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The changing indications for paediatric tracheostomy
International Journal of Pediatric Otorhinolaryngology (2003) 67, 7 /10
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The changing indications for paediatric tracheostomy Pandora J. Hadfield*, Ruth V. Lloyd-Faulconbridge, John Almeyda, David M. Albert, C. Martin Bailey Department of Paediatric Otolaryngology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK Received 13 June 2002; accepted 7 August 2002
KEYWORDS Tracheostomy; Paediatric; Tracheostomy incidence; Tracheostomy indications
Summary Objective: To investigate whether the incidence and indications for paediatric tracheostomy in this unit have changed over recent years. Methods: All paediatric tracheostomies performed between 1993 and 2001 were identified from our departmental database. The indications for these were ascertained by retrospective case note review. Results: Over the 9-year period studied 362 tracheostomies were performed, the number increased slightly between the first and second half of the period, with peaks in 1997 and 1999. The commonest indication was prolonged ventilation due to neuromuscular or respiratory problems. Conclusions: This large series shows that the increase in frequency of paediatric tracheostomy performed in this unit over the past decade has been due to conditions such as subglottic and tracheal stenosis, respiratory papillomatosis, caustic alkali ingestion and craniofacial syndromes. Conditions in which tracheostomy are now less common are subglottic haemangioma and laryngeal clefts. Prolonged ventilation remains the commonest indication overall. – 2002 Elsevier Science Ireland Ltd. All rights reserved.
1. Introduction Recent medical literature has suggested that both the number of paediatric tracheostomies performed and the indications for them have changed in recent years. In the 1970’s annual numbers seemed to remain stable [1 /3]. More recent studies have documented a fall in incidence [2,4 /7]. The commonest indication for tracheostomy in the 1970’s was acute inflammatory airway obstruction such as acute epiglottitis and laryngotracheobronchitis [2,3]. Recent series have shown *Corresponding author. Tel.: /44-207-4059-200; fax: /44207-829-8644.o.
that prolonged ventilation [1,8] or subglottic stenosis [9,10] are now the commonest indications.
2. Methods Our departmental database showed that in this unit 362 tracheostomies were performed between January 1993 and December 2001. A retrospective case note review of these revealed the indication for tracheostomy. In 21 cases, the notes were unavailable as they were in the process of being converted to microfilm. For the purposes of the study, only the main indication for tracheostomy
0165-5876/02/$ - see front matter – 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 5 - 5 8 7 6 ( 0 2 ) 0 0 2 8 2 - 3
8
P.J. Hadfield et al.
Table 1 Tracheostomy indications by year Indication
Year
Subglottic stenosis Tracheal stenosis Subglottic haemangioma Laryngeal cleft Respiratory papillomatosis Vocal cord palsy Laryngo/tracheo/bronchomalacia Other congenital laryngeal anomalies Craniofacial syndromes/OSA Caustic alkali ingestion H & N mass/cystic hygroma Neuro/respiratory/ventilation Retrognathia Other Unknown Total
1993
1994
1995
1996
1997
1998
1999
2000
2001
4 0 4 1 0 2 1 0 2 0 3 9 2 1 2 31
8 1 1 1 1 1 1 0 0 0 0 10 0 0 1 25
7 0 3 4 0 5 2 2 1 0 0 9 2 2 5 42
7 0 3 1 0 3 8 1 2 0 2 10 7 1 4 49
10 0 1 4 0 3 3 1 1 0 7 12 2 1 3 51
7 2 0 1 1 3 0 1 2 4 0 13 3 0 1 38
14 0 1 1 2 10 3 0 4 0 2 9 3 2 2 53
9 1 1 1 0 0 5 2 4 0 2 14 3 2 3 47
7 3 0 2 0 1 4 1 3 0 0 3 2 0 0 26
OSA, obstructive sleep apnoea. H & N, head and neck.
was recorded, although in some cases multiple indications had been identified.
