|Year : 2022 | Volume
| Issue : 3 | Page : 224-229
Pediatric tracheostomy: A 10-year experience at a tertiary care teaching hospital in Eastern India
Santosh Kumar Swain1, Ishwar Chandra Behera2
1 Department of Otorhinolaryngology and Head-and-Neck Surgery, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India
2 Department of Community Medicine, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India
|Date of Submission||11-Feb-2022|
|Date of Acceptance||31-Mar-2022|
|Date of Web Publication||17-Sep-2022|
Prof. Santosh Kumar Swain
Department of Otorhinolaryngology and Head and Neck Surgery, IMS and SUM Hospital, Siksha “O” Anusandhan University, K8, Kalinga Nagar, Bhubaneswar - 751 003, Odisha
Source of Support: None, Conflict of Interest: None
BACKGROUND: Tracheostomy in pediatric patients is considered a surgery of significant morbidity and mortality. However, the airway management with tracheostomy in the pediatric age group has changed over time with respect to indication and outcome.
OBJECTIVE: The objective of this study is to evaluate the indications and complications of pediatric tracheostomies.
MATERIALS AND METHODS: This is a prospective study done on pediatric tracheostomies at a tertiary care teaching hospital. The study period was from September 2011 to October 2021. The data on age, gender, indications, and complications over 10 years were analyzed. In this study, pediatric tracheostomy was classified into prolonged intubation, obstruction in the upper airway, anomalies in the craniofacial region, neurological disorders, and vocal fold paralysis. If a child required ventilator assistance, they were placed in the prolonged intubation group.
RESULTS: There were 162 pediatric tracheostomies performed during the study time. Of 162 children, 98 (60.49%) were male and 64 (39.50%) were female, with a male-to-female ratio of 1.5:1. Of 162 children, 112 (69.13%) underwent tracheostomy for prolonged ventilation and 50 (30.86%) underwent tracheostomy for upper airway obstruction. Intraoperative complications were seen in 9 (5.55%) cases of pediatric tracheostomy. There were 28 (17.28%) pediatric patients with a tracheostomy who presented with postoperative complications.
CONCLUSION: Standardization of the pediatric tracheostomy, the timing of the procedure, and appropriate indications of pediatric tracheostomy are helpful to minimize morbidity and mortality in pediatric patients.
Keywords: Airway, pediatric tracheostomy, prolonged ventilation, upper airway obstruction
|How to cite this article:|
Swain SK, Behera IC. Pediatric tracheostomy: A 10-year experience at a tertiary care teaching hospital in Eastern India. Indian J Health Sci Biomed Res 2022;15:224-9
|How to cite this URL:|
Swain SK, Behera IC. Pediatric tracheostomy: A 10-year experience at a tertiary care teaching hospital in Eastern India. Indian J Health Sci Biomed Res [serial online] 2022 [cited 2022 Sep 25];15:224-9. Available from: https://www.ijournalhs.org/text.asp?2022/15/3/224/356265
| Introduction|| |
A tracheostomy is a surgical method in which a tracheostomy tube is inserted into the trachea to allow direct connection with the outside. In comparison to the adult age group, tracheostomy has been associated with a high rate of morbidity and death in the pediatric age group, especially in newborns and infants. The tracheostomy has several advantages, such as less requirement of sedation, easier breathing, improved long-term laryngeal function, less requirement for mechanical ventilation, lower chance of ventilator-associated pneumonia, earlier discharge from the pediatric intensive care unit (ICU), and improved oral hygiene. Tracheostomy is a life-saving surgery for individuals who have an upper airway blockage and stridor due to a compromised airway. The indications for pediatric tracheostomy have changed significantly in the last few decades. Initially, upper airway obstruction due to infections was a major etiology for pediatric tracheostomy. Currently, the causes for pediatric tracheostomy are prolonged ventilation, upper airway obstruction by laryngotracheal stenosis, craniofacial anomalies, and neurological disease associated with hypoventilation. However, the use of the tracheostomy in the pediatric age group has changed, and currently, more specific indications are followed and satisfactory outcomes are found over long-term follow-up. Their numerous studies were done on adult tracheostomy concerning its indications, operative techniques, and complications of pediatric tracheostomy, but studies for pediatric tracheostomy are much less in the literature. There is always a requirement to establish a guideline for standard protocols for tracheostomy of childhood.
