burns 41 (2015) 248–251
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Tracheostomy in pediatric burn patients Soman Sen a,*, Jonathan Heather b, Tina Palmieri a, David Greenhalgh a a Department of Surgery, Division of Burn Surgery, Shriners Hospital for Children Northern California, University of California Davis, Sacramento, CA, United States b Middlemore Hospital, Department of Plastic Surgery, Auckland, New Zealand
article info
abstract
Article history:
Background: Tracheostomy is often performed in the pediatric burn population to establish
Accepted 8 October 2014
secure airways. Tracheostomy is safe in this population, but the duration of tracheostomy may be related to age and extent and severity of burn. We hypothesized that burn related
Keywords:
factors and not age determine the time to removal of a tracheostomy in pediatric burn
Tracheostomy
patients.
Pediatric burn injury
Methods: A 5-year retrospective review was performed for pediatric burn patients (age 18
Tracheostomy duration
years) who underwent tracheostomy. Patients were divided into three groups by age (group 1: 0 to 2 years, group 2: >2 to 12 years, group 3: >12 to 18 years). Data collected included: age, total body surface area burn injured (TBSA), gender, mechanism of injury, diagnosis of inhalation injury, mortality, time from injury to admission, time from admission to placement of tracheostomy, time of injury to placement of tracheostomy, duration of tracheostomy, days of mechanical ventilation, and tracheostomy related complications. Results: 45 patients were reviewed. There were no differences in TBSA, length of ICU stay, length of hospital stay, and mortality between the three groups. Additionally, there were no differences in ventilator days and duration of tracheostomy. Multivariate linear regression analysis indicated that TBSA and not age independently increased the duration of tracheostomy. Conclusion: Tracheostomy duration is dependent on the extent of burn in pediatric burn patients. # 2014 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
Airway management is a complex process in severely burned children. The complexity lies in both the anatomic considerations for different pediatric age groups as well as the pulmonary dysfunction that can arise from both burn and inhalation injuries. Establishment of secure and stable airways is an essential element in the acute management critically ill pediatric burn patients [1]. Tracheostomies are
sometimes performed in pediatric burn patients due to difficulty in establishing and maintaining a secure oral or nasal airway, extensive burn or severe inhalation injury necessitating prolonged mechanical ventilation, and severe prolonged pulmonary dysfunction [2]. Controversy exists over the utility of tracheostomies in burn patients [3,4]. However, more recent reports indicate that tracheostomy is a safe and efficacious method of airway management in children with burns [5,6]. Despite these reports, age or injury related factors involved in the length
* Corresponding author at: 2425 Stockton Blvd., Suite 718, Sacramento, CA 95817, United States. Tel.: +1 916 453 2050; fax: +1 916 453 2373. E-mail address: [email protected] (S. Sen). http://dx.doi.org/10.1016/j.burns.2014.10.005 0305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.
249
burns 41 (2015) 248–251
of time from placement to tracheostomy removal remain unknown. Possible age related factors include difficulty with pain control, agitation, communication, or concern about airway security and post-extubation failure [7,8]. We hypothesized that burn injury related factors and not age determine the time to removal of a tracheostomy in pediatric burn patients. Our primary goal was to compare age and injury related factors involved in the time to removal of tracheostomies in pediatric burn patients. Our secondary goal was to correlate tracheostomy specific complications to age and injury related factors.
2.
