The indications for tracheostomy were relief of upper airways obstruction in 41 patients, failed extubation and

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1 -14 Tracheostomy in children C A Shinkwin FRCS K P Gibbin FRCS J R Soc Med 1996;89: _*1 -ME4 Keywords: tracheostomy; children SUMMARY Tracheostomy is more hazardous in children than in adults, and carries special risks in the very young. The past 20 years have seen a large shift in the age distribution of tracheostomy. Whereas formerly the operation was done largely for management of epiglottitis and laryngotracheobronchitis, today the prime indication is subglottic stenosis in infants consequent upon intubation for respiratory distress syndrome and prematurity. We have reviewed experience with 57 tracheostomies in 56 children under 12 years old managed from a university hospital. All operations were done as elective procedures, in standard fashion, by otolaryngologists. Forty (70%) were in children under 1 year old, the indications being upper airways obstruction (41), failed extubation (11), and long-term assisted ventilation (5). Subglottic stenosis was the commonest cause of obstruction (21 operations). In 91.4 accumulated years with a tracheostomy there were 11 complications related to tracheostomy, one of which (a blocked tube) was fatal. Thirty-nine children were decannulated, the mean duration of cannulation being 21 months. In this series we suggest that the low morbidity and mortality rates were due to management by otolaryngologists; to postoperative intensive care; and, for the majority cared for at home, to careful education of parents and visits by specialist nurses. 188 INTRODUCTION The morbidity and mortality associated with tracheostomy in children is higher than in adults1,2, and the younger the child the greater the risks3. With the increasing survival of premature infants and the need for longer-term cannulation, the tracheostomy operation and the postoperative management in children requires particular care and skill. Here we review 10 years' experience at the University Hospital, Nottingham, with special emphasis on operative and postoperative management. PATIENTS AND METHODS The data for this study came from the medical and nursing notes of 56 patients under the age of 12 years undergoing tracheostomy in the 10 years to June 1992 at the University Hospital, Nottingham, which has a catchment area of Fifty-seven tracheostomies were performed on 56 patients-29 boys and 27 girls. Mean age at the time of tracheostomy was 16 months (range 1 day to 142 months), but 70% of the operations were performed in children under the age of 1 year (Figure 1) with half of these being performed in the first 3 months of life. Department of Otolaryngology, University Hospital, Queen's Medical Centre, Nottingham NG7 2UH, England Correspondence to: Mr C A Shinkwin The indications for tracheostomy were relief of upper airways obstruction in 41 patients, failed extubation and tracheopulmonary toilet in 11, and long-term assisted ventilation in five. None of the tracheostomies was done as an emergency; a standard procedure was followed; and all but two operations were performed or supervised by the senior author. Surgical technique and postoperative care The operations were performed in theatre under general anaesthesia with a controlled airway, over an endotracheal tube or with a bronchoscope in the trachea and the neck extended. In children less than 12 months of age a vertical skin incision was used. In older children, a horizontal skin crease incision situated just below the level of the cricoid was made. With blunt dissection, the thyroid isthmus, the thymus and the innominate vessels were displaced as necessary until the trachea was exposed. A vertical incision was made in the trachea centred on the third and fourth cartilaginous rings. The appropriate sized tracheostomy tube, usually Shiley in type, was then inserted and, after adequate control of ventilation was achieved through the tube, the endotracheal tube was withdrawn. To secure the tracheostomy, the neck was flexed and the flanges of the tube were sutured to the skin and tapes tied securely around the neck. The skin incision around the tube was approximated with a few loose sutures.