Table 2 Total tracheostomies performed during each half of the study period 1993 /1997 1997 /2001
3. Results The indications for tracheostomy are classified as in Table 1. The ‘other’ group included three cases of bilateral choanal atresia, two of epidermolysis bullosa, two of macroglossia, one of myaesthenia gravis and one of Langerhan’s cell histiocytosis. Total numbers performed were calculated by year (Fig. 1) and for each half of the 9-
Fig. 1
Total number of tracheostomies per year.
Subglottic stenosis Tracheal stenosis Subglottic haemangioma Laryngeal cleft Respiratory papillomatosis Vocal cord palsy Laryngo/tracheo/broncho malacia Other congenital laryngeal anomalies OSA/craniofacial syndromes Caustic alkali ingestion H & N mass/cystic hygroma Neuro/respiratory/ventila tion Retrognathia Other Unknown Total
31 1 11 10 1 14 12
42 6 3 6 3 17 15
4
4
6 0 9 44
13 4 7 45
12 5 15 175
12 4 6 187
year period studied (Table 2). In total 362 tracheostomies were performed, 175 from January 1993 to June 1997 and 187 from July 1997 to December 2001. The indication for tracheostomy was calculated as a percentage of the 341 tracheostomies for which the indications were known (Table 3).
Paediatric tracheostomy incidence
9
Table 3 Total tracheostomies performed over 9-year period and percentage (of total known indications) for each indication 1993 /2001 Subglottic stenosis Tracheal stenosis Subglottic haemangioma Laryngeal cleft Respiratory papillomatosis Vocal cord palsy Laryngo/tracheo/bronchomalacia Other congenital laryngeal anomalies OSA/craniofacial syndromes Caustic alkali ingestion H & N mass/cystic hygroma Neuro/respiratory/ventilation Retrognathia Other Unknown Total
73 7 14 16 4 31 27 8
% 20 6 4 4.5 1 9 8 2
19 5 4 1 16 4.5 89 26 24 7 9 2 21 362 100
4. Discussion Several published series have documented the changing indications for tracheostomy in children. Our series includes 362 cases over a 9-year period; most of the other series are smaller, with between 44 and 293 cases [2,3,5,7 /14]. Only one series is larger than ours [1] with 420 cases over 10 years, but it includes patients up to the age of 21 years whereas we only included children up to the age of 16 years. Our study shows that the total number of tracheostomies performed in this unit gradually increased during the past decade to peaks in 1997 and 1999, since when the incidence has fallen slightly. Early series in the 1970’s and 1980’s found that absolute numbers remained stable each year [1 /3]. More recent series found that the total number of tracheostomies performed had declined [2,4 /7]. There are probably several reasons why our series is different. One is that as a tertiary centre we have not experienced the reduction in referrals for acute infections such as acute epiglottitis and laryngotracheobronchitis [14] which are generally treated at acute general hospitals. Tracheostomy for these conditions has become uncommon with the introduction of endotracheal intubation in the 1970’s and 1980’s [2,4 /6] and more recently Haemophilus Influenzae type B vaccine for acute epiglottitis. Other reasons for our observation of an increase in tracheostomies performed are that children under 2 years of age who might previously have been treated in an acute
general hospital are increasingly referred to tertiary centres for reasons of anaesthetic expertise. In addition, innovations in disciplines such as chemotherapy, radiotherapy and immunology have improved life expectancy and the indications for tracheostomy have increased. The commonest indication for tracheostomy in our series was prolonged ventilation due to neuromuscular or respiratory problems. This group accounted for 26% of all tracheostomies, and was also the commonest in Wetmore’s [1] and Carron’s [8] series where it accounted for 53 and 61%. In both Carter’s [2], and Shinkwin’s [10] series 17% of all tracheostomies were performed for prolonged ventilation. The second commonest indication in our series was upper airway obstruction, especially subglottic stenosis, which accounted for 20% of cases. This is similar to Swift’s [9] finding of 19%. In earlier studies, performed in the 1970’s, subglottic stenosis accounted for a lower proportion of all tracheostomies */02% [2] and 5% [1]. From our results, it appears that tracheostomy for subglottic stenosis has become more common over the past decade (Table 2) despite the simultaneous increase in single-stage laryngotracheal reconstruction, by which tracheostomy can be avoided. Other conditions requiring tracheostomy, which we have seen with increasing frequency are tracheal stenosis and microtrachea, respiratory papillomatosis, caustic alkali ingestion and craniofacial syndromes. In the latter, the incidence of tracheostomy may have increased as more patients were referred to the craniofacial unit as it developed or as operative techniques evolved and more children required tracheostomies to cover reconstructive surgery. The incidence of tracheostomy in some conditions has fallen (Table 2). Subglottic haemangioma is now often treated by endoscopic intralesional injection of steroids or sub-mucosal excision via an external approach, avoiding the need for tracheostomy. Similarly, short laryngeal clefts can be repaired endoscopically.