Methods
A 5-year (2008–2012) retrospective chart review was performed for pediatric burn patients. Inclusion criteria were age 18 years, a second or third degree burn injury, and placement of a tracheostomy. Demographic data collected included: age, total body surface area burn injured (TBSA), gender, mechanism of injury, diagnosis of inhalation injury, and mortality. Hospital data collected included: time from injury to admission, time from admission to placement of tracheostomy, time of injury to placement of tracheostomy, duration of tracheostomy, days of mechanical ventilation, and tracheostomy related complications. All tracheostomies were open procedures and were performed by the treating burn surgeons in the operating room. No percutaneous tracheostomies were performed. All tracheostomies placed were cuffed. Cuff pressures were maintained between 20 and 30 mmHg using a Posey Cufflator (Posey Company, Arcadia, CA). The University of California Davis Institutional Review Board approved all human subjects research protocols. R statistical package (www.r-project.org) was used to analyze the data. Continuous variable comparisons between two groups were performed using the 2-sample Student’s ttest for continuous parametric data and Wilcox rank sum test for non-parametric continuous data. Analysis of variance with Tukey’s honest significant difference post hoc analysis was performed for comparisons between 3 or more groups for continuous data. The chi-square test was used to assess association between discrete categorical variables. Univariate and multivariate linear regression analysis was performed to determine associations between discrete continuous outcome variables and independent continuous and categorical predictor variables. Analysis was performed for variables that result in prolonged duration of tracheostomy (continuous outcome variable). Predictor variables for the analysis included age, gender, TBSA, inhalation injury, ventilator days, days of hospitalization, and mortality. Statistical significance was set at a p-value of 2 to 12 years old, and group 3 was from >12 to 18 years old. There were no differences in TBSA, length of ICU stay, length of hospital stay, and mortality between the three groups. Group 2 suffered significantly more inhalation injury (73%) than groups 1 and 3. However despite the increased rate of inhalation injury in Table 2 – Tracheostomy related complications. Complication
Number
Stenosis Tracheomalacia Granuloma
1 1 2
250
burns 41 (2015) 248–251
Table 3 – Patient demographics by age group. Demographic
Age 0– 2 yrs
Age >2–12 yrs
Age >12–18 yrs
p-Value
Patients Female Male Flame injury Scald injury Other mechanism Age (years) TBSA (%) Inhalation injury Died ICU length of stay (days) Hospital length of stay (days) Injury to admission (days) Admission to tracheostomy (days) Injury to tracheostomy (days) Duration of tracheostomy (days) Ventilator days
15 7 8 6 9 0 1.2 0.6 48.5 14.9 5 4 49.1 35.3 90.1 86 5.3 11.2 1.9 1.8 5.4 3.8 45.5 39 43.2 29.6
19 4 15 17 2 0 5.3 2.4 55.2 19.7 12 5 51.3 33 75.2 47 3.6 8.5 2.1 2.9 4.9 3 51.6 32.7 42.4 28.4
11 2 8 9 0 2 14.4 2.6 56 19.4 1 0 71.2 43.1 126.8 78.2 7 17.1 2.5 6.2 5.5 4.5 75 62.9 58.1 45.1
0.21 0.18 0.004 0.04 >0.0001 ns 0.012 0.162 ns ns ns ns ns ns ns
TBSA, total body surface burn injured.
group 2, there were no differences in ventilator days and duration of tracheostomy (Table 3). Univariate and multivariate linear regression analysis were performed to analyze factors that increase how long patients have a tracheostomy. On univariate analysis, extent of burn injury was the only admission variable that significantly prolonged tracheostomy duration. On multivariate analysis, which included age, TBSA, gender, inhalation injury, time from injury to admission, and time from injury to tracheostomy as independent variables, only TBSA was independently associated with prolonged tracheostomy duration (Table 4).
4.
Discussion
Past controversies about tracheostomies in burn patients have been resolved by current reports that indicate due to lower airway ventilation volumes and lower tracheostomy cuff pressures, tracheostomies are generally safe and effective [2,6,9,10]. However, although tracheostomies provide safe airways for pediatric burn patients, decisions on removal of tracheostomies may be influenced by age related factors and established guidelines for tracheostomy care to reduce time to decannulation have not been well studied especially in
Table 4 – Multivariate linear regression analysis for the outcome of duration of tracheostomy. Variable TBSA Age Inhalation injury Gender Time from injury to admission Time from injury to tracheostomy
B (slope)
Standard error
p-Value
1.7 0.82 4.83 14.2 1.7
0.44 1.23 14.4 14.2 1.9
0.0006 0.51 0.74 0.35 0.39
0.39
0.53
TBSA, total body surface burn injured.
