Pediatric tracheotomy: 17 year review

Summary

Objective

To study the outcomes, complications, and indications for pediatric tracheotomies performed at a major tertiary care children's hospital, Starship Children's Hospital in Auckland, New Zealand, over the period 1987–2003.

Methods

A retrospective review of hospital records from 1987 to 2003 was conducted to assess all pediatric patients who had undergone tracheotomies.

Results

A total of 122 tracheotomies (119 surgical, 3 percutaneous) were performed on patients less than 16 years of age. Upper airway obstruction (including craniofacial dysmorphism, n = 40, and subglottic stenosis, n = 18) was the most common indication for surgery (n = 86; 70%) with a lesser number (n = 36; 30%) requiring tracheotomy for prolonged ventilation. The median age at tracheotomy was 4.5 months in patients with upper airway obstruction and 16 months in those requiring prolonged ventilation. Decannulation was carried out successfully in 92 patients (75%), although 6 (6.5%) subsequently required recannulation. The overall complication rate was 51% (n = 62). Early postoperative complications occurred in a total of 9 (7.4%) patients, including difficulties with ventilation in intensive care due to inadequate seal or tube position in 5 (4.1%), and accidental decannulation in 3 (2.5%). Late complications included localized granulation in most patients, for which 15 (12.3%) required intervention whilst under a routine planned general anesthetic. Major vascular erosion was not encountered in any patient, although 5 (4.1%) required intervention for minor bleeding associated with granulation tissue. Suprastomal collapse occurred in 13 patients (10.7%); but did not affect their subsequent decannulation, although 2 (1.6%) developed tracheotomy-related subglottic stenosis. Closure of tracheocutaneous fistulas was required in 16 (13.1%) decannulated patients. Only 2 patients (1.6%) died from tracheotomy-related complications, with an overall mortality rate of 14%.

Conclusions

Pediatric tracheotomies performed at Starship Children's Hospital between 1987 and 2003 were associated with a low incidence of procedure-related mortality and morbidity and successful decannulation in most cases. The majority of procedures were performed to treat upper airway obstruction, most commonly caused by craniofacial dysmorphism or subglottic stenosis.

Introduction

Although the concept of a therapeutic surgical incision directly through the neck to access the trachea dates back to at least the days of Ancient Greece, the modern era of routine tracheotomy did not begin until the mid-1800s when the French physician Armand Trousseau employed the technique to treat many patients with diphtheria-associated dyspnea [1], [2]. Although tracheotomy is potentially life-saving, early reports in the literature suggested that the risks associated with the procedure are significantly higher in children than in adults [3]. However, there continue to be vast improvements in pediatric intensive care and medical management of many conditions that would have previously been treated with tracheotomy. In addition, survival rates of premature infants and those with severe congenital anomalies are higher in the modern era [4]. Consequently, the incidence of, and indication for, tracheotomy in infants and children has been changing. Although pediatric tracheotomy is still considered by many to be a high-risk procedure with high rates of associated morbidity/complications and mortality, more recent studies suggest that the incumbent risks associated with tracheotomy in children are not as high as once perceived [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17].

The objectives of our study were to assess the characteristics and rate of complications of pediatric tracheotomies performed at Starship Children's Hospital in Auckland, New Zealand from 1987 to 2003, and to compare our findings with other reports in the literature.