2 An Table 1 for tracheostomy in 40 patients presenting with upper airways obstruction Number of operations 'A CL 0. 6 z Figure 1 0- N N~~~~ Age at Tracheostomy (years) Age distribution of children at time of tracheostomy Postoperatively, all children had a chest radiograph to check the position of the tube in the trachea and were transferred to the neonatal or paediatric intensive care unit where they stayed until after the first tracheostomy change at 5 days. Patients who had tracheostomies for long-term indications (the majority) were discharged with the tube in situ. The parents or guardians were carefully instructed according to a strict protocol on all aspects of tracheostomy care including changing, suction, and humidification. Supervision in the community was undertaken by domiciliary nurses specializing in tracheostomy management. Before decannulation, all patients who had had tracheostomy for upper airways obstruction underwent tracheobronchoscopy to assess the airway. Then either the tube was corked for at least 24 h before decannulation or the stoma was closed at the time of endoscopy. RESULTS In the period under review, 215 new patients underwent endoscopy, 162 for symptoms of upper airways obstruction. Of these, 40 patients (25%) required 41 tracheostomies to by-pass an upper airway obstruction (Table 1). Eleven patients had tracheostomies performed after repeated failed attempts at extubation (Table 2) and five for long-term assisted ventilation (Table 3). The commonest indication for tracheostomy was acquired subglottic stenosis for which 16 operations in 15 patients (one child required a second tracheostomy because stenosis recurred after an initially successful laryngotracheoplasty) were performed. One patient developed subglottic stenosis after prolonged endotracheal intubation for a head injury at the age of 38 months; the remainder were a sequel to prolonged intubation for infant respiratory distress syndrome and prematurity, the mean Subglottic narrowing Acquired subglottic stenosis 16 Congenital subglottic stenosis 5 Haemangioma 2 Subglottic oedema due to pertussis 1 Other laryngeal disorders Laryngomalacia & micrognathia 3 Bilateral vocal cord paralysis 1 Fixed vocal cord 1 Congenital glottic web 2 Epidermolysis bullosa dystrophica 2 Laryngeal papillomatosis 2 Tracheal abnormalities Tracheomalacia 1 Miscellaneous Pierre Robin syndrome 3 Oropharyngeal tumour 1 Pharyngeal collapse/cor pulmonale 1 Total 41 Table 2 Underlying conditions in 10 patients with repeated failed extubation Neurological 4 Laryngotracheobronchitis 2 Oropharyngeal burns 1 Bronchopulmonary dysplasia 1 Retropharyngeal abscess 1 Cerebro-facio-thoracic dysplasia 1 Total 1 1 gestational age at birth being 30 weeks (range weeks). A set of twins born with the autosomal recessive condition epidermolysis bullosa dystrophica developed laryngeal lesions and required tracheostomy for increasing stridor at 10 and 1 months. Five patients required tracheostomy for obstructive pharyngeal causes: three had recurrent apnoeic episodes (Pierre Robin syndrome), one had cor pulmonale secondary to severe pharyngeal collapse (achondroplasia), and a onemonth-old infant had an oropharyngeal atypical angiomatoid fibrohistiocytoma. 189

3 190 Table 3 The indications for tracheostomy in five patients who required long-term assisted ventilation Congenital hypotonia 1 Congenital spinal cord compression 1 Bronchopulmonary dysplasia 2 Flaccid quadriparesis (post-meningococcal-meningitis) 1 Total 5 Three children had tracheostomy performed as a result of infective disease. A 1-month-old presented with severe stridor due to pertussis and tracheostomy was performed because of difficulty in intubating; direct laryngoscopy at the time revealed severe subglottic oedema. The other two had been intubated for laryngotracheobronchitis and could not be detubated despite repeated attempts; in both these patients, too, endoscopy at the time revealed subglottic oedema. The neurological conditions that required tracheostomy were all postoperative: after surgery for syringomyelia2, after posterior fossa tumour excision1 and after drainage of a subdural haematoma1. Most of the children (79%) were subsequently managed at home. Complications The accumulated duration of tracheostomy was 91.4 years during which 11 complications were recorded (Table 4). Eight children (14%) in this series died, but in only one was the death attributable to the tracheostomy. This child had had a tracheostomy for severe acquired subglottic stenosis at 6 months of age, and 3 weeks postoperatively was transferred to a hospital