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| ORIGINAL ARTICLE |
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| Year : 2017 | Volume
: 7
| Issue : 1 | Page : 7-10 |
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Changing trends in indications of pediatric tracheotomy: A tertiary care center experience
Jaskaran Singh Gill, Bhanu Bhardwaj, Sumant Singla
Department of ENT and Head and Neck Surgery, Sri Guru Ram Dass Institute of Medical Sciences and Research, Amritsar, Punjab, India
| Date of Web Publication | 14-May-2018 |
Correspondence Address:
Dr. Bhanu Bhardwaj
27-C Sant Avenue, The Mall, Amritsar - 143 001, Punjab
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jlv.JLV_5_17
 Abstract | | |
Background: Tracheotomy is one of the oldest procedures in medical science. In children, its role began as an emergency procedure to relieve stridor of infectious origin. There has been a change in the indications of tracheotomy over the past few years due to change in the epidemiology of pediatric diseases and advanced medical facilities. Still, a severe lacuna exists in the literature regarding the timing and indications of pediatric tracheotomy. It is a dilema for an otolaryngologist as to when he is justified in giving a child this added morbidity. Aims: To study the changing indications in a pediatric tracheotomy at a tertiary care center. Materials and Methods: A prospective study of 56 children who underwent tracheotomy was carried out over 4 years period at a tertiary care hospital in Punjab. Results: Out of 56 children studied, 19% of children had a tracheotomy for infectious etiology, 41% had a tracheotomy for prolonged intubation 5.3% for laryngotracheal stenosis, and 16% for head injury. Conclusion: With the development of advanced pediatric anesthesia techniques and vaccinations the role of pediatric tracheotomy is changing from an emergency life savior to a more elective procedure. Globalization with regards to the timing and indications of pediatric tracheotomy is the need of the hour to improve the overall mortality of children from various diseases.
Keywords: Changing, indications, pediatric, tracheotomy, trends
How to cite this article:
Gill JS, Bhardwaj B, Singla S. Changing trends in indications of pediatric tracheotomy: A tertiary care center experience. J Laryngol Voice 2017;7:7-10 |
| Background | |  |
Tracheotomy is one of the oldest medical procedures known.[1] It is a lifesaving procedure which has stood the test of time being routinely used since the middle of the 19th century.[2] However from the past three decades, this procedure has extended collaboration of both the otolaryngologists and the pediatricians in all tertiary care centers saving lives of many children.[3] The marked development of advanced neonatal care and anesthesia techniques in the past three decades have brought a substantial change in indications for pediatric tracheotomy. There is a paradigm shift of role of pediatric tracheotomy in neonatal care as this procedure has evolved from being just a reliever of upper airway obstruction of infectious origin on emergency basis initially to that of a more elective procedure.[4] The current indications of pediatric tracheotomy are varied. It is done for respiratory support in cases of prolonged orotracheal intubation, for pulmonary toileting in cases of hypoventilation and chronic aspiration associated with neurologic disorders, such as brain palsy and to manage upper airway obstruction caused by craniofacial malformations); laryngotracheal stenosis and trauma.[5] As the expanse of this procedure is getting widened so is the increased mental and economic burden of tracheotomy tube placement on the family as well as child's psychology. This entails that pediatric tracheotomy should be a detailed thoughtful decision rather than being done in every case where the child is critically ill. There is a need for guidelines which standardize the protocols of pediatric tracheotomy. The goal and purpose of the present study were to analyze the current trends associated with pediatric tracheotomies in our institute.
| Materials and Methods | | |
The present study was carried out in the Department of Otolaryngology and Head and Neck Surgery at a tertiary care hospital in Punjab for 4 years from September 2011 to September 2015. Records of all the 56 children under the age of 14 years who underwent tracheotomy during this period for various indications were kept in terms of their gender, the type of procedure (whether it was done as an emergency procedure or as an elective) and indications for which the tracheotomy was done. Informed consent including death on table in worse scenarios was obtained. The procedure was done in the presence of an anesthetist and a pediatrician in pediatric Intensive Care Unit (ICU) or pediatric emergency. The standard open surgical technique for tracheotomy followed by suturing of the trachea to the skin and insertion of the appropriately sized tracheotomy tube. The data so-obtained were analyzed. Indications were divided into nine categories as follows: prolonged intubation, obstructive sleep apnea infective airway obstruction, head injury, maxillofacial trauma, subglottic stenosis neuromuscular incoordination, and congenital lesions and laryngeal papillomatosis. Age of children was classified as neonates (<28 days), infants (up to 2 years), preschool (2–6 years), school going (7–9 years), and adolescents (from 10 to 14 years). Any death of a child which occurred on the operation table during the procedure was considered to be mortality due to tracheotomy.
| Results | | |
The total number of children that went under tracheotomy in our institute in our 4 years study period was 56. The mean age calculated was 5.5 years with most of the children who underwent tracheotomy were in preschool age group 2–6 years (31%) followed by the school going children (7–9 years) (26.1%) and adolescents (10–14 years) (25%). Only one neonate was tracheotomised who was 5 days old. Most of the children in our study were males (51.78%) as compared to females (48.21%). Nearly 76% (43 out of 56) were elective tracheotomies, whereas 23% were emergency tracheotomies [Figure 1]. The most common indication was prolonged intubation (41%) followed by infective airway obstruction (19.6). Head injury was a common indication in (16%) followed by congenital lesions (7%) severe maxillofacial trauma (5.3%), subglottic stenosis (5.3%), and laryngeal papillomatosis (3.5%) [Table 1] and [Figure 2]. | Figure 1: Distribution of total pediatric tracheotomies done into elective and emergency cases
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All the tracheotomies had successful outcomes in terms of mortality except one patient (5-day-old) which died on the table.
