The influence of peak airway pressure and oxygen requirement on infant tracheostomy

https://doi.org/10.1016/j.ijporl.2012.02.062Get rights and content

Abstract

Objective

To determine if and how the preoperative peak airway pressure and oxygen requirement of an infant (less than 6 months of age) who requires mechanical ventilation influences the physician's decision to perform a tracheostomy on that infant.

Study design

Nationwide survey.

Subjects

Pediatric Otolaryngologists.

Methods

A web-based survey was developed and sent to all members of the American Society of Pediatric Otolaryngology.

Results

150 of the 348 surveys were returned (43%). The majority of respondents do not consider the patient's requirement for elevated peak airway pressure (PAP) or the patient's requirement for a high percentage of oxygen as a contraindication to performing a tracheostomy in that patient (54.7 and 72.1% respectively). The presence of preoperative high PAP influenced 68.2% of respondents to consider using a cuffed tracheostomy tube. In the immediate postoperative period, the most common complication resulting in significant morbidity or mortality was mucous plugging, and the majority of respondents attributed postoperative morbidity and mortality to preoperative pulmonary comorbidity.

Conclusions

Preoperative PAP and the patient's oxygen requirement do not influence the surveyed otolaryngologists’ decision whether or not to perform a tracheostomy in the infant population. However, PAP do influence whether or not a cuffed tracheostomy tube is used.

Introduction

The preoperative indications for the placement of a tracheostomy in an infant (less than 6 months of age) are generally accepted and include: ventilator dependence, upper airway obstruction, and pulmonary toilet [1], [2], [3], [4], [5], [6], [7], [8]. However, it has yet to be determined if and how preoperative physiologic parameters influence the physician's decision to perform a tracheostomy in an infant. In the adult population, peak airway pressures (peak inspiratory pressures or PAP) above 35 cm H2O and FiO2 above 50% are considered relative contraindications to performing a tracheostomy [9]. When an endotracheal tube (ETT) is in place, high peak airway pressures are achievable due to the physiologic airway seal formed by the tongue, pharyngeal and laryngeal tissues that are compressed around the tube as well as to the seal from the ETT cuff itself. When a tracheostomy tube is in place the physiologic seal is no longer present and only the cuff on the tube is maintaining the seal. The cuff, when fully inflated, is not sufficient to maintain pressures above 35 cm H2O. Also, a fully inflated or over inflated cuff may damage the trachea when left in place for long periods of time. In the infant population, the use of preoperative ventilation parameters as a relative contraindication to surgery has not typically been so explicit. Few references discuss preoperative ventilatory parameters and only briefly mention them as guidelines [10]. To date, no study has examined these parameters as predictors of post-operative complications of tracheostomy among infants.

This study evaluates the relative importance of preoperative ventilator parameters to practicing otolaryngologists prior to performing a tracheostomy in the infant population. A nationwide survey of members of the American Society of Pediatric Otolaryngologists (ASPO) was conducted. The survey examined the physiologic parameters pediatric otolaryngologists consider in their preoperative evaluation and the postoperative complications encountered by pediatric otolaryngologists who perform tracheostomies in this population.

Section snippets

Questionnaire

An 18-item survey was developed and distributed to ASPO members to question which preoperative ventilation parameters and to what degree those parameters affect their decision to place a tracheostomy in an infant. Postoperative complications and the physician's interpretation of the factors contributing to complications were also questioned. The questionnaire was designed and reviewed by the authors. Approval was given through the Institutional Review Board.

Sample

The web-based survey was sent as a

Composition of respondents

Sixty-four percent of respondents have been in practice for more than 15 years. Seventy two percent of respondents practice in an academic/tertiary care setting and ninety percent are primarily affiliated with a hospital that runs a Level III NICU. Ninety-six percent of the respondents devote over three-quarters of their practice to pediatric patients. Seventy-six percent of subjects report performing between one and ten tracheostomies in the infant population within the last year.

Pre-operative characteristics

The

Discussion

Tracheostomy in the infant population is a safe and effective means to provide a reliable, stable airway in a critically ill child. However, when the patient has pulmonary or cardiac comorbidities necessitating elevated PAP, a tracheostomy may not be adequate to support ventilation and leaving the infant intubated with an ETT may be the better short term option. We believe that ventilator parameters are significant predictors of potential postoperative complications and guidelines for

Conclusion

In the predominantly academic pediatric otolaryngology community surveyed, 64% have been in practice for over 20 years and 91% have access to a level III NICU. Fifty-four percent of these physicians do not consider PAP and 72% do not consider preoperative FiO2 requirements when deciding to perform a tracheostomy on an infant. Elevated PAP influences the pediatric surgeon's choice of a cuffed tracheostomy tube 68% of the time. These results suggest that the preoperative ventilator parameters for

Financial disclosure

There was no financial support for this project.

Conflict of interest

None of the authors have a conflict of interest to report.

References (11)

There are more references available in the full text version of this article.

Cited by (0)

View full text
Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.