Paediatric tracheostomy—An 11 year experience at a Scottish paediatric tertiary referral centre

doi:10.1016/j.ijporl.2015.07.022

International Journal of Pediatric Otorhinolaryngology

Volume 79, Issue 10, October 2015, Pages 1673-1676

https://doi.org/10.1016/j.ijporl.2015.07.022 Get rights and content

Abstract

Aims

The aim of this paper was to review the indications, complications and outcomes for tracheostomy at a Scottish paediatric tertiary referral hospital.

Methods

All patients undergoing tracheostomy between January 2001 and September 2012 were identified. A retrospective case note analysis was performed.

Results

111 tracheostomies were done in the study period. The mean number per year was 11 (3–12). Full data was available for 95 patients. There were 56 (59%) males and 39 (41%) females. Age at time of tracheostomy ranged from one day to 15 years, the mean age of tracheostomy insertion was 69 weeks. The majority of patients, 75 (79%), were under one year old when they had their tracheostomy. The most common indication was long-term ventilation (20%), followed by craniofacial abnormality causing airway obstruction (18%), followed by subglottic stenosis (14%). 37% of patients were decannulated.

Conclusions

This series reflects current trends in the indications for paediatric tracheostomy, with chronic lung disease of prematurity being the most common indication.

Introduction

Tracheostomy is a life saving operation, however, it is associated with potential serious complications. Recent publications suggest that the indications for tracheostomy in children have been changing considerably over recent years, in comparison to the adult population where indications have remained the same. Life threatening infections, such as diphtheria, were historically the main indication for paediatric tracheostomy [1]. However with the introduction of modern immunizations, life-threatening infections are now less common, and subsequently the need for tracheostomy. Advances in neonatal medicine now allow children to stay on long-term ventilator support for many weeks to months. Tracheostomies help facilitate pulmonary toilet in such patients, and reduce chronic laryngotraceal lesions related to long term intubation, such as subglottic stenosis [2] Paediatric tracheostomy is technically more demanding than one performed on an adult, due to the size of the patient and the limited extent of the operating field. Paediatric patients have a higher reported mortality, morbidity and complication rate, particularly in pre-term infants, compared to the adult population [3], [4]. The aim of this paper was to review our 11 year experience of tracheostomies and compare it to the airway workload in our department.

Section snippets

Materials and methods

A retrospective review of all tracheostomies performed at the Royal Hospital of Sick Children between January 2001 and 1st September 2012 was carried out. The Royal Hospital for Sick Children, Glasgow, serves a population of around 1 million people, as well as being the tertiary referral centre in Scotland for paediatric airway services. Patient case notes were analysed with respect to the following variables: age, demographics, indication for procedure, co-morbidities, length of stay,

Patient demographics

One hundred and eleven patients underwent a tracheostomy over an 11-year period, with notes available for 95 patients. All tracheostomies were performed by ENT surgeons (consultants or surgeons in training with consultant supervision). There were 56 (59%) males and 39 (41%) females. Age at time of tracheostomy ranged from one day to 15 years, the mean age of tracheostomy insertion was 69 weeks. The majority of patients, 75 (79%), were under one year old when they had their tracheostomy

Discussion

Historically the most common indication for paediatric tracheostomy has been for the management of upper airway obstruction caused by infection [5]. However, no child in this series had a tracheostomy for infection of the upper airway, see Table 1. In this series of patients the most common indication was long-term ventilation (20%), followed by craniofacial abnormality causing airway obstruction (18%), followed by subglottic stenosis (14%). Several series have documented the changing

Conclusion

This series highlights the changing indications in paediatric tracheostomy. This is emphasized by the fact that only 37% of our series were successfully decannulated, highlighting again the change in paediatric tracheostomy over the past decade.

References (23)

B. Kremer et al.
Indications, complications, and surgical techniques for pediatric tracheostomies—an update
J. Pediatr. Surg.
(2002)
L.N. Ogilvie et al.
Changes in pediatric tracheostomy 1982–2011: a Canadian tertiary children's hospital review
J. Pediatr. Surg.
(2014)
M. Mahadevan et al.
Pediatric tracheotomy: 17 year review
Int. J. Pediatr. Otorhinolaryngol.
(2007)
M.J. Donnelly et al.
A twenty year (1971–1990) review of tracheostomies in a major paediatric hospital
Int. J. Pediatr. Otorhinolaryngol.
(1996)
H.J. Corbett et al.
Tracheostomy—a 10-year experience from a UK pediatric surgical center
J. Pediatr. Surg.
(2007)
P.J. Hadfield et al.
The changing indications for paediatric tracheostomy
Int. J. Pediatr. Otorhinolaryngol.
(2003)
S. Ozmen et al.
Pediatric tracheotomies: a 37-year experience in 282 children
Int. J. Pediatr. Otorhinolaryngol.
(2009)
J.S. Schlessel et al.
Tracheostomy: acute and long-term mortality and morbidity in very low birth weight premature infants
J. Pediatr. Surg.
(1993)
A.C. Swift et al.
The changing indications for tracheostomy in children
J. Laryngol. Otol.
(1987)
J.D. Carron et al.
Pediatric tracheotomies: changing indications and outcomes
Laryngoscope
(2000)

M.A. Kenna et al.

