Journal of Pediatric Surgery xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Changes in pediatric tracheostomy 1982–2011: a Canadian tertiary children's hospital review Lauren N. Ogilvie a, Jessica K. Kozak a, Simon Chiu a, Robert J. Adderley b, Frederick K. Kozak a,⁎ a b
Division of Pediatric Otolaryngology, BC Children's Hospital, Division of Otolaryngology, 4480 Oak Street, Vancouver, BC, V6H 3V4 Home Tracheostomy Care and Home Ventilation Program, BC Children's Hospital, 4480 Oak Street, Vancouver, BC, V6H 3V4
a r t i c l e
i n f o
Article history: Received 11 February 2014 Received in revised form 28 April 2014 Accepted 28 April 2014 Available online xxxx Key words: Tracheostomy Pediatric Indications Complications
a b s t r a c t Background: Pediatric tracheostomy has undergone notable changes in frequency and indication over the past 30 years. This study investigates pediatric tracheostomy at British Columbia Children's Hospital (BCCH) over a 30-year period. Methods: A retrospective chart review of tracheostomy cases at BCCH from 1982 to 2011 was conducted. Charts were reviewed for demographics, date of tracheostomy, indication, complications, mortality and date of decannulation. Data from three 10-year time periods were compared using Fisher's Exact test to examine changes over time. Results: 251 procedures (154 males) performed on 231 patients were reviewed. Mean age at tracheostomy was 3.74 years with 48% of procedures undertaken before the age of one year. Frequency of procedure by year has generally declined into the early 2000's. Upper airway obstruction was the most common indication accounting for 33% of procedures. The rate of complication across the entire cohort was 22% with 63% of patients being decannulated. Tracheostomy related mortality occurred in 2.0% of cases reviewed. Conclusions: Changes occurred in primary indications with infections indicating less procedures and neurological impairments indicating more procedures over time. Complications increased and the decannulation rate decreased over this 30-year review. Pediatric tracheostomy is considered a safe and effective procedure at BCCH. © 2014 Elsevier Inc. All rights reserved.
Tracheostomy and its associated outcomes have evolved from ancient origins to the present day. In the pediatric population the past 30 years have seen changes in the frequency, age and primary indications for this procedure. Comparable medical centers have reported a decline in frequency of tracheostomy during the period 1980–1990 and either a plateau or slight increase in frequency over the past 10 years [1–3]. The average age at tracheostomy has declined slightly over the last 30 years and currently most procedures are done on children in their first year of life [4–8]. The most prevalent indications for tracheostomy have changed over time owing to advancements in treatment and technology. Early in the 1980's many procedures were indicated as a result of infection of the upper respiratory tract [9]. Introduction of the Haemophilus influenzae type B vaccine and improvements in intensive care units have decreased the number of tracheostomies required for infectious diseases over the 1980's and 1990's [10]. Regional differences have also affected which tracheostomy indications are most prevalent. In Turkey, the 1990's saw a shift in the most prevalent indicator from
Abbreviations: BCCH, British Columbia Children's Hospital; UAO, Upper airway obstruction. ⁎ Corresponding author at: Division of Pediatric Otolaryngology BC Children's Hospital, K2-184 4480 Oak Street, Vancouver, BC, Canada, V6H 3V4. Tel.: +1 604 875 2113. E-mail address: [email protected] (F.K. Kozak).
upper airway obstruction (UAO), owing to infectious disease, to prolonged positive pressure ventilation [10]. Research from France and Singapore also reports a greater number of procedures being done for ventilator dependency in the late 1990's [11,12]. Recent analysis from the United States has suggested a reversal back to UAO as the most common indication; however, it is most often owing to congenital (syndromic) or acquired UAO (subglottic stenosis), rather than infection [3]. Results from Turkey maintain that prolonged intubation is still the primary indication [1]. These differences emphasize a need for regional consideration when analyzing the indications for tracheostomy. Research from Alberta Children's Hospital, a center comparable to BC Children's Hospital (BCCH), has reported that UAO accounts for most tracheostomies performed between 1990 and 2007 at their center [13]. Research into the complications either at the time of tracheostomy or during the period of time a patient has a tracheostomy is also important to the complete review of this procedure/condition. Complications have remained generally consistent over the past 30 years. Reported complication rates range from 18 to 64% [1,4,8,10,14–16]. When granulation tissue around the stoma has been considered as a complication the overall reported complication rate is at the higher end of this range [1,4,8,14–16]. Alternatively, studies considering granulation tissue as an expected outcome, a view that is supported by the literature, have reported lower complication
http://dx.doi.org/10.1016/j.jpedsurg.2014.04.014 0022-3468/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Ogilvie LN, et al, Changes in pediatric tracheostomy 1982–2011: a Canadian tertiary children's hospital review, J Pediatr Surg (2014), http://dx.doi.org/10.1016/j.jpedsurg.2014.04.014
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L.N. Ogilvie et al. / Journal of Pediatric Surgery xxx (2014) xxx–xxx
