A single-center 6-year experience with two types of pediatric tracheostomy

doi:10.1016/j.ijporl.2004.11.024

International Journal of Pediatric Otorhinolaryngology

Volume 69, Issue 5, May 2005, Pages 607-613

https://doi.org/10.1016/j.ijporl.2004.11.024 Get rights and content

Summary

Objective:

Among a wide variety of tracheostomy techniques, a vertical tracheal incision and a horizontal incision with creation of an inferior base tracheal flap have been favorized in children in the past. The aim of this study was to determine surgical and postoperative stoma complications after performing these two types of tracheal incision in tracheostomy in children.

Methods:

A 6-year, prospective, observational cohort study was undertaken in 24 children (range, 0.03 month–15 years) at the Department of Otorhinolaryngology, University of Ulm. All children who underwent an elective tracheostomy were included in this study. Early and late local disorders in wound healing of the tracheal stoma and the clinical follow-up of both groups (Flap group and Vertical group) were analyzed.

Results:

Formation of granulation tissue and tracheal stenosis were the most observed local disorders in both groups. Granulation tissue at the level of the stoma was the most frequently observed complication in the Flap group (4/12; 33%), whereas in the Vertical group only one child showed granulation tissue around the stoma (1/7; 14%). The difference between both groups was statistically not significant. The overall mortality rate 1 year after tracheostomy was 25% (6/24) and the tracheostomy-related death rate was 4% (1/24). An association of wound healing disorders with a feasible lethal outcome was not found after both tracheostomy types. There were no differences in the outcome between both tracheal incision types.

Conclusions:

Both types of tracheal incision proved to be a suitable surgical procedure for temporary or permanent tracheostomy in pediatric patients.

Introduction

Several retrospective studies on pediatric tracheostomy and different surgical techniques have been performed when infant tracheostomy was mainly performed because of laryngotracheobronchitis and epiglottitis [1], [2], [3], [4]. During the last decade, the main indications for pediatric tracheostomy have changed significantly. Nowadays, the main indications are respiratory insufficiency due to underlying neurologic and neuromuscular diseases and prolonged ventilator dependence because of upper or lower airway diseases or systemic deteriorating diseases, with an increase of late postoperative complications due to the stoma and cannulation [5], [6], [7], [8], [9], [10].

Several types of operative techniques, including different tracheal incisions such as vertical incision [2], [4], [6], [8], [11], [12], [13] and creation of inferiorly [3], [4], [10], [14], [15] or superiorly [16] based tracheal flaps, in children have been reported. Vertical tracheal incision [17], [18], [19] and creation of inferiorly [17], [18], [20] or superiorly [19] based tracheal flaps in animal models have also been studied. The incidence of late complications related to the stoma or tracheal lesions such as tracheal stenosis, formation of granulation tissue, suprastomal collapse, or fatal complications could not clearly be related to the type of tracheal incision or the creation of a tracheal flap [21], [22]. Among this wide variety of surgical techniques, a vertical tracheal incision [6], [8], [11], [12], [13] and a horizontal incision with creation of an inferior base tracheal flap [3], [10], [14], [15] have been favorized in the past. To our knowledge, however, only retrospective evaluations and reviews in pediatric tracheostomies have been published during the last 30 years.

To validate both types of tracheal incision (i.e., vertical incision versus horizontal incision with creation of a Björk flap [21]) in tracheostomy in children, we prospectively followed 24 consecutive pediatric patients for tracheostomy tube handling and early and late wound healing disorders and complications.

Section snippets

Patient population

The investigation was a prospective observational 6-year cohort study from September 1, 1996, until August 31, 2002. Twenty-four children (19 males and 5 females), hospitalized at the Ulm University Hospital, were enrolled in the study (Table 1). The main indications for tracheostomy were neurologic or neuromuscular underlying diseases, CNS diseases, and congenital or acquired airway anomalies. The age limit for inclusion was ≤15 years. Only those tracheostomies performed and managed by members

Early complications (first evaluation)

There were no serious perioperative complications. The mortality rate during the first (early) evaluation period was 4% (1/24), the tracheostomy-related death rate was 0% (0/24). Minor wound healing disorders in only few cases were stoma infection, bleeding, and stomal narrowing in the Flap group (Table 2). In one child, a displacement of the tracheal tube was noted which was recognized immediately without serious long-term complication (Table 3).

