| Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. Considerations in Pediatric Tracheostomy The first tracheotomy was reportedly performed in Rome in the second century B.C. Antyllus in the second century A.D. further refined the technique. He suggested that the trachea be divided between the third and fourth tracheal rings using a transverse incision. Mabicot is credited with performing the first pediatric tracheotomy in 1620. The procedure was reportedly performed on a 16-year-old boy who had swallowed a bag of gold to try to keep the gold from getting stolen. The bag then became lodged in the boy’s esophagus and obstructed his trachea, so Mabicot performed an emergency tracheotomy and then manipulated the bag of gold so that it would continue to pass through and was eventually recovered per rectum. In 1825, Bretonneu did a tracheotomy on a 5-year-old girl with diphtheria. Afterwards, Bretonneu reported performing tracheotomies on over 200 children with diphtheria. It was often used as a last resort in these cases, though, because there was only a 32 percent survival rate afterwards. Throughout the 1800s, tracheotomies became increasingly popular in hospitals, but the mortality and morbidity of the procedure remained very high. During the early 1900s, Chevalier Jackson standardized this procedure. This is his picture. He demonstrated that the mortality rate could be significantly reduced if careful attention was paid to postoperative care. During the early 1970s, the most common indications for tracheotomy were acute infections, such as epiglottitis and laryngotracheobronchitis. Since the early 1980s, nasotracheal intubation has virtually replaced tracheotomy for epiglottitis. After the discovery of vaccines against different bacteria and diphtheria and hemophilus influenza, there has been a significant reduction in the use of tracheotomies for acute airway infections. This is a characteristic picture of diphtheria, which most of us as residents have not seen. In other cases today, there is still considerable controversy on whether to perform a tracheotomy or endotracheal intubation and when this intervention should take place. We must consider the course of the patient’s illness, the etiology of the disease, and the age of the patient. Younger children have smaller airways, so a smaller amount of edema is required to lead to obstruction. Younger children also have less reserve and tire more easily than older children or adults. Also to be considered is the hospital capabilities, including the experience of the surgeons and available equipment and personnel. Today, in 2005, there are three basic indications for a tracheotomy in a pediatric patient. First, upper airway obstruction. Severe subglottic stenosis, such as shown here, can develop in the premature infant intubated for a prolonged period of time. Children can have craniofacial or structural abnormalities of the upper airway or they may be hypotonic due to neurological or neuromuscular disorders. Second, children may be premature or they may have bronchopulmonary dysplasia and need assisted ventilation. The third indication is pulmonary toilet in those with excessive secretions or those who are prone to aspiration. In 1996, Dr. Wooley surveyed 85 pediatric otolaryngologists across the nation. Together, this collective group performed approximately 2,000 tracheotomies per year. Forty percent were done for ventilator dependency, 30 percent for extrathoracic obstruction. They reported that 20 percent was done for neurologic dysfunction and 10 percent for intrathoracic obstruction. Today, in 2005, fewer pediatric tracheotomies are being performed overall. This is for several reasons. First, few are performed for infectious indications. In the past 30 years, there have been innovations in the management of subglottic stenosis. In children with craniofacial anomalies, more aggressive surgical management, such as mandibular advancement osteotomies has led to earlier decannulation. Today, more neurologically-impaired children are being referred for this procedure since there is now less stigma associated with having a chronic trach. These children often require trachs for years and need extended care and tertiary care as well. During the past century, there have been improvements in home health care decreasing the out-of-hospital mortality rate. During the 1940s and 1950s, mortality rates for these children were approximately 5 to 10 percent; and now, the current rate is approximately 0.5 to 2 percent. Morbidity is commonly defined as bleeding, infection, decannulation, airway obstruction or other complications. Today, rates of morbidity vary from 24 to 58 percent in different studies. Before we focus on individual patients, we will discuss this procedure in 2005 from a national perspective. Two years ago, Dr. Lewis in Seattle published her findings that pediatric tracheotomy varies among different states and different hospitals. This was a retrospective study drawn from administrative hospital discharge records from all pediatric admissions in 22 states in 1997. Texas was not included. The federal and state governments and private sectors all collaborated on this inpatient discharge