rates [10,17–19]. Exclusive consideration of serious complications such as pneumothorax, pneumomediastinum, accidental decannulation, wound erosion/infection, abscess and death has previously resulted in conservative complication rates [10,17–19]. Complications also vary based on the standards of care that a medical center can provide and patient characteristics such as prematurity or age at the time of tracheostomy [20]. At our institution a tracheostomy is essentially exclusively performed by a pediatric otolaryngologist, with follow-up care and training coordinated through outpatient programs once the patient is discharged from hospital. All children requiring a tracheostomy in British Columbia, with the exception of a few patients who are close to Alberta, are seen at our institution. To date, a comprehensive evaluation and follow up of tracheostomy at this center have not been published. A 30-year retrospective chart review of patients who have undergone a tracheostomy at BCCH was performed for quality assurance purposes, as well as to compare procedural indications and outcomes with the current literature and play a role in future care decisions. This review adds to previous knowledge on the prevalence of indications and the details of complications while highlighting our region's differences. Data were analyzed over three 10-year periods for comparison purposes. 1. Methods A retrospective chart review of all tracheostomy cases performed at BCCH from 1982 to 2011 with follow-up review until 2011 was conducted. Ethical approval was obtained from the University of British Columbia/Children's and Women's Health Centre of British Columbia Research Ethics Board. All tracheostomy procedures over the 30 year period were done by 11 surgeons with varying levels of experience using commonly practiced tracheostomy techniques. The majority of tracheal incisions were made vertically and stay sutures were used. Hospital database record of procedures was used to identify each patient and locate charts. Charts were reviewed for demographics, date of tracheostomy, surgeon, indication, complications, mortality and date of decannulation. Each patient's primary indication was further classified as either UAO, syndrome with UAO, prolonged intubation, neurological impairment, trauma, cancer, laryngeal abnormality or infection, which is similar to the methods described in previous research [3]. All charts were reviewed until decannulation, mortality, end of care at BCCH or until the end of the review period. As this study was retrospective no effort was made to standardize operating procedure or perioperative care that varied over time. The senior author co-reviewed 24% of charts to ensure reviewer consistency. Data from the BCCH Home Tracheostomy Care and Home Ventilation program were also briefly reviewed to verify particular results. Patients who had a tracheostomy for UAO included those with physical obstruction such as subglottic stenosis, tracheomalacia or a head/neck mass resulting in obstruction. Those in the “infection”
category included patients who had croup as their primary indication. Syndromes that involve UAO such as Pierre Robin, Goldenhar, Apert and others were classified under the primary indication “syndrome with UAO”. Prolonged intubation characterized patients who required long-term ventilator support (ie. prematurity, congenital heart disease, omphalocele, gastrochisis or hypoplastic lung). Neurological impairment primarily represented those with polyneuropathy or central hypoventilation. Patients who had experienced head or spinal cord trauma and required ventilation were categorized as “trauma”. Cancer cases included tracheostomy required for a condition secondary to treatment or for a cancerous tumor. Structural or functional abnormalities of the larynx were categorized as laryngeal abnormalities (ie. laryngomalacia, laryngeal web or vocal cord paralysis). Patients who had multiple indications attributed to their case were classified by their primary indication. Significant complications included in analysis were pneumothorax, pneumomediastinum, wound erosion, wound infection, accidental decannulation, abscess, size issues and mortality. Defining complications in such a way is consistent with the previous literature [10]. To compare these measures between time periods, patients were separated based on date of tracheostomy into three groups 1982–1991, 1992–2001, or 2002–2011. All statistical analysis was completed using Excel and VassarStats based on a significance value of p b 0.05. Categorical frequency data were analyzed using Fisher's Exact test. 2. Results Two hundred and sixty seven tracheostomies were performed at BCCH from 1982 to 2011. This review includes 251 procedures performed on 231 patients (154 male, 97 female), 16 patients were excluded owing to inability to access records. In 16 of the 251 cases (6%) reviewed, complete information could not be found; however, the information that was available from these patient charts was included in analysis and n values were adjusted to reflect missing patients. For the entire cohort, average age at tracheostomy was 3.7 years (ranged from 0.0 to 18.9 years) with 48% less than one year of age (Fig. 1). Average age remained fairly consistent over the 30 years of review. Frequency of tracheostomy varied between 1 and 21 procedures per year. A general decline in number of procedures per year occurred over the 1990's and the beginning of the 2000's with numbers increasing in the most recent 10 years (Fig. 2). Variation in frequency resulted in three 10-year time periods with differences in n-values (118 from 1982–91, 78 from 1992–01 and 55 from 2002–11). Cases were reviewed for a minimum of 0.0 days to a maximum of 6935.0 days, the median of this range was 206.0 days. The most prevalent primary indication was UAO, mainly acquired subglottic stenosis, accounting for 33% of all tracheostomies. Prolonged intubation was the indication in 15% of procedures while, laryngeal abnormalities and syndromes each contributed 13% and 11% respectively. Comparison of the three ten-year periods revealed changes in the proportion of two indications over time. UAO remained
Fig. 1. Number of procedures at each age by 10-year time period.
Please cite this article as: Ogilvie LN, et al, Changes in pediatric tracheostomy 1982–2011: a Canadian tertiary children's hospital review, J Pediatr Surg (2014), http://dx.doi.org/10.1016/j.jpedsurg.2014.04.014
L.N. Ogilvie et al. / Journal of Pediatric Surgery xxx (2014) xxx–xxx
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was 63%. Over time the number of patients decannulated decreased significantly (p b 0.05, Fisher's Exact test) from 84 (75%) in the first ten years to 46 (61%) in the second ten year time period and to 23 (42%) in the most recent ten years, however it must be noted that the most recent cases have been followed for a shorter length of time (Fig. 5). Average length in situ for those who were successfully decannulated was 451.7 days with a median of 151.0 days ranging from 0.0 to 4463.0 days. Overall mortality rate was 15% among the 248 patients for which there were data. Tracheostomy related mortality occurred in 5 (2%) of the 244 cases for which there were data about cause of mortality. All tracheostomy related mortality was attributed to accidental decannulation. 3. Discussion
Fig. 2. Frequency of tracheostomy by year.