0.47
children [11,12]. In a study of pediatric tracheostomy complications, children less than 1 year of age had the longest duration of tracheostomy followed by children 1–2 years of age, however the reasons for the prolonged tracheostomy durations were not explored [13]. Failure of tracheostomy removal in infant and neonate populations has been attributed to neurologic and severe pulmonary impairments [14]. In the pediatric population, successful decannulation rates vary from 34% to 94% and appear to be disease related and not age related [13,15]. Our results indicate, that for pediatric burn patients, tracheostomy duration is primarily related to the extent of burn injury and is not related to the age of the patient. In addition, successful decannulation occurred in 88% of the surviving patients in the first attempt and 100% overall. This is similar to a published report indicating that pediatric trauma patients undergoing a tracheostomy had a shorter duration of tracheostomy and a higher success rate of decannulation compared to medical pediatric patients. In addition, the study indicated that age was not related to tracheostomy specific outcomes [16]. Tracheostomy related complications also appear to be low and resolvable in pediatric burn patients. In our study, 4 patients had a tracheostomy related complication (9%), however all of the complications were resolved while in the hospital and all of these patients were successfully decannulated on the second attempt. In addition, none of the mortality was attributable to tracheostomy related complications. This is similar to a published report that indicates that mortality in pediatric patients with a tracheostomy is related to the severity of illness and not complications from the tracheostomy [13]. In addition, the decannulation rate and complications presented in our study are similar to a previous report in pediatric burn patients [2]. Thus, tracheostomy appears to be safe and effective for pediatric burn patients. Additionally, long-term airway management in pediatric burn patients can also be safely accomplished through oral–tracheal intubation as well [17]. More research is required to establish guidelines for tracheostomy care and decannulation protocols to reduce
burns 41 (2015) 248–251
tracheostomy patients.
5.
related
complications
in
pediatric
burn
Conclusion
Duration of tracheostomy in pediatric burn patients is related to the extent of burn injury. Age does not appear to influence how long a tracheostomy remains in place. Tracheostomy is a safe method of airway management for pediatric burn patients. However, guidelines need to be developed for tracheostomy care and decannulation protocols to reduce complications.
Authors’ contribution Dr. Sen, Heather, Greenhalgh and Palmieiri were involved in the study question and design. Dr. Heather reviewed the charts and collected the data. Dr. Sen analyzed the data and wrote the draft of the manuscript. Dr. Heather, Greenhalgh and Palmieri edited the final version of the manuscript. All authors have approved the final article.
Conflict of interest None of the authors have any conflict of interest.
references
[1] Sheridan RL, Schnitzer JJ. Management of the high-risk pediatric burn patient. J Pediatr Surg 2001;August (36)(8):1308–12. [2] Coln CE, Purdue GF, Hunt JL. Tracheostomy in the young pediatric burn patient. Arch Surg 1998;133(May (5)):537–9 [discussion 539–540]. [3] Hunt JL, Purdue GF, Gunning T. Is tracheostomy warranted in the burn patient? Indications and complications. J Burn Care Rehab 1986;7(November–December (6)):492–5.
