Pediatric tracheostomy decannulation: A prospective study at a tertiary care centre

P Prem Kumar; Abhilasha Somashekhar; Gangasamudra Veerappa Basavaraja; KS Sanjay; Afshan Fathima; Praveen Baskar

doi:10.4103/jpcc.jpcc_77_22

ORIGINAL ARTICLE

Year : 2023 | Volume : 10 | Issue : 1 | Page : 24-29

Pediatric tracheostomy decannulation: A prospective study at a tertiary care centre

P Prem Kumar¹, Abhilasha Somashekhar¹, Gangasamudra Veerappa Basavaraja², KS Sanjay², Afshan Fathima¹, Praveen Baskar¹
¹ Department of Pediatric ENT, Pediatric Critical Care Unit, IGICH, Bengaluru, Karnataka, India
² Department of Pediatric, Pediatric Critical Care Unit, IGICH, Bengaluru, Karnataka, India

Date of Submission	06-Sep-2022
Date of Decision	28-Oct-2022
Date of Acceptance	11-Nov-2022
Date of Web Publication	20-Jan-2023

Correspondence Address:
Dr. Abhilasha Somashekhar
Department of Pediatric ENT, IGICH, Bengaluru, Karnataka
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpcc.jpcc_77_22

Abstract

Background: Advances in neonatal and pediatric intensive care have increased the number of children who survive with disabilities. The management of the tracheostomized child is a complex and demanding assignment as they have higher rates of complications. Ideally, the decannulation process should proceed once the child no longer requires mechanical ventilation and the underlying pathology has resolved or been reversed. This study highlights our experience in managing pediatric tracheostomy decannulation at a tertiary care center.
Subjects and Methods: This was a single-center, prospective study conducted at the tertiary care pediatric hospital for a period of 1 year. Children with tracheostomy in situ who got admitted for laryngotracheobronchoscopy and decannulation were included.
Results: Indication of tracheostomy was broadly divided into reasons causing upper airway obstruction and those requiring prolonged intubation. It showed that 82% were due to prolonged intubation, in which 85.3% were due to neurological reasons. The success rate for decannulation was 97%. Age of child, duration of intubation, posttracheostomy period, and type of tracheostomy tube had no significant correlation with outcome of tracheostomy decannulation.
Conclusions: Resolution of primary indication for tracheostomy is required before planning of tracheotomy decannulation. Bronchoscopic airway evaluation and decannulation trial in operation theater is needed for successful decannulation. There was no impact of age, duration of intubation, posttracheostomy period, and type of tracheostomy tube on the outcome of tracheostomy decannulation.

Keywords: Laryngotracheobronchoscopy, pediatric decannulation, pediatric tracheostomy

How to cite this article:
Kumar P P, Somashekhar A, Basavaraja GV, Sanjay K S, Fathima A, Baskar P. Pediatric tracheostomy decannulation: A prospective study at a tertiary care centre. J Pediatr Crit Care 2023;10:24-9

How to cite this URL:
Kumar P P, Somashekhar A, Basavaraja GV, Sanjay K S, Fathima A, Baskar P. Pediatric tracheostomy decannulation: A prospective study at a tertiary care centre. J Pediatr Crit Care [serial online] 2023 [cited 2023 Mar 29];10:24-9. Available from: http://www.jpcc.org.in/text.asp?2023/10/1/24/368235

Introduction

Until the nineteenth century, tracheostomy was rarely performed in children. At times of outbreak of diphtheria and poliomyelitis, it became an important lifesaving measure. However, with advances of medical science, there was introduction of vaccines and antibiotics, which changed the indication of tracheostomy from infection to upper airway obstruction, progressive or irreversible neuromuscular disorders, abnormal ventilatory drive, and to allow adequate airway clearance.^[1],[2] Advances in neonatal and pediatric intensive care have increased the number of children who survive with disabilities. The management of the tracheostomized child is a complex and demanding assignment. They have higher rates of complications with almost 2–3 times more morbidity and mortality than adults.^[3]

