Functional assessment of the paediatric laryngeal airway*

After resolution of conditions necessitating tracheostomy in children, decannulation may be extremely difficult and associated with significant morbidity. Endoscopy and radiography can identify anatomical abnormalities preventing decannulation. Physiological abnormalities are, however, more difficult to assess. A system has been developed whereby functional upper airway resistance can be calculated in children with a tracheostomy. The instrument used was a modified Mercury Electronics rhinomanometer. A probe was placed through the tracheostome and another probe was situated in an occluding anaesthetic face mask. Upper airway resistance was derived from the differential pressure and flow changes recorded in anaesthetized children who were breathing spontaneously. Studies in 26 children have revealed low airway resistance in all those successfully decannulated. Further studies will hopefully allow identification in advance of children who will have decannulation difficulties.     

Tracheostomy Decannulation in Children: Approaches and Techniques

Various approaches and techniques are used in discontinuing tracheostomy in children. The variability in the use of resources is considerable. The objective of this study was to assess decannulation in children attended in a university-affiliated children's hospital. A retrospective analysis was made of the medical records of patients who had both tracheostomy (n = 177) and decannulation (n = 30) from 1985 to 1994. Tracheostomies, placed at a mean age of 38 months, were discontinued (on the average) 22 months later. Most children underwent airway endoscopy in the operating room in preparation for decannulation. Twenty-four children had downsizing, then capping of the tracheostomy as a functional trial. Six children underwent staged laryngotracheoplasty before decannulation. Two children had decannulation as part of a single-stage laryngotracheoplasty. Attention to at least one comorbid factor (e.g., pulmonary, neurologic, or cardiac disease) was important in the decannulation of each patient in this series. The individualization of tracheostomy decannulation is necessary for children.     

Current trends in paediatric tracheostomies

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.     

Predicting decannulation outcomes after distraction osteogenesis for syndromic micrognathia

OBJECTIVES: To characterize the airway anatomy by upper endoscopy in children with syndromal mandibular hypoplasia and to determine whether predistraction endoscopy is predictive of the likelihood of successful outcomes after mandibular distraction. STUDY DESIGN: Retrospective chart review. METHODS: Assessment of the upper airway by subsites was qualitatively extrapolated into a devised 4-point scale. Upper airways were characterized and evaluated in patients on the basis of decannulation outcomes after distraction. RESULTS: Of the 20 patients, 12 were decannulated, and 6 remain tracheostomy dependent. The average compiled preoperative airway obstruction scores in decannulated patients (2.25) compared with those who failed decannulation (2.36) was not statistically significant (P =.291). A significant change after distraction was noted only at the levels of the oropharynx and supraglottis (P <.001). The average airway scores at these subsites in decannulated patients improved from a mean of 3.46 to 2.17 (P =.002). In patients who failed decannulation, the pre- and postdistraction scores also improved from 3.92 to 2.50 (P =.026). Analysis of the average postdistraction airway scores in decannulated patients (2.17) compared with failures (2.5) failed to reveal a significant difference (P =.375), suggesting that some patients remain tracheostomy dependent despite adequate mandibular expansion. Preoperative airway scores in the two groups were statistically equivocal and, therefore, not predictive of the likelihood of decannulation. CONCLUSIONS: Preoperative airway endoscopy alone is not predictive of the likelihood of successful decannulation after distraction osteogenesis. Comparison of the airway patency after distraction revealed statistically equivocal airway caliber, suggesting that some children fail to advance to decannulation despite adequate mandibular distraction.     

Tracheostomy 'decannulation panic' in children: fact or fiction?

The phenomenon of tracheostomy 'decannulation panic' is likely to occur in children but probably is not psychologically based. The relatively small airway, local reflexes and changes in airway resistance seem sufficient to explain it on a mechanical basis. Because there were delays and failures in this series despite an apparently adequate airway, it is recommended that decannulation be performed on a controlled and gradual basis. The method of blocking a fenestrated tracheostomy tube provides a margin of safety. Chest physiotherapy, humidification and mucolytic agents will assist in preventing the acquisition of chest infection. Prophylactic antibiotics and steroids, however, do not appear to be of value and may actually be harmful.     

