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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 4  |  Page : 182-185

Indications and outcome of tracheostomy in a pediatric intensive care unit: A prospective observational study


1 DepartmentofPediatrics,KarwarInstituteofMedicalSciences,Karwar, Karnataka, India
2 DepartmentofPediatricOtorhinolaryngology, IGICH,Bengaluru,Karnataka, India
3 DepartmentofPediatrics, IGICH,Bengaluru,Karnataka, India

Date of Submission20-Jan-2020
Date of Decision16-Jun-2021
Date of Acceptance20-Jun-2021
Date of Web Publication10-Jul-2021

Correspondence Address:
Dr. Gangasamudra Veerappa Basavaraja
ProfessorandInchargePediatricCriticalCareUnit, DepartmentofPediatricMedicine,IGICH,Bengaluru-560029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpcc.jpcc_173_20

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  Abstract 


Background: Over the past decades, the indications for tracheostomy in children and the routine posttracheostomy course have changed significantly. The purpose of this study was to identify the indications, complications, and outcomes of pediatric tracheostomy.
Subjects and Methods: This prospective observational study was conducted involving all children admitted to the pediatric intensive care unit (PICU) requiring tracheostomy from January 2018 to June 2019. A pre-structured proforma was used. The data regarding indications of tracheostomy, complications, and outcomes were analyzed. Patients were followed up till decannulation during the study period.
Results: Out of 73 patients included in the study, 68.5% (n = 53) were males and 31.5% (n = 20) were females, with a mean age of 5.4 years. The most common primary indication for tracheostomy was neurological impairment (56.2%, n = 41) and airway obstruction (19.2%, n = 14). The average duration of PICU stay at the time of tracheostomy was 15.4 days. Prolonged mechanical ventilation was required in 62.3% of patients. Elective tracheostomy was done in 84.9% of patients. Complications due to tracheostomy were noted in 43.8% (n = 32) of cases, of which suprastomal granulations were the most common. The average length of PICU stay after tracheostomy was 21.8 days. The rate of successful decannulation was 69.9%. The most common cause for decannulation failure was subglottic stenosis.
Conclusions: Neurological impairment requiring prolonged mechanical ventilation was the most common indication for tracheostomy. Suprastomal granulations were the most common complication and subglottic stenosis being the most common cause for decannulation failure.

Keywords: Decannulation failure, decannulation, prolonged mechanical ventilation, tracheostomy


How to cite this article:
Ranjan AA, Kumar P P, Shivappa SK, Ahmed M, Basavaraja GV. Indications and outcome of tracheostomy in a pediatric intensive care unit: A prospective observational study. J Pediatr Crit Care 2021;8:182-5

How to cite this URL:
Ranjan AA, Kumar P P, Shivappa SK, Ahmed M, Basavaraja GV. Indications and outcome of tracheostomy in a pediatric intensive care unit: A prospective observational study. J Pediatr Crit Care [serial online] 2021 [cited 2021 Sep 19];8:182-5. Available from: http://www.jpcc.org.in/text.asp?2021/8/4/182/321098




  Introduction Top


As soon as the need for prolonged airway access is identified in critically ill children on mechanical ventilation, tracheostomy should be considered.[1],[2] Over the past couple of decades, the indications for tracheostomy in children have changed significantly.[3] In the past, acute infections such as diphtheria, croup, and epiglottitis were the leading causes of airway compromise leading to pediatric tracheostomy.[4] These indications have become less common due to the availability of effective vaccines and widespread immunization of children. With the changing clinical indications for tracheostomy, the routine posttracheostomy course has also undergone a substantial evolution.[5]

Majority of the available studies on tracheostomy are retrospective analytical studies largely in adults. There is also a need for guidelines to standardize the protocols of pediatric tracheostomy.[6] Prospective studies are, therefore, required to study the indications and outcomes of tracheostomy in pediatric patients. The purpose of this study was to identify the indications, complications, and outcomes of pediatric tracheostomy in pediatric intensive care unit (PICU).


  Materials and Methods Top


This was a prospective observational study carried out over a period of 18 months (January 2018 to June 2019) in a PICU of a pediatric tertiary care hospital. Children aged 1 month to 18 years who underwent tracheostomy during the study period were included. Children with tracheostomy tube in situ were excluded from the study. [Figure 1] shows the study flow pattern. The study protocol was approved by the institutional ethics committee, and written informed consent was obtained from parents of each patient before enrollment.
Figure 1: Study flow diagram

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The PICU at the study center is equipped with 35 beds and 20 ventilators with 5000–5100 admissions per year, and out of them, 1000–1100/year undergo mechanical ventilation. All elective tracheostomies were done by a single pediatric otorhinolaryngologist in the operating theater to maintain uniformity and strict asepsis. The tracheostomy was done by a horizontal skin incision followed by blunt dissection till the trachea with proper hemostasis. A vertical incision over the trachea and placement of the appropriate sized tube completed the procedure. Decannulation was attempted in all tracheostomized patients by subjecting them to laryngotracheobronchoscopy. If the airway was favorable, decannulation was done. Downsizing of the tracheostomy tube was done if there was airway stenosis or evidence of abductor palsy. Posttracheostomy care was a team effort that involved the resident doctors, nursing staff, and parents and caregivers of the patient. The parents were educated and trained about suctioning, use of suction catheter, and suction machine by proper demonstration.