251
[4] Moylan Jr JA, West JT, Nash G, Bowen JA, Pruitt Jr BA. Tracheostomy in thermally injured patients: a review of five years’ experience. Am Surg 1972;38(March (3)):119– 23. [5] Palmieri TL, Jackson W, Greenhalgh DG. Benefits of early tracheostomy in severely burned children. Crit Care Med 2002;30(April (4)):922–4. [6] Barret JP, Desai MH, Herndon DN. Effects of tracheostomies on infection and airway complications in pediatric burn patients. Burns 2000;26(March (2)):190–3. [7] Grant MJ, Balas MC, Curley MA, Team RI. Defining sedationrelated adverse events in the pediatric intensive care unit. Heart Lung 2013;42(May–June (3)):171–6. [8] Kemper KJ, Benson MS, Bishop MJ. Predictors of postextubation stridor in pediatric trauma patients. Crit Care Med 1991;19(March (3)):352–5. [9] Simma B, Spehler D, Burger R, Uehlinger J, Ghelfi D, Dangel P, et al. Tracheostomy in children. Eur J Pediatr 1994;153(April (4)):291–6. [10] Fraga JC, Souza JC, Kruel J. Pediatric tracheostomy. J Pediatr (Rio J) 2009;85(March–April (2)):97–103. [11] Mitchell RB, Hussey HM, Setzen G, Jacobs IN, Nussenbaum B, Dawson C, et al. Clinical consensus statement: tracheostomy care. Otolaryngology – Head Neck Surg. 2013;January (148)(1):6–20. [12] Sunder RA, Haile DT, Farrell PT, Sharma A. Pediatric airway management: current practices and future directions. Paediatr Anaesth 2012;22(October (10)):1008–15. [13] Carr MM, Poje CP, Kingston L, Kielma D, Heard C. Complications in pediatric tracheostomies. Laryngoscope 2001;111(November (11 Pt 1)):1925–8. [14] Sidman JD, Jaguan A, Couser RJ. Tracheotomy and decannulation rates in a level 3 neonatal intensive care unit: a 12-year study. Laryngoscope 2006;116(January (1)):136–9. [15] Mahadevan M, Barber C, Salkeld L, Douglas G, Mills N. Pediatric tracheotomy: 17 year review. Int J Pediatr Otorhinolaryngol 2007;71(December (12)):1829–35. [16] Funamura JL, Durbin-Johnson B, Tollefson TT, Harrison J, Senders CW. Pediatric tracheotomy: indications and decannulation outcomes. Laryngoscope 2014;124(August (8)):1952–8. [17] Kadilak PR, Vanasse S, Sheridan RL. Favorable short- and long-term outcomes of prolonged translaryngeal intubation in critically ill children. J Burn Care Rehab 2004;25(May–June (3)):262–5.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Tracheostomy in pediatric burn patients Soman Sen a,*, Jonathan Heather b, Tina Palmieri a, David Greenhalgh a a Department of Surgery, Division of Burn Surgery, Shriners Hospital for Children Northern California, University of California Davis, Sacramento, CA, United States b Middlemore Hospital, Department of Plastic Surgery, Auckland, New Zealand
article info
abstract
Article history:
Background: Tracheostomy is often performed in the pediatric burn population to establish
Accepted 8 October 2014
secure airways. Tracheostomy is safe in this population, but the duration of tracheostomy may be related to age and extent and severity of burn. We hypothesized that burn related
Keywords:
factors and not age determine the time to removal of a tracheostomy in pediatric burn
Tracheostomy
patients.
Pediatric burn injury
Methods: A 5-year retrospective review was performed for pediatric burn patients (age 18
Tracheostomy duration
years) who underwent tracheostomy. Patients were divided into three groups by age (group 1: 0 to 2 years, group 2: >2 to 12 years, group 3: >12 to 18 years). Data collected included: age, total body surface area burn injured (TBSA), gender, mechanism of injury, diagnosis of inhalation injury, mortality, time from injury to admission, time from admission to placement of tracheostomy, time of injury to placement of tracheostomy, duration of tracheostomy, days of mechanical ventilation, and tracheostomy related complications. Results: 45 patients were reviewed. There were no differences in TBSA, length of ICU stay, length of hospital stay, and mortality between the three groups. Additionally, there were no differences in ventilator days and duration of tracheostomy. Multivariate linear regression analysis indicated that TBSA and not age independently increased the duration of tracheostomy. Conclusion: Tracheostomy duration is dependent on the extent of burn in pediatric burn patients. # 2014 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
Airway management is a complex process in severely burned children. The complexity lies in both the anatomic considerations for different pediatric age groups as well as the pulmonary dysfunction that can arise from both burn and inhalation injuries. Establishment of secure and stable airways is an essential element in the acute management critically ill pediatric burn patients [1]. Tracheostomies are
sometimes performed in pediatric burn patients due to difficulty in establishing and maintaining a secure oral or nasal airway, extensive burn or severe inhalation injury necessitating prolonged mechanical ventilation, and severe prolonged pulmonary dysfunction [2]. Controversy exists over the utility of tracheostomies in burn patients [3,4]. However, more recent reports indicate that tracheostomy is a safe and efficacious method of airway management in children with burns [5,6]. Despite these reports, age or injury related factors involved in the length
* Corresponding author at: 2425 Stockton Blvd., Suite 718, Sacramento, CA 95817, United States. Tel.: +1 916 453 2050; fax: +1 916 453 2373. E-mail address: [email protected] (S. Sen). http://dx.doi.org/10.1016/j.burns.2014.10.005 0305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.
