of the greater amount of the secretion. In these cases we proceed in the following way: prior to decannulation, the elastic cannula is substituted with a metallic one with a so-called ‘speaking window’. In case the child with this cannula blocked is able to breathe through the upper respiratory passage for 24 hours, we perform a circumcision of the tracheostoma, remove the granulations and leave the wound open. The next day after the operation the child is decannulated and stroma is left free to close itself spontaneously. DISCUSSION
Despite the unquestionable advantages intubation offers, frequent complications can be observed in the form of larynx damage. It is necessary to consider the convenience of the endotracheal intubation in the cause of altb. We are of the opinion that in some more serious cases it is better to perform tracheostomy immediately. Thus, intubation applied in the case of acute epiglottitis is the method of choice. The persevering edema of the subglottic area as an effect of endotracheal intubation is mostly cured by tracheostomy; more gross changes require interventions that are a great burden to the child. In these cases, we prefer dilatations and general treatment by corticosteroids to surgical actions. These are often necessary in cases of stenosis of the subglottic area, although they are not always successful. A possible reason why applying stent to our patient was not successful is that the stenosis
203
was tough. Having removed the stent, we found the larynx to be free; the next day, however, the stenosis arose anew to the same extent. In the case of difficult decannulation with free respiratory passages, we recommend plastic operation of the tracheostoma. The success of this method can be explained by the fact that the time which has passed between the revision and the spontaneous healing of the tracheostoma is long enough for the inflammative changes around the cannula to retreat and for the cessation of the secretion which the child has coughed out through the tracheostoma. At any rate, larynx trauma caused by endotracheal intubation brings about great difficulties of treatment, particularly in children, and requires intensive individual care. REFERENCES 1 Baker, D.C., Jr. and Sawetsky, L., Decannulation problems in infants, Ann. Otol. (St. Louis), 81 (1972) 555-557. 2 BlBhova, 0. and Drastik, J., The difficult decannulation in children, Acta Univ. Carol. Med. (Praha), 13 (1967) 215. 3 Bryce, D.P., Briant, T.D.H. and Pearson, F.G., Laryngeal and tracheal complications of incubation, Ann. Otol. (St. Louis), 77 (1968) 442-461. 4 Fearon, B. and Cotton, R., Surgical correction of subglottic stenosis of the larynx in infants and children, Ann. Otol. (St. Louis), 83 (1974) 428-431. 5 Ferlic, R.M., Tracheostomy or endotracheal intubation, Ann. Otol. (St. Louis), 83 (1974) 739-744. 6 Flaum, F.G., Disorders of the Larynx. Current Pediatric Therapy, W.B. Saunders, Philadelphia, 1978. 7 Good, R.I. and Shinn, J.B., Long term stenting in the treatment of subglottic stenosis, Ann. Otol. (St. Louis), 86 (1977) 795-798. 8 Grahne, B., Operative treatment of severe chronic traumatic laryngeal stenosis in infants up to three years old, Acta oto-laryng. (Stockh.), 72 (1971) 134-137. 9 Hilding, A.C., Laryngotracheal damage during intratracheal anesthesia, Ann. Otol. (St. Louis), 80 (1971) 565-581. 10 Holinger, P.H., Kutnick, S.L., Schild, J.A. and Holinger, L.D., Subglottic stenosis in infants and children, Ann. Otol. (St. Louis), 85 (1976) 591-599. 11 Schulz-Coulon, H.J., Langzeit-Intubation oder Tracheotomie bei Kindern, HNO (Berlin), 24 (1976) 283-288. 12 Tonkin, J.P. and Harrison, G.A., The surgical management of the laryngeal complications of prolonged intubation, Laryngoscope (St. Louis), 81 (1971) 297-307.