Pediatric Intensive Care Unit Tracheostomy Experiences in Ondokuz Mayıs University Faculty of Medicine

Abstract

INTRODUCTION: Tracheostomy is a clinical practice that has been increasing in frequency recently in patients undergoing respiratory support (mechanical ventilation) with endotracheal intubation in the Pediatric Intensive Care Unit (PICU). In this study, patients who underwent tracheostomy with conventional surgical method while being followed up on mechanical ventilator with endotracheal intubation between 2006 and 2013 in our unit were evaluated retrospectively. In our study, ıt was aimed to share the positive changes in the clinical-mechanical ventilation parameters in the follow-up of the patients in the PICU after the tracheostomy procedure with the literature. METHODS: Study data were primarily obtained from medical records in the Hospital Information Management System (HIMS). After examining the medical records in detail in terms of the data below the "Child Patient Evaluation Form with Tracheostomy" was created. Medical records; some demographic data (eg, age, gender and chronic disease), diagnosis of PICU admission, indications for mechanical ventilation and tracheostomy, mechanical ventilation before/after the procedure (eg; PIP, PEEP, TV) parameters, total length of stay in the PICU before and after the procedure, complications of tracheostomy, decannulation time and results, and survival and death rates in discharged patients, etc. contained. Medical records for the post-discharge period were created by making phone calls with the families. IBM SPSS 21 (Statistical Package for Social Sciences) program was used for statistical analysis. The conformity of the data to the normal distribution was evaluated with the Kolmogorov-Smirrnov test. The sample sizes required for T-test, one-way ANOVA and Chi-square tests for independent groups with different effect sizes, different statistical power levels and 5% statistical significance were calculated using the GPower 3.1 program. Clinical studies ethics committee approval was received on 31.05.2013 with the number B.30.2.ODM.0.20.08/516. RESULTS: Tracheostomy was performed in 104 of 2406 patients followed in the PICU between January 2006 and April 2013. An annual average of 14.2 (4.3%) patients underwent the procedure. In our study the median age of tracheostomy was 13.5 (2-215) months; 44.2% of the patients were under the age of one at the time of the procedure and 62.0% were male. Neurological / neuromuscular diseases (45.0%) ranked first among primary health problems. In this study, the need for prolonged mechanical ventilation (67.0%) was the most common tracheostomy indication while the other frequent indication was upper airway obstruction (21.0%). Congenital airway anomalies (Pierre Robin sequence developmental malformations, retrognatti, etc.) were present in 57.2% of the patients who underwent tracheotomy due to upper airway obstruction. Due to the need for prolonged mechanical ventilation the decision to perform a tracheostomy was made after 4 weeks of hospitalization in the PICU in 52 (77.6%) of 67 patients. In this study clinical changes after the procedure were compared with those before in patients who had long-term mechanical ventilation with endotracheal intubation. In this patient group the Peak Inspiratory Pressure (PIP) requirement on the mechanical ventilator also decreased statistically significantly and the Tidal Volume (TV) increased significantly (both p<0.001). Also; the mean length of stay of the patients in the PICU was statistically significantly shorter after tracheostomy than before (p<0.001). Various complications developed in the early period (first 7 days) in 21.0% of the patients with tracheostomy and in the late period (after the 7th day) in 39.0%. Bleeding from the anastomotic line in the early period (12.0%) and unplanned (=accidental) decannulation in the late period were the most common complications. In our study 41.8% of the patients with tracheostomy were discharged from their PICU with free flow oxygen support and 57.0% with home-type mechanical ventilator support. Planned (=successful) decannulation could only be applied to one patient at the first hospitalization. Sixty-four patients in this study died due to complications associated with the primary disease and only four (6.2%) patients had tracheotomy-related deaths (eg, cannula occlusion, unplanned decannulation, etc.). The follow-up period of the patients in this study with tracheostomy was 5.1(0-79) months. Planned decannulation was performed in 17.0% of the patients but unplanned or accidental decannulation developed in 9.0% of patients. Decannulation success was 38.5% for all cases. The success of decannulation was statistically significantly higher in planned decannulation (p<0.05). In addition, the success of decannulation in patients who underwent tracheostomy due to upper airway obstruction was statistically significantly higher than in other indications (p<0.02). The median follow-up period on mechanical ventilator after tracheostomy was also statistically significantly shorter in the patient group whose decannulation was successful (p<0.01). DISCUSSION AND CONCLUSION: Although different results have been obtained in many clinical studies today the most common indication for tracheostomy in the pediatric age group is the need for prolonged mechanical ventilation. Tracheostomy treatment option should be considered by clinicians if extubation cannot be achieved in children and adolescents who are undergoing mechanical ventilation for a long time (>2-4 weeks) due to progressive primary disease. Despite the results of clinical studies in the literature that support the application of tracheostomy in the early period in patients given endotracheal intubation (mechanical ventilation) and respiratory support in the PICU as shown in some systematic analyzes patient-centered (=individual) decision making is more appropriate. In patients with insufficient pulmonary ventilation capacity tracheostomy may facilitate the transition to spontaneous breathing by improving respiratory mechanics (for example, by reducing workload). Tracheostomy is also very important in terms of providing general psychosocial-physical well being within appropriate medical indications as it shortens the length of stay in the hospital/PICU and provides medical care in a suitable home environment outside the hospital.