This study aims to evaluate the indication and complications of pediatric tracheostomy with maturation suture technique performed at a tertiary care teaching hospital.
| Materials and Methods|| |
This is a prospective study done at a tertiary care teaching hospital from September 2011 to October 2021. The institutional ethical committee (IEC) of our institute approved this study with the reference number IEC/IMS/SOA/12/May 16, 2011. All the pediatric tracheostomies were done by utilizing the maturation suture technique. Appropriate tracheostomy tube sizes for pediatric patients were selected based on age. The smallest tracheostomy tube that can provide sufficient air exchange is usually selected. For ventilator-dependent children, a bigger diameter tracheostomy tube may be required to prevent severe air leakage. A larger size tracheostomy tube can induce tracheal mucosal damage, ulceration, and bleeding, as well as tracheal stenosis or fistulization. An excessively lengthy tracheostomy tube may move to the right bronchus. For children above the age of 1 year, an age-appropriate tracheostomy tube size can be calculated using the endotracheal tube (ETT) formula: (years of age divided by 4) ± 4 mm = ETT's internal diameter. This can be appropriately converted into the required size of the tracheostomy tube. The patient charts were evaluated for details of demographic data, such as gender, age at tracheostomy, indications, comorbidities such as preterm birth, congenital heart disease, neurological, neuromuscular, neoplastic, bronchopulmonary dysplasia, any known syndrome, and severe systemic infection. The indications for pediatric tracheostomy were divided into two groups, such as prolonged intubation and upper airway obstruction. Children with age more than 18 years at the time of tracheostomy were excluded from this study.
| Surgical technique|| |
All the children underwent tracheostomy with general anesthesia. During tracheostomy, a pediatric patient was lying down in a supine position, and extension of the neck was done with help of a sandbag under the shoulder. A horizontal skin incision was performed on the mid-point between the sternal notch and cricoid cartilage. After the skin incision, a cervical lipectomy was done. The platysma was divided and the strap muscles were retracted laterally and regular finger palpation was done to confirm the medial position of the trachea. The pretracheal fascia was identified after the division of the thyroid gland. Then, the cricoid cartilage was identified superiorly after excision of loose fascia from the anterior wall of the trachea. Two traction sutures with 4-0 vicryl were kept at the third or fourth tracheal rings on either side. The incision on the trachea was made vertically between the sutures. 4-Polydioxanone (4-PDS) are placed between the skin and trachea. Then, a tracheostomy cannula was inserted and secured with help of twine and tightened around the neck. After the tracheostomy, the patient was promptly admitted to ICU. A chest X-ray (PA view) was done to confirm the position of the tracheostomy tube and the absence of pneumothorax or pneumomediastinum. Decannulation of the tracheostomy was planned when they no longer needed mechanical ventilation, nasal oxygen, and no longer suffered from airway obstruction. In our institute, the decannulation protocol obeys the following steps such as direct laryngoscopy and bronchoscopy to rule out airway stenosis, suprastomal collapse, and granulation. Then, one small size tracheostomy tube was placed and plugged. If the patient tolerates a plugged tracheostomy, the decannulation is performed and the patient is observed for 72 h before discharge.
