Favorable short- and long-term outcomes of prolonged translaryngeal intubation in critically ill children

In those children who require protracted mechanical ventilation, we use long-term intubation in order to avoid the consequences of tracheostomy in young children. A retrospective 9-year review was performed to document the efficacy and safety of this practice. A retrospective review of children admitted from January 1, 1991, to December 31, 1998, who required mechanical ventilatory support for at least 7 consecutive days was performed. Data are presented as mean +/- standard deviation. There were 98 children, ventilated for a total of 1967 days, who satisfied review criteria. They had an average age of 6.1 +/- 5.3 years (range, 3 months to 17 years) a total body surface area burn of 53 +/- 25% (range, 0-100%), and 71 of 98 (72%) had suffered an inhalation injury. They were ventilated for 19.7 +/- 16.8 days (range, 7-92 days) and were hospitalized for 67.8 +/- 48.9 days (range, 9-211 days). Ninety-three percent (91 of 98) of the patients were maintained on morphine infusions at a mean hourly rate of 0.35 +/- 0.33 mg/kg/hr (range, 0.01-4.38) and 78% (76 of 98) on midazolam infusions at a mean hourly rate of 0.14 +/- 0.17 mg/kg/hr (range, 0.01-1.82). Neuromuscular blocking agents were administered in 39% (38 of 98) of patients during all or part of 355 (18%) of the 1967 ventilator days. Patients were ventilated with an oral endotracheal (ET) tube in 82% of ventilator days and nasal ET tube in 18% of ventilator days. Two patients (2%) required tracheostomies for long-term management, and five patients (5.1%) died during the study period unrelated to airway issues. There were five unplanned extubation events, for an incidence rate of 2.54 per 1000 ventilator days. All patients were reintubated successfully. Thirteen ET tubes needed to be changed for issues such as leaking cuffs. Patients were followed up for a mean of 2.99 +/- 2.24 years (range, 1 month to 8 years). Possible sequelae related to prolonged intubation were noted in follow-up visits in 8 patients, including sinusitis (one; resolved without treatment), subglottic stenosis (one; required reconstructive surgery), persistent cough (three; all resolved spontaneously), occipital breakdown because of ET ties (one; healed after 1 month), soft voice (two; resolved spontaneously), and decreased pharyngeal sensation (one; resolved without treatment). Translaryngeal intubation is a safe and effective method to provide long-term ventilatory support in children.