Accidental choking in a patient with Treacher Collins syndrome

A 3-year-old boy with Treacher Collins syndrome had undergone tracheostomy and placement of a secured cannula at the age of 4 months. When he was 3 years old, he manually extracted the secured cannula by himself and choked to death. Autopsy revealed upper airway obstruction with posterior deviation and mucosal hyperplasia of the radix linguae, mandibular hyperplasia, and occlusion of the artifical airway owing to intratracheal granuloma due to the long-standing tracheotomy. For safe, long-term use of a tracheostomy to maintain the airway, children with craniofacial abnormalities should be carefully supervised by their families to prevent accidental decannulation.     

Tracheostomy in children--the Red Cross War Memorial Children's Hospital experience 1980-1985

During the 6 years (1980-1985) at The Red Cross Children's Hospital 293 children required a tracheostomy during treatment of a variety of disorders. Of these children 44% were under 1 year of age. Indications are discussed of which the commonest was LTB. Of the 3500 children seen with laryngotracheobronchitis (LTB) 4.6% had a tracheostomy--28% of those requiring airway intervention. Overall 67% of the children were decannulated within 10 weeks and 92% within a year. For 56% one or more further procedures prior to decannulation were required, including 34 children who required a laryngotracheoplasty. Obstructing stomal granulation tissue had to be removed from 51 children and suprastomal collapse was a cause of decannulation failure in 52 children. Use of an expiratory valve as an aid to decannulation is discussed. Five children died of tracheostomy airway complications and 25 children of a medical disorder. One complication, laryngeal incompetence, was particularly associated with herpetic laryngeal ulceration. Staphylococcus aureus and Hemophilus influenzae were the main organisms cultured in the early weeks, with Pseudomonas and Streptococcus species predominating later.     

Resolution of airflow obstruction on polysomnography after laryngotracheal reconstruction with anterior tracheal wall suspension in a patient with DiGeorge Syndrome

DiGeorge Syndrome (DGS) may be associated with airway abnormalities including laryngomalacia and suprastomal collapse of the trachea (SCT), which may lead to sleep disordered breathing (SDB). We present a 4-year-old boy with DGS, SCT, and SDB by polysomnography (PSG) while the tracheostomy tube was capped. The patient underwent anterior tracheal wall suspension (ATWS) with concurrent tracheostomy decannulation. Following the repair, the patient experienced improved airway patency visually and by PSG with resolution of obstructive sleep apnea and hypoventilation. ATWS is an effective method to repair SCT in selected patients and may lead to early decannulation and improvement of SDB.     

Tracheocutaneous fistula following paediatric tracheostomy—A 14-year experience at Alder Hey Children's Hospital

Objective: To assess the rate of tracheocutaneous fistula requiring surgical repair and the complications and outcomes following it in the ENT department of a tertiary referral university paediatric hospital. Methods: A retrospective review of all children requiring airway support with a tracheostomy between 1995 and 2009 and subsequently requiring closure of tracheocutaneous fistula. Results: One hundred and ninety-three children underwent 196 tracheostomies. Seventy-three children were successfully decannulated until now. Twenty-three children (11.9%) required subsequent surgical closure of their tracheocutaneous fistula. In all these children the age at tracheostomy was less than 1 year old, and the median age at decannulation was 4 years old, (range 2-9 yo). Surgical repair was undertaken 6-12 months after decannulation. There were 4 minor complications in the postoperative period (wound infection, haemorrhage and early recurrence) and no major complications. None of the patients have experienced any degree of significant airway stenosis and there was no need for a repeat tracheotomy in any of the tracheocutaneous fistula closure patients. The cosmetic results were deemed to be good. Conclusions: Our rate of tracheocutaneous fistula compares well with the reported rates in the literature (13-43%). There appears to be a significant relation to age at tracheostomy and duration of tracheostomy.     