Late complications (second evaluation)

During the second evaluation period (6 weeks–6

Discussion

The aim of this study was to prospectively evaluate the clinical outcome and complications, wound healing disorders, and cannula handling in children after tracheostomy. Two different tracheostomy techniques, a vertical tracheal incision and an inferiorly based tracheal flap technique, were compared. For this purpose, over a 6-year period, a prospective database was initiated and 24 children, hospitalized at the Ulm University Hospital, who underwent an elective tracheostomy were included in

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Cited by (16)

Epidemiology of pediatric tracheotomy: A population-based study using National Health Insurance Research Database in Taiwan
2022, International Journal of Pediatric Otorhinolaryngology
Tracheostomy in children is a surgical procedure with considerable morbidity and mortality. However, there is still a lack of population-based survey in pediatric tracheostomy. This study analyses population-based data in pediatric tracheostomy among different ages in Taiwan.
This study used National Health Insurance Research Database in Taiwan. All children (aged <18 years) who underwent tracheostomy during 1997–2016 were identified. We retrieved data regarding baseline characteristics, perioperative care, and mortality associated with pediatric tracheostomy, and compared differences in variables between different age groups.
We observed that 2300 children received tracheostomy (mean age, 8.7 years; 64% boys). Regarding the age group distribution of the patients, 585 (25.4%) were infants (<1 year), 227 (9.9%) were toddlers (1–3 years), 175 (7.6%) were preschool-aged children (3–6 years), 317 (13.8%) were school-aged children (6–12 years), and 996 (43.3%) were adolescents (12–18 years). Surgical indications included pulmonary disorders (64.9%), neurological disorders (38.4%), trauma (32.3%), head injury (25.2%), and congenital anomalies (21.5%). Of these patients, 94.9% required intensive care unit (ICU) care, with the mean length of ICU stay being 63.8 days. The mean length of hospital stay was 74.5 days. The overall mortality at the last follow-up was 43.96% (1011/2300), and the tracheostomy related mortality at the last follow-up was 1.43% (33/2300). Compared with adolescents, infants more commonly underwent tracheostomy in the northern area (66.7% vs 37.2%, P < .001), more commonly received tracheostomy indicated by congenital anomalies (53.7 vs 4.6%, P < .001), had longer ICU stays, had longer hospital stays (100.7 vs 57.5 days, P < .001), and had a higher 5-year mortality rate (42.4 vs 29.6%, P < .001). Multivariable logistic and Cox regression models revealed that young age was associated with an increased risk of prolonged hospital stay and long-term mortality, respectively.
This study elaborates the epidemiology of pediatric tracheostomy in different age groups.
Factors associated with the occurrence of stomal stenosis after tracheostomy in adults
2021, Auris Nasus Larynx
Citation Excerpt :
Other studies have indicated that the use of Bjork's inferiorly based flap increased the incidence of stomal granulations [10,30]. Formation of stomal granulation was not associated with tracheostomy techniques, a vertical tracheal incision, or a horizontal tracheal incision with creation of an inferiorly base tracheal flap [31]. Studies on the relationship between percutaneous dilatational tracheostomy and tracheostomy-related granulation have shown conflicting results.
Although tracheal stomal stenosis can be life-threatening, factors associated with the occurrence of stomal stenosis remain unknown. This study was performed to evaluate these factors in adult patients.
We retrospectively identified adult patients who underwent tracheostomy from 2010 to 2016 using a Japanese national inpatient and outpatient database. We performed Cox proportional hazard regression analyses to evaluate factors associated with the occurrence of tracheal stomal stenosis.
We obtained data on 25,436 eligible patients. The proportion of tracheal stomal stenosis was 0.9%. Tracheal stomal stenosis was significantly less likely to occur in patients with regular use of oral steroids [hazard ratio (HR), 0.28; 95% confidence interval (CI), 0.09–0.88; P = 0.03] and in male patients (HR, 0.75; 95% CI, 0.57–0.97; P = 0.03). The occurrence of tracheal stomal stenosis was significantly associated with use of a mechanical ventilator at home (HR, 2.54; 95% CI, 1.55–4.15; P < 0.001) and a body mass index of <18.5 kg/m² (HR, 1.45; 95% CI, 1.06–1.99; P = 0.02).