data. Included in this data base was data from 2500 hospitals, and it included 1.9 million pediatric discharges. Pediatric tracheotomies were defined as in those less than 18 years of age. Approximately 2,065 pediatric tracheotomy procedures were recorded in this group. She found that pediatric tracheotomies are a relatively infrequent procedure. The incidence is 6.6 children per 100,000 and it is associated with less than 1 percent of all pediatric discharges nationally. The means length for each of these children of hospital stay was 50 days with a mean total hospitalization cost per patient of approximately $200,000. Infants had longer stays and higher hospital charges relative to other age groups. In these 2,000 cases across the country, she found significant variations in outcomes among different regions and different hospitals. Two factors were found to correlate with reduced mortality. If the tracheotomy was performed in a children’s hospital or in a hospital with higher case volume, children cared for in a teaching or a children’s hospital were more likely to go home. They were less like to be discharged to a long-term facility, and children in the western region were discharged to long-term care facilities at half the rate of patients in the northeast. The author speculated that these teaching hospitals may have more resources for discharge coordination and planning. The rate of tracheotomy was highest among infants nationwide. This graph from their article shows the bimodal age distribution of pediatric tracheotomy, with peaks in infancy and peaks in late adolescence. Again, patients who received their tracheotomy at a children’s hospital had half the rate of dying during this admission, compared with patient who were cared for in a non-children’s hospital. Hospitals were stratified in different quartiles by their case volume. Hospitals that performed more pediatric tracheotomies and that were in the top quartile of case volume had a significantly lower risk of mortality than those hospitals that had lesser case volume. Ninety-three percent of the tracheotomies done in the northeast were performed in children’s hospitals, while only five percent of the tracheotomies done in the south were in children’s hospitals. Nationally, approximately 952 million dollars was spent on health charges for the children in this study. Almost half of these children were sent either to a long-term care facility or set up with home health. Children stay in these facilities and stay cannulated for varying amounts of time. A study by Dr.Carron in 2000 reviewed 204 children who underwent tracheotomy in Virginia between 1988 and 1998. The average age of tracheotomy was 3.2 years; and more than half of the tracheotomies were performed in children who were under 1 year of age. Decannulation was successful in approximately 40 percent of patients. The craniofacial abnormality group had the highest rate at 63 percent, while only 12.5 percent of neurologically-impaired children were able to be decannulated. The average length of time that all the children in the study had to keep the trach in was almost two years—23.5 months. Neurologically-impaired children took almost as long as the average to reach decannulation at 45.6 months. This graph shows the average age of tracheotomy for different patient groups in their study. The different groups was the overall group in the study, those with upper airway obstruction, those with the craniofacial abnormality, those who had been intubated for a long period, neurologically-impaired, trauma, and vocal cord paralysis—and you can see that the neurologically-impaired children tended to be older at the time of tracheotomy, as well as those who had it performed because of trauma. Neurologically-impaired children also have a less likelihood to have decannulation and then they take longer before decannulation than other children with tracheotomies. During the past 50 years, changes in epidemiology of infectious disease and the capabilities of modern medicine have altered the indications for pediatric tracheotomy. As a consequence of these changing trends, decannulation rates have tended to drop and the average length of cannulation has risen. During these two years of cannulation, what are these children’s lives like? Our goal today is not to review technical aspects of the procedure but rather to explore the lives of these patients postoperatively. How does the tube affect the development of their speech and their swallowing? Beyond just the mortality and morbidity associated with the procedure alone, the impact on the family is significant. Parents of infants, especially, are assuming a significant new care role. Their first questions usually are, “How will I hear my baby cry?” and “Will my child ever speak?”