5. Conclusion This large series shows that the total number of paediatric tracheostomies performed in this unit has increased over the past decade. This is mainly due to conditions such as subglottic and tracheal stenosis, respiratory papillomatosis, caustic alkali ingestion and craniofacial syndromes. The commonest indication overall is prolonged ventilation due to neuromuscular or respiratory disease, the
10
P.J. Hadfield et al.
incidence of which appears to be stable. Conditions in which tracheostomy is now less common, due to recent surgical advances, are subglottic haemangioma and laryngeal clefts.
References [1] R.F. Wetmore, S.D. Handler, W.P. Potsic, Paediatric tracheostomy: experience during the past decade, Ann. Otol. Rhinol. Laryngol. 91 (1982) 628 /632. [2] P. Carter, B. Benjamin, Ten-year review of paediatric tracheotomy, Ann. Otol. Rhinol. Laryngol. 92 (1983) 398 / 400. [3] W.J. Newlands, W.S. McKerrow, Paediatric tracheostomy, J. Laryngol. Otol. 101 (1987) 929 /935. [4] P. Arcand, J. Granger, Paediatric tracheostomies: changing trends, J. Otolaryngol. 17 (1988) 121 /124. [5] W.S. Crysdale, R.I. Feldman, K. Naito, Tracheotomies: a 10year experience in 319 children, Ann. Otol. Rhinol. Laryngol. 97 (1988) 439 /443. [6] P.M. Palmer, J.M. Dutton, T.M. McCulloch, R.J.H. Smith, Trends in the use of tracheotomy in the paediatric patient: the Iowa experience, Head Neck 17 (1995) 328 /333.
.
[7] B.W. Duncan, L.J. Howell, A.A. deLorimier, S.N. Adzick, M.R. Harrison, Tracheostomy in children with emphasis on home care, J. Paediatr. Surg. 27 (1992) 432 /4435. [8] J.D. Carron, S.D. Craig, L.S. Strope, J.E. Nosonchuk, D.H. Darrow, Paediatric tracheotomies: changing indications and outcomes, Laryngoscope 110 (2000) 1099 /1104. [9] A.C. Swift, J.H. Rogers, The changing indications for tracheostomy in children, J. Laryngol. Otol. 101 (1987) 1258 /1262. [10] C.A. Shinkwin, K.P. Gibbin, Tracheostomy in children, J. R. Soc. Med. 89 (1996) 188 /192. [11] W.S. Line, D.B. Hawkins, E.F. Kahlstrom, MacLaughlin, J.L. Ensley, Tracheostomy in infants and young children: the changing perspective 1970 /1985, Laryngoscope 96 (1986) 510 /515. [12] C.A. Prescott, M.J. Vanlierde, Tracheostomy in children: the Red Cross War Memorial Children’s Hospital experience */1980 /1985, Int. J. Paediatr. Otorhinolaryngol. 17 (1989) 97 /107. [13] P.A. Okewo, The role of tracheostomy in otological practice in a developing country, J. Otolaryngol. 12 (4) (1983) 231 / 234. [14] C.R. Gerson, G.F. Tucker, Infant tracheotomy, Ann. Otol. Rhinol. Laryngol. 91 (1982) 413 /416.