| Results|| |
One hundred and sixty-two children with tracheostomy were enrolled in this study. All of them underwent tracheostomy during the study. Of 162 children, 98 (60.49%) were male and 64 (39.50%) female. The male-to-female ratio is 1.5:1 in this study. The age of the study participants was ranged from 1 to 18 years. There were three groups of age of the patients participating in the study, such as 1–5 years, 6–10 years, and 11–18 years. There were 32 (19.75%) patients in the age range of 1–5 years, 70 (43.20%) patients in the age range of 6–10 years, and 60 (37.03%) patients in the age range of 11–18 years [Table 1]. In this study, the mean age of the children is 7.4 years. There were two important indications for tracheostomy such as prolonged intubation and airway obstruction. The age-wise indications for tracheostomy are given in [Table 1]. Of 162 children, 112 (69.13%) underwent tracheostomy for prolonged ventilation and 50 (30.86%) underwent tracheostomy for upper airway obstruction. Of 112 children who underwent tracheostomy for prolonged ventilation, 62 (38.27%) were with cardiopulmonary disease [Figure 1], 40 (24.69%) with neuromuscular diseases, and 10 (6.17%) with chronic aspiration. In patients with airway obstruction, 12 (7.40%) resulted from subglottic stenosis, 11 (6.79%) resulted from laryngeal papillomatosis [Figure 2], 10 (6.17%) with bilateral vocal fold palsy [Figure 3], 9 ((5.55%) with head-and-neck neoplasm, 5 (3.08%) with subglottic hemangioma, and 3 (1.85%) with laryngomalacia [Table 2]. Intraoperative complications were seen in 9 (5.55%) cases of pediatric tracheostomy. Of 9 patients with intraoperative complications, 6 (3.70%) had intraoperative bleeding and 3 (1.85%) had apnea. There were 28 (17.28%) pediatric patients with a tracheostomy who presented with postoperative complications. Postoperatively, 5 (3.08%) had blockage of the tracheostomy tube, 4 (2.46%) had accidental displacement of the tracheostomy tube, 3 (1.85%) had aspiration bronchopneumonia, 4 (2.46%) had surgical emphysema in the neck, 5 (3.08%) had stomal infections, 3 (1.85%) had pneumothorax, 1 (0.62%) developed tracheal stenosis, 2 (1.23%) had postdecannulation tracheocutaneous fistula, 1 (0.62%) had tracheomalacia, and 1 (0.62%) had stenosis of trachea [Table 3]. There were 25 deaths; with only 2 being directly related to the tracheostomy. The primary disease was the cause of death in 23 children. There was one death due to blockage of the tracheostomy tube and another was due to bleeding from the stoma region of the tracheostomy. Twenty-three patients suffered from cardiopulmonary arrest because of complications associated with their disease.
|Figure 1: A 2-year male child with cardiopulmonary disease underwent tracheostomy for prolonged ventilation|
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|Figure 2: A child with multiple laryngeal papillomatosis with upper airway obstruction|
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|Figure 3: A child with bilateral vocal fold palsy with airway obstruction|
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|Table 1: Children with different age group and their indications for tracheostomy|
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| Discussion|| |
In the early years, pediatric tracheostomy has been viewed as a great challenge and concern for clinicians with a high incidence of complications and mortality. By allowing access to the tracheobronchial toilet, a tracheostomy avoids aspiration. By avoiding lengthy intubation, a tracheostomy also avoids stenosis of the laryngotracheal airway. It aids in the weaning process by removing the ventilator dead space. Pediatric tracheostomy patients have two to three times the morbidity and mortality of adult tracheostomy patients. Complications are more likely during neonatal age, especially in preterm neonates, for whom the tracheostomy is a high-risk procedure. The indications for tracheostomy are changing, as is the procedure's safety in pediatric patients. Although there is a decrease in the number of emergency tracheostomies, the incidence of pediatric tracheostomies has not decreased; instead, it has increased particularly in tertiary health-care centers. The increasing survival of patients in pediatric and neonatal critical care units is primarily responsible for this. In children with persistent ventilator dependency, congenital or acquired upper airway abnormalities, and neurological impairment, pediatric tracheostomy is currently the most common procedure. Indications for pediatric tracheostomy include upper airway obstruction as in Pierre Robin syndrome and subglottic stenosis. Recurrent laryngeal