Parental perceptions and morbidity: tracheostomy and Pierre Robin sequence

OBJECTIVE: Evaluate parental perceptions associated with tracheostomy morbidity and quality of life in the management of Pierre Robin Sequence (PRS). STUDY DESIGN: Retrospective review/survey. METHODS: 42 Pierre Robin patients were identified, records were reviewed and airway assessments evaluated relative to airway compromise. Twenty patients had undergone tracheostomy. Perceptions of quality of life/morbidity related to tracheostomy were assessed using parental surveys. RESULTS: 31/41 (76%) patients participated in the survey. 15/31 (48%) of survey participants required tracheostomy and were decannulated after a mean of 28 months. Of the patients who had undergone tracheostomy, 10/15 (67%) had isolated Pierre Robin (iPRS) and the remaining 5/15 (33%) had syndromes associated with Pierre-Robin (sPRS). 9/10 (90%) iPRS and 4/5 (80%) sPRS families' expectations were met regarding expected duration of tracheostomy although 3/5 (60%) sPRS, and 8/10 (80%) iPRS described the overall experience as difficult. Of the 2/15 patient's families who were dissatisfied 1 patient had iPRS and the other sPRS. 9/15 (60%) required multiple (>/=3) hospitalizations. 3/13 (23%) reported airway problems after decannulation and 2/15 (13%) remained tracheostomy dependent at the time of survey. Prolonged tracheostomy duration represented a significant parental concern. CONCLUSIONS: A subset of patients required extended duration of tracheostomy; some continued to have airway problems after decannulation and/or distraction. Although some patients benefit from early mandibular distraction other Pierre Robin patients have multi-level obstruction requiring additional therapies and often tracheostomy. Parental concerns and perceptions relative to tracheostomy have not been adequately studied for Pierre Robin airway obstruction. Of those responding to this survey, the majority of parents' expectations were met regarding tracheostomy. Of those whose expectations were not met, it seems that better pre-intervention counseling regarding length of tracheostomy tube dependence, as well as a discussion about potential complications and hospitalizations frequently associated with prolonged tracheostomy, may lead to improved parental expectations.     

A twenty year (1971–1990) review of tracheostomies in a major paediatric hospital

Changing trends in the indications for paediatric tracheostomies, with decreasing numbers of tracheostomies being performed, have been reported in the literature. In a retrospective analysis of the period 1971 to 1990 the experience of tracheostomies in children under the age of 15 at Our Lady's Hospital (Dublin) is reviewed. Only 29 tracheostomies were performed during this time with an increase in numbers (90%) performed during the second 10 year period. The major underlying indication for tracheostomy in both 10 year periods was for the management of an airway problem secondary to congenital abnormalities (65%). In 14 children the operation was performed during the first year of life. However, while 90% of the children were under the age of one in the period 1971–1980 this fell to 26% during 1981–1990. Complications occurred in 41% overall, however, in the under 1 year old group 64% developed complications. There were no deaths as a direct result of the tracheostomy or its complications, but six children died because of the severity of the underlying disease. The average length of time before decannulation was 2.1 years, with decannulation difficulties occurring infrequently (11%).     

Decannulation and survival following tracheostomy in an intensive care unit

We investigated the long-term outcome of patients requiring tracheostomy in an intensive care unit (ICU) in an attempt to identify risk factors that would indicate a low probability of early decannulation. A retrospective study was conducted of a consecutive series of 106 patients who underwent tracheostomy in the period between January 1, 2001, and December 31, 2001, during their admission to the ICU at the Royal Melbourne Hospital, Melbourne, Australia. There were 61 male and 39 female patients with a median age of 65 years. The indications for tracheostomy were prolonged mechanical ventilation (47), tracheobronchial toilet or risk of aspiration (45), and an unstable or obstructed airway (8). Thirty-seven patients died during the study period. All surviving patients were successfully decannulated (median cannulation time, 25 days). Patients with tracheostomies inserted for an unstable or obstructed airway had a significantly shorter cannulation time (median time of 13 days) as compared to the other two indications (mechanical ventilation, 25 days; risk of aspiration, 33 days; log-rank test, chi2(2) = 14.62 and p = .0007). Multivariate analysis showed that the effect of an unstable or obstructed airway was independent of the remaining group variables. We conclude that ICU patients who need a tracheostomy have a high mortality rate. Only the indication for tracheostomy insertion predicts early decannulation, and other patient variables are not significant predictors.     

Airway complications in the head injured

Fifty head-injured patients who had tracheostomy were followed during rehabilitation by video fiberoptic laryngoscopy examination. Complications of aspiration (23/50), airway stenosis (13/50), and phonation dysfunction (16/24) were followed. Spontaneous resolution of aspiration may require a prolonged course. A majority of patients (37/50) had improvement and could be decannulated. Prognostic factors correlated to eventual decannulation included age, level on the Glasgow Coma Outcome Scale, and type of head injury. Those with poor neurologic improvement and glottic incompetence (13/50) are poor candidates for decannulation. Significant airway stenosis can involve both laryngeal and tracheal sites. Neurologic dysfunction may complicate the decannulation process after airway anatomy has been restored by surgery. Dysphonia resulting from intubation, peripheral laryngeal and nerve injury, or central laryngeal movement dysfunction are common. Preventive maintenance with ongoing evaluation can avoid airway crises such as aspiration pneumonia, hemoptysis, and innominate artery.     

