Paediatric Tracheostomy - A Retrospective Study Experience

INTRODUCTION

Tracheostomy is a life-saving surgical procedure performed on critically ill patients with airway compromise.^[1] Armand Trousseau was the first physician to perform tracheostomy in children with diphtheria in the mid-1800s.^[2] Chevalier Jackson modified the technique in the 20^th century. Earlier, tracheostomy was conducted for upper airway obstruction in patients with infectious diseases. Presently, it is commonly performed for prolonged intubation, trauma, and neurological disorders.^[3] Indications and techniques of tracheostomy differ between adults and children. There is a fundamental variation in the anatomy of adult and paediatric tracheae. The paediatric larynx is smaller, while surrounding structures like the arytenoid and aryepiglottic folds are larger. As the child grows, the larynx descends, and by the age of 6, it reaches the size of that of an adult. Paediatric tracheostomy is technically challenging because of the anatomical distinction from the adult airway. The subglottic area is the narrowest point in infants; it is the glottic area in adults.^[4] The cartilage of the infant larynx is softer and pliable, so an uncuffed tracheostomy tube is preferred to prevent pressure necrosis.^[5] However, a cuffed tracheostomy tube is preferred in patients requiring ventilatory support. The most frequent complications noted are emphysema, pneumothorax, and pneumomediastinum.^[6] High apical pleura and innominate artery pose high intraoperative risks for paediatric tracheostomies. Other dreadful complications were accidental decannulation and cannula obstruction.^[7] Some patients develop late complications such as granulations and laryngeal and tracheal stenosis.^[8]

This study is a comprehensive analysis of paediatric tracheostomies performed in our hospital, where we analysed the age, sex, indications, duration of tracheostomy, complications, and outcome in those cases.

MATERIAL AND METHODS

This is a retrospective study based on medical case records. The data were retrieved from the medical records department of KS Hegde Charitable Hospital, a tertiary care referral hospital in Mangalore, India. We collected data from the hospital’s medical records department on patients aged under 18 years who underwent tracheostomy between January 2012 and December 2022. Details such as a demographic profile, medical diagnosis, indications, how long the patient was on the tracheostomy tube, details of decannulation, and outcomes were collected. These data were entered into Excel sheets and analysed. The results were represented as proportions and percentages.

RESULTS

In our study, there were 26 paediatric patients with tracheostomies. Of these, 15 were males, and 11 were females. The youngest patient was a 3-month-old child with Pierre Robin syndrome. Four tracheostomies were done as emergency procedures. Of these, two were done in burn patients with laryngeal oedema, one was for neck injury, and another one for bilateral vocal cord palsy presenting with stridor. Most tracheostomies in our study were elective procedures (22 cases). Five patients with head injuries, three with CNS tumors, and one with post-meningitis hydrocephalus required tracheostomy because of prolonged intubation after the neurosurgical intervention. For five cases, a tracheostomy was done due to a congenital disorder. The most common congenital condition requiring tracheostomy in our study was Pierre Robin syndrome (two cases). Others were one case of Treacher Collins syndrome, one mitochondrial disorder, and one Duchenne muscular dystrophy. In one case, a tracheostomy was done for intraoperative airway management. Status epilepticus, electrocution, pneumonitis secondary to kerosene poisoning, acute necrotising encephalopathy, tetralogy of Fallot, and polymyositis are other indications that require tracheostomy in view of prolonged intubation. Table 1 shows the various indications for emergency and elective tracheostomy in our study.

No immediate complications were documented. Ten patients had undergone successful decannulation. Difficult decannulation was encountered in one patient, diagnosed while planning for decannulation. After several attempts at decannulation failed, he was diagnosed with tracheal stenosis at the second tracheal ring, just above the stoma. He was later decannulated after 15 cycles of cryotherapy. Among 26 cases of tracheostomies, five patients succumbed due to the primary disease, five patients were referred out following the procedure, and six were lost to follow-up. As a result, the duration of tracheostomies could not be assessed.