Keywords

• Pediatric İntensive Care Unit
• Prolonged Mechanical Ventilation
• Tracheostomy
• Decanulation

References

1. References1. Funamura JL, Durbin-Johnson B, Tollefson TT, Harrison J, Senders CW.Pediatric tracheotomy: indications and decannulation outcomes. Laryngoscope. 2014 Aug;124(8):1952-1958.
2. References2. Lawrason A, Kavanagh K. Pediatric tracheotomy: are the indications changing? Int J Pediatr Otorhinolaryngol 2013;77(6):922-925.
3. References3. Carron JD, Derkay CS, Strope GL, Nosonchuk JE, Darrow DH. Pediatric tracheotomies: changing indications and outcomes. Laryngoscope 2000;110(7):1099-1104.
4. References4. Cheung NH, Napolitano LM. Tracheostomy: epidemiology, indications, timing, technique, and outcomes. Respir Care 2014;59(6):895-915; discussion 916-899.
5. References5. Schweiger C, Manica D, Becker CF, Abreu LSP, Manzini M, Sekine L, Kuhl G.Tracheostomy in children: a ten-year experience from a tertiary center in southern Brazil. Braz J Otorhinolaryngol. 2017 Nov - Dec;83(6):627-632.
6. References6. Perez-Ruiz E, Caro P, Perez-Frias J, Cols M, Barrio I, Torrent A, et al. Paediatric patients with a tracheostomy: a multicentre epidemiological study. Eur Respir J 2012;40(6):1502-1507.
7. References7. Hadfield PJ, Lloyd-Faulconbridge RV, Almeyda J, Albert DM, Bailey CM. The changing indications for paediatric tracheostomy. Int J Pediatr Otorhinolaryngol 2003;67(1):7-10.
8. References8. Ertugrul I, Kesici S, Bayrakci B, Unal OF. Tracheostomy in Pediatric Intensive Care Unit: When and Where? Iran J Pediatr. 2016 Feb;26(1):e2283.