Our study revealed several factors that are associated with tracheal stomal stenosis. These findings may help physicians to manage tracheal stomas.
Pediatric Tracheotomy and Decannulation
2021, Cummings Pediatric Otolaryngology
Pediatric tracheotomy can greatly improve the lives of the sickest children. Although most surgical cases are technically straightforward for an experienced otolaryngologist, the complexity of tracheotomy lies in the postoperative management. Once a tracheotomy tube has been placed, meticulous care is required to avoid complications. Early rehabilitation of a child with a tracheotomy is essential to preserve normal development and function. Children should be decannulated carefully and expeditiously through a multidisciplinary approach. This chapter discusses the practical management of tracheotomies through a review of recent literature and best practices.
Tracheostomy in childhood: review of the literature on complications and mortality over the last three decades
2017, Brazilian Journal of Otorhinolaryngology
Citation Excerpt :
One hundred and 32 articles that represented case reports and case series were excluded. After another review for relevance by two independent otolaryngologists, 547 articles were excluded and 47 articles remained.1–47 Most of the papers excluded at this time did not have sufficient data for review.
Tracheostomy is a procedure with unique characteristics when used on pediatric patients due to the greater technical difficulty and higher morbidity and mortality rates relative to the procedure in adults. In recent decades, there have been significant changes in the medical care available to children, particularly for those who need intensive care. Surgical conditions have also improved, and there has been an advent of new equipment and medications. These advances have brought changes to both tracheostomy indications and tracheostomy complications.
To perform a review of the articles published over the last three decades on the complications and mortality associated with tracheostomies in children.
Articles were selected from the Cochrane, Latin American and Caribbean Health Sciences Literature, SciELO, National Library of Medicine (Medline Plus), and PubMed online databases. The articles selected had been published between January 1985 and December 2014, and the data was compared using the Chi-square test.
A total of 3797 articles were chosen, 47 of which were used as the basis for this review. When the three decades were evaluated as a whole, an increase in tracheostomies in male children under one year of age was found. The most common complications during the period analyzed in descending order of frequency were granuloma, infection, and obstruction of the cannula, accidental decannulation, and post-decannulation tracheocutaneous fistula. In the second and third decades of the review, granulomas represented the most common complication; in the first decade of the review, pneumothoraces were the most common. Mortality associated with tracheostomy ranged from 0% to 5.9%, while overall mortality ranged from 2.2% to 59%. In addition, the review included four studies on premature and/or very underweight infants who had undergone tracheostomies; the studies reported evidence of higher mortality in this age group to be largely associated with underlying diseases.
Improved surgical techniques and intensive care, the creation of new medications, and vaccines have all redefined the main complications and the mortality rates of tracheostomy in children. It is a safe procedure that increases chances of survival in those who require the prolonged use of mechanical ventilation.
A traqueostomia é um procedimento com características exclusivas quando usada em pacientes pediátricos devido à maior dificuldade técnica e maiores taxas de morbidade e mortalidade em relação ao procedimento em adultos. Nas últimas décadas, houve mudanças significativas na assistência médica disponível para crianças, especialmente para aqueles que necessitam de cuidados intensivos. As condições cirúrgicas também melhoraram e houve um advento de novos equipamentos e medicamentos. Estes avanços trouxeram mudanças tanto para as indicações de traqueostomia como para as suas complicações.