. A tracheotomy has a long-range impact on socialization, habituation, and health of an infant or child. Will long-term speech therapy be indicated? Will the stressful family situation prohibit the normal development of a happy, healthy child? Will the child have long-term special education requirements? A few of these questions have been answered in the literature, but most remain unanswered. First, speech—The impact of tracheotomy on speech and language has been studied for many years. In adult patients with normal cognitive linguistic abilities, the tracheotomy results in a sudden loss of communication. Frequently, this loss causes frustration, isolation, and depression. These factors are compounded in children with trachs. The inability to communicate distress can frighten both children and their families. Many factors combine to cause speech problems in these children, and it is exacerbated by hearing loss. Dr. Beste in 1999 did a four-year retrospective study of a pediatric tracheotomy population in Wisconsin. Eighty-three outpatients comprise the study population. Chronic otitis media with effusion was defined by the presence of middle ear effusion in more than half of the ear evaluations during this four-year study period or by PE tube placement. The prevalence of chronic otitis media with effusion was 60 percent in the study population. Certain groups had higher prevalences. Craniofacial anomaly patients had a rate of 90 percent, and those who were chronically ventilated had a rate of 79 percent. He speculated that these patients may be at higher risk for hearing loss because of Eustachian tube dysfunction, neuromuscular disorders, and the high incidence of upper respiratory infections in these patients. The child’s basic disease condition may directly affect language development. They may have developmental delays and chronic deprivation states. Indirect factors include chronic or repeated hospitalizations. They may have inadequate pulmonary reserve to mount sufficient airflow. Infants and children who have neurological problems, along with the tracheotomy, are at even higher risk for language deficits. These children also may have lack of auditory and orosensory feedback from hearing loss, as we mentioned, or from compromised oral motor control. Finally, overwhelmed parents may not realize how much stimulation their children need. All of these factors combine to cause delay and deficiencies. Dr. Kaslon in 1985 studied the effect of chronic tracheotomy on the acquisition of voice, speech, and language skills. He evaluated children at the chronological ages of 16 to 41 months. His results consistently showed a receptive communication delay of 4.8 months delay in development and a nine-month delay in expressive communication age. All of the infants and toddlers in his study then improved after a rigorous speech therapy protocol. His study demonstrates that without intervention children with tracheotomies are at risk for delays in both receiving and expressing language. Dr. Kanen looked at eight children who underwent tracheotomy during the prelingual period and then had been decannulated. He compared them to match controls on standard measures of speech proficiency, and he found that the children who had had tracheotomies were much more limited in their ability. Their oral motor patterns were less mature. They had variable sound substitutions, and their speech overall reflected persistent maladaptive compensations that they had picked up during cannulation. The more time spent with a tracheotomy indwelling, the more severe the results in impairment. Dr. Simon studied language development in 23 children with long-term tracheotomies pre- and post-decannulation. The language-delayed children responded well to therapy with the impairment resolving after six months on average. Children who were decannulated during the prelingual stage were found to have appropriate language skills, while children who were decannulated later, during the postlingual stage, were found to be delayed. Many tracheotomies now are long-term in infants under 1 year of age. The prelingual stage is defined as the time prior to their acquiring true expressive language and producing their own words, usually before 9 to 12 months of age. A child who is decannulated during this time usually will begin to speak appropriately without help and will have little, if any, expressive delay. They may have voice and breath support problems but this can usually be helped with proper speech therapy. Those decannulated at ages 1 to 4 years old may have significant expressive delay and need much more extensive therapy in addition. Speech therapy in both the prelingual and the postlingual stages is essential. However, children are sometimes not referred to speech pathology because their tracheotomies are thought of as short-term or the children are very ill for very long periods of time. Physicians tend to refer infants less often than older children, but it has been shown that all ages can benefit. The speech therapist will be able to help them develop their oral motor skills, maximize receptive language, and encourage nonvocal behavior as precursors to stimulation. Speech pathologists can work even in an intensive care unit setting to help with these problems, and this will help reduce the frustrations of both the child and the parent. Speech pathologists can facilitate effective parent-child interactions by training parents to encourage all nonverbal and gestural behavior. Exercises that they teach include parent training, parents keeping log books of the child’s daily communication