|Year : 2023 | Volume
| Issue : 1 | Page : 5-6
Pediatric tracheostomy – From a rare procedure to an elective procedure
Pradeep Kumar Sharma
Department of Pediatrics, Shree Aggarsain International Hospital, New Delhi, India
|Date of Submission||04-Dec-2022|
|Date of Acceptance||12-Dec-2022|
|Date of Web Publication||20-Jan-2023|
Dr. Pradeep Kumar Sharma
Flat No. 48, Pocket-7, Sector-21, Rohini, New Delhi - 110 086
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sharma PK. Pediatric tracheostomy – From a rare procedure to an elective procedure. J Pediatr Crit Care 2023;10:5-6
Until the last two decades, tracheostomy was rarely performed in children. It was usually performed as an emergency life-saving measure for airway obstruction. Pediatric tracheostomy is more challenging because of the small, pliable trachea, limited extension of the surgical field, and the risk of anesthesia. The morbidity and mortality for pediatric tracheostomy are around two to three times more than for adult patients.,, Furthermore, most pediatricians have concerns regarding the safety, feasibility, and outcome of tracheostomy. These, along with the lack of quality pediatric critical care services, were reasons for infrequent tracheostomies in children. However, with the availability of quality pediatric critical care across India, many children require elective tracheostomies. The indication for tracheostomy has significantly changed over the last few decades, from upper airway obstructions following infections to prolonged mechanical ventilation. With the advent of vaccination and improvement in pediatric intensive care, Pediatric tracheostomy is commonly done for prolonged ventilation, upper airway obstruction, trauma, and neurological diseases.,, There is a lack of guidelines with respect to timing, home care, and decannulation practices for pediatric tracheostomies. As the number of pediatric tracheostomies is small with heterogeneous age groups (from the neonatal period to adolescence), heterogeneous indications, it is difficult to formulate guidelines. Nonetheless, in recent years, the outcome of pediatric tracheostomies has been very encouraging. These studies have not only shown that tracheostomies are feasible but also can be maintained at home, even in resource-limiting settings with good decannulation rates.,, The successful decannulation rate from various studies ranges from 15%–82%. There are many factors affecting successful decannulation, like age, the primary indication, duration of tracheostomy, care while tracheostomised, and complication of primary disease and tracheostomy procedures.,, Certain factors cannot be modified; however, if caregivers or parents are properly educated and trained in tracheostomy care, these children can be managed on home tracheostomy care with good outcomes. A predecannulation bronchoscopy is being increasingly done nowadays; however, there is still a lack of evidence of bronchoscopic findings that may influence decannulation.
In this issue of JPCC, Kumar et al. have reported their experience with pediatric tracheostomies. The authors, during 1 year, had 50 tracheostomies with prolonged intubation due to primary neurological disease as the most common (82%) cause. Out of these, 31 were considered for decannulation, and all of them underwent predecannulation laryngo-tracheo-bronchosopy. Airway granulations were the most common finding, and the same was surgically removed before decannulation. They have reported a decannulation rate of 97%.
Airway complications such as granulations, collapse, and stenosis can be delineated with bronchoscopy, with granulation being the most common finding. However, not all of these require intervention before decannulation, and decannulation was reported to be successful in around 50% of cases without the need for any intervention. In the author's own experience, 80% of cases are successfully decannulated without bronchoscopy. Tracheostomy tubes are routinely changed every 3–4 weeks intervals. In a resource limiting country like India, doing a pre-decannulation bronchoscopy in high risk cases, or in those who have failed decannulation seems a more logical and feasible approach rather than doing for all cases. Decannulation can be attempted in children without predecannulation bronchoscopy. We need more research before forming any recommendations on optimal decannulation procedures.
Pediatric tracheotomies have come a long way from being a rare and life-saving procedure to an elective procedure in pediatric intensive care units. The indications show a shift from upper airway obstruction to prolonged intubation. The post tracheostomy care and home tracheostomies are feasible with good outcomes. There is a need for more research, especially regarding the optimal decannulations of pediatric tracheostomies.
| References|| |
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Sachdev A, Chaudhari ND, Singh BP, Sharma N, Gupta D, Gupta N, et al.
Tracheostomy in pediatric intensive care unit-a two decades of experience. Indian J Crit Care Med 2021;25:803-11.
Sharma PK, Vinayak N. A single center experience of pediatric tracheostomy. Indian Pediatr 2018;55:1091-2.
Kumar PP, Somahekhar A, Basavaraja GV, Sanjay KS, Afshan F, Baskar P. Pediatric tracheostomy decannulation: A prospective study at a tertiary care centre. J Pediatr Crit Care 2023;10:24-9. [Full text]
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