the most common indication across all three time periods with no significant change in prevalence. Infection cases significantly (p b 0.05, Fisher's Exact test) declined from eight in the first 10 years to zero in the most recent 10-year time period. A significant (p b 0.05, Fisher's Exact test) increase occurred in the number of procedures indicated by neurological impairment over the 30 years of this review (Fig. 3). Patients at BCCH who had a primary indication of infection were all successfully decannulated. The next highest rate for decannulation was for those who had a primary indication of trauma (77%) or UAO (73%). Those patients who underwent a tracheostomy for neurological impairment had the lowest rate of decannulation (20%). The highest average ages at tracheostomy were as a result of trauma (9.0 years) and cancer (6.8 years). Complication rate was 22% for the entire cohort with a maximum of 2 complications occurring in any one patient. The most common complication was accidental decannulation, this occurred 16 times at a rate of 6% (Table 1). Wound erosion was the second most prevalent with 10 instances at a rate of 4% followed by wound infection and tracheal tube size issues. The majority (67%) of complications occurred after the first week postoperatively (Table 2). Complication rates increased significantly (p b 0.05) from 15% in the 80's to 27% in the 90's and remained at 27% in the most recent decade (Fig. 4). Decannulation was achieved in 153 cases, 90 patients have not been decannulated and 8 were lost to follow-up. Of those reviewed whose decannulation status was known, the rate of decannulation
At BCCH frequency of tracheostomy has declined over the 1990's and into the 2000's. In the most recent 10 years of this review there has been a plateau and slight increase in the number of procedures performed. This pattern is generally consistent with the current literature, although the plateau has been reported to start earlier [10]. Some spikes in frequency may be explained by corresponding increases in premature infants for that year, however not all spikes show this corresponding increase. Separating the number of procedures by 10-year increments resulted in varying n-values that were similar to those obtained in a longitudinal analysis from Zurich, Switzerland [6]. Interestingly, results on frequency may differ based on whether a care center is primary or tertiary; a primary center in London, UK did not experience any decrease in number of procedures [21]. Almost half of procedures at BCCH were done on patients under one year of age; this remained fairly consistent over the 30-year review. The majority of centers similar to BCCH provide evidence to support a growing under 1-year old (at time of tracheostomy) patient population; however, there have been some exceptions [13,14]. These include Ireland in the 1990's where a decline was seen in the number of patients under 1-year of age at time of tracheostomy. Doctors there were reluctant to perform a tracheostomy on this population because of their high susceptibility to complication [22]. A Nigerian care center is also an exception; the majority of patients studied had an age at tracheostomy in the range of 6–10 years reflecting the high prevalence of respiratory papillomatosis and motor vehicle accidents in the area [23]. While in some cases region seems to have an impact on age at tracheostomy our results are consistent with the majority. For the entirety of this review UAO remained the most prevalent indication for pediatric tracheostomy. During the most recent 10-year time period UAO continued to be the most prevalent indication with prolonged intubation and neurological impairment as the second most prevalent. This is consistent with previous reviews from similar centers that have documented an increase in the indication of prolonged intubation in the 2000's, but not so much as to exceed
Fig. 3. Indication percentage by 10-year time period. * denotes significance (p b 0.05).
Please cite this article as: Ogilvie LN, et al, Changes in pediatric tracheostomy 1982–2011: a Canadian tertiary children's hospital review, J Pediatr Surg (2014), http://dx.doi.org/10.1016/j.jpedsurg.2014.04.014
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Table 1 Complications by 10-year time period. All years Accidental decannulation (no mortality) Accidental decannulation (mortality) Pneumothorax Pneumomediastinum Wound infection Erosion Size Abscess Total complications
1982–1991
1992–2001
2002–2011
11 (4%)
2 (2%)
6 (8%)
3 (5%)
5 (2%)
3 (3%)
2 (3%)
0 (0%)
1 (1%) 3 (3%) 3 (3%) 4 (3%) 2 (2%) 0 (0%) 18 (16%)
5 (6%) 1 (1%) 3 (4%) 2 (3%) 0 (0%) 2 (3%) 21 (27%)
0 (0%) 0 (0%) 2 (4%) 4 (7%) 6 (11%) 0 (0%) 15 (27%)
6 4 8 10 8 2 54
(2%) (2%) (3%) (4%) (3%) (1%) (22%)
the number of patients indicated by UAO [6,24]. Conflicting research suggests prolonged intubation is currently the most prevalent indication for tracheostomy; however, prevalence is often affected by the country where care is located [22,25–27]. In our review the indication of neurological impairment increased over time resulting in greater numbers of a complex, long-term indication for tracheostomy; an increase that has not previously been reported in this indication. Our results also add to the evidence that infection is no longer a notable indication for tracheostomy [24]. As infection often indicates short-term tracheostomy, this decline also supports a shift to more complex, long-term tracheostomy. Indications for tracheostomy were related to decannulation rate and age at procedure in a manner that is consistent with previous research from Germany with neurological impairment as an indication resulting in the lowest decannulation rate and infection resulting in the highest [24]. The very low decannulation rate for those who underwent a tracheostomy for neurological impairment is indicative of the long-term nature and complexity of this patient population. At BCCH care is coordinated through an outpatient program that provides training to families and frequent contact with healthcare expertise in tracheostomy care. As a result of this program, full records of most patients' tracheostomy experience were available for review. Serious complications occurred at a rate that is on the lower end of the significant range of complication rates that are presented in the current literature (18–46%) [1,4,8,10,14–16]. Upon comparison of the three 10-year time periods an increase occurred in long-term complications between the 1980's and 1990's. This increase in complications is not often reported from one center. It may be owing to the changing nature of indications for a tracheostomy and care in more long term patients as this population can have multiple indications and greater opportunity for complication than in past time periods [4,6]. The most common complication observed was accidental decannulation which is contrary to previous research that names pneumomediastinum as the most common early complication [17]. The higher prevalence of accidental decannulation in this population is consistent with the finding that most complications occurred after
Fig. 4. Complication percentage by 10-year time period. * denotes significance (p b 0.05).
one week of tracheostomy in situ. As expected, other long-term complications were size issues and wound infection [10]. The BCCH tracheostomy related mortality rate of 2% is comparable to the literature that when compiled, records a range of 0–4% [1,4,10,14–16,18,28–30]. The exclusive cause of mortality in this review, accidental decannulation, is a common cause of tracheostomy related mortality noted in the literature [28,31]. Data from the BCCH Home Tracheostomy Care and Home Ventilation program add to these findings by examining a set of patients who were cared for at home in BC. They had 133 patients under their care from 1982 to 2011 with 9 instances of mortality (7%). Total mortality for our study, reviewing pediatric tracheostomy at BCCH, was 15%. Mortality (tracheostomy related and unrelated) decreased slightly across the three time periods; however, this may be a result of the decreased amount of time that the most recent patients have been followed. Retrospective reviews have inherent limitations such as difficulty to obtain complete data on all patients. Full records of the time period starting at the time of tracheostomy were obtained and reviewed; however, anything that was not recorded in the patient's chart would not be possible to review. In an effort to report current data the most recent 10-year period has not been reviewed for as long as the first two time periods, this may have resulted in an underrepresentation of complication and decannulation rates for this group. Difficulty in comparison across the literature is apparent owing to varying classifications for indications. Complication rates are also difficult to directly compare as the previous literature has variable consensus on what can be considered a true complication. Previous research that recorded similar major complications had rates that were comparable to ours [10,17,18]. 4. Conclusions At BCCH patients with a tracheostomy have changed in relation to frequency, indications, complications and decannulation rates over the last 30 years. This review presents an increase in complications over time and decrease in percent decannulated, as indicated by the
Table 2 Complications by length of time since procedure Fig. 1.