interactions, individual therapy sessions, and enrollment in preschool or play groups to stimulate social interactions. Again, the goal of all of this is to improve the deficits in their speech and language development. Increased feeding difficulties are another rehabilitation hurdle for these patients. Unfortunately, there is not much in the literature specifically about how children with tracheotomies swallow. In adults, it has been shown that tracheotomy does alter normal glottic reflexes and swallowing predisposing patients to aspiration. The pathophysiology of impaired swallowing is thought to be both mechanical and neuromuscular in nature. It results from tethering of the larynx at the surgical site, weakened glottic closure, muscle atrophy, and laryngeal desensitization. The Passy-Muir valve was developed in the early 1980s by David Muir, a patient with muscular dystrophy who had a tracheotomy. The speaking valve allows the patient with a tracheotomy to speak without the use of the finger occlusion of the tracheotomy stoma. It is a positive pressure valve, which opens only during inspiration to allow air to enter via the tracheotomy. Following inspiration, the positive pressure mechanism shuts forcing air out through the vocal cords, nose, and mouth thus allowing for phonation. The valve allows patients to resume speaking, which enhances social interactions, decreases isolation, and improves the overall mental status of the patient. The Passy-Muir valve requires no digital occlusion, is reversible, and it decreases frustration because it makes it much easier to produce spontaneous vocalizations. Passy-Muir valves are contraindicated with constantly inflated cuff tubes, severe tracheal stenosis, excessive secretions, or the unconscious or seriously-ill patient. The efficacy and benefits of the speaking valve have been well studied in the adult population. While there are strict criteria for selection of adult patients for use of the speaking valve, these selection factors have not been defined as clearly for the pediatric patient. Children have a different distribution of co-morbid conditions from adults and have much smaller airways. Besides speech, the speaking valve in adults has displayed a wide variety of benefits, including improvement of swallow function, reduction of secretions, and improvement of olfaction. Adults with a speaking valve have decreased meaning times with mechanical ventilation, return of a normal cough, improved mental status, and decreased depression. In adults with mild swallowing dysfunction, placement of a speaking valve during feeding reduces aspiration, and it normalizes the feeding process more. There is still a need for research in the pediatric population to determine if the benefits seen in adults translate to infants and children. We can hypothesize that use of a speaking valve would help children with trachs swallow better. A recent study illustrated that children are able to tolerate speaking valves. Dr. Cho Lieu in 1999 performed a retrospective analysis of 55 consecutive cases of children with tracheotomy using the Passe-Muir valve. The children ranged in age from 3 to 18 years at the time of surgery, and nearly half were 12 months old or younger. The youngest children in this study, those less than 1 year, averaged 27 months prior to decannulation. Successful use of the valve required patient and family training. Fifty-two children out of the 55 who were evaluated as candidates for the Passy-Muir valve tolerated its use, but many did require two or more trials and significant training prior to the patient and family being comfortable with its use. Speech and feeding are worrisome issues for the family. A tracheotomy in a child can be a life-saving procedure; however, caring for a child with a tracheotomy is a major burden on the parents and traumatic for the child. Especially difficult is the daily care of suctioning cannula and tie changes. The indications for pediatric tracheotomy have been changing, and the majority of pediatric tracheotomies is now performed for chronic disease and it is now required for longer periods of time. Changes in the family now include physical demands on the caregiver and economic in terms of increased cost required for medical visits and follow-up. Most children see multiple doctors, including a pediatric otolaryngologist, a pediatric pulmonologist, speech pathologist, as well as their own pediatrician. Home care is also essential in many of these children. One study found that 77 percent of these patients have home care for an average of 11 hours per day, and 83 percent were required to have home apnea monitors. The specific impact of tracheotomy on parent-child interaction and the quality of life of families has not been well studied. Last year, Dr. Martnick at Massachusetts Eye and Ear wanted to further delineate the caregiver burden of these patients. He administered the Medical Outcomes Study-Short Form, and a Pediatric Tracheotomy Health Status Instrument to 154 families of children with trachs. This study was open between Januarys and July of 2001. This Pediatric Tracheotomy Health Status Instrument has been developed and pilot-tested as a disease-specific