www.elsevier.com/locate/ijporl
The changing indications for paediatric tracheostomy Pandora J. Hadfield*, Ruth V. Lloyd-Faulconbridge, John Almeyda, David M. Albert, C. Martin Bailey Department of Paediatric Otolaryngology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK Received 13 June 2002; accepted 7 August 2002
KEYWORDS Tracheostomy; Paediatric; Tracheostomy incidence; Tracheostomy indications
Summary Objective: To investigate whether the incidence and indications for paediatric tracheostomy in this unit have changed over recent years. Methods: All paediatric tracheostomies performed between 1993 and 2001 were identified from our departmental database. The indications for these were ascertained by retrospective case note review. Results: Over the 9-year period studied 362 tracheostomies were performed, the number increased slightly between the first and second half of the period, with peaks in 1997 and 1999. The commonest indication was prolonged ventilation due to neuromuscular or respiratory problems. Conclusions: This large series shows that the increase in frequency of paediatric tracheostomy performed in this unit over the past decade has been due to conditions such as subglottic and tracheal stenosis, respiratory papillomatosis, caustic alkali ingestion and craniofacial syndromes. Conditions in which tracheostomy are now less common are subglottic haemangioma and laryngeal clefts. Prolonged ventilation remains the commonest indication overall. – 2002 Elsevier Science Ireland Ltd. All rights reserved.
1. Introduction Recent medical literature has suggested that both the number of paediatric tracheostomies performed and the indications for them have changed in recent years. In the 1970’s annual numbers seemed to remain stable [1 /3]. More recent studies have documented a fall in incidence [2,4 /7]. The commonest indication for tracheostomy in the 1970’s was acute inflammatory airway obstruction such as acute epiglottitis and laryngotracheobronchitis [2,3]. Recent series have shown *Corresponding author. Tel.: /44-207-4059-200; fax: /44207-829-8644.o.
that prolonged ventilation [1,8] or subglottic stenosis [9,10] are now the commonest indications.
2. Methods Our departmental database showed that in this unit 362 tracheostomies were performed between January 1993 and December 2001. A retrospective case note review of these revealed the indication for tracheostomy. In 21 cases, the notes were unavailable as they were in the process of being converted to microfilm. For the purposes of the study, only the main indication for tracheostomy
0165-5876/02/$ - see front matter – 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 5 - 5 8 7 6 ( 0 2 ) 0 0 2 8 2 - 3
8
P.J. Hadfield et al.
Table 1 Tracheostomy indications by year Indication
Year
Subglottic stenosis Tracheal stenosis Subglottic haemangioma Laryngeal cleft Respiratory papillomatosis Vocal cord palsy Laryngo/tracheo/bronchomalacia Other congenital laryngeal anomalies Craniofacial syndromes/OSA Caustic alkali ingestion H & N mass/cystic hygroma Neuro/respiratory/ventilation Retrognathia Other Unknown Total
1993
1994
1995
1996
1997
1998
1999
2000
2001
4 0 4 1 0 2 1 0 2 0 3 9 2 1 2 31
8 1 1 1 1 1 1 0 0 0 0 10 0 0 1 25
7 0 3 4 0 5 2 2 1 0 0 9 2 2 5 42
7 0 3 1 0 3 8 1 2 0 2 10 7 1 4 49
10 0 1 4 0 3 3 1 1 0 7 12 2 1 3 51
7 2 0 1 1 3 0 1 2 4 0 13 3 0 1 38
14 0 1 1 2 10 3 0 4 0 2 9 3 2 2 53
9 1 1 1 0 0 5 2 4 0 2 14 3 2 3 47
7 3 0 2 0 1 4 1 3 0 0 3 2 0 0 26
OSA, obstructive sleep apnoea. H & N, head and neck.
was recorded, although in some cases multiple indications had been identified.