nearer home for further management. One month later, he had a cardiorespiratory arrest due to a blocked tracheostomy tube. The other seven deaths were attributable to the underlying conditions. Three of the patients were ventilator dependent;, one with congenital hypotonia died of pneumonia, the other two as a result of bronchopulmonary dysplasia. A set of twins died of epidermolysis bullosa dystrophica, and two patients succumbed to cardiac failure (as a result of CHARGE syndrome and cerebro-facio-thoracic dysplasia). In two children, both of whom had had tracheostomy for subglottic stenosis, the tube became displaced within 48 h of surgery and one (aged 54 months) had a cardiorespiratory arrest and was left with mild spasticity; the other (aged 19 months) had no sequelae. Five children developed stomal granulations which required removal. However, in no case did this lead to a delay in decannulation. Table 4 Complications of tracheostomy Early Late Complications ( 1 wk) (S 1 wk) Blocked tube (fatal) 1 Dislodged tube with sequelae 1 Dislodged tube without sequelae 1 Chest infection 1 Wound infection 1 Stomal granulations 5 Revision of scar 1 Total 4 7 Decannulation Of the 48 surviving children, 39 were successfully decannulated in the period under review. However, as mentioned above, one of these required a second tracheostomy for recurrence of airway obstruction. The mean duration of tracheostomy of these 39 patients was 21 months (3 weeks to 67 months). Twenty (51%) had their tracheostomies for longer than 1 year (Table 5). Sixteen (41%) of the 39 children underwent surgical closure of their tracheostomies by the method of Joseph et al.4. Thirteen had primary closure at the time of decannulation (mean duration of tracheostomy 45 months ( ) ). Three other children required secondary closure for persistent tracheocutaneous fistula; the delayed closure caused no complications. One patient required revision of the scar after spontaneous closure. DISCUSSION The use of tracheostomy in children has changed greatly over the past 20 years. In the late 1970s, tracheostomy as a primary measure in the management of epiglottitis and laryngotracheobronchitis was abandoned in favour of nasotracheal intubation5'6. However, the improved survival of ventilated neonates led to an increase in the prevalence of Table 5 Duration of tracheostomy in the 39 decannulated children Months < >12 20

4 subglottic stenosis and the number of tracheostomies performed to relieve it7. As a result, there has been a major shift in the age distribution of children requiring tracheostomy: in Tucker and Silberman's series, reported in 1972, only 30% of the children requiring tracheostomy were under the age of 1 year8. Carter and Benjamin quoted figures of 45% in 19836, compared with 70% in this report of which half were less than 3 months old at the time of surgery. These changes demand great skill on the part of the surgeon, who is asked to perform tracheostomies on ever younger and smaller infants the smallest infant in our series weighed 810 g. In our hospital paediatric practice, all tracheostomies are performed by otolaryngologists, and emergency tracheostomies are avoided by prudent evaluation of any critical airway and placement of either an endotracheal tube or a bronchoscope. Line et al. reported that 50% of children who did not have airways established before the tracheostomy developed life threatening complications7. Post-operatively all the children were managed on the neonatal or paediatric intensive care units until the first tube change at 5 days. We feel these measures are important in keeping early complications to a minimum. The technical aspects of the operative procedure remain controversial, especially the type of tracheal incision. In children, excision of the anterior wall results in tracheal stenosis. Hotaling et a]. advocated use of the Bjork flap, stating that it is less dependent on the cannula to maintain patency; however, 3.5% of their patients developed tracheal stenosis12. We have used a vertical incision in the trachea without any difficulties at the first tube change or stenosis at the time of decannulation. Another important operative point is the siting of the tracheostomy at the appropriate level; the larynx in the infant is higher in the neck than in the adult. If dissection is done too low in the neck one risks injury to the innominate vein, which can rise into the jugular notch, and to the domes of the pleura, which are paratracheal in the neck of neonates. The direction of the skin incision probably makes little difference