Accidental decannulation (no mortality) Accidental decannulation (mortality) Pneumothorax Pneumomediastinum Wound infection Erosion Size issues Abscess Total complications
b24 h
24–48 h
N48 h–1 week
4 (2%)
0
1 (0.3%)
N1 week 6 (2%)
0
0
0
5 (2%)
2 (0.6%) 3 (1%) 0 0 0 0 9 (4%)
1 (0.3%) 0 1 (0.3%) 0 0 0 2 (0.6%)
0 0 1 (0.3%) 4 (2%) 1 (0.3%) 0 7 (3%)
3 (1%) 1 (0.3%) 6 (2%) 6 (2%) 7 (3%) 2 (0.6%) 36 (14%)
Fig. 5. Decannulation percentage by 10-year time period. Significant p b 0.05.
Please cite this article as: Ogilvie LN, et al, Changes in pediatric tracheostomy 1982–2011: a Canadian tertiary children's hospital review, J Pediatr Surg (2014), http://dx.doi.org/10.1016/j.jpedsurg.2014.04.014
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changes from the first ten year time period to the second. These changes may be the result of increased length of time in situ and complexity of indication for the average tracheostomy patient. Overall, low rates of complication and tracheostomy related mortality confirm that pediatric tracheostomy at BCCH will continue to be considered a safe and effective procedure. Further research into the subjective experience of those who undergo tracheostomy at BCCH and subsequently live with a tracheostomy is necessary to determine where improvements in care may be possible. Acknowledgments Rachelle Dar Santos- for administrative assistance Current and former members of the Division of Pediatric Otolaryngology. All surgeons who have performed a tracheostomy at BCCH. References [1] Atmaca S, Bayraktar C, Asilioglu N, et al. Pediatric tracheotomy: 3-year experience at a tertiary care center with 54 children. Turk J Pediatr 2011;53(5):537–40. [2] Mahadevan M, Barber C, Salkeld L, et al. Pediatric tracheotomy: 17 year review. Int J Pediatr Otorhinolaryngol 2007;71(12):1829–35. [3] Lawrason A, Kavanagh K. Pediatric tracheotomy: are the indications changing? Int J Pediatr Otorhinolaryngol 2013;77(6):922–5. [4] Carron JD, Derkay CS, Strope GL, et al. Pediatric tracheotomies: changing indications and outcomes. Laryngoscope 2000;110(7):1099–104. [5] Corbett HJ, Mann KS, Mitra I, et al. Tracheostomy—a 10-year experience from a UK pediatric surgical center. J Pediatr Surg 2007;42(7):1251–4. [6] De Trey L, Niedermann E, Ghelfi D, et al. Pediatric tracheotomy: a 30-year experience. J Pediatr Surg 2013;48(7):1470–5. [7] Dursun O, Ozel D. Early and long-term outcome after tracheostomy in children. Pediatr Int 2011;53(2):202–6. [8] Ilce Z, Celayir S, Tekand GT, et al. Tracheostomy in childhood: 20 years experience from a pediatric surgery clinic. Pediatr Int 2002;44(3):306–9. [9] Prescott CAJ, Vanlierde MJRR. Tracheostomy in children- the Red Cross War Memorial Children's Hospital experience 1980–1985. Int J Pediatr Otorhinolaryngol 1989;17(2):97–107. [10] Ozmen S, Ozmen OA, Unal OF. Pediatric tracheotomies: a 37-year experience in 282 children. Int J Pediatr Otorhinolaryngol 2009;73(7):959–61.
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[11] Butnaru CS, Colreav MP, Ayari S, et al. Tracheotomy in children: evolution in indications. Int J Pediatr Otorhinolaryngol 2006;70(1):115–9. [12] Ang AHC, Chua DYK, Pang KP, et al. Pediatric tracheotomies in an Asian population: the Singapore experience. Otolaryngol Head Neck Surg 2005;133(2):246–50. [13] Al-Samri M, Mitchell I, Drummond DS, et al. Tracheostomy in children: a populationbased experience over 17 years. Pediatr Pulmonol 2010;45(5):487–93. [14] Midwinter KI, Carrie S, Bull PD. Paediatric tracheostomy: Sheffield experience 1979–1999. J Laryngol Otol 2002;116(7):532–5. [15] Pereira KD, MacGregor AR, McDuffie CM, et al. Tracheostomy in preterm infants: current trends. Arch Otolaryngol Head Neck Surg 2003;129(12):1268–71. [16] Tantinikorn W, Alper CM, Bluestone CD, et al. Outcome in pediatric tracheotomy. Am J Otolaryngol 2003;24(3):131–7. [17] Kremer B, Botos-Kremer AI, Eckel HE, et al. Indications, complications, and surgical techniques for pediatric tracheostomies- an update. J Pediatr Surg 2002;37 (11):1556–62. [18] Ward RF, Jones J, Carew JF. Current trends in pediatric tracheotomy. Int J Pediatr Otorhinolaryngol 1995;32(3):233–9. [19] Shinkwin CA, Gibbin KP. Tracheostomy in children. J R Soc Med 1996;89 (4):188–92. [20] Berry JG, Graham RJ, Roberson DW, et al. Patient characteristics associated with inhospital mortality in children following tracheotomy. Arch Dis Child 2010;95 (9):703–10. [21] Hadfield PJ, Lloyd-Faulconbridge RV, Almeyda J, et al. The changing indications for paediatric tracheostomy. Int J Pediatr Otorhinolaryngol 2003;67(1):7–10. [22] Donnelly MJ, Lacey PD, Maguire AJ. A twenty year (1971–1990) review of tracheostomies in a major paediatric hospital. Int J Pediatr Otorhinolaryngol 1996;35(1):1–9. [23] Adoga AA, Ma'an ND. Indications and outcome of pediatric tracheostomy: results from a Nigerian tertiary hospital. BMC Surg 2010;10(2):1–4. [24] Zenk J, Fyrmpas G, Zimmermann T, et al. Tracheostomy in young patients: indications and long-term outcome. Eur Arch Otorhinolaryngol 2009;266(5):705–11. [25] Suslu M, Ermutlu G, Akyol U. Pediatric tracheotomy: comparison of indications and complications between children and adults. Turk J Pediatr 2012;54(5):497–501. [26] Puhakka HJ, Kero P, Lisalo E. Tracheostomy in pediatric patients. Acta Paediatr 1992;81(3):231–4. [27] Perez-Ruiz E, Caro P, Perez-Frias J, et al. Paediatric patients with a tracheostomy: a multicentre epidemiological study. Eur Respir J 2012;40(6):1502–7. [28] Alladi A, Rao S, Das K, et al. Pediatric tracheostomy: a 13-year experience. Pediatr Surg Int 2004;20(9):695–8. [29] Simma B, Spehler D, Burger R, et al. Tracheostomy in children. Eur J Pediatr 1994;153(4):291–6. [30] Rozsasi A, Kuhnemann S, Gronau S, et al. A single-center 6-year with two types of pediatric tracheostomy. Int J Pediatr Otorhinolaryngol 2005;69(5):607–13. [31] Carr MM, Poje CP, Kingston L, et al. Complications in pediatric tracheostomies. Laryngoscope 2001;111(11 Pt. 1):1925–8.