papillomatosis, laryngomalacia, and laryngotracheal stenosis are common causes for performing tracheostomy in the pediatric age group, which were also found in this study. The increased number of tracheostomies in pediatric patients has been attributed to more premature babies surviving and requiring prolonged ventilation. In this study, the majority of the children those underwent tracheostomy were in the age group of 6–10 years (43.20%), followed by 11–18 years (37.03%) and 1–5 years (19.75%). In one study during 1988–1998, neurological disorders and prolonged ventilation were the most common indications to do tracheostomy in children. In one long period study with a review of 37 years on pediatric patients, obstruction in the upper airway was the most common indication during 1968–2005, there was also an increased number of tracheostomies done for prolonged ventilation during the late part of this study. There were two series during 1996–2001 in France and 1999–2003 in Singapore, which concluded that an increased number of tracheostomies were being performed in children for prolonged intubations., During the previous 5 years, the number of pediatric tracheostomies for cardiopulmonary diseases has increased significantly. Another research found that neurological defects (38.9%) and cardiovascular disorders (21.2%) were the most prevalent reasons for tracheostomies in children, similar to our findings. Prolonged intubation (35%), upper airway blockage (28%), neurological illnesses (12%), and craniofacial deformities (12%) were the most prevalent reasons for childrens' tracheostomies, according to a retrospective analysis. The shifting profile of tracheostomy indications in pediatric patients is not limited to any one region. Similar studies have recently been reported in India, where the indications have shifted from infectious to other airway issues. In this study, of 162 children, 112 (69.13%) underwent tracheostomy for prolonged ventilation and 50 (30.86%) underwent tracheostomy for upper airway obstruction. In this study, with patients with airway obstruction, 12 (7.40%) resulted from subglottic stenosis, 11 (6.79%) resulted from laryngeal papillomatosis, 10 (6.17%) with bilateral vocal fold palsy, 9 ((5.55%) with head-and-neck neoplasm, 5 (3.08%) with subglottic hemangioma, and 3 (1.85%) with laryngomalacia.
The size of the tracheostomy tube and its curvature are often associated with the outcome of the pediatric tracheostomy. The selection of exact sized tracheostomy tube is helpful for successful procedure and avoidance of complications. Typically, the selection of the appropriate size of the tube, particularly the diameter of the tracheostomy tube, corresponds to the age of the patient. However, in some cases, the general rule may not apply because the patient's tracheostomy tube size is out of proportion to his or her chronological age. In addition to the diameter of the tracheostomy tube, the length and curve of the tube are generally affected by the tube's size. When choosing a tracheostomy tube, the length and curve of the tracheostomy should be taken into account. The tracheostomy should preferably extend at least 2 cm beyond the stoma and tip within 1–2 cm of the carina. To avoid contacting the trachea's anterior or posterior walls, the tracheostomy tube's distal end should be parallel to the trachea. The long-standing abutment might cause granulation and erosion in the esophagus or innominate artery, resulting in potentially fatal hemorrhage. The polyvinyl chloride tubes can be changed with silicon tubes that adapt more easily to the airway's contour if the tracheostomy tube's curvature is not ideal. A cuffed tracheostomy may not be essential in children unless high-pressure breathing is required or the patient is at high risk of aspiration. If a cuffed tracheostomy is required and the cuff is left inflated for an extended period, tracheal granulation and stenosis may occur. When deflating the cuff, there is a potential that secretion will be aspirated and collected above the cuff. Suctioning should be done before and after cuff deflation to limit the risk of aspiration. The fenestrated tracheostomy tube is available for translaryngeal airflow and phonation. However, there is controversy for using a fenestrated tracheostomy tube in the pediatric age group as it promotes the formation of granulation at the site of fenestration. For promoting the phonation, the tracheostomy tube size can be downsized for allowing the airflow around the tube or use of the speaking valve. In newborns and early children, the airway diameter is tiny (6 mm at 6 months and 8–11 mm at 10 years of age). As a result, even minor narrowing of the airway