Current trends in paediatric tracheostomies

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Summary

Objective

In the 1970s, the most common indication for tracheostomy in children was acute inflammatory airway obstruction. Modern neonatal intensive care units have turned long-term intubation into an alternative to tracheostomy. Long-term intubation itself has become the most important indication for tracheostomy combined with subglottic stenosis.

Methods

Retrospective analysis in a tertiary referral center. A total of 38 patients who underwent tracheostomy for respiratory failure and upper airway obstruction from 1 November 1998 to 30 November 2004.

Results

Total complication rate was 42.1%. In children under 1 year of age the complication rate was 47.4%, in children over 1 year the complication rate was 26.3%. Decannulation was attempted in 12 patients with a cannulation time of 22 months.

Conclusions

Long-term intubation and its sequelae have now become one of the most important indication for tracheostomy. The change of indication has also entailed a decrease of the average age of children who require tracheostomy. A longer period before decannulation and a lower average age have changed the complication rate of tracheostomy in paediatric patients.

Introduction

Scientific reports suggest that over the last 30 years the role and the indications of tracheostomy in children have been changing considerably, whereas indications and implications of tracheostomy in adults are widely described and well defined, although some controversy still exists.

Paediatric tracheostomy 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 especially among pre-term infants [1], [2], [3].

In the 1970s, the most common indication for tracheostomy in children were acute inflammatory airway obstructions such as acute epiglottitis, croup and diphtheria. The use of vaccines against Haemophilus influenzae and Corynebacterium diphteriae, combined with modern neonatal intensive care units, has turned long-term intubation into an alternative to tracheostomy. However, children who require ventilatory support for many weeks or months need tracheostomies in order 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 tracheostomy [2], [4].

A complete analysis of the available literature shows that indications, epidemiology and complications are changing, and that no definite guidelines have been established.

We present our experience of tracheostomies performed in paediatric patients from 1998 to 2004 at our hospital (Catholic University in Rome), a major hospital with a catchment population of over three million people. We analyzed retrospectively our paediatric tracheostomies, in terms of indications and complications, and compared our data with those made available by the international literature.

Section snippets

Materials and methods

We performed a retrospective review of children who underwent tracheostomy at the Catholic University of Rome between November 1998 and November 2004.

The records of children admitted to the intensive care unit (ICU) for the management of airway problems over the same period were also examined.

This study was approved by the Ethics Committee of the Medical Faculty of the Catholic University in Rome.

Patients were evaluated as long as indications, complications and mortality were observed. A total

Results

Our departmental database and our operating theatre records showed that in our study, the intubation period before tracheostomy ranged from 1 to 69 days (M = 34).

Total complication rate in our group of patients was 36.8% (14 patients). However, no early complications (such as emphysema, pneumomediastinum, pneumothorax, bleeding) nor fatal ones (such as decannulation and cannula obstruction) were observed. In children under 1 year of age we observed six stomal granulomas, two tracheocutaneous

Discussion

Indications, techniques, and complications of paediatric tracheostomy have changed over the past couple of decades. Heterogeneity of different studies available in the international literature can be helpful for the sake of specificity, but the subclassification of groups makes them much smaller, thus causing their comparison to be less meaningful. In fact, analysing the data, differences in terms of indications, age groups, surgical technique and choice of investigated complications are quite

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