249
burns 41 (2015) 248–251
of time from placement to tracheostomy removal remain unknown. Possible age related factors include difficulty with pain control, agitation, communication, or concern about airway security and post-extubation failure [7,8]. We hypothesized that burn injury related factors and not age determine the time to removal of a tracheostomy in pediatric burn patients. Our primary goal was to compare age and injury related factors involved in the time to removal of tracheostomies in pediatric burn patients. Our secondary goal was to correlate tracheostomy specific complications to age and injury related factors.
2.
Methods
A 5-year (2008–2012) retrospective chart review was performed for pediatric burn patients. Inclusion criteria were age 18 years, a second or third degree burn injury, and placement of a tracheostomy. Demographic data collected included: age, total body surface area burn injured (TBSA), gender, mechanism of injury, diagnosis of inhalation injury, and mortality. Hospital data collected included: time from injury to admission, time from admission to placement of tracheostomy, time of injury to placement of tracheostomy, duration of tracheostomy, days of mechanical ventilation, and tracheostomy related complications. All tracheostomies were open procedures and were performed by the treating burn surgeons in the operating room. No percutaneous tracheostomies were performed. All tracheostomies placed were cuffed. Cuff pressures were maintained between 20 and 30 mmHg using a Posey Cufflator (Posey Company, Arcadia, CA). The University of California Davis Institutional Review Board approved all human subjects research protocols. R statistical package (www.r-project.org) was used to analyze the data. Continuous variable comparisons between two groups were performed using the 2-sample Student’s ttest for continuous parametric data and Wilcox rank sum test for non-parametric continuous data. Analysis of variance with Tukey’s honest significant difference post hoc analysis was performed for comparisons between 3 or more groups for continuous data. The chi-square test was used to assess association between discrete categorical variables. Univariate and multivariate linear regression analysis was performed to determine associations between discrete continuous outcome variables and independent continuous and categorical predictor variables. Analysis was performed for variables that result in prolonged duration of tracheostomy (continuous outcome variable). Predictor variables for the analysis included age, gender, TBSA, inhalation injury, ventilator days, days of hospitalization, and mortality. Statistical significance was set at a p-value of 2 to 12 years old, and group 3 was from >12 to 18 years old. There were no differences in TBSA, length of ICU stay, length of hospital stay, and mortality between the three groups. Group 2 suffered significantly more inhalation injury (73%) than groups 1 and 3. However despite the increased rate of inhalation injury in Table 2 – Tracheostomy related complications. Complication
Number
Stenosis Tracheomalacia Granuloma
1 1 2
250
burns 41 (2015) 248–251
Table 3 – Patient demographics by age group. Demographic
Age 0– 2 yrs
Age >2–12 yrs
Age >12–18 yrs
p-Value
Patients Female Male Flame injury Scald injury Other mechanism Age (years) TBSA (%) Inhalation injury Died ICU length of stay (days) Hospital length of stay (days) Injury to admission (days) Admission to tracheostomy (days) Injury to tracheostomy (days) Duration of tracheostomy (days) Ventilator days
15 7 8 6 9 0 1.2 0.6 48.5 14.9 5 4 49.1 35.3 90.1 86 5.3 11.2 1.9 1.8 5.4 3.8 45.5 39 43.2 29.6
19 4 15 17 2 0 5.3 2.4 55.2 19.7 12 5 51.3 33 75.2 47 3.6 8.5 2.1 2.9 4.9 3 51.6 32.7 42.4 28.4
11 2 8 9 0 2 14.4 2.6 56 19.4 1 0 71.2 43.1 126.8 78.2 7 17.1 2.5 6.2 5.5 4.5 75 62.9 58.1 45.1
0.21 0.18 0.004 0.04 >0.0001 ns 0.012 0.162 ns ns ns ns ns ns ns
TBSA, total body surface burn injured.