Please cite this article as: Ogilvie LN, et al, Changes in pediatric tracheostomy 1982–2011: a Canadian tertiary children's hospital review, J Pediatr Surg (2014), http://dx.doi.org/10.1016/j.jpedsurg.2014.04.014
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Changes in pediatric tracheostomy 1982–2011: a Canadian tertiary children's hospital review Lauren N. Ogilvie a, Jessica K. Kozak a, Simon Chiu a, Robert J. Adderley b, Frederick K. Kozak a,⁎ a b
Division of Pediatric Otolaryngology, BC Children's Hospital, Division of Otolaryngology, 4480 Oak Street, Vancouver, BC, V6H 3V4 Home Tracheostomy Care and Home Ventilation Program, BC Children's Hospital, 4480 Oak Street, Vancouver, BC, V6H 3V4
a r t i c l e
i n f o
Article history: Received 11 February 2014 Received in revised form 28 April 2014 Accepted 28 April 2014 Available online xxxx Key words: Tracheostomy Pediatric Indications Complications
a b s t r a c t Background: Pediatric tracheostomy has undergone notable changes in frequency and indication over the past 30 years. This study investigates pediatric tracheostomy at British Columbia Children's Hospital (BCCH) over a 30-year period. Methods: A retrospective chart review of tracheostomy cases at BCCH from 1982 to 2011 was conducted. Charts were reviewed for demographics, date of tracheostomy, indication, complications, mortality and date of decannulation. Data from three 10-year time periods were compared using Fisher's Exact test to examine changes over time. Results: 251 procedures (154 males) performed on 231 patients were reviewed. Mean age at tracheostomy was 3.74 years with 48% of procedures undertaken before the age of one year. Frequency of procedure by year has generally declined into the early 2000's. Upper airway obstruction was the most common indication accounting for 33% of procedures. The rate of complication across the entire cohort was 22% with 63% of patients being decannulated. Tracheostomy related mortality occurred in 2.0% of cases reviewed. Conclusions: Changes occurred in primary indications with infections indicating less procedures and neurological impairments indicating more procedures over time. Complications increased and the decannulation rate decreased over this 30-year review. Pediatric tracheostomy is considered a safe and effective procedure at BCCH. © 2014 Elsevier Inc. All rights reserved.
Tracheostomy and its associated outcomes have evolved from ancient origins to the present day. In the pediatric population the past 30 years have seen changes in the frequency, age and primary indications for this procedure. Comparable medical centers have reported a decline in frequency of tracheostomy during the period 1980–1990 and either a plateau or slight increase in frequency over the past 10 years [1–3]. The average age at tracheostomy has declined slightly over the last 30 years and currently most procedures are done on children in their first year of life [4–8]. The most prevalent indications for tracheostomy have changed over time owing to advancements in treatment and technology. Early in the 1980's many procedures were indicated as a result of infection of the upper respiratory tract [9]. Introduction of the Haemophilus influenzae type B vaccine and improvements in intensive care units have decreased the number of tracheostomies required for infectious diseases over the 1980's and 1990's [10]. Regional differences have also affected which tracheostomy indications are most prevalent. In Turkey, the 1990's saw a shift in the most prevalent indicator from
Abbreviations: BCCH, British Columbia Children's Hospital; UAO, Upper airway obstruction. ⁎ Corresponding author at: Division of Pediatric Otolaryngology BC Children's Hospital, K2-184 4480 Oak Street, Vancouver, BC, Canada, V6H 3V4. Tel.: +1 604 875 2113. E-mail address: [email protected] (F.K. Kozak).