DISCUSSION

Tracheostomy is a surgical procedure performed to maintain a normal airway, which has improved neonatal and paediatric ICU care. The proportion of paediatric tracheostomies is less compared to adult tracheostomies.^[5] Ogilvie et al.^[9] in the British Columbia Children’s Hospital reviewed the tracheostomy cases performed from 1982-2011. They observed that the mean age at which tracheostomy was performed was 3.74 years, with 48% of the cases performed before one year. In our study, most patients were less than 5 years of age, and two patients were less than 1 year old with congenital syndromes. There has been a decline in the number of tracheostomies since the 1980s, as the primary indication during those years was upper respiratory obstruction due to infections. The introduction of vaccines against Corynebacterium diphtheriae and Haemophilus influenzae type B has reduced the number of infections, thus reducing the number of tracheostomy cases.^[9]

In a study on Treacher Collins and Pierre Robin’s syndrome by Rasch DK, et al.^[10], an elective tracheostomy was performed due to suspicion of an airway oedema within hours of surgery, which caused difficulty in re-intubation. The primary pathophysiology of these syndromes is the posteriorly located tongue, which may reduce the posterior pharyngeal airway. Sometimes, mechanical intubation may be difficult, or the airway may be compromised after extubation, following which reintubation may be difficult.^[10] In our study, seven patients required emergency tracheostomies.

Neck trauma has been one of the surgical emergencies in ENT. Sachdev, in his study, observed that in the neck trauma cases, 58.8% of them had to undergo tracheostomy first, followed by primary laryngotracheal repair. It was done to secure the airway, and general anaesthesia was given through that for the surgical exploration.^[11]

Parilla C et al., explained the standard technique of tracheostomy with horizontal midline skin incisions and vertical incisions on the anterior tracheal wall with stay sutures on the trachea.^[12] The same technique was followed in our study. Macrae et al. conducted a study in 93 paediatric tracheostomies with different incisions and concluded that there is no difference in the outcome of the procedure in horizontal or vertical incisions.^[6]

The size of the tracheostomy tube is calculated by the formula: (age in years/4)+4 mm.^[5] If the tracheostomy tube is inappropriate, it may cause tracheal mucosal injury, causing ulcerations, bleeding, fistula formation, and tracheal stenosis. The same criteria had been adopted in our study to select the tube size.

Obatake et al. explained the ligation of innominate arteries while performing tracheostomy, a dreadful and common complication in paediatric tracheostomy that prevents trachea-innominate fistula.^[13] Puncture of the high apical pleura is also an intraoperative complication commonly seen in paediatric tracheostomy.

Mahadevan et al.^[14] conducted a study on 122 paediatric tracheostomies, in which they assessed the post-procedure complications. Early complications are less common compared to late complications. Ventilation problems followed by accidental decannulation were common early complications. The common late complications included stomal granulations, followed by stomal collapse and subglottic stenosis.^[14] In our study, out of 26 patients, only one developed tracheal stenosis.

Paediatric tracheostomies have a higher incidence of failed decannulation than adults, owing to developmental barriers and smaller anatomy.^[15] Decannulation is difficult in patients who undergo tracheostomy for neurological conditions because of the prolonged nature and complexity of the disease.^[9] Before complete decannulation, a capped tracheostomy tube, followed by a downsizing tube, can also be done to facilitate decannulation. Schweiger et al. conducted a study on the successful decannulation of paediatric tracheostomies, in which the success rate was low due to restricted follow-up.^[16]

As per the study, decannulation could not be done for patients with neurological and respiratory comorbidities and those with syndromes with compromised airways. Lack of follow-up can also be an important factor in not assessing the outcome of decannulation. In our study, successful decannulation was done only on 10/25 patients. The remaining patients were discharged with the tracheostomy, but did not come for follow-up to assess the outcome and further evaluation.

Salley et al.^[17] conducted a study comparing the outcomes in paediatric tracheostomy patients. In that study, the mortality is due to secondary diseases or unknown complications. There was no difference in the death rate of infant and paediatric tracheostomy patients.^[17] In our study, out of all five patients expired due to poor general conditions, not as a complication of tracheostomy. With the increased survival rate of premature infants and the need for longer-term ventilation, paediatric tracheostomy and postoperative care in children demand special consideration.^[18]

CONCLUSION

Tracheostomy is a surgical procedure that can be performed as an emergency or elective procedure in tertiary care centers. The complications can be minimised if the procedure is performed in a controlled setting. The deaths in the study population were due to their underlying disease, not the tracheostomy per se. Most of the recent paediatric tracheostomies are performed for prolonged intubation. Laryngeal oedema due to burns often necessitates tracheostomy to secure the airway. The long-term complications of the procedure and the exact outcomes of this study could not be analysed due to a lack of follow-up in many patients and the retrospective design of the study.