2017 Sec 1 Green Book

tracheostomy, and spontaneous ventilation maintained. All patients received a dose of intravenous steroids. Direct laryn- goscopy was performed with application of topical anesthesia to the glottis, and rigid tracheoscopy and bronchoscopy was per- formed. The tracheostomy tube was removed, allowing the sur- geon to thoroughly examine the entire airway, supraglottis, glottis, subglottis, trachea, carina, and mainstem bronchi with photodocumentation of all subsites. When necessary, debride- ment of suprastomal or peristomal granulation tissue was per- formed with a combination of techniques depending on surgeon preference, including sharp dissection or microdebrider. Simi- larly, there were several techniques used for dilation of subglot- tic stenosis when indicated, including balloon dilation, microlaryngoscopy and CO 2 laser, serial dilation with rigid bronchoscopes, or a combination of techniques. The tracheos- tomy tube may have been exchanged with one of different type or size, depending on intraoperative findings. The patient was allowed to recover in the postanesthesia care unit and was typi- cally discharged home the same day depending on the intrao- perative findings and stability of the airway. Caregivers were provided photodocumentation of intraoperative findings, and outpatient follow-up was typically scheduled for 4 to 6 weeks in uncomplicated cases. Data Analysis Data analysis was performed with assistance from the Texas Children’s Hospital Outcomes and Impact Service. Continuous variables were reported as medians with a minimum-maximum range or means with standard deviation (SD). Categorical varia- bles were reported with frequencies and percentages. Statistical analysis was performed using logistic regression and multivariate analysis. RESULTS A total of 489 patients underwent 1,094 screening DLBs with a mean 2.3 procedures per patient (range, 1– 14). Two hundred seventy-nine patients (57%) were males, and the mean age was 5.1 years (SD 4.9 years). The most common indication for tracheostomy was con- genital anomaly (49%), followed by neuromuscular dis- ease (19%), isolated bronchopulmonary dysplasia (17%), and trauma (6%). Nine percent of patients had congeni- tal anomalies with bronchopulmonary dysplasia (9%). Forty-one percent of patients were premature (Table I). The mean interval time between surveillance DLB was 430 days. Two hundred fifty-three DLBs (23%) were accompanied by preprocedural symptoms. The most com- mon complaint prior to DLB was increased tracheal secretions (78%). Other preoperative symptoms included bleeding from tracheostomy (8%), intermittent difficul- ties ventilating (7%), voice complaints (1%), aspiration of secretions (1%), tracheitis (1%), dysphagia (1%), and stoma erythema (1%) (Table II, Fig. 1). There were a total of 619 procedures that required 817 interventions, accounting for 58% of the total num- ber of DLBs. Two hundred sixty-six patients (54%) required an intervention during surveillance DLB. The most common intervention performed was debridement of suprastomal granulation tissue (41%), followed by tracheostomy tube exchange (27%), tracheal dilation (10%), and stoma revision (6%) (Table III, Fig. 1). Of the patients who had tracheostomy tube changes, 47% of

TABLE I. Demographic Data.

Patients, No. (%), N 5 489

Patients Male

279 (57%) 210 (43%)

Female

Indications for tracheostomy Congenital anomaly

240 (49%) 93 (19%) 83 (17%)

Neuromuscular disease

Bronchopulmonary dysplasia

Trauma

29 (6%) 44 (9%)

Congenital anomaly and bronchopulmonary dysplasia

Premature

200 (41%)

patient care, potentially reduce the risk of unnecessary procedures, and decrease the economic burden of chronic tracheostomy care. This study investigates the utility of surveillance DLB in pediatric tracheostomy patients to help facilitate the development of clinical practice guide- lines regarding chronic tracheostomy care.

MATERIALS AND METHODS Data Collection

The current practice of nine pediatric otolaryngologists at Texas Children’s Hospital (TCH) is to perform annual surveil- lance DLB on all pediatric patients with tracheostomies. A ret- rospective chart review was conducted of all of the children < 18 years of age with tracheostomies who underwent surveillance DLB between 2003 and 2012 at TCH, an academic tertiary referral center. Patients with existing tracheostomies who transferred care to TCH and underwent surveillance DLB at TCH were included in the study. The institutional review board at Baylor College of Medicine approved this study. Charts were reviewed for demographic data, date of tracheostomy, indication for tracheostomy, symptoms prior to surveillance DLB, dates of surveillance DLB, operative findings, and interventions. Indica- tions for tracheostomy were categorized as congenital anomaly, neuromuscular disease, bronchopulmonary dysplasia, and trauma. Congenital anomalies included craniofacial dysmor- phism, laryngeal anomalies, laryngomalacia, subglottic stenosis, hemangioma, tracheal anomaly, and other congenital syn- dromes. Interventions included debridement of suprastomal granulation tissue, change in tracheostomy tube size or type, tracheal dilation, and tracheostomy stoma revision. Charts were also reviewed for plans for decannulation or laryngotracheal reconstruction following surveillance DLB. Patients with incom- plete medical records were excluded from this study. Those patients with subglottic hemangioma and recurrent laryngeal papillomatosis were excluded from this study, as these patients require serial DLB with planned intervention. Patients who underwent DLB in conjunction with a planned procedure, including intraoperative decannulation, laser cordotomy, or lar- yngotracheal reconstruction, were also excluded.

Surgical Technique Yearly surveillance bronchoscopies are performed in all children with chronic tracheostomies. Patients were taken to the operating room, and general anesthesia was induced via

Laryngoscope 125: October 2015

Richter et al.: DLB in Children With Tracheostomies

15