The presence of tracheostomy causes bronchorrhea, affects swallowing and speech, and might cause increased risk of airway infection and bleeding.^[4] Occurrence of granulation tissue, malacia, stenosis, and vascular and esophageal fistulas are some of the late complications. Decannulation should be performed as early as possible to reduce these tracheostomy related complications. It also reduces the negative impact caused by tracheostomy on the quality of life of both patient and the care giver and the socioeconomic burden.^{[4],[5],[6],[7]}

Ideally, the decannulation process should proceed once the child no longer requires mechanical ventilation, can manage their own secretions, and the underlying pathology has resolved or been reversed.^[8]

However, there is a paucity of validated objective data on determining readiness for decannulation. Although several groups have evaluated decannulation success rates and tracheostomy outcomes based on indication of placement, there is no evidence evaluating the impact of age, tracheostomy duration, size of the tube used, and method of tracheostomy on decannulation outcomes. There is a lack of evidence on bronchoscopy finding that may influence decannulation outcome.^[5] Hence, this study was conducted to highlight our experience in managing pediatric tracheostomy decannulation at a tertiary care center.

Materials and Methods

This was a single-center, prospective single study conducted at a tertiary care pediatric hospital from Karnataka, India, for a period of 1 year. After obtaining clearance and approval from the institutional ethics committee (NO. EC-01/2020–21/743) and written informed consent from parents/guardian, children who fulfilled the inclusion criteria were enrolled in the study.

Our inclusion criteria were all the children who underwent tracheostomy using the same method at our institute. Children were considered for decannulation trial once they fulfilled the prerequisites for it. The prerequisites considered were as follows:

The initial medical conditions that required a child to have tracheostomy has resolved
Child can maintain saturation at room air, have effective cough reflex, and with good oral food intake
No significant abnormalities in the chest radiograph.

The exclusion criteria were those who did not fulfill the prerequisites for decannulation during the study period. The exclusion criteria includes

Those who underwent tracheostomy in other hospitals.
Tracheostomy done before the study period.
Children who did not fulfil the pre requisites for decannulation.

Demographic data, history of indication of tracheostomy, duration of intubation before tracheostomy, post tracheostomy duration were noted. Later, general and ENT examination was carried out. Treating pediatric intensivist's opinion regarding the condition of the child was taken.

If pre-requisites for decannualtion were fulfilled the child was taken up for laryngo-tracheo-bronchoscopy under general anesthesia. The procedure was carried out under adequate anesthetic plane using a rigid bronchoscope. The airway assessment was done. Airway assessment was done which included examination of the laryngeal inlet. The position and movement of vocal cord was assessed. Subglottic area was examined and if stenosis present it was graded using Mayer cotton grading system. Condition of trachea and bronchus were noted.

If any airway lesions were noted like granulation, it was addressed at the same setting. Once adequate airway was achieved, tracheostomy decannulation was attempted on a table. After removal of tracheostomy tube, the stoma was occluded with an occlusive dressing to promote skin closure. The child was observed for next 30 min depending on the time taken to achieve spontaneous breath attempts. Later, they were watched for the maintenance of saturation in postoperative ward. If no signs of distress seen, the patient was shifted to intensive care unit (ICU) where vital monitoring was done for next 24 h. Next day, the child was shifted to ward and was discharged the following day. Overall, the time taken from admission till discharge varied from 48 to 72 h. The dressing was removed on 10^th day and then the wound was assessed. Child was on regular follow-up, if any postdecannulation complications were noted, it was treated accordingly.

All these data were entered into Excel sheet and later analyzed using SPSS software. The data was analysed using PSPP software.

Results

It was a prospective study conducted for 1 year. The total number of children who underwent tracheostomy was 50. Among them, 25 were female and 25 male. The age ranged from day 5 to 17 years with a mean age being 6.7 years. Indication of tracheostomy was broadly divided into reasons causing upper airway obstruction and those requiring prolonged intubation. Eighty-two percent were due to prolonged intubation in which 85.3% were due to neurological reasons [Table 1]. The duration of intubation ranged from 0 to 18 days, with a mean of 10.4 days.

Table 1: Indication for tracheostomy

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Among 50, those who fulfilled the prerequisite for decannulation process during the study period were 31 children (62%).