lumen due to congenital and inflammatory diseases can cause blockage. Male predominance in pediatric tracheostomy cohorts has been linked to a greater risk of congenital abnormalities and acquired airway illness in boys. The complications of tracheostomy include hemorrhage, subcutaneous emphysema, accidental decannulation, pneumothorax, pneumomediastinum, intratracheal mucosal plugs, blockage of the tracheostomy tube with mucus, granuloma at the stoma of the tracheostomy, and infection like tracheitis. In this study, intraoperative complications of pediatric tracheostomy such as 6 (3.70%) patients had intraoperative bleeding and 3 (1.85%) had apnea. There were 28 (17.28%) pediatric patients with tracheostomy presented with postoperative complications where 5 (3.08%) had blockage of the tracheostomy tube, 4 (2.46%) had an accidental displacement of the tracheostomy tube, 3 (1.85%) had aspiration bronchopneumonia, 4 (2.46%) had surgical emphysema in the neck, 5 (3.08%) had stomal infections, 3 (1.85%) had pneumothorax, 1 (0.62%) developed tracheal stenosis, 2 (1.23%) had postdecannulation tracheocutaneous fistula, 1 (0.62%) had tracheomalacia, and 1 (0.62%) had stenosis of trachea. Long-term usage of a tracheostomy tube may cause the stoma to shrink to a nonfunctional size, but it may not entirely close, resulting in a tracheocutaneous fistula. Early accidental decannulation was documented as 2.5%–3.7%. Recannulation of the tracheostomy is often prevented by the tracheal suture tension on both sides of the incision. The maturation suture technique is helpful to secure the trachea to the skin which forms a safe stoma and is also helpful for doing recannulation. The cause for bleeding from the stoma area of tracheostomy is the formation of granulation tissue at the stoma region. Granulation appears as a red-to-pink color. Bleeding may cause a serious issue if comes from the tracheostomy tube and is not controlled by repeated suction. However, there was one death due to bleeding from the stomal region following tracheostomy. After tracheostomy in the pediatric patient, the first chance of the tube is performed after 1 week to allow sufficient maturation of the stoma. With the aid of a shoulder roll, the patient's head and neck are extended. Before and after replacing the tracheostomy tube, it must be suctioned. Then, the tracheostomy tube is inserted at an angle of 45° from the vertical plane and is straightened during insertion. Before the discharge of the patient, the caregivers must be adequately taught to care for tracheostomy. Problems such as tube suctioning, breathing trouble, and mucus clogging should be identified by the parents or caregivers. Parents must be able to change the tracheostomy tube quickly and efficiently. They should be able to do cardiopulmonary resuscitation as well. Parents or caregivers should have extra tracheostomy tubes, suction catheters, sterile saline, a portable suction machine, humidifier, and an oxygen saturation monitor on available. To facilitate progressive closure of the stoma, decannulation of the tracheostomy tube should be done with gradual downsizing of the tracheostomy tube. During the daytime, the tracheostomy tube is capped to measure tolerance. Parents and caregivers must be warned not to leave a child with a capped tracheostomy tube unsupervised, or to keep the tube capped during naptime and at night without checking oxygen saturation. When the patient can tolerate the tracheostomy tube being capped during the day, the child should be brought to the hospital for 24 h of observation. The tracheostomy tube is withdrawn, and the stoma is wrapped with an occlusive covering to promote stoma closure. The patient should be monitored for another 48 h or until the stoma closes. Provided the stoma is not closed, the child can be discharged from the hospital with follow-up at the outpatient clinic if his or her breathing is stable.
| Conclusion|| |
Tracheostomy in pediatric age is often challenging. In the pediatric age group, tracheostomy is indicated for prolonged ventilation and airway obstruction. The timing and precise indications of tracheostomy in pediatric patients reduce tracheostomy-related morbidity and death. Pediatric patient problems are potentially life-threatening and require specialist treatment from a multidisciplinary team. The frequency of pediatric tracheostomy has increased over the last several years. Cardiopulmonary and neurological problems were the most common reasons for pediatric tracheostomy in this study, presumably reflecting the greater survival rate of preterm children and those receiving cardiothoracic surgery.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]