Tracheotomy in the preterm infant

Ann. Otol. Rhinol. Laryngol.

(1987)

Cited by (33)

Time considerations and outcomes in pediatric tracheostomy decannulation
2024, International Journal of Pediatric Otorhinolaryngology
The study objective is to identify factors that impact the time to decannulation in pediatric patients ages 0 through 18 years who are tracheostomy-dependent.
This retrospective chart review from January 1, 2005 through December 31, 2020 identified pediatric tracheostomy patients at a single pediatric institution. Data extracted included demographic, socioeconomic factors, and clinical characteristics. Multivariate regression and survival analysis were used to identify factors associated with successful decannulation and decreased time with tracheostomy.
Of the 479 tracheostomy-dependent patients identified, 162 (33.8%) were decannulated. Time to decannulation ranged from 0.5 months to 189.2 months with median of 24 months (IQR 12.91–45.71). In the multivariate analysis, patients with bronchopulmonary dysplasia (p = 0.021) and those with Passy-Muir® Valve at discharge (p = 0.015) were significantly associated with decannulation. In contrast, neurologic comorbidities (p = 0.06), presence of gastrostomy tube (p < 0.001), or discharged on a home ventilator (p < 0.001) were associated with indefinite tracheostomy. When adjusting for age, sex, race, ethnicity, and insurance status, for every one month delay in establishment of outpatient otolaryngology care, time to decannulation was delayed by 0.5 months (p = 0.010). For each additional outpatient otolaryngology follow-up visit, time to decannulation increased by 3.36 months (p < 0.001).
Decannulation in pediatric tracheostomy patients is multifactorial. While timely establishment of outpatient care did correlate with quicker decannulation, factors related to medical complexity may have a greater impact on time to decannulation. Our results can help guide institutional decannulation protocols, as well as provide guidance when counseling families regarding tracheostomy expectations.
External peri-stomal skin granulations in paediatric tracheostomy: Incidence, outcomes and a proposed treatment algorithm
2024, International Journal of Pediatric Otorhinolaryngology
External peri-stomal skin granulations after tracheostomy in children are common and may interfere with routine tube changes. This study is the first attempt to describe the incidence and outcomes, along with a proposed treatment algorithm.
A retrospective review of all inpatient children with a tracheostomy between January 2020 and May 2022 at the Royal Hospital for Children (RHC) in Glasgow. The presence of external peri-stomal granulation, date of onset and resolution, recurrence and treatment modalities were noted. All tracheostomy tubes used during the study period were made of silicone.
A total of 50 episodes of peri-stomal granulation were identified in 27 children (52 %). Median age at the end of the study period was 4.3 years, with younger children experiencing more frequent granulation. 3 episodes interfered with tracheostomy tube changes. Time to resolution of the granulation was significantly longer with topical steroid/antimicrobial ointment monotherapy, but recurrence was less common when this was used a first treatment modality.
Non-invasive measures such as topical anti-microbials should be used in the first instance when managing external stoma-site granulations. More invasive measures, such as silver nitrate cautery and surgical excision, should be considered if the granulation tissue is not improving or when it poses a risk to safe tube changes.
Republication of: Tracheostomized children tracheal colonization and antibiotic resistance profile - A STROBE analysis
2023, Annales Francaises d'Oto-Rhino-Laryngologie et de Pathologie Cervico-Faciale
To verify the prevalence of Potentially pathogenic bacteria (PPB) and their antimicrobial resistance profile in tracheal aspirates of children with tracheostomy and compare it to clinical data.
A cross-sectional study was conducted in patients aged 0–18 years who all underwent tracheostomy cannula change (TCC) performed by the Otolaryngology Unit at Hospital de Clínicas de Porto Alegre, Brazil, between October, 2017 and December, 2018. Patients were submitted, at the time of TCC, to a tracheal aspirate through the tracheostomy and secretion was sent to microbiological analysis and antimicrobial susceptibility testing. Clinical data were evaluated through available patients’ electronic medical records.
Forty-four patients had their tracheostomy aspirate cultured and all but one presented PPB growth (97.7%). Median age was 3 years-old. Pseudomonas aeruginosa was the most prevalent bacteria (56.9%) and it was resistant to gentamycin, amikacin and cefepime in 36%, 28% and 12% of the culture tests, respectively. P. aeruginosa resistance to gentamycin and to cefepime suggested an association with the number of antibiotic classes used in the 12 months before enrollment (both p = 0.04) and with 2 or more hospital admissions in the same period (p = 0.03 and p = 0.02, respectively). Staphylococcus aureus was isolated in 9.1% and there was no MRSA.
It was found a 97.7% prevalence of PPB in the cultured aspirates; the most prevalent bacterium was P. aeruginosa and there was no MRSA identification. Data suggest an association between P. aeruginosa antimicrobial resistance with previous use of antibiotic therapy.
Tracheostomized children tracheal colonization and antibiotic resistance profile – A STROBE analysis