upper airway obstruction (UAO), owing to infectious disease, to prolonged positive pressure ventilation [10]. Research from France and Singapore also reports a greater number of procedures being done for ventilator dependency in the late 1990's [11,12]. Recent analysis from the United States has suggested a reversal back to UAO as the most common indication; however, it is most often owing to congenital (syndromic) or acquired UAO (subglottic stenosis), rather than infection [3]. Results from Turkey maintain that prolonged intubation is still the primary indication [1]. These differences emphasize a need for regional consideration when analyzing the indications for tracheostomy. Research from Alberta Children's Hospital, a center comparable to BC Children's Hospital (BCCH), has reported that UAO accounts for most tracheostomies performed between 1990 and 2007 at their center [13]. Research into the complications either at the time of tracheostomy or during the period of time a patient has a tracheostomy is also important to the complete review of this procedure/condition. Complications have remained generally consistent over the past 30 years. Reported complication rates range from 18 to 64% [1,4,8,10,14–16]. When granulation tissue around the stoma has been considered as a complication the overall reported complication rate is at the higher end of this range [1,4,8,14–16]. Alternatively, studies considering granulation tissue as an expected outcome, a view that is supported by the literature, have reported lower complication
http://dx.doi.org/10.1016/j.jpedsurg.2014.04.014 0022-3468/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Ogilvie LN, et al, Changes in pediatric tracheostomy 1982–2011: a Canadian tertiary children's hospital review, J Pediatr Surg (2014), http://dx.doi.org/10.1016/j.jpedsurg.2014.04.014
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L.N. Ogilvie et al. / Journal of Pediatric Surgery xxx (2014) xxx–xxx
rates [10,17–19]. Exclusive consideration of serious complications such as pneumothorax, pneumomediastinum, accidental decannulation, wound erosion/infection, abscess and death has previously resulted in conservative complication rates [10,17–19]. Complications also vary based on the standards of care that a medical center can provide and patient characteristics such as prematurity or age at the time of tracheostomy [20]. At our institution a tracheostomy is essentially exclusively performed by a pediatric otolaryngologist, with follow-up care and training coordinated through outpatient programs once the patient is discharged from hospital. All children requiring a tracheostomy in British Columbia, with the exception of a few patients who are close to Alberta, are seen at our institution. To date, a comprehensive evaluation and follow up of tracheostomy at this center have not been published. A 30-year retrospective chart review of patients who have undergone a tracheostomy at BCCH was performed for quality assurance purposes, as well as to compare procedural indications and outcomes with the current literature and play a role in future care decisions. This review adds to previous knowledge on the prevalence of indications and the details of complications while highlighting our region's differences. Data were analyzed over three 10-year periods for comparison purposes. 1. Methods A retrospective chart review of all tracheostomy cases performed at BCCH from 1982 to 2011 with follow-up review until 2011 was conducted. Ethical approval was obtained from the University of British Columbia/Children's and Women's Health Centre of British Columbia Research Ethics Board. All tracheostomy procedures over the 30 year period were done by 11 surgeons with varying levels of experience using commonly practiced tracheostomy techniques. The majority of tracheal incisions were made vertically and stay sutures were used. Hospital database record of procedures was used to identify each patient and locate charts. Charts were reviewed for demographics, date of tracheostomy, surgeon, indication, complications, mortality and date of decannulation. Each patient's primary indication was further classified as either UAO, syndrome with UAO, prolonged intubation, neurological impairment, trauma, cancer, laryngeal abnormality or infection, which is similar to the methods described in previous research [3]. All charts were reviewed until decannulation, mortality, end of care at BCCH or until the end of the review period. As this study was retrospective no effort was made to standardize operating procedure or perioperative care that varied over time. The senior author co-reviewed 24% of charts to ensure reviewer consistency. Data from the BCCH Home Tracheostomy Care and Home Ventilation program were also briefly reviewed to verify particular results. Patients who had a tracheostomy for UAO included those with physical obstruction such as subglottic stenosis, tracheomalacia or a head/neck mass resulting in obstruction. Those in the “infection”
category included patients who had croup as their primary indication. Syndromes that involve UAO such as Pierre Robin, Goldenhar, Apert and others were classified under the primary indication “syndrome with UAO”. Prolonged intubation characterized patients who required long-term ventilator support (ie. prematurity, congenital heart disease, omphalocele, gastrochisis or hypoplastic lung). Neurological impairment primarily represented those with polyneuropathy or central hypoventilation. Patients who had experienced head or spinal cord trauma and required ventilation were categorized as “trauma”. Cancer cases included tracheostomy required for a condition secondary to treatment or for a cancerous tumor. Structural or functional abnormalities of the larynx were categorized as laryngeal abnormalities (ie. laryngomalacia, laryngeal web or vocal cord paralysis). Patients who had multiple indications attributed to their case were classified by their primary indication. Significant complications included in analysis were pneumothorax, pneumomediastinum, wound erosion, wound infection, accidental decannulation, abscess, size issues and mortality. Defining complications in such a way is consistent with the previous literature [10]. To compare these measures between time periods, patients were separated based on date of tracheostomy into three groups 1982–1991, 1992–2001, or 2002–2011. All statistical analysis was completed using Excel and VassarStats based on a significance value of p b 0.05. Categorical frequency data were analyzed using Fisher's Exact test. 2. Results Two hundred and sixty seven tracheostomies were performed at BCCH from 1982 to 2011. This review includes 251 procedures performed on 231 patients (154 male, 97 female), 16 patients were excluded owing to inability to access records. In 16 of the 251 cases (6%) reviewed, complete information could not be found; however, the information that was available from these patient charts was included in analysis and n values were adjusted to reflect missing patients. For the entire cohort, average age at tracheostomy was 3.7 years (ranged from 0.0 to 18.9 years) with 48% less than one year of age (Fig. 1). Average age remained fairly consistent over the 30 years of review. Frequency of tracheostomy varied between 1 and 21 procedures per year. A general decline in number of procedures per year occurred over the 1990's and the beginning of the 2000's with numbers increasing in the most recent 10 years (Fig. 2). Variation in frequency resulted in three 10-year time periods with differences in n-values (118 from 1982–91, 78 from 1992–01 and 55 from 2002–11). Cases were reviewed for a minimum of 0.0 days to a maximum of 6935.0 days, the median of this range was 206.0 days. The most prevalent primary indication was UAO, mainly acquired subglottic stenosis, accounting for 33% of all tracheostomies. Prolonged intubation was the indication in 15% of procedures while, laryngeal abnormalities and syndromes each contributed 13% and 11% respectively. Comparison of the three ten-year periods revealed changes in the proportion of two indications over time. UAO remained
Fig. 1. Number of procedures at each age by 10-year time period.