group 2, there were no differences in ventilator days and duration of tracheostomy (Table 3). Univariate and multivariate linear regression analysis were performed to analyze factors that increase how long patients have a tracheostomy. On univariate analysis, extent of burn injury was the only admission variable that significantly prolonged tracheostomy duration. On multivariate analysis, which included age, TBSA, gender, inhalation injury, time from injury to admission, and time from injury to tracheostomy as independent variables, only TBSA was independently associated with prolonged tracheostomy duration (Table 4).
4.
Discussion
Past controversies about tracheostomies in burn patients have been resolved by current reports that indicate due to lower airway ventilation volumes and lower tracheostomy cuff pressures, tracheostomies are generally safe and effective [2,6,9,10]. However, although tracheostomies provide safe airways for pediatric burn patients, decisions on removal of tracheostomies may be influenced by age related factors and established guidelines for tracheostomy care to reduce time to decannulation have not been well studied especially in
Table 4 – Multivariate linear regression analysis for the outcome of duration of tracheostomy. Variable TBSA Age Inhalation injury Gender Time from injury to admission Time from injury to tracheostomy
B (slope)
Standard error
p-Value
1.7 0.82 4.83 14.2 1.7
0.44 1.23 14.4 14.2 1.9
0.0006 0.51 0.74 0.35 0.39
0.39
0.53
TBSA, total body surface burn injured.
0.47
children [11,12]. In a study of pediatric tracheostomy complications, children less than 1 year of age had the longest duration of tracheostomy followed by children 1–2 years of age, however the reasons for the prolonged tracheostomy durations were not explored [13]. Failure of tracheostomy removal in infant and neonate populations has been attributed to neurologic and severe pulmonary impairments [14]. In the pediatric population, successful decannulation rates vary from 34% to 94% and appear to be disease related and not age related [13,15]. Our results indicate, that for pediatric burn patients, tracheostomy duration is primarily related to the extent of burn injury and is not related to the age of the patient. In addition, successful decannulation occurred in 88% of the surviving patients in the first attempt and 100% overall. This is similar to a published report indicating that pediatric trauma patients undergoing a tracheostomy had a shorter duration of tracheostomy and a higher success rate of decannulation compared to medical pediatric patients. In addition, the study indicated that age was not related to tracheostomy specific outcomes [16]. Tracheostomy related complications also appear to be low and resolvable in pediatric burn patients. In our study, 4 patients had a tracheostomy related complication (9%), however all of the complications were resolved while in the hospital and all of these patients were successfully decannulated on the second attempt. In addition, none of the mortality was attributable to tracheostomy related complications. This is similar to a published report that indicates that mortality in pediatric patients with a tracheostomy is related to the severity of illness and not complications from the tracheostomy [13]. In addition, the decannulation rate and complications presented in our study are similar to a previous report in pediatric burn patients [2]. Thus, tracheostomy appears to be safe and effective for pediatric burn patients. Additionally, long-term airway management in pediatric burn patients can also be safely accomplished through oral–tracheal intubation as well [17]. More research is required to establish guidelines for tracheostomy care and decannulation protocols to reduce
burns 41 (2015) 248–251
tracheostomy patients.