2023, European Annals of Otorhinolaryngology, Head and Neck Diseases
To verify the prevalence of Potentially pathogenic bacteria (PPB) and their antimicrobial resistance profile in tracheal aspirates of children with tracheostomy and compare it to clinical data.
A cross-sectional study was conducted in patients aged 0–18 years who all underwent tracheostomy cannula change (TCC) performed by the Otolaryngology Unit at Hospital de Clínicas de Porto Alegre, Brazil, between October, 2017 and December, 2018. Patients were submitted, at the time of TCC, to a tracheal aspirate through the tracheostomy and secretion was sent to microbiological analysis and antimicrobial susceptibility testing. Clinical data were evaluated through available patients’ electronic medical records.
Forty-four patients had their tracheostomy aspirate cultured and all but one presented PPB growth (97.7%). Median age was 3 years-old. Pseudomonas aeruginosa was the most prevalent bacteria (56.9%) and it was resistant to gentamycin, amikacin and cefepime in 36%, 28% and 12% of the culture tests, respectively. P. aeruginosa resistance to gentamycin and to cefepime suggested an association with the number of antibiotic classes used in the 12 months before enrollment (both p = 0.04) and with 2 or more hospital admissions in the same period (p = 0.03 and p = 0.02, respectively). Staphylococcus aureus was isolated in 9.1% and there was no MRSA.
It was found a 97.7% prevalence of PPB in the cultured aspirates; the most prevalent bacterium was P. aeruginosa and there was no MRSA identification. Data suggest an association between P. aeruginosa antimicrobial resistance with previous use of antibiotic therapy.
Complications of tracheostomy in children: a systematic review
2022, Brazilian Journal of Otorhinolaryngology
Tracheostomy is a procedure that can be associated with several well-described complications in the literature, which can be divided into transoperative, early postoperative and late postoperative. When performed in children, these risks are more common than in adults.
To perform a systematic review of complications, including deaths, in tracheostomized pediatric patients.
A search was carried out for articles in the Latin American and Caribbean Health Sciences Literature and PubMed databases. Cohort studies and series reports were selected, in addition to systematic reviews, published between January 1978 and June 2020, with patients up to 18 years old, and written in English, Spanish or Portuguese.
1560 articles were found, of which 49 were included in this review. The average complication rate was 40%, which showed an association with age, birth weight, prematurity, comorbidities, and emergency procedures. The most common complications were cutaneous lesions and granulomas. Mortality related to the procedure reached up to 6% in children and was mainly related to cannula obstruction or accidental decannulation.
Pediatric tracheostomy is associated with several complications. The tracheostomy-related mortality rate is low, but the overall mortality of tracheostomized patients is not negligible.
Tracheostomy practices in children on mechanical ventilation: a systematic review and meta-analysis
2022, Jornal de Pediatria
To evaluate current practices of tracheostomy in children regarding the ideal timing of tracheostomy placement, complications, indications, mortality, and success in decannulation.
The authors searched PubMed, Embase, Cochrane Library, Google Scholar, and complemented by manual search. The guidelines of PRISMA and MOOSE were applied. The quality of the included studies was evaluated with the Newcastle-Ottawa Scale. Information extracted included patients’ characteristics, outcomes, time to tracheostomy, and associated complications. Odds ratios (ORs) with 95% CIs were computed using the Mantel-Haenszel method.
Sixty-six articles were included in the qualitative analysis, and 8 were included in the meta-analysis about timing for tracheostomy placement. The risk ratio for “death in hospital outcome” did not show any benefit from performing a tracheostomy before or after 14 days of mechanical ventilation (p = 0.49). The early tracheostomy before 14 days had a great impact on the days of mechanical ventilation (-26 days in mean difference, p < 0.00001). The authors also found a great reduction in hospital length of stay (-31.4 days, p < 0.008). For the days in PICU, the mean reduction was of 14.7 days (p < 0.007).
The meta-analysis suggests that tracheostomy performed in the first 14 days of ventilation can reduce the time spent on the ventilator, and the length of stay in the hospital, with no effect on mortality. The decision to perform a tracheostomy early or late may be more dependent on the baseline disease than on the time spent on ventilation .

View all citing articles on Scopus

View full text

Paediatric tracheostomy—An 11 year experience at a Scottish paediatric tertiary referral centre

Abstract

Aims

Methods

Results

Conclusions

Introduction

Section snippets

Materials and methods

Patient demographics

Discussion

Conclusion

J. Pediatr. Surg.

J. Pediatr. Surg.

Int. J. Pediatr. Otorhinolaryngol.

Int. J. Pediatr. Otorhinolaryngol.

J. Pediatr. Surg.

Int. J. Pediatr. Otorhinolaryngol.

Int. J. Pediatr. Otorhinolaryngol.

J. Pediatr. Surg.

The changing indications for tracheostomy in children

J. Laryngol. Otol.

Pediatric tracheotomies: changing indications and outcomes

Laryngoscope

Tracheotomy in the preterm infant

Ann. Otol. Rhinol. Laryngol.