Please cite this article as: Ogilvie LN, et al, Changes in pediatric tracheostomy 1982–2011: a Canadian tertiary children's hospital review, J Pediatr Surg (2014), http://dx.doi.org/10.1016/j.jpedsurg.2014.04.014
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was 63%. Over time the number of patients decannulated decreased significantly (p b 0.05, Fisher's Exact test) from 84 (75%) in the first ten years to 46 (61%) in the second ten year time period and to 23 (42%) in the most recent ten years, however it must be noted that the most recent cases have been followed for a shorter length of time (Fig. 5). Average length in situ for those who were successfully decannulated was 451.7 days with a median of 151.0 days ranging from 0.0 to 4463.0 days. Overall mortality rate was 15% among the 248 patients for which there were data. Tracheostomy related mortality occurred in 5 (2%) of the 244 cases for which there were data about cause of mortality. All tracheostomy related mortality was attributed to accidental decannulation. 3. Discussion
Fig. 2. Frequency of tracheostomy by year.
the most common indication across all three time periods with no significant change in prevalence. Infection cases significantly (p b 0.05, Fisher's Exact test) declined from eight in the first 10 years to zero in the most recent 10-year time period. A significant (p b 0.05, Fisher's Exact test) increase occurred in the number of procedures indicated by neurological impairment over the 30 years of this review (Fig. 3). Patients at BCCH who had a primary indication of infection were all successfully decannulated. The next highest rate for decannulation was for those who had a primary indication of trauma (77%) or UAO (73%). Those patients who underwent a tracheostomy for neurological impairment had the lowest rate of decannulation (20%). The highest average ages at tracheostomy were as a result of trauma (9.0 years) and cancer (6.8 years). Complication rate was 22% for the entire cohort with a maximum of 2 complications occurring in any one patient. The most common complication was accidental decannulation, this occurred 16 times at a rate of 6% (Table 1). Wound erosion was the second most prevalent with 10 instances at a rate of 4% followed by wound infection and tracheal tube size issues. The majority (67%) of complications occurred after the first week postoperatively (Table 2). Complication rates increased significantly (p b 0.05) from 15% in the 80's to 27% in the 90's and remained at 27% in the most recent decade (Fig. 4). Decannulation was achieved in 153 cases, 90 patients have not been decannulated and 8 were lost to follow-up. Of those reviewed whose decannulation status was known, the rate of decannulation
At BCCH frequency of tracheostomy has declined over the 1990's and into the 2000's. In the most recent 10 years of this review there has been a plateau and slight increase in the number of procedures performed. This pattern is generally consistent with the current literature, although the plateau has been reported to start earlier [10]. Some spikes in frequency may be explained by corresponding increases in premature infants for that year, however not all spikes show this corresponding increase. Separating the number of procedures by 10-year increments resulted in varying n-values that were similar to those obtained in a longitudinal analysis from Zurich, Switzerland [6]. Interestingly, results on frequency may differ based on whether a care center is primary or tertiary; a primary center in London, UK did not experience any decrease in number of procedures [21]. Almost half of procedures at BCCH were done on patients under one year of age; this remained fairly consistent over the 30-year review. The majority of centers similar to BCCH provide evidence to support a growing under 1-year old (at time of tracheostomy) patient population; however, there have been some exceptions [13,14]. These include Ireland in the 1990's where a decline was seen in the number of patients under 1-year of age at time of tracheostomy. Doctors there were reluctant to perform a tracheostomy on this population because of their high susceptibility to complication [22]. A Nigerian care center is also an exception; the majority of patients studied had an age at tracheostomy in the range of 6–10 years reflecting the high prevalence of respiratory papillomatosis and motor vehicle accidents in the area [23]. While in some cases region seems to have an impact on age at tracheostomy our results are consistent with the majority. For the entirety of this review UAO remained the most prevalent indication for pediatric tracheostomy. During the most recent 10-year time period UAO continued to be the most prevalent indication with prolonged intubation and neurological impairment as the second most prevalent. This is consistent with previous reviews from similar centers that have documented an increase in the indication of prolonged intubation in the 2000's, but not so much as to exceed
Fig. 3. Indication percentage by 10-year time period. * denotes significance (p b 0.05).
Please cite this article as: Ogilvie LN, et al, Changes in pediatric tracheostomy 1982–2011: a Canadian tertiary children's hospital review, J Pediatr Surg (2014), http://dx.doi.org/10.1016/j.jpedsurg.2014.04.014
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Table 1 Complications by 10-year time period. All years Accidental decannulation (no mortality) Accidental decannulation (mortality) Pneumothorax Pneumomediastinum Wound infection Erosion Size Abscess Total complications
1982–1991
1992–2001
2002–2011
11 (4%)
2 (2%)
6 (8%)
3 (5%)
5 (2%)
3 (3%)
2 (3%)
0 (0%)
1 (1%) 3 (3%) 3 (3%) 4 (3%) 2 (2%) 0 (0%) 18 (16%)
5 (6%) 1 (1%) 3 (4%) 2 (3%) 0 (0%) 2 (3%) 21 (27%)
0 (0%) 0 (0%) 2 (4%) 4 (7%) 6 (11%) 0 (0%) 15 (27%)
6 4 8 10 8 2 54
(2%) (2%) (3%) (4%) (3%) (1%) (22%)
the number of patients indicated by UAO [6,24]. Conflicting research suggests prolonged intubation is currently the most prevalent indication for tracheostomy; however, prevalence is often affected by the country where care is located [22,25–27]. In our review the indication of neurological impairment increased over time resulting in greater numbers of a complex, long-term indication for tracheostomy; an increase that has not previously been reported in this indication. Our results also add to the evidence that infection is no longer a notable indication for tracheostomy [24]. As infection often indicates short-term tracheostomy, this decline also supports a shift to more complex, long-term tracheostomy. Indications for tracheostomy were related to decannulation rate and age at procedure in a manner that is consistent with previous research from Germany with neurological impairment as an indication resulting in the lowest decannulation rate and infection resulting in the highest [24]. The very low decannulation rate for those who underwent a tracheostomy for neurological impairment is indicative of the long-term nature and complexity of this patient population. At BCCH care is coordinated through an outpatient program that provides training to families and frequent contact with healthcare expertise in tracheostomy care. As a result of this program, full records of most patients' tracheostomy experience were available for review. Serious complications occurred at a rate that is on the lower end of the significant range of complication rates that are presented in the current literature (18–46%) [1,4,8,10,14–16]. Upon comparison of the three 10-year time periods an increase occurred in long-term complications between the 1980's and 1990's. This increase in complications is not often reported from one center. It may be owing to the changing nature of indications for a tracheostomy and care in more long term patients as this population can have multiple indications and greater opportunity for complication than in past time periods [4,6]. The most common complication observed was accidental decannulation which is contrary to previous research that names pneumomediastinum as the most common early complication [17]. The higher prevalence of accidental decannulation in this population is consistent with the finding that most complications occurred after
Fig. 4. Complication percentage by 10-year time period. * denotes significance (p b 0.05).