cosmetically. However, Kirchner, supporting use of the vertical incision, stated that the redundant tissue above the horizontal incision tends to rest on the tracheostomy tube, displacing its distal end posteriorly and causing obstruction and mucosal irritation; whereas the vertical incision allows for free movement of the tube with respiration and swallowing, and during surgery can be easily extended1 3. With the mean duration of tracheostomy 21 months (which is similar to that in other recent reports14) the parents need to be competent in all aspects of management. They are thoroughly briefed before the child is discharged; they have a suction apparatus and a humidifier in the home; and they receive regular visits from specialized nurses. They also have free access to the ward should they need it. Three of our 56 children had serious complications two tube displacements and one tube obstruction. Tube displacement is commonly reported, both early (as here) and late after operationl. When it occurs before the tracheocutaneous fistula is well established, reinsertion of the tracheostomy tube is difficult, and creation of a false passage can make matters worse. Preventive measures are to use the correct size of tracheostomy tube15 and secure it with sutures and tapes only with the neck flexed and the proper suspension of any ventilating equipment attached; however, most important is the availability ofnursing staff competent in tracheostomy management in infants. Our protocol now for the management of tube displacement in the first week after surgery is to reintubate endotracheally, with the tracheostomy tube reinserted later under controlled conditions. Tracheostomy tube obstruction continues to be the commonest cause of tracheostomy-related death7'14'16. The importance of regular suction, the use of humidification, and tube changes cannot be overemphasized to nursing staff and parents. What of tracheal granulations? These are so common as to be routine findings rather than complications'0. Five children required removal of peristomal granulations, with three of the five having them removed at endoscopy before decannulation, which then proceded uneventfully. There is just one published report of a death related to endoscopic removal of granulations resulting in haemorrhage and airway obstruction1. Much has been written about difficulties with decannulation, but in our series delay in decannulation was never due to tracheostomy related problems. Once the indication for the tracheostomy had either resolved or been dealt with, decannulation was possible in all cases. Sixteen (41%) of the decannulated children in this review underwent either primary or secondary closure of the stoma. The need for surgical closure of the stoma should not be seen as a complication but rather a consequence of the duration of the tracheostomy. REFERENCES I Crysdale WS, Feldman RI, Naito K. Tracheostomies: a 10-year experience in 319 children. Ann Otol Rhinol Laryngol 1988;97: Gilmore BB, Mickelson SA. Pediatric tracheostomy: controversies in management. Otolaryngol Clin N Am 1986;19: Chew JY, Cantrell RW. Tracheostomy complications and their management. Arch Otolaryngol 1972;96: Joseph HT, Jani P, Preece JM, Bailey CM, Evans JNG. Paediatric tracheostomy: persistent tracheo-cutaneous fistula following decannulation. IntJ Ped Otolaryngol 1991;22: Gerson CR, Tucker GF. Infant tracheostomy. Ann Otol Rhinol Laryngol 1982;91 : MacRae DL, Rae RE, Heeneman H. Paediatric tracheostomy. J Ocolaryngol 1984;13:309-11I 191

5 7 Line WS, Hawkins DB, Kahlstrom EJ, MacLaughlin EF, Ensley JL. Tracheostomy in infants and young children: the changing perspective Laryngoscope 1986;%: Swift AC, Rogers JH. The changing indications for tracheostomy in children. J Laryngol Otol 1987; 101: Tucker JA, Silberman HD. Tracheostomy in pediatrics. Ann Otol Rhino) Laryngol 1972;81: Carter P, Benjamin B. Ten-year review of pediatric tracheostomy. Ann Otol Rhino) Laryngol 1983;92: Arola MK, Inberg MV, Puhakka H. Tracheal stenosis after tracheostomy and after orotracheal cuffed intubation. Acta Chir Scand 1981 ;147: Hotaling AJ, Robbins WK, Madgy DN, Belenky WM. Pediatric tracheostomy: a review of technique. AmJ Otol 1992;13(2): Kirchner JA. Avoiding problems in tracheostomy. Laryngoscope 1986;%: Swift AC, Rogers JH. The outcome of tracheostomy in children. J Laryngol Otol 1987;101: Irving RM, Jones NS, Bailey CM, Melville J. A guide to the selection of paediatric tracheostomy tubes. J Laryngol Otol 1991; 105: Hawkins DB, Williams EH. Tracheostomy in infants and young children. Laryngoscope 1976;86: (Accepted 2 November 1995) 192