|Year : 2021 | Volume
| Issue : 4 | Page : 173-174
Tracheostomy in pediatric intensive care unit: Why, when, and how?
Suresh Kumar Angurana
Department of Pediatrics, Division of Pediatric Critical Care, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Submission||16-Jun-2021|
|Date of Acceptance||20-Jun-2021|
|Date of Web Publication||10-Jul-2021|
Dr. Suresh Kumar Angurana
Department of Pediatrics, Division of Pediatric Critical Care, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Angurana SK. Tracheostomy in pediatric intensive care unit: Why, when, and how?. J Pediatr Crit Care 2021;8:173-4
Tracheostomy is a common intervention performed in critically ill children admitted to the Pediatric intensive care unit (PICU). The advantages of tracheostomy include improvement in patient comfort, speech, and oral intake; better handling of secretions and airway toileting; and reduction in the risk of laryngeal injury as compared with endotracheal intubation. Previously, upper airway obstruction due to infective causes (such as diphtheria, croup, and epiglottitis) was the leading indications for tracheostomy, especially in developing countries. However, with availability of safe and effective vaccines, these indications are less prevalent these days. Now-a-days, the common indications for tracheostomy include prolonged mechanical ventilation, failure to wean from mechanical ventilation, long-term ventilation, and postextubation upper airway obstruction. The tracheostomies are now commonly performed as elective procedure for neurological indications and prolonged ventilation rather than emergency life-saving procedure for upper airway obstruction due to infective causes.,
The data on tracheostomy, trend, indications, timing, complications, and long-term outcome among pediatric population are available from the developed countries.,, Until recently, the literature regarding tracheostomy among Pediatric populations is limited from India. However, in last 4–5 years, few studies from India documented the changing trend of tracheostomy, indications, and outcome.,,,,,,
A recently published article titled “Indications and outcome of tracheostomy in a PICU: A prospective observational study” by Ranjan et al. is an important contribution to the limited literature in this field. The authors enrolled 73 children aged 3 months to 12 years (mean age 5.4 years) who underwent tracheostomy in the PICU of a tertiary care hospital over a period of 18 months (January 2018 to June 2019). Majority of tracheostomies were planned or elective (84.9%, n = 62). The most common indications for tracheostomy were neurological impairment (56.2%, n = 41) followed by upper airway obstruction (19.2%, n = 14). Half (52.1%) of the cases required prolonged mechanical ventilation (>14 days). The average duration of PICU stay before tracheostomy, average duration of PICU stay after tracheostomy, and average hospital stay was 15.4 days, 20 days, and 67.3 days, respectively. Tracheostomy-related complication was noted in 43.8% (n = 32) cases and common complications were supra-stomal granulations (21.9%, n = 16), tube block (8.2%, n = 6), persistent tracheocutaneous fistula (n = 3), and accidental decannulation (n = 1). During the study period, 69.9% (n = 51) cases underwent decannulation successfully after an average of 112 days of tracheostomy and rest (30.1%, n = 22) had decannulation failure. The most common cause of decannulation failure was subglottic stenosis. The most common cause for tracheostomy was neurological disorder in 64.4% (n = 47) cases including 6 cases with severe traumatic brain injury.
The recent studies from India demonstrated that the rate of tracheostomy among mechanical ventilated children varied from 4% to 10% and common reasons for tracheostomy were neurological diseases (35%–50%) and prolonged duration of mechanical ventilation (40%–90%). The average timing of tracheostomy in most of the studies was at the end of 2nd week of mechanical ventilation. Majority of the tracheostomies performed were elective (80%–92%). The rate of complications is varied from 20% to 55% and common complications included hemorrhage, accidental decannulation, tube occlusion, pneumothorax, and peristomal granulation. The successful decannulation was done in 55%–76% cases. The mortality directly attributable to tracheostomy was rare.,,,,,,,
The timing of tracheostomy is a contentious issue with no guidelines on the optimal timing of tracheostomy in Pediatric patients undergoing prolonged ventilation. There is some data (retrospective cohort studies) to support that early tracheostomy (after 7–14 days of mechanical ventilation) was associated with higher decannulation and weaning rate; lesser complications; lesser duration of mechanical ventilation, PICU stay, and total hospital stay; and significant reductions in mortality as compared to late tracheostomy., In the absence of randomized controlled trials, the timing and indications of Pediatric tracheostomy are a challenge for Pediatric intensivists and otorhinolaryngologists. They have to weigh the benefits and risks of tracheostomy and adding an additional morbidity of tracheostomy.
Pediatric tracheostomies are challenging to perform and thought to be associated with more complications and higher risk of mortality than adult cases. However, as more and more children are undergoing tracheostomy in PICU, intensivists and otorhinolaryngologists are gaining experience about the procedure, acute care of tracheostomy, long-term follow-up and care, and decannulation. The data demonstrated that the elective Pediatric tracheostomies are safe without any major short- and long-term side-effects and majority of children can be successfully decannulated during the same admission or during the follow-up. Furthermore, the attributable mortality to tracheostomy is negligible.,,,,,,, All these facts suggest that the elective pediatric tracheostomy is a safer procedure in experienced hands. The day is not far when tracheostomies will be performed by the pediatric intensivists with or without supervision of otorhinolaryngologists right at the bedside in the PICU.
| References|| |
Abdelaal Ahmed Mahmoud M Alkhatip A, Younis M, Jamshidi N, Hussein HA, Farag E, Hamza MK, et al
. Timing of tracheostomy in pediatric patients: A systematic review and meta-analysis. Crit Care Med 2020;48:233-40.
Roberts J, Powell J, Begbie J, Siou G, McLarnon C, Welch A, et al
. Pediatric tracheostomy: A large single-center experience. Laryngoscope 2020;130:E375-80.
Powell J, Buckley HL, Agbeko R, Brodlie M, Powell S. Tracheostomy trends in paediatric intensive care. Arch Dis Child 2021;106:712-4.
Gill J, Bhardwaj B, Singla S. Changing trends in indications of pediatric tracheotomy: A tertiary care center experience. J Laryngol Voice 2017;7:7-10. [Full text]
Sharma PK, Vinayak N. A Single center experience of pediatric tracheostomy. Indian Pediatr 2018;55:1091-2.
Lele SJ, Stephen S, Raman EV. Changing indications for pediatric tracheotomy: An urban Indian study. Indian J Otolaryngol Head Neck Surg 2019;71(Suppl 1):501-5.
Mishra P, Sharma S, Otiv M, Kapadia M. Pediatric tracheostomy: indications and outcomes from Indian tertiary care centre. Int J Otorhinolaryngol Head Neck Surg 2019;5:750-4.
Syed KA, Naina P, Pokharel A, John M, Varghese AM. Paediatric tracheostomy: A modified technique and its outcomes, results from a South Indian tertiary care. Int J Pediatr Otorhinolaryngol 2019;118:6-10.
Sarkar M, Roychowdhoury S, Bhakta S, Raut S, Nandi M. Tracheostomy before 14 days: Is it associated with better outcomes in pediatric patients on prolonged mechanical ventilation? Indian J Crit Care Med 2021;25:435-40.
Jain MK, Patnaik S, Sahoo B, Mishra R, Behera JR. Tracheostomy in pediatric intensive care unit: Experience from Eastern India. Indian J Pediatr 2021;88:445-9.
Ranjan A, Kumar P, Shivappa SK, Ahmed M. Basavaraja GV. Indications and outcome of tracheostomy in a pediatric intensive care unit (PICU): A prospective observational study. J Pediatr Crit Care 2021;8:182-85. [Full text]