Table 2 Total tracheostomies performed during each half of the study period 1993 /1997 1997 /2001
3. Results The indications for tracheostomy are classified as in Table 1. The ‘other’ group included three cases of bilateral choanal atresia, two of epidermolysis bullosa, two of macroglossia, one of myaesthenia gravis and one of Langerhan’s cell histiocytosis. Total numbers performed were calculated by year (Fig. 1) and for each half of the 9-
Fig. 1
Total number of tracheostomies per year.
Subglottic stenosis Tracheal stenosis Subglottic haemangioma Laryngeal cleft Respiratory papillomatosis Vocal cord palsy Laryngo/tracheo/broncho malacia Other congenital laryngeal anomalies OSA/craniofacial syndromes Caustic alkali ingestion H & N mass/cystic hygroma Neuro/respiratory/ventila tion Retrognathia Other Unknown Total
31 1 11 10 1 14 12
42 6 3 6 3 17 15
4
4
6 0 9 44
13 4 7 45
12 5 15 175
12 4 6 187
year period studied (Table 2). In total 362 tracheostomies were performed, 175 from January 1993 to June 1997 and 187 from July 1997 to December 2001. The indication for tracheostomy was calculated as a percentage of the 341 tracheostomies for which the indications were known (Table 3).
Paediatric tracheostomy incidence
9
Table 3 Total tracheostomies performed over 9-year period and percentage (of total known indications) for each indication 1993 /2001 Subglottic stenosis Tracheal stenosis Subglottic haemangioma Laryngeal cleft Respiratory papillomatosis Vocal cord palsy Laryngo/tracheo/bronchomalacia Other congenital laryngeal anomalies OSA/craniofacial syndromes Caustic alkali ingestion H & N mass/cystic hygroma Neuro/respiratory/ventilation Retrognathia Other Unknown Total
73 7 14 16 4 31 27 8
% 20 6 4 4.5 1 9 8 2
19 5 4 1 16 4.5 89 26 24 7 9 2 21 362 100
4. Discussion Several published series have documented the changing indications for tracheostomy in children. Our series includes 362 cases over a 9-year period; most of the other series are smaller, with between 44 and 293 cases [2,3,5,7 /14]. Only one series is larger than ours [1] with 420 cases over 10 years, but it includes patients up to the age of 21 years whereas we only included children up to the age of 16 years. Our study shows that the total number of tracheostomies performed in this unit gradually increased during the past decade to peaks in 1997 and 1999, since when the incidence has fallen slightly. Early series in the 1970’s and 1980’s found that absolute numbers remained stable each year [1 /3]. More recent series found that the total number of tracheostomies performed had declined [2,4 /7]. There are probably several reasons why our series is different. One is that as a tertiary centre we have not experienced the reduction in referrals for acute infections such as acute epiglottitis and laryngotracheobronchitis [14] which are generally treated at acute general hospitals. Tracheostomy for these conditions has become uncommon with the introduction of endotracheal intubation in the 1970’s and 1980’s [2,4 /6] and more recently Haemophilus Influenzae type B vaccine for acute epiglottitis. Other reasons for our observation of an increase in tracheostomies performed are that children under 2 years of age who might previously have been treated in an acute
general hospital are increasingly referred to tertiary centres for reasons of anaesthetic expertise. In addition, innovations in disciplines such as chemotherapy, radiotherapy and immunology have improved life expectancy and the indications for tracheostomy have increased. The commonest indication for tracheostomy in our series was prolonged ventilation due to neuromuscular or respiratory problems. This group accounted for 26% of all tracheostomies, and was also the commonest in Wetmore’s [1] and Carron’s [8] series where it accounted for 53 and 61%. In both Carter’s [2], and Shinkwin’s [10] series 17% of all tracheostomies were performed for prolonged ventilation. The second commonest indication in our series was upper airway obstruction, especially subglottic stenosis, which accounted for 20% of cases. This is similar to Swift’s [9] finding of 19%. In earlier studies, performed in the 1970’s, subglottic stenosis accounted for a lower proportion of all tracheostomies */02% [2] and 5% [1]. From our results, it appears that tracheostomy for subglottic stenosis has become more common over the past decade (Table 2) despite the simultaneous increase in single-stage laryngotracheal reconstruction, by which tracheostomy can be avoided. Other conditions requiring tracheostomy, which we have seen with increasing frequency are tracheal stenosis and microtrachea, respiratory papillomatosis, caustic alkali ingestion and craniofacial syndromes. In the latter, the incidence of tracheostomy may have increased as more patients were referred to the craniofacial unit as it developed or as operative techniques evolved and more children required tracheostomies to cover reconstructive surgery. The incidence of tracheostomy in some conditions has fallen (Table 2). Subglottic haemangioma is now often treated by endoscopic intralesional injection of steroids or sub-mucosal excision via an external approach, avoiding the need for tracheostomy. Similarly, short laryngeal clefts can be repaired endoscopically.