5.
related
complications
in
pediatric
burn
Conclusion
Duration of tracheostomy in pediatric burn patients is related to the extent of burn injury. Age does not appear to influence how long a tracheostomy remains in place. Tracheostomy is a safe method of airway management for pediatric burn patients. However, guidelines need to be developed for tracheostomy care and decannulation protocols to reduce complications.
Authors’ contribution Dr. Sen, Heather, Greenhalgh and Palmieiri were involved in the study question and design. Dr. Heather reviewed the charts and collected the data. Dr. Sen analyzed the data and wrote the draft of the manuscript. Dr. Heather, Greenhalgh and Palmieri edited the final version of the manuscript. All authors have approved the final article.
Conflict of interest None of the authors have any conflict of interest.
references
[1] Sheridan RL, Schnitzer JJ. Management of the high-risk pediatric burn patient. J Pediatr Surg 2001;August (36)(8):1308–12. [2] Coln CE, Purdue GF, Hunt JL. Tracheostomy in the young pediatric burn patient. Arch Surg 1998;133(May (5)):537–9 [discussion 539–540]. [3] Hunt JL, Purdue GF, Gunning T. Is tracheostomy warranted in the burn patient? Indications and complications. J Burn Care Rehab 1986;7(November–December (6)):492–5.
251
[4] Moylan Jr JA, West JT, Nash G, Bowen JA, Pruitt Jr BA. Tracheostomy in thermally injured patients: a review of five years’ experience. Am Surg 1972;38(March (3)):119– 23. [5] Palmieri TL, Jackson W, Greenhalgh DG. Benefits of early tracheostomy in severely burned children. Crit Care Med 2002;30(April (4)):922–4. [6] Barret JP, Desai MH, Herndon DN. Effects of tracheostomies on infection and airway complications in pediatric burn patients. Burns 2000;26(March (2)):190–3. [7] Grant MJ, Balas MC, Curley MA, Team RI. Defining sedationrelated adverse events in the pediatric intensive care unit. Heart Lung 2013;42(May–June (3)):171–6. [8] Kemper KJ, Benson MS, Bishop MJ. Predictors of postextubation stridor in pediatric trauma patients. Crit Care Med 1991;19(March (3)):352–5. [9] Simma B, Spehler D, Burger R, Uehlinger J, Ghelfi D, Dangel P, et al. Tracheostomy in children. Eur J Pediatr 1994;153(April (4)):291–6. [10] Fraga JC, Souza JC, Kruel J. Pediatric tracheostomy. J Pediatr (Rio J) 2009;85(March–April (2)):97–103. [11] Mitchell RB, Hussey HM, Setzen G, Jacobs IN, Nussenbaum B, Dawson C, et al. Clinical consensus statement: tracheostomy care. Otolaryngology – Head Neck Surg. 2013;January (148)(1):6–20. [12] Sunder RA, Haile DT, Farrell PT, Sharma A. Pediatric airway management: current practices and future directions. Paediatr Anaesth 2012;22(October (10)):1008–15. [13] Carr MM, Poje CP, Kingston L, Kielma D, Heard C. Complications in pediatric tracheostomies. Laryngoscope 2001;111(November (11 Pt 1)):1925–8. [14] Sidman JD, Jaguan A, Couser RJ. Tracheotomy and decannulation rates in a level 3 neonatal intensive care unit: a 12-year study. Laryngoscope 2006;116(January (1)):136–9. [15] Mahadevan M, Barber C, Salkeld L, Douglas G, Mills N. Pediatric tracheotomy: 17 year review. Int J Pediatr Otorhinolaryngol 2007;71(December (12)):1829–35. [16] Funamura JL, Durbin-Johnson B, Tollefson TT, Harrison J, Senders CW. Pediatric tracheotomy: indications and decannulation outcomes. Laryngoscope 2014;124(August (8)):1952–8. [17] Kadilak PR, Vanasse S, Sheridan RL. Favorable short- and long-term outcomes of prolonged translaryngeal intubation in critically ill children. J Burn Care Rehab 2004;25(May–June (3)):262–5.