The median duration posttracheostomy before decannulation was 4.7 months.

The laryngotracheobronchoscopy was done to assess the airway before decannulation in all 31 children. Examination of laryngeal inlet showed normal epiglottis, are-epiglottic fold, inter arytenoid region, false vocal cord and true vocal cord in all children. All 30 children had normal arytenoid and only child had left arytenoid granulation. When the scope was introduced further down to assess the subglottic region, two children had Grade 2 subglottic stenosis. The findings of suprastomal area varied. Fifteen children had normal area, 11 children showed suprastomal granulation, 4 children showed minimal suprastomal collapse, and 1 showed complete collapse [Table 2]. On further evaluation of the airway, all the children had normal trachea and bronchi. Only one child had granulation in trachea at the tip of the tracheostomy tube. All 12 children who had the granulation tissue underwent microlaryngeal surgery using cold instrument to remove it before decannulation. One child who had arytenoid granulation underwent microlaryngeal surgery using cold instrument and decannulation trial was planned for next visit which was successful.

Table 2: Findings of suprastomal area seen on laryngotracheobronchoscopy

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The success rate for decannulation was 97% on follow-up, and 12.9%^[4] showed tracheocutaneous fistula (TCF). One healed spontaneously within 4 months. Other three required excision and closure of the tract. One child who had arytenoid granulation prior presented with voice change after decannulation. Video laryngoscopy was done and found to be normal. His voice was restored after speech therapy [Table 3].

Table 3: Postdecannulation sequelle

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The statistical analysis was done on to see the relationship of various factors with outcome of tracheostomy decannulation. Age of child, duration of intubation, posttracheostomy period, and type of tracheostomy tube had no significant correlation with outcome of tracheostomy decannulation.

Discussion

The primary indication for pediatric tracheostomy has changed over the last few decades from acute infection to those conditions demanding prolonged intubation.^[1] Although introduction of vaccination has reduced the infective reasons for tracheostomy, it is not absolute. Our study had 2 cases (7.5%) who had diagnosed with diphtheria presented to us with severe upper airway obstruction which demanded immediate intervention with emergency tracheostomy. Both the cases were unvaccinated, highlighting the importance of immunization in control of the infection.^[1],[9]

Jain et al. in their retrospective study found 92% of the indication for tracheostomy to be prolonged ventilation secondary to neuromuscular problem.^[9] In an urban Indian study, which was done to evaluate the changing indications for pediatric tracheostomy by Lele et al. showed neurological impairment which required prolonged ventilation as the most common reason.^[10] Other studies have also shown the primary indication for tracheostomy to be prolonged ventilation.^{[2],[11],[12],[13]}

Advances in vaccination, improvement in neonatal, and intensive pediatric care are the main reasons for survival of pediatric patients with complex medical conditions who demands prolonged ventilator dependence.^[14] There are no consensus regarding when to do the tracheostomy in a pediatric age. As per recent meta-analysis it is shown that tracheostomy done at the earliest has better outcome. It showed 7 days of intubation to be optimal. However, the decision lies with the treating physician and institutional protocol.^[1] A study by Al-Samri et al. showed a median 13-day duration of intubation before tracheostomy.^[15] In our study, we had the mean of 10.4 days of intubation before tracheostomy. Pediatric patients tolerate the intubation better for longer period, but early intervention by tracheostomy reduces the overall risk of ventilator-associated problems, length of ICU stay, cost, and sedation requirement and improves the patient comfort.^[9]

Total recovery of the medical condition which necessitated the tracheostomy is the fundamental criteria to consider the child for decannulation. In our study, the success rate of decannulation was independent of the primary indication. The mean duration posttracheostomy before decannulation was 4.7 months. Canning et al. showed the mean of 23 months as their cannulation time, which they quoted to be like several other studies.^[6] Another study by Jain et al. showed 48 days (5–180 days) as their average length of tracheostomy.^[9]

We considered the readiness of a child for decannulation on their ability to maintain saturation at room air, ability to maintain the airway without the tracheostomy tube, having effective cough reflex, and with good oral food intake.^[16] A study conducted by Nozomi Takahashi et al. suggested that feeding ability could be an indicator of local pharyngolaryngeal function and therefore predict the success of decannulation.^[17]