A pre-structured proforma was used to collect the data which included the demographic details, indications for tracheostomy, duration of mechanical ventilation before and after tracheostomy, complications of tracheostomy, and duration of hospital stay after tracheostomy. During the follow-up, complications were noted, if any, during the study period. The reasons for decannulation failure, if any, were also noted.

Data were entered into Microsoft Excel datasheet and analyzed using R version 3.5.2. Summary statistics were represented as number, percentages, mean (standard deviation), and median (interquartile range). Comparison between two groups was done using Kruskal–Wallis rank-sum test and Fisher's exact test. Correlation was done using Spearman's rank correlation rho test. Any P < 0.05 was considered statistically significant.


  Results Top


During the study period, 20% of children received mechanical ventilation and a total of 73(4.8%) tracheostomies were performed. The mean age at tracheostomy was 5.4 years. The study group included 68.5% (n = 50) of males and 31.5% (n = 23) of females. The most common indication for tracheostomy was neurological impairment in 56.2% (n = 41) of cases and upper airway obstruction in 19.2% (n = 14) of cases. Among the cases of neurological impairment, the Landry–Guillain–Barre syndrome was the most common primary diagnosis in 28.77% (n = 21). Prolonged mechanical ventilation (more than 14 days) was required in 52.1% (n = 38) of cases. Elective tracheostomy was performed in 84.9% of children, whereas emergency tracheostomy was performed in 15.1% of children. The indications of tracheostomy, duration of mechanical ventilation and duration of hospital stay, complications of tracheostomy, and frequency of decannulation failure are shown in [Table 1].
Table 1: Clinical summary of cases of tracheostomy

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The median duration of PICU stay after tracheostomy was 20 days (range: 2–93 days). This is because majority of the cases that were tracheostomized were neurological cases (P = 0.007) that required prolonged mechanical ventilation and hence were ventilator dependent, thus requiring longer length of PICU stay posttracheostomy. The average duration of hospital stay was 67.3 days. The duration of hospital stay was longer for cases with neurological impairment (P = 0.009).

Complications due to tracheostomy were noted in 43.8% (n = 32) of cases. The most common complications were suprastomal granulations in 21.9% (n = 16) of cases and tube block in 8.21% (n = 6) of cases. Majority of the cases (99%) did not have any immediate complications due to tracheostomy. Accidental decannulation occurred only in one case. Three cases had persistent tracheocutaneous fistula for which fistula excision and repair was done.

During the study period, all children were subjected to laryngotracheobronchoscopy and decannulation was attempted. Out of 73 children, the decannulation was successful in 69.9% (n = 51) and 30.1% (n = 22) of children had decannulation failure. Grade 3 subglottic stenosis was the most common reason for decannulation failure. The average time taken from tracheostomy to decannulation (tracheostomy time) was 111.9 days.

The duration of PICU stay was longer in the decannulated group (P = 0.006) as compared to those with decannulation failure because majority of the cases in this group had neurological impairment, thereby requiring longer duration of posttracheostomy care attributed by the primary disease and associated comorbidities. However, majority of the cases in the decannulation failure group had varying degrees of airway obstruction which was relieved by tracheostomy, and therefore, the airway pathology prevented the decannulation.


  Discussion Top


Around 5% of mechanically ventilated children underwent tracheostomy in our PICU during the study period. Neurological impairment requiring prolonged mechanical ventilation was the most common indication for tracheostomy. Elective tracheostomies outnumbered the emergency tracheostomies and hence the lesser short-term complications posttracheostomy. Majority of the cases were successfully decannulated.

Recent studies demonstrated that the majority of the indications for pediatric tracheostomies consist of prolonged intubation due to neurological causes.[7] A standard categorization scheme for tracheostomy indication is needed to allow for comparisons between centers and countries. Gill et al.[8] in a retrospective study (n = 56) demonstrated that elective tracheostomies were done in 76% of cases as compared to 84.9% in our series, and 41% underwent tracheostomy for prolonged intubation as compared to 52.2% in our study. Therefore, long duration of endotracheal intubation and its sequelae have become the most important indication for tracheostomy in the current years.

Pediatric tracheostomy is technically more demanding than among adults due to smaller and more pliable trachea and to the limited access to the operating field. Tracheostomy can be associated with numerous complication rates ranging from 6% to 66%. The complications following tracheostomy are different based on its type and nature, the condition of the patient, indications, place of procedure, management facilities, and the experience of the surgeon. In recent times, studies have shown that this procedure is safe and carries less risk of complications if carried out by a trained and experienced team at a tertiary care hospital.