5. Conclusion This large series shows that the total number of paediatric tracheostomies performed in this unit has increased over the past decade. This is mainly due to conditions such as subglottic and tracheal stenosis, respiratory papillomatosis, caustic alkali ingestion and craniofacial syndromes. The commonest indication overall is prolonged ventilation due to neuromuscular or respiratory disease, the
10
P.J. Hadfield et al.
incidence of which appears to be stable. Conditions in which tracheostomy is now less common, due to recent surgical advances, are subglottic haemangioma and laryngeal clefts.
References [1] R.F. Wetmore, S.D. Handler, W.P. Potsic, Paediatric tracheostomy: experience during the past decade, Ann. Otol. Rhinol. Laryngol. 91 (1982) 628 /632. [2] P. Carter, B. Benjamin, Ten-year review of paediatric tracheotomy, Ann. Otol. Rhinol. Laryngol. 92 (1983) 398 / 400. [3] W.J. Newlands, W.S. McKerrow, Paediatric tracheostomy, J. Laryngol. Otol. 101 (1987) 929 /935. [4] P. Arcand, J. Granger, Paediatric tracheostomies: changing trends, J. Otolaryngol. 17 (1988) 121 /124. [5] W.S. Crysdale, R.I. Feldman, K. Naito, Tracheotomies: a 10year experience in 319 children, Ann. Otol. Rhinol. Laryngol. 97 (1988) 439 /443. [6] P.M. Palmer, J.M. Dutton, T.M. McCulloch, R.J.H. Smith, Trends in the use of tracheotomy in the paediatric patient: the Iowa experience, Head Neck 17 (1995) 328 /333.
.
[7] B.W. Duncan, L.J. Howell, A.A. deLorimier, S.N. Adzick, M.R. Harrison, Tracheostomy in children with emphasis on home care, J. Paediatr. Surg. 27 (1992) 432 /4435. [8] J.D. Carron, S.D. Craig, L.S. Strope, J.E. Nosonchuk, D.H. Darrow, Paediatric tracheotomies: changing indications and outcomes, Laryngoscope 110 (2000) 1099 /1104. [9] A.C. Swift, J.H. Rogers, The changing indications for tracheostomy in children, J. Laryngol. Otol. 101 (1987) 1258 /1262. [10] C.A. Shinkwin, K.P. Gibbin, Tracheostomy in children, J. R. Soc. Med. 89 (1996) 188 /192. [11] W.S. Line, D.B. Hawkins, E.F. Kahlstrom, MacLaughlin, J.L. Ensley, Tracheostomy in infants and young children: the changing perspective 1970 /1985, Laryngoscope 96 (1986) 510 /515. [12] C.A. Prescott, M.J. Vanlierde, Tracheostomy in children: the Red Cross War Memorial Children’s Hospital experience */1980 /1985, Int. J. Paediatr. Otorhinolaryngol. 17 (1989) 97 /107. [13] P.A. Okewo, The role of tracheostomy in otological practice in a developing country, J. Otolaryngol. 12 (4) (1983) 231 / 234. [14] C.R. Gerson, G.F. Tucker, Infant tracheotomy, Ann. Otol. Rhinol. Laryngol. 91 (1982) 413 /416.