The American thoracic society guidelines recommends to do an endoscopic evaluation of the airway when the child is planned for decannulation procedure. It helps understand the dynamics of the airway and to ensure the absence of airway lesions such as vocal cord paralysis, granulation, suprastomal collapse, distal tracheal granulation, or malacia, which disrupts safe decannulation when present.^[18]

We performed laryngotracheobronchoscopy using rigid bronchoscope, which not only helped in the evaluation but also aided in the therapeutic intervention. The incidence of airway granulation ranges from 72% to 80%. The first most common airway lesion noted in our study was suprastomal granulation (35.5%). Poor peristomal hygiene might be the reason for development of granulation tissue.^[19] With the help of rigid bronchoscope, the granulation tissues were removed, and airway patency was achieved [Figure 1].

Figure 1: Intraoperative pictures of laryngotracheobronchoscopy; (a) note the suprastomal granulation completely occluding the airway, (b and c) removal of granulation, (d) patent airway postgranulation removal

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The second most common airway lesion noted in the current study was suprastomal collapse. When the pediatric population is tracheostomized, some degree of suprastomal collapse is inevitable. This is due to prolonged pressure over the cartilage by tracheostomy tube, leading to chondritis and thinning of the cartilage. Mild suprastomal collapses are usually non-threatening which are noticeable only on the endoscopic evaluation, but severe suprastomal collapse may lead to decannulation failure.^[20] This was found to be true in our study, where children with severe suprastomal collapse did not sustain the decannulation procedure showing the significance of airway evaluation before decannulation.

Various institute adapt different techniques for pediatric decannulation. A slight reduction in diameter of the airway in children will give rise to increased resistance.^[18] By downsizing into a smaller tube, possibility of tube blockage due to mucus plug pose as a risk factor. Airway evaluation and decannulation trial in a controlled environment in operation theater is safe and effective [Figure 2]. Decannulation is followed by close monitoring of the child for next 24 h in a pediatric ICU. The majority of decannulation failure occurs within 12-36hrs. Hence keeping the child in PICU post operatively helps to intervene immediately by pediatric intensivist if any respiratory distress is noted.

Figure 2: Decannulation process. (a) Positioning of child under GA, (b) removal of tracheostomy tube, (c) approximating the tracheostomy opening, (d) tight occlusive dressing

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Usually, the duration of hospitalization for a child ranges from 3 to 10 days according to various other methods of decannulation where it involves downsizing of the tube.^[21] In this study, the overall the time taken from admission till discharge ranged from 48 to 72 h. This reduces the overall burden for family as well as allows better utilization of hospital resources.

Al-Samri et al. in their 17 years of experience showed 87% decannulation success rate.^[15] In the current study, it was found to be 97% [Figure 3]. In a study by Sachdev et al., the decannulation failure was mainly due to neurological status of the child and contributed to 10% of total sample.^[16] In our study, it was 3% contributed by one case who primarily neurological case and also had collapse of suprastomal area.

Figure 3: Decannulation process. (a) positioning of child under GA, (b) removal of tracheostomy tube, (c) tight occlusive dressing, (d) postoperative showing complete closure of the stoma

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Postdecannulation follow-up showed 12.9%^[4] TCF. The incidence is quoted to be 3–37%. Seligman et al. showed a high rate of persistent TCF (48%), which they attributed to their method of allowing the tracheostomy tract to heal by secondary intension without the suturing.^[7]

We have also followed the same method, where the wound was allowed to close on own. Inability for child to occlude the lumen during the cough and phonation might result in TCF. In our study 3 children underwent excision of TCF and one healed spontaneously over period of 3 months.

Conclusions

Resolution of primary indication for tracheostomy is required before planning of tracheotomy decannulation. Bronchoscopic airway evaluation and decannulation trial in an operation theater is needed for successful decannulation. There was no impact of age, duration of intubation, posttracheostomy period, and type of tracheostomy tube on the outcome of tracheostomy decannulation.

Acknowledgment

We acknowledge the anesthesia team for their invaluable support during the procedure and PICU team for postoperative monitoring.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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