Realizar uma revisão dos artigos publicados ao longo das últimas três décadas sobre as complicações e mortalidade em crianças associadas a traqueostomia.
Os artigos foram selecionados das bases de dados online da Cochrane, Latin American and Caribbean Health Sciences Literature, SciELO, National Library of Medicine (Medline Plus) e PubMed. Os artigos selecionados foram publicados entre janeiro de 1985 e dezembro de 2014 e os dados foram comparados com uso de teste do Chi-quadrado.
Foram selecionados 3.797 artigos, 47 dos quais foram usados como base para esta revisão. Quando as três décadas foram avaliadas como um todo, encontrou-se um aumento das traqueostomias em crianças do sexo masculino com menos de um ano de idade. As complicações mais comuns no período analisado, em ordem decrescente de frequência, foram granuloma, infecção, obstrução da cânula, decanulação acidental e fístula traqueocutânea pós-decanulação. Na segunda e terceira décadas de revisão, os granulomas representaram a complicação mais comum; na primeira década da revisão, pneumotórax foram as mais comuns. A mortalidade associada à traqueostomia variou de 0% a 5,9%, enquanto que a mortalidade global variou de 2,2% a 59%. Além disso, a revisão incluiu quatro estudos sobre lactentes prematuros e/ou nascidos com muito baixo peso que tinham sofrido traqueostomias; os estudos relataram evidências de que a maior mortalidade nessa faixa etária era em grande parte associada a doenças subjacentes.
A melhoria das técnicas cirúrgicas e de cuidados intensivos, a criação de novos medicamentos e vacinas redefiniram as principais complicações e as taxas de mortalidade da traqueostomia em crianças. É um procedimento seguro que aumenta as chances de sobrevida naqueles que requerem o uso prolongado de ventilação mecânica.
Changes in pediatric tracheostomy 1982-2011: A Canadian tertiary children's hospital review
2014, Journal of Pediatric Surgery
Pediatric tracheostomy has undergone notable changes in frequency and indication over the past 30 years. This study investigates pediatric tracheostomy at British Columbia Children's Hospital (BCCH) over a 30-year period.
A retrospective chart review of tracheostomy cases at BCCH from 1982 to 2011 was conducted. Charts were reviewed for demographics, date of tracheostomy, indication, complications, mortality and date of decannulation. Data from three 10-year time periods were compared using Fisher's Exact test to examine changes over time.
251 procedures (154 males) performed on 231 patients were reviewed. Mean age at tracheostomy was 3.74 years with 48% of procedures undertaken before the age of one year. Frequency of procedure by year has generally declined into the early 2000's. Upper airway obstruction was the most common indication accounting for 33% of procedures. The rate of complication across the entire cohort was 22% with 63% of patients being decannulated. Tracheostomy related mortality occurred in 2.0% of cases reviewed.
Changes occurred in primary indications with infections indicating less procedures and neurological impairments indicating more procedures over time. Complications increased and the decannulation rate decreased over this 30-year review. Pediatric tracheostomy is considered a safe and effective procedure at BCCH.
Complications of Tracheostomy and Tracheal Surgery
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A single-center 6-year experience with two types of pediatric tracheostomy

Summary

Objective:

Methods:

Results:

Conclusions:

Introduction

Section snippets

Patient population

Early complications (first evaluation)

Late complications (second evaluation)

Discussion

Int. J. Pediatr. Otorhinolaryngol.

J. Pediatr. Surg.

Int. J. Pediatr. Otorhinolaryngol.

Am. J. Otolaryngol.

Clin. Chest. Med.

Tracheotomy in pediatrics

Ann. Otol.

Paediatric tracheotomy

Can. J. Otolaryngol.

Tracheostomy in children

Arch. Otolaryngol.

Pediatric tracheostomy. Experience during the past decade

Ann. Otol. Rhinol. Laryngol.

Paediatric tracheotomy: Sheffield experience 1979–1999

J. Laryngol. Otol.

Pediatric tracheotomies: changing indications and outcomes

Laryngoscope

Pediatric tracheotomies: changing trends

J. Otolaryngol.

Suprastomal granulation tissue and pediatric tracheotomy decannulation

Laryngoscope