9. References9. Combes A, Luyt CE, Nieszkowska A, Trouillet JL, Gibert C, Chastre J. Is tracheostomy associated with better outcomes for patients requiring long-term mechanical ventilation? Crit Care Med 2007;35(3):802-807.
10. References10. Dursun O, Ozel D. Early and long-term outcome after tracheostomy in children. Pediatr Int 2011;53(2):202-206.
11. References11. Heffner JE. The role of tracheotomy in weaning. Chest 2001;120(6 Suppl):477S-481S.
12. References12. Serra A, Cocuzza S, Longo MR, Grillo C, Bonfiglio M, Pavone P.Tracheostomy in childhood: new causes for an old strategy. . Eur Rev Med Pharmacol Sci. 2012 Nov;16(12):1719-22.
13. References13. Watters KF. Tracheostomy in Infants and Children. Respiratory Care 2017 June, 62 (6) 799-82
14. References14. Sauthier M, Rose L, Jouvet P. Pediatric Prolonged Mechanical Ventilation: Considerations for Definitional Criteria. Respir Care 2017;62(1):49-53.
15. References15. Wood D, McShane P, Davis P. Tracheostomy in children admitted to paediatric intensive care. Arch Dis Child 2012;97(10):866-869.
16. References16. Holloway AJ, Spaeder MC, Basu S. Association of timing of tracheostomy on clinical outcomes in PICU patients. Pediatr Crit Care Med 2015;16(3):e52-58.
17. References17. Rizk EB, Patel AS, Stetter CM, Chinchilli VM, Cockroft KM. Impact of tracheostomy timing on outcome after severe head injury. Neurocrit Care 2011;15(3):481-489.
18. References18. Scales DC, Thiruchelvam D, Kiss A, Redelmeier DA. The effect of tracheostomy timing during critical illness on long-term survival. Crit Care Med 2008;36(9):2547-2557.
19. References19. Holscher CM, Stewart CL, Peltz ED, Burlew CC, Moulton SL, Haenel JB, et al. Early tracheostomy improves outcomes in severely injured children and adolescents. J Pediatr Surg 2014;49(4):590-592.
20. References20. Lipovy B, Brychta P, Rihova H, Suchanek I, Hanslianova M, Cvanova M, et al. Effect of timing of tracheostomy on changes in bacterial colonisation of the lower respiratory tract in burned children. Burns 2013;39(2):255-261.
21. References21. Atmaca S, Bayraktar C, Asilioglu N, Kalkan G, Ozsoy Z. Pediatric tracheotomy: 3-year experience at a tertiary care center with 54 children. Turk J Pediatr 2011;53(5):537-540.
22. References22. Lee W, Koltai P, Harrison AM, Appachi E, Bourdakos D, Davis S, et al. Indications for tracheotomy in the pediatric intensive care unit population: a pilot study. Arch Otolaryngol Head Neck Surg 2002;128(11):1249-1252.
23. References23. Davis K, Jr., Campbell RS, Johannigman JA, Valente JF, Branson RD. Changes in respiratory mechanics after tracheostomy. Arch Surg 1999;134(1):59-62. 24. Namdar T, Stollwerck PL, Stang FH, Klotz KF, Lange T, Mailander P, et al. Early postoperative alterations of ventilation parameters after tracheostomy in major burn injuries. Ger Med Sci 2010;8:Doc10.
24. References25. Sofi K, Wani T. Effect of tracheostomy on pulmonary mechanics: An observational study. Saudi J Anaesth 2010;4(1):2-5.
25. References26. Knollman PD, Baroody FM. Pediatric tracheotomy decannulation: a protocol for success. Curr Opin Otolaryngol Head Neck Surg 2015;23(6):485-490.
26. References27. Kremer B, Botos-Kremer AI, Eckel HE, Schlondorff G. Indications, complications, and surgical techniques for pediatric tracheostomies--an update. J Pediatr Surg 2002;37(11):1556-1562.
27. References28. Karapinar B, Arslan MT, Ozcan C. Pediatric bedside tracheostomy in the pediatric intensive care unit: six-year experience. Turk J Pediatr 2008;50(4):366-372.
28. References29. de Trey L, Niedermann E, Ghelfi D, Gerber A, Gysin C. Pediatric tracheotomy: a 30-year experience. J Pediatr Surg 2013;48(7):1470-1475.
29. References30. Maged Abdelkader, John Dempster Emergency Tracheostomy: Indıcatıons and Texhnique Special Feature/ General Surgery Vol.21 Issue 6 . p 153-155, June 01, 2003.