Decanulación y evaluación de la deglución del paciente traqueotomizado en cuidados intensivos no-neurocríticos

With intensive care patients, decannulation and deglutition disorders are frequent reasons for otorhinolaryngological assessment.The objective of a tracheostomy is to maintain a patent airway. It does not necessarily prevent episodes of aspiration and may even favour them. When the cause that led to the tracheostomy resolves, a decannulation may be proposed.Deglutition is a complex act involving the coordinated interaction of several structures of the aerodigestive tract. Fibre-optic endoscopy and videofluoroscopy are 2 useful, complementary tools for the evaluation of patients with swallowing disorders. In managing these patients, a thorough knowledge of laryngeal and swallowing physiology, as well as of the different therapeutic alternatives, is required.Although it is not uncommon for swallowing disorders to coexist in tracheostomy patients, decannulation evaluation is not synonymous with deglutition assessment. A patient could be a candidate for decannulation and have a swallowing disorder, or a tracheostomy patient could swallow adequately.Knowing and understanding these concepts will lead to more efficient management and help to clarify communication between the intensive care physician and the otorhinolaryngologist. Ideally, a multidisciplinary team should be formed to evaluate and manage these patients.     

Paediatric subglottic stenosis

Most reports on paediatric subglottic stenosis have arisen from tertiary referral centres. At the Sheffield Children's Hospital, referrals come from the surrounding region such that almost all paediatric airway problems from this area are seen. This allows an opportunity to look at the overall picture of this condition. A retrospective study was performed to identify all children with subglottic stenosis requiring a tracheostomy since 1979 and to examine the management and eventual outcome in relation to the severity of their stenosis. Forty-two children were identified. There have been four mortalities, two of which have been tube related. Twenty-two laryngotracheoplasty procedures have been performed in 17 patients. Successful decannulation has been achieved in 82%. In the majority of children with more minor stenoses conservative management has lead to successful decannulation. However, with increasingly severe stenosis the necessity of undergoing a laryngotracheoplasty procedure to provide an adequate airway becomes more likely.     

Tracheostomy decannulation at the Royal Hospital for Sick Children in Glasgow: Predictors of success and failure

BackgroundTracheostomy techniques, indications and care are extensively covered in the literature. However, little is written about the process of removing the tracheostomy tube. At the Royal Hospital for Sick Children in Glasgow we use a stepwise ward-based protocol for safe tracheostomy decannulation. Our aim therefore was to review all the paediatric tracheostomy decannulations that we attempted over the last 3 years to evaluate our protocol, to determine our success rate and to see whether any modifications to the protocol are required.MethodWe reviewed all patients who had undergone ward decannulation between January 2012 and May 2015. We extracted data from clinical records including patient characteristics, indications for tracheostomy, timing of decannulation and success or failure of the process.ResultsThe 45 children in the study underwent 57 attempts at decannulation during the study period. 25 were male (56%) and 20 were female (44%), and they were aged between 1 day and 16 years 6 months at the time of the original tracheostomy operation. 33 attempts were successful (58%). 10 children had more than one attempt at decannulation. Children were found to fail at every stage of the protocol, with the commonest point of failure being day 2 when the tracheostomy tube was capped.DiscussionWe have demonstrated that our current protocol for ward decannulation is effective and safe, and that all five days of the protocol are required.     

Laser arytenoidectomy in children with bilateral vocal fold immobility

Bilateral vocal fold immobility in children is a challenging problem because a balance between good airway and voice quality has to be achieved. Surgery to improve the airway is often postponed or avoided because of fear of losing the voice. In this study our results of laser arytenoidectomy in children are described. This was a retrospective case notes review at a tertiary level paediatric ENT department. The six patients in this case series ranged from nine to 16 years old at the time of laser arytenoidectomy. Post-operative airway and voice quality were assessed. All children in the series had an adequate post-operative airway. Four of these patients had tracheostomies pre-operatively and achieved decannulation. All six patients rated their post-operative voice as better than pre-operatively. This is principally due to increased loudness associated with increased airflow through the larynx, particularly after tracheostomy decannulation. It is recommended that special care should be taken not to disturb the anterior two thirds of the vocal fold during the surgery in order to achieve a good post-operative voice outcome.     