| Discussion | | |
The main indication for tracheotomy in the late 70s and 80s were infectious etiology including diphtheria, epiglottitis, and larynotracheobronchitis. The introduction of endotracheal intubation, Hemophilus Influenzae type B vaccine for acute epiglottitis; vaccine against corynebacterium diphteriae, and ICU care, the indications of tracheotomy for infectious acute diseases declined dramatically.[3],[6] Arcand and Grangerin their study have observed this decline from 50% to 3% when they compared the period from 1970 to 1975 with the one from 1980 to 1985.[7] Waddell et al. had only 3 out of 84 children who were reviewed for decanulation being tracheotomised for infection.[8]
In this study, however, 11 out of 56 (19%) children were tracheotomized because of acute infective upper airway obstruction. Of these 11, only 1 child was diagnosed with diphtheria who finally succumbed to disease even after a successful tracheotomy. Three children had epiglottitis, whereas 1 had croup. Six out 11 of the children in this group had deep neck space infections which included paratonsillar followed by parapharyngeal and submandibular space infections in this order. This was also similar to study by Waki et al. who also quoted acute upper respiratory obstruction of the airway as a declining indication but differ from Crysdale et al. who in their study in 1988 reported a higher incidence of airway obstruction.[9],[10] Butnaru et al. and Mahadevan et al. reported that prolonged intubation was the main indication in 57% and 70% of their series, respectively.[11],[12]
Our series also had 41% of children who were tracheotomized for a similar reason. This correlated well with 44.7% in the study by Parrilla et al. Children who require ventilatory support for many weeks or months need tracheotomies to facilitate pulmonary toilet and to reduce chronic laryngotracheal lesions related to long-term intubation, such as subglottic stenosis or tracheomalacia. Therefore, long-term intubation itself and the relevant sequelae have become the most important indication for tracheotomy in the recent years.[13]
Conversely, among the indications for tracheotomy, an increase of acquired subglottic stenosis, neuromuscular diseases, premature birth, and congenital anomalies could be observed.[7],[14] The increase of acquired subglottic stenosis is certainly due to prolonged endotracheal intubation, which became the most important indication for tracheotomy in several reports, ranging from 28% to 36%.[11],[15],[16] Although in cases of laryngotracheal stenosis, it is indicated to observe and follow the patient up when the obstruction does not cause respiratory distress to the child, nor interferes in his/her daily activities, feeding, sleep, growth, and development. With the introduction of cricoid split and single stage laryngotracheal reconstruction, one can avoid the need for tracheotomy. Nonetheless, in most of the cases, tracheotomy is needed because of the respiratory distress, to secure the airway in the postoperative or when the age of the patient prevents surgical reconstruction.[17],[18]
In our series, however, only 5.3% were tracheotomized for subglottic stenosis. This is due to an early intervention by tracheotomy in children who require prolonged intubation. Although studies indicate that depending on endoscopic and clinical findings the period of intubation before tracheotomy can be decided from 2 to 134 days.[19],[20] In the present study, this average period of intubation before tracheotomy was 20 days. This was done because several authors suggest a weekly fiber optic control or an early tracheostomy (when indicated) for children who are intubated for a long-term period, to avoid subglottic or tracheal stenosis.[16],[20] Since a weekly fiberoptic control becomes cumbersome in children, we followed an early tracheotomy which also may be the reason for an average of 1.1 tracheotomy/month at our center. Trauma was another major indication with 16% of cases having tracheotomy following head injury and 5.3% of cases having tracheotomy due to mandibular and maxillary fractures causing difficult intubation and severe facial edema. This was supported by a study by Holscher et al. who did a comprehensive retrospective review of 91 children and documented that early tracheotomy in children going under trauma was associated with fewer ventilator days, ICU days, hospital days, and tracheal complications compared to those undergoing tracheotomy after postinjury day 7 and those undergoing prolonged intubation.[21]
Congenital lesions (7%) and laryngeal papillomatosis (3.5%) for all tracheotomies in our study. Congenital cases included cystic hygroma; laryngeal cleft and vascular malformations. A vertical incision was preferred in emergency situations due to a rapid exposure and in children with short neck. A horizontal incision was preferred in children with elective procedures and thin built.
Pediatric tracheotomy is technically more demanding than the one performed on adults, due to the smaller, more pliable trachea and to the limited extension of the operating field. It has a higher mortality, morbidity and complication rate, well supported with documentary evidence.[22] Although the comprehensive analysis of the available literature shows that indications, epidemiology, and complications are changing; however, there are no definite guidelines that specify when to perform a tracheotomy in critical children. Part of the problem may be due to researchers studying the effect of tracheotomy have focused mainly in adults Due to the lack of guidelines the decision to perform tracheotomy in children is currently based on clinical outcome which may not lead to an optimal outcome and is definitely not justified in today's era where medical science is doing marvels.
In a survey of members of the American Academy of Otolaryngology–Head and Neck Surgery Foundation, most members agreed that a clinical practice guideline regarding tracheotomy care would be useful.[23] Standardization of posttracheotomy care in pediatric patients may help to improve the quality of patient care, potentially reduce the risk of unnecessary procedures, and decrease the economic burden of chronic tracheotomy care.
| Conclusion | | |
Most of the available literature focuses on complications from tracheotomies. Few report on overall tracheotomy rates. The study throws light on the changing indications in a developing country and the impact this procedure is having in the current management of critically ill patients. Although current guidelines are lacking, we recommend that tracheotomy is a safe procedure in children, and it should be used in all children who require prolonged ventilatory support with a tendency toward an early tracheotomy.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1]
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