As per our study, complications were significantly more when neurological impairment was the primary indication for tracheostomy and when emergency tracheostomy was done. This clearly indicates that the elective procedures are safer when done in a tertiary hospital with advanced PICU care.[6] In the present study, the most common complications were suprastomal granulations (21.9%) and tube block (8.2%). In a study conducted by Mishra et al.,[9] the most common complications encountered were peristomal granulations (10%) and tube block (10%), followed by hemorrhage (6%) and accidental decannulation (6%).

Our study shows a decannulation rate of 70% in contrast to a decannulation rate of 29% in the study conducted by Carr et al.[10] This striking difference in the rates of decannulation is because their primary indication for tracheostomy was airway obstruction which was less likely to get decannulated. The average duration of tracheostomy was 112 days in our study as compared to 759.2 days in the study conducted by Carr et al.[10] This longer tracheostomy time is because it was a retrospective study conducted over a period of 10 years. The majority of the pediatric patients requiring tracheostomy can expect effective resolution of their underlying airway pathology and will tolerate decannulation. The likelihood of being decannulated also correlates with the underlying indication for the tracheostomy.

In our study, the average length of PICU stay after tracheostomy was 24 days in the decannulated group in contrast to 5 days in the study by Dursun and Ozel,[11] both being clinically significant. This longer duration was because 24.7% (n = 18) out of 69.9% of tracheostomized cases were decannulated in the same admission as that of tracheostomy. However, the length of hospital stay in the decannulated group was 71 days in our study as compared to 43 days in the study by Dursun and Ozel.[11] This is because neurological impairment requiring prolonged mechanical ventilation was the most common indication for tracheostomy in our series, thus requiring longer duration of hospital stay for neurological recovery and treatment of associated comorbidities.

Outcomes appear to be significantly worse for patients who receive a tracheostomy for neurologic, especially in terms of duration of hospital stay, complications, and longer time taken for decannulation as reflected in our study. In the study by Adoga and Ma'an,[12] the overall mortality recorded was 17.4% (n = 8) and these were from underlying diseases. No tracheostomy-related death occurred in our study.

Limitations of our study were that the study duration was not long enough to follow up all the enrolled cases until they underwent decannulation. Hence, among those who were not decannulated at the end of the study, we could not know the rate of decannulation failure.

This was a single-center study. The strengths of the study included that we demonstrated that there is a significant change in the trend of indications of tracheostomy in critically ill children admitted to the PICU. We also highlighted the importance of team effort in reducing the posttracheostomy complications in children.


  Conclusions Top


Neurological impairment requiring prolonged mechanical ventilation was the most common indication for tracheostomy. Suprastomal granulations were the most common complication and subglottic stenosis being the most common cause for decannulation failure.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Durbin CG Jr. Indications for and timing of tracheostomy. Respir Care 2005;50:483-7.  Back to cited text no. 1
    
2.
Powell J, Buckley HL, Agbeko R, Brodlie M, Powell S. Tracheostomy trends in paediatric intensive care. Arch Dis Child 2021;106:712-4.  Back to cited text no. 2
    
3.
Arcand P, Granger J. Pediatric tracheostomies: Changing trends. J Otolaryngol 1988;17:121-4.  Back to cited text no. 3
    
4.
Fageeh N. Pediatric tracheostomy: Indications and clinical outcome. Pak J Surg 2015;31:128-2.  Back to cited text no. 4
    
5.
Funamura JL, Durbin-Johnson B, Tollefson TT, Harrison J, Senders CW. Pediatric tracheotomy: Indications and decannulation outcomes. Laryngoscope 2014;124:1952-8.  Back to cited text no. 5
    
6.
Ishaque S, Haque A, Qazi SH, Mallick H, Nasir S. Elective tracheostomy in critically Ill children: A 10-year single-center experience from a lower-middle income country. Cureus 2020;12:e9080.  Back to cited text no. 6
    
7.
Young D, Harrison DA, Cuthbertson BH, Rowan K, TracMan Collaborators. Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: The TracMan randomized trial. JAMA 2013;309:2121-9.  Back to cited text no. 7
    
8.
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.  Back to cited text no. 8
  [Full text]  
9.
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.  Back to cited text no. 9
    
10.
Carr MM, Poje CP, Kingston L, Kielma D, Heard C. Complications in pediatric tracheostomies. Laryngoscope 2001;111:1925-8.  Back to cited text no. 10
    
11.
Dursun O, Ozel D. Early and long-term outcome after tracheostomy in children. Pediatr Int 2011;53:202-6.  Back to cited text no. 11
    
12.
Adoga AA, Ma'an ND. Indications and outcome of pediatric tracheostomy: results from a Nigerian tertiary hospital. BMC Surg 2010;10:2.  Back to cited text no. 12
    


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