Closure of persistent tracheocutaneous fistula following "starplasty" tracheostomy in children

OBJECTIVE: The "starplasty" technique of pediatric tracheostomy was introduced in 1990 as an alternative pediatric tracheostomy technique associated with several advantages. The only apparent drawback of this technique is the higher incidence of persistent tracheocutaneous fistula following decannulation. Several methods have been proposed for closure of persistent tracheocutaneous fistula in children, including fistulectomy with primary closure and fistulectomy with healing by secondary intent. Some authors advocate placement of a drain at the time of primary closure. We present our experience with closure of persistent tracheocutaneous fistula following starplasty in children over the past 15 years. METHODS: Ninety-six starplasty procedures were performed on 96 children from 1990 to present, all by the senior author or under the guidance of the senior author. Twenty-eight of these children have been decannulated. Three fistulas closed spontaneously following decannulation. Of the remaining 25 children, 13 have undergone surgical closure of the tracheocutaneous fistula by the senior author. All tracheocutaneous fistula closures were performed as a fistulectomy with primary closure in three layers. Drains were not used in any of the patients. RESULTS: There were three minor complications in the postoperative period (wound infection and airway granuloma) and no major complications. None of the patients have experienced any degree of airway stenosis and there was no need for a repeat tracheotomy in any of the tracheocutaneous fistula closure patients. The cosmetic results were deemed to be good. CONCLUSIONS: "Starplasty" is a safe, reliable pediatric tracheostomy technique that has been shown to decrease the incidence of perioperative morbidity and mortality. The only drawback appears to be a high incidence of postoperative tracheocutaneous fistula. Our method of persistent tracheocutaneous fistula closure following starplasty is safe and effective, with no major complications and no incidence of postoperative airway narrowing.     

Indications and Complications of Tracheostomy in Children

Indications for tracheostomy have changed and its complications are more common in children.Aim: To evaluate the indications and complications of tracheostomies performed in children.Materials and Methods: A retrospective study with review of medical records of patients aged from 1 day to 16 years who underwent tracheostomy at a university hospital during the period of August 2000 to July 2008. We assessed data on age, gender, indications and intra and postoperative complications.Results: Fifty-eight children under 16 years of age underwent tracheotomy during the study period. The mean age was 3.7 years. Airway obstruction was the main indication for surgery (n = 40; 69%). The incidence of complications in the postoperative period was 19% (11 patients), the majority happening during the late postoperative period. A further complication observed was cannula clogging. There were no complications related to the procedure during the surgery.Conclusion: The main indications for tracheostomy in children were airway obstruction and prolonged OTI. The most frequent postoperative complications were cannula obstruction and decannulation. The indications and complications observed were similar to those reported in the literature by other services.     

Peak inspiratory flow as predictor for tracheotomy

ObjectivesQuantitative evaluation of upper airway obstruction cannot be commonly performed under acute dyspnea, especially in head and neck cancer (HNC); the decision whether or not to perform airway control surgery may be difficult to reach. Peak inspiratory flow (PIF) has been previously demonstrated to be a useful tool to decide on decannulation after HNC surgery. The aim of the present study was to assess the role of PIF as a standardized non-invasive tool in quantifying severe inspiratory dyspnea requiring emergency tracheostomy.Materials and methodsA single-center prospective observational pilot study analyzed PIF measurements in 22 patients exhibiting acute dyspnea due to upper airway obstruction.Main outcome measuresThe decision whether or not to perform tracheotomy was taken prior to PIF measurement. PIF was measured with a hand-held PIF meter (In-Check method), and laryngeal fiberoscopy was then performed. Obstruction severity was defined by PIF values.ResultsPIF could be measured prior to tracheotomy (imminent in 21 cases, postponed in 1) in all cases. PIF values below 53.1 L/min (i.e., 18.3% of theoretic value) correlated with necessity for emergency tracheotomy. This threshold is concordant with that previously found for the feasibility of decannulation (60 L/min).ConclusionsPIF is a non-invasive quantitative parameter assessing severity of upper airway obstruction, that may be helpful in decision-making for tracheostomy. Testing is simple, quick and reproducible.