one week of tracheostomy in situ. As expected, other long-term complications were size issues and wound infection [10]. The BCCH tracheostomy related mortality rate of 2% is comparable to the literature that when compiled, records a range of 0–4% [1,4,10,14–16,18,28–30]. The exclusive cause of mortality in this review, accidental decannulation, is a common cause of tracheostomy related mortality noted in the literature [28,31]. Data from the BCCH Home Tracheostomy Care and Home Ventilation program add to these findings by examining a set of patients who were cared for at home in BC. They had 133 patients under their care from 1982 to 2011 with 9 instances of mortality (7%). Total mortality for our study, reviewing pediatric tracheostomy at BCCH, was 15%. Mortality (tracheostomy related and unrelated) decreased slightly across the three time periods; however, this may be a result of the decreased amount of time that the most recent patients have been followed. Retrospective reviews have inherent limitations such as difficulty to obtain complete data on all patients. Full records of the time period starting at the time of tracheostomy were obtained and reviewed; however, anything that was not recorded in the patient's chart would not be possible to review. In an effort to report current data the most recent 10-year period has not been reviewed for as long as the first two time periods, this may have resulted in an underrepresentation of complication and decannulation rates for this group. Difficulty in comparison across the literature is apparent owing to varying classifications for indications. Complication rates are also difficult to directly compare as the previous literature has variable consensus on what can be considered a true complication. Previous research that recorded similar major complications had rates that were comparable to ours [10,17,18]. 4. Conclusions At BCCH patients with a tracheostomy have changed in relation to frequency, indications, complications and decannulation rates over the last 30 years. This review presents an increase in complications over time and decrease in percent decannulated, as indicated by the
Table 2 Complications by length of time since procedure Fig. 1.
Accidental decannulation (no mortality) Accidental decannulation (mortality) Pneumothorax Pneumomediastinum Wound infection Erosion Size issues Abscess Total complications
b24 h
24–48 h
N48 h–1 week
4 (2%)
0
1 (0.3%)
N1 week 6 (2%)
0
0
0
5 (2%)
2 (0.6%) 3 (1%) 0 0 0 0 9 (4%)
1 (0.3%) 0 1 (0.3%) 0 0 0 2 (0.6%)
0 0 1 (0.3%) 4 (2%) 1 (0.3%) 0 7 (3%)
3 (1%) 1 (0.3%) 6 (2%) 6 (2%) 7 (3%) 2 (0.6%) 36 (14%)
Fig. 5. Decannulation percentage by 10-year time period. Significant p b 0.05.
Please cite this article as: Ogilvie LN, et al, Changes in pediatric tracheostomy 1982–2011: a Canadian tertiary children's hospital review, J Pediatr Surg (2014), http://dx.doi.org/10.1016/j.jpedsurg.2014.04.014
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changes from the first ten year time period to the second. These changes may be the result of increased length of time in situ and complexity of indication for the average tracheostomy patient. Overall, low rates of complication and tracheostomy related mortality confirm that pediatric tracheostomy at BCCH will continue to be considered a safe and effective procedure. Further research into the subjective experience of those who undergo tracheostomy at BCCH and subsequently live with a tracheostomy is necessary to determine where improvements in care may be possible. Acknowledgments Rachelle Dar Santos- for administrative assistance Current and former members of the Division of Pediatric Otolaryngology. All surgeons who have performed a tracheostomy at BCCH. References [1] Atmaca S, Bayraktar C, Asilioglu N, et al. Pediatric tracheotomy: 3-year experience at a tertiary care center with 54 children. Turk J Pediatr 2011;53(5):537–40. [2] Mahadevan M, Barber C, Salkeld L, et al. Pediatric tracheotomy: 17 year review. Int J Pediatr Otorhinolaryngol 2007;71(12):1829–35. [3] Lawrason A, Kavanagh K. Pediatric tracheotomy: are the indications changing? Int J Pediatr Otorhinolaryngol 2013;77(6):922–5. [4] Carron JD, Derkay CS, Strope GL, et al. Pediatric tracheotomies: changing indications and outcomes. Laryngoscope 2000;110(7):1099–104. [5] Corbett HJ, Mann KS, Mitra I, et al. Tracheostomy—a 10-year experience from a UK pediatric surgical center. J Pediatr Surg 2007;42(7):1251–4. [6] De Trey L, Niedermann E, Ghelfi D, et al. Pediatric tracheotomy: a 30-year experience. J Pediatr Surg 2013;48(7):1470–5. [7] Dursun O, Ozel D. Early and long-term outcome after tracheostomy in children. Pediatr Int 2011;53(2):202–6. [8] Ilce Z, Celayir S, Tekand GT, et al. Tracheostomy in childhood: 20 years experience from a pediatric surgery clinic. Pediatr Int 2002;44(3):306–9. [9] Prescott CAJ, Vanlierde MJRR. Tracheostomy in children- the Red Cross War Memorial Children's Hospital experience 1980–1985. Int J Pediatr Otorhinolaryngol 1989;17(2):97–107. [10] Ozmen S, Ozmen OA, Unal OF. Pediatric tracheotomies: a 37-year experience in 282 children. Int J Pediatr Otorhinolaryngol 2009;73(7):959–61.
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Please cite this article as: Ogilvie LN, et al, Changes in pediatric tracheostomy 1982–2011: a Canadian tertiary children's hospital review, J Pediatr Surg (2014), http://dx.doi.org/10.1016/j.jpedsurg.2014.04.014