instrument with a 34-item measure. It studies the child’s physical symptoms, medical visits and costs, parental rating of the child’s psychological health status, and parental rating of their own caregiver burden. Parents answered 34 questions, such as these: How would you describe your overall quality of life? How often are you worried or concerned about your child’s safety when you perform a tracheotomy tube change, or with regard with their overall ability to breathe? During the past four weeks, how often has your child’s condition affected your health or interrupted various everyday family activities? Over the past four weeks, how often did you need help from skilled medical personnel? He found a significant correlation between parental caregiver burden and the child’s physical health status as well as between parental caregiver burden and increasing economic costs associated with their care. He concluded that people caring for children with tracheotomies experience significant caregiver burden. This burden increases as the child gets physically sicker and its economic costs increase. The adult’s mental health status is significantly more affected than their actual physical health. In this study, the mean scores for adults were compared with normative data for the U.S. population. The first bar represented the mental health score, and the second bar represented the physical health score of the parent. This first group is caregivers for children with a trach. The other groups represent adults with hypertension, those who have had a recent myocardial infarction, those with congestive heart failure, and those diagnosed with type II diabetes. You can see that caregivers of pediatric trachs have significantly poor emotional functioning. Some future questions in this area would be, “Does the eventual removal of the tracheotomy tube and decannulation affect the health status of the child and caregiver?” and “How is the child’s health status affected by being cared for by a parent who is experiencing significant mental burden?”. Again, thousands of these procedures are performed nationwide currently. It has been found that there are significant variations in outcomes across regions and among different hospitals. Speech therapy is essential. This procedure affects speech and swallowing in children, and it also significantly impacts families. Much research remains to be done. Case Presentation Her past medical history included multiple episodes of pneumonia. Medications included oral prednisone. Review of systems was positive for weakness, fatigue, and joint pain. She was taken to the operating room and underwent a tracheotomy. A #6 cuffed Shiley was placed. Postoperatively, fresh trach precautions were observed, and she underwent routine local trach care. She was kept in the intermediate care unit postoperatively for rehabilitation. She followed up as an outpatient in TCH clinic. She has subsequently been decannulated. Bibliography: Arvedson J, Brodsky L. Pediatric tracheotomy referrals to speech-language pathology in a children’s hospital. Int J Pediatric Otorhinolaryngol 1992;23: 237-243. Beste DJ, Conley SF, Milbrath MM. Prevalence of chronic otitis media with effusion in a pediatric tracheotomy population. Pediatric Pulmonology 1999;28:194-198. Carron JD, Derkay CS, Strope GL. Pediatric tracheotomies: changing indications and outcomes. Laryngoscope 2000;110:1099-1104. Duncan BW, Howell LJ, DeLorimier AA, Adzick NS, Harrison MR. Tracheotomy in children with emphasis on home caer. J Pediatr Surg 1992;27;432-435. Cho Lieu J, Muntz HR, Prater D, Blount-Stahl M. Passy-Muir valve in children with tracheotomy. Int J Pediatric Otorhinolaryngol 1999;50:197-203. Gereau SA, Cluterio GC, Mulllan E, Bassila M, Ruben RJ. Selection of pediatric patients for use of the Passy-Muir valve for speech production. Int J Pediatric Otorhinolaryngol 1996;35:11-17. Hartnick CJ, Bissell C, Parsons SK. The impact of pediatric tracheotomy on parental caregiver urden and health status. Arch Otolaryngol Head Neck Surg 2003;129:1065-1069. Hartnick CJ, Giambra BK, Bissell C, Fitton CM, Cotton RT, Parsons SK. Final validation of the Pediatric Tracheotomy Health Status Instrument. Otolaryngol Head Neck Surg 2002;16:228-233. Kamen, RS, Watson BC. Effects of long-term tracheotomy on spectral characteristics of vowel production. J Speech Hearing Res. 1991;34:1057-1065. Lewis CW, Carron JD, Perkins JA, Sie KC, Feudtner C. Tracheotomy in pediatric patients: a national perspective. Arch Otolaryngol Head Neck Surg 2003;129:523-529. Simon B, Flower S, Handler S. Communication development in young children with long term tracheostomies. Int J Pediatr Otorhinolaryngol 1983;6:37-41. Stool SE and Eavey R. Tracheotomy. In: Bluestone and Stool, ed. Pediatric Otolaryngology. Philadelphia: W.B. Saunders; 1983. Wetmore RF, Marsh RR, Thompson ME, Tom LW. Pediatric tracheostomy: a changing procedure? Ann Otol Rhinol Laryngol 1999;108;695-699. Wooley A, Muntz H, Prater D. Physician survey on care of children with tracheotomies. Am J Otolaryngol 1996;17:50-53. BCM Public | BCM Intranet | Privacy Notices | Contact BCM | BCM Site Map | ©2001-2005
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